by ZHANG XINSHU
Wrist and ankle acupuncture, often shortened to WAA, was developed in the 1970s. The method comes from China, and like ear and skull acupuncture differs from methods of treatment in TCM. WAA is a refl ex theory, based on the concept that the body is divided into six bilateral longitudinal zones (see Fig. 4.9).Needles are inserted into the wrists and ankles in the zones that correspond to the parts of the body needing treatment.
Only six acupuncture points are used on the wrist and
six more on the ankle. (In TCM there are 365 regular acupuncture points.) In WAA the needles are inserted superfi cially and pulled under the skin.
It also differs fromTCM (in which needles can be inserted deeply) in that WAA does not strive to achieve ‘de qi’ — the characteristic feeling of numbness, pricking and similar, which according to TCM should occur in acupuncture. This means that WAA treatment is neither painful nor unpleasant. WAA can be used to treat both pain and other conditions.
Points, symptoms and signs should all be located in
terms of the six regions.
For instance, for disorders in
Region 1, Point 1 is selected, and for disorders in Region
2, Point 2 is selected. The principle of 'fewer but better
points' should be followed. The following principles
should be observed in the selection of points.
i. Points are selected on the diseased side.
ii. Points at the wrist are selected for disorders in the
upper part of the body (above the transverse line
drawn from the vertex of the lower end of the sternum),
and points at the ankle are selected for disorders
in the lower part of the body (below that transverse
iii. If disorders are located on the midline, or if it is
impossible to determine on which side they are located,
select points on both sides. In the treatment of
disorders on the anterior midline, use Point 1 on both
sides, e.g. Upper 1 bilaterally for frequent cough due
to tracheitis, Lower 1 bilaterally for nocturnal enuresis
or excess leucorrhea, and Lower 6 bilaterally for
pain at the spinal processes of the lumbar vertebrae.
iv. If disorders are located on the midline, but part of the symptoms and signs are on the side, Point 1 or Point-6 on the diseased side is selected.
v. If more than one of the symptoms and signs is present
at the same time, the dominating one is taken as the
primary one. If there is pain, this is regarded as the
chief symptom. Points are selected according to the
region where the tenderness is located.
vi. In the treatment of motor impairment of the limbs,
such as paralysis and tremor, Upper 5 is selected if the
upper limbs are diseased, and Lower 4 is selected if
the lower limbs are diseased.
vii.Upper 1 is selected bilaterally for symptoms and
signs involving the entire body or those which cannot
be correctly located, such as general pruritis, urticaria,
night sweating, insomnia, and certain psychoses.
To facilitate subcutaneous needling in wrist and ankle
acupuncture, it is not advisable to use thick needles.
Stainless steel filiform needles, 3O-32 gauge, and 4 cm. in
length, are usually used. 2.5 cm. long needles are used for
2. Position of the patient
A sitting position is taken when the points at the wrist are
needled. Supine or prone position is taken when the
points at the ankle are needled. Ensure that the patient is
comfortable so that the muscles in the vicinity of needling
3. Needing direction
Needles in wrist and ankle acupuncture should be directed
towards the disordered area. This means that
needles are directed proximally if the disorder is proximal
to the wrist or ankle, and distally if the disorder is in
the hand and foot such as arthralgia of
the wrist and ankle, and frost bite at the dorsum of hand
and foot. In these latter conditions, the point should be
moved a bit proximally to prevent the tip of the needle
from hurting the joint.
4. Location of points
Generally points in wrist and ankle acupuncture have a
fixed location. The following conditions are exceptions:
i. There are visible blood vessels in the way of needling.
ii. There is pronounced pain when the tip of the needle
penetrates the skin.
iii. There is a scar, injury, or adhesion of the skin and
subcutaneous tissues at the point.
iv. When the needle is directed distally, the point is
moved a bit proximally. To maintain the correspondence
between the region and point, avoid moving the
point laterally or medially.
Clean and sterilize the skin at and nearby the point with
75% alcohol soaked cotton balls. Do not hold the body of
the needle with the fingers after the needle is sterilised.
6. Needling techniques
This includes insertion, adjustment, retention and withdrawal
of the needle.
i. Insertion of the needle:
How to hold the needle: When the right hand is used, the
handle of the needle is held by the thumb, index finger
and middle finger, with the middle part of the distal
segment of the index and middle fingers holding the
upper side of the needle, the tip of the slightly flexed
thumb holding the lower side of the needle, the ring
finger holding the lower side of the needle just below the
middle finger, and the small finger touching the skin
Penetration of the skin by the tip of the needle: To ensure the
body of the needle goes subcutaneously, the needle and
the skin should form an angle of 30°. If the angle is less
than 30°, the tip of the needle will enter the dermis, thus
causing pain to the patient. If the angle is more than 30°,
the tip of the needle will go deep to the subsarcolemmal
layer, thus affecting the therapeutic results. It is essential
to keep the body of the needle straight, and not to push
forcefully when inserting the needle. Pull the skin tight
with the thumb of the left hand to facilitate the penetration.
