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

M Diane McKee, Arya Nielsen, Belinda Anderson, Elizabeth Chuang, Mariel Connolly, Qi Gao, Eric N Gil, Claudia Lechuga, Mimi Kim, Huma Naqvi, Benjamin Kligler, M Diane McKee, Arya Nielsen, Belinda Anderson, Elizabeth Chuang, Mariel Connolly, Qi Gao, Eric N Gil, Claudia Lechuga, Mimi Kim, Huma Naqvi, Benjamin Kligler

Abstract

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

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

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

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

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

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

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

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

Trial registration: Clinicaltrials.gov # NCT02456727.

Keywords: acupuncture therapy; health disparities; integrative medicine; pain.

Conflict of interest statement

The authors report no conflicts of interest.

Figures

Figure 1
Figure 1
Participant flow in AADDOPT-2 (CONSORT diagram). a No further data collected; b Available for analysis at 12 weeks for primary outcomes (ITT).

References

    1. Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10(260). 2014; . Accessed January 14, 2018.
    1. Brown A. Chronic pain rates shoot up until Americans reach late 50s. Gallup Healthways 2012; . Accessed May 6, 2018.
    1. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):715–724.
    1. Grol-Prokopczyk H. Sociodemographic disparities in chronic pain, based on 12-year longitudinal data. Pain. 2017;158(2):313–322.
    1. Institute of Medicine, Committee on Advancing Pain Research, Care and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington (DC): National Academies Press (US); 2011.
    1. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 2010;11(11):1230–1239.
    1. Kennedy J, Roll JM, Schraudner T, Murphy S, McPherson S. Prevalence of persistent pain in the U.S. adult population: new data from the 2010 National Health Interview Survey. J Pain. 2014;15(10):979–984.
    1. Reyes-Gibby C, Aday L, Cleeland C. Impact of pain on self-rated health in the community-dwelling older adults. Pain. 2002;95(1–2):75–82.
    1. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1545–1602.
    1. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD). Washington, DC: The National Academies Press 2003.
    1. National Academies of Sciences Engineering and Medicine. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (2017). Washington, DC: The National Academies Press. doi: 10.17226/24781; 2017.
    1. Tick H, Nielsen A, Pelletier KR, et al. Evidence-based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018;14(3):177–211.
    1. Elliott A, Smith B, Hannaford P, Smith W, Chambers W. The course of chronic pain in the community: results of a 4-year follow-up study. Pain. 2002;99(1–2):299–307.
    1. Gureje O, Simon G, Von Korff M. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1–2):195–200.
    1. Gureje O, Von Korff M, Simon G, Gater R. Persistent pain and well-being: a World Health Organization Study in Primary Care. JAMA. 1998;280(2):147–151.
    1. Goetzel R, Hawkins K, Ozminkowski R, Wang S. The health and productivity cost burden of the “top 10” physical and mental health conditions affecting six large U.S. employers in 1999. J Occup Environ Med. 2003;45(1):5–14.
    1. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444–1453.
    1. Vickers AJ, Linde K. Acupuncture for chronic pain. JAMA. 2014;311(9):955–956.
    1. Yuan QL, Wang P, Liu L, et al. Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep. 2016;6:30675.
    1. MacPherson H, Vickers A, Bland M, et al. Acupuncture for chronic pain and depression in primary care: a programme of research. Programme Grants for Appl Res. 2017;5(3).
    1. Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017;166(7):493–505.
    1. Liu L, Skinner M, McDonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of systematic reviews. Evid Based Complement Alternat Med. 2015;2015:328196.
    1. Tang S, Mo Z, Zhang R. Acupuncture for lumbar disc herniation: a systematic review and meta-analysis. Acupunct Med. 2018;36(2):62–70.
    1. Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS One. 2015;10(2):e0117146.
    1. Willich SN, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt CM. Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain. 2006;125(1–2):107–113.
