Content uploaded by Kate Thomas
Author content
All content in this area was uploaded by Kate Thomas
Content may be subject to copyright.
THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE
Volume 12, Number 9, 2006, pp. 873–880
© Mary Ann Liebert, Inc.
Beyond Needling—Therapeutic Processes in Acupuncture Care:
A Qualitative Study Nested Within a Low-Back Pain Trial
HUGH M
AC
PHERSON, Ph.D.,
1,2
LUCY THORPE,
3
and KATE THOMAS
3
ABSTRACT
Background: In the medical and scientific literature, there is a dearth of reports about how acupuncturists
work and deliver care in practice. An informed characterization of the treatment process is needed to support
the appropriate design of evaluative studies in acupuncture.
Methods: The design was that of a nested qualitative study within a pragmatic clinical trial. Six acupunc-
turists who treated up to 25 patients each were interviewed after the treatment phase of the trial to obtain an
account of their experiences of providing acupuncture care to patients with low back pain referred by their GP.
Using semistructured interviews and a topic guide, data were collected and analyzed for both a priori and emer-
gent themes. This paper focuses on practitioners’ accounts of the goals and processes of care, and describes the
strategies employed in addition to needling and other hands-on treatments.
Results: From the interview data, it is clear that a coherent body of theoretical knowledge informed clinical
decisions and practice, and that the goals of treatment went beyond the alleviation of immediate pain-related
symptoms. Acupuncturists in this study all described a pattern of patient-centered care based on a therapeutic
partnership. Study participants confirmed the importance of three processes that characterized acupuncture care
in this trial, each contributing to the goal of a positive long-term outcome; building a therapeutic relationship;
individualizing care; and facilitating the active engagement of patients in their own recovery. Acupuncturists
described elements of care that characterized these processes including establishing rapport, facilitating com-
munication throughout the period of care, using an interactive diagnostic process, matching treatment to the in-
dividual patient, and the use of explanatory models from Chinese medicine to aid the development of a shared
understanding of the patient’s condition and to motivate lifestyle changes that reinforce the potential for a re-
covery of health. Acupuncturists did not view these therapeutic goals, processes, and strategies as a departure
from their usual practice.
Conclusions: This study suggests that acupuncture care for patients with chronic conditions such as low back
pain is likely to be a complex intervention that utilizes a number of patient-centered strategies to elicit long-
term therapeutic benefits. Research designed to evaluate the effectiveness of acupuncture as it is practiced in
the UK needs to accommodate the full range of therapeutic goals and related treatment processes.
873
INTRODUCTION
A
recent trial of a short course of acupuncture for chronic
low back pain has provided evidence of significant
longer-term benefits to patients.
1
This trial was funded by
the Health Technology Assessment (HTA) research and de-
velopment program, and was conducted collaboratively by
researchers at the University of Sheffield and the Founda-
1
Foundation for Traditional Chinese Medicine, York, UK.
2
Department of Health Sciences, University of York, Heslington, York, UK.
3
Medical Care Research Unit, ScHARR, University of Sheffield, UK.
tion for Traditional Chinese Medicine in York. The design
was that of an open pragmatic randomized controlled trial,
comparing acupuncture with usual general practitioner care
alone. The trial was conducted in York between 1999 and
2003, and 241 patients were recruited, 160 of whom were
randomized to the acupuncture group. The short course of
acupuncture comprised up to 10 sessions, provided over an
initial 3-month period. When we compared the acupuncture
group to the control group, the clinical benefits of acupunc-
ture were found to increase between 3 and 12 months and
again between 12 and 24 months post-treatment. Analysis
of covariance, adjusting for baseline score, found an effect
of 5.6 points on the SF-36 Pain dimension in favour of the
acupuncture group at 12 months, growing to a statistically
significant difference of 8 points at 24 months.
The acupuncture within the trial was based on principles
of Traditional Chinese Medicine (TCM). Six acupuncturists
with at least 3 years of postqualification experience provided
the treatment at three clinics in York. Up to 10 treatment
sessions were available to each patient, and acupuncturists
were encouraged to provide their normal treatment, in order
to evaluate the impact of routine care. Within the clinical
trial, the six participating acupuncturists made a precise
recording of the main aspects of the diagnoses and treat-
ments they provided.This mainly quantitative description
has recently been published.
