Medical Pain Education
Acupuncture for Pain and Autonomic Dysfunction:
Simon Strauss MBBS, Dip. Acupuncture,
Nanjing 1978. Four
retrospective surveys were carried out to assess the patient's
opinion of acupuncture efficacy for a range of pain and
autonomic dysfunction conditions. The acupuncture treatment
method used was based on the techniques taught at the first
WHO sponsored course for Western medical practitioners held in
Nanjing, China, at the Nanjing School of Traditional Chinese
Medicine in 1978. Each survey was carried out at different
lengths of follow up. The first group of
124 patients were all referred and all followed up by
telephone after about 6 weeks. The method of
acupuncture that was usually used for chronic pain conditions
is best described as the near-and-far method. This method
utilises both local/segmental and supraspinal reflexes to
promote muscle relaxation, increase tissue perfusion and
remove trigger points. It is a rehabilitation technique not
designed to provide analgesia as a primary objective.
Electrical stimulation of the needles was rarely done.
Attention was paid to precise point location, and the
Bu/Tonifying/warming needling technique, where the needle is
inserted painlessly and gently twirled until needle grasp (De
Qi) is obtained and then left in situ for 20 minutes, was used
most frequently. Moxibustion was used when indicated. Cupping,
aquapuncture, laser and osteopuncture were not
used. METHOD
Is your
pain: More
frequent? More
severe? Has your range
of movement: Improved? Remains
unchanged? The above questions
were asked about each of the pain conditions treated. COMMENT RESULTS Survey
Comparisons Survey Number of
responders Length of follow
up Method % survey
responders Acupuncture of
benefit 1. 124 6
Weeks Telephone 100% Yes!
84% 2. 478 6
Months Mail 75% Yes!
88% 3. 1146 1
Year Mail 55% Yes!
87% 4. 128 1 to 4
Years Mail 35% Yes!
85% Table 1
(Survey 1) Effectiveness of Acupuncture Therapy
in Chronic Pain Conditions
Condition Acupuncture
Frequency of
Pain Severity of
Pain Range of
Number Pain
Duration Yes Less None- much
less Less None- much
less Impro-ved Very much
Improved Cervical Brachial
Syndrome 90% 35% 45% 32% 57% 25% 57% 9.4 6.1 Multiple Site
Backache 82% 76% 11% 35% 41% 35% 41% 12.4 6.9 Sciatica 86% 35% 28% 28% 42% 14% 28% 11.5 3.4 Low Back Pain 76% 54% 15% 23% 52% 15% 30% 8.8 9.6 Headache 70% 30% 40% 40% 40% - - 9.7 10 Migraine 86% 42% 42% 28% 57% - - 8.5 17 Painful
Shoulder 100% 60% 40% 50% 50% 50% 50% 10.8 3.4 CBS and Frozen
Shoulder 75% 60% 40% 60% 40% 60% 40% 10 6.2 Tennis Elbow 60% - 40% - 40% 40% - 7.8 1.8 CBS and Tennis
Elbow 100% 50% - - 50% 50% 50% 8.5 5 Knee Pain 75% 30% 50% 30% 50% - 50% 7.5 4 Total 84% 42% 35% 29% 50% 9.8 7
Acupuncture of benefit? 427 Yes. 51
No Sleep Disturbance
233 Improved 50% Table 2 Symptom
Profile with Patients' Opinion Where
greatly helped = (much less frequent - no pain,) + (very much
less severe - no pain)/2.
