Audit in Acupuncture Practice

Facial Pain: A Review of 200 CasesTreated with Acupuncture

Nazim Merchant

This arlicle is based on a presentation at tha BMAS SprinE Meetin! at Warwick in May 1995

SummaryA group of 2Al patients who hacl rec-.ivedacupuncture for chronic facial pain during the last10 years was reviewed. Of patients with temparo-mandibular jaint of muscular pain, 16y" claimedfull recovery alier acupuncture and 61yo repartedbenefit. In tigeninal neural]ia there was a 30.Byoclaim of considerable improvement with a 69.2%o\ . r t l l b"n" [ i ' . l l ' ,1 . \ lp l l ] l t r t BrpJler r t tu ! . r \ tninterpreting response rates would result from the Ltseof a visual analogue scale to record pain; so this wasassessed in a small group, in which 75',1, showedi nprovement after ac u pu ncture.

Key wordsAcupuncturc, Audit,tn a nd i bu I ar jo i nt pa i n,

Facial pain, Tetnporc-Tr i Benr i na I neu ra l9ia.

IntrcductionMany patients with chronic facial pain are seen by oraland maxillo facial surgeons. Three quafters of thesepatients have temporomandibular joint (TMJ) problems,which are conventionally treated by one or more otseveral therapies: analgesics, jaw exercises, physio-therapy (short wave diathermy or ultrasound), biteraising appliancc, anti depressants, arthfoscopy andeventually, in a few cases, sLrrgery. Belween 1984 and1993, 2O1 oi these patients at Crosshouse Hospitalreceived acupuncture. This has previously beenreported as beneficial in TMj pain (/). Somc othercases of facial pain were treated with acupuncture andlhese are also includecl in lhe feview aZ ll.The review was carried out retrospecti\,ely and lhe resLrlls

were purely subjective, relying on patient asseisnrenl olthe symptorns. No formal rrrethod ol pain assessment suchas a visual analogue scale (VAS)was used.Subsequently, i t was decided to repeat the study

prospectively, this t ime using a VAS to assess theresults, and the f irst 12 cases assessed by thisme-ho t l . r re .nL luded d l . he .nd u f t h J re \ c \

CenerJl deital pra.l tioneGCeneral med .al practit on€rsCons! tants in other special tiesAccidenl and emeEency depatment

l8. l t

6.0.t,0.5,/.

Prior to attendance, 6,+% had had no treatment,anaigesics had been used rn 3l.57o of cases andantibiotics in ,+.5"1,. After assessment at the hospitalclinic, 60'% of these patients were trcatcd by othermethods prior to acupuncture. In the rcmaining 80patients (40' l .) acupuncture was the f irst l ine oftreaLmenl, and of these, 34 had no treatment othertha n acupuncture.The dLrration ol acupunclLre trealrfent ranged from

I u B l - o r l h . . $ r l L - B o o o t p J l r p n l . e e r \ r n t

treatment for less than 3 months. The number ofacupuncture treatments ranSed {rom 1 to 14,1 with/07o of patients receiving less than 4.

Acupuncture pointsl h e l o l o $ r t p o r t . $ p r p r , . e d r o e p , l l r 8 :Temporon and i bu I a I jolntlmusc/esr TriBger points, 11.4.h i gem i n a I neLt ra I gi a (Second D iv isiotl) : L|.4,1 9,2A,sT,2, s t .1B.

higeminal neuralBia (Third Division):MFJ ld l .u t . mtsr , \4d\ \e le ' l . , la , L ;B. .

In cases of Trigeminal neuralgia, needles wereinserted into the tr igger points on the affected sidewithout precipitat ing the pain.Migraine: C,B.2o,21 .

PROBTTMSTREATED

Diagnosis Numbcr of Patients

TMJ dyftnction/mlscr ,r p.)in 15) t76"/,,)Pon l ra lma 21 111 .9"1)Tr iSemind Neurd 8 i r I I (6 .5 '1,MiSrainc I {0.5%)Othcr (atypical fa. ia pain) l0 (5.0%

MethodThe study group of 201females and 37 malesw i th 50% under 35 .

