2.2.6 Correlations between course attendance and post-test results

In this program, the trainees were free to participate in the classes according to their individual schedules. Due to the fact that the working hours and locations of the hospital residents might change, some trainees were unable to attend the entire course. The attendance rate and frequency of practice using the ultrasound instrument are presented in Table 5. When a trainee was not able to attend a class, video recordings and slides were provided for self-learning. Of the original 17 trainees recruited to this study, one withdrew; therefore, the data of 16 trainees were included for analysis.


#### Table 3.

S-CVI values obtained from the five experts as raters in this study.


#### Table 4.

Comparison of pre- and post-test scores by the Mann-Whitney U test (two-tailed).

Nine trainees attended the "Introduction and operation of ASM21" class (attendance rate = 56%); 12 trainees attended the "Advanced clinical application of GB21" class, but one left early (attendance rate = 69%); 12 participated in the "Patient safety and safe needle depth" class (attendance rate = 75%); and 15 participated in the "Principles and application of ultrasonography" class, but one left early (attendance rate = 88%). The average attendance rate was 75 0.25%. The total number of trainees who practiced using the ultrasound instrument was 12, accounting for 75% of the total number of participants (Table 5).

pneumothorax post-test. Finally, no significant relationship was found between

According to the second item (ultrasound skills) on the DOPS scale (score range = 1–6), the post-test score distribution of the trainees was 3–5. Three trainees had a score of 3 (2 had practiced using the instrument, 1 had not); 12 trainees had a score of 4 (9 had practiced, 3 had not), and one had a score of 5 (who had practiced). Fisher's exact test showed that practice using the ultrasound instrument was not correlated with improvement of ultrasound skills. In the post-test, the depth measurements at acupoint GB21 obtained by seven trainees were 3.0, 3.0, 3.2, 3.3, 3.5, 3.8 and 5.0 cm; the average depth was 3.5 0.7 cm, which was very close to the actual depth of 3.5 cm. The depth measurement of 5.0 cm was much larger than the

General 107010818010 I used to utilize oblique insertion and avoid dangerous

ethics

medicine

107040918001 107040918012

acupuncture points. Now, I am glad that ultrasound can assist practitioners in precisely placing acupuncture needles, and reduce the fear of performing acupuncture at difficult points. In order to make this course more meaningful, I suggest having a

ASM21 allows us the opportunity to practice very well at GB21. As GB21 is not often used clinically, performance in reality is rarely seen. I am looking forward to practicing at this point. Patient safety has always been an important principle in medical

timing of using GB21, and learn how pneumothorax

Training helped us to understand that a needle at the acupuncture point GB21 will reach the pleura at a certain depth (about 2–3 cm), and insertion of the needle to a deeper position will penetrate the lung. Studies from Western medicine also showed that even anesthesia cannot block the pain at this point

depth, and learned about pneumothorax complications caused by acupuncture from cases of evidence-based

Learning of personal experience from the lecturer about acupuncture-caused pneumothorax was impressed. This highlighted that the needle depth is critical during acupoint selection in clinical practice

Following hands-on operation, the trainees gave positive feedback on the use of ultrasound to detect the

The ultrasound device is simple and easy to use, and effectively prevents pneumothorax. It was a novel experience to use ultrasound, especially its application

qualifying examination after the course

107010918005 Trainees were curious about using the ASM21 model to

107020618004 Trainees had the opportunity to further understand the

107030818012 Trainees improved their knowledge of the safe needle

safe needle depth for acupuncture

in acupuncture in the clinical setting

can occur and its management

practice acupuncture

Correlation between practice using the ultrasound instrument and improvement

practice using the ultrasound machine and puncture of the lung.

Ultrasound Detection Acupuncture Needling Training: Description of the Method

Class Case numbers Interview key content

of ultrasound skills.

DOI: http://dx.doi.org/10.5772/intechopen.82802

Class 1: introduction and operation of ASM21

Class 2: advanced clinical application of the GB21

Class 3: patient safety and safe acupuncture needle

Class 4: principles and application of ultrasonography

Interview records from trainees.

acupoint

depth

Table 6.