Symptom Number
with. Greatly
helped Helped Back Pain 136 56.5% 30.5% Headache 100 63% 22% Anxiety 94 67% 22% Neck & Arm
Pain 72 73.5% 14% Knee Pain 66 54.5% 32% Sciatica Pain 58 56% 30% Neck Pain 56 59.5% 26.5% Hip Pain 53 48% 36% Sinus/hay fever 50 64.5% 18.5% Shoulder Pain 45 60% 26% Vertigo 42 67% 10% Elbow Pain 38 81% 16% Ankle Pain 35 43% 46.5% Asthma 23 62.5% 23% Edema 22 55% 45% Angina 15 40% 46% Trigeminal N. 11 90% 10% Zoster 10 77% 22% Table
3 (From Survey
2)
Cervicobrachial Syndrome/ Neck and Arm
Pain No. of patients 72 Average No. of
Treatments 7.4 Acupuncture of
benefit?
Yes 87% Frequency of pain Less 18% None - very much
Less 70% Severity of pain Less 10% None - very much
less 77% Effectiveness Rate
Pain: (18 + 70) + (10
+ 70)/2 = 87.5% Limitation of
movement: Improved 26% Full - Greatly
Improved 71% Medication Less 43% None -
Greatly Decreased 46% Sleep Improved 64% Back to normal 19% Pain
duration Helped
group 7.5
years Greatly
helped group 4.3
years Greatly helped With less than 5
treatments 2.1 years More than 5
treatments 5.4
years Table 4 Headache (From Survey 2)
46 Subjects randomly selected for
analysis 29 Myogenic, 14
Vascular/migraine, 3 mixed Average number of
treatments 7.8 Acupuncture of
benefit? Yes 91% Pain Frequency Less 24% None - Much Less 67% Pain severity Less 20% None - Much Less 59% Medication Less 16% None - Much Less 67% Sleep Improved 55% Back to normal 35% Pain duration Helped group 7 years Greatly helped group 6 years Not helped
group 13 years Greatly helped < 5
treatments 5 years duration Greatly helped > 5
treatments 8 years
duration Table 5
Acupuncture of
benefit? Yes
119 No 17 Is the frequency of
PAIN: More? 1% Less? 32% Very much
less? 38% No pain 17% Is the severity of PAIN: More? 2% Less 29% Very much less? 40% No pain 16% Sleep disturbance Less 50% Sleep back to
normal 38% Overall effectiveness rate
87% Greatly helped rate
56% Helped rate
30% Table 6 (Survey 3) Pain Condition No. Average
age Helped Greatly
helped Neck 398 61 24.0% 44.5% Neck only 34 47 13.5% 59.5% Neck & arm 239 58 26.0% 44.5% Shoulder 297 56 26.5% 44.5% Hand 163 57 23.0% 46.0% Back 393 53 29.0% 48.0% Back only 66 47 44.0% 49.0% Sciatica 184 58 17.5% 61.5% Sciatica Only 15 52 20.0% 57.0% Hip 156 58 30.0% 45.5% Knee 206 59 42.5% 52.0% Ankle 107 57 42.5% 48.0% Feet 138 57 22.0% 47.5% Headache 240 52 33.0% 50.0% Head only 29 46 22.0% 42.0% Where Helped = (Less Freq +
Less Severe Pain)/2. (Survey 3) contd. Autonomic
condition No. Age Less V. much less -
Nil Anxiety 230 53 25.5% 55% Vertigo 105 55 20.0% 42% A.M. sickness 14 37 29.0% 57% Period pain 15 34 20.0% 40% P.M.T. 16 37 56.0% 31% Fluid ret 52 51 38.0% 43% Skin disease 53 48 34.0% 42% Chest 63 48 14.0% 64% Sinus/Hayfever 139 48 28.0% 50% Conjunct. 21 52 24.0% 62% Diarrhoea 32 51 19.0% 51% Constipation 42 54 7.0% 54% Shingles 24 62 17.0% 75% (Survey 4)
Freq. % Can't remember 1 0.8% Less than 2 weeks 15 11.8% Less than 1 year 39 30.7% One year plus 72 56.7% Pain Severity Scale 1 -
5 Freq. % No pain 1 1 0.8% 2 4 3.2% 3 37 29.0% 4 38 30.0% Unbearable pain 5 36 28.0% Freq. % Sex Male 57 45% Female 70 55% Age in years < than 30 6 4.7% 30-39 16 12.4% 40-49 17 12.6% 50-59 27 21.3% 60-69 30 23.6% 70 plus 31 24.4% Marital status Married 88 69.3% Never
Married 6 4.1% Ex. Married 32 25.2% Comparison of age,
sex and marital status with treatment outcome was not
significant. Duration Freq. % Less than 2 weeks 8 7.4% 2 weeks - 3 months 8 7.4% More than 3 months 18 16.4% Still better time of
survey 74 68.5% State of pain immediately after
acupuncture course Freq. % Worse 2 1.6% Same 17 13.4% Better 67 52.7% No pain 41 32.3%
Freq. % It occurred less
frequently 10 9.2% It was not as intense 12 11.1% It was less intense and occurred
less freq. 108 79.7% 128 replies from randomly selected
musculoskeletal pain patients drawn from survey 3 four years
later.
