acupuntura

7212019 acupuntura

httpslidepdfcomreaderfullacupuntura-56d9d7936f042 16

Group acupuncture for knee pain evaluation of acost-saving initiative in the health service

Adrian White1 Marion Richardson2 Pamela Richmond3 Jonathan Freedman2

Mark Bevis4

1Department of Primary CarePeninsula Medical SchoolPlymouth University PlymouthUK2Parkbury House SurgerySt Albans UK3Midway Surgery St AlbansHerts UK4St Albans and HarpendenMSK CATS

Correspondence toDr Adrian White Department of Primary Care Peninsula MedicalSchool Plymouth University

N21 ITTC Building TamarScience Park Plymouth PL68BX UKadrianwhitepmsacuk

Received 29 February 2012Accepted 28 May 2012

AbstractBackground Acupuncture has been provided innurse-led group clinics in St Albans since 2008 It isfunded by a commissioning group within theNational Health Service on a trial basis for patientswith knee osteoarthritis who would otherwise bereferred to an orthopaedic surgeonAim To evaluate the patients seen in the service rsquos 1047297rst year of operation and their outcome up to theend of 2010Methods Service evaluation was made of patient

data from the referral centre and the acupunctureclinics including baseline characteristics attendancedata and Measure Yourself Medical Outcome Pro 1047297le(MYMOP) symptom function and well-being scoresover at least 2 yearsResults 114 patients were offered acupuncture of whom 90 patients were assessed in theacupuncture clinics 41 of these were still attendingafter 1 year and 31 (34) after 2 years MYMOPscores showed clinically signi 1047297cant improvements at1 month for pain (42 (SD 12) to 29 (SD 14))stiffness (41 (SD 13) to 29 (SD 13)) and function(45 (SD 11) to 33 (SD 12)) which continued upto 2 years Well-being scores did not changeConclusions This is the 1047297rst evaluation of nurse-led group (multibed) acupuncture clinics for patientswith knee osteoarthritis to include a 2 year follow-up It shows the practicability of offering a low-costacupuncture service as an alternative to kneesurgery and the servicersquos success in providing long-term symptom relief in about a third of patientsUsing realistic assumptions the cost consequencesfor the local commissioning group are an estimatedsaving of pound100 000 a year Sensitivity analyses arepresented using different assumptions

BACKGROUNDKnee osteoarthritis is common causing sig-ni1047297cant pain in 17 of the UK populationover the age of 50 years1 Conservative treat-ment is sometimes unsatisfactory core treat-ment is with exercise2 which has a relatively small mean effect size (standardised meandifference 040 95 CI 03 to 05 for pain)3

Non-steroidal drugs are commonly used butevidence of long-term effect is inadequate and

adverse reactions are well documented

including gastrointestinal haemorrhage car-diovascular events such as stroke and nephro-toxicity and cardiovascular events such asstroke4 Total knee replacement (TKR)surgery is now routine and about 76 500 wereperformed in England in 20105 The operationis effective and cost-effective6 but is not theappropriate choice for everyone who is eli-gible The cost at over pound5000 is not trivial

West Herts Primary Care Trust revised itscare pathway in 2006 setting up the musculo-

skeletal clinical assessment and treatment ser-vices (MSK CATS) to improve patient care andreduce referrals and costs These were operatedby four commissioning groups one of whichthe St Albans and Harpenden practice-basedcommissioning group (STAHCOM) coversthe St Albans and Harpenden area with 13practices and about 180 000 patients Thelocality is residential city suburbs and sur-rounding countryside The population islargely middle class and the county of Hertfordshire has a favourable deprivationindex being ranked 139th out of 149 Englishauthorities7

STAHCOM decided to offer acupuncture topatients who were being considered for referralfor TKR Acupuncture was already provided inprimary care St Albans by JF and MR withinthe NHS8ndash10 and so a service with two clinicsspeci1047297cally for knee pain was set up withnurses providing acupuncture to groups of patients to save costs see 1047297gure 111 In amodel similar to that in the Royal LondonHospital for Integrated Medicine12 groups arenot organised in formal cohorts but patients

simply attend on a rolling recruitment basiswhich has bene1047297ts including greater 1047298exibility of appointments The acupuncture servicewas opened in 2008 on a trial basis in twolocations in GP surgeries in St Albans Theclinics have received national acclaim winningin 2008 a Princersquos Foundation IntegratedHealth Award as well as an NHS Alliance

