Visual abstract

Introduction

Acupuncture treatment (AT) is a widely practiced form of complementary and integrative medicine globally. It follows a traditional therapeutic approach that involves the application of mechanical stimulation through needles at specific points on the body’s surface with the aim of regulating the body’s Qi (vital energy) and blood flow, thereby preventing, alleviating, and treating numerous diseases [1]. By stimulating acupoints via diverse manipulation methods, AT activates the meridians, offering a relatively safe and effective treatment for a wide range of clinical disorders. Recent advancements in AT have led to the development and clinical application of sophisticated manipulation techniques such as electroacupuncture (EA), warm needling, and pharmacopuncture, which integrate electrical stimulation, heat stimulation, and pharmacotherapy respectively, into traditional AT [2]. Furthermore, practitioners are now integrating ultrasound technology with traditional AT for diagnostic and therapeutic purposes [3].

Ultrasound technology is a highly efficient diagnostic and therapeutic tool. It can be easily applied as it helps the practitioner visualize anatomical structures within the body in a noninvasive manner with few contraindications [4]. The advancement in ultrasound-guided AT technology has remarkably improved the safety and accuracy of AT compared with traditional palpation methods used for determining acupoints. This approach provides detailed anatomical information facilitating the correct location of acupoints to deliver the desired therapeutic effects. Consequently, this development represents a crucial turning point in the field of complementary and integrative medicine, whereby the focus has shifted from superficial body structures to internal anatomical structures to identify acupoints [5].

As ultrasound-guided diagnostic and therapeutic technologies continue to evolve, an increasing number of research studies are underway to address their limitations. In South Korea, clinical studies have been published on ultrasound-guided AT and pharmacopuncture [6,7]. A study published in 2018 reported on the status of ultrasound-guided AT, acupotomy (knife needle), and pharmacopuncture, and highlighted that research dedicated exclusively to AT remains limited [8].

As the number of clinical studies on ultrasound-guided AT has increased, this study aimed to provide a comprehensive scoping review of essential clinical data for practical applications. Specifically, given the current lack of research that clearly defines the applicable conditions and techniques for ultrasound-guided AT, this review will analyze existing literature to provide a thorough overview of clinical studies in terms of the treated conditions, application methods, clinical effectiveness, and safety of this technique. The findings of this review are expected to enhance the clinical utility of ultrasound-guided AT and suggest directions for future research.

Materials and Methods

This study was conducted according to the five-stage framework proposed by Arksey and O’Malley [9].

1. Identifying the research question

The following research questions were formulated to determine: (1) the current state of research on ultrasound-guided AT; (2) the conditions/diseases where ultrasound-guided AT is used; (3) how ultrasound-guided AT is specifically used; (4) the clinical efficacy and safety outcome of ultrasound-guided AT; and (5) future research directions for ultrasound-guided AT.

The following databases were used to identify the relevant literature to be analyzed in this scoping review: 4 English-language databases (Ovid-Medline, Ovid-EMBASE, AMED, and Cochrane Library); 1 Chinese database (China National Knowledge Infrastructure, CNKI); 1 Japanese database (CiNii); and 5 Korean databases [KoreaMed, Korean Medical Database (KMBASE), Korean Studies Information Service System (KISS), Science On, and Oriental Medicine Advanced Searching Integrated System (OASIS)].

2. Data sources and search strategy

The search string used in English-language databases was as follows: (Acupuncture OR Warming acupuncture OR Dry Needling OR Electroacupuncture) AND (Ultrasound OR Ultrasound-guided). The search targeted all literature published until April 2024. In other databases, the search string was slightly modified using Korean, Chinese, and Japanese keywords “Acupuncture OR Warming acupuncture OR Dry Needling OR Electroacupuncture” and “Ultrasound-guided.”

3. Study selection

3.1. Inclusion criteria

This scoping review encompassed all clinical studies that assessed the clinical impact of ultrasound-guided AT on functional improvement, pain reduction, efficacy, and safety. The review targeted clinical studies that employed ultrasound-guided AT as an intervention in adult patients, utilizing techniques such as general AT, warm needling, dry needling (DN), and EA. Outcome measures for evaluating pain, function, and safety included the visual analogue scale (VAS), Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Japanese Orthopedic Association (JOA) score, McGill Pain Questionnaire, range of motion (ROM), effective rate, and safety reports.