57

There was no incidence of puncture of the lung during use of the ASM21 model. To test whether attendance at the course was correlated with post-test performance, Fisher's exact test was performed, and showed that P = 1.0, indicating that class attendance had no significant association with the incidence of lung puncture. Additionally, analysis of the relationship between attendance at Class 4 ("Principles and application of ultrasonography") and the incidence of lung puncture also demonstrated that no correlation existed (P = 1.0). Further analysis indicated that acquisition of a good ultrasound technique reduced the incidence of lung puncture (P < 0.05), suggesting that acquisition of ultrasound skills helped to prevent

#### Figure 4.

Course satisfaction survey.


#### Table 5.

Correlation analyses of trainee course attendance with post-test results.

Ultrasound Detection Acupuncture Needling Training: Description of the Method DOI: http://dx.doi.org/10.5772/intechopen.82802

pneumothorax post-test. Finally, no significant relationship was found between practice using the ultrasound machine and puncture of the lung.

Correlation between practice using the ultrasound instrument and improvement of ultrasound skills.

According to the second item (ultrasound skills) on the DOPS scale (score range = 1–6), the post-test score distribution of the trainees was 3–5. Three trainees had a score of 3 (2 had practiced using the instrument, 1 had not); 12 trainees had a score of 4 (9 had practiced, 3 had not), and one had a score of 5 (who had practiced). Fisher's exact test showed that practice using the ultrasound instrument was not correlated with improvement of ultrasound skills. In the post-test, the depth measurements at acupoint GB21 obtained by seven trainees were 3.0, 3.0, 3.2, 3.3, 3.5, 3.8 and 5.0 cm; the average depth was 3.5 0.7 cm, which was very close to the actual depth of 3.5 cm. The depth measurement of 5.0 cm was much larger than the


Table 6. Interview records from trainees.

Nine trainees attended the "Introduction and operation of ASM21" class (attendance rate = 56%); 12 trainees attended the "Advanced clinical application of GB21" class, but one left early (attendance rate = 69%); 12 participated in the "Patient safety and safe needle depth" class (attendance rate = 75%); and 15 participated in the "Principles and application of ultrasonography" class, but one left early (attendance rate = 88%). The average attendance rate was 75 0.25%. The total number of trainees who practiced using the ultrasound instrument was 12,

There was no incidence of puncture of the lung during use of the ASM21 model. To test whether attendance at the course was correlated with post-test performance, Fisher's exact test was performed, and showed that P = 1.0, indicating that class attendance had no significant association with the incidence of lung puncture. Additionally, analysis of the relationship between attendance at Class 4 ("Principles and application of ultrasonography") and the incidence of lung puncture also demonstrated that no correlation existed (P = 1.0). Further analysis indicated that acquisition of a good ultrasound technique reduced the incidence of lung puncture (P < 0.05), suggesting that acquisition of ultrasound skills helped to prevent

Item P-value Attending all classes vs. performance 1 Attending ultrasound class vs. lung puncture 1 Acquisition of ultrasound skills vs. lung puncture 1.6121e<sup>05</sup>\*\*\* Practice using ultrasound instrument vs. lung puncture 1

accounting for 75% of the total number of participants (Table 5).

Acupuncture - Resolving Old Controversies and Pointing New Pathways

Figure 4.

Table 5.

56

Course satisfaction survey.

Fisher's exact test ( \*\*\*P < 0.001).

