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J Acupunct Meridian Stud 2024; 17(5): 165-171

Published online October 31, 2024 https://doi.org/10.51507/j.jams.2024.17.5.165

Copyright © Medical Association of Pharmacopuncture Institute.

The Transformation of Acupuncture Practice Using Ultrasonography: Expert Opinions

Eunbyul Cho , Changsop Yang , Sungha Kim *

KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea

Correspondence to:Sungha Kim
KM Science Research Division, Korea Institute of Oriental Medicine, Daejeon, Korea
E-mail bozzol@kiom.re.kr

Received: May 29, 2024; Revised: September 22, 2024; Accepted: October 6, 2024

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Importance: The rapidly growing use of ultrasound in South Korea has revolutionized the real-world application of acupuncture, making it a safer, more accurate treatment. However, little is known about the challenges Korean medicine doctors (KMDs) encounter, as well as the procedures and resources necessary for hygienic, safe ultrasound-guided acupuncture.
Objective: This study aimed to investigate the purpose, indications, and procedure for ultrasound-guided acupuncture in Korean medicine (KM) practice and the challenges KMDs encounter in using ultrasonography.
Methods: Eleven KMDs with expertise in practicing or teaching ultrasonography were consulted in detail. The purpose of ultrasonography in real-world practice, the overall process, resources utilized in ultrasound-guided procedures, and the unaddressed needs of KMDs were investigated.
Results: Ultrasound guidance, employed for various diseases in KM practice, is crucial for pharmacopuncture and acupotomy to increase accuracy and safety. Ultrasoundguided acupuncture involves covering the probe, putting on sterile gloves, and scanning with disinfectants, though the exact steps vary among experts. They also suggested that a lack of insurance coverage was a common obstacle for KMDs utilizing ultrasonography.
Conclusions and Relevance: Acupuncture with ultrasound guidance has become a prevalent procedure in South Korea. Standard procedure guidelines and insurance coverage for ultrasonography used for acupuncture procedures are essential to ensure safe, accurate procedures.

Keywords: Korean medicine, Acupuncture, Education, Safety, Ultrasonography

INTRODUCTION

Ultrasound guidance enhances the safety and accuracy of procedures by allowing real-time observation of internal structures and precise needle positioning, minimizing damage to surrounding structures [1]. Additionally, ultrasonography has been utilized in Korean medicine (KM) to identify pathological lesions, determine treatment sites, and objectively monitor treatment progress [2-4]. According to a recent survey, the primary objective and indication of ultrasonography in KM practice was “to improve the accuracy and efficacy” of pharmacopuncture, particularly for shoulder joint diseases [5]. However, the details of the entire ultrasound-guided procedure, including common treatment locations and necessary materials in KM practice, remain unknown.

Ultrasound-guided procedures are essential in pharmacopuncture and acupotomy, as they are often used for deep, infection-prone body structures, including joint cavities and bursae [5]. The ultrasound probe itself can also be a vector of infection [6]. Rigorous sterilization and a clean needle technique are required during the procedure. However, standardized protocols for ultrasound-guided acupuncture have not been established. Investigating the particular methods and resources that professionals employ for ultrasound-guided acupuncture is essential.

The growing demand for safe, effective procedures created a corresponding need for training in ultrasound-guided acupuncture [5]. Despite the high demand for ultrasonography education, course content and effective teaching methods for Korean medicine doctors (KMDs) and undergraduates remain unidentified [5]. Current ultrasonography training for KMDs relies more on books and private lectures than on formal curricula of universities or academies, indicating the need to design regular curricula for ultrasound-guided procedures [5,7]. Since the use of ultrasound has rapidly increased since 2022, accelerated by the Supreme Court’s ruling in favor of KMD’s use of ultrasonic devices [5], the insights of experts with extensive experience in ultrasound may offer valuable implications for future research and education in KM.

The current study was conducted to investigate the purpose, standard treatment methods, and intricate procedure of ultrasonography by KMDs with expertise and the challenges they encounter in practice. Our research questions were: 1) What are the primary indications and successful applications for ultrasound-guided procedures? 2) What are the resources required for ultrasound-guided procedures? and 3) What are the challenges and unresolved needs in clinical practice, research, and education? We examined the perspectives and experiences of experts to investigate the entire procedure of ultrasound-guided acupuncture.

METHODS

1. Study design

In-person consultations were conducted with 11 experts, all of whom were KMDs, to obtain expert opinions. Based on a pre-developed questionnaire, opinions were collected by selecting questions tailored to the KMDs’ areas of expertise and experience. Consultation meetings were held from November 8, 2023, to April 7, 2024, with each meeting lasting approximately one hour.

