The patients interviewed were 2 men and 10 women, purposively sampled to reflect the diversity of known characteristics across all participants in the trial. In the three-month questionnaires, which were completed at around the same time of the interviews, all study participants reported their health as fair to excellent, and the majority reported satisfaction with the acupuncture they had received. Only half of the patients who were interviewed reported satisfaction with the level of their back pain at three months.
Three over-arching themes pertaining to the acceptability of acupuncture treatment were identified. The first over-arching theme entitled “Facilitators of acceptability” contained five subthemes; reduction in symptoms, improved physical activity, relaxation, reduction of psychological symptoms and reduced reliance on medication (Table1). The second over-arching theme entitled “Barriers to acceptability” encompassed four subthemes: needle-related discomfort, temporary worsening of symptoms, and tiredness, and the pressure to continue treatment with its’ potential financial cost (Table2). The third over-arching theme entitled “Mediating factors” comprised pre-treatment mediators (Table 3), and treatment related mediators with four separate subthemes; time, therapeutic alliance, lifestyle advice, and patient’s active involvement, each with the potential to induce positive or negative influences on the patients’ perception of the treatment.
Facilitators of Acceptability
Reduction in symptoms.
The first facilitator of acceptability of treatment to be identified from the coding was the subtheme “reduction in symptoms of low back pain"(Table1). Two patients reported experiencing a reduction in pain symptoms from the first treatment session. More commonly, the pain relief became apparent gradually, following a trajectory over a period of several weeks. For example, several patients reported that they noticed a reduction in symptoms of low back pain about 4–6 weeks into treatment.
“I had gone at first where it ached for two or three sessions, and I thought, this is not going to work, and then on the fourth session it was a lot easier. It was either the fifth or the sixth session when it was severe, and after that great. Each time I went then I got better and better. It got to the last one and I thought well really I don’t need it”. (p10)
Through the patients’ descriptions of pain relief, different types of pain were identified; commonly, severe pain was referred to in threatening terms such as sharp, stabbing, burning, whilst dull and aching pain was considered more tolerable. Two patients reported a reduction in their severe pain, to leave a dull aching, which they considered a good outcome. The relief from constant pain was reported in some cases, whereas for others, the specific types of pain changed in nature. Several patients reported a reduction in the frequency of radiating nerve pain or sciatic pain, bodily dissociation and numbness associated with back pain. One patient graphically described improvement as a sensation of energy flowing, warmth generated, and “the nerves have come back to life” (p7). Most patients still experienced a degree of pain during specific household or work related tasks.
“I don’t have constant pain like I did before, I know when I do certain things I'm going to get pain, but I don’t have it constantly which is a big difference to me in my life” (p12)
The reduction in painful symptoms was not limited to low back pain; two patients reported that their chronic knee pain had been relieved, and another patient was pleased that her shoulder pain was treated during the course of treatment. In summary, the perceived reduction in the symptoms of back pain appeared to facilitate the acceptability of acupuncture.
Improved physical activity.
A second subtheme to facilitate acceptability of treatment was the improvement in energy levels and physical functioning. For the majority of patients the awareness of the reduction in daily pain became apparent through their ability to increase physical activity. Several patients compared their levels of activity before and after acupuncture. Their descriptions allude to the debilitating nature of chronic pain and illustrate how pain regularly interrupted everyday tasks, whereby short periods of rest were necessary in order to complete the task in hand. Over the course of treatment, several patients noticed an increase in their level of energy, which enabled them to complete daily chores more easily.
“My energy level has increased. I can now cook a meal without having to lie down every couple of minutes in between doing something, which is better”. (p5)
The salience of improved physical function differed; for one patient the ability to conduct self-care and simple activities of daily living were a very positive aspect. For several others the improvement in energy levels meant they could engage in beneficial exercise, an aspect that helped to focus the patient on their abilities rather than disability. This served to reduce frustration and, for some, led to being able to engage in gentle exercise activities to help regain strength and fitness. These positive outcomes in functioning were a welcome effect of the treatment.
“You can get about; you can do things you’re not just kind of stuck to a chair or confined to the house… I like to go swimming which you know I couldn’t do and I’ve done it since the treatment. I’ve been back swimming I do that, and I hoover up now, which I didn’t do before and I’ve done a lot of walking” (p8).
A third facilitator of acceptability of treatment was a positive, and for some unexpected, side effect of treatment, namely relaxation. Within this subtheme, several patients reported feeling very relaxed whilst the acupuncture needles were in situ, although the interpretation of relaxation differed between individuals.
