J. Acupunct. Tuina. Sci. 2011, 9 (5): 269-272 DOI: 10.1007/s11726-011-0529-x

© Shanghai Research Institute of Acupuncture and Meridian and Springer-Verlag Berlin Heidelberg 2011︱● 269 ●

Critical Review

Acupuncture Skills and Its Evidence-based Assessment

针刺技法及其循证评价 Li Jing (李靖)1,2, Mary X Wu2,3, Heather Carnahan2,4 1 Department of Sports and Health, Nanjing Sport Institute, Nanjing 210014, P. R. China 2 Wilson Centre, University of Toronto, Toronto, ON, Canada 3 Toronto School of Traditional Chinese Medicine, Toronto, ON, Canada 4 Department of Occupational Science &Occupational Therapy, University of Toronto, Toronto, ON, Canada

【摘要】针刺疗法起源于数千年前的中国，目前已在中国及世界各地广泛使用，并被证实是一种行之有效的防治疾病的手段。然而，目前关于如何客观评估针刺技术的研究仍十分缺乏。现有的评估方法主要基于专家的主观判断，这在一定程度上是不准确的。建立针刺技术的循证评估体系可以从专家评判的标准化、针刺技术的运动学分析及高仿真针灸模型的研制或标准化病人的培训等方面入手。 【关键词】针刺疗法；标准化；评估；循证医学；教育 【中图分类号】R245.3 【文献标志码】A 【Abstract】Acupuncture originated in China several thousand years ago, and this therapeutic approach has been shown to be an effective treatment of many diseases and the maintenance of health in China and other countries all over the world. However, there is little study into how the important skills of acupuncture should optimally be taught and how competence at this skill should be evaluated. The current competency assessment of acupuncture skills is primarily based on evaluations by experts, which can be subjective with large variations and potentially inaccurate. Developing evidence-based assessment standards for acupuncture skills is required to move the assessment of the clinical practice of acupuncture forward, and this performance evaluation could be based on standardized expert evaluation, computer-based measurements such as motion analysis，and high-fidelity simulators or standardized patients. 【Key Words】Acupuncture Therapy; Standardization; Evaluation; Evidence-based Medicine; Education

Acupuncture is one of the therapeutic methods with

a history of several thousand years in traditional Chinese medicine (TCM)[1]. Acupuncture skills involve the technique of inserting and twirling filiform needles into acupoints to stimulate the body to improve and rectify disturbances and dysfunction. Acupuncture can treat a broad range of internal, external, pediatric, gynecological diseases and disorders with significant curative effects[1]. Currently, acupuncture has been practiced in about 130 countries and regions and contributed much to the healthcare and medical treatment for the people all over the world[2].

Essentially, the concept of what "acupuncture skills are" can be expanded to include all the peri-

Fund Item: Jiangsu Government Scholarship for Overseas Studies (JS-2009) Author: Li Jing, PhD, associate professor, lijing197512@ 163.com

operative activities of an acupuncturist. However, this paper only focuses on the evaluation of technical clinical skills of acupuncture.

1 Current Assessment of Acupuncture Skills

Technically, acupuncture skills include four basic

parts that are sterilization, needle insertion, needling manipulation techniques and needle withdrawal. Lifting-thrusting and twirling-rotating belong to basic manipulation techniques. The angle and depth of needling depend on the location of acupoints. Even in needling the same acupoint, the speed, frequency, amplitude, force and depth of lifting-thrusting and twirling-rotating vary according to the constitution and pathological conditions of the patient. This leads to three different methods, e.g., the reinforcing method, reducing method and even method[1]. Therefore acupuncture skills are very complicated and varied. Incompetent acupuncture skills could result in

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needle pain, infection, bleeding and even some needling accidents, such as pneumothorax or cardiac tamponade, when acupuncturists misjudge the depth that the needle has been inserted[1]. Hence, the assessment of acupuncture skills is of paramount importance in the professional regulation of acupuncture.

