INTRODUCTION

DeQi,derived from theHuang Di Nei Jing,1is also called"Qiarrival",which refers to the reaction of meridianQiat the needling site after the acupuncturist inserts the needle to a certain depth and performs needle manipulationvialifting,thrusting,twisting,and rotating.The presence of DeQican be determined by two factors:the sensations felt by the patient in response to acupuncture,and the sensations perceived by the hand of acupuncturist.WhenQiarrives,patients often perceive soreness,numbness,fullness,and heaviness,while the acupuncturists often experience a heaviness,tightness,or stagnation at the hand.IfQidoes not arrive,there will not be any specific sensations or reactions felt by the patient,and the acupuncturist will feel sensations of hollowness,looseness,or emptiness.2

According to traditional acupuncture theory,DeQiis a critical part of acupuncture that is closely correlated to the curative effects.However,this correlation between DeQiand curative effect is still controversial in present studies on DeQi.3Although many clinical trials suggests a correlation between curative effect and DeQi,4-9other trials have reported no such correlation.10,11Hence,this topic has recently become a focus in the field of acupuncture research.12,13

It is of great importance to standardize and normalize the definition and evaluation of DeQito enable the study of DeQiin a scientific and systematic manner.It is generally accepted that DeQiis characterized by both the needling sensations felt by the patient,and the perception felt in the hand of the acupuncturist.Ancient Chinese medical literature reports that the induction and control of DeQiis of great importance,and the acupuncturist's perception was thought to be vital proof ofQiregulation by acupuncture.However,the evaluation of DeQiin modern studies is mainly based on the needling sensation felt by the patient,14as the acupuncturists'perceptions might be influenced by their individual thinking patterns.15

The present review analyzed and compared the scales/questionnaires available to evaluate DeQi.Furthermore,we advised on the development and improvement of such questionnaires through integration with classical DeQitheory.

METHODS

Between 1st Aug and 31st Oct 2014,an electronic database search of all fields was conducted at the Beijing University of Chinese Traditional Medicine.To identify relevant Chinese literature,the China National Knowledge Infrastructure database and the Wanfang database were searched from 1949 to 2014 for articles containing the words"DeQi","acupuncture sensation","needling sensation",or"Qiarrival"in the title,Abstract,or keywords list.This search retrieved 549 articles.After screening,76 articles were included for assessment.

To identify relevant English literature,the PubMed database was searched from 1950 to 2014 using the search words"DeQi","acupuncture sensation","needling sensation",or"Qiarrival".The search scope included all subjects,with the language restricted to English.This search retrieved 103 articles.After screening,21 articles were included for assessment.

After careful screening of the retrieved articles,a final total of 97 articles were included in the present review.The included articles fulfilled the following criteria:(a)the DeQisensation was recorded during manual acupuncture or electroacupuncture;(b)interventions were performed on humans;(c)the article was a research article,review,or case report.

RESULTS

Existing subjective methods for evaluating De Qi

The methods currently used to subjectively evaluate DeQiin China and abroad include simple evaluation and a DeQiscale/questionnaire.Simple evaluation comprises qualitative evaluation,while a DeQiscale/questionnaire comprises quantitative evaluation.

Simple evaluation of De Qi

Simple evaluation is the determination of the presence of DeQibased on the patient orally reporting to the acupuncturist that they have felt the characteristic DeQisensations(including soreness,numbness,fullness,and heaviness)during needling procedures.Before 2010,most Chinese researchers adopted this simple evaluation to determine the presence of the DeQicondition in patients.7,16,17Simple evaluation is easy to perform,and is suitable for use in studies that need to determine whether DeQiis achieved;this method has been widely used in clinical trials,due to its rapidity,convenience,and technical ease.However,simple evaluation has great limitations.The patient's response might be influenced by the acupuncturist's manner,leading to bias of the results.In addition,the simple evaluation method requires patients to have had adequate experience with acupuncture therapy to enable them to accurately detect DeQi.Hence,simple evaluation is more suitable for clinical practice in China,but is probably not practical for worldwide use,and does not have universal applicability.

Evaluation of De Qi using a Scale/Questionnaire

The DeQicondition can be evaluated via quantitative evaluation using a scale/questionnaire with specific structure and data collection style that uses screening terms capable of describing DeQi.In this method,the acupuncturist asks the patient to independently fill in the scale or questionnaire,and the DeQiconditions are evaluated based on the data collected.

8 Sui MH,Wang ZY,Ma WZ.Effect of arrival ofQiand the method of reinforcing－reducing by twirling and rotating the needle by acupuncturing Quchi(LI 11)on the blood pressure of essential hypertension patients.Zhong Yi Yao Xin Xi 2012,29(3):87-90.