Correlation analyses of trainee course attendance with post-test results.

other measurements, and the trainee who made this measurement had not practiced using the ultrasound instrument and had a poor ultrasound skills score. If this outlier value was removed, the average depth was 3.3 0.3 cm.

them to clearly identify the position of the lungs, it improved their confidence in performing acupuncture at the GB21 point. Most of the trainees who attended the course expressed that if the hospital could provide an ultrasound instrument at their out-patient clinic, they would be willing to apply the UDA knowledge they had

Ultrasound Detection Acupuncture Needling Training: Description of the Method

Currently, the largest barrier to Chinese medicine practitioners or acupuncturists using ultrasound is the high cost of the instrument. Even an entry-level new machine will cost more than \$10,000 USD. At this moment, with the exception of large hospitals or medical centers, most small clinics are not able to afford to install this instrument at their practice locations. To solve this problem and enable UDA to be widely-used, the purchase of used ultrasound instruments is an option. Alternatively, the development of a low-cost, small-sized simple ultrasound instrument without an imaging function (such as the Butterfly IQ [17], which can easily detect

Education in traditional Chinese medicine is still relatively conservative in comparison with modern medical education. Although acupuncture is considered a less invasive therapy, it does require thousands of hours of training to gain the proper skills. However, education in acupuncture still very rarely uses modern teaching aids to assist learning, and especially rarely uses simulation-based learning. These issues are in urgent need of improvement. This study utilized an innovative method that integrated a simulator that mimicked the chest body part and modern ultrasound technology to help trainees to learn how to safely perform acupuncture at the GB21 point. The UDA approach allows greater application of the traditional acupuncture points in therapy, as many of the difficult points are known to be very important, but it is difficult to master the necessary skills. We used UDA in acupuncture education, emphasizing patient safety, which differed from traditional acupuncture education, which mainly focuses on classroom teaching and observational learning [18, 19]. The outcomes of this study indicated that new teaching methods are required for education in acupuncture, as the conventional education system for acupuncture is known to have many problems and needs to be improved

The introduction of a body part model in acupuncture education is very useful for the learner. Body parts or organ sets have been created, and others have developed a 3-D interactive virtual environment, phantoms or integrated platforms to assist learners in acupuncture training [22–25]. However, such types of models or virtual training simulation systems still cannot provide sensations similar to those felt when practicing on the human body. We developed the ASM21 model using material that could be punctured by stainless steel acupuncture needles and that was penetrable by ultrasound. Integrating this material with a sensor detector and a light alarm, the goal was to allow the learners to practice on an object similar to a patient in clinic, and to measure the needle depth by ultrasound. Using a highquality simulator with a realistic chest model, learners are able to perform sufficient practice before applying UDA in actual patients. Rehabilitation medicine has attempted to incorporate acupuncture as one of its therapy techniques, and has integrated acupuncture with the ultrasound technique [26]. However, that application mainly focuses on soft tissue-related diseases, such as muscle and tendon disorders. Neither patient safety nor the theory of the Meridians has been paid attention to. From a different aspect, in the present study, we used the theory of traditional Chinese medicine and considered patient safety to promote acupuncture

Although Chinese medicine has a long history, its modernization has followed a

difficult path. In the development of the UDA training course, we had a great

learned from the course in patient practice.

DOI: http://dx.doi.org/10.5772/intechopen.82802

the needle depth), should be considered.

[20, 21].

modernization.

59

The average duration of operation of the ultrasound instrument by the trainees was 87 42 s (ranging from 45 s to 2 min and 9 s).

#### 2.2.7 Post-test interview

After attending the course, the trainees expressed that it helped them to reduce their fear of performing acupuncture at the GB21 point, and practice using the ASM21 model helped to improve their self-confidence. Some positive feedback received is presented below:

With the assistance of ultrasound, the depth of the GB21 point can be easily identified. It helps to choose the correct length of needle. By using a proper needle, it prevents causing the problem of puncturing the lung (10704201801001) (Table 6).

During the pre-test, I did not know what I was doing as I was full of fear. I never perform acupuncture at the GB21 point, and was therefore very nervous. During the post-test, I felt it was quite an interesting task, as I am more self-confident and can perform it immediately without delay (10704201800901).

When I perform acupuncture at points in the chest, I will double-check by using ultrasound, especially if the patient is elderly, a young woman or a child (10704201801703).