Acorn Award in the integrated and comple-mentary healthcare category

Patients access the service by means of aGPrsquos referral letter which is triaged by the

MSK CATS team including a consultant

170 Acupunct Med 201230170ndash175 doi101136acupmed-2012-010151

Original paper

OPEN ACCESS

7212019 acupuntura


orthopaedic surgeon senior physiotherapist (extended

scope practitioner) and general practitioners with interestand expertise in musculoskeletal medicine If surgicalreferral is a likely outcome the physiotherapist tele-phones the patient to assess whether they meet threeclinic entry criteria (unrelieved pain reduced walking dis-tance and night pain)11 Subsequently this informationthe referral letter and the x-ray 1047297lm are reviewed withthe consultant orthopaedic surgeon Any patients with aclinical or radiological diagnosis of osteoarthritis who arejudged to qualify for referral to an orthopaedic surgeonare offered acupuncture treatment 1047297rst

The acupuncture service is provided by two clinics and

funded by the health service Acupuncture is given atweekly intervals for 1 month then reduced progressively to 6 weekly Hitherto funding has been continued forpatients who have found the treatment bene1047297cial11

Patients who do not respond to manual acupuncture aregiven electroacupuncture (EA) Acupuncture is discontin-ued at 6 weeks if there is still no response and the patientreferred back to MSK CATS for consideration of furthertreatment

The effect of acupuncture is evaluated using MYMOPa self-completed measure of four items two symptomsfunction on a nominated activity and well-being eachduring the previous week13 It is scored on scales of zero

to six six being worst For this service the MYMOP wasmodi1047297ed by de1047297ning the two scored symptoms as painand stiffness Patients completed the modi1047297ed MYMOPat 1 and 6 months then every 6 months

It was decided to evaluate the outcomes of thepatients who were referred to the group acupunctureservice during its 1047297rst year of operation This serviceevaluation was conducted in parallel with a qualitativestudy of the acceptability of the clinics14

METHODS We examined routine clinical data collected from both

clinics for all patients assessed in the MSK CATS who

were offered acupuncture before referral to an ortho-paedic surgeon during the acupuncture servicersquos 1047297rst yearof operation January to December 2008 Anonymiseddata on these patients were extracted from computerisedhealth service records up to December 2010mdashthat is aminimum of 2 years follow-up Missing data werechecked with clinicians Patients discontinuing treatment

were classi1047297

ed as lsquo

lost to follow-uprsquo

except whenimprovement was clearly documented as the reason fordischarge in which case they were classi1047297ed aslsquoimproved treatment suspendedrsquo Data on patient 1047298owwere presented in a CONSORT (Consolidated Standardsof Reporting Trials)-style 1047298ow chart15 Outcomes scoresand other data were summarised descriptively and ana-lysed using the t-test function of Excel 2010

No additional data were sought or collected frompatients for the purpose of this report which thus meetsthe criteria of service evaluation not requiring independ-ent ethical review16

RESULTSOf the 114 patients considered for surgery and offeredacupuncture during 2008 90 (79) accepted andattended one of the clinics Patient 1047298ow during the fol-lowing 24 months is shown in 1047297gure 2

MSK CATS referral serviceDuring the reference year the MSK CATS service consid-ered surgical referral for 114 patients who had the follow-ing characteristics The mean VAS pain score was 61 (SD22) Forty-eight reported night pain 40 reported none

(23 did not reply) Their assessment of their walkingability was homebound = 7 10 min (or 100 yards)=26walk longer but lt30 min (or one mile) = 25 at least half an hour (or one mile) = 34 no information = 21 Fifty would accept surgery four said lsquo yes as a last resortrsquo and29 would decline