“While I was there having the treatment I felt relaxed…it was just nice to be peace and quiet and just lay there… It’s a relaxant, it just levels you, it levels you an talking relaxes you so that you’ve got time…you walk home floating” (p6)
One patient cited a feeling of well-being, another reported being able to clear their mind during treatment. Two others actually fell asleep during treatment, with one person reporting feeling revitalised afterwards, an effect that continued into the following day.
In summary, independent of whether there was a reduction in symptoms of pain, the feeling of wellbeing and relaxation during the treatment enhanced acceptability of the treatment.
Psychological symptoms reduced.
The fourth subtheme of facilitators of acceptability was the psychological change experienced by some patients. Three patients linked the psychological components and physical components of chronic pain from different perspectives. One patient was clear in saying that the “awful” pain experienced from neural symptoms was the cause of their low mood and tearful state (p11). Another acknowledged that stress was a major contributor to poor posture and other physical problems.
“You get a load of stress in your head and your body doesn’t work properly, you know that stress is transmitted into your posture and everything else”. (p3)
This patient explicitly acknowledged the benefit of a holistic approach, where the acupuncturist was able to prioritise the treatment of his psychological symptoms. Unfortunately, for one patient the lack of ability to find suitable work due to chronic pain and the worry of the subsequent financial difficulty created extreme anxiety. Despite these worries the patient said, “I’ve been listened to… I felt supported”. (p5) The ability to share the emotional or psychological aspects of chronic pain with a supportive practitioner, who could include these aspects in the treatment, was an important element of acceptability.
The fifth subtheme identified as a facilitator of acceptability was the reduced use of medication. Several patients reported reliance on a combination of over the counter anti-inflammatory medication and prescribed analgesics. One patient recounted how he took analgesics as a prophylactic measure before engaging in exercise. Another used analgesics as an aid to sleep.
“Prior to the acupuncture I was taking pain killers for my back to get to sleep at night, and then as the acupuncture progressed I didn’t take any for my back… I don’t like taking pills because of their effects on the body.” (p1)
Most patients disliked being dependent on medication, citing unpleasant side effects, fear of addiction and ineffectiveness of commonly used analgesics as major drawbacks. Once acupuncture treatment had started, one patient stopped taking medication as a means of testing the efficacy of acupuncture. Several patients reported a reduction in the dosage and frequency of usage over the course of the treatment. Overall, reduced reliance on medication, along with reduced concern about unwanted side effects was a further contributor to the acceptability of acupuncture.
Barriers to Acceptability
The over-arching theme of barriers to acceptability comprised three subthemes related to treatment - needle-related discomfort, temporary worsening of symptoms, and tiredness - and a further subtheme on the pressure to continue with treatment with its potential financial cost (Table 2).
Needle related discomfort.
The first barrier was associated with needling discomfort. Discomfort due to needling varied across several patients; in most cases the type of treatment reactions reported were transient and mild.
“Sometimes the needles themselves, when they put them in a certain point, they twist them and you get a sharp pain, and they do it again till it’s a kind of achy pain” (p5)
One patient described a possible needling injury; one of her fingers twitched for four days after treatment and she/he was concerned that a needle had hit a nerve (p6).
Another patient reported finding the treatment somewhat painful at times, but acknowledged that subsequent physical activity may have contributed to their discomfort.
Reactions to treatment: Temporary worsening of symptoms.
Two patients reported an unpleasant worsening of back pain symptoms after treatment, which lasted into the following day, and was relieved by taking paracetomol. One patient had been warned of the possibility of a reaction. The warning helped to reduce the patient’s concern and enabled them to view the reaction as an acceptable temporary discomfort with potential for overall improvement (p11). In contrast, warning of a possible reaction led the other patient to assume that the discomfort they experienced was entirely due to the treatment. They did not link the worsening of their symptoms to the effects of an extended car journey taken immediately after treatment.
“I got the most awful back-ache in the car…really really bad backache. I ended up taking paracetomol that night. I think it was a temporary thing, a reaction to the acupuncture ‘cos in fact she warned me I may get an adverse effect to it to start with and of course I did”, (p4)
Reactions to treatment: Tiredness.
Three patients felt extremely tired during the earlier sessions of the course of treatment. For one this was quite unexpected and inconvenient when lasting into the following day. In contrast, the second patient found the tiredness difficult to cope with initially, but later construed this reaction as an acceptable part of the healing process. The third patient successfully managed the situation by carefully planning appointment times. In doing so, the tiredness they experienced became part of their relaxation routine, and was viewed as recovery time.
