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Evaluation of a group acupuncture service in a National Health Service outpatient physiotherapy department


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Group acupuncture sessions set up as a drop in for patients with chronic MSK Pain. Evaluation reveals pain relief, reduced medication load, and high levels of patient satisfaction
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Journal of the Acupuncture Association of Chartered Physiotherapists, Spring 2013, 00–00
Evaluation of a group acupuncture service in a
National Health Service outpatient
physiotherapy department
C. Waldock
Musculoskeletal Physiotherapy Department, Medway Community Healthcare, Gillingham,
Kent, UK
A large number of patients suffer from ongoing musculoskeletal pain, and a significant
proportion of this population report that they find acupuncture helpful. However, this form of
treatment can make demands on the UK National Health Service (NHS ) that are often difficult
to satisfy. Therefore, group acupuncture sessions were introduced in an NHS physiotherapy
department in order to provide a maintenance therapy service for this population. The service
was evaluated using a patient questionnaire and the feedback received was very encouraging.
Respondents reporting benefits not only in terms of pain relief, but also with regard to peer
support. In the future, this type of group treatment could also be offered to patients with other
chronic problems such as rheumatoid arthritis and fibromyalgia.
Keywords: chronic pain, coping strategies, group acupuncture, patient questionnaire, service
Chronic widespread pain affects approximately
one in five adults in Europe (Croft et al. 1993;
Breivik et al. 2006). Acupuncture has been shown
to help people manage a variety of types of
chronic pain (Carlsson & Sjölund 2001; Thomas
et al. 2006; Haake et al. 2007; Mavrommatis et al.
2012). Some physiotherapy services are based in
areas of significant economic deprivation and see
higher numbers of patients with chronic wide-
spread pain. Such services faces constant chal-
lenges, such as the need to treat more patients
and the pressure to accomplish more with less in
the present restrictive financial climate. One of
the greatest of these challenges is to make better
use of the clinician’s time since it is accepted that
this represents the most expensive part of a
treatment. For example, band 6–8a physio-
therapists incur costs of at least £20 per hour
(NHS 2012 ).
Phillips et al. (2004 ) described the use of
acupuncture in group settings, and presented
evidence that the provision of this form of
treatment can provide symptom relief. It has
been proposed that treating patients in a group
has many benefits for both the UK National
Health Service (NHS ) and the individuals under-
going needling, one of which is the maintenance
of benefits over the long term (Mutrie et al.
The present author’s physiotherapy team
sought the views of patients with chronic pain
who were receiving acupuncture treatment.
The concept appeared to be popular with the
majority of patients, and consequently, in
September 2010, a group acupuncture session
was introduced in the Musculoskeletal Physio-
therapy Department of Medway Community
Healthcare, Gillingham, Kent, UK, for those
who met the inclusion criteria.
Correspondence: Colin Waldock, Physiotherapy Depart-
ment, c/o Medway Maritime Hospital, Windmill Road,
Gillingham, Kent ME7 5NY, UK (e-mail:
2013 Acupuncture Association of Chartered Physiotherapists 1
JOBNAME: jaacp PAGE: 2 SESS: 3 OUTPUT: Thu Dec 13 08:10:27 2012
Subjects and methods
The inclusion criteria were that the patients
should have:
+previously reported a positive response to
+shown evidence of chronic widespread pain;
+had continual pain for more than 3 months;
+a requirement for maintenance therapy.
In order to maximize patient safety, the group
was run by a physiotherapist who was experi-
enced in the use of acupuncture. The participants
were treated in a semi-recumbent position in
half-lying and were in visual contact with the
physiotherapist at all times. In such situations,
clinicians should have a heightened awareness of
patient responses to needling, and take into
account the fact that patients who react strongly
to treatment often report sensations of light-
headedness and/or increased discomfort after
treatment (White et al. 2001 ). The participants in
the sessions were in control of the duration of
their treatments and the physiotherapist regularly
checked on patients to assess their comfort
status. While each treatment was individually
tailored, the average treatment time was approxi-
mately 10–15 min.
