"It's Better in a Group Anyway": Patient Experiences of Group and Individual Acupuncture

Participants experiences regarding the use of acupuncture as a treatment modality: A qualitative systematic review

BACKGROUND

Acupuncture is a promising modality in clinical practice, where the participants' experiences are crucial to acupuncture's use and effects. However, a comprehensive review synthesising participant experiences throughout treatment sessions is lacking. This study aims to explore the qualitative literature regarding participants' experiences of acupuncture as a potential treatment modality.

METHODS

A qualitative systematic review of existing literature was conducted through AMED, MEDLINE, Scopus, Embase, and Web of Science. The Joanna Briggs Institute (JBI) critical appraisal checklist was employed to evaluate research quality. Subsequently, the data were extracted and synthesised utilising the JBI Qualitative Assessment and Review Instrument (QARI) tool and data synthesis was carried out through meta-aggregation.

RESULTS

A total of twenty-eight articles were incorporated into the analysis. Four synthesised findings were identified: (1) Before acupuncture: last trust and hope; (2) During acupuncture: relaxing and calming; (3) After acupuncture: mind-body effects; and (4) Practitioner-participant relationship.

CONCLUSION

The findings highlight the changes participants experienced before and after acupuncture sessions. Implementing additional promotional initiatives for acupuncture can increase public awareness and encourage individuals to consider it an early symptom management option.

REVIEW REGISTRATION

This review was registered in PROSPERO (No. CRD42023475373).

[Concept for integrative pain treatment of osteoarthritis of the knee based on the evidence for conservative and complementary therapies]

BACKGROUND

Osteoarthritis of the knee (gonarthritis) represents a medical challenge.

RESEARCH QUESTION

What is the evidence with respect to approaches of complementary medicine and their integration into multimodal pain management concepts?

MATERIAL AND METHODS

Qualitative nonsystematic literature search on the epidemiology and pathophysiology as well as informative clinical trials, meta-analyses and clinical guidelines about conservative treatment including complementary therapy for gonarthritis.

RESULTS

Osteoarthritis of the knee is a frequent condition with biopsychosocial risks factors for chronification. The German S2k clinical guideline (k = consensus-based, not based on scientific systematic literature searches) published by the Association of the Scientific Medical Societies in Germany (AWMF) in 2017 has not yet been updated. The current guidelines of the American College of Rheumatology (ACR) date from 2020. Both guidelines recommend exercise therapy, weight reduction, short-term analgesics, topical therapy, intra-articular corticoid injections and acupuncture with variable strengths. Furthermore, transcutaneous electrical nerve stimulation (TENS), laser and other electrophysical therapies, shock waves, traction treatment, ergotherapy, comfrey poultices and mudpacks can also be used. Current research supports the benefits of tai chi/qigong and medicinal leaches.

CONCLUSION

Complementary treatment approaches, such as acupuncture, tai chi/qigong, topical naturopathic self-treatment and leeches (with limitations) can, in addition to behavioral changes, exercise therapy and short-term pharmacological treatment, be important evidence-based components of integrative pain management concepts, e.g. in terms of an interdisciplinary multimodal pain treatment (IMPT). Besides pain reduction and functional improvement they promote the internal control conviction through the possibility of self-treatment and self-exercise.

SIO-ASCO guideline on integrative medicine for cancer pain management: implications for racial and ethnic pain disparities

Racial and ethnic disparities in pain management pose major challenges to equitable cancer care delivery. These disparities are driven by complex interactions between patient-, provider-, and system-related factors that resist reductionistic solutions and require innovative, holistic approaches. On September 19, 2022, the Society for Integrative Oncology and the American Society of Clinical Oncology published a joint guideline to provide evidence-based recommendations on integrative medicine for cancer pain management. Integrative medicine, which combines conventional treatments with complementary modalities from cultures and traditions around the world, are uniquely equipped to resonate with diverse cancer populations and fill existing gaps in pain management. Although some complementary modalities, such as music therapy and yoga, lack sufficient evidence to make a specific recommendation, other modalities, such as acupuncture, massage, and hypnosis, demonstrated an intermediate level of evidence, resulting in moderate strength recommendations for their use in cancer pain management. However, several factors may hinder real-world implementation of the Society for Integrative Oncology and the American Society of Clinical Oncology guideline and must be addressed to ensure equitable pain management for all communities. These barriers include, but are not limited to, the lack of insurance coverage for many complementary therapies, the limited diversity and availability of complementary therapy providers, the negative social norms surrounding complementary therapies, the underrepresentation of racial and ethnic subgroups in the clinical research of complementary therapies, and the paucity of culturally attuned interventions tailored to diverse individuals. This commentary examines both the challenges and the opportunities for addressing racial and ethnic disparities in cancer pain management through integrative medicine.

