Reliability of Chinese Medicine Diagnostic Variables in the Examination of Patients with Osteoarthritis of the Knee

A Survey on Perceptions of the Direction of Korean Medicine Education and National Licensing Examination

Recent changes in medical education and assessment led to a focus on occupational competency, and this study investigated the perceptions of Korean medicine doctors (KMDs) on the national licensing examination for KMDs (NLE-KMD). The survey aimed to understand KMDs' recognition of the current situation, items to improve, and items to emphasize in the future. We conducted the web-based survey from 22 February to 4 March 2022, and 1244 among 23,338 KMDs answered voluntarily. Through this study, we found the importance of competency-related clinical practice and Korean standard classification of disease (KCD), and the presence of a generation gap. KMDs considered clinical practice (clinical tasks and clinical work performance) and the item related to the KCD important. They valued (1) the focus on KCD diseases that are frequently seen in clinical practice and (2) the readjustment and introduction of the clinical skills test. They also emphasized KCD-related knowledge and skills for the assessment and diagnosis of KCD diseases, especially those frequently treated at primary healthcare institutes. We confirmed the generation gap in the subgroup analysis according to the license acquisition period, and the ≤5-year group emphasized clinical practice and the KCD, while the >5-year group stressed traditional KM theory and clinical practice guidelines. These findings could be used to develop the NLE-KMD by setting the direction of Korean medicine education and guiding further research from other perspectives.

Inter-Rater Agreement of Biofield Tuning: Testing a Novel Health Assessment Procedure

Objectives: Practitioners of Biofield Tuning assess health status of their clients by detecting off-the-body biofield perturbations using tuning fork (TF) vibrations. This study tested inter-rater agreement (IRA) on location of these perturbations. Design: Three Biofield Tuning practitioners, in randomized order, identified locations of the 4-5 "strongest" perturbations along each of 4 sites for the same series of 10 research subjects. Setting/Location: An Integrative Health and Medicine Center in La Jolla, CA. Subjects: Adult volunteers with no serious current illness and no prior experience of a Biofield Tuning session. Interventions: Practitioners used an activated 174 Hz unweighted TF to "comb" the same four sites per subject, located on the left and right sides of the base of the spine and the heart. Outcome Measures: Practitioners identified and vocalized the distance from the body of perturbations along each site. Distances were recorded by a research assistant in the clinic room. No health information related to perturbation sites was discussed with the subjects. Results: Practitioners reported 6.3 ± 0.6 (mean ± standard deviation) perturbations per combed site per subject, with no significant difference among the raters. The overall level of IRA was low based initially on a first-pass, nonstatistical, analysis of results, with "agreement" defined within a tolerance of ±2 inches. In this approach agreement was 33%. More rigorous statistical analysis, including a statistical test using a Monte Carlo approach, strongly supported the conclusion of poor IRA. Conclusions: IRA was low despite attempts to balance the real-world practice of Biofield Tuning with the constraints of research. For example, while IRA necessitates multiple assessments of the same subject, no information exists as to whether an initial assessment may affect subsequent assessments. Our study exemplifies the challenges faced when attempting to fit interventions with incompletely understood procedures and mechanisms into conventional research designs.

Experimental Studies of Inter-Rater Agreement in Traditional Chinese Medicine: A Systematic Review

Objectives: It has been recommended that clinical trials of Traditional Chinese Medicine (TCM) would be more ecologically valid if its characteristic mode of diagnostic reasoning were integrated into their design. In that context, however, it is also widely held that demonstrating a high level of agreement on initial TCM diagnoses is necessary for the replicability that the biomedical paradigm requires for the conclusions from such trials. Our aim was to review, summarize, and critique quantitative experimental studies of inter-rater agreement in TCM, and some of their underlying assumptions. Design: Systematic electronic searches were conducted for articles that reported a quantitative measure of inter-rater agreement across a number of rating choices based on examinations of human subjects in person by TCM practitioners, and published in English language peer-reviewed journals. Publications in languages other than English were not included, nor those appearing in other than peer-reviewed journals. Predefined categories of information were extracted from full texts by two investigators working independently. Each article was scored for methodological quality. Outcome measures: Design features across all studies and levels of inter-rater agreement across studies that reported the same type of outcome statistic were compared. Results: Twenty-one articles met inclusion criteria. Fourteen assessed inter-rater agreement on TCM diagnoses, two on diagnostic signs found upon traditional TCM examination, and five on novel rating schemes derived from TCM theory and practice. Raters were students of TCM colleges or graduates of TCM training programs with 3 or more years experience and licensure. Type of outcome statistic varied. Mean rates of pairwise agreement averaged 57% (median 65, range 19-96) across the 9 studies reporting them. Mean Cohen's kappa averaged 0.34 (median 0.34, range 0.07-0.59) across the seven studies reporting them. Meta-analysis was not possible due to variations in study design and outcome statistics. High risks of bias and confounding, and deficits in statistical reporting were common. Conclusions: With a few exceptions, the levels of agreement were low to moderate. Most studies had significant deficits of both methodology and reporting. Results overall suggest a few design features that might contribute to higher levels of agreement. These should be studied further with better experimental controls and more thorough reporting of outcomes. In addition, methods of complex systems analysis should be explored to more adequately model the relationship between clinical outcomes, and the series of diagnoses and treatments that are the norm in actual TCM practice.