    1. Trinh KV, Graham N, Gross AR, et al. Acupuncture for neck disorders. Cochrane Database Syst Rev. 2006(3):Cd004870.
    1. Berman B, Lao L, Langenberg P, Lee W, Gilpin A, Hochberg M. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004;141(12):901–910.
    1. Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral joint osteoarthritis: a systematic review and meta-analysis. Rheumatology (Oxford). 2006;45(11):1331–1337.
    1. Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan S. The effects of acupuncture on chronic knee pain due to osteoarthritis: a meta-analysis. J Bone Joint Surg Am. 2016;98(18):1578–1585.
    1. Zhang Y, Bao F, Wang Y, Wu Z. Influence of acupuncture in treatment of knee osteoarthritis and cartilage repairing. Am J Transl Res. 2016;8(9):3995–4002.
    1. Manyanga T, Froese M, Zarychanski R, et al. Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC Complement Altern Med. 2014;14:312.
    1. Woods B, Manca A, Weatherly H, et al. Cost-effectiveness of adjunct non-pharmacological interventions for osteoarthritis of the knee. PLoS One. 2017;12(3):e0172749.
    1. Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for chronic pain: update of an individual patient data meta-analysis. J Pain. 2018;19(5):455–474.
    1. Skelly AC, Chou R, Dettori JR, et al. AHRQ Comparative Effectiveness Reviews. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018.
    1. Qaseem A, Wilt TJ, McLean RM, Forciea M. Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–530.
    1. Joint Commission enhances pain assessment and management requirements for accredited hospitals. 2017; Accessed May 22, 2019.
    1. The Joint Commission. Clarification of the pain management standard. 2015; . Accessed May 22, 2019.
    1. Kligler B, Buonora M, Gabison J, Jacobs E, Karasz A, McKee MD. “I Felt Like It Was God’s Hands Putting the Needles In”: a qualitative analysis of the experience of acupuncture for chronic pain in a low-income, ethnically diverse, and medically underserved patient population. J Altern Complement Med. 2015;21(11):713–719.
    1. McKee MD, Kligler B, Blank AE, et al. The ADDOPT study (Acupuncture to Decrease Disparities in Outcomes of Pain Treatment): feasibility of offering acupuncture in the community health center setting. J Altern Complement Med. 2012;18(9):839–843.
    1. Davis RT, Badger G, Valentine K, Cavert A, Coeytaux RR. Acupuncture for chronic pain in the Vermont Medicaid population: a prospective, pragmatic intervention trial. Glob Adv Health Med. 2018;7:2164956118769557.
    1. White A, Richardson M, Richmond P, Freedman J, Bevis M. Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service. Acupunct Med. 2012;30(3):170–175.
    1. Phillips KD, Skelton WD, Hand GA. Effect of acupuncture administered in a group setting on pain and subjective peripheral neuropathy in persons with human immunodeficiency virus disease. J Altern Complement Med. 2004;10(3):449–455.
    1. Asprey A, Paterson C, White A. ‘All in the same boat’: a qualitative study of patients’ attitudes and experiences in group acupuncture clinics. Acupunct Med. 2012;30(3):163–169.
    1. Tippens KM, Chao MT, Connelly E, Locke A. Patient perspectives on care received at community acupuncture clinics: a qualitative thematic analysis. BMC Complement Altern Med. 2013;13:293.
    1. White A, Tough L, Eyre V, et al. Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial. Pilot Feasibility Stud. 2016;2:10.
    1. Kligler B, Nielsen A, Kohrrer C, et al. Acupuncture therapy in a group setting for chronic pain. Pain Med. 2018;19:393–403.
    1. Rohleder L. Community acpuncture: making buckets from Ming vases. J Chinese Med. 2012;98:22.
    1. Deadman P. Community acupuncture - making Ming vases from buckets: a reply to Lisa Rohleder. J Chinese Med. 2012;99:55–59.
    1. Nielsen A, Anderson B, Citkovitz C, et al. Developing and employing a ‘responsive manualization’ in the ‘Acupuncture Approaches to Decrease Disparities in Outcomes of Pain Treatment’ comparative effectiveness study. Acupunct Med. 2019:964528419834015.
    1. Schnyer RN, Allen JJ. Bridging the gap in complementary and alternative medicine research: manualization as a means of promoting standardization and flexibility of treatment in clinical trials of acupuncture. J Altern Complement Med. 2002;8(5):623–634.
    1. Clean Needle Technique Manual 7th Edition; Best Practices for Acupuncture Needle Safety and Related Procedures.: Council of Colleges of Acupuncture and Oriental Medicine; 2015.