When asked what were their expectations of treat-ment 75 said pain reduction 1047297ve said increased mobility and four said surgery Fifteen did not want acupunctureand requested referral elsewhere instead

Group acupuncture service A total of 90 patients (23 men 26) were assessed in thetwo clinics in 2008 with mean age 71 (SD 95) yearsDuration of symptoms was gt5 years in 5388 (60)1ndash5 years in 2688 (30) and lt1 year in 888 (9)Baseline modi1047297ed MYMOP scores for the whole cohortwere pain 42 (SD 13) stiffness 43 (SD 14) reducedactivity 46 (SD 11) and general well-being 29 (SD 16)

When choosing their lsquoworst affected activity rsquo 65 nomi-nated walking 15 climbing hills or stairs 1047297ve generalmobility and 1047297ve named other activities includingbathing bowls cycling dancing and tennis Data weremissing on three

The clinics provided these 90 patients with a total of

1489 treatments (mean 165 per patient SD 95) up to

Figure 1 Patients receiving acupuncture in a group clinic in

St Albans

Acupunct Med 201230170ndash175 doi101136acupmed-2012-010151 171

Original paper

7212019 acupuntura


Figure 2 Flow chart of 114 patients considered for knee joint replacement surgery CATS MSK musculoskeletal clinical assessment

and treatment services


Original paper

7212019 acupuntura


the end of 2010 Acupuncture was given to both knees in50 patients right knee only in 22 and left only in 18

After 1 month 84 were still attending the service of whom 46 continued to receive manual acupuncture and27 had EA (data missing on 11) After 6 months 57(63) were still attending and MYMOP scores for thisgroup are given in table 1 After 12 months 41 (46)were still attending and at 2 years 31 (34) still contin-ued acupuncture having by then received a mean of 27(SD 42) treatments each Figure 3 shows that the initialimprovement in scores was sustained over this periodthough these data are somewhat limited by the smallernumber of responses in later evaluations

Predicting responders We explored baseline characteristics to see if any mightpredict the likelihood of response at 6 monthsResponders were of similar age (708 SD 98 years com-pared with 714 SD 91 years for those who stopped)

marginally less likely to be male (23 compared with30 of dropouts) and had marginally worse MYMOPscores for symptoms and activity (see table 2) None of these differences was statistically signi1047297cant

At 24 months there were no meaningful differences inage or baseline MYMOP scores between those who were

still receiving treatment and those who had stopped(data not shown) Use of EA was not in itself associatedwith continued bene1047297t since 29 of those still in treat-ment at 2 years were receiving EA compared with 37at 1 month

DISCUSSION About 80 of patients with knee osteoarthritis whoattended MSK CATS in 2008 and were considered candi-dates for TKR surgery were willing to try acupuncture

1047297rst Ninety patients were screened for acupuncture inthis NHS service offering treatment in groups Of these90 patients we know that at least 31 had not had TKR within the following 2 years

The strengths of this evaluation are the completeness of MSK CATS and clinic records and the detail of patientfollow-up attendance data throughout their associationwith the clinics Given the age and health status of many who attended it is remarkable that only 30 of patientshad to be classi1047297ed as lost to follow-up The evaluationrsquoslimitations include missing MYMOP scores on a propor-tion of patients owing to pressures on clinic nursesrsquo time

and lack of administrative support and lack of informationon the eventual outcome of patients who discontinuedacupuncture Another limitation is due to a subtle shift inreason for referral to MSK CATS over time GPs started torefer patients to MSK CATS speci1047297cally for acupuncturetreatment including some who did not want or were not1047297t for surgery It was decided that to deny them acupunc-ture would be unethical and so some patients who do notmeet the criteria were included on a case-by-case basis

Estimating the cost consequences of these acupunctureclinics is necessarily somewhat speculative We set outour data assumptions and estimations in the web-based