The team chose to focus on the use of distal
acupuncture points, predominantly the ‘‘Four
Gates’’, i.e. Large Intestine 4 (Hegu ) and Liver 3
(Taichong). This ensured ease of application
across the group, and is a needle prescription
that has found to be of value in the treatment of
patients with chronic pain. The use of distal
points such as the Four Gates was supported by
Bradnam-Roberts (2007 ) in her paper reviewing
the use of acupuncture within Western physio-
logical models. Maciocia (1989 ) described the
use of the Four Gates as being of value in easing
pain and calming the mind. Disposable acupunc-
ture needles (0.2 13 mm; Scarboroughs Ltd,
Crewkerne, Somerset, UK) were used with guide
tubes. The needles were not manipulated, and
the depth of insertion was between 5 and
10 mm.
The team also decided that participants would
not necessarily be required to receive treatment
for 30 min or more with high-intensity stimula-
tion. This was primarily for pragmatic reasons,
including time availability, and was based on
experiential evidence from patients who had
previously received treatment within the depart-
ment. The decision was also supported by
authors such as MacPherson et al. (2008 ), who
described the similarities in functional magnetic
resonance imaging scans of individuals who had
received superficial needling and those who had
undergone deep needling. Recent research also
shows a plethora of evidence suggesting that
verum acupuncture does not appear to have a
significantly superior outcome to so-called sham
approaches, which often involve superficial nee-
dling (Haake et al. 2007 ). It is the present
author’s belief that evidence requires the inclu-
sion of both empirical and experiential views in
order to match research outcomes to the needs
of patient populations (Schön 1991 ), and that
the evidence base includes propositional know-
ledge, professional craft knowledge and personal
knowledge (Higgs & Titchen 1995 ). In other
words, it is important to incorporate evidence
from more than just systematic reviews or
double-blind randomized controlled trials
(RCTs ) in the determination of what is to be
viewed as best practice. This is not intended to
demean the evidence presented by RCTs, but
rather, it is meant to supplement it.
On reviewing the current classes run by the
department, it became clear that the patients’
preference was for the open class model. This
allowed participants to attend at any time
between 1700 and 1800 h. This period was
chosen because it is a quiet time for the depart-
ment, allowing up to seven plinths at a time to be
utilized by patients without interfering with the
normal activity levels within the clinic.
When the group was initially set up, it attracted
approximately 10 patients to each session. This
number increased over the next 6 months until,
at the time of writing, it had almost doubled.
Nineteen people now attend and there is a
possibility that even more will participate in
future: the team are currently seeing over 20
regular patients each week and the numbers can
occasionally be as high as 28.
The team believed that it was appropriate to
ask the group for their opinions in order to help
evaluate the success or otherwise of this innova-
tion, and therefore, group attendees were given
the opportunity to offer feedback via a question-
naire. The NHS clinical governance policy
Evaluation of a group acupuncture service
2013 Acupuncture Association of Chartered Physiotherapists2
JOBNAME: jaacp PAGE: 3 SESS: 4 OUTPUT: Thu Dec 13 08:10:27 2012
recommends the monitoring of services through
service evaluation, audits and patient surveys
(DH 1999 ). In view of the present work being a
service evaluation and not research, it was unnec-
essary to obtain an ethical opinion, as per the
advice given by the NRES (2009 ).
Questionnaires were distributed to all the
patients, during class attendance with a concur-
rent 100% return rate. The feedback from
patients attending the class helped to highlight
the benefits, problems and outcomes from the
Question 1 asked, ‘‘Can you give your overall
views on the concept of an acupuncture class?’’
This elicited a variety of positive responses,
+‘‘ideal as no fixed appt.’’;
+‘‘So much better than 1:1, this way more
people benefit in same time’’;
+‘‘[. . .] makes acupuncture available to every-
+‘‘[. . .] a brilliant thing’’;
+‘‘[. . .] invaluable [. . .]’’;
+‘‘[. . .] stunning [. . .]’’; and
+‘‘a resource [. . .] available to many clients’’.