A Novel Approach to Describing Traditional Chinese Medical Patterns: The "Traditional Chinese Medical Diagnostic Descriptor"

Objectives: In the first of a series of three articles by the present authors, diagnostic agreement between Traditional Chinese Medicine (TCM) practitioners was found to be low. This was the first time that TCM diagnoses had been evaluated with an open population of patients and this result is a cause of concern. In the second article, incorrect statistics were shown to have often been used to calculate chance-removed inter-rater agreement, and appropriate statistics such as Gwet's Agreement Coefficient 2 (AC2) was recommended for future studies. In this, the third article, a novel approach to recording TCM diagnostic patterns, the Traditional Chinese Medical Diagnostic Descriptor (TCMDD), is presented that allows chance-removed agreement calculation. An example of mapping TCM diagnostic patterns to the TCMDD format is given and diagnostic agreement is evaluated. Design, Settings, Subjects: The same 35 subjects used to report agreement in our first article were also diagnosed by additional practitioners using the TCMDD format during the same experimental sessions at the University of Technology, Sydney Clinic. TCM diagnoses from the first article were also mapped to the TCMDD format. Outcome measures: Linearly weighted simple agreement and the AC2 statistic were utilized and all results compared. Results: Linearly weighted simple agreement using the TCMDD and TCM mapped to TCMDD format averaged 0.80 ± 0.02 compared with 0.19 for TCM. TCMDD and TCM mapped to TCMDD chance-removed agreement, as calculated with AC2, ranged between 0.67 and 0.73 ± 0.03. Conclusions: The TCMDD allows the essence of diagnoses expressed by TCM practitioners to be appropriately compared. This was confirmed by the TCM mapped to TCMDD results. In both cases, simple agreement was significantly greater than that obtained with the TCM format. Chance-removed statistics and error estimates can be reliably calculated with the AC2 and the TCMDD in open populations.

Interaction of energetic points, tendinomuscular meridian and 5 elements in the treatment of osteoarthritis of the knee in patients over 45 years old: a randomized controlled trial

INTRODUCTION

Acupuncture had a different approaches since its beginnings. Using traditional energetic points with an interaction of 5 elements and meridian theories with manual diagnosis of tender points has been proposed. This procedure can be an effective treatment in musculoskeletal disease but its development is short.

OBJECTIVES

To evaluate the efficacy of energetic points of tendinomuscular meridian in the treatment of pain, quality of life and function of the knee.

DESIGN

Randomized controlled trial, non standardized and double blind. Inclusions criteria were: being over 45 years, having had pain for more than 3 months, level II o greater in Kellgren-Lawrence and suffering morning stiffness. Exclusion criteria were artoplasty, corticosteroids and rehabilitation, arthropaties, autoinmune diseases and neuropathic pain.

RESULTS

Intervention group had significant improvement in average pain in the last 15 days at end of treatment (p<0.04) and quality of life at the end of follow-up (p<0.015). Other measurements no show significant differences between groups.

CONCLUSIONS

Energetic points of tendinomuscular meridian and the 5 elements related are equal or better than local acupuncture in the treatment of pain, quality of life and function in osteoarthritis of the knee. However, it is necessary to have more research with more tracing and poblation to improve the quality of the results.