Thus,the first acupuncture sensation scale(ASS)was formulated.The reliability and validity of this ASS was carried out using 125 native English speakers as subjects.The results confirmed the reliability and validity of the ASS,and that acupuncture did induce DeQisensations.

After the ASS,some descriptions of DeQiused in traditional acupuncture theory were added to the scale,formulating the Park DeQiQuestionnaire.19The newly added terms included burning,pinching,pressing,flickering,and tenderness.This updated scale was then tested in 64 healthy volunteers.

Improvement of the De Qi Scale

The ASS provided the basis for the development of a DeQiscale that quantitatively evaluated DeQi.However,the results also showed no significant difference in DeQisensations between needling at acupoints versus non-acupoints.Therefore,many acupuncturists have sought to improve the DeQievaluation scale.

In 2005,brain functional MRI revealed that the cerebral hemodynamics exhibited by patients experiencing DeQiwere different compared with patients experiencing sharp pain,suggesting that DeQicould be distinguished from sharp pain caused by needling.20The difference between DeQiversus acute pain caused by a harmful stimulus was recognized,and MacPherson and Asghar primarily attempted to categorize terms representing these two different kinds of sensations.21On the basis of the Park Questionnaire,terms describing needling sensations corresponding to DeQiwere classified into two categories:one related to DeQi,and the other to sharp pain felt at the point that was being needled.21Whiteet al22then developed the Southampton needle sensation questionnaire(SNSQ),which classified DeQisensations into two categories:aching DeQiand tingling DeQi,to further distinguish the pain caused by needling sensations.

At the beginning of this century,the most representative widely used DeQiscales/questionnaires were the Massachusetts General Hospital(MGH)ASS(MASS)23and the SNSQ.These scales included classical terms used to describe DeQi(including coolness and warmth),but also included the terms'stabbing'and'burning'into the category of sharp pain,and newly differentiated'dull'pain from'sharp'pain.The MASS could evaluate DeQisensations experienced during acupuncture procedures,and could distinguish DeQisensations from the sharp pain that often accompanies needling.Moreover,the MASS was the first DeQiscale to consider the influence of the mood of the patient on DeQisensations,using a Mood Scale.The SNSQ classified DeQisensations into two categories:aching DeQiand tingling DeQi,which could further clearly distinguish DeQisensations from the sharp pain caused by needling.These developments in the MASS and the SNSQ improved the scientific value of these scales/questionnaires.The unique characteristics and the designs of the MASS and the SNSQ seemed to be more scientific and rigorous than previous DeQiscales,and the efficacy of the MASS and the SNSQ were confirmed through reliability and validity tests.The MASS and the SNSQ have been widely applied in DeQistudies in recent years,and have been translated into various languages for validation.15,24However,these two scales have not been validated in all languages.

Improvement of Evaluating Tools Used in De Qi Scales

DeQiscales that were developed after the ASS included tools to evaluate and improve the terms.In the ASS,Vincentet al17used a grade ranging from 0-3 to rate the intensity of different sensations,with a score of 0 representing the absence of a certain sensation,and a score of 3 indicating that the patient had experienced a severe degree of the certain sensation.After the introduction of this grading system in the ASS,some investigators introduced a scale for the quantitative evaluation of DeQiusing a 0-10 cm segment on which the patient indicated the intensity of a certain sensation,with 0 indicating the absence of the sensation,and 10 indicating the most intense degree of that sensation imaginable.23This method was intended to more accurately and intuitively express the intensity of a sensation;an example of such a scale is shown in Figure 1A.Another study used a 0-100 mm visual analogue scale(VAS)to quantify each term used to describe a sensation,25and confirmed that the VAS was a reliable objective tool for quantitative DeQievaluation that could be easily applied.Figure 1B shows an example of a VAS.

Figure 1 Evaluation tools used to quantify DeQi

Many DeQiscales/questionnaires are currently available for use in DeQistudies,each with their own unique characteristics.Table 1 summarizes the most commonly used scales.

DISCUSSION

Potential limitations of existing De Qi Scales

Based on the present primary analyses of studies using existing DeQiscales,we consider that further improvement is needed in the following aspects.