The referrals were from

A.upun.tute i n Me.lici ne

patients was made up ot I64ranging in age irom 13 B0

the fol lowing sources:

Restr/fsThe results were purcly subjcctive and no pain scalewas used for these cases. After about 4 scssions ofacupuncture the decision was left 1() the palienl as towhether further acLrpunctLrre should be carried outor not-

L t 0 Nov 1995 vol l3 Na 2

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This makes a total of 126 cases (62.7%) whoimproved. Of the remainder, 43.17o ir.proved withother treatments, 18.57o were lost to review 3.87.were still attending, and the rest were reierred to othercl inics, i .e. Pain cl inic, ENT surgeons, or neurologrsts.

Tem poron andibular jai nt/m usc u I ar pa i nOut of 153 patients with this diagnosis who weretreated with acupuncture, the results were as fol lows:

2l pat ienrs (rs%)

Thjs gives a total of 94 patients (61%) who benefitedfrom acupuncture.

TriEeninal neuralBiaThirteen Datients with this diagnosis were treatedwith acupuncture. The results were as fol lows:

ConslderabLe inrprovemcnt 4 pailcnts {30.8%)

The overal l results were as fol lows: visual Analogue scale assessmettFollowing this review of 201 palients, i t wasdecided to try and assess the pain by means ol alocm VAS. Twelve patients were assessed by thismethod f/able 2).one patient had a vaso vagal react'on to the

acupunclure and developed a rash on the face andneck, Her acupuncture was discontinued. (Jnepatient had no improvernent at al l after 9 weeks oiacupuncture and there was l i t t le improvement inone olher. Overal l , 9 out of the 12 patients (75'�2tshowed improvement with acupuncture.

conclusionAcupunctlrre has a signif icant role to play in thetreatment of facial pain, although there are othereffective methods of treating this. Patients withternporomandibular ioint or muscle pain benefitgfeatly from acupuncture, which may sometimes bethe only treatment required and while acupuncturedoes not usLral ly completely rel ieve the pain oftr igerninal nelrralgia, the cl inical impfession is thatit can al low a reduction in the dosage olcatbamazepine rcquied to control the paLn.It is intended to repeat this study more ful ly, using

the vAS to assess results.

Nazim Merchant BDS FDSRCSConsultant Oral & Maxillo Facial Surgeon

Ctusshouse Hospital, Kilmarnock, Scotland

l . Ho V Bradley P (1992) Acuplncfure tor res stant temporo 'mandib! rf loint pain dysfunction syndrome. Aclpun.tufein Medicine. 1 o(2): 53's

3 .

5 .

Thompson R (1990) A denta e lect lve to Chna r9 ' r0A.upun.turc in Med i.ine. 812): 70-1B.jrg um Jensen L, TallSren A, noest T, B.jrglum lensen s(1977) EJfect ol ac!puncturc on myo8en c headacheScandinarian lournal D€ntal Res.85:456 70lenkjns M {1990) Tr lSeminal ne!ra lSia: What does thepaticnt need ? ,A.uplr.ture in Medicile.8(2):65 7Cral ' t I ( r988) Elcct roacup!ncture for t r Seminal neufa 8 ia:A t€n \reaf revlew A.lpun.turc in Medi.ine. 511):35-6Loh L, Nathan PW Schot t CD, Z i lkha Kl (1984)Acupuncture vefsus medlcal treatment lor migraine andmusc e iension headaches. /o!d ai Neurcb\v,Nedr.rd[qerr .rnd P(l.hirtrJ. 4- ] I I 7, , . . - - p l s- .1"6 L n,an J -J | . r rFn o r r , , l | . . ,nby acupuncL!re. Acta Nedro.:hir. (Wisn). 59:279

5 patienrs (38.4%)

12.5%29.2%8 3 %

2 | par ients (61.8%)3 par ienrs (8.8%)

I par ient (2.9%). l par lents l l l .8%)

This gives a total of 69.2% of patients who benefitedlrom acupuncture.Seven patients were treated with acupuncture

alone, and the resulls were as fol lows:Conqiderable impro!-"ment l i ra t ient

Of the 6 that were also given carbamazepine, 5b-refl led, in hrt lor 'rer do.e. o[ tatbomazepinewere required to control the pain f4,5), but 1 patienthad no ben€fit at al l .