3.2. Exclusion criteria

No restrictions were imposed with regards to patient groups. However, studies lacking clear reporting on intervention methods were excluded from the analysis. Studies involving injection AT and pharmacopuncture were excluded, as were those using AT solely for diagnostic purposes (e.g., gastrointestinal motility tests and gastric cancer tests) rather than as a treatment.

4. Data extraction

Two independent researchers (SHL and JMY) conducted the screening process. Initially, they performed a screening of the titles and abstracts to identify studies that satisfied the inclusion and exclusion criteria. This was followed by a full-text review to determine the eligibility of the studies. After reviewing and cross-tabulating the analyzed content, the researchers further examined the selected studies to extract data including the authors, publication year, study design, country of publication, sample size, condition/disease, treatments in the intervention and control groups, outcome measures, main results, and adverse events (Table 1 [3,10–33]).

Results

1. General characteristics of the included studies

A total of 2,644 articles were identified through the literature search. The distribution across the databases were as follows: MEDLINE (426), Embase (384), AMED (39), Cochrane (642), CNKI (933), CiNii (4), KoreaMed (0), KMBASE (15), OASIS (1), Science On (91), and KISS (109). After removing duplicates, 2,198 studies were screened by their titles and abstracts, resulting in the exclusion of 2,119 articles based on the inclusion and exclusion criteria. Of the remaining 79 articles, screening of the full-text led to the exclusion of 54 studies due to noncompliance according to the PICO criteria, nonclinical research design, or other reasons. Consequently, 25 studies [3,10–33] (17 randomized controlled trials (RCTs), 2 clinical trials (CTs), 3 case series, and 3 case reports) published between 2004 and 2023 were included in the analysis. The PRISMA flow diagram outlining the literature selection process is presented in Figure 1, and the distribution of included studies illustrated by year and study design is presented in Figure 2.

2. Participants in the included studies

Most participants suffered from musculoskeletal pain, with some experiencing symptoms of post-stroke sequelae. The most common condition was myofascial trigger points which appeared in 5 studies [21–23,25,32], 4 studies on knee pain (pes anserinus bursitis [12], jumper’s knee [18,20] and knee osteoarthritis [19]), and 4 studies on back pain (low back pain [3,15,16] and lumbar disc herniation [11]). There were 2 studies each on post-stroke sequelae (lower limb muscle spasm after stroke [10], suprahyoid muscle group for pharyngeal dysphagia after stroke [28]), and piriformis syndrome [24,26], and 2 studies each on lateral epicondylitis [13,30], wrist drop [14] and tennis elbow [14]. There was 1 study each on cervical spondylosis [17], spinal cord injury [33], supraspinatus tendinopathy [27], intractable hiccup [29], and superficial angioma [31].

3. Type of intervention

The interventions used were as follows: ultrasound-guided AT, ultrasound-guided warming AT, ultrasound-guided DN, and ultrasound-guided EA. Color Doppler ultrasound-guided AT was mainly used in diagnosis, and the frequencies used were tailored to the target condition/disease: 9 MHz for low back pain [3], and 7–12 MHz for pes anserinus bursitis [12]. Most target acupoints were within the ultrasound-guided lesion areas [12] needling directly at the acupoints. Studies whereby ultrasound-guided warming AT was employed, Color Doppler ultrasound diagnosis was made: a frequency of 50 Hz/2 Hz was used for low back pain [15], and 8–15 MHz for cervical spondylosis [17], needling in the lesion area was guided using the ultrasound. The frequencies used in ultrasound-guided DN were: 7–14 MHz for jumper’s knee [18,20], 4–12 MHz for knee osteoarthritis [19], 7–12 MHz for myofascial trigger points [23], 3–5 MHz for piriformis syndrome (myofascial Trigger Points) [26], and 7–13 MHz for supraspinatus tendinopathy [27]. Within the ultrasound-guided EA interventions [28] used a Color Doppler ultrasound diagnosis with a frequency range of 5–18 MHz to precisely target lesion areas in the suprahyoid muscle group to treat pharyngeal dysphagia after stroke. Ultrasound-guided EA utilized B-mode ultrasound without specified frequencies [29], ultrasound in the 5–13 MHz range for Chronic lateral epicondylitis [30], ultrasound set at 12 Hz for Spinal cord injury [33], a Model 3000 Color Doppler ultrasound device set at 7.5 MHz for Superficial angioma [31], and real-time ultrasound imaging at 10 MHz for Thoracic myofascial pain syndrome [32] to target the condition being treated (Supplementary Table 1).