2. Questionnaire

Two authors (EC and SK) who are specialists in acupuncture and moxibustion medicine drafted the questionnaire by reviewing previous publications, including ultrasound perception surveys and needs analyses [5,7], to identify the diseases and treatment areas in which ultrasound-guided procedures are frequently performed in current KM practices. The questionnaire was subsequently evaluated by a third researcher (CY), finalized through consensus of all authors, and categorized by topic into 6 sections and 17 questions: experience with ultrasound, procedures of ultrasound-guided treatment, necessary resources, indications of ultrasound-guided procedures, suggestions for ultrasound education, and unmet needs (Supplementary Material 1).

3. Recruiting expert panels

The consultation meeting focused on KMDs with a minimum of three years or 300 cases of ultrasound experience. Experts were purposely selected for their extensive use of ultrasonography in practice or their proficiency in teaching ultrasonography, ensuring diversity in workplace settings. To confirm the 300-case experience, potential participants were pre-screened by inquiring about their initiation date of ultrasound use and the typical monthly number of cases in which they use ultrasound. Subsequently, snowball sampling was employed, with initial participants suggesting additional experts who fulfilled the criteria. Informed consent was obtained to incorporate the experts’ perspectives in the research.

4. Data collection and analysis

The consultations were not transcribed, but the researcher compiled them into a Word document during meetings with experts in real-time. Content analysis was used to gain insight into KMDs’ adoption of ultrasound in their practices and the barriers they encountered [8]. First, the researchers sought to comprehend the data by reviewing them repeatedly. Then, meaningful statements were noted, and their interpretations were reconstructed using codes. These codes were classified based on their implications and associations. The categories and codes were presented alongside their respective frequencies and were verified by another researcher (SK) to enhance trustworthiness. The responses to some short-answer questions were analyzed using descriptive statistics.

RESULTS

1. Characteristics of experts

Seven of the 11 experts were self-employed KMDs in KM clinics. Six were specialists in the following fields: KM internal medicine (n = 2), rehabilitation (n = 2), acupuncture and moxibustion medicine (n = 1), and neuropsychiatry (n = 1). Regarding ultrasound experience, 3 experts had over 10 years of utilizing ultrasound in their clinical practice or research (Table 1). The most common type of ultrasound device used was a console ultrasound machine (n = 8), followed by portable and console machines (n = 2) and a portable machine (n = 1) (Table 1).

Table 1

Demographic characteristics of the 11 experts.

CategoryCharacteristicsNumber
Type of institutionKorean medicine clinic7
Korean medicine hospital1
Hospital2
College of Korean medicine1
Years of clinical practice or research5 ≤ < 102
10 ≤ < 203
≥ 206
Years of ultrasound experience3 ≤ < 56
5 ≤ < 102
≥ 103
QualificationsGeneral practitioner5
Specialist6
Final academic degreeBachelor2
Doctorate9


2. Indications and methods of ultrasound guidance in real-world KM practice

The collective experiences of experts on ultrasound were consolidated into five categories: areas that require ultrasound-guided procedures for safety, regions and indications that require ultrasound-guided procedures for accuracy, notable ultrasound-guided procedure cases and targeted areas, functions of the ultrasound device used, and the requisite resources. The neck area was particularly identified as requiring ultrasound guidance for the procedure’s safety and accuracy. Nerves were identified as the structures most commonly requiring ultrasound guidance to physically isolate them from their surrounding tissues through pharmacopuncture, particularly in cases of nerve entrapment syndromes. Ultrasound-guided procedures were recognized as effective for treating various diseases and conditions, including a stiff neck, acute lumbago, carpal tunnel syndrome, and intervertebral disc herniation.

The overall ultrasound-guided procedure was summarized in eight steps: applying the probe cover prior to the procedure, positioning the patient, putting on sterile gloves, disinfecting the treatment site and probe, conducting an ultrasound scan using povidone-iodine as a gel to confirm the site, performing interventions such as pharmacopuncture or acupotomy, disinfecting the treated site, and applying a pressure bandage. Color Doppler (n = 5) was the most common ultrasound function the experts utilized; however, four experts refrained from using any functions due to their demanding practice hours and ultrasound imaging frame rate drops. The consumable materials required for the ultrasound-guided procedure included probe covers (n = 9), sterile gloves (n = 2), and disinfectants such as povidone-iodine (n = 9), alcohol (n = 7), and chlorhexidine (n = 1). The time for the core procedure typically required 5-10 minutes, and the need for additional assistance during the procedure was also noted (Table 2).