2
As part of this acupuncture trial, we were also interested
in understanding how the acupuncturists worked, and their
experiences of delivering care in the context of a clinical
trial. We conducted a nested qualitative study within the
acupuncture trial, interviewing all six of the participating
acupuncturists. To help us contribute a richer interpretation
of the results of the trial, our aim was to capture their
thoughts and processes, provide insights into acupuncture
from their experiences and observe and record the ways in
which they tried to elicit benefits to health.
METHODS
Nested within York Acupuncture for Back Pain Trial
were two qualitative studies. One involved in-depth inter-
views with all 6 participating acupuncturists, and one with
a sample of 12 patients. The former study is reported in this
paper, and ethical approval was obtained from the York Na-
tional Health Service Local Research Ethics Committee.
Each of the six acupuncturists (labeled P1 to P6 below)
was interviewed by two interviewers, one of whom was him-
self one of the participating acupuncturists as well as a coau-
thor (HM) of this paper. He cointerviewed with researcher
(LT) all the other 5 acupuncturists, and was interviewed in
his role as an acupuncturist by LT and one of the other
acupuncturists (AG). The interviews were conducted in each
practitioner’s place of work and lasted approximately 1 hour.
Questions were drawn from a prepared topic guide that in-
vited practitioners to reflect on their experiences of treating
patients in the following five areas: (1) acupuncture diag-
nosis; (2) acupuncture treatment; (3) patient–practitioner re-
lationship; (4) the providing of treatment within the con-
straints of the trial; and (5) the potential for creating a
flexible trial treatment protocol.
The interviews were tape-recorded, transcribed verbatim,
and checked for accuracy. Analysis of the data was under-
taken using a thematic “framework” approach.
3
After fami-
larization and initial coding based on the a priori topic guide,
an index was developed to explore the goals and processes
of treatment that were not concerned with aspects related to
specific needling techniques. Within this framework, the in-
terview data were coded using the software Atlas/Ti and
then charted in a spreadsheet in two dimensions: across the
six acupuncturists, and across a priori and emergent themes.
The findings are considered in the light of debates about re-
search in acupuncture in the discussion below.
RESULTS
Building a therapeutic relationship
Acupuncturists confirmed the importance of establishing
a positive practitioner–patient relationship as a basis for pro-
ceeding with treatment:
I think it is about reciprocity and being able to get a
sense of trust from the patient, and enough rapport so
that you can work with them so that they trust you are
going to do physically and they’re more likely to take
advice. (P3)
I think there are things about the practitioner being able
to hold the patient and contain you know whatever goes
on really in the relationship . . . with the effect of the
patient feeling safe then. Physically and emotionally
safe to let whatever’s going to happen, happen. (P4)
When asked about how they built relationships with pa-
tients, practitioners described a number of strategies or
processes: establishing rapport; meeting the patient where
they were; capitalizing on immediate treatment effects;
inviting and sharing information; and helping patients to
make sense of their condition.
The first of these, establishing rapport, has much in com-
mon with therapeutic encounters generally. The acupunctur-
ists aimed to establish rapport through openness and honesty,
encouraging dialogue, and “connecting” with the patient:
It’s something to do with connection, connecting with
the patient. . . . That’s how I see a successful thera-
peutic relationship, it’s like you’re doing work but at
the same time there is a human being there to connect
with. (P1)
M
AC
PHERSON ET AL.
874
Rapport in a therapeutic relationship was also seen as
something requiring reciprocity, a two-way process: “We
have things where we understand each other.” (P2). One (1)
acupuncturist talked about trying to “really meet the patient
where they are” (P5), and described how sometimes this
might be about treating back pain as a single symptom and
sometimes involve tending to wider issues.