The second question was, ‘‘What do you find
most valuable about the class?’’ which also gen-
erated a range of encouraging comments:
+‘‘Pain relief [. . .] I don’t know what I’d do
without this class’’;
+‘‘pain relief and feeling that I am not
+‘‘I see other people in the same position and
can talk to them or the practitioner’’;
+‘‘that I can have ongoing acupuncture’’;
+‘‘Reducing pain, reducing medication’’;
+‘‘time helps me stay at work’’; and
+‘‘the open time of a 1 hour session’’.
In contrast, question 3 asked, ‘‘What do you
find unhelpful about the class?’’ Although most
of the responses given simply stated, ‘‘Nothing’’,
two issues were raised, ‘‘Parking’’ and ‘‘Perhaps a
class could be offered at 8am as well’’.
The fourth question asked, ‘‘In your opinion,
what would you change within the current set
up?’’ The responses included:
+‘‘[. . .] to meet up with others in group after’’;
+‘‘longer treatment time [. . .]’’;
+‘‘make this service available to more people –
inform GPs [general practitioners] about it’’;
+‘‘Make available for 2
time a week or make
available at other venues as well.’’
Question 5 was, ‘‘Would you be willing to pay
a small fee to attend?’’ which elicited a 100%
positive response, although with some qualifica-
tions, such as:
+‘‘worried as a pensioner that cost may rise’’;
+‘‘[. . .] wouldn’t want to see it priced out of
+‘‘I struggle to meet ends at the moment’’; and
+‘‘yes, but as a taxpayer [. . .] this should be
provided on [the] NHS’’.
The sixth question asked, ‘‘On a score out of
100, how much has attendance helped with the
amount of pain that you normally suffer?’’ The
team were expecting a score of about 30 here
because of the fact that the patients who attend
the group are commonly suffering from long-
term complex pain problems. However, the
responses given cited a range of scores between
50% and 95% (average score =76%), suggesting
that attendance is significantly easing the inten-
sity of the pain that the participants suffer
(Fig. 1 ).
Question 7 asked, ‘‘On a score out of 100, how
much has attendance helped with your ability to
cope with the pain?’’ This was intended to probe
the effect of acupuncture on the participants’
well-being and their ability to cope with daily life
while suffering from chronic pain. Once again,
the replies were very encouraging with the re-
spondents citing an improvement in their ability
0 2 4 6 8 101214161820
Improvment in pain
Patient number
Figure 1. Percentage improvement in pain (n=19).
C. Waldock
2013 Acupuncture Association of Chartered Physiotherapists 3
JOBNAME: jaacp PAGE: 4 SESS: 4 OUTPUT: Thu Dec 13 08:10:27 2012
to cope with pain of between 60% and 100%.
The mean score for the group was 80% (Fig. 2 ).
The eighth and final question was, ‘‘Would
you recommend this service to a friend?’’ This
also elicited a 100% positive response, and
additional comments included:
+‘‘most definitely – thank you’’;
+‘‘[. . .] already have’’; and
+‘‘[. . .] I recommend this to everyone’’.
The feedback received from patients attending
the group acupuncture sessions was very encour-
aging. First, the participants were experiencing
significant relief from their pain, and for some,
this has led to a reduction in their reliance on
pain medication. The patients appreciated the
support that they received from other partici-
pants in the group and the realization that
they were not the only ones with chronic pain
(Griffiths et al. 2009). There have also been
important social benefits for these patients, who
have developed friendships that have proved to
be long-lasting. Isolation has been reported as
being a factor of living with chronic pain
(Løyland et al. 2010 ), and therefore, the develop-
ment of long-term relationships outside the
group is encouraging because this suggests that
these benefits could be enduring.