Group Acupuncture Therapy With Yoga Therapy for Chronic Neck, Low Back, and Osteoarthritis Pain in Safety Net Settings for an Underserved Population: A Feasibility Pilot Study

Background

Acupuncture and yoga have both been shown to be effective in chronic pain. Underrepresented populations have poorer pain outcomes with less access to effective pain care.

Objective

To assess the feasibility of bundling group acupuncture with yoga therapy for chronic neck, back or osteoarthritis pain in safety net settings.

Methods

This was a feasibility pilot in Bronx and Harlem primary care community health centers. Participants with chronic neck, back or osteoarthritis pain received acupuncture and yoga therapy over a 10-week period. Participants received 10 weekly acupuncture treatments in group setting; with Yoga therapy sessions beginning immediately following the 3rd session. Primary outcome was pain interference and pain intensity on the Brief Pain Inventory (BPI); Outcomes were measured at baseline, 10-week close of intervention, and 24-week follow-up.

Results

93 patients were determined to be eligible and completed the baseline interview. The majority of participants were non-White and Medicaid recipients. 78 (84%) completed the intervention and 10-week survey, and 58 (62%) completed the 24-week post intervention survey. Participants received an average number of 6.5 acupuncture sessions (out of a possible 10), and 4 yoga sessions (out of a possible 8) over the 10-week intervention. Patients showed statistically significant improvements in pain at the close of the intervention and at a somewhat lesser rate, at 24-weeks post intervention. Challenges included telephone outreach and site coordination integrating acupuncture with yoga therapy. The trial also had to be stopped early due to the COVID-19 pandemic.

Conclusions

Bundling acupuncture therapy and yoga therapy is feasible for an underrepresented population with chronic pain in urban community health centers with preliminary indications of acceptability and benefit to participants.

Exploring patient experiences and acceptability of group vs. individual acupuncture for Cancer-related pain: a qualitative study

Background

Individual acupuncture (AP) is a safe and effective treatment for cancer-related pain and other symptoms in cancer survivors. However, access to individual AP is limited, and costs can be prohibitive. Group AP could be a more cost-effective alternative as it is less expensive and non-inferior to individual AP for pain relief. Despite growing evidence in favour of group AP, patient acceptability and experience of group AP in cancer patients is relatively unknown. This exploratory study sought to compare patient experiences and acceptability of group versus individual AP in cancer patients.

Methods

Semi-structured, open-ended, in-depth interviews were conducted in a subset of 11 cancer patients enrolled in a randomized non-inferiority trial of group vs. individual AP for cancer pain. Participants for this study were recruited via purposive sampling, aiming for diversity in age, sex, education, employment, cancer types, and treatment arms. Data was analyzed using inductive thematic analysis.

Results

Two major themes were identified: a) overall experience of AP treatment b) value of AP. Participants across both treatment arms acknowledged improvement in pain, quality of sleep, mood and fatigue. Participants in the group AP arm reported a significant increase in perceived social support, while participants in the individual arm valued privacy and one-on-one interaction with the acupuncturist. Although some participants in the group arm had privacy-related concerns before the commencement of the program, these concerns waned after a few AP sessions. Participants across both the treatment arms reported cordial clinician-patient relationship with the acupuncturist. Willingness to pursue AP treatment in the future was comparable across both the treatment arms and was limited by out-of-pocket costs.

Conclusion

Patient acceptability and experience of treatment in group AP was on par with individual AP. Group AP may further augment perceived social support among patients and privacy concerns, if any, subside after a few sessions.

Trial registration

ClinicalTrials.gov (NCT03641222). Registered 10 July 2018 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03600-6.

"The Pain Left, I Was Off and Running": A Qualitative Analysis of Group Acupuncture and Yoga Therapy for Chronic Pain in a Low-Income and Ethnically Diverse Population