Appendix Practices charge pound20 per treatment whichcomfortably covers running costs The estimated cost tothe primary care trust of providing acupuncture for these90 patients was pound16 440 in the 1047297rst year and aboutpound30 000 over the whole period of this evaluation TheNHS tariff cost of uncomplicated TKR (code 9HB21C) ispound545617 A total of 41 patients had acupuncture and notsurgery in the 1047297rst 12 months of whom 31 had not hadsurgery at the end of 2 yearsmdashand anecdotally wereunlikely to undergo surgery in the near future since nonediscussed this with nurses in the clinics Deferring treat-ment costs frees up resources for the current year andhealth economists re1047298ect this bene1047297t by lsquodiscountingrsquo

costs at the current rate which is 3518

Table 1 Measure Yourself Medical Outcome Profile (MYMOP)

scores at baseline and 1 and 6 months for those still receiving

treatment and providing data at 6 months

Time

Pain

(n = 42)

Stiffness

(n = 41)

Activity

(n = 42)

General well-being

(n = 41)

Baseline 42 (12) 41 (13) 45 (11) 29 (18)

One

month

29 (14) 29 (13) 33 (12) 24 (14)

Six

months

25 (13) 26 (12) 28 (14) 21 (14)

Higher scores worse (SD)

Figure 3 Modi1047297ed Measure Yourself Medical Outcome Pro1047297le

(MYMOP) scores over time in the patients who continued

treatment for 24 months (number of responses at each time

point in parentheses) GWB general well-being

Table 2 Comparison of baseline Measure Yourself Medical

Outcome Profile (MYMOP) scores of those continuing and those

stopping acupuncture at 6 months

Pain Stiffness Activity General well-being

Continuing (n = 57) 42 (12) 41 (13) 45 (11) 29 (18)

Stopping (n = 27) 46 (13) 47 (12) 47 (12) 28 (14)

p Value (t test) 0124 0069 0498 0759



Original paper

7212019 acupuntura


Assuming that only about two-thirds of patientsoffered surgery would take up the offer in the 1047297rst yearour lsquobest guessrsquo estimate of realistic cost consequences isthat the acupuncture service would achieve savings of about pound100 000 a year Sensitivity analysis using differentassumptions suggests that maximum savings might be inthe region of pound171 000 a year and in the lsquoworst-case scen-

ariorsquo the service could generate net costs of about pound7000a year

We are reluctant to extrapolate the data from thisservice evaluation to other health trusts and other set-tings but we note that there are four commissioninggroups in this primary care health trust and there areabout 100 similar trusts in England altogether

The numbers of recorded episodes of TKR forSTAHCOM and the neighbouring three commissioninggroups are presented in 1047297gure 4 The original data are pre-sented in the web-based Appendix Rate 1047298uctuations areconsiderable and likely to be due to many factors but inthe third and fourth years after introduction of the acu-

puncture service in the STAHCOM commissioninggroup this group had the lowest proportional number of TKRs about 3 lower than the Dacorum area practised-based commissioning group (DACCOM) in 2010 and10 lower in 2011 The same differences are seen using2007 or 2008 as baseline but using 2006 as baselineSTAHCOM shared the lowest place with DACCOM Inaddition orthopaedic surgeons reported to one of us(MB) that referrals from the MSK CATS were moreappropriate in STAHCOM than the other commissioninggroups which could be partly due to the availability of acupuncture

The savings achieved by avoiding TKR in somepatients could be used to make acupuncture treatmentavailable for others even if not speci1047297cally to avoidsurgery For example some decline the offermdashas many as30 of patients in one survey 19

mdashand others are not eli-gible Criteria for surgery are highly variable and there isno clear indication who will have the best results20

Although TKR is successful in the sense that revisionrates are low as many as 15 of patients experiencesevere knee pain 3ndash4 years later21 and 18 are dissatis1047297edwith the results22 Experts recommend that all conserva-tive options should be offered before resorting tosurgery20 The evidence published on acupuncture inpatients with knee osteoarthritis shows that it is safe 23

and effective in reducing pain and improving function

24

thus qualifying it as an appropriate conservative treat-ment for this condition

Similar cost savings from reduced use of secondary carethrough acupuncture have been described before Threerandomised controlled trials of acupuncture for knee painreported an incidental 1047297nding of reduced demand forsurgery25ndash27 Lindall used (individual) acupuncture inprimary care for patients who would otherwise havebeen referred to orthopaedic or rheumatology outpati-ents savings were calculated to be about pound232 perpatient (1999 1047297gures) in consultation costs alone28