One practitioner also made explicit reference to the con-
tribution of immediate treatment outcomes to building rela-
tionships and rapport:
The simplest way to get that is to deliver results, so
that the patient feels different after your treatment,
they know something’s happened, they think well this
is interesting, this is really going to help and that im-
mediately creates a big amount of bonding, but that’s
I think the sort of strongest factor, a successful rela-
tionship evolves out of successful treatment. (P5)
Types of nonverbal communication were also mentioned,
including the specific contribution of touch in reinforcing
the therapeutic bond:
I mean there are people who . . . just want to have a
quiet interlude away from their mad life but I think
what does actually happen once I get them on the
couch and get my hands on them is something else al-
together; it’s a merging of energies and stuff like that
and it all gets a bit hard to define, but there is some-
thing really, that really clearly goes on and I can feel
there’s an atmosphere around us as I’m working which
sort of just . . . it supports the whole thing. . . . It’s
like giving them a sense that there is a possibility with-
out bringing it up verbally. (P6).
All practitioners stressed the importance of two-way com-
munication with their patients. The process of eliciting in-
formation for diagnosis and treatment created the opportu-
nity for sharing information and active listening:
I want to share lots of information about TCM, how
TCM shows their problem to them and I want them
to share details of the problem and their situation and
give me lots of feedback. . . . [I] try to make sure that
I’m open to the big picture all of the time, so there is
room for it, at least in my consciousness, and I really
listen. (P4)
Therapeutic alliances were also forged through the mech-
anism of helping patients to make sense of their condition,
or see their symptoms in a new light:
“So our job is not treating the symptoms, is getting
health for the patient. So . . . symptoms are only the
sign giving you a warning there is something you need
to do about it and then . . . so I explain that to the pa-
tient.” (P1)
Important to several of the acupuncturists was the idea
that Chinese medicine can provide a framework for simple
models of health and disease and explanations of how treat-
ment might work for them:
It’s such a good simple model and it actually does
make sense to them when you talk in terms of sim-
ple energetics and alignments and direction and en-
ergy and “stuckness” and so forth. Those sort of
words they make a lot of sense to people . . . the ba-
sic nature of the Chinese medical model is very ac-
cessible. (P3)
We’re into actually understanding the condition and
feeding that back to the patient in a way that makes
sense, so that’s why I use the phrase explanatory
model. And I think that’s a really crucial part of help-
ing the patient understand why they’ve got what
they’ve got, what’s going on there . . . even if it’s in
a language like “stagnation” or “blockage,” the pa-
tients often relate to that especially if the (have) stiff-
ness, they think oh it’s all locked up, so you can make
them understand the word constrained, blocked. I
don’t know if they understand the word energy but it
sounds alright. . . . So basically you put together an
explanatory model that explains why they’ve got what
they’ve got and what you are going to do to shift it
. . . and later down the line then the lifestyle advice
will also fit into the same explanatory model, so you
would be doing, you know there would be a congru-
ency if you like between all of those explanations
around. So I like my patient to think “thank goodness
someone understands what’s going on.” (P5)
These explanations, and other strategies for supporting
the therapeutic relationship, were not seen as something sep-
arate from the treatment, but rather as integral components
that reinforced the potential for a return to health.
Individualizing of treatment
The individualizing of treatment is usually seen as a core
approach within TCM. Integral to this was the diagnostic
process and the taking of the case history. The latter extends
beyond simple symptoms, when these symptoms started,
how they started, and what exacerbates them. It also can in-
clude related symptoms and signs (observation of the tongue
and palpation of the pulse), as well as the patient’s medica-
tion. The focus can be very broad, for example:
The first consultation is very important, I ask all sorts
of questions. . . . From lifestyle, diet and exercise and
everything, and I find out what is going on.” (P1)
ACUPUNCTURE FOR LBP
875
One practitioner reported this initial phase as one where
she and the patient would have a general talk, with the aim
of trying to “glean . . . what their orientation in life is in a
sense and feel whether it’s basically healthy within the terms
of the Chinese model.” (P3)
Practitioners were very interested in the possible causes
of the back pain: “I would be interested in a person’s lifestyle
and all of the factors that might be repeatedly causing prob-
lems, heavy lifting, outdoor work, exposure to the elements,
all these sorts of things” (P5). It was not just physical fac-
tors in a person’s life, as one practitioner reported: “things
are caused by stress and emotions as well as being made
worse by them.” (P2)
Practitioners were keen to use palpation to find out the
exact location of the pain, often asking first where they felt
the pain, then, when they were on the couch, using palpa-
tion to locate it more precisely. One practitioner talked about
saying to the patient: “Is this where you feel it? And the pa-
tient’s thought was: “Thank God, actually someone has got
the place where it really hurts.’” (P5) Palpation was seen as
“a vital part of . . . diagnosis in back pain cases.” (P3)
Within the rubric of Chinese medicine, practitioners drew
out the underlying patterns of the diagnosis. Important fil-
ters in this process included whether the back pain was acute
or chronic, whether it was a case of “excess” or “deficiency”
(or a mixture of both), and the extent to which there was
“stagnation” in the low back. These filters, along with the
three predefined syndromes (Stagnation of Qi and Blood, Bi
Syndrome, Kidney Deficiency), which were agreed upon be-
tween acupuncturists at the outset, guided the pulling to-
gether of a diagnosis.
