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.

Method

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?
• Unchanged?
• Less severe?
• Very much less severe?
• Gone?

Has your range of movement:

• Improved?
• 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?

Comment

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.

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

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 (CBS)	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

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
Acupuncture of benefit?	427 Yes. 51 No.
Sleep Disturbance 233	Improved 50% Back to normal 33% Unchanged 15%

Table 2. Symptom Profile with Patients' Opinion

Legend

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
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 (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%
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 (From Survey 2). Low Back Pain

136 cases

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)

One year plus, average follow up.
55% response to mail survey. 1146 replies.

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.
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
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)

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

	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%

Severity of pain prior to Acupuncture

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%

Sex, age and marital status of survey population.

		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. Daily coffee intake was not an influential variable.

Duration of improvement for those who reported pain relief

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%

Immediate outcome of acupuncture Rx for 127 musculoskeletal pain patients

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%

In what way had the pain lessened for those who reported a successful treatment outcome?

	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.

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).

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 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.

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 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:

1. How robust is the longevity of the placebo response for an afferent stimulation technique?
2. What is the response rate to a placebo acupuncture treatment?
3. Is there a valid placebo acupuncture technique?
4. And for the fee-for-service practitioner, would it be ethical?
5. 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.

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.

My thanks to Samantha Strauss for the preparation of this manuscript.