Other reports have suggested that acupuncture achieves

reduced drug expenditure29 30 Formal economic analyseshave assessed cost-effectiveness of acupuncture for kneeosteoarthritis as pound3889 per quality-adjusted life-year(QALY) for health costs alone31 and euro22 314 per QALYfrom a societal perspective32

Possible concerns about delaying surgery include risk of clinical deterioration There is evidence that surgery inpatients with a worse condition is less likely to be suc-cessful particularly with valgus deformity progressingbeyond 25deg33 It is important to monitor all patientsattending such clinics speci1047297cally for valgus deformity and for overall function for example with the Oxford

Knee Score34

In conclusion this 1047297rst evaluation of nurse-led groupacupuncture clinics for patients with knee osteoarthritisincluding 2 year follow-up shows the practicability of offering a low-cost acupuncture service as an alternativeto knee surgery and its success in achieving long-termsymptom relief in about a third of patients The realisticcost consequences for the local commissioning group arean estimated saving of about pound100 000 a year

Additional data are published online only To view this1047297le please visit the journal online (httpdxdoiorg101136acupmed-2012-010151)

Summary points Nurse-led group acupuncture is offered to patients who would

be referred for orthopaedic surgery

80 of patients accept and 30 who try it gain suf1047297cient

symptom relief to avoid surgery

Savings for this commissioning group were about pound100000 per

annum

Acknowledgements Julie Brumby ran the MSK CATS and provided data on the 1047297rstyearrsquos patients James Ferguson and Michael Cannell both GPs at Midway Surgeryfacilitated the clinic at that site Stephanie Martin-Smith also ran the clinic at Parkbury

House Surgery

Figure 4 Annual episodes of knee replacement surgery for

St Albans and Harpenden practice based commissioning group

(STAHCOM) compared with neighbouring groups (data

standardised to 2005ndash6 baseline) Acupuncture clinic started in

2008


Original paper

7212019 acupuntura


Contributors Concept JF and MR planned and set up the clinic in ParkburyHouse surgery PR James Ferguson and Michael Cannell (seeAcknowledgements) set up the clinic in Midway Surgery MB facilitated theclinics within STAHCOM commissioning groupMR PR and StephanieMartin-Smith (see Acknowledgements) delivered the acupuncture and collectedthe clinic data Julie Brumby (see Acknowledgements) collected MSK CATSreferral service data AW planned the evaluation analysed the data drafted thereport and is guarantor for the study

Competing interests AW has received lecture fees and travel expenses from the

British Medical Acupuncture Society (BMAS) related to the present work AW ispaid by BMAS as editor of the journal Acupuncture in Medicine and receivesroyalties on books on acupuncture The Peninsula Medical School received aresearch grant from BMAS to cover the costs of another researcher for workrelated to this study MR has been paid by BMAS for lecturing PR no competinginterest declared JF is a partner in one of the practices where a knee clinic takesplace and receives payment as a practice for each treatment MB no competinginterest declared

Patient consent Obtained

Ethics approval Meets the criteria of service evaluation

Provenance and peer review Not commissioned externally peer reviewed

REFERENCES1 Jinks C Jordan K Ong BN et al A brief screening tool for knee pain in primary care

(KNEST) 2 Results from a survey in the general population aged 50 and over Rheumatology (Oxford) 20044355ndash61

2 National Collaborating Centre for Chronic Conditions Osteoarthritis national

clinical guideline for care and management in adults London Royal College of Physicians 2008

3 Fransen M McConnell S Bell M Exercise for osteoarthritis of the hip or kneeCochrane Database Syst Rev 20084CD004376

4 Salvo F Fourrier-Reglat A Bazin F et al Cardiovascular and gastrointestinal safety of NSAIDs a systematic review of meta-analyses of randomized clinical trials Clin