2
A consequence of this diagnostic process was that prac-
titioners gained an in-depth understanding of the complex-
ity of the patient’s condition, enabling them to “unearth
some of what may be the key things underlying the back
pain” (P3). This was seen as essential for providing appro-
priate treatment, tailored to the specific dynamics and issues
of the individual patient’s condition and situation.
Each of the practitioners in the study brought to the ther-
apeutic encounter their own style of treating. It was not as-
sumed that once the actual needling started the therapeutic
relationship became secondary:
I’ll do the acupuncture, and in terms of building a good
relationship . . . the whole needling process is quite
important if it is pitched at the right level. (P5)
In addition patients brought their own expectations of
treatment. Some patients just wanted to be “fixed,” whereas
others were willing to engage more fully in the treatment
process, which might mean taking specific actions to reduce
the impact of their lifestyle on their low-back pain. Some-
times external constraints influenced the treatments provided,
such as patients having limited availability because of their
work commitments. Some patient had other symptoms that
the practitioners perceived as needing concurrent treatment,
such as a very stiff back from the neck to the sacrum. Prac-
titioners were concerned that by not addressing these broader
symptoms, there would have been a slower recovery process.
Also, some patients were unusually sensitive to needling, so
that this sensitivity necessarily influenced the nature of the
treatment. In the interviews, these factors were discussed by
practitioners as being important criteria to take into account
when treating someone with low-back pain. For example,
one practitioner talked about deciding how to treat on the ba-
sis of an appropriate strategy and the “strength” of the pa-
tient: “I tend to start off quite minimal until I know, till I get
a measure of the patient’s qi.” (P4)
In addition, the practitioners talked about following the
patients over time. This involved monitoring carefully
whether the location of the pain had changed, and what had
happened to the other symptoms, which led to new judg-
ments about treatment at each follow-up session.
The resulting mix of the practitioner’s style and the pa-
tient’s responsiveness create a unique set of descriptors for
each session. The location of the pain, the selection of points,
the number of needles, the depth of insertion, the strength
of needle stimulation, and the option of auxiliary interven-
tions such as moxibustion, all add up to acupuncture being
a very complex intervention.
Facilitating patients’ active involvement in
their recovery
All six practitioners emphasized the need to actively in-
volve patients in their own recovery process.
Recurrence is very common, and what I’m trying to
do in a way is to avoid a recurrence: in the longer term
that’s the key issue and so back care advice [along]
with acupuncture . . . can get someone better, but it
can’t stop recurrence, it’s the person who has to make
some changes. (P5)
Two common themes emerged from the qualitative analy-
sis with respect to mechanisms used to achieve this: first the
engagement with their patients’ attitudes; and second the fa-
cilitation of patients in helping them make necessary
changes to behavior and lifestyle.
Practitioners reported seeing a great variability in the ex-
tent to which patients were willing to take responsibility for
getting better. In part, this was seen as patients’ lack of
knowledge of what they could do to help themselves, but
also for some patients there was an attitude that acupunc-
ture would do all the changing for them and it was not their
role to help themselves. In a more extreme case, there ap-
peared to be a resistance to getting well at all:
One woman . . . had decided she wasn’t going to get
better and she kept me at arms length. . . . There was
M
AC
PHERSON ET AL.
