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

Abstract

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
SERVICE EVALUATION
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
Abstract
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
evaluation.
Introduction
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.
2012).
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:
colinwaldock22@gmail.com).
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Subjects and methods
The inclusion criteria were that the patients
should have:
+previously reported a positive response to
acupuncture;
+shown evidence of chronic widespread pain;
+had continual pain for more than 3 months;
and
+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
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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 ).
Results
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
class.
Question 1 asked, ‘‘Can you give your overall
views on the concept of an acupuncture class?’’
This elicited a variety of positive responses,
including:
+‘‘ideal as no fixed appt.’’;
+‘‘So much better than 1:1, this way more
people benefit in same time’’;
+‘‘[. . .] makes acupuncture available to every-
one’’;
+‘‘[. . .] 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
isolated’’;
+‘‘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’’;
and
+‘‘Make available for 2
nd
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
reason’’;
+‘‘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
10
20
30
40
50
60
70
80
90
100
0 2 4 6 8 101214161820
Improvment in pain
(%)
Patient number
Figure 1. Percentage improvement in pain (n=19).
C. Waldock
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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’’.
Discussion
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.
Conclusions
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
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Figure 2. Percentage improvement in coping (n=19).
Evaluation of a group acupuncture service
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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.
Acknowledgements
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