Pharmacol Ther 201189855ndash665 wwwhesonlinenhsuk (accessed 9 Feb 2012)6 Dakin H Gray A Fitzpatrick R et al Rationing of total knee replacement a

cost-effectiveness analysis on a large trial data set BMJ Open 20122e0003327 The English Indices of Deprivation 2010 County summaries wwwcommunitiesgovuk

(accessed 20 Feb 2012)8 Freedman J An audit of 500 acupuncture patients in general practice Acupunct Med

20022030ndash4

9 Freedman J Richardson M Introducing voluntary donations to fund primary careacupuncturemdasha user survey Acupunct Med 200523137ndash40

10 Richardson M Freedman J A model for acupuncture training in primary care Acupunct Med 200523135ndash6

11 Freedman J Richardson M Setting up an acupuncture knee clinic under PracticeBased Commissioning Acupunct Med 200826183ndash7

12 Berkovitz S Cummings M Perrin C et al High volume acupuncture clinic (HVAC) forchronic knee painmdashaudit of a possible model for delivery of acupuncture in the

National Health Service Acupunct Med 20082646ndash5013 Paterson C Langan CE McKaig GA et al Assessing patient outcomes in acute

exacerbations of chronic bronchitis the measure your medical outcome pro 1047297le

(MYMOP) medical outcomes study 6-item general health survey (MOS-6A) andEuroQol (EQ-5D) Qual Life Res 20009521ndash7

14 Asprey A Paterson C White A lsquoAll in the same boatrsquo a qualitative study of patientsrsquoattitudes and experiences in group acupuncture clinic Acupunct Med 2012 doi

101136acupmed-2012-01015015 Schulz KF Altman DG Moher D CONSORT 2010 statement updated guidelines for

reporting parallel group randomised trials BMJ 2010340c33216 National Research Ethics Service De1047297 ning research National patient safety agency

London National Patient Safety Agency 201017 Major Knee Procedures for non Trauma Category 2 without CC March 2011 wwwdh

govukenPublicationsandstatisticsPublicationsPublicationsPolicyAndGuidance DH_124356 (accessed 21 Feb 2012)

18 NICE Guide to the methods of technology appraisal 2008 Section 561 httpwww

niceorgukmediaB52A7TAMethodsGuideUpdatedJune2008pdf (accessed 2 May2012)

19 Mitchell HL Hurley MV Management of chronic knee pain a survey of patientpreferences and treatment received BMC Musculoskelet Disord 20089123

20 Dieppe P Lim K Lohmander S Who should have knee joint replacement surgery forosteoarthritis Int J Rheum Dis 201114175ndash80

21 Wylde V Hewlett S Learmonth ID et al Persistent pain after joint replacement

prevalence sensory qualities and postoperative determinants Pain 2011152566ndash7222 Wylde V Dieppe P Hewlett S et al Total knee replacement is it really an effective

procedure for all Knee 200714417ndash2323 Yamashita H Safety of acupuncture for osteoarthritis of the knee mdasha review of

randomized controlled trials Acupunct Med 200624(Supp)S49ndash52

24 Manheimer E Cheng K Linde K et al Acupuncture for peripheral joint osteoarthritis

Cochrane Database Syst Rev 2010(1)CD00197725 Christensen BV Iuhl IU Vilbek H et al Acupuncture treatment of severe kneeosteoarthrosis a long-term study Acta Anaesthesiologica Scandinavica 199236519ndash25

26 Williamson L Wyatt MR Yein K et al Severe knee osteoarthritis a randomizedcontrolled trial of acupuncture physiotherapy (supervised exercise) and standard

management for patients awaiting knee replacement Rheumatology (Oxford)

2007461445ndash927 Soni A Joshi A Mudge N et al Supervised exercise plus acupuncture for moderate

to severe knee OA a small randomised controlled trial Acupunct Med

201230176ndash81

28 Lindall S Is acupuncture for pain relief in general practice cost-effective Acupunct

Med 19991797ndash10029 Downey P Acupuncture in the normal general practice consultation an assessment

of clinical and cost effectiveness Acupunct Med 19951345ndash730 Bourne IHJ Economic aspects of tender spot injection therapy Acupunct Med