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts. US = ultrasound; SCM = sternocleidomastoid; SASD = subacromial-subdeltoid; CRPS = complex regional pain syndrome..

&md=tbl&idx=2' data-target="#file-modal"">Table 2

Experts’ experiences with ultrasound in Korean medicine clinical practice.

Summary of responsesFrequency
Areas that require US-guided procedures for safety
High-risk areas1
Neck area1
Scalene muscle and brachial plexus1
Psoas major muscle1
Lumbar yellow ligament1
Areas and indications that require US-guided procedures for accuracy
Neck area2
Accessory nerve2
Facet joint2
SCM muscle1
Occipital membrane1
Anterior scalene muscle1
Middle cervical plexus1
Brachial plexus1
Dorsal scapular nerve1
Shoulder joint capsule1
Supraspinatus tendon1
SASD bursa1
Nerve root1
Superior cluneal nerve1
Sciatic nerve1
Common fibular nerve1
Sural nerve1
Intraarticular1
Shoulder and back pain1
Circulatory disorder1
Occipital neuralgia1
Notable US-guided procedure cases and targeted areas
Stiff neck1
Longus colli for CRPS-like symptoms1
Acute lumbago1
Acute subdeltoid bursitis1
Median nerve for carpal tunnel syndrome1
Nerve root for intervertebral disc herniation1
Sciatic nerve and sacral plexus for numbness in legs1
Sciatic nerve near popliteal fossa for numbness in legs1
Common fibular nerve for foot drop1
Functions of ultrasound device used
Color Doppler5
Non-use4
Measure size2
Dual image1
Elastography1
Highlighting the needle1
Marking the area where the needle will be inserted1
Power Doppler1
Avoid using functions that drop frame rates1
Requisite resources
Sterile gloves2
Probe cover9
Plastic wrap2
Povidone-iodine9
Alcohol7
Chlorhexidine1
Sterile gel3
Gel (not sterile)2
Pressure bandage1
Probe cleaning solution1
Footswitch1
Time required9
Assistants to help with parts of the procedure5
Assistants to be present for sensitive procedures1

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts. US = ultrasound; SCM = sternocleidomastoid; SASD = subacromial-subdeltoid; CRPS = complex regional pain syndrome..



3. Experts’ perceptions of and suggestions for using ultrasound in KM practice

The intended purpose of utilizing ultrasound was to space the nerve entrapments or tissue adhesions (n = 6), followed by preventing side effects, such as anaphylaxis and vasovagal syncope (n = 3), and elucidating the procedure to the patient (n = 3). While the patient’s condition and needling depth were factors influencing the use of ultrasound, two experts consistently utilized ultrasound for nearly all patients, irrespective of these factors. The most common barrier for KMDs utilizing ultrasound was that it is not covered by National Health Insurance (NHI) (n = 8). Research gaps encompassed the need for clinical studies associated with ultrasound-guided procedures and the challenges of conducting pharmacopuncture clinical trials. It was also suggested that target structures confirmed by ultrasound should be precisely defined in clinical studies. Aligning the needle with the probe and hands-on practice with experts were identified as the most significant course content and training method, respectively, for ultrasound-guided procedures (Table 3).

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts..

&md=tbl&idx=3' data-target="#file-modal"">Table 3

Analysis of consultation meetings.

CategoriesCodesFrequency
Purpose of using ultrasoundSpacing the entrapment and adhesion6
Preventing side effects3
Explaining the procedure to the patient3
Accurate procedure2
Understanding 3D anatomy1
Establishing the treatment direction1
Follow-up treatment progress1
Identification of red flags1
Determinants of ultrasound useWhen a guided procedure is clearly better than a blind procedure2
For almost every patient2
When treating a deep area of the body2
When blind procedures are dangerous2
Serious symptoms and diseases2
Accompanying neurological symptoms1
Barriers to ultrasound useOut-of-insurance coverage8
Ambiguity in AI diagnostic accountability1
Difficulties of ultrasound-guided proceduresDifficulty complying with clean needle technique1
Difficulty wearing gloves1
Avoiding probe and needle contact1
Difficulty obtaining informed consent from patients1
Research gapClinical studies of ultrasound-guided interventions2
Challenges of clinical studies on pharmacopuncture2
Determining target structures with ultrasound1
Required course contentAligning the needle and probe5
3D anatomy3
Understanding ultrasound imaging3
Methods of ultrasound-guided procedures for frequent acupoints2
Documenting the indications of ultrasound-guided procedures in KM practice2
Procedure manual1
Clean needle technique1
Guidance for procedure planes1
Tips for needle manipulation1
Direct and indirect techniques required1
How to teach ultrasound effectivelyHands-on practice with experts4
Questions and answers concerning ultrasound imaging3
Practice with people rather than dummies2
Practice with dummies1
Training certification1
Invasive techniques should be covered in specialty training1
Practice on large muscles1

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts..


