Using simulation in complementary medicine education: an overview of clinical trials

Background

There was a long history of using simulation in learning medical interventions and practices.It is a way of acquiring new skills in a safe environment and preparing trainees and students for the real clinical practice[1].Furthermore,simulation-based training allows instructors to assess,and monitor trainees’ performance and evaluate their acquired skills and ability to practice in a safe clinical environment[1].

Complementary medicine is a broad term which represented various practices and therapies that are not part of the conventional medicine[2].

Using simulation in the complementary medicine education is dated back to the year 1,027 when Wang Wei-Yi(a Chinese physician)used statutes for teaching acupuncture[3].The used statutes had 354 open body holes which represented acupuncture points.These holes were filled with a liquid and covered by wax.When a trainee put the acupuncture needle correctly in the hole and remove it,a drip of the solution – which was located inside the hole – should appear.Appearing of drips indicated the success of the trainee[3].

The aim of this review is to assess the use of simulation-based learning in the field of complementary medicine education.This study highlighted the importance of using health simulation in complementary medicine training and gave a descriptive review of the status of using simulation in complementary medicine education.Introduction of simulation into complementary medicine clinical training is very important to decrease any harms that may result from training on healthy volunteers which is a common practice in complementary medicine education.To the best of our knowledge,this is the first full narrative review which gave an overview of the conducted clinical trials that assessed using simulation in complementary medicine therapies.

Materials and methods

Three medical databases(PubMed,Cochrane Library,Scopus)were searched from inception to 15 November 2021.The search keywords were:(“Complementary medicine”,“Complementary health”,“Integrative health”,“Integrative medicine”,“acupuncture”,“massage therapy”,“cupping”,“chiropractic”,“osteopathy”,“Simulation”,“Training”,“Education”).Search terms were adjusted according to the searched database.A manual search was also performed on references of retrieved articles.The inclusion criteria were clinical trials that used simulation in the field of complementary medicine training or education,in English language and the full text can be retrieved.Articles which were not clinical trials,not directly related to complementary medicine therapies,were not in English or could not be retrieved as a full text were excluded.

The included studies were conducted in 6 countries(Australia = 3[7,12,14],Korea = 2[8,9],USA = 3[4,5,13],Canada = 1[6],Saudi Arabia = 1[10]and China Taiwan = 1[11]).

Results

There were reported adverse events related to acupuncture practice.Examples of acupuncture related adverse events were fainting,nerve/organ injury,pneumothorax,stuck needle,broken needle,bent needle,vascular injury and excessive bleeding from acupuncture point[20].Using simulation-based learning in the field of acupuncture training and education will ensure that the acupuncture trainees will practice as much as they need to be confident and acquire clinical skills in a safe environment.

This review identified 11 clinical trials in the field of 5 complementary medicine therapies(Chiropractic = 5[4,6,7,12,14],acupuncture = 2[8,9],Massage therapy = 1[13],cupping therapy = 1[10]and osteopathy = 1[5])and general complementary medicine training = 1[11].

As for the sister, she made herself so much hated that her own mother turned her off; and the miserable15 wretch, having wandered about a good while without finding anybody to take her in, went to a corner of the wood, and there died.40

There were 719 participants in all included clinical trials.The highest number of participants in one clinical trial was 173 and the smallest number was 12[8,12].

All included clinical trials reported positive effects regarding using simulation-based learning in the training of various complementary medicine therapies.Table 1 showed the characteristics of the included clinical trials.

Discussion

Hospital-based massage therapy course was developed and introduced in 2015[27].The simulation was a part of the course[27].Furthermore,a new massage therapy simulation platform using two types of flexible array sensors was developed in 2020 for medical training[28].

Using part-task trainer as a method of simulation and training of cupping therapy was developed and introduced in 2017[22].A questionnaire to evaluate the use of simulation in cupping therapy training was developed and validated in 2018[23].

Then he turned round sharply, and, seizing the little creature by his beard, he gave him such a shaking that he tore his beard out, and the dwarf sank groaning19 to the ground

Using simulation in acupuncture training

Using simulation in the field of acupuncture training is dated back to 1,027[4].In this review,two clinical trials evaluated the use of simulation in acupuncture training and education.The included clinical trials used haptic and phantom acupuncture points(using 5%agarose gel)to simulate acupuncture points.The first trial was conducted to evaluate the impact of developed phantom acupuncture simulation points on the training of new students of acupuncture[8].The second trial was conducted to evaluate pre- and postsimulation-based training on performance of acupuncture students using phantom acupuncture points and visual feedback[9].Furthermore,the two clinical trials included 33 participants and reported the positive impact of using simulation in acupuncture training.