MigraineThe 1 patient with this dia8nosis (6) benefited fromrhp d , Jpun , l J e bu t n - - t hpn o - l l o rp \ i ew

Post TraumaTwenty folrr patients with this diagnosis were treated\,\, i th acupuncture. The results were as fol lows:

Considerable improvement 50.0"1,

Atypicalfacial painTen patients were seen with this dia8nosis aZ). Theresulls were as fol lows:

Gr€ai mprovement )o1'Some improvement 10%No improvement 50%Lostlo revie{, 1A%

Acuputlcture aloneOf the overall group of 201 patients, 34 were treatedwjth acupuncture alone and no other treatmentbefore or after The results were as follows:

Creat mprovenrenl5ome mprovement

Nov 1.)95 Val 13 Na.2

VASASSTSSMENT OT PAIN IN 12 PAfIENTS

Patient Follow-up vAs (cm) vAs (cm)No. (weels) Pie acupunctur€ Post Acupunctur€

2t . 54.5

1 . 530

1 . 5

65

4.56.5

5

t . 5

t 12 3t 9

5 9

7 28 2 29 2

1 1 l1 2 9

111 Acupun.tute in Medi.tnc

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Funding of Acupuncture Sessions inCeneral

Charles Walker

This paper is based on a prcsentation at the BMAS Autumn Meeting in London in Octobet 1991

Practice

SufimaryA genetal practice acupunctureservice was set up with financialsupport from both the local FamilyHealth Services Authotity and theRegional Health Authotity. Refeffalswere taken from within the grouppnctice and other local practices in abid to rcduce the referral ftte tohospital clinics. This appears to havebeen successful.

Key wordsAcupuncture, Audit, Funding, Ceneralpractlce, Muscu lo-skel etal pai n. The ALthor in his surgery

(Phat by krnd pe,nhsid ot Pul.e)

to continue the scheme unti l mid-Apri lwhen lwas due to go on extendedstudy leave on an acupuncture coursein China. A iurther t l2,250 was to bemade available on my return in Augustto continue the service unti l Apri l1996. Addit ionally, within the f irst 10months I had gained t l ,065 in privatefees and t75 in lecture fees.

conditions trcatedOvef the f irst 12 months, 492conditions were treated in a total of390 patients (Iable /), involving 1,890treatments; 67.9% ol treatedcondit ions were musculo-skeletal. The

tntroductionAftef attending a BMAS basic acupuncture course rnJanuary 1994 I introduced an acupuncture service atour three partner Medical Centre, serving 5000patienis in Merseyside. Init ial ly, this was an unpaidservice, but in March 1994 I applied to the NorthWest Re8ional Health Authority (NWRHA) forwait ing l ist init iat ive money to reduce hospitalrefenals, primari ly to orthopaedic, rheumatologyand physiotherapy cl inics.A f igure of I15 per 15 minute treatment was

suggested. In response to a request for a detailedbreakdown of treatment costs including my owntime, my nurse's t ime/ heatinS, l iShting, stationefy,needles, moxa etc., expenses in the reSion of {29per treatment were identified. My personalexpenditure on courses and equipment was f2,675.Continuous audit of patient symptomatolo8y using

a visual scoring systern during the course oftreatment, provided data to support the bid forfunding. A support ive Family Health ServicesAuthority (FHSA) and an interested local newspapergave further momentum and advertisement to aservice provided within the National Health Servicein an area of high unemployment.On 4ih July, NWRHA, joint ly with Wirral Health

FHSA, offered prospective funding of f8,900 as a 12month, once only, scheme based upon f15 pertreatment and equivalent to 593 treatments. Theservice was to be available to both practice andnon-practice patients al ike. This was well reportedin the national general practice newspapers. Thescheme commenced in August and 157 treatments\ e re B r \e1 i n l he f i r s r 5 i \ wee l ' uonh -12 , . j 55 r . By30th lanuary 1995, 18,100 had been uti l ised,providing 163 patients with a total of 540treatments- Wifral Health provided a further f2,000

Acupuncturc in Medicine

average number ot treatrnents per patient was 4.B;53% of patients received only one or tlvo treatment

Number ol lrealmen|s

FiEurc 1. Frcquency ol acupunclurc treatment.

sesston5.