历史上，吕、范交恶也是著名的历史事件。范仲淹的几次被贬，确实大多与吕夷简有关，富弼作为范仲淹的坚决支持者，与吕夷简的矛盾由来已久。在此剑拔弩张之时，当着仁宗之面，作为至亲，也为了维护朝廷大局，化解眼前如此紧张的局面，晏殊出面打圆场，表示吕夷简不是有意，恐怕真是失误。对此，富弼情急之下，竟然说出“殊奸邪，党夷简以欺陛下”。面临国家大事之成败甚至涉及个人的生死，富弼情急之下口出此极端之言，虽然情有可原，但对于晏殊，如此无礼的指责也显然不公。

Quantitative evaluation of De Qi focused on needling sensations experienced by the patient

In traditional acupuncture theory,DeQiwas characterized by not only the needling sensations experienced by the patient,but also by the sensations perceived by the hand of the acupuncturist.As some people are notsensitive to the sensations induced by needling,the evaluation of the intensity of the patient's DeQimust rel on the experience and perception of the acupuncturist. Therefore,the quantitative evaluation of DeQishould integrate the sensations experienced by the patient with the perception of the acupuncturist.However,current studies involving the detection of DeQionly include quantitative evaluation of the needling sensations experienced by the patient,without considering the perception of the acupuncturist.

Table 1 Existing De Qi scales currently in commonuse

N naoirtee;s:GA-SSSN:SaQcu:pGuenrcmtuarne v seenrssiaotnio onf stchaele S;NSASQSS.:subjective ASS;MASS:MassachusettsGeneral HospitalASS;C-MMASS:modifiedMASS-Chineseversion;SNSQ:Southamptonneedlingsensation question-

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Emphasis on the quantitative evaluation of De Qi while ignoring the qualitative evaluation

Most existing scales have focused on the quantitative evaluation of needling sensations,and enable clinicians to calculate scores that indicate the intensity of each type of needling sensation and the intensity of the overall sensation.In contrast,few studies have focused on the qualitative evaluation of DeQi.Only including a graded score of some sensation considered to be part of DeQiseems inconsistent with the connotation of DeQiin Traditional Chinese Medicine theory.Therefore,qualitative determination of DeQiseems very important,and this aspect should be involved in subsequent studies.

Limitation of the methods used to select terms that describe De Qi sensations

After a pool of terms was established in the existing DeQiscales,two methods for selecting these terms were generally adopted:(a)viae-mail questionnaires and consultations with acupuncturists;(b)by recruiting healthy subjects in an experiment model and then recording the needling sensations reported by these subjects.The needling sensations determined merely by the experience of the acupuncturist might be influenced by the acupuncture education that they have received and their conceptions,and so an investigation should be performed to identify the real sensations felt by the patient.The experimental model is separated from actuality and objectivity,and is limited to healthy subjects only,thereby lacking reports of some types of needling sensations.Therefore,comprehensive consideration of the screening methods used to select terms is recommended in future development of DeQiscales to guarantee that the sample is true and comprehensive.

Separation of sharp pain from De Qi

As acupuncture is an invasive intervention,it is usually accompanied by pain to a certain degree,mainly including the pain experienced when the needle penetrates the skin,and the dull or sharp pain provoked by needling into deep tissue and stimulating deep pain receptors.DeQiis a human response to the variation in theQiinduced by the insertion of a needle into the acupoint,and the activating effect upon functional brain areas when DeQiis accompanied by sharp pain is significantly different to the effect of DeQialone.20Therefore,penetrating pain,sharp pain,and dull pain should be separated when designing a DeQiscale;furthermore,penetrating pain or sharp pain should not be misinterpreted as DeQi.

定义 1.1[11-12] 设L是有界格。二元算子L2→L满足交换律、结合律、对每个变量都不减,且∀L, 1⊗x=x,则⊗被称为L上的一个t-模。

㉓即Jan Becan (Jan van Gorp),Hieroglyphica Ioannis Goropii Becani,Antwerpen,Christopher Plantijn,1580.

Incorporation of other characteristics of De Qi

Based on the present analysis and summary of the existing DeQiscales/questionnaires,we offer the following suggestions to improve the quantification of DeQiusing scales:(a)add a scale to evaluate the sensations perceived by the acupuncturist,which is more in accordance with Traditional Chinese Medicine theory;(b)consider distinguishing penetrating pain from the pain of needling sensations induced by needling the muscle layer;(c)use methods more suitable to classical acupuncture theory to appraise the total needling manifestation;(d)consider the effects of psychological factors of individual patients on DeQi.

云南水电资源优势突出，全省水电资源蕴藏量达1.04亿千瓦，已开发装机突破6200万千瓦，居全国第2位。全省电力装机总容量目前已突破9000万千瓦，以水电为主的清洁能源装机占全省发电装机比例达到82%，远高于全国平均水平的29%，清洁能源发电量占比93.6%，达国际一流水平。

[3] 吴拥政,何 杰,司林坡,等.义马矿区深部矿井地应力分布规律研究[J].煤炭科学技术,2018,46(10):16-21.