Currently in China, TCM students require 3 to 5 years of formal education to receive an acupuncture diploma or undergraduate TCM degree in acupuncture. Then they must pass a national acupuncture competency examination in order to be registered as the TCM acupuncturists. This examination consists of two parts, a written comprehensive exam and a clinical exam. Acupuncture technical skills are primarily tested in the clinical exam. During the clinical exam, candidates demonstrate entire needling procedures on one another or on soft pads under the direct observation of examiners. In North America and Europe, candidates also must meet educational requirements, e.g., 3 academic years of formal education with a minimum of 1905 h including 660 h of clinical training for acupuncture in USA, and pass the acupuncture competence examinations before they are licensed to practice in some jurisdictional areas where acupuncture has been regulated[2]. The acupuncture clinical practice competency examinations in those jurisdictions are similar to China except that candidates are only allowed to perform acupuncture skills on inanimate models, e.g., models made of foam or sponge in British Columbia, Canada[3]. In addition, Clean Needle Techniques (CNT) are also tested by the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) in USA[4,5].

However, there are some obvious weaknesses in the current competency assessment of acupuncture skills. First, the observation of examiners is non-standardized, so there is little sense of reliability or validity of the evaluation. Moreover, it is difficult for examiners to judge accurately the force, angle, speed, frequency and amplitude of needling manipulation just based on observation. Therefore, in light of the complexity and potential risk of acupuncture skills, there may be alternative methods for evaluating technical performance in addition to expert based measure.

2 Evidence-based Modern Medical Education Best evidence medical education (BEME) is the

practice and implementation of methods and approaches to education based on the best evidence available to teachers[6]. BEME has become increasingly popular in North America and Europe. Reliable and valid measurement or assessment of variables and parameters in the laboratory is one foundation for producing best evidence[7].

In terms of surgery, which is a medical field that has led the way in developing standardized methods for evaluating the performance of technical clinical skills, surgical skills are taught using simulators in laboratories and subsequently assessed by both expert-based and computer-based performance measurements[8].

Expert-based performance measurements primarily include standardized task-specific checklists and global rating forms. A task-specific checklist usually consists of 10 to 30 items that have been deemed essential elements of a specific surgical procedure. Each item is scored either 0 or 1. A score of 0 suggests that this item is done incorrectly, while 1 indicates that it is conducted correctly[9]. Global rating forms include five to eight surgical behaviors, such as respect for tissue, time and motion, instrument handling, knowledge of instruments, flow of operation, knowledge of specific procedures, overall performance and quality of the final product. Each behavior is graded on a 5-point scale with 1 being the minimum score and 5 the maximum score. Points 1, 3, and 5 are anchored with explicit behavioral descriptors[10]. With these measurements, experts can evaluate surgical skills reliably and validly.

There are also some computer-based performance measurements for the assessment of surgical skills. Many surgical simulators, both low and high fidelity, have been validated as effective teaching and evaluating tools[6]. For example, the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills program can score the laparoscopic skills for time and accuracy. Based on this program, the Fundamentals of Laparoscopic Skills are developed for the teaching and certification of laparoscopic knowledge and technical ability[8]. Beyond the basic metrics of time and errors, several sophisticated markers have emerged for testing proficiency of

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surgical skills. These include the measurement of instrument motion or limb motion and the use of a tensiometer to quantify the strength of a tied suture knot[8,11].

Both the expert-based and the computer-based performance measurements are valuable because they can provide the best evidence to demonstrate varying levels of expertise, the progress through training regimens, and the effects of intervention in surgical skills training[10]. By which, modern medical education is moving from opinion-based tradition to evidence- based education[6].

3 Developing Evidence-based Assessment of

Acupuncture Skills TCM could be considered a similar shift. However,

BEME has not received the same level of attention in TCM. In 2009, Liu et al[12] reported an acupuncture manipulation real-time analysis system for the measurement of frequency, speed and amplitude of lifting-thrusting and twirling-rotating. The manipulation of acupuncture experts was recorded by this system. Students practiced, adjusted and corrected their skills by comparing their movements with the manipulation of experts during their training. Moreover, students' performances were also tested by this system. It is this type of innovation that will contribute to objective and valid assessment of acupuncture skills.