Characterization of hidden rules linking symptoms and selection of acupoint using an artificial neural network model

Comprehension of the medical diagnoses of doctors and treatment of diseases is important to understand the underlying principle in selecting appropriate acupoints. The pattern recognition process that pertains to symptoms and diseases and informs acupuncture treatment in a clinical setting was explored. A total of 232 clinical records were collected using a Charting Language program. The relationship between symptom information and selected acupoints was trained using an artificial neural network (ANN). A total of 11 hidden nodes with the highest average precision score were selected through a tenfold cross-validation. Our ANN model could predict the selected acupoints based on symptom and disease information with an average precision score of 0.865 (precision, 0.911; recall, 0.811). This model is a useful tool for diagnostic classification or pattern recognition and for the prediction and modeling of acupuncture treatment based on clinical data obtained in a real-world setting. The relationship between symptoms and selected acupoints could be systematically characterized through knowledge discovery processes, such as pattern identification.

Consensus in Traditional Chinese Medical Diagnosis in Open Populations

Objectives: An acceptable level of diagnostic agreement is a prerequisite for consistent administration of treatment. It is critical for investigating effectiveness of different treatment approaches using multiple practitioners. To the best of our knowledge, no previous investigation of diagnostic consensus using open populations in Chinese medicine (CM) has been reported. Investigations restricted to individual medical conditions, such as have been usually studied, do not reveal any information as to what occurs in real world clinical settings. This knowledge gap led to the current study being conducted. Design/Location/Subjects/Interventions: Investigating diagnostic agreement specifically in Traditional Chinese Medicine (TCM) in an open population, two or three practitioners diagnosed 35 subjects at the University of Technology, Sydney (UTS), TCM clinic. The practitioners were restricted to a list of the 56 most frequently used TCM diagnoses at the UTS clinic. Up to three diagnostic patterns per subject could be selected, with nominated patterns scored between 1 and 5. Outcome measures: Agreement was determined with two criteria, both expressed as simple percentages: pattern and linearly weighted agreements. Results: The results showed that 23% of practitioners obtained pattern agreement, while 19% demonstrated weighted agreement. Conclusion: There appears to be very low diagnostic agreement between practitioners. This is an important finding. If unchallenged by further investigation, the recognition of such poor diagnostic consensus may lead to rejection of TCM theory before it has been adequately assessed. Diagnostic agreement must be improved so that future investigations into treatment effectiveness or mechanisms of action are made on a valid basis. Additionally, the current TCM diagnostic format must be altered to allow the application of chance-removed statistics or the calculation of a standard error with open populations. This article is the first of a series of three that report problems in TCM diagnostic reliability and proposes solutions to the issues outlined.

The application of PRECIS-2 ratings in randomized controlled trials of Chinese herbal medicine

This study tests the feasibility of applying the pragmatic-explanatory continuum indicator summary (version "PRECIS-2") tool to randomized controlled trials of Chinese herbal medicine. A search was conducted to identify potentially eligible randomized controlled trials. Using the PRECIS-2 tool, assessment of trials was performed independently by 2 evaluators using a scale of 1-5 for each criterion (1 = maximal efficacy, 5 = maximal effectiveness). A total of 7,166 reports were retrieved from databases and 159 were included in the full text. Though PRECIS-2 describes quantitative scoring in detail, evaluators were uncertain about several specific operationalizations and found high evaluator variation in the first independent ratings. After discussion and reaching consensus, inter-evaluator reliability improved. For PRECIS-2 ratings over time, there was no evidence that the design and performance of RCTs of CHM paid more attention to "efficacy" criteria after the implementation of PRECIS (all P > 0.05). More research is needed to establish the easiest and most useful tool to distinguish between effectiveness and efficacy results.

Why We Need Minimum Basic Requirements in Science for Acupuncture Education

As enthusiasm for alternatives to pharmaceuticals and surgery grows, healthcare consumers are turning increasingly to physical medicine modalities such as acupuncture. However, they may encounter obstacles in accessing acupuncture due to several reasons, such as the inability to locate a suitable practitioner, insufficient reimbursement for treatment, or difficulty gaining a referral due to perceived lack of evidence or scientific rigor by specialists. Claims made about a range of treatment paradigms outstrip evidence and students in acupuncture courses are thus led to believe that the approaches they learn are effective and clinically meaningful. Critical inquiry and critical analysis of techniques taught are often omitted, leading to unquestioning acceptance, adoption, and implementation into practice of approaches that may or may not be rational and effective. Acupuncture education for both licensed physicians (DOs and MDs) and non-physicians needs to include science (i.e., explanation of its effects based on contemporary explanations of biological processes), evidence, and critical thinking. Erroneous notions concerning its mechanisms such as moving "stuck Qi (Chi)" or "energy" with needles and that this energy stagnates at specific, tiny locations on the body called acupuncture points lead to mistakes in methodologic design. For example, researchers may select sham and verum point locations that overlap considerably in their neural connections, leading to nonsignificant differences between the two interventions. Furthermore, attributing the effects of acupuncture to metaphorical and arcane views of physiology limits both acceptance and validation of acupuncture in both research and clinical settings. Finally, the content and quality of education and clinical exposure across acupuncture programs varies widely, with currently no minimum basic educational requirements in a scientific methodology. Considering the pressures mounting on clinicians to practice in an evidence-based and scientific manner that also demonstrates cost-effectiveness, acupuncture schools and continuing medical education (CME) courses need to provide their students a strong foundation in rational approaches supported by research.