I wish that ultrasound could be more popularized. I will use it in the clinic, especially at those acupuncture points with a high risk of causing an accident. For the common points, I will not use it as it takes time to use it (10704201800203).

#### 2.3 Discussion

UDA is an innovative acupuncture technique. It employs modern ultrasound technology to inject new vitality into this ancient medical system. UDA may reduce the risk of complications at difficult acupoints, such as pneumothorax. It can improve patient safety, and render acupuncture at several important but difficult and less-used acupoints (e.g., Gaohuangshu BL-43, and Back-Shu points) more easily performed by acupuncture practitioners. This will help the advantages of traditional acupuncture to be restored and preserved.

In this study, we developed a program that employed ultrasound technology during training in the use of difficult acupuncture points. In the course described in this study, the focus was the Jianjing point GB21. The course included four 2-h classes: "Introduction and operation of ASM21", "Advanced clinical application of GB21", "Patient safety and safe needle depth", and "Principles and application of ultrasonography". The design of the course aimed not just to teach trainees to operate the ultrasound instrument and the ASM21 model, but also to educate them about patient safety and the safe needle depth at the GB21 acupoint.

According to the satisfaction survey completed by the trainees who undertook the course, the trainees showed high interest in two of the classes in particular: "Advanced clinical application of GB21" and "Principles and application of ultrasonography". This might be due to these two classes being directly correlated with clinical application, while the other two classes were related to simulation education and medical quality, which hospital residents are often less interested in. In the post-test interviews, most of the trainees were positive about integrating the ultrasound technique into the teaching of acupuncture. As ultrasound imaging helps

#### Ultrasound Detection Acupuncture Needling Training: Description of the Method DOI: http://dx.doi.org/10.5772/intechopen.82802

them to clearly identify the position of the lungs, it improved their confidence in performing acupuncture at the GB21 point. Most of the trainees who attended the course expressed that if the hospital could provide an ultrasound instrument at their out-patient clinic, they would be willing to apply the UDA knowledge they had learned from the course in patient practice.

Currently, the largest barrier to Chinese medicine practitioners or acupuncturists using ultrasound is the high cost of the instrument. Even an entry-level new machine will cost more than \$10,000 USD. At this moment, with the exception of large hospitals or medical centers, most small clinics are not able to afford to install this instrument at their practice locations. To solve this problem and enable UDA to be widely-used, the purchase of used ultrasound instruments is an option. Alternatively, the development of a low-cost, small-sized simple ultrasound instrument without an imaging function (such as the Butterfly IQ [17], which can easily detect the needle depth), should be considered.

Education in traditional Chinese medicine is still relatively conservative in comparison with modern medical education. Although acupuncture is considered a less invasive therapy, it does require thousands of hours of training to gain the proper skills. However, education in acupuncture still very rarely uses modern teaching aids to assist learning, and especially rarely uses simulation-based learning. These issues are in urgent need of improvement. This study utilized an innovative method that integrated a simulator that mimicked the chest body part and modern ultrasound technology to help trainees to learn how to safely perform acupuncture at the GB21 point. The UDA approach allows greater application of the traditional acupuncture points in therapy, as many of the difficult points are known to be very important, but it is difficult to master the necessary skills. We used UDA in acupuncture education, emphasizing patient safety, which differed from traditional acupuncture education, which mainly focuses on classroom teaching and observational learning [18, 19]. The outcomes of this study indicated that new teaching methods are required for education in acupuncture, as the conventional education system for acupuncture is known to have many problems and needs to be improved [20, 21].

