Abstract

Acupuncture is unique to Chinese medicine and is widely used in practice. In order to avoid the complication of pneumothorax due to needle puncture of the lungs, we developed an ultrasound detection acupuncture (UDA) approach to measure the safe needle depth to improve patient safety. This study established a UDA training program and recruited trainees in our hospital to validate the effectiveness of the program. The trainees attended an eight-hour course, and practiced their skills using an acupuncture simulator model of GB21. Pre- and post-test data were analyzed. The level of satisfaction of the trainees was assessed by interview. In total, 16 trainees completed the course. Kendall's coefficient for the program was 0.82, and the average CVI was 0.98, showing good reliability and validity. Trainees exhibited significant improvement in terms of reduction of the incidence of pneumothorax after completing the course (P < 0.05), and the trainees were satisfied with the teaching of the ultrasound skill. Feedback from interviews showed that use of ultrasound to measure the safe needle depth may improve the mastery of acupuncture point GB21 and reduce the fear of causing pneumothorax.

Keywords: acupuncture, ultrasound, medical education, patient safety

## 1. Introduction

Acupuncture is a technique that is unique to Traditional Chinese medicine for treating illness and improving health [1]. Since it was introduced to Western countries in the 1970s, acupuncture has been widely-studied using modern clinical research approaches. In 2000, a large-scale acupuncture clinical trial was conducted in Germany due to controversy over insurance reimbursements for acupuncture treatment. According to the results of the trial, acupuncture was found to be valuable for pain relief, benefiting patients with back pain, knee pain and headache. In 2002, the World Health Organization (WHO) conducted a review of the results of controlled clinical trials, and concluded that the indications for acupuncture can be classified into four groups of disorders. The first group is diseases, symptoms or conditions for which acupuncture has been proved to be an effective management technique through controlled trials. There are 28 disorders belonging to this group, including stroke, lower back pain, headache, and hypertension [2]. In recent years, more clinical trials have been performed in patients with other disorders, such as dysmenorrhea [3]. Although the scientific community does not yet

completely understand the mechanism of acupuncture, its efficacy is widelyaccepted worldwide.

As with most medical interventions, acupuncture can also cause varying degrees of side effects. In a study by White [4], the risk of adverse events occurring in association with acupuncture was found to be very low when performed by qualified practitioners. As some serious adverse events may cause life-threatening complications, it is very important to actively prevent serious side effects. Common acupuncture side effects include pain at the punctured region, ecchymosis or hematoma, lightheadedness/dizziness, and pneumothorax [4–7]. With the exception of lightheadedness/dizziness, which is more relevant to the patient's physiological condition during acupuncture, the adverse events are related to the practitioner's technique and the depths of needles at acupoints. Among the major acupuncture-related adverse events, pneumothorax is the most severe, and therefore it is crucial that acupuncture practitioners identify safe depths of insertion of acupuncture needles for individual patients. Studies by Professor Lin and colleagues have extensively investigated the safe needle depth [8–12]. In one study of 11 acupuncture points in the neck and shoulder region, they found that the mean depths for the points around the shoulder in all study subjects, regardless of BMI and gender, were as follows: GB21 = 5.6 cm, SI14 = 5.2 cm, and SI15 = 8.8 cm. Subjects with a higher BMI had greater measured depths for most points [9]. However, the researchers also pointed out that differences between individuals are present, and it is difficult to set a standard. Therefore, study has been performed using modern imaging techniques, such as tomography, nuclear magnetic resonance, and ultrasonography, to directly measure the safe needle depths at acupuncture points in patients [12]. Ultrasoundguided aspiration has been widely-used to remove extra fluid from parts of the body, such as paracentesis of ascitic fluid, thoracentesis of pleural fluid [13], insertion of small-bore chest tubes in patients on clopidogrel [14], and placement of a central venous catheter [15]. Ultrasound-aided procedures are non-invasive, and the device is easy to access and relatively simple to operate. It is therefore the most suitable technique for detecting the needle depth during acupuncture. When practitioners perform acupuncture at dangerous acupoints, ultrasound imaging can help to identify the safe needle depth and prevent damage to organs. We named this technique, which combines acupuncture with ultrasound, ultrasound detection acupuncture (UDA). Taking acupoint GB21 (Jianjing; Gallbladder 21) in the chest area as an example, ultrasound was first used to measure the distance from the skin surface at the acupoint to the pleura, and the safe needle depth at the acupoint was then defined as a distance shorter than the one measured. In this way, pneumothorax can be avoided by preventing the needle from puncturing the lung or pleural cavity, which improves the safety and quality of treatment.