199614114ndash1631 Whitehurst DG Bryan S Hay EM et al Cost-effectiveness of acupuncture care as an

adjunct to exercise-based physical therapy for osteoarthritis of the knee Phy Ther 201191630ndash41

32 Reinhold T Witt CM Jena S et al Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain Eur J Health Econ

20089209ndash1933 Rajgopal A Dahiya V Vasdev A et al Long-term results of total knee arthroplasty for

valgus knees soft-tissue release technique and implant selection J Orthop Surg

(Hong Kong) 20111960ndash334 Conaghan PG Emerton M Tennant A Internal construct validity of the Oxford Knee

Scale evidence from Rasch measurement Arthritis Rheum-Arthritis Care Res

2007571363ndash7


Original paper

7212019 acupuntura


orthopaedic surgeon senior physiotherapist (extended

scope practitioner) and general practitioners with interestand expertise in musculoskeletal medicine If surgicalreferral is a likely outcome the physiotherapist tele-phones the patient to assess whether they meet threeclinic entry criteria (unrelieved pain reduced walking dis-tance and night pain)11 Subsequently this informationthe referral letter and the x-ray 1047297lm are reviewed withthe consultant orthopaedic surgeon Any patients with aclinical or radiological diagnosis of osteoarthritis who arejudged to qualify for referral to an orthopaedic surgeonare offered acupuncture treatment 1047297rst

The acupuncture service is provided by two clinics and

funded by the health service Acupuncture is given atweekly intervals for 1 month then reduced progressively to 6 weekly Hitherto funding has been continued forpatients who have found the treatment bene1047297cial11

Patients who do not respond to manual acupuncture aregiven electroacupuncture (EA) Acupuncture is discontin-ued at 6 weeks if there is still no response and the patientreferred back to MSK CATS for consideration of furthertreatment

The effect of acupuncture is evaluated using MYMOPa self-completed measure of four items two symptomsfunction on a nominated activity and well-being eachduring the previous week13 It is scored on scales of zero

to six six being worst For this service the MYMOP wasmodi1047297ed by de1047297ning the two scored symptoms as painand stiffness Patients completed the modi1047297ed MYMOPat 1 and 6 months then every 6 months

It was decided to evaluate the outcomes of thepatients who were referred to the group acupunctureservice during its 1047297rst year of operation This serviceevaluation was conducted in parallel with a qualitativestudy of the acceptability of the clinics14

METHODS We examined routine clinical data collected from both

clinics for all patients assessed in the MSK CATS who

were offered acupuncture before referral to an ortho-paedic surgeon during the acupuncture servicersquos 1047297rst yearof operation January to December 2008 Anonymiseddata on these patients were extracted from computerisedhealth service records up to December 2010mdashthat is aminimum of 2 years follow-up Missing data werechecked with clinicians Patients discontinuing treatment

were classi1047297

ed as lsquo

lost to follow-uprsquo

except whenimprovement was clearly documented as the reason fordischarge in which case they were classi1047297ed aslsquoimproved treatment suspendedrsquo Data on patient 1047298owwere presented in a CONSORT (Consolidated Standardsof Reporting Trials)-style 1047298ow chart15 Outcomes scoresand other data were summarised descriptively and ana-lysed using the t-test function of Excel 2010

No additional data were sought or collected frompatients for the purpose of this report which thus meetsthe criteria of service evaluation not requiring independ-ent ethical review16

RESULTSOf the 114 patients considered for surgery and offeredacupuncture during 2008 90 (79) accepted andattended one of the clinics Patient 1047298ow during the fol-lowing 24 months is shown in 1047297gure 2

MSK CATS referral serviceDuring the reference year the MSK CATS service consid-ered surgical referral for 114 patients who had the follow-ing characteristics The mean VAS pain score was 61 (SD22) Forty-eight reported night pain 40 reported none

