Longer term benefits of a

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Longer term benefits of a short course of
traditional acupuncture for patients with
chronic back pain  
Hugh MacPherson Research Director Foundation
for Traditional Chinese Medicine York Senior
Research Fellow University of York
Kate Thomas Deputy DirectorMedical Care
Research UnitFaculty of MedicineUniversity of
Sheffield
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Acknowledgements

• Patients
• Acupuncturists
•  
• Patient representative
• David Laverick
• Advisory Board
• Trevor Sheldon
• Sally Bell?Syer
• Funders
• NHS Health Technology
• Assessment Programme

• Research Team
•  
• Lucy Thorpe
• Mark Roman
• Julie Ratcliffe
• John Brazier
• Mike Fitter
• Mike Campbell
• Ann Morgan
• Liz Oswald
• Helen Wilkinson
• Jon Nicholl

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The initial challenge.

• . How can we evaluate acupuncture when every
  patient is different, and requires different
  treatment
• ..and when every acupuncturist is different,
• and would want to treat the same patient
  differently.

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We tested the hypothesis that.

• . primary care patients
• with persistent low back pain,
• when given access to an acupuncture service
• provided by British Acupuncture Council (BAcC)
  acupuncturists,
• gain more relief from pain
• than those offered normal GP care only
• for equal or less cost.

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241 patients



81 patients in control group receive normal GP
care

160 patients receive 10 acupuncture treatments
over three months plus normal GP care








Outcomes measured at 3, 12 and 24 months
Outcomes measured at 3, 12 and 24 months










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Demographic profiles (at baseline)
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SF-36 Bodily Pain Scale adjusted for baseline
Diff5.5 pts p0.079
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SF-36 Bodily Pain Scale adjusted for baseline
Diff6.0 pts P0.074
Diff5.5 pts p0.079
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SF-36 Bodily Pain Scale adjusted for baseline
Diff5.5 pts p0.079
Diff6.0 pts P0.074
Diff9.0 pts P0.015
Pop norm.
Pop. norm
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Worry about back pain (comparing reports at 24
months with baseline)
Diff. between groups Plt0.001
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Based on the findings..

• Primary care commissioners
• would be justified in funding
• 10 sessions of individualised acupuncture
• provided by British Acupuncture Council
  acupuncturists
• for patients with persistent low back pain
• when referred by their GP.

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Remaining questions

• Are there variations between acupuncturists?
• What role does belief have?
• Why do the benefits grow over time?

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Variations between acupuncturists?
Acupuncturists contribute 2 of variability
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What role does belief have? At randomisationDo
you believe that acupuncture can help your low
back pain?
P-value for interaction p0.07
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Why do the benefits grow over time?

• Other trials that have shown this increasing
  benefit over time
• Migraine - Vincent et al 1989
• Stroke - Kjendahl et al 1997
• And others .
• Mechanism for this is not clear

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A qualitative sub-study within the back pain
trial

• In depth interviews with all six acupuncturists
• Interviews taped and transcribed
• Data managed using Atlas T/i
• Analysed using Framework

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Using Framework for analysis

• Indexing for
• A priori themes
• Emergent themes
• Charting, a matrix-based approach
• Compares within/between practitioners
• Compares within themes

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Themes impacting on outcome

• Building a relationship
• Diagnostic processes
• Treatment approaches
• Facilitating change

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Building a relationship

• Encouraging communication
• Building rapport
• Utilising explanations

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Diagnostic processes

• Taking the case history
• Identifying co-factors
• Exploring causes
• Physical assessment
• Arriving at a diagnosis

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Treatment processes

• Repertoire/style of practitioner
• Palpation location of pain/tension etc
• Matching treatment to patient
• Individualising points
• Auxiliary interventions
• Following patients over time

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Facilitating change

• Patients willingness to take responsibility
• Engaging with potential for change
• Advising on self help and life-style
• Supporting longer-term changes
• Patients life journey

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Longer-term change awareness

• . dont have to wait till things have gone
  wrong, they can actually avoid it
• the person has to make some changes
• . talk them round to being nice to themselves
• a lot of people are doing counter-productive
  things give them something that will change
  their habits

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Longer-term change a real shift

• a positive decision to protect their back
  from being re-injured again
• try not to hate your back
• . change their life-style and the change will
  keep, otherwise it wouldnt keep
• . the dialogue over ten sessions is good (so
  that) theres been a real shift

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Longer-term changeconsolidation

• . something dripped into their lives
• self management applies long after treatment has
  finished
• long-lasting (change is) self-motivated and
  has meaning

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How acupuncturists see a patient and their life
journey

• I am open to the big picture all the time
• acupuncture helps people align themselves with
  their true path
• it does affect a large proportion
  unconsciously..
• intuitively people understand this

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What impacts on outcome the practitioners
perspective
What the patient brings to the encounter
Impact of acupuncture on outcome
What happens in the way of a partnership
What the practitioner brings to the encounter
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Conclusions

• Acupuncturists provide a individualised and
  complex package of care
• Longer-term change is a practitioner goal
• Acupuncturists foster patient involvement in the
  healing process
• Longer-term change is in the interest of the
  patient
• and requires their active involvement