Reliability of Manual Pulse Diagnosis Methods in Traditional East Asian Medicine: A Systematic Narrative Literature Review

BACKGROUND/OBJECTIVE

Little evidence shows the reliability of Chinese medicine pulse diagnosis. Regularly used in modern practice, it is believed to gather important diagnostic information. However, in the current evidence-based healthcare system, basing clinical decisions on unproven methods is problematic and obviously questions the relevancy of the procedure. Therefore, the literature on reliability of practitioners implementing the method was reviewed.

METHODS

Major medical databases and reference lists of identified articles were searched. All studies published in English that investigated manual pulse diagnosis applied to the radial artery by human testers were considered.

RESULTS

Twelve eligible studies were included; three evaluated intra- and inter-rater pulse diagnosis reliability, and nine assessed inter-rater reliability. Acceptable levels of intra- and inter-rater reliability were achieved with operationally defined methods. Poor reliability was related to unclear definitions and terminology existing within the classical definitions, and with standardized systems to persisting imprecise descriptions that can be interpreted differently. Reliability of pulse qualities was influenced by sensation complexity and the amount of sensory input provided to the testers' fingers by the impulse. Consistent study limitations included small sample sizes; the possibility that testers' prior knowledge confounded the data; and, most notably, the fact that many studies did not consider intra-rater reliability. Assessing the effectiveness of interventions in clinical practice is guided by comparisons of markers to baseline. The absence of intra-rater results may therefore raise methodologic concerns for these types of studies.

CONCLUSION

Strategies for future studies include using pulse methods with concrete operational definitions; investigating intra- and inter-rater reliability for extrapolation to clinical practice; similar training and experience in the method to control for tester variance; maintaining independence of the data by ensuring testers have no prior knowledge of the participants' pulses; and for more rigorous testing, consideration of the number of pulse variables, participants, and testers.

Inter-observer reliability of indicators and decision of pattern identification using diagnostic flowchart with traditional Korean medicine

OBJECTIVE

To evaluate the consistency of patterns and pattern identification (PI), and the improvement in the diagnosis of blood stasis after the standard operating procedures (SOPs) were enhanced by using a diagnostic flflowchart. Methods A total of 358 subjects who were admitted by the Jaseng Hospital of Korean Medicine between June 2013 and December 2014 were included in the study. Each patient was independently diagnosed by two experts from the same department. In 2014, the SOPs included the use of a diagnostic flflowchart for each indicator. Inter-observer consistency was assessed by simple percent agreement and by the kappa and AC1 statistics.

RESULTS

The improvements in inter-observer agreement for the indicators (for all patients) and PI were greater in 2014 than in 2013. In 2013, the j-value measure of agreement between the two experts ranged from "poor" (κ=-0.051) to "good" (κ=0.968). The AC1 measure of agreement between the experts was generally high for the indicators and ranged from-0.010 to 0.978. In most cases, agreement was considerably lower when it was assessed by the j-values compared with the AC1 values. In 2014, the j-value measure of agreement on the indicators (for the subjects) generally ranged from poor to good, with the values ranging from-0.007 to 0.994. Moreover, the AC1 measure of agreement between the experts was generally high for all of the indicators and ranged from "moderate" (AC1=0.408) to "excellent" (AC1=0.996).

CONCLUSIONS

In four examinations, there was moderate agreement between the clinicians on the PI indicators of blood stasis. To improve clinician consistency (e.g., in the diagnostic criteria used), it is necessary to analyse the reasons for inconsistency and to improve clinician training. (Trial registration No. KCT0000916).