Res.rrtsClinic t ime was available for 36 treatments perweek; 390 patients were treated over a 52 weekperiod, with a total of 1,890 individual treatmentsessions (Frgure /).A score card was used to assess the benefit

obtained fol lowing treatment. This was marked from0 to 10 in centimetres (Fiqurc 2) and patients wereasked to complete a card anonymously prior to eachtreatment session, includinB the f irst. l t was not seenby the doctor treating, who merely asked if thepatient's symptoms were static, better or worse,before deciding whether to use the same selection of

- - - - - - - - " . - -> deterorat ing

0 1 2 3 4 5 6 7 I 9 1 0

GOOD <-_--_ ' -__- ' - improvins aAD

Figure 2. Scorc cad used ta asses benefit.

112 Nov 1995 Vol l3 No.2

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CONDITIONS TREATED BY ACUPUNCTURE

whiplash

fieumatoid arthritis

rheumatoid arthritiscarpar tunner synorome

muscular pain (2 presnanr)

osteoarthritis1 6

E. Cadiov$cular6 cal fcnmpvpain6 venous invrestless leSs

3710 F. Drug withdnwavdietinqI ciearette cessation

4A weight reductiondrug withd.awaJ

22 G. Dematological

itch eczema5 jaundice

3 H, Respiratory

K CNsBell's palsytic (epileptic)pon herpetic ne!raligiatr igeminalne!ralgia

L. Ophthalnologial

9

1

52 Lawet IeBmedial compaft rnent strain

3 7

1 1742

31

5a

'14

4

29 A. ENr

20

232

5

I

3 12A

553

injury

2I

t o

l2Ia

7

in jury

sinusitis (2 pregnant)rhinitiYnasal congestion

labyrinthitispharynSitis

1 21 0

833ll

46

t 5t l31

io

9832I

23

tension (l prcgnanl)

l115

2lIl5

2IJ

82

potnts or nor.Due to an error, some patients d;d not complete a

card before their first session. A number of themlater did this retrospectively, but 64, who had hadonly one treatment session, remain witfr no scorecard. A standard, ungraduated, 1ocm visual

D€sB. ol impovement (%)

Figurc 3 . Degree af inprovenent in patients obaining benefit.

e

i

analogue score was not used as it was thought thatthis would need more explanation and there was notime available for this.

Cards were analysed comparing the first and lastscores:326 score cards encompassed 42B primaryconditions (F/gufe J)j 68.5o/0 1337) improved; 7.5%(37) remained the same; 7.5% (37) showed noprogression; 3.57o (17) deteriorated; 13.0% (64) hadno score card, thus their proSression is unknown.Of the 492 primary conditions treated, 337

(68.5%) showed some improvement on the scorecards and 357o of the improvement Sroup (24"k otthe total treated) showed a benefit greater than 50%in symptom control. Side effects noticed were: onefaint, three cases of light headedness, onehaematoma (1cm diameter) and occasional bruisesThe NWRHA funding was intended to reduce

hospital referrals, thus any treatment that a patientwould have received had acupuncture not been

Nov 1995 Val 13 No.2 113 Acupunctu re i n Med ic i re

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available was noted.' fhis was determined by myselland fol lowed my former routines, used prior tostarl ing acupunctl lre.In the period from August 1994 to lanuary 1995,

while the NWRHA scheme was running,l63 patieftswere treated, inclLrding 21 referrals from otherDractices; lhcy had 540 tfeaim€nt sessions Hospitalreferral was avoided in 79 cases alable 2)t medicationwould have been Llsed in the remaininS 84

Discussion_l-he general practice cnvironment is idea forthe Llseof acupunctufe, as prel iminary screening oicondit ions for fLlrther investigation of westelnmedical treatment can a ready have iaken place/thLrs obviating the need for secondary reierral

Paticnts can thefefore receive lreatment locally insLritable cl inic surroundings. "Minimal st imulatian"

techniques give a cheap, quick, effective trealmentwith l i t t le disruption to Eeneral cl inic t ime Thisincrcases lreatment options to both doctor andpa(ient. The minirnal st irnulation technique that Iused init ial ly on a I pal ients, involved taking oneneedle per paticnt (except i f C8.30 was beingneedled, when lused an addit ional, longer needLe)and insert ing i t serial ly at mult iple points lst imulated al each poinL for a maximum oi lOsecunli l needling sensation (de ql) was reported, bcforemo\,ing on to the next point- C)n rare o.(:asions Iused electroacLtpuncture for 20min at 15Hz; whichwas lhe on y t ime needles were left in fof more than1osec. I offered six, weekly treatrnents as standard,but treatment was dlscontinued after louf sessions i lno imDrovement had been experienced. The cndpoint of treatment fof those rvho had improved wasvariable. I would carry on for rnore than the sixsessions if the patient ielt symptoms contlnued tojmprove, although in some cases t leatment waso i j (on r rucd Lp , ruse o i t n r ' . u . l . i l . .

conclusionThe redcrcLion in drug expenditure, side cffects andhospital referrals in t imes ol l inancial constraint, andthe openini l up of an essential y private seclorservice in an area of high unemployment have beenwelcorteo.