4. Type of comparators

As comparator groups, AT, conservative therapy, DN, and no intervention were used. The AT group encompassed general AT, warm needling, and EA. The conservative therapy group included single treatments such as medication and rehabilitation treatment including combined treatments such as medication + rehabilitation treatment, and injection + rehabilitation treatment. The no intervention group was assigned to noninterventional treatment such as being placed on a waiting list and receiving advice (Table 1).

5. Effectiveness

The effectiveness of ultrasound-guided AT was assessed using various metrics including pain, functional disability, and effective rate, with most studies reporting significant improvements. Pain outcomes were measured using the VAS in 3 studies [3,11,12], functional outcomes included the JOA score in 2 studies [3,11], the ODI for low back pain in 1 study [11], and quality of life (QOL) in 1 study [12]. All metrics showed statistically significant differences between the intervention and control groups. Effective rates exceeded 93% in all 3 studies [3,11,12]. Ultrasound-guided warming AT also demonstrated statistically significant improvements in VAS scores in 3 studies [15–17] and the ODI in 1 study[16], with all 3 studies reporting an effective rate over 90% [15–17]. Ultrasound-guided DN studies showed significant intergroup differences in VAS scores in 7 studies [18–21,24,25,27], in the NPRS score in 2 studies [22,23], in the ODI in 1 study [24], in ROM in 3 studies [22,24,27], and in the Knee Injury and Osteoarthritis Outcome Score in 3 studies [18–20]. In a study using the SF-36 QOL scale [23], while the Physical Component Summary score demonstrated a significant difference, the Mental Component Summary score did not. In studies on ultrasound-guided EA, significant differences were observed in VAS scores in 1 study [30], and in effective rate in 1 study [29]. One study [32] reported a reduction in the numeric pain scale score from 7 to 3. Statistically significant results were also yielded in various other outcome measures.

6. Adverse events

Among the 6 ultrasound-guided AT studies (5 clinical trials and 1 case series) no AEs occurred in the case series study by Parthasarathy [14], and other studies reported no AEs. In the 3 RCTs involving ultrasound-guided warming AT as an intervention, Zhou et al [15] reported no AEs in the treatment group but reported 1 case of hematoma in the control group. Wang et al [16] observed no AEs in both the intervention and control groups, while Zhang et al [17] reported no AEs. Among the 10 ultrasound-guided DN studies, AEs were reported in 3 studies. Huang et al [21] noted 6 AEs in the intervention group and 14 in the control group such as dizziness, nausea, and vomiting; however, they reported no serious AEs. Tabatabaiee et al [24] reported 2 cases of AEs (pain and bleeding) in the intervention group. In the 6 ultrasound-guided EA studies, Jin et al [28] reported no AEs in the intervention group but 8 cases of hematoma and 19 other AEs were reported in the control group. Liu et al [29] reported no occurrence of AEs, and the remaining studies did not specify.

Discussion

This scoping review is the first to report on domestic and international research trends, indicated conditions/diseases, intervention type and procedure, clinical effectiveness, and safety of ultrasound-guided AT. It included a total of 25 studies consisting of 17 RCTs, 2 CTs, 3 case series, and 3 case reports. Most participants suffered from musculoskeletal pain, and numerous other conditions/diseases were treated with ultrasound-guided AT interventions. The interventions included ultrasound-guided AT, ultrasound-guided warming AT, ultrasound-guided DN, and ultrasound-guided EA. The efficacy of ultrasound-guided AT was evaluated using metrics assessing pain (VAS, NPRS, and numeric pain scale), functional disability (JOA, ODI), and effectivity rate, with most interventions leading to significant improvements. In terms of AEs, no serious AEs occurred or were reported in ultrasound-guided AT and ultrasound-guided warming AT, and while AEs occurred in ultrasound-guided DN, no serious events were documented.