the inclusion criterion being medical residents of the Department of Chinese Medicine who volunteered to participate in the training course. The participants were informed in detail about the training and completed a consent form before the start of the course. As the residents were trainees, which constitute a vulnerable group, and therefore in order to safeguard their rights, the recruitment process was publicly announced, and there was no mentor-trainee or colleague relationship between the recruiter and potential participants in order to ensure that the participants

Ultrasound Detection Acupuncture Needling Training: Description of the Method

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

After enrollment in the study, a pre-test and an interview were carried out for each participant, followed by a program of four 2-h ultrasound acupuncture training classes. After completion of the course, a post-test and another interview were

A preliminary draft of the course was designed by ultrasound clinicians, clinical acupuncturists, and medical education experts, and then reviewed by a committee comprising five Chinese medical physicians qualified to teach in traditional Chinese medicine medical institutions under the regulations implemented by The Ministry of Health and Welfare, Taiwan. Course standards and DOPS (Direct Observation

Four experts were invited to serve as lecturers for the program. After the initial course content had been established, two lecturers generated teaching slides, and a test course was taught to two students. The students were then asked to provide feedback in order to improve the course, and the review committee also gave suggestions on the revision of the teaching content, enabling completion of the first

Next, we generated a questionnaire, which was reviewed by the five members of the review committee. The questionnaire was then revised until it passed validity and reliability testing, and the teaching content was modified to obtain the final teaching materials for the program. The classes of the program were taught by four

3. Design of DOPS as the tool to assess the effectiveness of the course (Table 1).

2. Discussion of the ultrasound technique to be taught in the course.

joined the study completely of their own accord.

2.1.2.1 Design

Figure 1. Study flow chart.

draft of the course.

lecturers (Figure 2).

49

Meeting agenda for course planning:

1. Clinical experience of dangerous acupoints.

performed to assess the efficacy of the training (Figure 1).

2.1.2 Development of the ultrasound detection acupuncture program

Procedural Skills) were then established to assess trainee skills.

This study aimed to integrate the ultrasound technique into acupuncture training, and developed a course that teaches the use of ultrasound to measure the safe needle depth at difficult acupoints (e.g., GB21). We created a model of an acupoint for the course participants to practice on, and evaluated the efficacy of the training by qualitative and quantitative assessment.

#### 2. Educational efficacy of an ultrasound detection acupuncture program

#### 2.1 Materials and methods

#### 2.1.1 Participants

This study was approved by the Institutional Review Board of our hospital (IRB No.: 151211) before the study was initiated. Residents in our hospital were recruited, Ultrasound Detection Acupuncture Needling Training: Description of the Method DOI: http://dx.doi.org/10.5772/intechopen.82802

Figure 1. Study flow chart.

completely understand the mechanism of acupuncture, its efficacy is widely-

Acupuncture - Resolving Old Controversies and Pointing New Pathways

of side effects. In a study by White [4], the risk of adverse events occurring in association with acupuncture was found to be very low when performed by qualified practitioners. As some serious adverse events may cause life-threatening complications, it is very important to actively prevent serious side effects. Common acupuncture side effects include pain at the punctured region, ecchymosis or hematoma, lightheadedness/dizziness, and pneumothorax [4–7]. With the exception of