(23 did not reply) Their assessment of their walkingability was homebound = 7 10 min (or 100 yards)=26walk longer but lt30 min (or one mile) = 25 at least half an hour (or one mile) = 34 no information = 21 Fifty would accept surgery four said lsquo yes as a last resortrsquo and29 would decline

When asked what were their expectations of treat-ment 75 said pain reduction 1047297ve said increased mobility and four said surgery Fifteen did not want acupunctureand requested referral elsewhere instead

Group acupuncture service A total of 90 patients (23 men 26) were assessed in thetwo clinics in 2008 with mean age 71 (SD 95) yearsDuration of symptoms was gt5 years in 5388 (60)1ndash5 years in 2688 (30) and lt1 year in 888 (9)Baseline modi1047297ed MYMOP scores for the whole cohortwere pain 42 (SD 13) stiffness 43 (SD 14) reducedactivity 46 (SD 11) and general well-being 29 (SD 16)

When choosing their lsquoworst affected activity rsquo 65 nomi-nated walking 15 climbing hills or stairs 1047297ve generalmobility and 1047297ve named other activities includingbathing bowls cycling dancing and tennis Data weremissing on three

The clinics provided these 90 patients with a total of

1489 treatments (mean 165 per patient SD 95) up to

Figure 1 Patients receiving acupuncture in a group clinic in

St Albans


Original paper

7212019 acupuntura





Original paper

7212019 acupuntura


















Time

Pain

(n = 42)

Stiffness

(n = 41)

Activity

(n = 42)

General well-being

(n = 41)

Baseline 42 (12) 41 (13) 45 (11) 29 (18)

One

month

29 (14) 29 (13) 33 (12) 24 (14)

Six

months

25 (13) 26 (12) 28 (14) 21 (14)










Continuing (n = 57) 42 (12) 41 (13) 45 (11) 29 (18)

Stopping (n = 27) 46 (13) 47 (12) 47 (12) 28 (14)

p Value (t test) 0124 0069 0498 0759



Original paper

7212019 acupuntura











24






Knee Score34








annum


House Surgery





2008


Original paper

7212019 acupuntura

















20022030ndash4



























201230176ndash81











2007571363ndash7


Original paper

7212019 acupuntura





Original paper

7212019 acupuntura


















Time

Pain

(n = 42)

Stiffness

(n = 41)

Activity

(n = 42)

General well-being

(n = 41)

Baseline 42 (12) 41 (13) 45 (11) 29 (18)

One

month

29 (14) 29 (13) 33 (12) 24 (14)

Six

months

25 (13) 26 (12) 28 (14) 21 (14)










Continuing (n = 57) 42 (12) 41 (13) 45 (11) 29 (18)

Stopping (n = 27) 46 (13) 47 (12) 47 (12) 28 (14)

p Value (t test) 0124 0069 0498 0759



Original paper

7212019 acupuntura











24






Knee Score34








annum


House Surgery





2008


Original paper

7212019 acupuntura

















20022030ndash4



























201230176ndash81











2007571363ndash7


Original paper

7212019 acupuntura


















Time

Pain

(n = 42)

Stiffness

(n = 41)

Activity

(n = 42)

General well-being

(n = 41)

Baseline 42 (12) 41 (13) 45 (11) 29 (18)

One

month

29 (14) 29 (13) 33 (12) 24 (14)

Six

months

25 (13) 26 (12) 28 (14) 21 (14)










Continuing (n = 57) 42 (12) 41 (13) 45 (11) 29 (18)

Stopping (n = 27) 46 (13) 47 (12) 47 (12) 28 (14)

p Value (t test) 0124 0069 0498 0759



Original paper

7212019 acupuntura











24






Knee Score34








annum


House Surgery





2008


Original paper

7212019 acupuntura

















20022030ndash4



























201230176ndash81











2007571363ndash7


Original paper

7212019 acupuntura











24






Knee Score34








annum


House Surgery





2008


Original paper

7212019 acupuntura

















20022030ndash4



























201230176ndash81











2007571363ndash7


Original paper

7212019 acupuntura

















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2007571363ndash7


Original paper

acupuntura

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