Among studies on ultrasound-guided AT retrieved from 2004 to 2023, 25 studies were reviewed for this current study: 14 originated from China, 2 each from the USA, Spain, and Pakistan, and 1 each from India, Australia, Iran, Italy, and Portugal. Most of the studies published in Korea utilized ultrasound diagnostically (including for biopsies), and therapeutically. Studies on AT using ultrasound were excluded from analysis due to their focus on guide acupotomy or pharmacopuncture, which did not satisfy the inclusion and exclusion criteria of this review. Interestingly, however, while most publications came from China, where AT is widely practiced, publications also emerged from a diverse range of 8 other countries. In these nations, regulatory frameworks permit the use of ultrasound imaging to ensure safe needle positioning for AT which offers both the practitioner and patient a visual display for the procedure. This supportive regulatory environment likely facilitated the publication of numerous studies on this topic.

The 25 included studies spanned a variety of study designs: 17 RCTs, 2 CTs, 3 case series, and 3 case reports (Figure 2). Although Kim et al [8] provided a comprehensive overview of ultrasound-guided AT, incorporating studies on guide needles and pharmacopuncture, this scoping review underscored exclusively on ultrasound-guided AT. The substantial growth in the clinical applications of this technique appears to have been adopted in response to Kim’s study [8]. Notably, this review expanded the evidence base significantly, encompassing 25 studies published within the past 6 years compared with Kim’s 3 included papers [8].

Ultrasound-guided AT was employed to treat a diverse range of conditions/diseases including musculoskeletal disorders such as myofascial trigger points, knee pain, back pain (low back pain, lumbar disc herniation), piriformis syndrome, lateral epicondylitis, wrist drop/tennis elbow, supraspinatus tendinopathy, and cervical spondylosis including conditions such as post-stroke sequelae, spinal cord injury, intractable hiccup, and superficial angioma. While this current study demonstrated the broad applicability of ultrasound-guided AT, the heterogeneity of treated conditions/diseases hindered comprehensive mapping and synthesis of data by condition/disease type. To advance the field, future research should prioritize high-quality RCTs adhering to CONSORT guidelines [34] to better understand the effects of ultrasound-guided AT by condition/disease type.

The intervention methods utilized in the reviewed studies included ultrasound-guided AT, ultrasound-guided warming AT, ultrasound-guided DN, and ultrasound-guided EA. Ultrasound-guided AT primarily involved real-time ultrasound imaging to ensure accurate positioning of the AT needle at the target site. Liu et al [35] specifically targeted acupoints directly for treating pes anserinus bursitis, whereas other studies used ultrasound imaging to identify lesion sites for needle insertion. The Color Doppler ultrasound diagnosis system was frequently used, with operating frequencies typically ranging from 7–12 MHz. Ultrasound-guided warming AT also employed real-time ultrasound imaging to verify accurate needle placement at target points, with AT performed at ultrasound-identified lesion sites. Similarly, Color Doppler ultrasound systems were predominantly used, with a frequency range of 2–15 and 50 MHz. Ultrasound-guided DN utilized ultrasound imaging to locate lesion sites for needle insertion, employing a variety of devices including Color Doppler and high-frequency ultrasound equipment. Ultrasound-guided EA combined Color Doppler and B-ultrasound to identify lesion locations for needle placement, with frequencies ranging 5–13 MHz (Supplementary Table 1). This current review provides a comprehensive overview of the diverse ultrasound technologies and frequencies employed across different AT interventions and condition/disease types. Future research should establish standardized ultrasound frequency guidelines for specific conditions/diseases.

Analysis of clinical effectiveness demonstrated significant improvements by reducing pain and functional disability, as well as overall clinical efficacy. Ultrasound-guided AT demonstrated statistically significant differences in pain outcomes as assessed by the VAS, functional outcomes as assessed by the JOA score, low back pain disability as assessed by the ODI, and QOL. In addition, the effective rate indicated high efficacy. Ultrasound-guided warming AT consistently yielded significant reductions in pain (VAS) and improved functional outcomes (ODI) in both intervention and control groups (Ultrasound-guided warming AT vs. AT, conventional treatment, or Warming AT + moxibustion), with high effective rates. Ultrasound-guided DN effectively managed pain (VAS and NPRS), enhanced functional outcomes (ODI, ROM, and Knee Injury and Osteoarthritis Outcome Score), and improved the physical component scores of QOL (SF-36 Physical Component Summary), revealing statistically significant differences between the intervention and control groups. While ultrasound-guided EA effectively reduced pain (VAS and NPRS), further research is warranted to evaluate its impact on functional outcomes and QOL.