Cha es Walker MRCPCavendish Med ical Cenlre

211Park Road North, Bikcnhead (UK) LlI Bl lU

REFERRATS AVOID ED THROUGH THE USE OT

ACUPUNCTURT

ENT

401.1t 05

2

A Review of the Use of AcuPuncture

SummafvTltis is i practice aLtalil reviewinE the oulcome ofacupLt!1(Iure treatnent over a t\/o nonth periacl Aquestionnaire was used tct determine the ben-'fitabtainerl by patients followinp, acupttncture ancl alsoto hvesf4ate any changc in atlilude towards theft, Jttn-nt buu+ht dbru! bt -h. p cnd c\p' ' ien e

l n e t a \ p m , n t \ o - , l " i n a d b \ B ' n t t P * a n d ' Ft . lhc , lue ' t ia tu ' . , t rc \^ t th c- t iFCl 'nB lh l bcn"hl

laste(l morc than 5 days. lnilially 50'n' ol pattentswere saeptical about acupunctLtre, but altertreatmenl 91 lo haal becone enthusiasts

Key wordsAauputicture, Audit, GeneraI Practice

lntroductionI havc been a genera practi t iofer for more than 20vears. In June 199'1 I attended a course on the; 'New" Acupuncture taught by Dr Fcl ix Mann andquick!y began to 8et some interesting results,i n i t i a l l y i n a l im i ted l i ed o l c l i n i ca l p rob ems ,

Acupuncture i n Medi.i ne

in General Practicemainly musculo-skeletal.ln September and October 1994 I was able to

attend the Naniini l Colle8e of Tradit iona ChineseMedicine as a "Forei]n Sluclent". I spent the timeob-F r \ i ng t l ^e l , o : l i u d - . u f . , Lp . l ' , l r r p i 1hosDital al inics and attending lectures on tradil ionalChinese medicine (TCM). I 6ad no wish to learn toneedle patients in the TCM manner as I was al leadyconfident of the outcome usin], "minimal"

acupuncture- In this, onc needle is inserted brie{ly ata l imited nLrr.ber oi points. The Chinese know aboutsingle poinl needling, using meridians and"Eitraordinary" points, but not many doctors inChina actually use single points routinely, as patientsseem to expecl, or pleier, the tradit ional mLllt i needletechnique, wilh extended jnsert ion t ime and extrastimulation wilh ..oxa, cupping or eLectrotherapy.(ln retufn to general practice lbegan lo neeclle

Tnanv more paiients for a much wider range ofproblems than before and incorporated.a nunrber ofthe Exlraordinary points into my reperlolre

I do not set t ime aside specif ical ly foI acupLrncture,

1 1 4 Nov 1995 Yol 1l No.?

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but offer i t during the normal course of a consulta-t ion. As the local Brapevine begins to wofk, rnorepatients are specif ical ly coming lvith a request fofd , Lpu1 , l u te I ' ed lmen l , wh i l p o he rs rema insurprised but pleased that I can treat themimmediately.I make no charge to NHS registered patients in the

practice, and get no reimbursement from the FHSA,but I am getting a lot of experience and am gratetulfor al l those patients who let me treat them. Inaddition I treat non-registered patients frorn otherpractices at their request, {or a nominal fee. I needleover 100 patients each month.