Efficacy of De Qi Scales in other languages

Until now,no study has aimed to evaluate DeQiscales,and most of the tools used to evaluate DeQiin China were those translated from English versions,without corrections between languages or testing of reliability and validity.Some researchers believe that the efficacy of evaluation tools might be influenced by differences between cultural backgrounds or languages.24Chinese researchers have suggested that it remains to be confirmed whether a translated scale could reflect accurately the DeQiperceived by Chinese patients.27Therefore,some researchers(either Chinese or abroad)have tested the reliability and validity of some translated versions of available DeQiscales.Currently,the most influential scale used to evaluate DeQiis the English version of the MASS.The Chinese version of the MASS has been tested for reliability and validity,with results showing that the modified MASS-Chinese version could effectively and credibly evaluate De Qi in young healthy Chinese subjects.14This was the first translation of an English version of a DeQiscale to be tested for reliability and validity,providing a tool for Chinese researchers.However,the verification test only used a small sample of 30 subjects,14which did not satisfy the least sample required by a verification test;hence,the reliability of the results is decreased.Therefore,the compilation and verification of a multi-language scale for DeQiare still to be completed.

Suggestions for developing the scales used to evaluate De Qi

Existing DeQiscales have focused on recording and appraising types of DeQisensations,while ignoring some important features of DeQisuch as the propagation of the sensation along the channel.To thoroughly evaluate DeQi,other features of DeQibesides intensity should also be included in the evaluation scale.

REFERENCES

1 Wang B.Huang Di Nei Jing.Beijing,China:TCM ancient Books Press,2003:49.

2 Shi XM,Science of acupuncture and moxibustion.Beijing:China Traditional Chinese Medicine Publishing House,2010:147.

（二）准确把握任务中的知识宽度。数学教师需在探究任务当中对教材知识进行体现，并且为对初中生的知识面进行拓展，对其数学思维进行发散，数学教师还需在探究任务当中融入课外知识，以此来对初中生总体学习需求加以满足，促使其学习质量进行提高。比如，探究“把三角形面积进行四等分”的若干方法之时，假设按照类分能够分为两种，首先进行二等分，之后在进行一次二等分，或者直接进行四等分。此时数学教师可引导初中生进行探究，寻找一种最佳解决方法，之后发散学生思维，让其根据三角形的等分经验来对矩形面积的四等分的方法加以探究，这样能够对学生的知识面加以有效拓展。

3 Park JE,Ryu YH,Liu Y,et al.A literature review of De Qi in clinical studies.Acupunct Med 2013;31(2):132-142.

4 Witt C,Brinkhaus B,Jena S,et al.Acupuncture in patients with osteoarthritis of the knee:a randomised trial.Lancet 2005;366(9480):136-143.

9 Xiong J,Liu F,Zhang MM et al.De-Qi,not psychological factors,determines the therapeutic efficacy of acupuncture treatment for primary dysmenorrhea.Chin J Integr Med 2012,18(1):7-15.

6 Vas J,Perea-Milla E,Méndez C,et al.Efficacy and safety of acupuncture for chronic uncomplicated neck pain:a randomised controlled study.Pain2006;126(1-3):245-255.

7 Huang XQ.Preliminary observation of DeQiphenomenon and the relationship between DeQiand the efficacy of acupuncture.Zhong Guo Zhen Jiu 1999,19(1):19-21.

首先，要考虑评价主客体的有效覆盖面，评价主客体应涵盖学生、教师、学校教学评估部门、社会企业、教育行政部门、第三方评估等多个领域。其次，要构建多元协商的课程教学质量监测与评价体系评价方法。第四代评估理论认为：评价的过程是评价主客体在原有不同的价值立场上不断交换意见和共同构建同一观点的过程。构建评价主客体和第三方评估多元协商的评价方法能有效提升监测与评价体系的实效性。

The earliest study to use a DeQiscale/questionnaire was published in the late 1980s.Vincentet al18invited 10 acupuncturists to select terms from the McGill Pain Questionnaire that they thought were suitable for describing the needling sensation of DeQi,and a final total 20 terms were selected and incorporated into the DeQiscale.Through component analysis,these 20 needling sensations were divided into seven categories.