The participants in this survey would have
liked to have seen more classes of this type. They
liked the concept of having an open appoint-
ment, thus giving them ownership of when they
attended within the parameters of the group, and
they appeared to be happy with the set-up. Since
this was a new service, it is important that it
should continue to be developed and improved
on the basis of feedback from the service users.
The class has been easy to run during a period of
relative quiet in the department; however, find-
ing times such as this elsewhere during the week
is challenging. It has proved possible to increase
the length of the class by 30 min, which now
runs from 1630 to 1800 h. The provision of
group acupuncture using point prescriptions
such as the Four Gates could also be attached to
exercise classes like those currently provided for
patients with rheumatoid arthritis or fibromyal-
gia. This has now been accomplished within the
present author’s department with some success.
Interestingly, both of these groups are also
drop-in classes.
It is encouraging that the findings from this
service evaluation appear to echo those recently
published in Acupuncture in Medicine by Asprey
et al. (2012 ) and White et al. (2012 ), who showed
both the cost-effective benefits of group acu-
puncture sessions and the acceptability of such
treatments to patients. Both of these studies
focused on groups set up for a condition-specific
group, whereas the group discussed in the pre-
sent paper was heterogeneous with regard con-
ditions, the common factor being chronic pain.
Further evaluation of offering acupuncture in
group settings is indicated in view of its accept-
ability to patients, its value-for-money use of
physiotherapy time and the ability to offer
patients long-term supportive treatment.
Further work is needed in this area, including
well-designed research projects aimed at determi-
ning the most efficient and cost-effective
methods of integrating approaches within
physiotherapy in order to produce a rehabilita-
tion programme that is both successful and
popular. Having been associated with the run-
ning of this particular group for almost 2 years
now, the present author has been consistently
humbled by the patients whom we treat. Seeing
them in a group pragmatically allows us to keep
participants within the system, thus reducing
their anxieties about being fully discharged, and if
appropriate, they can then be seen for one-to-one
assessments should the need arise. One concern
is that, with the current building pressure to open
Patient number
Figure 2. Percentage improvement in coping (n=19).
Evaluation of a group acupuncture service
2013 Acupuncture Association of Chartered Physiotherapists4
JOBNAME: jaacp PAGE: 5 SESS: 4 OUTPUT: Thu Dec 13 08:10:27 2012
up departments for longer times and even
offer 7-day services, it may prove increasingly
difficult to offer services such as this in busy
NHS departments.
Most of all, I would like to acknowledge the
patients who participated in this study; they
showed admirable patience while we set these
group sessions up, something that they had been
asking us to do. I would also like to thank my
colleagues for not complaining too much when-
ever the department is taken over, and I am
especially grateful to those who have taken the
plunge and joined me in a venture in which we put
our patients first. Finally, I would like to thank
JAACP Clinical Editor Helen Oakes, without
whom this paper would not have seen publication.
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Colin Waldock is a clinical specialist with specific areas
of interest in myofascial pain. He is also a supplementary
prescriber. Colin has been practising acupuncture for 19
years, and acts as mentor and tutor on continuing
professional development courses.
C. Waldock
2013 Acupuncture Association of Chartered Physiotherapists 5
... A recent study evaluating acupuncture for chronic pain in geriatric patients found that an average of five treatments were required before there was a significant reduction in pain (Couilliot et al. 2013). With these restrictions in mind, one option that some practitioners employ is offering group or multi-bed acupuncture treatments to make better use of limited resources (Asprey et al. 2012;White et al. 2012;Waldock 2013). ...