Safety profiles for ultrasound-guided AT were generally favorable in the studies that assessed safety in the form of AE reporting. No serious AEs were reported in the intervention groups for ultrasound-guided AT, warming AT, and EA, with only minor AEs occurring in some control groups. AEs were reported for ultrasound-guided DN, but they did not involve serious cases. The use of ultrasound imaging to precisely target and visualize lesions, including their depth and size, contributed to the overall safety of the procedures utilized, demonstrating ultrasound-guided AT as a safe approach. However, despite the general assumption that these procedures are clinically safe and by the noninvasive nature of ultrasound imaging, the limited reporting of AEs in some studies underscores the need for comprehensive safety data. To establish a robust safety profile for ultrasound-guided AT, future research should prioritize consistent AE reporting.

Future research into ultrasound-guided AT should specifically focus on detailing the clinical trial AT intervention. To evaluate according to the STRICTA guidelines, needle types, forms of needle stimulation, needle specifications, and additional components of interventions including detailed descriptions of various practices within the AT groups, and their control and comparator groups need to be reported. However, crucial details such as the number of needles used per treatment, needle depth, names of acupoints, retention times, and comprehensive treatment details (including the number of treatments, their frequency, and duration) as well as practitioner background have only been partially reported or omitted. Future research must rigorously adhere to the STRICTA guidelines and ensure detailed reporting on: (1) rationale for using specific types of acupuncture needles; (2) detailed needling procedures; (3) comprehensive treatment regimens; (4) additional components of the treatment; (5) background of the practitioners; and (6) detailed descriptions of control and comparator interventions [36].

This current study represents the first scoping review of research on ultrasound-guided AT. Its significance lies in the comprehensive analysis of national and international clinical studies examining the clinical efficacy of this intervention, without language restrictions. While ultrasound-guided AT is not universally adopted, its application extends beyond China to several Western countries. The findings in this current review report that although the application of this technique spans a broad range of conditions/diseases, the technique is primarily used to manage musculoskeletal disorders. Despite the majority of included studies from a specific country, this scoping review adhered rigorously to systematic review methodology. Further large-scale clinical trials conducted in accordance with CONSORT and STRICTA guidelines are necessary to definitively establish the clinical effectiveness of ultrasound-guided AT [37].

Conclusion

In this study, ultrasound-guided AT was categorized into 4 major techniques: AT, warming AT, DN, and EA. While predominantly used for musculoskeletal conditions/diseases, ultrasound-guided AT has also been employed to treat disorders including post-stroke sequelae and spinal cord injuries. Research on ultrasound-guided AT applied to specific conditions/diseases is limited. There is a wide variety of techniques in use, with ultrasound application sites and frequencies varying depending on the disorder/disease being treated. Future research should prioritize high-quality RCTs for each disorder/disease, along with standardized guidelines for ultrasound parameters such as frequency and application site, to optimize outcomes.

Supplementary Material

Acknowledgments

Article information

Author Contributions

Conceptualization: SHL, YJL, and IHH. Methodology: SHL, YJL, and IHH. Formal investigation: SHL, YJL, and IHH. Writing original draft: SHL. Writing-review and editing: YJL, JYK, IH, JHC, BKS, YCP, JHK, and IHH.

Conflicts of Interest

SHL is a managing editor, and YJL and IHH are the editors of Perspectives on Integrative Medicine, but this had no influence in the decision to publish this article. No other potential conflict of interest relevant to this article was reported.

Funding

This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute, funded by the Ministry of Health and Welfare, Republic of Korea (grant no.: RS-2023-KH139336).

Ethical Statement

This research did not involve any human or animal experiments.

Data Availability

Figure 1

Flow chart of study selection process.

Figure 2

The number of articles based on the classification of study design, type of intervention, and publication year.

AT = acupuncture treatment; CT = clinical trial; DN = dry needling; EA = electroacupuncture; RCT = randomized controlled trial.

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References

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