876
something missing from the relationship with her in
terms of an authentic transaction, which meant that
she never bonded with me, because she was always
like fending me off, pushing me away at some level.
That was rare, that was unusual. (P5)
For other patients, it was just too difficult:
Then there’s the people whose lives are really out of
control, you know they just seem to be in this sort of
whirlwind and I can get that sense when they first
come in. Like this is going to be hard work and I am
never really that sure that I can make a difference if
they are really stuck in a confusing and chaotic life.
I’m always a bit anxious that I’m not going to make
that much difference. (P6)
Although some patients were not interested in being, or
willing or able to be, actively involved in doing things to
help themselves, many others were the opposite, asking from
the outset what they could do to help themselves.
Practitioners discussed how in different ways they helped
their patients become more aware of their low backs, what
made the back pain worse and what helped. This could be
a first step in helping patients choose behaviors that did not
aggravate their low-back pain. From the traditional acupunc-
ture perspective, specific lifestyle changes can help relieve
or ameliorate related patterns of disharmony. For example,
one practitioner reported
helping the patient discover their own patterns so that
they can be empowered to introduce necessary
changes into their lives. This kind of change is likely
to be long lasting as it is self-motivated and has mean-
ing. (P3)
This could be facilitated by helping patients to feel more
in control:
that they are in charge, that they are not coming to
somebody else to be fixed, that they actually have the
ability to look after themselves properly and keep
themselves well, that they don’t have to wait till things
go wrong, they can actually avoid it. (P6)
Long-term change was seen by practitioners as being at-
tainable if the patient was self-motivated, and subsequently
reinforced if in some way the resulting changes had some
meaning for the patient.
To attain this mental shift sometimes required a softly-
softly approach and sometimes a more forceful one. What-
ever the approach, the hope was that the combination of the
treatment and the lifestyle changes would help the patient
to begin to feel better. When this started to happen, then
small setbacks could often be linked to events or actions
taken by the patient, such that the lifestyle advice appeared
more pertinent. For example, if the advice was about doing
less, and an aggravation in back pain occurred when doing
more, then the association would become clear in the pa-
tient’s mind. Not that it was always “advice” that was in-
structional; sometimes it was more of a discussion of etio-
logical and precipitating factors. For example, patients might
suddenly become aware how when they were in a lot
of stress at work or when things were going bad in
their relationships, their back suddenly got much
worse, and when they could see those connections they
would take time to look at their lives a bit more. And
one who became more and more aware of how much
emotion and tension and holding she was doing with
her back and went off to have more counselling. (P3)
At other times, the advice might be very practical, with
the practitioner teaching the patient simple movements that
involved stretching exercises. The exercises might be de-
signed exactly for that patient or to be more generally use-
ful for anyone with low-back pain.
We also asked practitioners about whether they addressed
what might be called “spiritual issues” without actually
defining what we meant. One practitioner talked about al-
ways trying to be open to “the big picture all of the time,
so there’s room for it, at least in my consciousness, and I
really listen, I really listen to what they are saying.” (P4)
Another practitioner discussed this area at more length:
“If you’re talking about the spiritual stuff and the
meaning of life and sense of purpose . . . the way I
see it with my patients is that acupuncture helps peo-
ple align themselves with their true path and then if
you are on your true path then things feel right and
you have a sense of meaning and purpose and you feel
fulfilled and . . . I think intuitively people understand
it and so for those people who are ready and willing
to talk about the meaning of life, then I’ll talk about
it and actually I think that’s a very fertile area . . .
quite interesting things happen in acupuncture because
of this realignment that takes place, people often do
make quite sort of useful insights. They might not
make immediate changes, in fact their lives might look
quite similar even but something might have shifted,
some understanding or sense of what’s happening or
where they’re going, it can be quite important. (P5)
In apparent contrast, another practitioner reported: “I
don’t talk about spiritual stuff” but then went on to say:
But some people are already talking about it them-
selves, I kind of take my lead from them, really, . . .
just talk about life, the universe and everything kind
of in a general sort of way.” (P6)
ACUPUNCTURE FOR LBP
877
Providing acupuncture within a clinical trial:
the practitioners’ experience
The acupuncturists in this clinical trial normally provided
their acupuncture to non–National Health Service (NHS) pa-
tients who paid for treatment themselves. However, in this
study all the patients were referred by their GP, and received
free acupuncture treatment. In the interviews, we asked the
acupuncturists whether their approach to treatment differed
from their normal practice and whether they thought the
NHS patients were any different from those they usually en-
countered.