MethodI record all acupuncture treatment on patients'cornputer records. Using "Batch Reporfs" lrom theserecords, in ianuary and February 1995 I wrote to al lpatients treated in November and December 1994invit ing completion of a simple questionnaire. Idecided against incl lrding stamped addressedenvelopes, but rel ied on the personal interest of thepatients to respond, as many did by post or handdelivery. suff icient numbers replied for quali tat iveanalysis.A lesson learned from the f irst batch of replies

made me re-phrase question 4. Init ial ly I had askedwhether a condition was '2cute or chronic", butquickly learned that patients didn't understand theseterms: at least 2 patients thought that chronic meantmaliBnant or l i fe-threatening, while others left thequestion unanswered- I therefore substitlted thewords "recent or long term".Although I could review only those patients who

had a,, epted lrearme']r. thpr{. \ Frp a ferr o,, a-ion'when, although it was offered, it was refused: acouple of times because patients "didn't believe init", and on one baffling occasion because thepatient claimed, "lt's against my religion."!

The repliesNot al l f igures add up to 100%. In some questionspatients fai led to Eive clear answers of leltunanswered some of the sections. PercentaSe f igureshave been simplif ied to the nearest whole number.

No. of questionnaires sent out: November '94= 1 36December '94= 115

No. of replies received back: Total = 197 (78%)

1. Was this the f irst t ime that you had hadacupuncture?

Yes:156 (79' l")No:36 (18' l")

2. l f no, was previous treatment "tradit ionaJ" or"minirnal" (that is, usinB only a few needles, andnot leaving them in for long)?

36 replies: Tradit ional:25 1691")M in ima l :B (22%)

3. Were you a "sceptic" or an "enthusiast" init ial ly?There were: Sceptics:87 (50%)

Enthusiasti :86 (50%)

3a. Have you changed your mind?There are now: Sceptics: 10 (6%)

Enthusiasts: 1 5B (91%)

4.Was the condit ion acute or chronic (recent orlong term)? (November f igures excluded becauseof the misunderstanding of the words "acute" and

Recen t :44 (52%)Long-tefm :41 l41o/o)

5. was the condit ion improved or not?lmproved: i67 (85%)

Not improved: 26 (13%)

6. l f the condit ion was improved, was that completeor part ial?

complere:50 (25%)Patt ial.124 (63'k)

lThese f igures add up to more than the originaltotals for irnprovement as some patients had morethan one condit ion)

7. If paftial improvement, can you say by how much?<25Y" :25 113Y" )

25-50%:51 126%)>7 5%: 48 (24%)

B. l f there was improvement, how long did i t last?167 rep l i es : <1 day :15 (9 ' l " )

1 5 days: 46 (28olo)>5 days:96 (57%)

9.lf improvement, how did the acupuncturecompare with other more orthodox treatments?

137 replies: Worse: 2 (1"/.JSame: 22 (16010)

Be t te r :113 (82%)

10.Was there a worseninB of symptoms before anybenefit was felt?

I 7' l repl ies: Yes: 16 l9%)No : 1 55 (91%)

1l.woLrld you be prepared to use acupuncture forother condit ions?

182 replies: Yes: 178 (9A%)No :4 t2%)

1 2. Please add any of your own comments:

DiscussionThe most str iking results show an overwhelmingshift in att i tude from an init ial, even, balancebetween "scepilc" and "enthuslasts", to the vastrnajority of patients becomin|- "enthusiasts" (91ok).Bearing in mind the chronicity of some of the clinical

problems, there was a good outcome in a siSnificantnumber of patients. The challenge lies in trying torcduce the "not improved"group and also in extendingthe lenSth oftirne for which benefit was achieved.Condit ions ireated successful ly included :

painful shoulders, knees, backs, elbows, necks,ankles, hands, plantar fasciitis; emotional distressand insomnia; irritable bowel syndrome; nauseaand vomiting; hiccouEh; toothache; asthma; sinusitisand catarrh (acupuncture has become my prefered

Nov 1995 Vol 13 Na.2 115 Acupuncturc in Medicine

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option for chranic rhinitis); dysnenorrheoa anclprcmensttLtal tension; cystitis and uinary inconti-nence; parst-viral fatigue; acute iniuries (t'aranalBesia); miBraine and other lleadache; piles;weight reductian and cessation of smokinS.Some condit ions did not respond:

1 catarrh; I lliccou1h (thou7h my impression was ot'a najor psychalogical component which perhapsinflucnced (rutcone); 4 headaches; sone jointproblems includittg 3 backs, I shoulder, 1 wfist, 2knees, 1 tae and 1 tennis elbow.The l ist, mainly of functional condit ions, requ'res a

flexiblc approach to treatrnent re8it es: the Sreatr.ajority wil need only one or two lreatments toobtain an extended period of re iei. For morechronic condit ions l ike stress incontinencc, orprophylaxis of rniBraine, I f ind that weeklytreatm-onts over 4 or 6 weeks scem to brinB the LJestresult. My patients play i t by ear in discussion withme. l t is diff icult to be precise, hence the challengeof acupuncture, because of the constantly shift ingvariables of the "dose" given, the individual patientresponse and the role of lhe physician. I a.. verygrateful for Dr Fcl ix Mann's original obseNations onthe phenonrenon ol "Super reactors" and hiswanring that sorne patients gel worse before Eett ingbetter. This has hclped curb my init ial tendency toovef needle some patients,

In the early slagcs oi Saining experience Isometimes found myself trying to persuade reluctantpaticnts to accept trealmcnt. I now ofler it if 1 feel itwould be appropriatc, but no longer spend t irnelrying to sweet talk patients into acceptance. I teellhis is something which, i f freely offered, should be

ireeJy accepted. My impression is that a patient 'sstate of mjnd actually has l i t t le ef{ect on the. u l , o m p u I p d l m e r l 1 r h . r l l h - \ F , o m e l o p r p . rpat'ents who are a l i t t le sceptjcal at the outset tothose w6o "really believe in it"!The questionnaire was deviscd while my use of

acupuncture was sti l l fair ly neh,, so I was pleased Losee the signif icant shift of opinion from sceptic tocrt l^uri".t rnur E.l m) pdr on... Ore. r . irg c\cn dsimple audit takes considerable t ime, but to see if Ihave improved my outcomes signit icantly over thepast year I intend to repeat the exercise, thou:lh overonly one rnonth, in December 1995. I do not oltenuse acupuncture for patients under about ten yearsof age. Older people seem Lo respond very well. lnfuture questionnaires I shall be more specif ic aboutage. In quest'on 7 there was an error: the group 51-75% was omitted on the ori8inal questionnaire.None of the patients repofted noticjng this, but i twil l have introduced an error in the results. This wil lbe corrected in the 1995 audit.Suggestions for other r.odi i ications to the question-

naire would be welcome.

ConclusionThe use of acupuncture in my routine Seneralpra, t i , e has ludpo : beneli , id oplinn jr m.rn\situations which would otherwise be cl inical lyt iresome to rnanage. I wil l continue to use it tor anexpanding range of problems.

Sarah Watkins MB BS MRCCPEuropa House, WeJl Sreet

Leighton lluzzard, Beds (UK) LU7 7DD

Acupuncture for the Treatment ofMusculo-skeletal Pain in General Practice

lohn B

SummaryAn au(lit of 28 patients treate(l wiLh acupuncture forntusculo-skeleLtl pain, of whom visual analoSuescorcs were analysecl for 2a, showed a ntarkeddecrease in pain follor\litig trcatment. Need/es usedin treatment cosl /ess than 50p pet session, butconsultations wete doubled in len]th to 2omin.

Key wordsAcuputlcturc, Audit, Ceneral Practice, Musculoskeletal pain, Visual analogue scores.

lntrcductionlbeBan treating my l leneral practice patients wjthacupunctlrre after attending lhe Brit ish MedicalAcLrpuncture Society (BMAS) basic course in October1994. This was an intensive, 1wo weel<end courseconcentral ing on practical, hands on demonstTations.

Hynes

To audit the eflectiveness and eff iciency ofacupuncture jn the treatment of muscuJo skeletalpain in my general practice, I asked patients tocomplele visual analogue scores (VAS), I checkedthe number of acupunctlrre needles used and t imedthe consultations.

MethodThe patients drawn for this study were those seen Infoutine consullat ion. When patients presented withmusculo-skeletal pain I discussed the optionsavailable to them such as analSesia, non steroldalanti- inf larnmaiory drugs, physiotherapy, "wait andsee" or acupuncture. During examination I wouldreiterate the treatments available and if requestedwould perform acupuncture there and then.However, as a CP there afe quile a few optionsavailable for treating musculo-skeletal pain, so Idid

Acupun.turc in Medicine 1 1 6 Nov /995 Yol 7.:i No.-2

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IMPROVEMENT IN MUSCULO-SKITETAT PAINTOLLOWINC ACUPUNCTURE

3 days

Overallthere lvas a 52.5% redlction in pain as meas!rcd by VAs.