DISCUSSION

The present study aimed to identify the specific procedures of ultrasound-guided KM interventions by KMDs with extensive ultrasonographic experience, as well as the current barriers to their utilization. The methods for ultrasound-guided acupuncture involve using a probe cover and sterile gloves, disinfecting both the treatment area and the probe, and applying povidone for scanning. The additional time and expense borne by KMDs is the primary disincentive for using ultrasonography.

While it is widely recognized that ultrasound guidance is crucial for ensuring the safety, accuracy, and effectiveness of procedures [9], information regarding which treatment sites of the body specifically require ultrasound guidance in KM practice is lacking. Drawing on expert opinion, we have identified the specific structures in the body that necessitate ultrasound-guided procedures for safety and accuracy. Nerves were the most frequently cited procedure target that required accuracy and in line with previous research [5], ultrasound guidance was commonly employed to physically expand the space between the entrapped nerve and surrounding adhesions.

As indicated by the previous survey, most KMDs perceived that NHI should cover ultrasound-guided KM procedures [5]; however, administrative decisions have yet to be made. Our findings indicate that ultrasound-guided procedures necessitate consumable materials, such as sterile gloves, probe covers, and disinfectant materials, as well as personnel to assist during the procedure. Although most of the experts reported that only 5-10 minutes are necessary for ultrasound-guided procedures, this brief time frame is likely a reflection of their proficiency. It is important to note that this reported time excludes the preparation phase prior to the ultrasound-guided procedure and the post-procedure observation period. Further research is needed to precisely quantify the complete duration needed for the entire procedure, including preparation and post-procedure care, in real-world clinical settings. The prior survey indicated that ultrasound-guided procedures take approximately three times longer than those without ultrasound guidance [5]. To encourage the use of ultrasound for safe KM procedures, the additional exertion and expense for KMDs should be considered. Since it requires additional time to include ultrasonography in a procedure, some experts stated that they did not use it when they faced time constraints. Notably, the most significant barrier for KMDs was not being authorized to be paid for ultrasound-guided procedures despite the additional material costs and time involved.

The surveyed experts indicated a high demand for clinical studies demonstrating the safety and efficacy of ultrasound-guided interventions and advocated for hands-on training with KM experts. Only a few retrospective observational and case series studies on ultrasound-guided procedures have been conducted, most involving fewer than 20 cases and limited to conditions such as rotator cuff disease, anterior shoulder pain, rib fractures, pain after a car accident, and plantar fasciitis [2-4,10-13]. Well-designed clinical studies are essential for generating evidence for ultrasound-guided KM procedures, and the purpose, indications, and methods of the procedure need further refinement. In addition, hands-on training is crucial for teaching scanning techniques [14] and should be encouraged for KMDs and undergraduate students.

While this study offers valuable insights into current KM practices through ultrasound, it also presents certain limitations. The study examined the perspectives of 11 experts and, therefore, cannot be generalized. The challenges faced by novice KMDs in ultrasound were not evident in the results. Nevertheless, the present study discerned the purpose, indications, and methods of ultrasound use by experts who are KMDs and investigated the determinants and barriers to the current use of ultrasound by in-depth consultations. The study results will serve as fundamental reference material for future ultrasound research and education in KM.

CONCLUSIONS

This study suggests that ultrasound guidance enhances the safety and accuracy of KM procedures for various symptoms and diseases. We investigated the purpose, indications, and methods of ultrasound-guided procedures, and more future clinical studies are necessary to further refine these techniques. We also discovered that KMDs currently bear the cost of materials, must invest significant additional time, and require assistants to use ultrasound. The study lends further weight to the necessity of insurance coverage for KMDs utilizing ultrasonography.

SUPPLEMENTARY MATERIAL

Supplementary data to this article can be found online at https://doi.org/10.51507/j.jams.2024.17.5.165.

ACKNOWLEDGEMENTS

We thank the experts who generously contributed their experiences and perceptions to this study.

FUNDING

This work was supported by the Korea Institute of Oriental Medicine (Grant No. KSN2121211). The funding source had no input regarding the interpretation or publication of the study results.