As with most medical interventions, acupuncture can also cause varying degrees

lightheadedness/dizziness, which is more relevant to the patient's physiological condition during acupuncture, the adverse events are related to the practitioner's technique and the depths of needles at acupoints. Among the major acupuncture-related adverse events, pneumothorax is the most severe, and therefore it is crucial that acupuncture practitioners identify safe depths of insertion of acupuncture needles for individual patients. Studies by Professor Lin and colleagues have extensively investigated the safe needle depth [8–12]. In one study of 11 acupuncture points in the neck and shoulder region, they found that the mean depths for the points around the shoulder in all study subjects, regardless of BMI and gender, were as follows: GB21 = 5.6 cm, SI14 = 5.2 cm, and SI15 = 8.8 cm. Subjects with a higher BMI had greater measured depths for most points [9]. However, the researchers also pointed out that differences between individuals are present, and it is difficult to set a standard. Therefore, study has been performed using modern imaging techniques, such as tomography, nuclear magnetic resonance, and ultrasonography, to directly measure the safe needle depths at acupuncture points in patients [12]. Ultrasoundguided aspiration has been widely-used to remove extra fluid from parts of the body, such as paracentesis of ascitic fluid, thoracentesis of pleural fluid [13], insertion of small-bore chest tubes in patients on clopidogrel [14], and placement of a central venous catheter [15]. Ultrasound-aided procedures are non-invasive, and the device is easy to access and relatively simple to operate. It is therefore the most suitable technique for detecting the needle depth during acupuncture. When practitioners perform acupuncture at dangerous acupoints, ultrasound imaging can help to identify the safe needle depth and prevent damage to organs. We named this technique, which combines acupuncture with ultrasound, ultrasound detection acupuncture (UDA). Taking acupoint GB21 (Jianjing; Gallbladder 21) in the chest area as an example, ultrasound was first used to measure the distance from the skin surface at the acupoint to the pleura, and the safe needle depth at the acupoint was then defined as a distance shorter than the one measured. In this way, pneumothorax can be avoided by preventing the needle from puncturing the lung or pleural cavity, which

This study aimed to integrate the ultrasound technique into acupuncture training, and developed a course that teaches the use of ultrasound to measure the safe needle depth at difficult acupoints (e.g., GB21). We created a model of an acupoint for the course participants to practice on, and evaluated the efficacy of the training

2. Educational efficacy of an ultrasound detection acupuncture program

This study was approved by the Institutional Review Board of our hospital (IRB No.: 151211) before the study was initiated. Residents in our hospital were recruited,

accepted worldwide.

improves the safety and quality of treatment.

by qualitative and quantitative assessment.

2.1 Materials and methods

2.1.1 Participants

48

the inclusion criterion being medical residents of the Department of Chinese Medicine who volunteered to participate in the training course. The participants were informed in detail about the training and completed a consent form before the start of the course. As the residents were trainees, which constitute a vulnerable group, and therefore in order to safeguard their rights, the recruitment process was publicly announced, and there was no mentor-trainee or colleague relationship between the recruiter and potential participants in order to ensure that the participants joined the study completely of their own accord.

After enrollment in the study, a pre-test and an interview were carried out for each participant, followed by a program of four 2-h ultrasound acupuncture training classes. After completion of the course, a post-test and another interview were performed to assess the efficacy of the training (Figure 1).

### 2.1.2 Development of the ultrasound detection acupuncture program

#### 2.1.2.1 Design

A preliminary draft of the course was designed by ultrasound clinicians, clinical acupuncturists, and medical education experts, and then reviewed by a committee comprising five Chinese medical physicians qualified to teach in traditional Chinese medicine medical institutions under the regulations implemented by The Ministry of Health and Welfare, Taiwan. Course standards and DOPS (Direct Observation Procedural Skills) were then established to assess trainee skills.