Introduction: Chronic pain and the current opioid epidemic are pressing public health concerns, especially in low-income and ethnically diverse communities. Nonpharmacologic therapies that are safe, effective, and acceptable for the treatment of chronic pain conditions may provide a solution for addressing this issue. This qualitative analysis explores the experience of study participants who received combined acupuncture and yoga therapy (YT) to treat chronic pain delivered in a primary care setting. Methods: The group acupuncture with yoga therapy for chronic neck, low back, and osteoarthritic pain trial (GAPYOGA) assessed the feasibility and effectiveness of group acupuncture (GA) combined with YT in a low-income, racial, and ethnically diverse population. Individual in-depth interviews were conducted with a subset of patients in the trial. Nineteen participants were interviewed for qualitative analysis of their experience. Using the immersion and crystallization method, transcribed interviews were analyzed for themes meaningfully representing participant experience. Results: The combined GA and YT resulted in significant pain relief and transformative healing experiences. Three themes emerged from participant narratives: (1) transformative engagement with self in the healing process through pain relief, psychological well-being, and self-efficacy; (2) therapeutic relationship with acupuncture and yoga providers; and (3) fostering relationships with fellow participants in the group. Discussion: In this study of a low-income and ethnically diverse population, the combination of acupuncture and YT was found to alleviate pain, improve function, promote psychological well-being, and engage participants in self-care practices in a transformative healing process-resulting in physical and psychological benefits.

Cost-Utility of Group Versus Individual Acupuncture for Cancer-Related Pain Using Quality-Adjusted Life Years in a Noninferiority Trial

Introduction: Individual acupuncture (AP) is the gold standard method of AP delivery for cancer-related pain; however, costs can be prohibitive. Group AP allows four to six patients to be treated in a single session. This study sought to examine the cost-utility of group AP compared with individual AP from a patient perspective. Materials and Methods: Effectiveness and cost data from a noninferiority randomized trial of group versus individual AP for cancer-related pain were used. In the trial, 74 patients were randomly assigned to individual or group AP treatments twice per week for 6 weeks. The EuroQol five-dimension five level questionnaire (EQ-5D-5L) was used to assess health-related quality of life, and the EQ-5D Utility Index was used as a composite measure constituted of five domains (mobility, self-care, usual activities, anxiety-depression, and pain-discomfort). Linear mixed models were used to compare the change in EQ-5D-5L states pre-post intervention between the two arms. A cost-utility analysis was performed in terms of the incremental costs per additional quality-adjusted life year (QALY) gained. Results: Group AP participants experienced more significant relief in the pain-discomfort subscale of the EQ-5D-5L measure compared with individual AP participants (group × time, F = 6.18; p = 0.02). The effect size on pain-discomfort for group AP (d = 0.80) was higher than that of individual AP (d = 0.34). There were no significant differences between the two study arms for other subscales of the EQ-5D-5L over time. QALYs at 6 weeks were slightly higher for group AP (0.020) compared with individual AP (0.007) leading to an incremental QALY gained by the group arm of 0.013, but this difference was not statistically significant (p = 0.07). The cost of delivering AP treatment for the group arm over 6 weeks ($201.25) was nearly half of the individual arm ($400). Conclusions: Group AP was superior to individual AP in cancer patients. These findings have implications for the use of group AP in low-resource settings and in health care systems where AP for cancer patients is not covered by public health insurance. ClinicalTrials.gov (NCT03641222). Registered July 10, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/study/NCT03641222.

Barriers and Facilitators to Implementing Bundled Acupuncture and Yoga Therapy to Treat Chronic Pain in Community Healthcare Settings: A Feasibility Pilot

Objective: To identify factors associated with implementing bundled group acupuncture and yoga therapy (YT) to treat underserved patients with chronic pain in community health center (CHC) settings. This is not an implementation science study, but rather an organized approach for identification of barriers and facilitators to implementing these therapies as a precursor to a future implementation science study. Design: This study was part of a single-arm feasibility trial, which aimed to test the feasibility of bundling GA and YT for chronic pain in CHCs. Treatment outcomes were measured before and after the 10-week intervention period. Implementation feasibility was assessed through weekly research team meetings, weekly yoga provider meetings, monthly acupuncture provider meetings, and weekly provider surveys. Settings: The study was conducted in New York City at two Montefiore Medical Group (MMG) sites in the Bronx, and one Institute for Family Health (IFH) site in Harlem. Subjects: Participants in the feasibility trial were recruited from IFH and MMG sites, and needed to have had lower back, neck, or osteoarthritis pain for >3 months. Implementation stakeholders included the research team, providers of acupuncture and YT, referring providers, and CHC staff. Results: Implementation of these therapies was assessed using the Consolidated Framework for Implementation Research. We identified issues associated with scheduling, treatment fidelity, communication, the three-way disciplinary interaction of acupuncture, yoga, and biomedicine, space adaptation, site-specific logistical and operational requirements, and patient-provider language barriers. Issues varied as to their frequency and resolution difficulty. Conclusions: This feasibility trial identified implementation issues and resolution strategies that could be further explored in future implementation studies. Clinical Trial Registration No.: NCT04296344.