Rotate the handle of the needle slightly with the tip
of the right thumb, while the index and middle fingers
keep still in order to control and minimise the rotation of
the needle, facilitate penetration, and reduce pain to the
The following conditions show that the tip of the
needle has penetrated the skin and reached the subcutaneous
i. Needling resistance is reduced at the tip of the needle.
ii. Slight pain,which may occur when the tip of the
needle is penetrating the skin, disappears.
iii. The needle drops naturally to the skin surface when
let go; a skin prominence of about 0.2cm. in diameter
is seen above the tip of the needle; no resistance is felt
when the needle is pushed forward gently. If the
needle drops, but not as far as the skin surface when
the hold is released, too deep penetration is indicated.
Withdraw the needle a little until it drops
naturally to the skin surface when the hold is released.
Of all the three conditions, the last one is the
After penetration of the skin, the needle is slowly pushed
forward subcutaneously. See to it that the skin does not
move together with the needle, no folds occur on the
skin, and no resistance is felt by the pushing fingers.
There is no need to rotate the needle when it is pushed
forward. No needling sensation is required in wrist and
ankle acupuncture, so tell the patient that no sensations
of soreness, numbness, distension, heaviness, or pain
The occurrence of the needling sensation
is caused when the tip of the needle contacts the tissues
at a deep level, whilst pain is the result of hitting the
walls of the vessels. If either needling sensation or pain
do occur, the needle should be withdrawn slightly, and
then redirected more superficially. The required length
of needling is 3.8 cm. Some patients may find that their
symptoms and signs have disappeared before this required
length is reached.
Push the needle further to
reach 4 cm. if there is no improvement.
ii. Adjustment of the needle.
When the needle is in the point, and the required length
of needling is reached, ask the patient whether the
symptoms and signs have improved. Try to resolve the
symptoms completely after one treatment, especially in
cases of pain. It usually takes longer to restore motor
function. Poor results are often caused by the following
improper needling techniques which necessitate adjustment
of the needle:
i. Needling is not shallow enough. This is quite common,
because the proximal part is thicker than the
distal part of the wrist and ankle, and the tip of the
needle is likely to go deep to the sarcolemma, muscular
layer, and superficial nerves, producing distension
and pain in the local area. A numb sensation may
occur at the previously painful area, or the pain may
move to nearby areas. Adjust the needle by withdrawing
it to the layer just beneath the skin, and then
redirecting it more superficially to resolve the symptoms
ii. The needling direction is deviated. Deviation of needling
direction results from incorrect position of the
doctor and the patient. If needling is deviated from
the longitudinal axis, withdraw and redirect.
iii. The needling length is incorrect. Insufficient length
of needling will fail to partially or completely relieve
the symptoms and signs. In this case, push the needle
Over-needling may cause a numb sensation at the diseased
area or produce new symptoms such as dizziness
and palpitations. These symptoms will go away when
the needle is withdrawn a little.
The adjustment of the needle plays an important role
in achieving satisfactory results. In certain cases, some
symptoms and signs will remain unchanged until the
needle has been retained for a period of time, such as
certain kinds of pain, numbness, asthma and psychosis.
In the treatment of diseases such as sleep disturbance,
excess leucorrhea and nocturnal enuresis, the needle
does not have to be adjusted, since you cannot judge the
therapeutic results of these diseases immediately. After
the needle is adjusted properly, the handle of the needle
is fixed with adhesive plaster.
iii. Retention of the needle.
Generally, the needle is retained for half an hour. Longer
retention is needed if the pathological condition is severe,
or the duration of the disease is long. It is not
advisable to retain the needle for a very long time,
because scarring is likely to occur at the point, and this is
not good for the therapeutic results. In a very few cases,
the needle can be retained for as long as 24 hours. When
the needle is retained at the point, it is not manipulated,
and there is no need to enhance the stimulation. During
retention of the needle there may be a re-occurrence of
symptoms a few minutes after the patient moves their
limbs, resulting in the needle moving out a little. These
symptoms will disappear when the needle is pushed in
iv. Withdrawal of the needle.