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Group acupuncture clinics have been introduced in a London hospital and in two general practices in Hertfordshire for the treatment of knee osteoarthritis (OA). Encouraging preliminary reports have been published of the efficacy of the treatment delivered in this setting but its acceptability to patients has not yet been established. The aim was to investigate the acceptability and perceived advantages and disadvantages of acupuncture delivered in the group setting for the treatment of knee OA. Semistructured interviews were conducted with 16 patients in their own homes and with four nurses over the telephone. Interviews were recorded, transcribed, fully anonymised and analysed thematically. Group acupuncture was delivered with enthusiasm by nurses, was acceptable and popular with patients and recognised to be cost-efficient. Factors affecting acceptability were situational, interpersonal and intrapersonal. Situational factors included adequacy of the physical space used, flexibility of the appointment system and the changing and adaptable nature of the group. Interpersonal factors were mutual support, the exchange of information, the provision of mixed or single-sex sessions and the role of the acupuncture nurse. Intrapersonal factors that increased acceptability were less clear, but nurses expressed the view that the group setting was less suitable for patients with complex conditions or severe pain. Acceptability is very high and may be maximised by taking a number of factors into account: full information should be provided before treatment begins; flexibility should be maintained in the appointment system and different levels of contact between fellow patients should be fostered; sufficient space and staffing should be provided and single-sex groups used wherever possible.
Full-text available
Acupuncture has been provided in nurse-led group clinics in St Albans since 2008. It is funded by a commissioning group within the National Health Service, on a trial basis, for patients with knee osteoarthritis who would otherwise be referred to an orthopaedic surgeon. To evaluate the patients seen in the service's first year of operation and their outcome up to the end of 2010. Service evaluation was made of patient data from the referral centre and the acupuncture clinics, including baseline characteristics, attendance data and Measure Yourself Medical Outcome Profile (MYMOP) symptom, function and well-being scores over at least 2 years. 114 patients were offered acupuncture, of whom 90 patients were assessed in the acupuncture clinics. 41 of these were still attending after 1 year and 31 (34%) after 2 years. MYMOP scores showed clinically significant improvements at 1 month for pain (4.2 (SD 1.2) to 2.9 (SD 1.4)), stiffness (4.1 (SD 1.3) to 2.9 (SD 1.3)) and function (4.5 (SD 1.1) to 3.3 (SD 1.2)) which continued up to 2 years. Well-being scores did not change. This is the first evaluation of nurse-led group (multibed) acupuncture clinics for patients with knee osteoarthritis to include a 2 year follow-up. It shows the practicability of offering a low-cost acupuncture service as an alternative to knee surgery and the service's success in providing long-term symptom relief in about a third of patients. Using realistic assumptions, the cost consequences for the local commissioning group are an estimated saving of £100 000 a year. Sensitivity analyses are presented using different assumptions.
Full-text available
Purpose In an earlier randomised controlled trial, we showed that early stage breast cancer patients who received a supervised exercise programme, with discussion of behaviour change techniques, had psychological and functional benefits 6 months after the intervention. The purpose of this study was to determine if benefits observed at 6 months persisted 18 and 60 months later. Methods Women who were in the original trial were contacted at 18 and 60 months after intervention. Original measures were repeated. Results Of the 148 women from the original study who agreed to be contacted again, 114 attended for follow-up at 18 months and 87 at 60 months. Women in the original intervention group reported more leisure time physical activity and more positive moods at 60 months than women in the original control group. Irrespective of original group allocation, women who were more active consistently reported lower levels of depression and increased quality of life compared to those who were less active. Conclusions We have shown that there are lasting benefits to an exercise intervention delivered during treatment to breast cancer survivors. Regular activity should be encouraged for women with early stage breast cancer as this can have lasting implications for physical and psychological functioning.
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The purposes of this study were to compare the health-related quality of life (HRQOL) of long-term social assistance recipients (LTRs) with and without chronic pain and determine the effect of select demographic, social, pain, alcohol, and illicit drug use characteristics on the physical and mental components of their HRQOL. In this cross-sectional study, which is part of a larger study that evaluated the health and functional abilities of LTRs in Norway, 405 LTRs of which 178 had chronic pain were recruited from 14 of 433 municipalities. LTRs with chronic pain were older (P < .001), more often married (P = .002), feeling more lonely, (P = .048), and had more problems with alcohol (P = .035). The final regression model explained 41.2% (P < .001) of the variance in PCS scores and 32.2% (P < .001) of the variance in MCS scores. Being in chronic pain (29.7%), being older (4.7%), and never married (2%) predicted worse PCS scores. Feeling lonely (11.9%), having problems with illicit drug use (5.9%), and being in chronic pain (2.9%) predicted worse MCS scores. LTRs with chronic pain rated both the physical and mental components of HRQOL lower than LTRs without chronic pain. The MCS score in both groups was negatively effected.