    1. MacPherson H, Altman DG, Hammerschlag R, et al. Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): Extending the CONSORT statement. J Evid Based Med. 2010;3(3):140–155.
    1. Chen X, Chen B, Gu X, Shi Z, Chen Z. Role of pressing hand in the clinical practice of acupuncture. Zhongguo Zhen Jiu. 2017;37(11):1215–1217.
    1. Ni Y, Rosenbaum RL. Navigating the channels of traditional Chinese medicine. San Diego: Oriental Medicine Center; 1996.
    1. Bisio T, Butler F. Zheng Gu Tui na: a Chinese medical massage textbook. New York, NY: Zheng Gu Tui Na; 2007.
    1. Pritchard S.Tui na: the Chinese massage manual. Edinburgh: Churchill Livingstone; 2009.
    1. Nielsen A.Gua sha: A Traditional Technique for Modern Practice. 2nd ed: Elsevier Health Sciences UK; 2013.
    1. Kwong KK, Kloetzer L, Wong KK, et al. Bioluminescence imaging of heme oxygenase-1 upregulation in the Gua Sha procedure. J Vis Exp. 2009(30):pii: 1385.
    1. Asher GN, Jonas DE, Coeytaux RR, et al. Auriculotherapy for pain management: a systematic review and meta-analysis of randomized controlled trials. J Altern Complement Med. 2010;16(10):1097–1108.
    1. Yeh CH, Chiang YC, Hoffman SL, et al. Efficacy of auricular therapy for pain management: a systematic review and meta-analysis. Evid Based Complement Alternat Med. 2014;2014:934670.
    1. Yang LH, Duan PB, Hou QM, et al. Efficacy of Auricular Acupressure for Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2017;2017:6383649.
    1. You E, Kim D, Harris R, D'Alonzo K. Effects of Auricular Acupressure on Pain Management: A Systematic Review. Pain Manag Nurs. 2019;20(1):17–24.
    1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613.
    1. Pain Interference: a brief guide to the PROMIS Pain Interference instruments. 2019; . Accessed August 31, 2019.
    1. Tan G, Jensen MP, Thornby JI, Shanti BF. Validation of the Brief Pain Inventory for chronic nonmalignant pain. J Pain. 2004;5(2):133–137.
    1. Badia X, Muriel C, Gracia A, et al. [Validation of the Spanish version of the Brief Pain Inventory in patients with oncological pain]. Med Clin (Barc). 2003;120(2):52–59.
    1. Olsen MF, Bjerre E, Hansen MD, Tendal B, Hilden J, Hrobjartsson A. Minimum clinically important differences in chronic pain vary considerably by baseline pain and methodological factors: systematic review of empirical studies. J Clin Epidemiol. 2018;101:87–106.e102.
    1. Hays RD, Bjorner JB, Revicki DA, Spritzer KL, Cella D. Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Qual Life Res. 2009;18(7):873–880.
    1. Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38(3):418–425.
    1. Knotkova H, Fine PG, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage. 2009;38(3):426–439.
    1. Patient-Centered Outcomes Research Institute (PCORI). .
    1. MacPherson H, Maschino AC, Lewith G, et al. Characteristics of acupuncture treatment associated with outcome: an individual patient meta-analysis of 17,922 patients with chronic pain in randomised controlled trials. PLoS One. 2013;8(10):e77438.
    1. Hays RD, Spritzer KL, Fries JF, Krishnan E. Responsiveness and minimally important difference for the patient-reported outcomes measurement information system (PROMIS) 20-item physical functioning short form in a prospective observational study of rheumatoid arthritis. Ann Rheum Dis. 2015;74(1):104–107.
    1. Lee AC, Driban JB, Price LL, Harvey WF, Rodday AM, Wang C. Responsiveness and minimally important differences for 4 Patient-Reported Outcomes Measurement Information System Short Forms: Physical Function, Pain Interference, Depression, and Anxiety in Knee Osteoarthritis. J Pain. 2017;18(9):1096–1110.
    1. U.S. Food and Drug Administration. FDA education blueprint for health care providers involved in the management or support of patients with pain (May 2017). 2017; . Accessed May 22, 2019.
    1. Nahin RL, Boineau R, Khalsa PS, Stussman BJ, Weber WJ. Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clin Proc. 2016;91(9):1292–1306.
    1. Chuang E, Hashai N, Buonora M, Gabison J, Kligler B, McKee MD. “It’s Better in a Group Anyway”: patient experiences of group and individual acupuncture. J Altern Complement Med. 2018;24(4):336–342.
    1. Saper RB, Lemaster C, Delitto A, et al. Yoga, physical therapy, or education for chronic low back pain: a randomized noninferiority trial. Ann Intern Med. 2017;167(2):85–94.
    1. McKee MD, Kligler B, Fletcher J, et al. Outcomes of acupuncture for chronic pain in urban primary care. J Am Board Fam Med. 2013;26(6):692–700.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner