Is it Feasible and Effective to Provide Osteopathy and Acupuncture For Patients With Musculoskeletal Problems in a GP Setting?

A Service Evaluation

Anna Cheshire; Marie Polley; David Peters; Damien Ridge


BMC Fam Pract. 2011;12(60) 

In This Article


The Osteopathy and Acupuncture Service

The service was based at the Victoria Medical Centre, a large GP practice in central London with approximately 11 500 registered patients. The practice serves a broad demographic of patients in an area with diverse ethnicities, a high level of asylum seekers and refugees, and with wards at the extremes of the deprivation scale (i.e. affluent and deprived).[30] The service operated from September 2009 until August 2010. Two osteopaths and one acupuncturist provided 20 hours a week of treatment time. The service provided GPs with additional treatment options for patients registered at the practice who presented with MSK pain at routine surgery appointments. GPs based their referral decision on guidelines provided to them by the service director (DP) on MSK conditions appropriate for osteopathic or acupuncture treatment, taking patient preference into account. Patients could receive up to 6 treatments. Appointment making was integrated into the practice's computer-based reception system, so that patients could book their sessions in the normal way via the practice reception (in person or by telephone). Decisions about patients' treatments were not constrained by any research protocol, but were delegated to the practitioners who were free to treat as they would in everyday practice. Inclusion criteria for referral to the service were that the patient was experiencing MSK pain, registered at the GP practice, and referred by their GP. Exclusion criteria were patients aged less than 18 years or displaying symptoms indicative of a serious underlying condition. See Appendix for key aspects of the service model

GPs and CAM practitioners involved in the service were provided with formal training regarding intake criteria and forms, and the service and its delivery, evaluation and its ethical dimensions. Training was delivered by the evaluation manager (DR) and the service director (DP). For CAM practitioners, training comprised two face-to-face sessions (supplemented with written training materials) totalling five hours. Owing to constraints on GP time, GP training comprised provision of written materials supplemented with a lunchtime training session.

The Evaluation

To conduct a service evaluation, data were collected from a variety of sources. Quantitative patient outcome data were collected using pre- and post- treatment patient questionnaires, using consecutive sampling. Patient experiences and opinions of the service were obtained using a post-treatment service survey, collecting predominantly qualitative data. Interviews with healthcare professionals involved in the service collected qualitative data regarding their views of the service. These mixed methodologies are recommended for this type of evaluation.[31] Ethics approval for the evaluation was obtained from the University of Westminster Ethics Committee. Informed written consent was collected from all study participants.

Patient Questionnaires

Participants were provided with their pre-treatment questionnaire by reception staff when they booked their first appointment, and their post-treatment questionnaire by their acupuncturist/osteopath at the end of their final session. Participants who did not attend their final session had their questionnaire posted to them by the researcher (AC). All participants were able to ask a researcher for help completing the questionnaires, enabling participants with low literacy or whose first language was not English to be included in the evaluation. Participant demographics (including age, gender and ethnicity) and previous CAM use were collected by the pre-treatment questionnaire. Patient questionnaire measures included:

MSK pain, which was measured using the Bournemouth questionnaire (BQ) core items.[32] The BQ was developed specifically for patients with MSK pain and has been shown to be reliable, valid and responsive to clinical change [e.g. [32]] The BQ incorporates dimensions of the biopsychosocial model for MSK pain including levels of pain, interference with everyday tasks and social activities, anxiety, depression, the extent to which work affects their condition and coping ability. It comprises seven items scored from 0 to 10 which can then be summed to provide a total score ranging from 0 to 70. Higher scores indicate increased MSK problems.

Quality of Life (QoL), which was measured using the EuroQol-5D (EQ-5D)[33] a widely used, generic measure of health-related quality of life. It is quick and easy to complete and has been shown to be valid and reliable.[34,35] The first part comprises five items (measuring mobility, self-care, usual activities, pain and anxiety/depression) which are graded on three levels according to severity. Using the established algorithms for the UK,[36] these items were translated directly into index scores, ranging from −0.59 (worst possible health state) to 1 (best possible state). The second part is a visual analogue scale (VAS) measuring overall health, anchored 0 (worst possible health state) to 100 (best possible health state).

Participants were further asked if they were using analgesics, and about areas where they experienced pain and work status. They were also asked to rate their general health and well-being, and physical activity levels on a five and six point Likert scale respectively.

Service Survey

Participants who completed their post-treatment questionnaire were also asked to complete a service survey. According to patient preference, the service survey was available to complete online or by hand. Both versions of the survey were identical. The survey comprised a combination of open-ended questions with space for participants to write answers, as well as "yes"/"no" closed response questions aimed at ascertaining participants' opinions and experiences of the service including: perceived benefits, satisfaction, problems, suggestions for improvement, continuing provision of the service, treatment by staff and future use of acupuncture/osteopathy.

Healthcare Professional and CAM Practitioner Interviews

All healthcare professionals involved in the service (all seven GPs and the administration manager at the practice, and the three CAM practitioners) were invited to participate in an interview. Semi-structured interviews aimed to elicit participants' views on the service were conducted approximately five months into the service by AC. While questions and topics were on the interview schedule, there was flexibility to follow up issues raised by the interviewee. Topics included benefits of the service, problems encountered, helpfulness to patients, ease of incorporation and improvements to the service. Interviews lasted between 10 and 20 minutes. Ten of the interviews were recorded; one was documented using note taking at the request of the participant.

Data Management and Analysis

Quantitative data were analysed using SPSS version 16. Statistical significance was set at the 5% level. To ensure a conservative analysis, Non-parametric tests[37,38] (Mann-Whitney-U, Wilcoxon Signed Rank, McNemar and Chi-square as appropriate) were used to compare the differences between those who did and did not return questionnaires on baseline variables. Non-parametric tests were further used to compare pre- and post- treatment variables including the BQ, EQ-5D, physical activity, analgesic use, and current work status. Percentage of participants experiencing a clinically significant improvement was determined by calculating the effect size for the BQ (raw change score divided by the standard deviation of the baseline scores). An effect size of 0.5 has been found to represent a clinically significant change for the BQ.[39]

Qualitative data were collected from the service survey and the healthcare professional interviews. All data were analysed using a descriptive thematic analysis.[40] Service survey data were read and re-read, and input into the qualitative data analysis tool Weft QDA.[41] AC and DR independently developed a list of themes and compared coding frameworks to debate and arrive at a final coding list. AC investigated the themes across the data in detail, in order to code all the data. For the analysis of healthcare professional interviews, interviews revealed that there was very little variation in experiences and opinions of the service amongst health professionals. Thus, analysis involved AC repeatedly listening to all interview recordings and writing down key points that each participant was making along with transcribing only representative quotes illustrating key points.[42] Using these notes a list of key themes and illustrative quotes was then compiled relating to healthcare professionals opinions and experiences of the service. The key issues across both sets of data were assembled into themes in order to explain the data collected. Typical quotes are used to illustrate findings.


The results are presented in three sections. Firstly, participant characteristics (patients and healthcare professionals) and response rates are presented. The second section examines patient outcomes using quantitative data from patient questionnaires and qualitative data from the service survey. The final section examines acceptability of the service to patients and stakeholders, using data from the service survey and interviews with healthcare professionals.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.