DISCUSSION Scientific probity and cost
effectiveness
are the two important issues that should be assessed before a
new therapy is introduced into current patient management.
Many reviews of acupuncture mechanisms have now been
published. However, by and large these have dealt with basic
underlying neurophysiological effects of acupuncture. Clinical
literature, particularly from Australia, remains scarce. In
part this has been due to a less than enthusiastic response
from our medical schools and government authorities. Funds for
research projects remain difficult to obtain. Despite a rather
negative or even hostile sociopolitical environment, medical
acupuncture in Australia has flourished with around 10% of
general practitioners now integrating acupuncture into their
daily practice. Recognising that there is little worth
than an isolated individual can add to the rigorous
literature, I set out to gain the opinion of my patients who
used acupuncture. The tool chosen was perhaps a clumsy one,
lacking scientific validity. However, in a plea for mitigation
I would state that double blind trials for many reasons are
perhaps impossible to design when studying an afferent
stimulation technique that depends on the operator's skill of
application. Placebo controlled trials are the province of
those that graze in non-fee for service pastures. Further, the
few studies of placebo and afferent stimulation that have
analysed the long-term response indicate that placebo does not
exhibit temporal robustness. Hence
the retrospective survey*, as described above warts and all,
was used to gain the patient's opinion of outcome. The type of acupuncture used -the Near
and Far technique- is a very gentle method usually tolerated
well by young children and the frail elderly. It entails the
painless introduction of fine 30-32 gauge stainless steel
needles into specific loci - local trigger points plus distal
analgesia/sympatholytic producing points. The technique of
needle manipulation was dictated by the condition to be
treated. Pain was avoided as was electrical stimulation, point
injection (aquapuncture), and periosteal stimulation. Thus it
is entirely possible that a greater range of techniques or
different types of acupuncture could produce superior results.
It therefore should be emphasised that the presented results
reflect my own derivation of a type of acupuncture taught at
the Nanjing School of Traditional Chinese Medicine, Nanjing,
China. Survey
Comparisons Survey 1. represents the results given by
a consecutive series of chronic pain patients. All were
referred for acupuncture for control of chronic pain with a
mean duration of 7 years. Following an average of 9.8
acupuncture sessions 100% of the patients were surveyed by
telephone interview after an average of six weeks. 84% felt
that acupuncture had been of benefit, with 88% of those with
disturbed sleep reporting improvement of sleep pattern. The
overall effective rate for decrease of severity and frequency
of pain was 78%. Survey 2. 475 patients responded to a
mail survey, representing a response rate of 75%. The patients
can be regarded as a consecutive case series with an average
follow-up of 6 months. Following an average of 7.8 acupuncture
sessions, 88% felt that acupuncture had been of benefit, with
83% of those with disturbed sleep reporting improvement. The
average duration of those with head and neck pain was 6.8
years. Survey 3. 1146 responded to
a mail survey administered on average 12 months plus from
their last acupuncture treatment. Around 55% of the surveys
were returned. The majority had conditions of chronic pain.