Many simulation devices and techniques were used,introduced and developed in the field of acupuncture training including virtual reality,learning-based games,model silicon ears for the auricular acupuncture education and mobile application learning using augmented reality[15–19].

That was 34 years ago. Today, the boy is a successful architect in New York City. His father’s cabin is still there on the island in the middle of the lake. He takes his own son and daughters fishing from the same dock.

495 articles were retrieved after performing search,235 articles were excluded for duplication,and 249 articles were excluded after screening of titles/abstracts and applying inclusion and exclusion criteria.Finally,11 articles were included in this review[4–14].Figure 1 showed the search strategy and results.

Using simulation in chiropractic training

This review included five clinical trials that assessed the use of simulation in chiropractic training and education[6,12,14].The clinical trials included 494 participants and used different simulation devices and techniques(high velocity procedure,manikin,projection virtual reality and online videos)[4,6,7,12,14].All included clinical trials reported positive effects of using simulation,the highest was obtained by using the manikin and the smallest effect was obtained by using the online videos[6,7,12].

Most of the adverse events related to chiropractic were mild,however,there have been serious reported adverse events such as arterial dissection,extrusion of vertebral disc and epidural hematoma[21].Practicing chiropractic by simulation in a safe environment can increase trainees’ confidence and abilities and it is highly recommended[7].The main reported benefits of using simulation in chiropractic training included the ability of students to repeat tasks many times as required until they were satisfied with the results[14].

Using simulation in cupping therapy training

The reindeer told Gerda s whole history, but first he told his own, for that seemed to him much more important, and Gerda was so cold that she could not speak

This review included one clinical trial.The clinical trial included 41 participants and reported significant and positive effects of using simulation[10].

Cupping therapy is a relatively safe practice,but there were many reported adverse events related to cupping therapy[24].A classification of cupping therapy adverse events was developed in 2018 and updated in 2021[25,26].The most cupping therapy reported adverse events were scars,vasovagal attack,dermatitis,abscesses,anemia and others[25].Most of cupping therapy adverse events can be prevented by proper training and by following infection control guidelines[25].Part-task simulation training will ensure proper training especially for invasive procedure such as doing skin scarifications in wet cupping therapy training[10].

Using simulation in massage therapy training

This review included one clinical trial that assessed using simulation technology for massage therapy therapists in the field of skin cancer prevention[13].This clinical trial included 81 participants,and reported positive results[13].

Using simulation is very important to train massage therapy therapists in a safe environment.

This review included 11 clinical trials that assessed the using of simulation-based learning in complementary medicine training and education.These clinical trials assessed the use of simulation in theeducation of 5 complementary medicine therapies and were conducted in 6 countries.In addition,these clinical trials included 719 participants and reported positive impact of using simulation in complementary medicine education.

Most of massage therapy related adverse events were mild.Serious adverse events were reported such as soft tissue trauma,neurologic compromise,cervical cord injury,and myopathy[29,30].

He mustered11 his strength and climbed to the top, and there he found a giant tree whose foot kept firm the wrinkled earth, and whose crest12 touched the very heaven

When she afterwards brought out the picture book, he said, “It was only fit for babies in long clothes,” and when grandmother told any stories, he would interrupt her with “but;” or, when he could manage it, he would get behind her chair, put on a pair of spectacles, and imitate her very cleverly, to make people laugh

Using simulation in osteopathic medicine training

Using simulation in osteopathic medicine education is relatively new[31].Many simulation techniques and devices were used in training such as videos,virtual learning environment[31,32].Mannequins,task trainers and virtual clinical skill systems[33].

4. Queen-mother: It is interesting that the Queen-mother devises and administers the test. The implication is that the prince is unaware11 of the test until the next morning. While his inability to find a wife and produce an heir is probably frustrating12 to the parents, they seem to support his search for a true princess through their actions. The father allows the princess admittance into their home. The mother tests the princess sensitivity. Return to place in story.

This review included one clinical trial which evaluated the palpatory diagnosis using virtual haptic back.The clinical trial had 21 participants and reported positive effect on outcomes of learning[5].

Adverse events related to osteopathic medicine is commonly mild.Serious adverse events were reported;however,these adverse events were preventable especially with proper training[34].

The status of using simulation-based learning in integrative and complementary medicine was published as an abstract only in a conference proceeding in 2017[35].The abstract gave broadlines and general brief overview about the status of the use[35].This review assessed the use of simulation in complementary medicine education through the inclusion of clinical trials only,is the first full text review– to the best of our knowledge – to give a detailed description about the use and impact of using simulation as a method of learning in various complementary medicine therapies.