Because the trial was a pragmatic one, the instructions to
the acupuncturists at the outset were to treat the patients
within the trial in just the same way as they would normally
do. With one exception, the practitioners confirmed that this
was how they had practiced within the trial. The exception
was the practitioner who reported feeling constrained by the
fixed number of (free) treatments available in the trial and
by the need to focus on back pain.
However, the practitioners did comment on perceived dif-
ferences between patients seen within the trial and those who
they treated in private practice:
I think the biggest difference (was that) . . . they just
took a bit longer to take on the fact that they could do
things for themselves, . . . it was like a newer idea the
fact that they could do something to help themselves.
. . . I mean they are basically the same sort of people
and once they engage they are pretty quick to jump
on the idea that they can really help themselves long-
term. And there were probably one or two . . . excep-
tions obviously. (P5)
Another practitioner reported that her patients were more
“single-issue oriented,” primarily focused on wanting help
with their low-back pain, and perhaps a “little more pas-
sive.” Several reported that, overall, the patients in the trial
had less awareness of their health, and were less prepared
to take responsibility for appropriate lifestyle changes, per-
haps needing more in the way of “an educational process.”
Finally, several acupuncturists reported an unexpected
benefit from participating in the trial—the opportunity to
hone their diagnostic skills in treating a large group of pa-
tients with the same condition: low-back pain.
DISCUSSION
In this descriptive, interview-based study, we explored
aspects of acupuncture care delivered to patients in addition
to the specific techniques and processes associated with the
actual needling. Despite differences in individual styles of
treating patients, the acupuncturists in this study all de-
scribed a pattern of patient-centered care that was based on
a partnership model of interaction between practitioner and
patient.
4–6
Participants confirmed the importance of three el-
ements of successful treatment beyond the needling aspects
of acupuncture, all of which were seen as contributing to
the goal of positive long-term outcomes: building a thera-
peutic relationship; tailoring care to the individual patient;
and actively engaging patients in their own recovery.
Acupuncturists also identified a number of strategies or
mechanisms for achieving these goals.
Strategies for building successful therapeutic relationships
included establishing rapport with patients, active listening,
and utilizing explanatory models taken from Chinese medi-
cine to aid the development of a shared understanding of the
patient’s condition that reinforced the potential for a recovery
of health. Individualized care is achieved via the interactive
and iterative nature of the diagnostic process, and the careful
matching and adjustment of treatments in response to feed-
back from patients. Successful therapeutic relationships and
explicit individualized care can be seen as mutually reinforc-
ing, and both appear to support the third goal of enlisting pa-
tients in their own recovery. Further strategies to achieve this
third goal include engaging with patients’ attitudes to health
and illness, using Chinese medicine models and concepts to
motivate lifestyle changes, and giving meaning to what is go-
ing on for the patient by encouraging them to link their illness
experience to their broader life experiences.
The goals and strategies described above derive from in-
terviews with six practitioners working in the specific con-
text of treating patients referred by their GP with low-back
pain within a clinical trial. Although participants suggested
that their experience of treating patients within the trial was
not substantially different from treating patients in other con-
texts, the transferability of these findings to other acupunc-
ture encounters cannot be assumed. In particular, the rele-
vance of these findings to the acupuncture treatment process
for other chronic patient groups warrants further investiga-
tion. Despite the specific focus of the study, the findings
presented here may have implications for a number of on-
going debates in the field of acupuncture research.
Characterizing acupuncture as an intervention in
clinical trials
There is a place for acupuncture research that has a fo-
cus on a simplified needling intervention for an acute con-
dition with short-term outcomes, such as clinical trials of
the acupuncture point P-6 [Neiguan] for acute nausea.