87% felt acupuncture had been of benefit, with the overall
effective rate for decrease in severity and frequency of pain
varying according to the condition treated.From the returned surveys
the strongly gained impression is that acupuncture seems to
have helped the majority of patients that have responded to
the surveys. The second important question that must
be asked: Is it
valid to ask the patient's opinion? Several questions concerning placebo need
to be answered before using the lack of a placebo control
group as a criticism. These are: (I would argue that the results probably
do reflect a valid response in that the effective rate is much
higher than the usual placebo response rate of around 35% and
that the placebo component of these response rates would be
washed out, especially in the three last surveys with their
follow-up times of 6 months, 1 year and 3-4 years.)
Apart from the conditions of chronic
pain, patients with complaints such as anxiety and vertigo
seem to have done well. Interestingly, in each of the two
larger surveys anxiety was a very commonly treated condition.
Survey 4 was perhaps flawed because of it
complexity. Patients involved in this survey felt that it
could be best answered by those with a university degree
perhaps reflecting on its origins. Nevertheless, survey 4,
despite it low response rate, gives a much needed description
of the type and status of patients presenting to the
specialist medical acupuncturist. From information found on
Table 7 1 & 2, 86% of patients could be regarded as
chronic pain patients with 28% claiming unbearable pain and a
further 59% claiming moderate to severe pain (3-4 on a 1-5
scale). Their commonest reasons for presentation were that
other forms of treatment had not helped and they would have
tried anything likely to help. Thus, from the information
gained from survey 4 (Table 7., 1 & 2) survey 1 (duration
of pain state- Table 1.) survey 2 (Table 3, 4, 5). We can
begin to form a picture of patients with severe to unbearable
pain that could well be described as chronic who have failed
to respond to other interventions. This would accord well with
the author's own perception of his daily work. Cost effectiveness is difficult to
define. From survey 1, an average of 9.8 treatments was given,
survey 2, 7.8 treatment session were given. The schedule fee
for acupuncture is that of a standard consultation. On this
basis the average cost per patient is $13.95 x 9 = $125.50
(Fees at time of survey) and provides a helped rate of around
85% varying with the condition treated. CONCLUSION
The results of four retrospective surveys
designed to gain the patient's opinion of their response to
one form of acupuncture have been presented. The survey
methodology should be treated with caution. However, it would
seem that patients who frequently are the poor desperates for
whom multiple interventions have failed are generally well
pleased by their perceived long lasting pain relief coupled
with diminution of drug intake, improvement of sleep and
increased range of movement. For technical reasons
footnotes and references have not been included.
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The Patient's Opinion
First published:
International Journal of Clinical Acupuncture
The second group were
surveyed by mail after about 6 months, with 75% of 478
responding.
The third group were followed up after more
than one year. Questionnaires returned numbered 1146,
representing a 55% response rate. This larger survey was
funded in part by the National Health and Medical Research
Council of Australia (NHMRC).
The fourth survey group was
derived from a random selection of responders to the third
survey after 4 years, 128 questionnaires returned yielding a
35% response.
For the first
three surveys the following questions were asked to gain the
patient's opinion of their response.
The same freq.?
Less freq.?
Much less
freq.?
Entirely relieved?
Unchanged?
Less severe?
Very much less
severe?
Gone?
Greatly improved?
Become
full?
Was your range of movement not limited
before?
In
addition these general questions were asked:
Was acupuncture of benefit to
you?
If your sleep was disturbed, has it improved? Is it
back to normal? Unchanged?
How many practitioners did you
consult prior to acupuncture?
The fourth survey, designed to give information about
musculoskeletal pain patients, was very much more complicated.
Reasons for seeking acupuncture, caffeine intake,
education level, severity of pain, chronicity of pain, and
short and long term response to acupuncture were all assessed.