However, with all approaches there are limitations. The analysis system did not measure the force and angle of needling, which are considered as critical variables of acupuncture techniques. In addition, this system only focuses on needling manipulation, and it is not able to provide any information about the skills of sterilization, needle insertion and withdrawal which are also important components in the whole process of needling for safe practice.

Surgical skills assessment in modern medical education has set a good example for acupuncture. Some of these models and techniques for surgical skills assessment can be used for the evaluation of acupuncture skills. 3.1 Proposed expert-based assessment

Both task-specific checklists and global rating forms can be used to evaluate the proficiency of the entire procedure of needling. TCM educational

scientists should design a checklist for acupuncture skills. Delphi methods are often suggested for the development of checklists. This checklist lists all specific and essential items in the process of needling with a score, 0 or 1, for each item. Moreover, the reliability and validity of this checklist should be tested. The global rating form which is currently viewed as the gold standard for surgical skills assessment can also be administered for the evaluation of acupuncture skills[10].

Two or more independent examiners should be involved in the competence assessment of acupuncture skills. Inter-rater reliability of 0.7-0.8 is generally deemed acceptable. In this way, examiners evaluate acupuncture skills under standardized observation, which ensures subjective opinion is reduced to a minimum level[13]. 3.2 Proposed computer-based assessment

While expert based measurements are typically very good at differentiating between expert and novice performance, this method does not allow for the judgment of movement speed, amplitude, frequency, angle and force of needling manipulation techniques. Therefore the approaches of computer- based measurement should also be considered.

Acupuncture experts should be invited to laboratories to perform their skills on a simulated skin pad which is made of silicon rubber. The speed, amplitude, frequency, angle and force of needling can be measured accurately by advanced motion analysis systems and force transducers. These systems can capture and deliver real-time data with high accuracy and resolution. Subsequently a database of expert lifting-thrusting and twirling-rotating by reinforcing method, reducing method and even method could be established. The database could be of value in the eventual assessment of acupuncture skills. 3.3 Proposed assessment of the arrival of qi

The arrival of qi refers to the patients’ sensation of aching, numbness, heaviness or distension around the acupoints and the acupuncturists’ sensation of heaviness and tension beneath the needle. It is directly related to acupuncture therapeutic effects. The depth of needling insertion depends upon the arrival of qi. Therefore, compared with the depth of needling insertion, the measurement of the arrival of qi is more significant and necessary in the competence assessment of acupuncture skills.

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Probably, the following two ways are feasible to evaluate whether the arrival of qi is induced. One is to design high-fidelity simulators which can enable eligible candidates to feel heaviness and tension beneath the needle when the needle is inserted into a certain depth, and at the same time the simulators can provide instantaneous feedback to show that the needling depth is appropriate. The other way is to train or employ standardized patients[14]. According to the conditions of patients and specific syndromes or scenarios, candidates select acupoints and perform acupuncture skills directly on these patients under close supervision. Furthermore, candidates are allowed to ask the patients about their sensation so as to decide the depth of needling insertion. These standardized patients are entitled to the evaluation of the arrival of qi during the clinical competence assessment of acupuncture skills. 4 Conclusion

In conclusion, acupuncture is becoming widely accepted worldwide. The current evaluation methods of acupuncture skills could be further developed for optimal objectivity and accuracy. Surgical skills assessment in modern medical education provides opportunities for evaluating some of the elements of acupuncture skills performance technically, though technical skills only explain some of the whole acupuncture skills. Moreover, this insight can be used to further attempt to develop optimal teaching methods of acupuncture skills. We recommend that acupuncturists, TCM educators and scientists should work as a team to conduct the work in which acupuncturists and TCM educators act as interpreters of acupuncture theory and clinical experience and scientists serve as methodologists and creative partners who can use the expertise of acupuncturists in formulating testable study questions and interpretable outcome measurements[15]. 5 Acknowledgements

Li J is supported by the Jiangsu Education Bureau, China and Heather C is supported by the BMO Chair

in Health Professions Education Research.

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Received Date: July 5, 2011

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