The introduction of a body part model in acupuncture education is very useful for the learner. Body parts or organ sets have been created, and others have developed a 3-D interactive virtual environment, phantoms or integrated platforms to assist learners in acupuncture training [22–25]. However, such types of models or virtual training simulation systems still cannot provide sensations similar to those felt when practicing on the human body. We developed the ASM21 model using material that could be punctured by stainless steel acupuncture needles and that was penetrable by ultrasound. Integrating this material with a sensor detector and a light alarm, the goal was to allow the learners to practice on an object similar to a patient in clinic, and to measure the needle depth by ultrasound. Using a highquality simulator with a realistic chest model, learners are able to perform sufficient practice before applying UDA in actual patients. Rehabilitation medicine has attempted to incorporate acupuncture as one of its therapy techniques, and has integrated acupuncture with the ultrasound technique [26]. However, that application mainly focuses on soft tissue-related diseases, such as muscle and tendon disorders. Neither patient safety nor the theory of the Meridians has been paid attention to. From a different aspect, in the present study, we used the theory of traditional Chinese medicine and considered patient safety to promote acupuncture modernization.

Although Chinese medicine has a long history, its modernization has followed a difficult path. In the development of the UDA training course, we had a great

other measurements, and the trainee who made this measurement had not practiced using the ultrasound instrument and had a poor ultrasound skills score. If this

The average duration of operation of the ultrasound instrument by the trainees

After attending the course, the trainees expressed that it helped them to reduce

their fear of performing acupuncture at the GB21 point, and practice using the ASM21 model helped to improve their self-confidence. Some positive feedback

it prevents causing the problem of puncturing the lung (10704201801001)

ultrasound, especially if the patient is elderly, a young woman or a child

can perform it immediately without delay (10704201800901).

traditional acupuncture to be restored and preserved.

With the assistance of ultrasound, the depth of the GB21 point can be easily identified. It helps to choose the correct length of needle. By using a proper needle,

During the pre-test, I did not know what I was doing as I was full of fear. I never perform acupuncture at the GB21 point, and was therefore very nervous. During the post-test, I felt it was quite an interesting task, as I am more self-confident and

When I perform acupuncture at points in the chest, I will double-check by using

I wish that ultrasound could be more popularized. I will use it in the clinic, especially at those acupuncture points with a high risk of causing an accident. For the common points, I will not use it as it takes time to use it (10704201800203).

UDA is an innovative acupuncture technique. It employs modern ultrasound technology to inject new vitality into this ancient medical system. UDA may reduce the risk of complications at difficult acupoints, such as pneumothorax. It can improve patient safety, and render acupuncture at several important but difficult and less-used acupoints (e.g., Gaohuangshu BL-43, and Back-Shu points) more easily performed by acupuncture practitioners. This will help the advantages of

In this study, we developed a program that employed ultrasound technology during training in the use of difficult acupuncture points. In the course described in this study, the focus was the Jianjing point GB21. The course included four 2-h classes: "Introduction and operation of ASM21", "Advanced clinical application of GB21", "Patient safety and safe needle depth", and "Principles and application of ultrasonography". The design of the course aimed not just to teach trainees to operate the ultrasound instrument and the ASM21 model, but also to educate them

According to the satisfaction survey completed by the trainees who undertook the course, the trainees showed high interest in two of the classes in particular: "Advanced clinical application of GB21" and "Principles and application of ultrasonography". This might be due to these two classes being directly correlated with clinical application, while the other two classes were related to simulation education and medical quality, which hospital residents are often less interested in. In the post-test interviews, most of the trainees were positive about integrating the ultrasound technique into the teaching of acupuncture. As ultrasound imaging helps

about patient safety and the safe needle depth at the GB21 acupoint.

outlier value was removed, the average depth was 3.3 0.3 cm.

Acupuncture - Resolving Old Controversies and Pointing New Pathways

was 87 42 s (ranging from 45 s to 2 min and 9 s).

2.2.7 Post-test interview

(Table 6).

(10704201801703).

2.3 Discussion

58

received is presented below:

appreciation of the obstacles faced. Modern medicine is closely integrated with modern science; modern medicine keeps pace with the development of sciencebased technology, and new technology is used to develop new products and treatments to improve patient care. However, the majority of Chinese medicine practitioners do not pay attention to new technology. Many researchers have continued to work hard to improve this dilemma [27–29], while more Chinese medicine peers are still needed to join in the modernization. The ASM21 model developed in this study can be further improved to incorporate ultrasound techniques by collaborating with medical engineering manufacturers, which might create a new path for the development of technology for use in the application of Chinese medicine.

