Acupuncture for Pain and Autonomic Dysfunction: The Patient's Opinion
Simon Strauss MBBS, Dip. Acupuncture, Nanjing 1978.
First published: International Journal of Clinical Acupuncture
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 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.
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.
For the first three surveys the following questions were asked to gain the patient's opinion of their response.
Is your pain:
- More frequent?
- The same freq.?
- Less freq.?
- Much less freq.?
- Entirely relieved?
- More severe?
- Less severe?
- Very much less severe?
Has your range of movement:
- Greatly improved?
- Become full?
- Remains unchanged?
- Was your range of movement not limited before?
The above questions were asked about each of the pain conditions treated. 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.
|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||75%||Yes! 88%|
|3||1146||1 Year||55%||Yes! 87%|
|4||128||1 to 4 Years||35%||Yes! 85%|
Table 1 (Survey 1). Effectiveness of Acupuncture Therapy in Chronic Pain Conditions
124 Patients, 100% follow up @ six weeks plus
|Condition Treated||Acupuncture of Benefit?||Frequency of Pain||Severity of Pain||Range of Movement||Number of Treatments||Pain Duration (years)|
|Yes||Less||None- much less||Less||None-much less||Improved||Very much Improved|
|Cervical Brachial Syndrome
|Multiple Site Backache||82%||76%||11%||35%||41%||35%||41%||12.4||6.9|
|Low Back Pain||76%||54%||15%||23%||52%||15%||30%||8.8||9.6|
|CBS and Frozen Shoulder||75%||60%||40%||60%||40%||60%||40%||10||6.2|
|CBS and Tennis Elbow||100%||50%||-||-||50%||50%||50%||8.5||5|
|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|
|Acupuncture of benefit?||427 Yes. 51 No.|
|Sleep Disturbance 233||Improved 50%
Back to normal 33%
Table 2. Symptom Profile with Patients' Opinion
Greatly helped = (much less frequent - no pain,) + (very much less severe - no pain)/2.
Helped = (less frequent + less severe)/2
|Symptom||Number with.||Greatly helped||Helped|
|Neck & Arm Pain||72||73.5%||14%|
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%|
|None - Greatly Decreased||46%|
|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 (From Survey 2). Headache
46 Subjects randomly selected for analysis from 100 survey responders with headache.
29 Myogenic, 14 Vascular/migraine, 3 mixed.
|Average number of treatments||7.8|
|Acupuncture of benefit?||Yes||91%|
|None - Much Less||67%|
|None - Much Less||59%|
|None - Much Less||67%|
|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 (From Survey 2). Low Back Pain
|Acupuncture of benefit?||Yes||119|
|Is the frequency of PAIN:||More?||1%|
|Very much less?||38%|
|Is the severity of PAIN:||More?||2%|
|Very much less?||40%|
|Sleep back to normal||38%|
|Overall effectiveness rate||87%|
|Greatly helped rate||56%|
Table 6 (Survey 3)
One year plus, average follow up.
55% response to mail survey. 1146 replies.
|Pain Condition||No.||Average age||Helped||Greatly helped|
|Neck & arm||239||58||26.0%||44.5%|
Where Helped = (Less Freq + Less Severe Pain)/2.
Greatly Helped = (Very Much Less Freq + No Pain) + (Very Much Less Severe + No Pain)/2
Table 7 (Survey 3) contd.
|Autonomic condition||No.||Age||Less||V. much less - Nil|
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).
Duration of pain prior to start of Acupuncture
|Less than 2 weeks||15||11.8%|
|Less than 1 year||39||30.7%|
|One year plus||72||56.7%|
Severity of pain prior to Acupuncture
|Pain Severity Scale 1 - 5||Freq.||%|
Sex, age and marital status of survey population.
|Age in years||< than 30||6||4.7%|
Comparison of age, sex and marital status with treatment outcome was not significant. Daily coffee intake was not an influential variable.
Duration of improvement for those who reported pain relief
|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%|
Immediate outcome of acupuncture Rx for 127 musculoskeletal pain patients
|State of pain immediately after acupuncture course||Freq.||%|
In what way had the pain lessened for those who reported a successful treatment outcome?
|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.
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).
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 first of these surveys was carried out in the late seventies and at that time little was known about the design issues etc)
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.
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%.
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.
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 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.
The second important question that must be asked: Is it valid to ask the patient's opinion?
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.
Several questions concerning placebo need to be answered before using the lack of a placebo control group as a criticism. These are:
- How robust is the longevity of the placebo response for an afferent stimulation technique?
- What is the response rate to a placebo acupuncture treatment?
- Is there a valid placebo acupuncture technique?
- And for the fee-for-service practitioner, would it be ethical?
- And has the "Placebo Controlled Trial" been used to disenfranchise/invalidate the clinicians opinion?
(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 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.
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.
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.
My thanks to Samantha Strauss for the preparation of this manuscript.