“I used to feel very tired… It was just a progression maybe of just your body saying you know you needed time to heal…I intentionally used to make my appointments later on in the day so I could come home and relax.” (p9)
Several patients had previous experience of acupuncture and expected minor discomfort as an acceptable risk as part of the treatment. Although some patients continued to experience unpleasant reactions in later sessions, they had also experienced some benefit and persevered with the course of treatment. For a minority, these reactions detracted from the overall acceptability of the treatment, particularly where any overall benefit from treatment was less than expected.
Pressure to continue treatment and potential financial cost.
The fourth barrier to acceptability was the pressure to continue with treatment after the course of treatment paid for by the YACBAC trial had ended. None of the twelve people interviewed reported 100% pain relief without later recurrence of some of the back pain symptoms. Several patients were still in pain at the end of the 10 session course and reported that their acupuncturist had suggested one or two (or more) treatments as a private patient. Two patients welcomed the opportunity to continue. Another, who had not experienced pain relief felt unsure, but had appreciated the care and concern they had received and agreed to pay for additional sessions in the hope that it would work eventually.
“She suggested it; it was her who suggested five more because she thought… she was hoping we would have cracked it really in five more sessions. I mean that must have been at the time when we were still feeling there was some improvement being maintained”. (p12)
Two more patients would have liked to continued treatment, or would have considered treatment in the future, but were constrained by the financial cost of each session. Another patient tried to have the treatment continued via the GP but was told that funds were not available. In summary, patients found the cost of treatment more acceptable if they were experiencing some benefits, however, where the benefit was in question, or if they felt pressured to pay or could not pay, then the pressure to continue treatment and the potential financial cost of ongoing treatment were not acceptable.
The third over-arching theme is that of mediating factors, which could potentially influence a patient’s behaviour, experience and perception of treatment in either positive or negative ways. Pre-treatment mediating factors related to aspects of expectation and previous experience (Table 3). Two treatments related mediating factors, that of time and the therapeutic alliance highlighted contrasts between the consultations with their acupuncturist and their General Practitioner. Two further treatments related mediating factors were life style advice designed to promote and sustain a reduction in back pain and the patient’s active involvement, both of which were influenced by the type of advice offered to patients, and the willingness to act on the advice.
Expectation and experience.
Expectation of efficacy varied; six patients with previous experience of acupuncture felt that it might be helpful. For those without previous experience, two patients expressed doubt, and were influenced by the attitudes and experiences of others, one had read extensively and was very positive. Another felt excited at the prospect, but realised that the effect may be limited; one was convinced that belief was the key to efficacy. Most patients welcomed the opportunity to try acupuncture because their pain was severe, and they disliked taking medication. Only one patient, based on previous experience, offered an explanation of how he expected acupuncture to work:
“with acupuncture it tends to keep the energy flowing through everything so it can obviously work better…if you’ve got energy going through properly which is what acupuncture does really, it controls these hidden energy lines which goes through and activates or deactivates muscles really or invigours(sic) them, so if you can organise that and get that kind of thing balanced then your back’s going to be straight and that’s how I think it works for me anyway” (p3).
Treatment Related Mediators
Time, the first mediating subtheme, represented a component of treatment that had a multifaceted impact that underpinned all aspects of the treatment process. The majority of patients interviewed enjoyed the time spent within an acupuncture consultation and contrasted it with that of a GP consultation. The acupuncture consultation was found to be more acceptable by several patients because it allowed them time to fully explain their experience of pain, receive individualised treatment for their back pain and other concurrent physical and psychological symptoms within the same consultation.
“It’s totally for you, not for anybody else, totally for you and its lovely to have the attention instead of being on this five minutes list at a doctors and they don’t listen. They’ve got to listen to you and she’s interested”. (p6)
One patient reported her enjoyment of the acupuncture session as a personal time to relax and reflect. In contrast, another patient who had a pressing workload found the treatment too time consuming for the pain relief gained and resented setting time aside to attend sessions. Even where GPs had given a diagnosis, prescribed several medications and made a referral to a physiotherapist, the brevity of the GP consultation was the overriding memory for most patients. For most people interviewed, the disparity in the time allowed for the GP consultation enhanced the perceived acceptability of the acupuncturists’ consultation.
It’s a very nice sort of atmosphere there all friendly there and very relaxed. It’s not like sitting in the doctor’s waiting room you know pretending not to look at each other and waiting… You know it’s completely different … well it’s holistic compared to hustle-istic in the doctors. (p3)
The therapeutic alliance.