124 Patients, 100%
follow up @ six weeks plus
Treated
of Benefit?
Movement
of
Treatments
(years)
(CBS)
(Survey
2)
Patient number =
478.
Average follow up 6 months by mail.
Responders = 75%
No. of
practitioners consulted prior to acupuncture = 882.
Av. = 1.84.
Total number of specifically
treated complaints = 912. Av. = 1.98.
Average number of
treatments per patient = 7.8.
Back to
normal 33%
Unchanged
15%
Helped = (less frequent + less
severe)/2
Neck and Arm Pain (CBS)
from 100 survey responders
with headache
(From Survey 2)Low Back Pain. 136
cases.
One
year plus, average follow up.
55%
response to mail survey. 1146 replies.
Greatly Helped =
(Very Much Less Freq + No Pain) + (Very Much Less Severe + No
Pain)/2Table
7
128 replies from randomly selected
musculoskeletal pain patients drawn from survey 3 four years
later.
Reasons for seeking
acupuncture:
"Other forms of
treatment had not helped". -Listed as important by 63%. (n =
80).
"I'd have tried anything if I
thought it would help!" -Listed as important by 61%. (n =
78).
Daily coffee intake was
not an influential variable.
for 127
musculoskeletal pain patients.
those who reported a
successful treatment outcome?
"Other forms
of treatment had not helped".-Listed as important by 63%. (n
= 80).
"I'd have tried anything if
I thought it would help!"-Listed as important by 61%. (n =
78).
(*The first of
these surveys was carried out in the late seventies and at
that time little was known about the design issues
etc)
The first question to ask is: Is there a
bias in the results brought about by those who have gained a
positive result being more likely to respond to a
retrospective survey? Comparison of survey 1(100% follow-up)
with the other 3 surveys seems to mitigate against this.
Addressing the general question, was acupuncture of benefit to
you? There seems to be no real difference between any of the
groups surveyed. (Survey 1 = Yes 84%, Survey 2 = Yes 88%,
Survey 3 = 87%, Survey 4 = Yes 85%). Additionally, 50 failures
to treatment from survey 3 were re-surveyed after 5 years with
a return rate of 50%, apparently the same rate of return that
survey 3 had, suggesting that response to survey is
independent of treatment outcome.
Undoubtedly at the present time when we
try to analyse a patient's response to pain therapy we
eventually come to the patient's opinion. Tools such as VAS,
McGill Questionnaire etc all depend on the patient's opinion
and understanding. My view is if a
patient says he has not been helped then the treatment has
failed. If the patient claims to have been helped he probably
has benefited, especially if sleep, and range movement has
increased and medication decreased.
Survey 2 reveals that of 94 anxiety
cases, 67% felt themselves to be greatly helped, with 22%
being helped.
Survey 3 with 230 cases
had a greatly helped rate of 55% with an additional helped
group of 25%.
It would seem that
80-90% of patients with anxiety claim to have been helped.
Whether this represents a specific response or is due to a
reduction of pain remains to be defined.
From surveys 2 & 3 between 60-70% of
patients with vertigo claimed relief.
Another striking result from surveys 2
& 3 was he claimed result of the treatment of zoster. The
author's experience with acute zoster in the elderly indicates
that acupuncture has a place for the prevention of progression
to post herpetic neuralgia and in the short term is well
appreciated by patients as evidenced by 75%+ claiming to have
been greatly helped. Patients with chest disorders such as
asthma and chronic bronchitis seem to have also benefited,
with over 60% claiming to have been very greatly helped. (This
result seems to have been confirmed in a recent placebo
controlled trial of asthma and acupuncture carried out by the
author in conjunction with Brisbane University).
Sleep patterns also seem to have been
substantially improved with survey 1 claiming an 88% effective
rate, survey 2 83%. Again whether this was a specific response
or due to less pain or less anxiety remains to be
defined.
My thanks to Samantha Strauss for the
preparation of this manuscript.