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The aim was to explore the concerns and expectations of women invited to attend group physiotherapy sessions for the management of female urinary incontinence and whether the experience changed their views; and to gather recommendations from women attending group sessions on the design and delivery of these sessions An interview study nested within a randomised controlled trial in five British NHS physiotherapy departments, including 22 women who had expressed a preference for an individual physiotherapy session but were randomised to, and attended, group sessions. Embarrassment was woven throughout women's accounts of experiencing urinary incontinence and seeking health care. Uncertainty about the nature of group sessions was a source of concern. Attending the first session was seen as a big hurdle by many women. However, a sense of relief was common once the session started, with most women describing some benefit from attendance. Recommendations for design and delivery of the sessions from women focused on reducing embarrassment and uncertainty prior to attendance. Taking account of women's embarrassment and providing detailed information about the content of group sessions will enable women to benefit from group physiotherapy sessions for the management of female urinary incontinence. Trial Registration Trial registration number: ISRCTN 16772662
Objective To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care. Design Pragmatic, open, randomised controlled trial. Setting Three private acupuncture clinics and 18 general practices in York, England. Participants 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. Interventions 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients). Main outcome measures The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction. Results 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported. Conclusions Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain. Trial registration ISRCTN80764175 [] .
The efficacy of acupuncture as an adjunctive therapy to pharmacological treatment of chronic pain due to knee osteoarthritis was studied with a 3-armed, single-blind, randomized, sham-controlled trial; it compared acupuncture combined with pharmacological treatment, sham acupuncture including pharmacological treatment, and pharmacological treatment alone. A total of 120 patients with knee osteoarthritis were randomly allocated to 3 groups: group I was treated with acupuncture and etoricoxib, group II with sham acupuncture and etoricoxib, and group III with etoricoxib. The primary efficacy variable was the Western Ontario and McMaster Universities (WOMAC) index and its subscales at the end of treatment at week 8. Secondary efficacy variables included the WOMAC index at the end of weeks 4 and 12, a visual analogue scale (VAS) at the end of weeks 4, 8, and 12, and the Short Form 36 version 2 (SF-36v2) health survey at the end of week 8. An algometer was used to determine changes in a predetermined unique fixed trigger point for every patient at the end of weeks 4, 8, and 12. Group I exhibited statistically significant improvements in primary and secondary outcome measures, except for Short Form mental component, compared with the other treatment groups. We conclude that acupuncture with etoricoxib is more effective than sham acupuncture with etoricoxib, or etoricoxib alone for the treatment of knee osteoarthritis.
SummaryIn this paper the critical question of knowledge as the underpinning of clinical practice is examined. The nature of knowledge is explored in this paper, with support being given to the constructivist perspective. Types of knowledge include propositional, professional craft and personal knowledge. The importance and validity of each of these forms of knowledge is argued. Knowledge construction is a task which requires much attention from students, teachers and researchers. Approaches to generating knowledge include: working through research paradigms (such as the empirico-analytical, critical and interpretive paradigms) and also utilising different ‘ways of knowing’. Physiotherapists need to gain a deep understanding of the nature of knowledge and of how to generate knowledge in order to enrich their own knowledge bases and to contribute to the knowledge of the field of physiotherapy.
To establish the prevalence of chronic widespread pain and associated symptoms in a general population sample. Cross sectional postal survey of 2,034 adults in the north of England. The point prevalence of chronic widespread pain was 11.2%. The symptom was strongly associated with other somatic complaints and with measures of depression and anxiety. In the general population, this cardinal symptom of fibromyalgia is common and identifies a group who are more likely also to report symptoms of fatigue and depression.