Underpinned by the subtheme of time, the second mediating factor was the subtheme of the therapeutic alliance. On a superficial level, three patients reported that their acupuncturist was kind, considerate and friendly. For two patients the development of good rapport and a trusting bond were key components of the therapeutic alliance and instilled faith in the acupuncturist’s abilities.
“She’s well trained to do things, she’d know what she was doing… they are more thorough in examining you and ironing out your problems” (p5)
For one patient, the level of courtesy and privacy was a special feature of the acupuncturist’s care. Two patients also comment on the acupuncturist’s care, concern and understanding of their condition compared to a perceived lack of sympathy from their doctor. Although one patient considered their doctor enthusiastic and sympathetic, the patient still lacked confidence in the doctor’s knowledge of treatment for back pain.
“I think, with backs, GPs just don’t know what they are talking about. They just don’t know. You have to go to someone that is a specialist… if I do need to go back then I shan’t go to my GP” (p10)
In contrast, where an acupuncturist was working in a multi-bed setting in a college clinic and moving between several patients at a time, the attention was not as personal, and the patient was left to glean information from passing acupuncture students.
In summary, for most patients the provision of sufficient time and one-to-one attention clearly facilitated the development of the therapeutic relationship and contributed to the acceptability of the treatment.
The third component within the theme of mediating factors was the provision of appropriate lifestyle advice. For the majority of patients, lifestyle advice was a common feature in consultations within both acupuncture and GP care. Patients were offered lifestyle advice related to their acupuncture diagnosis over the course of treatment. For several patients, the supportive encouragement from the acupuncturist helped them to engage in gentle exercise and regular activity according to their individual ability and with realistic expectations. In contrast, one patient seemed to be irritated with advice on exercise as at the time they regularly engaged in exercise that they considered appropriate to help them regain function and mobility. Three patients received dietary advice to lose weight, whereas another was offered individualised dietary advice to help them understand the importance of warm and cold foods in relation to their traditional Chinese diagnosis. Several patients received advice from the acupuncturist about their posture when walking:
“She did give me two exercises to do with my hips which I have tried to do. She also talked to me about trying to look at myself in the mirror and see, try to be aware of my posture and also try to walk… keep my hips mobile and keep them moving in the right way really. So it’s been more to do with physical posture and things like that” (p11)
Two patients were advised to take more rest. One of these was specifically asked to do exercise to strengthen their back muscles but very clearly not to go beyond the point where the pain would get worse. The second was advised not to do anything, and to take it easy, and the patient summed up that “I wouldn’t say they learned me an awful lot” (p10).
Overall, lifestyle advice was reported to be more acceptable when the acupuncturist provided it gradually, over the course of treatment.
Patients’ active involvement.
The fourth mediating factor was the subtheme of the patients’ personal involvement in their own recovery. Three people reported that the treatment had brought them to an acceptance of their back pain. Two of those accepted that there was always going to be a certain amount of pain, but they could live with that. Another two patients became more aware of their fragility, but managed their back pain by maintaining personal vigilance of their posture and engaging in specific strengthening exercises.
Two patients reported regaining a strong sense of control of their life and cited taking personal control as a key feature of their ongoing recovery, and the importance of setting time aside for themselves. Although acupuncture was not particularly effective for another person, they felt better placed to seek other treatment rather than putting up with back pain. In contrast, two people knew what steps to take in order to manage their back pain, but were unwilling to make changes. One other patient felt that he had taken all lifestyle steps possible to ensure a good recovery, and though capable of lifting heavy objects, he remained fearful of taking a labouring job that might lead to re-injury. In summary, for most patients, the taking of responsibility and being supported to gain control were potential facilitators of acceptability.
“The start of curing yourself is to take steps to do something about it. That’s an acceptance, you know something’s wrong with you and you’ve got to get it sorted out. It does help to create a positive attitude. I deliberately altered me posture, trying to get it back over a year or two”. (p3)
Sarah Richards LMT
30-year-old male presents with severe back and left leg pain, exhibiting postural deviation as a way to relieve pain from an L5/S1 disc herniation. When prescription of daily acupuncture and massage was followed diligently, patient experienced a more dramatic reduction in pain, improved posture and attitude.
30-year-old male patient presents with severe back and leg pain on left side, with severe postural deviation to relieve pain. Symptoms began 7 months ago with no known cause. Patient has, however, throughout his life, carried heavy bags of rice on his back and head. He complains of sharp pain and stiffness with movement, when standing from sitting or squatting and when walking up stairs. Sharp pain wakes patient at night with movement of left leg or twisting to turn over.
After getting an MRI patient is told that he has a “compressed bone” in low back, but does not know the specifics. He expresses his desire to delay or avoid surgery for his condition.