The needle is withdrawn quickly with a sterilised cotton
ball pressing gently on the point. Ask the patient to stay
until you are sure no bleeding occurs. The number of
treatments depends on the pathological condition. Treat
once daily in acute cases, and once every other day in
chronic cases. Ten treatments comprise a course, and an
interval is not required between the two courses of
7. Possible accidents
i. Subcutaneous haematoma. Veins are densely accumulated
in the wrist and ankle. Large ones are visible and
therefore avoidable in thin patients. They may be damaged,
however, causing subcutaneous haematoma in
fatter patients. The following methods will help avoid or
reduce the possibility of causing subcutaneous haematoma:
a. Fine needles should be used. b. If the skin at
the tip of the needle swells up slowly during needling,
subcutaneous bleeding is suggested. Withdraw the needle
immediately, try to squeeze blood from the acupuncture
hole, and then press the hole to stop bleeding. If
subcutaneous haematoma does occur, tell the patient not
to worry as it will subside by itself, and will not leave any
ii. Fainting. Fainting may infrequently occur during treatment,
possibly in sensitive patients especially young
women. The chance is greater when the wrist is treated
than when the ankle is treated. Fainting may occur both
in patients who are being treated for the first time, and in
patients with previous experience of acupuncture. Symptoms
and signs suggesting fainting include dizziness,
nausea, tinnitus, blurred vision, pallor, sweating and a
cold sensation of the body, and slowed heart rate. The
needle should be withdrawn immediately. Lie the patient
flat with their collar unbuttoned and check the
blood pressure. Needling Upper 1 on both sides helps
the patient recover more quickly at the early stage of
fainting. To play safe, the patient should discontinue the
treatment. People who have experienced fainting in
general acupuncture may or may not suffer from fainting
in wrist and ankle acupuncture. Over the past twenty
years, the author has noted only 5 cases of fainting in
several thousand patients. All these five cases recovered
soon after the above management.
Therapeutic results vary from disease to disease, and
from person to person. There are five possibilities:
i. Symptoms and signs disappear immediately, or don’t
return within a short period of time after a single
treatment, e.g.some cases of common cold, sprains
ii. Symptoms and signs gradually improve and finally
disappear following a couple of successive treatments,
e.g. excessive leucorrhea.
iii. Symptoms and signs disappear soon after each treatment,
but return; they fluctuate, gradually improving
or disappearing completely over a whole course
of treatment e.g. periarthritis of the shoulder, sciatica
iv. Therapeutic results are not noticeable until several
treatments are given, e.g.nocturnal enuresis.
v. Only short-term results are achieved, and there is no
marked improvement on the whole following a considerable
number of treatments, e.g.some cases of
Frontal headache, spasm of eyelid muscles, stye,
conjunctivitis, distention and pain of the eyeball,
impaired vision, nasal obstruction, rhinitis,
trigeminal neuralgia, facial paralysis, front
toothache, thick tongue coating, lacrimation,
sore throat, tonsillitis, frequent cough, nausea,
vomiting, anorexia, motor aphasia from wind
stroke, angina pectoris, costal neuralgia.
Disorders which cannot be correctly located:
hypertension, numbness of the skin on one or
both sides, systemic pruritus, urticaria, aversion
to cold, night sweating, certain non-organic
psychoses, post-epileptic state
Anterio-temporal headache, back toothache,
pain of the submandibular lymph nodes, chest
pain, stuffiness in the chest, distension and pain
in the breast, asthma, acroparesthesia
Pain of the superficial temporal artery, pain in
the lateral chest wall.
Parietal headache, tinnitus, impaired hearing,
temporo-mandibular arthralgia, pain of the
anterior aspect of shoulder, lateral chest pain,
pain in the elbow, arthralgia of the thumb
Dizziness, vertigo, headache, common cold,
pain in the posterior aspect of the neck, shoulder
pain, arthralgia of the shoulder, sensory disturbance
of the upper limbs, motor disturbance of
the upper limbs (paralysis, tremor), arthralgia of
the wrist, arthralgia of the fingers.
Pain in the cervical and thoracic vertebrae, pain
in the posterior aspect of the shoulder, frost bite.
Upper abdominal pain, pain around the
umbilicus, nocturnal enuresis, dysmenorrhea,
excessive leucorrhea, pain in the medial aspect
of m. gastrocnemius, muscular spasm of the leg,
pain in the heel.
Pain in the hepatic region, lateral abdominal
pain, pain of the lymph nodes in the groin, pain
at the medial aspect of the knee joint, pain at the
medial aspect of the ankle.
Pain at the medial aspect of the knee.
Meralgia paresthetica, arthralgia of the knee,
sensory disturbance of the lower limbs, motor
disturbance of the lower limbs (paralysis,
tremor), pain in the dorsum of the foot.
Syndrome of the transverse process of the third
lumbar vertebra, meralgia of the lateral aspect of
the leg, arthralgia of the ankle.
Lumbago, sciatica, pain in the anterior sole.