Limitations of this review included the small number of clinical trials that evaluated the use of simulation in complementary medicine education,and the inclusion of English only published clinical trials.

Weeks later, with a joyful11 burst of energy, Timmy sprinted12 towards me. He proudly pulled the bandage off to show me the result if his work. See, he said, It s growing back really good! A year later, Timmy came to say good-bye to me. He and his family were moving to another neighborhood. Timmy s finger was completely healed. It was round and padded just as any index finger should be. Only a fine hairline scar remained.

This review highlighted the importance of using simulation in complementary medicine education.Implementation of simulation-based learning in complementary medicine education was encouraged for providing safe environment to train and practice.Furthermore,there is a high need for development of new methods of simulation to be used in complementary medicine training.More clinical trials should be conducted for evaluation of satisfaction and performance of the trainees and students.

Conclusion

Simulation-based learning was used for complementary medicine education.Chiropractic,acupuncture,massage therapy,cupping therapy and osteopathy education were examples of using simulation-based learning.All clinical trials reported positive effects from using simulation-based learning in complementary medicine education.Using simulation in complementary medicine education is recommended to ensure safe environment for training especially for new students and trainees.Conducting high quality clinical trials to evaluate the satisfaction,and performance of trainees is highly recommended.Developing new simulation devices for complementary medicine education and training is encouraged.

1.Phillips J,Grant JS,Milligan GW,Moss J.Using a multicultural family simulation in public health nursing education.

.2012;8(5):e187–e191.https://doi.org/10.1016/j.ecns.2011.08.007

2.Foley H,Steel A,Cramer H,Wardle J,Adams J.Disclosure of complementary medicine use to medical providers:a systematic review and meta-analysis.

.2019;9:1573.https://doi.org/10.1038/s41598-018-38279-8

3.Owen H.Early use of simulation in medical education.

.2012;7(2):102–116.https://doi.org/10.1097/SIH.0b013e3182415a91

4.Scaringe JG,Chen DP,Ross D.The effects of augmented sensory feedback precision on the acquisition and retention of a simulated chiropractic task.

.2002;25(1):34–41.https://doi.org/10.1067/mmt.2002.120419

5.Howell JN,Conatser RR,Williams RL 2nd,Burns JM,Eland DC.Palpatory diagnosis training on the virtual haptic back:performance improvement and user evaluations.

.2008;108(1):29–36.https://www.degruyter.com/document/doi/10.7556/jaoa.2008.108.1.29/html

6.McGregor M,Giuliano D.Manikin-based clinical simulation in chiropractic education.

.2012;26(1):14–23.https://doi.org/10.7899/1042-5055-26.1.14

7.Chapman PD,Stomski NJ,Losco B,Walker BF.The simulated early learning of cervical spine manipulation technique utilising mannequins.

.2015;23:23.https://doi.org/10.1186/s12998-015-0067-6

8.Lee IS,Lee YS,Park HJ,Lee H,Chae Y.Evaluation of phantom-based education system for acupuncture manipulation.

.2015;10(2):e0117992.https://doi.org/10.1371/journal.pone.0117992

9.Jung WM,Lim J,Lee IS,Park HJ,Wallraven C,Chae Y.Sensorimotor learning of acupuncture needle manipulation using visual feedback.

.2015;10(9):e0139340.https://doi.org/10.1371/journal.pone.0139340

10.Aboushanab T,Khalil M,El-Olemy A,Alsanad S.Cupping therapy simulation course;a pilot study assessing self reporting of confidence,expectations/satisfaction and performance.

.2017;1(1):53–59.https://doi.org/10.21467/ajss.1.1.53-59

11.Chang HY,Chang HL.A virtual simulation-based educational application about complementary and alternative medicine:a pilot study of nurses’ attitudes and communication competency.

.2021;97:104713.https://doi.org/10.1016/j.nedt.2020.104713

12.Fong KK,Gilder S,Jenkins R,Graham PL,Brown BT.The influence of online video learning aids on preparing postgraduate chiropractic students for an objective structured clinical examination.

.2020;34(2):125–131.https://doi.org/10.7899/JCE-18-8

13.Heslin KM,Silva GE,Loescher LJ,Muramoto ML.Incorporating decision simulation technology in a skin cancer prevention E-training for massage therapists.

.2021.https://doi.org/10.1007/s13187-021-02081-4

14.Shanahan M,Molyneux T,Vindigni D.Chiropractic students’experiences on the use of virtual radiography simulation:a pilot observational study.