3.2 Future work

Acknowledgements

Conflict of interest

Author details

61

Ying-Ling Chen<sup>1</sup> and Mark C. Hou<sup>2</sup>

1 China Medical University, Taichung, Taiwan

provided the original work is properly cited.

2 Changhua Christian Hospital, Changhua, Taiwan

\*Address all correspondence to: dr.markhou@gmail.com

Hospital (no: 106-CCH-MST-133).

fresh acupuncture can be presented to the world.

DOI: http://dx.doi.org/10.5772/intechopen.82802

There is no financial relationship to disclose.

In order to prompt UDA further, a specific and affordable ultrasound devise is urgent needed. All the ultrasound devises available are too complicated and expensive for acupuncturists. We are currently in cooperation with medical engineers to develop a UDA special ultrasound. This ultrasound devise for safety depth (USD) will be a handy and useful devise specially designed to measure the safe needling distance of dangerous points. We believe that only by introducing and developing new ideas and practices can renew and update acupuncture. Thus an energetic and a

Ultrasound Detection Acupuncture Needling Training: Description of the Method

We like to thank Dr. Su-ChingLin, Dr. Jian-GuoBau, Dr. Bo-Shiu Chen, Dr.Yuen-Chun Lo, and Dr. Mao Sheng Sun for their help and inspirations. We also want to thank Miss Davy Kuo, Ariel Yu, and Sherry Ho. This study was funded by Ministry of Technology (no: MOST 106-2511-S-371-001) and Changhua Christian

\*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

The outcomes of our study show promise. However, there were some limitations. First, this study was an educational study conducted in a single group, i.e., hospital residents, and was not a randomized controlled trial. The small sample size was also a limitation.

However, by using qualitative and quantitative analyses to validate the efficacy, the results are still valuable, and can be taken as a useful reference for developing similar courses. The significant improvement in score after the trainees had attended the course indicated a well-designed course, which can help to reduce the risk of pneumothorax, a complication of acupuncture at difficult chest acupoints. Both the attendance rate and practice of the ultrasound technique were independent of the reduction in the incidence of pneumothorax, suggesting that the use of ultrasound is key to reducing the incidence of this complication. As the operation of the ultrasound instrument is simple, no special repeat practice is required, which is a significant advantage of UDA that should be promoted in the future. The trainees only need to learn to measure the safe depth of the needle, rather than being familiar with diagnostic sonography. Based on the outcomes and the feedback obtained from the trainees, the course could be shortened by focusing on the operation of the ultrasound instrument and practice using the simulator. In terms of satisfaction, the post-test interviews demonstrated that the trainees gave the highest ratings for the course, indicating that the course design was successful.

In conclusion, a course design for acupuncture training needs to include practice using a simulator, which can greatly enhance the interest and motivation of the trainees. In the interviews, several trainees suggested that acupuncture clinical instructors should receive UDA training, which showed that they were not satisfied with the conventional educational approach. Some trainees also had different opinions to those of the lecturers for the classes, suggesting that the new generation no longer fully accepts the arrangements of traditional education. In order to achieve the goal of a high level of education, it is necessary to implement more communication between teachers and students in the current medical education setting.

### 3. Conclusion

#### 3.1 UDA

UDA, by introducing ultrasound into acupuncture practice, will be a revolution technique for traditional acupuncture. UDA can not only reduce the risk of severe advertise effect when needing dangerous points, but also increase the usage of some important points traditionally, such as GB21 and BL43. We proposed the standard operating procedure for UDA and developed a course for UDA training. A video demonstration could be found at the web www.Dr-Hou.com. We truly hope that UDA would be widely accepted and performed popularly everywhere in acupuncture practice.

Ultrasound Detection Acupuncture Needling Training: Description of the Method DOI: http://dx.doi.org/10.5772/intechopen.82802