AUTHORS’ CONTRIBUTIONS

EC participated in expert meetings, investigated and analyzed the responses, and wrote the original draft. SK conceptualized the study and provided supervision, while SK and CY revised the manuscript. All the authors approved the final manuscript.

DATA AVAILABILITY

The data analyzed and presented in this paper can be provided upon reasonable request to the corresponding author.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

There is no Figure.

Table 1 . Demographic characteristics of the 11 experts.

CategoryCharacteristicsNumber
Type of institutionKorean medicine clinic7
Korean medicine hospital1
Hospital2
College of Korean medicine1
Years of clinical practice or research5 ≤ < 102
10 ≤ < 203
≥ 206
Years of ultrasound experience3 ≤ < 56
5 ≤ < 102
≥ 103
QualificationsGeneral practitioner5
Specialist6
Final academic degreeBachelor2
Doctorate9

Table 2 . Experts’ experiences with ultrasound in Korean medicine clinical practice.

Summary of responsesFrequency
Areas that require US-guided procedures for safety
High-risk areas1
Neck area1
Scalene muscle and brachial plexus1
Psoas major muscle1
Lumbar yellow ligament1
Areas and indications that require US-guided procedures for accuracy
Neck area2
Accessory nerve2
Facet joint2
SCM muscle1
Occipital membrane1
Anterior scalene muscle1
Middle cervical plexus1
Brachial plexus1
Dorsal scapular nerve1
Shoulder joint capsule1
Supraspinatus tendon1
SASD bursa1
Nerve root1
Superior cluneal nerve1
Sciatic nerve1
Common fibular nerve1
Sural nerve1
Intraarticular1
Shoulder and back pain1
Circulatory disorder1
Occipital neuralgia1
Notable US-guided procedure cases and targeted areas
Stiff neck1
Longus colli for CRPS-like symptoms1
Acute lumbago1
Acute subdeltoid bursitis1
Median nerve for carpal tunnel syndrome1
Nerve root for intervertebral disc herniation1
Sciatic nerve and sacral plexus for numbness in legs1
Sciatic nerve near popliteal fossa for numbness in legs1
Common fibular nerve for foot drop1
Functions of ultrasound device used
Color Doppler5
Non-use4
Measure size2
Dual image1
Elastography1
Highlighting the needle1
Marking the area where the needle will be inserted1
Power Doppler1
Avoid using functions that drop frame rates1
Requisite resources
Sterile gloves2
Probe cover9
Plastic wrap2
Povidone-iodine9
Alcohol7
Chlorhexidine1
Sterile gel3
Gel (not sterile)2
Pressure bandage1
Probe cleaning solution1
Footswitch1
Time required9
Assistants to help with parts of the procedure5
Assistants to be present for sensitive procedures1

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts. US = ultrasound; SCM = sternocleidomastoid; SASD = subacromial-subdeltoid; CRPS = complex regional pain syndrome..


Table 3 . Analysis of consultation meetings.

CategoriesCodesFrequency
Purpose of using ultrasoundSpacing the entrapment and adhesion6
Preventing side effects3
Explaining the procedure to the patient3
Accurate procedure2
Understanding 3D anatomy1
Establishing the treatment direction1
Follow-up treatment progress1
Identification of red flags1
Determinants of ultrasound useWhen a guided procedure is clearly better than a blind procedure2
For almost every patient2
When treating a deep area of the body2
When blind procedures are dangerous2
Serious symptoms and diseases2
Accompanying neurological symptoms1
Barriers to ultrasound useOut-of-insurance coverage8
Ambiguity in AI diagnostic accountability1
Difficulties of ultrasound-guided proceduresDifficulty complying with clean needle technique1
Difficulty wearing gloves1
Avoiding probe and needle contact1
Difficulty obtaining informed consent from patients1
Research gapClinical studies of ultrasound-guided interventions2
Challenges of clinical studies on pharmacopuncture2
Determining target structures with ultrasound1
Required course contentAligning the needle and probe5
3D anatomy3
Understanding ultrasound imaging3
Methods of ultrasound-guided procedures for frequent acupoints2
Documenting the indications of ultrasound-guided procedures in KM practice2
Procedure manual1
Clean needle technique1
Guidance for procedure planes1
Tips for needle manipulation1
Direct and indirect techniques required1
How to teach ultrasound effectivelyHands-on practice with experts4
Questions and answers concerning ultrasound imaging3
Practice with people rather than dummies2
Practice with dummies1
Training certification1
Invasive techniques should be covered in specialty training1
Practice on large muscles1

The figures in this table are based on content analysis of the consultations and may include multiple responses from individual experts..


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