7
However, the overwhelming majority of acupuncture prac-
titioners in the West are treating patients with chronic con-
ditions such as back pain, and in the UK, for example, it is
known that back pain is the most commonly treated single
condition.
8
For patients with this type of chronic condition,
our data support the case for treating acupuncture as a “com-
plex intervention,” an approach to research that has been set
out in the Medical Research Council’s guidelines for the
M
AC
PHERSON ET AL.
878
evaluation of such interventions.
9
Research into acupunc-
ture’s effectiveness can be designed around a characteriza-
tion of the intervention that goes beyond the needling
process to include the associated and related diagnostic,
treatment, and the therapeutic relationship components that
are specific to acupuncture as commonly practiced.
In this study, practitioners were also aiming for each treat-
ment to be matched to the patient, such that patients with the
same presenting condition of low-back pain were all treated
differently, depending on their constellation of symptoms and
their willingness and openness to engage actively in their re-
covery. Not only were all patients treated differently, but also
each patient’s treatment was changed over time, with the
practitioner aiming to follow the changing symptoms. The
use of a standardized treatment, either one treatment fitting
all, or even one treatment being fixed for a patient over time,
was not supported by our data and is unlikely to have been
an acceptable model to the acupuncturists in our trial. Indi-
vidualized care provides additional challenges in the trial de-
sign.
10
More flexible treatment guidelines are appropriate,
along with careful recording of all aspects of the interven-
tions. This could provide sufficient transparency to enable
replicability while at the same time allowing sufficient flex-
ibility to cover the expected range of patient variability.
Distinguishing between specific (characteristic)
effects and nonspecific (context) effects
The second research issue relates to the nature of specific
and nonspecific effects in acupuncture. This study also re-
inforces the point made by Paterson and Dieppe
11
that spe-
cific (characteristic) and nonspecific (incidental or context)
effects of treatment are not easily separated. The desire to
separate out these two types of effects stems from an es-
sentially reductionist agenda of some scientists and acade-
mics for whom the proof of a specific effect (efficacy) is a
precondition for the wider acceptance of acupuncture. How-
ever, this qualitative study has raised questions about what
exactly is “specific” and what is “nonspecific”? Interpreting
the practitioner interviews, it would seem that the thera-
peutic relationship has both specific and nonspecific di-
mensions. Engendering rapport in a general way, for exam-
ple, through empathy and compassion, might be seen as
“nonspecific.” Adopting a warm, friendly and reassuring
manner, thereby contributing to the nonspecific effect, is
known to improve outcome.
12
Yet for the practitioners in
this qualitative study, some of the rapport building and com-
munication was specific to acupuncture, including the uti-
lization of appropriate explanatory models from TCM, the
use of touch to reinforce the therapeutic bond, and the way
practitioners facilitated patients’ active involvement. The
implication is that the traditional split between specific and
nonspecific components cannot be assumed to reflect other
health care modalities, and it is questionable whether a clear
boundary could ever be delineated between the two.
Process measures and long-term outcomes
The therapeutic goals and strategies for achieving them
that we have identified here suggest that there may be scope
within evaluative research to develop measures of treatment
impact that relate to the process of care itself, such as pos-
itive long-term expectations, rapport with practitioner, en-
gagement with self-care, lifestyle changes, and perceptions
of illness. Such measures may even prove to be useful proxy
measures for outcome, although the need for long-term fol-
low-up is evident from this study. The interview data sug-
gest that a long-term focus was adopted by practitioners, re-
quiring patients to take on lifestyle changes that were related
to their specific patterns of disharmony. Without this active
involvement, acupuncturists were less confident about the
patient maintaining the improvements engendered by the
acupuncture. Evidence suggests that patients treated by the
acupuncturists continued to experience improvements in re-
ported pain up to 24 months after entering the trial.
1
Other
acupuncture trials have also shown similar longer-term ben-
efits, for example, in the treatment of headaches and mi-
graine
13,14
and stroke.
15
The implications for research are
that acupuncturists should be given scope within a trial de-
sign to facilitate patients’ active involvement, and that clin-
ical trials should monitor change over at least 12 months
and preferably over 24 months. This argument is also rel-
evant when an economic impact is being evaluated, be-
cause it will take time for potential savings to outweigh
the upfront costs associated with a course of acupuncture
treatment.