Four experts were invited to serve as lecturers for the program. After the initial course content had been established, two lecturers generated teaching slides, and a test course was taught to two students. The students were then asked to provide feedback in order to improve the course, and the review committee also gave suggestions on the revision of the teaching content, enabling completion of the first draft of the course.

Next, we generated a questionnaire, which was reviewed by the five members of the review committee. The questionnaire was then revised until it passed validity and reliability testing, and the teaching content was modified to obtain the final teaching materials for the program. The classes of the program were taught by four lecturers (Figure 2).

Meeting agenda for course planning:

1. Clinical experience of dangerous acupoints.


Acupuncture - Resolving Old Controversies and Pointing New Pathways

#### Figure 2.

Establishment of the ultrasound detection acupuncture course.

DOPS is an assessment tool developed by the Royal College of Physicians that is used to evaluate the performance of a trainee in learning a practical procedure in the United Kingdom [16]. This study used DOPS to assess the performance of the students after taking the course.

3. Advanced clinical application for GB21 (2 h): the function and anatomical position of the acupoint GB21, its possible complications and their

Scoring standard for acupuncture at GB21 using the direct observation of procedural skills (DOPS) tool.

7. Overall assessment □ <sup>1</sup>□ <sup>2</sup> □ <sup>3</sup> □ <sup>4</sup> □ <sup>5</sup> □ <sup>6</sup> □

4.Introduction and practice for ASM21 (2 h): the configuration of the ASM21 model and its function. The benefit and improvement in clinical skills when used in combination with ultrasonography. The importance of implantation of

In this study, GB21 was used as the target acupoint, and ASM21, an acupuncture simulator model of GB21, was developed to help the trainees to easily manage this acupoint (Figure 3). The ASM21 model was designed with a sensor that detected whether the needle was placed in the correct position and within a safe depth, and an alarm sounded when the needle reached the lung. As it was constructed with material that is penetrable by ultrasound, the trainees could also measure the safe needle depth when the model was used together with an ultrasound

We used the inter-rater reliability and employed Kendall's coefficient of concor-

<sup>i</sup> � <sup>1</sup> ð Þ Ri <sup>2</sup> N

<sup>12</sup>K<sup>2</sup> <sup>N</sup><sup>3</sup> � <sup>N</sup> (1)

dance (W) for statistical analysis according to the scores given by the raters, as

<sup>W</sup> <sup>¼</sup> <sup>R</sup> <sup>2</sup>

1

management.

machine.

shown below:

51

simulation in learning.

2.1.2.3 Reliability of the ultrasound acupuncture course

Evaluation items Under

1. Ability in acupoint identification and

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

3. Suitable needle length selection before

4. Whether needle is placed in the correct acupoint area (simulator model

5. Whether needle punctured the lung, causing pneumothorax (simulator model

6. Whether acupuncture procedure was completed within the set test time

acupoint selection.

procedure

sensor light on)

alarm light on)

Table 1.

expected standard

Ultrasound Detection Acupuncture Needling Training: Description of the Method

2. Ultrasound operation skills □ <sup>1</sup>□ <sup>2</sup> □ <sup>3</sup> □ <sup>4</sup> □ <sup>5</sup> □ <sup>6</sup> □

Close to expected standard Achieved expected standard

□ <sup>1</sup>□ <sup>2</sup> □ <sup>3</sup> □ <sup>4</sup> □ <sup>5</sup> □ <sup>6</sup> □

□ <sup>1</sup>□ <sup>2</sup> □ <sup>3</sup> □ <sup>4</sup> □ <sup>5</sup> □ <sup>6</sup> □

□ <sup>1</sup> □ □ <sup>4</sup> □

□ <sup>1</sup>□ <sup>2</sup> □ <sup>4</sup> □

□ <sup>1</sup>□ <sup>2</sup> □ <sup>3</sup> □ <sup>4</sup> □ <sup>5</sup> □ <sup>6</sup> □

Over expected standard

Total score/ average /

Total