Multi-stakeholder perspectives on managing insomnia in cancer survivors: recommendations to reduce barriers and translate patient-centered research into practice

PURPOSE

Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions.

METHODS

Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that may influence dissemination and implementation.

RESULTS

Multidisciplinary and stakeholder workshop participants (N = 51) identified barriers and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g., knowledge, time, cost), clinician (e.g., education, time, capacity), institutional (e.g., space, insurance reimbursement, referrals), and societal (e.g., lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology.

CONCLUSION

Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care.

IMPLICATIONS FOR CANCER SURVIVORS

Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.

What if Acupuncture Were Covered by Insurance for Pain Management? A Cross-Sectional Study of Cancer Patients at One Academic Center and 11 Community Hospitals

OBJECTIVE

In response to the national opioid crisis, governmental and medical organizations have called for broader insurance coverage of acupuncture to improve access to nonpharmacologic pain therapies, especially in cancer populations, where undertreatment of pain is prevalent. We evaluated whether cancer patients would be willing to use insurance-covered acupuncture for pain.

DESIGN AND SETTING

We conducted a cross-sectional survey of cancer patients with pain at one academic center and 11 community hospitals.

METHODS

We used logistic regression models to examine factors associated with willingness to use insurance-covered acupuncture for pain.

RESULTS

Among 634 cancer patients, 304 (47.9%) reported willingness to use insurance-covered acupuncture for pain. In univariate analyses, patients were more likely to report willingness if they had severe pain (odds ratio [OR] = 1.59, 95% confidence interval [CI] = 1.03-2.45) but were less likely if they were nonwhite (OR = 0.59, 95% CI = 0.39-0.90) or had only received high school education or less (OR = 0.46, 95% CI = 0.32-0.65). After adjusting for attitudes and beliefs in multivariable analyses, willingness was no longer significantly associated with education (adjusted OR [aOR] = 0.78, 95% CI = 0.50-1.21) and was more negatively associated with nonwhite race (aOR = 0.49, 95% CI = 0.29-0.84).

CONCLUSIONS

Approximately one in two cancer patients was willing to use insurance-covered acupuncture for pain. Willingness was influenced by patients' attitudes and beliefs, which are potentially modifiable through counseling and education. Further research on racial disparities is needed to close the gap in utilization as acupuncture is integrated into insurance plans in response to the opioid crisis.

"It Gave Me Hope" Experiences of Diverse Safety Net Patients in a Group Acupuncture Intervention for Painful Diabetic Neuropathy

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients.

Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pain and quality of life (QOL), as well as semistructured qualitative interviews about participants' experiences with PDN and the intervention. Interview transcripts were coded and analyzed using an inductive thematic framework.

Results: We recruited 40 participants from diverse racial/ethnic backgrounds from a public hospital and conducted in-depth qualitative interviews with a subset of 17 participants. Participants randomized to acupuncture experienced greater decreases in pain compared with usual care as well as improved QOL. In interviews, they described a myriad of socioeconomic and personal life stressors that compounded the significant suffering and disability brought on by PDN. Those who received acupuncture were able to decrease reliance on pain medication, improve their sleep and daily function, reduce stress, and engage more with their own self-care. They noted that the acupuncture intervention also gave them hope in the face of their chronic disease.

Conclusion: Acupuncture is a valuable adjunct treatment for low-income and marginalized populations with PDN. In addition to reducing pain and improving QOL, acupuncture may offer powerful benefits by increasing patient activation and hope.

Group versus Individual Acupuncture (AP) for Cancer Pain: A Randomized Noninferiority Trial

Background

A service delivery model using group acupuncture (AP) may be more cost-effective than individual AP in general, but there is little evidence to assess whether group AP is a comparable treatment in terms of efficacy to standard individual AP. The study aimed to compare the group to individual delivery of 6-week AP among cancer patients with pain.

Methods

The study design was a randomized noninferiority trial of the individual (gold standard treatment) vs. group AP for cancer pain. The primary outcome was pain interference and severity, measured through the Brief Pain Inventory (BPI). Secondary outcomes included measures of mood, sleep, fatigue, and social support. Changes in outcomes from pre- to postintervention were examined using linear mixed effects modeling and noninferiority was inferred using a noninferiority margin, a difference of change between the two arms and 95% CIs. Pain interference was tested with a noninferiority margin of 1 on the BPI, while pain severity and secondary outcomes were compared using conventional statistical methods.