Pain medication does not provide any relief, and he intentionally stands “crooked” to alleviate severe pain in his low back, but then tries to over-correct in order to look “normal.” He denies experiencing pain or discomfort in upper back or neck. (See photos)
An MRI taken 15 weeks ago appears to show L5/S1 disc herniation with L4/5 disc desiccation, as reported in radiology report. Visual observation of the torso shows lateral curvature of the spine and depression of the left scapula (see photos). When not weight-bearing, lying on massage table prone or supine, spinal curvature corrects to more normal alignment and shoulder blades relax in neutral position.
While standing, and asked to actively straighten his spine, patient feels pain in lower back on the left side with radiating pain in the left lower leg. Trunk flexion produces pain when patient’s fingers are 8 inches from the ground, with pain felt in lower back on the left side with radiating pain in the left lower leg. Trunk extension produces pain in low back only, without radiation, and a left straight leg raise elicits pain at 45 degrees. A left side bend test produces pain in low back, with tingling and radiating pain to lower leg while right side bend elicits no pain.
Mood changes are noticeable and vary depending on level of pain each day, ranging from sullen and angry to hopeful and excited.
DX: L5/S1 disc herniation with L4/5 disc desiccation causing severe lower back pain with radiating symptoms to left lower leg
PROGNOSIS: In order to have a long-term positive impact on the patient’s condition, it will likely require frequent treatments for many months. Since the patient travels more than 1 hour to the clinic, often by foot, it is improbable that compliance to a long-term, daily treatment plan is realistic. Consequently, a significant lo
INITIAL TREATMENT PLANng-term result is doubtful.
Daily acupuncture and massage therapy focusing on pain relief for 10 treatments before reassessing.
Typical massage tx: 30-40 minute sessions focusing on releasing fascial and muscular restrictions to reduce compressive forces on affected disc and nerve root, thereby decreasing pain and inflammation giving the disc a chance to heal, and allowing the patient to stand with proper alignment and return to work and regular activities.
After 14 acupuncture treatments and 11 massage sessions, patient reported mixed results based on frequency of care. Missing only 1 day of massage or acupuncture did not produce a significant set back. However, there was a 5-day break in co-treating, in which the patient received only 3 acupuncture treatments, no massage therapy and experienced a decrease in progress. Subsequently, after missing massage appointments 5 days in a row, the patient returned complaining of an increased pain level; a level similar to which he had been experiencing prior to beginning treatment, stating a pain level of 6 out of 7. Upon returning to the subscribed daily treatment plan, after only 3 treatments consisting of both modalities on the same day, patient reported improvement of low back pain from 6 down to 4, as well as an improvement in posture and mood. As seen in the before and after photos, the change in posture was significant. These pictures were taken immediately following an acupuncture treatment.
Massage techniques that provided the most relief and change for the patient include friction to address bilateral, lumbar paraspinal and erector spinae musculature, compression and friction of the sacral origin of gluteus maximus, tensor fasciae latae and quadratus lumborum (QL). Fascial release to the thoracolumbar region, utilizing flexion of low back in child’s pose (a pain-free position for this patient) proved to be particularly helpful and was thought to be most productive by the patient. In addition, while in child’s pose, having the patient flex laterally allowed access to the transverse processes insertion of QL. In a side-lying position, inferior distraction of the left ilium provided significant and immediate relief to patient. Passive stretching of the left side body, including obliques, QL and latissimus dorsi while patient was supine, added to the ability of the patient to stand taller and straighter.
It is interesting to note that by working primarily on the painful left side, his posture improved and pain decreased more quickly and efficiently than by working primarily on the right side or more bilaterally. (See photos)
Patient was advised to avoid twisting movements and carrying heavy objects. He was also counseled that creating lasting reduction of pain would take many treatments. In order for treatment to have a chance to help him avoid surgery, he will need to take it easy and not push himself to do heavy work, even once he
starts feeling better, allowing the tissues time to heal
Unfortunately, more data could not be collected in this case because the patient discontinued care after only 3 weeks of treatment in order to visit family. Had I been able to continue to treat this patient, I would add abdominal and psoas major releases. I would recommend a course of anti-inflammatory medication and add a component of self-care and education in order to avoid further or recurring injury to the disc.
With frequent visits, his acute symptoms responded to the cotreatment plan of daily acupuncture and massage fairly quickly - within 3 visits. The 2 modalities, combined, show more promising results than just 1 on its own. Overall, it is promising to see how cotreating, specifically with acupuncture and massage therapy, can have a positive short-term outcome on pain and posture associated with disc herniation