3 Neck & headache

6 Neck & shoulder7 Neck & shoulder

10 Headachdtensionl l Shoulderl2 Neck & shoulder

l4 Shoulder

18 Shoulder

20 Neck

9 2 79 3 61 0 3 79 1 87 2 5

8.5 6 2.58.5 s 3.59 2 7t 0 4 67 2 5

7.5 I 6 .55 1 49 3 65 3 29 2.5 6.s5 t 25 2 3t 0 3 78 2 68 1 7

not overstress the acupuncture, but found none theless that a significant majority were quite keen to tryit . Usually I have a ten minute consultation t ime, butwith acupuncture this extended to twenty minutes.However I have not found that this has causeddisruption to my surgeries.During the consultation, a history of the musculo-

skeletal pain was taken to identify its caLrse andduration. The patients were then asked to Srade thelevel of pain they were currently experiencinS, usinBa VAS with 0 bein8 no pain and 10 being the worstpain they could imagine. Acupuncture treatmentwas at recognised acupuncture points andmyofascial tr igger points, where these were found intrapezius, rhomboid, erector spinae, quadratuslumborum or mult i f idi muscles; 4-7 needles wereu .ed fo r - l 0 m inu le . . Pa l i en l s we 'e S i ren d rinformation leaflet on acupuncture (7), supple-mented by verbal explanation, and were requestedto feturn in three days for a second acupuncturetreatment. The VAS was used to assess therrresponse on this and subsequent visits.

ResultsThere were 28 patients init ial ly treated withacupuncture in this study; only 22 of them returnedfor follow up treatment and 2 of these had to beexcluded from the study, as one had a dramaticphobia to needles and the oiher had ankylosingspondyli t is with wildly f luctuating pain levels whichmade assessment diff icult. The results of the 20patients f inai ly included in the study are shown InIable /. They had a total of 43 treatments: 3 patientshad one treatment each, 1'l patients had 2, and 6patients had 3.

Nov 1995 vol 13 No.2

DiscussionThis was quite a small qualitative siudy. Howevetgiven the l imitations, the results proved verysatisfyinS. Of the patients who remained in thestudy, 71% showed a marked decrease in pain, withan average reduction of 52.57o as measured by VAS.Six patients, 21"h ol the initial 8roup, did not returnfor their fol low up appointment after the init ialtreatment. There are various possible reasons forthis: the acupuncture may have been ful ly effectiveafter the one treatmentj it may have given no reliefor caused exacerbation; the pain i tself may havebeen self limitinS anywayi the patients may not haveliked the acupuncture or found it uncomfortable; or,as in my practice al l the CPs run personal l ists,patients may have returned to their own CP instead.

Pain can be very difficult to measure objectively;however, the VAS, adequately explained init ial lyand at each subsequent treatment, should have beena rel iable means of pain measurement.Consultations of 15-20 minutes were required for

acupuncture treatment. I did not f ind this personallydisruptive to my surgeries, although some CPs mayfind it a problem. Modern acupuncture needles costapproximately 7p each, which compares veryfavourably with the cost of non steroidal anti inf lammatory druBs. Thus, each treatment session cost lessthan 50p for equipment, but was double the cost indoctor t ime.Success in al leviatinB pain, especial ly chronic

musculo skeletal condit ions, and a strong posit ivefeed back from grateful patients, which I thoroughlyenjoyed, has maintained my enthusiasm forcontinuing the use of acupuncture where suitable inroutine consultations,

lohn B Hynes MB LRCP&SI NUICP Registrar, Exeter Vocational Training Scheme

Addrcss for correspondenceConvent Road, Ballinrobe

County Mayo, lreland

1. BMAS (1994) Ihe Iheory and Practice of Acupundurc.Brirish Medical Acupuncturc Society

B.M.A.S. INTRODUCTORY

February 9-1' l th and MaOXFORDMay 17-191h and June

BIRMINGHAMSeptember and Octo

SLOUGHNovember 1-3rd and

Detaits trcrn the BMASTel: 01925 730727 Fax: 01

' t17AcLpDn.turc tn Medione

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doi: 10.1136/aim.13.2.110 1995 13: 110-111Acupunct Med

 Nazim Merchant with acupunctureFacial pain: a review of 200 cases treated

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