CONCLUSIONS
In this paper, we have described three interlinked goals
of the therapeutic process, and their related strategies, each
operating through a partnership between the patient and the
acupuncturist, and all contributing to the practitioner-de-
fined aim of achieving long-term health improvement. These
therapeutic goals and strategies underpinned the treatment
offered to patients with low-back pain in a clinical trial, but
were not considered to be a departure from usual practice
by the acupuncturists concerned. This study suggests that
acupuncture care for patients with chronic conditions, such
as low-back pain, is a multifaceted complex intervention that
aims to generate long-term therapeutic benefits. Research
designed to evaluate the effectiveness of acupuncture as it
is practiced needs to accommodate the full range of thera-
peutic goals and related treatment strategies.
ACKNOWLEDGMENTS
Thanks are due to the five other participating acupunc-
turists, Wendy Epstein, Alison Gould, Han Liping, Harriet
ACUPUNCTURE FOR LBP
879
Lansdown, and June Tranmer as well as Hannah Taylor for
help with coding and charting the interview data.
REFERENCES
1. Thomas KJ, MacPherson H, Ratcliffe J, Thorpe L, et al. Longer
term clinical and economic benefits of offering acupuncture
care to patients with chronic low back pain. Health Technol
Assess 2005;9:iii–x,1.
2. MacPherson H, Thorpe L, Thomas K, Campbell M. Acupunc-
ture for low back pain: traditional diagnosis and treatment of
148 patients in a clinical trial. Complement Ther Med
2004;12:38–44.
3. Ritchie J, Lewis J. Qualitative Research Practice: A Guide for
Social Science Students and Researchers. London: Sage, 2003.
4. Cassidy CM. Chinese medicine users in the United States. Part
II: Preferred aspects of care. J Altern Complement Med
1998;4:189–202.
5. Gould A, MacPherson H. Patient perspectives on outcomes af-
ter treatment with acupuncture. J Altern Complement Med
2001;7:261–268.
6. Paterson C, Britten N. Acupuncture as a complex intervention:
a holistic model. J Altern Complement Med 2004;10:791–801.
7. Ezzo JM, Richardson MA, Vickers A, et al. Acupuncture-point
stimulation for chemotherapy-induced nausea or vomiting.
Cochrane Database Syst Rev 2006;2:CD002285.
8. MacPherson H, Sinclair-Lian N, Thomas K. Patients seeking
care from acupuncture practitioners in the UK: a national sur-
vey. Complement Ther Med 2006;141:20–30.
9. Medical Research Council. A framework for development
and evaluation of RCTs for complex interventions to im-
prove health [report] London, UK: Medical Research Coun-
cil, 2000.
10. Mason S, Tovey P, Long AF. Evaluating complementary med-
icine: methodological challenges of randomized controlled tri-
als. Br Med J 2002;325:832–834.
11. Paterson C, Dieppe P. Characteristic and incidental (placebo)
effects in complex interventions such as acupuncture. Br Med
J 2005;330:1202–1205.
12. Di Blasi Z, Harkness E, Ernst E, et al. Influence of context ef-
fects on health outcomes: a systematic review. Lancet 2001;
357:757–762.
13. Vincent CA. A controlled trial of the treatment of migraine by
acupuncture. Clin J Pain 1989;5:305–312.
14. Vickers AJ, Rees RW, Zollman CE, et al. Acupuncture of
chronic headache disorders in primary care: randomised con-
trolled trial and economic analysis. Health Technol Assess
2004;8:1–50.
15. Kjendahl A, Sallstrom S, Osten PE, et al. A one year follow-
up study on the effects of acupuncture in the treatment of stroke
patients in the subacute stage: a randomized, controlled study.
Clin Rehabil 1997;11:192–200.
Address reprint requests to:
Hugh MacPherson, Ph.D.
Department of Health Sciences
University of York
Heslington
York YO10 5DD
United Kingdom
E-mail: hm18@york.ac.uk
M
AC
PHERSON ET AL.
880