.2021;21(1):404.https://doi.org/10.1186/s12909-021-02827-0

15.Kanehira R,Shoda A,Yagihashi M,Narita H,Fujimoto H.Development of an acupuncture training system using virtual reality technology.

.2008;4:665–668.https://doi.org/10.1109/FSKD.2008.575

16.Gao HL,Gao Y,Kan HX,Chen GE.Research on development and design of virtual acupuncture teaching software based on HTC VIVE.

.2019:660–6603.https://doi.org/10.1109/ICMCCE48743.2019.00153

17.Huang YL,Liu RQ,Zhou MQ,Ma XG.Design and development of learning-based game for acupuncture education.

2014:2375–2380 https://doi.org/10.1007/978-94-007-7618-0_293

18.Jan AL.Lessons learned in teaching battlefield(Ear)acupuncture to emergency medicine clinicians.

.2020;32(5):253–262.https://doi.org/10.1089/acu.2020.1436

19.Ng SC,Lui AK,Chan PY,Yu KY,Hung SK.Mobile learning with augmented reality:a case study of acupuncture points.

2020:75–87.https://doi.org/10.1007/978-981-15-6591-5_6

20.World Health Organization.WHO benchmarks for the practice of acupuncture.World Health Organization;2020.ISBN:978-924-001-6880

21.Gouveia LO,Castanho P,Ferreira JJ.Safety of chiropractic interventions:a systematic review.

.2009;34(11):E405–E413.https://doi.org/10.1097/BRS.0b013e3181a16d63

22.Aboushanab T,AlSanad SM.Simulation in cupping training:an innovation method.

.2017;10(6):409–410.https://doi.org/10.1016/j.jams.2017.10.003

23.Aboushanab T,Khalil M,El-Olemy A,AlSanad S.Development of a new tool for self-assessment of confidence,expectations/satisfaction and performance for cupping therapy simulation training modules.

.2018;3(Suppl 1):A9.https://doi.org/10.1186/s41077-018-0065-6

24.Kim TH,Kim KH,Choi JY,Lee MS.Adverse events related to cupping therapy in studies conducted in Korea:a systematic review.

.2014;6(4):434–440.https://doi.org/10.1016/j.eujim.2013.06.006

25.Aboushanab TS,AlSanad S.Cupping therapy:an overview from a modern medicine perspective.

.2018;11(3):83–87.https://doi.org/10.1016/j.jams.2018.02.001

26.Aboushanab TS.Response to Moghimi et al.Classification of cupping therapy adverse events:an update.

.2021;14(1):2–3.https://www.journal-jams.org/journal/view.html?uid=1042&v md=Full

27.Dion LJ,Cutshall SM,Rodgers NJ,et al.Development of a hospital-based massage therapy course at an academic medical center.

.2015;8(1):25–30.https://doi.org/10.3822/ijtmb.v8i1.249

28.Wang CB,Sun ZD,Long JJ,et al.Development of a novel massage therapy platform for medical training.

.2020;28(S1):89-101.https://doi.org/10.3233/THC-209010

29.Posadzki P,Ernst E.The safety of massage therapy:an update of a systematic review.

.2013;18(1):27–32.https://doi.org/10.1111/fct.12007

30.Yin P,Gao NY,Wu JY,Litscher G,Xu SF.Adverse events of massage therapy in pain-related conditions:a systematic review.

.2014;2014.https://doi.org/10.1155/2014/480956

31.Fitzgerald K,Denning T,Vaughan B.Simulated learning activities as part replacement of clinical placements in osteopathy:a case study.

.2017;26:44–48.https://doi.org/10.1016/j.ijosm.2017.10.003

32.McCoy L,Lewis JH,Bennett T,Fernandez M,Heath DM,Schwartz FN.Teaching medical students about health systems science and osteopathic principles and practice using a virtual world:The Envision Community Health Center.

.2018;118(8):545–554.https://doi.org/10.7556/jaoa.2018.123

33.Maddox RW,Schmid RJ.New frontiers in medical education:simulation technology at Campbell University School of Osteopathic Medicine.

.2014;75(1):59–61.https://doi.org/10.18043/ncm.75.1.59

34.Seffinger MA.The safety of osteopathic manipulative treatment(OMT).

.2018;118(3):137–138.https://doi.org/10.7556/jaoa.2018.031

35.Aboushanab T,AlSanad S.The current status of using simulation-based learning in integrative and complementary medicine training programs.

.2018;3(Suppl 1):A10.https://www.researchgate.net/publication/325056728_A10_