Results

The trial included 74 participants randomly allocated to group (35) or individual (39) AP. The noninferiority hypothesis was supported for pain interference [Ө - 1, Δ 1.03, 95% CI: 0.15-2.20] and severity [Ө - 0.81, Δ 0.52, 95% CI:.33-1.38] as well as for mood [Ө - 7.52, Δ 9.86, 95% CI: 0.85-18.86], sleep [Ө - 1.65, Δ 2.60, 95% CI: 0.33-4.88], fatigue [Ө 8.54, Δ - 15.57, 95% CI: 25.60-5.54], and social support [Ө.26, Δ - 0.15, 95% CI:  - 0.42-0.13], meaning that group AP was not inferior to individual AP treatment. Both arms evidenced statistically significant improvements across all symptoms before and after the intervention. Effect sizes for the group vs. individual AP on outcomes of pain, sleep, mood, and social support ranged from small to very large and were consistently larger in the group condition. The total average cost-per-person for group AP ($221.25) was almost half that of individual AP ($420).

Conclusions

This is the first study to examine the noninferiority of group AP with the gold standard individual AP. Group AP was noninferior to individual AP for treating cancer pain and was superior in many health outcomes. Group AP is more cost-effective for alleviating cancer pain and should be considered for implementation trials.

Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care-a Randomized Trial

BACKGROUND

Acupuncture has been shown to be effective for the treatment of chronic musculoskeletal back, neck, and osteoarthritis pain. However, access to acupuncture treatment has been limited in medically underserved and low-income populations.

OBJECTIVE

Acupuncture therapy delivered in groups could reduce cost and expand access. We compared the effectiveness of group versus individual acupuncture for pain and function among ethnically diverse, low-income primary care patients with chronic musculoskeletal pain.

DESIGN

This was a randomized comparative effectiveness non-inferiority trial in 6 Bronx primary care community health centers. Participants with chronic (> 3 months) back, neck, or osteoarthritis pain were randomly assigned to individual or group acupuncture therapy for 12 weeks.

PARTICIPANTS

Seven hundred seventy-nine participants were randomized. Mean age was 54.8 years. 35.3% of participants identified as black and 56.9% identified as Latino. Seventy-six percent were Medicaid insured, 60% reported poor/fair health, and 37% were unable to work due to disability.

INTERVENTIONS

Participants received weekly acupuncture treatment in either group or individual setting for 12 weeks.

MAIN MEASURES

Primary outcome was pain interference on the Brief Pain Inventory at 12 weeks; secondary outcomes were pain severity (BPI), physical and mental well-being (PROMIS-10), and opiate use. Outcome measures were collected at baseline, 12 and 24 weeks.

KEY RESULTS

37.5% of individual arm and 30.3% in group had > 30% improvement in pain interference (d = 7.2%, 95% CI - 0.6%, 15.1%). Non-inferiority of group acupuncture was not demonstrated for the primary outcome assuming a margin of 10%. In the responder analysis of physical well-being, 63.1% of individual participants and 59.5% of group had clinically important improvement at 12 weeks (d = 3.6%, 95% CI - 4.2%, 11.4%).

CONCLUSIONS

Both individual and group acupuncture therapy delivered in primary care settings reduced chronic pain and improved physical function at 12 weeks; non-inferiority of group was not shown.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT02456727.

Developing and employing a 'responsive manualization' in the 'Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment' comparative effectiveness study

OBJECTIVE

The aim of this article is to describe the process used to develop an acupuncture therapy manual for a large effectiveness trial comparing individual care against group care for chronic pain in an underserved population. The design needed to not only ensure research consistency and replicability but also be 'responsive' to real world heterogeneous and evolving presentations in challenging physical settings.

BACKGROUND

Chronic pain is prevalent in the United States. While acupuncture is effective for chronic pain, minority, ethnically diverse and lower socioeconomic populations have limited access. Group acupuncture is proposed as a lower cost option to facilitate access in safety net settings, but research on the effectiveness of group versus individual acupuncture is lacking.

METHODS

We engaged a modified Delphi process with expert practitioners from diverse backgrounds who were experienced in individual and group practice. All contributions were recorded and collated for second- and third-round consensus discussions that included contributions by the trial's research acupuncturists.

RESULTS

A 'responsive manual' flow chart was created with suggested sequencing that included interviews concurrent with palpation, Tui na, Gua sha, acupuncture needling, ear treatment, basic recommendations and options for departure with rationale. The manual was implemented by six research acupuncturists in five primary care settings in the Bronx, New York, with weekly team meetings to discuss manual use. There were no serious adverse events (AE) and few minor AE reported in this trial.

CONCLUSION

A 'responsive manual' can be structured and implemented that is not only consistent and replicable but also flexible to accommodate the real-world clinical needs of practitioners and patients in challenging physical settings.