Duhuo Jisheng decoction inhibits endoplasmic reticulum stress in chondrocytes induced by tunicamycin through the downregulation of miR-34a

Our previous study showed that Duhuo Jisheng decoction (DHJSD) inhibited chondrocyte apoptosis by the mitochondria-dependent signaling pathway. Endoplasmic reticulum (ER) stress is upstream of the mitochondria-dependent signaling pathway and has been shown to promote chondrocyte apoptosis that occurs in osteoarthritis (OA). The present study aimed to evaluate whether DHJSD inhibits the chondrocyte apoptosis by regulating ER stress. DHJSD enhanced the viability of tunicamycin (TM)‑exposed chondrocytes, a model of ER stress-induced apoptosis, in a dose‑ and time‑dependent manner, as shown by MTT assay. The present results showed that DHJSD and sodium 4-phenylbutyrate (PBA), an ER stress inhibitor, reduced TM‑induced chondrocyte apoptosis by 4',6-diamidino‑2-phenylindole staining. To gain insight into the mechanisms of DHJSD that are responsible for enhancing the viability and inhibiting TM‑induced chondrocyte apoptosis, the associated mRNA expressions and protein levels were detected by reverse transcription‑polymerase chain reaction (RT‑PCR) and western blot analysis, respectively. The results showed that the expression levels of Xbp1, Xbp1s and Bcl‑2 were increased, and the expression levels of Bip, Atf4, Chop, Bax, caspase‑9 and ‑3 were decreased in the TM‑exposed chondrocytes treated with DHJSD or PBA compared with that in the TM‑exposed chondrocytes. To identify the possible mechanisms, the expression of miR‑34a was examined by the TaqMan microRNA assay, and was downregulated in the TM‑exposed chondrocytes treated with DHJSD or PBA compared with that in the TM-exposed chondrocytes. DHJSD inhibits ER stress in chondrocytes induced by exposure to TM by downregulating miR‑34a, suggesting that DHJSD may be a potential therapeutic agent for OA.

Interobserver reliability of four diagnostic methods using traditional korean medicine for stroke patients

Objective. The aim of this study is to evaluate the consistency of pattern identification (PI), a set of diagnostic indicators used by traditional Korean medicine (TKM) clinicians. Methods. A total of 168 stroke patients who were admitted into oriental medical university hospitals from June 2012 through January 2013 were included in the study. Using the PI indicators, each patient was independently diagnosed by two experts from the same department. Interobserver consistency was assessed by simple percentage agreement as well as by kappa and AC₁ statistics. Results. Interobserver agreement on the PI indicators (for all patients) was generally high: pulse diagnosis signs (AC₁ = 0.66–0.89); inspection signs (AC₁ = 0.66–0.95); listening/smelling signs (AC₁ = 0.67–0.88); and inquiry signs (AC₁ = 0.62–0.94). Conclusion. In four examinations, there was moderate agreement between the clinicians on the PI indicators. To improve clinician consistency (e.g., in the diagnostic criteria used), it is necessary to analyze the reasons for inconsistency and to improve clinician training.

Poor multi-rater reliability in TCM pattern diagnoses and variation in the use of symptoms to obtain a diagnosis

BACKGROUND

Pattern differentiation and diagnosis are fundamental principles of Traditional Chinese Medicine (TCM). Studies have shown low inter-rater reliability in TCM pattern diagnoses. This variability may originate from both the identification and the interpretation of symptoms and signs.

OBJECTIVE

To examine the inter-rater reliability in TCM pattern diagnoses made in the style of Maciocia for 25 case histories by eight acupuncturists and to explore the impact of demographic factors on the diagnostic conclusion. Further, the association between the diagnosis and the presence of symptoms was examined for a single TCM diagnosis.

METHODS

Eight acupuncturists independently diagnosed 25 women (15 fertile, 10 infertile) based on written case histories. Descriptive statistics, logistic regression and inter-rater reliability (κ) were used.

RESULTS

Poor inter-rater reliability on TCM patterns (κ<0.20) and large variation in the number of TCM pattern diagnoses were found. Sex, duration of practice and education had a highly significant effect (p<0.001) on the use of TCM patterns and working hours had a significant effect (p=0.029). There was considerable intra- and inter-rater variation in the use of symptoms to make a diagnosis. Symptoms occurring frequently as well as infrequently were inconsistently used to diagnose Liver Qi Stagnation. The study was limited by a small sample size.

CONCLUSIONS

The results showed extensive variation and poor inter-rater reliability in TCM diagnoses. Demographic variables influenced the frequency of diagnoses and symptoms were used inconsistently to set a diagnosis. The variability shown could impede individually tailored treatment.