5 Takeda W,Wessel J.Acupuncture for the treatment of pain of osteoarthritic knees.Arthritis Care Res 1994;7(3):118-122.

10 White P,Prescott P,Lewith G.Does needling sensation(DeQi)affect treatment outcome in pain?Analysis of data from a larger single-blind,randomised controlled trial.Acupunct Med 2010,28(3):120-125.

11 Enblom A,Johnsson A,Hammar M,et al.Acupuncture compared with placebo acupuncture in radiotherapy-induced nausea—a randomized controlled study.Ann Oncol 2012,23(5):1353-1361.

12 Chen Q,Zhang QX,Jiang LY,et al.Effectiveness of strengthened stimulation during acupuncture for the treatment of allergic rhinitis:study protocol for a randomized controlled trial.Trials 2014;15:301.

13 Xie H,Li XR,Lai JQ,Zhou YN,Wang CY,Liang J.Effectiveness of DeQiduring acupuncture for the treatment of tinnitus:study protocol for a randomized controlled trial.Trials 2014;15:397.

14 Hu NJ,Lin C,Zhu J,et al.Remarks on the relationship between DeQiand effect of acupuncture.Zhong Guo Zhen Jiu 2013;34(4):413-441.

15 Yu DTW,Jones AYM,Pang MYC.Development and validation of the Chinese version of the massachusetts general hospital acupuncture sensation scale:an exploratory and methodological study.Acupunct Med 2012;30(3):214-221.

16 Wu WF,Liang HZ,Yuan ZC.Treating primary HBP by acupuncture.Zhong Yi Lin Chuang Za Zhi 2013;5(10):50-54.

17 Yi GQ.DeQiand its effect factors.Guangxi Zhong Yi Xue Yuan Xue Bao 2003;6(3):3-5.

18 Vincent CA,Richardson PH,Black JJ,Pither CE.The significance of needle placement site in acupuncture.J Psychosom Res 1989;33(4):489-496.

19 Park J,White A,Stevinson C,Ernst E,James M.Validating a new nonpenetrating sham acupuncture device:two randomised controlled trials.Acupunct Med 2002;20(4):168-174.

有49名（13.57%）学生认为医学统计学对于今后学习及工作帮助很大，245名（67.87%）学生认为有一定帮助，67名（18.56%）学生认为学习医学统计学对今后工作、学习没有帮助或不清楚有无帮助。

电力电缆系统本身有重要的作用，在整个技术应用阶段，需要了解实际类型，凸显出技术模式的优势，实现创新应用。以下对类型分析：

20 Hui KK,LiuJ,MarinaO,et al.The integrated response of the human cerebro-cerebellar and limbic systems to acupuncture stimulation at ST 36 as evidenced by fMRI.Neuroimage 2005;27(3):479-496.

（一）预防措施 仔猪副伤寒的预防，应特别注意初春时节温度变化不定，做好仔猪圈舍的保暖，中午仔猪可适当晒太阳；圈舍保持清洁干燥，食槽要经常洗刷，粪便发酵处理。加强饲养管理，初生仔猪应争取早吃初乳，并提前补料，以防乱吃脏物，断奶分群时，不要突然改变环境，猪群尽量分小一些。仔猪断奶前后（建议28日龄），口服仔猪副伤寒弱毒冻干苗进行预防。较大规模养猪场发病后，应将病猪隔离治疗，猪舍彻底消毒。未发病的猪可用药物预防，在每吨饲料中加入金霉素100 g或氟苯尼考（50～100 ppm），可起较好的预防作用。

21 MacPherson H,Asghar A.Acupuncture needle sensations associated withDeQi:a classification based on experts'ratings.J Altern Complement Med 2006;12(7):633-637.

22 White P,Bishop F,Hardy H,et al.Southampton needle sensation questionnaire:development and validation of a measure to gauge acupuncture needle sensation.J Altern Complement Med 2008;12(7):373-379.

23 Kong J,Gollub R,Huang T,et al.Acupuncture DeQi,from qualitative history to quantitative measurement.J Altern Complement Med 2007;13(10):1059-1070.

24 Pach D,Hohmann C,Ludtke R,Zimmermann-Viehoff F,Witt CM,Thiele C.German translation of the southampton needle sensation questionnaire:use in an experimental acupuncture study.Forsch Komplementmed 2011;18(6):321-326.

25 Kou W,Gareus I,Bell JD,et al.Quantification of DeQisensation by visual analog scales in healthy humans after immune stimulating acupuncture treatment.Am J Chin Med 2007;35(5):753-765.

26 Lin C,Yuan HW,Zhang P,et al.Review of studies on DeQiof acupuncture mainly in foreign countries.Zhen Ci Yan Jiu 2013;38(2):168-173.