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

Disclosures

BMC Fam Pract. 2011;12(60) 

In This Article

Participant Characteristics and Response Rates

Patient Data

All 147 patients referred to the service after 19th October 2009 who completed their treatments before the end of June 2010 were eligible to participate in the evaluation. 21 patients did not attend sessions and three did not want to participate in the evaluation; therefore data were available for 123 patients. Participants had a mean age of 49.0 years (SD 9.5, range 22–83 years). Seventy-nine (64.2%) were female, and the majority of participants were White (51.2%) or Black/Afro-Caribbean (12.2%). Thirty-one (25.2%) participants had experienced their pain for over 6 months, and half (50.4%) had previously experienced a similar complaint. The most common places participants experienced pain were their lower backs (53.7%), shoulders (43.9%) and necks (37.4%); 79.7% were taking pain medication. Twenty percent had used CAM before, commonly acupuncture (8.1%) and osteopathy (4.1%). According to the EQ-5D subscale 60% of patients rated their anxiety and depression as moderately (46%) or extremely (14%) high.

Participants waited a mean of 15.9 days from referral to the service to their first appointment; 48 (32.5%) received acupuncture, 87 (59.3%) osteopathy and 12 (8.1%) a combination of the two. Participants completed a mean of 4.7 sessions (SD 2.4). Twenty-eight (22.8%) participants stopped attending sessions.

Of the 123 participants, complete patient questionnaire data sets (pre- and post- treatment) were available for 102 participants. Data were examined for differences between those who did not respond and those who responded to their follow-up questionnaire. The only statistically significant difference found between responders and non-responders (using a Mann-Whitney-U test) was regarding the length of time the participant had been experiencing current painful episode (p = 0.015) (those with more chronic pain were more likely to respond to the follow-up questionnaire).

105 participants who completed their follow-up questionnaire were sent a service survey; and 91 (87%) returned their completed service survey to the evaluation team. Data were examined for differences between those who did not respond and those who responded to the service survey. The only statistically significant difference found between responders and non-responders (using a Mann-Whitney-U test) was on pre-treatment BQ scores (p = 0.014) (those with greater severity of condition were less likely to respond to the survey).

Healthcare Professionals

All healthcare professionals invited to participate in interviews took part. Seven (64%) were female, six (55%) were of White-British ethnicity, two (18%) were Asian-British, two (18%) were East Asian and one was mixed ethnicity. Participants had an average age of 44.5 years (SD 8.9).

Patient Outcomes

Comparisons between pre- and post-treatment for the primary outcome measure, the BQ, revealed a highly statistically significant improvement in MSK problems, including BQ total score (p < 0.0001) and all seven subscales: pain (p < 0.0001), interference with daily activities (p < 0.0001), interference with social routine (p < 0.0001), anxiety (p < 0.0001), depression (p < 0.0001), effect of work on pain (p < 0.0001), and coping with pain (p < 0.0001), see Table 1. Applying the threshold of 0.5 for effect size, 52.9%, 95%CI [42.3%, 61.7%] of participants experienced a clinically significant reduction in their MSK pain.

Comparisons between other study variables pre- and post-treatment revealed a statistically significant improvement in health-related QoL (EQ-5D index) (p < 0.0001), however, there was only a trend towards an improvement on the EQ-5D VAS (p = 0.064). A statistically significant reduction in analgesic use (82.8% to 68.7%, p < 0.003) was also found but there was no significant change for physical activity (p = 0.307) or general health and well-being (p = 0.541), see Table 2. There were inadequate numbers of participants in categories to conduct statistical analysis regarding current work status.

The service survey provided qualitative data supporting outcome benefits of the treatment to patients. In tune with the quantitative data, many patients reported that they valued the improvements in their MSK problem as a result of treatment. Patients reported decreased pain, and improved mobility including joint mobility. Some patients felt these improvements helped them to get on better with their daily lives.

"The treatment was really efficient. Since then I haven't had any problems with my back." P102

In addition, some patients reported improvements in other physical health conditions, for example decreased headaches, menstruation pain and improved energy levels. Other patients felt they had experienced improvements in their psychological well-being. Some patients described finding treatment relaxing and enjoyable, others experienced a reduction in their depression and anxiety, or felt more able to cope with their lives.

"It was surprisingly effective for many ailments. I had acupuncture and it helped with not only back pain but also illness reduction and depression." P84

Some patients felt better able to self-manage their condition. They learnt from practitioners a better understanding of their MSK problem, including what had caused it, what exacerbated it, and which exercises, stretches and changes to undertake to manage their condition better and prevent relapse.

"I was able to find out and understand more about what was wrong and learn new techniques to help me deal with the problem in my knees." P7

Acceptability of the Service

Service survey data showed that patient satisfaction with the service was extremely high. More than 9 in 10 participants reported that they were satisfied with the way they had been treated by staff in relation to the service, and 96.7% believed that the surgery should continue to provide the service in the future. Themes emerging from the qualitative analysis revealed the aspects of the service patients valued. Patients appreciated having the service at their GP practice, it was a convenient location and a familiar environment. They trusted a service provided through their GP practice, and felt reassured that their GP would know details about their osteopathy/acupuncture treatment. Patients also described finding the service straightforward (especially in terms of booking appointments), they appreciated the short waiting time for appointments and the efficient time-keeping of the service. In addition, some participants welcomed being offered a CAM therapy in the first place. They liked using these approaches compared to medication, as well as the additional time and attention given to the pain problem. Some patients liked the alternative (e.g. Chinese) explanatory model for health given by their practitioner, and the way in which treatment sought to get to the "root" of their problem. Other participants were just grateful that they had been offered something new to try to help with their MSK problem.

"Treatment at the practice would be in a familiar place and my doctor would be informed sooner than going to hospital and waiting. It's a good system, because you are being treated within your doctor's practice and communication should be more efficient. Local, to save you travelling to different hospitals." P43
"Osteopathy is an essential treatment as it treats the condition causing the pain. This is much better than taking painkillers." P25

A number of participants mentioned the positive qualities of their CAM practitioner. They valued the relationship they had formed with them, their professionalism and caring nature, and being provided with an explanation of the treatment they were receiving.

"The osteopath was very professional, pleasant and easy to talk to in regard to my problem. It was the first time I had been referred to an osteopath before and he was understanding and made me feel relaxed when being treated." P82

Ninety-one percent of participants said that they would use osteopathy/acupuncture again at their GP surgery, predominantly because they felt it had the potential to help MSK problems. This figure fell to only 30.8% who would use it privately, this was principally because of the cost of treatment, but also for the aforementioned reasons (e.g. convenience).

"Acupuncture and osteopathy are very good for people who suffer from pain, but in private it's very expensive. Myself I cannot afford to pay for it privately." P10

One quarter of participants said they had experienced some problems with the service. The analysis showed that the majority of these issues were related to the popularity of the service. For example, as the service became full, some participants had to wait for their first appointment, or for longer between appointments. Some participants wanted more appointment availability and flexibility (such as outside of working hours); others wanted to receive more and/or longer sessions. In addition, a small number of participants said they would like to receive more assistance from the reception, and some would have preferred a female practitioner.

"I had difficulty booking a time that would fit into my work schedule. Plus I couldn't book weekly appointments and I feel this was important for treatment. More flexible appointment times [needed]." P3

Interviews with healthcare professionals involved in the service also revealed high levels of satisfaction with the service among staff. In terms of service provision by the practice, all practitioners reported that the service had been incorporated well; overall the referral process had been simple and straightforward and the service ran smoothly. In relation to patient benefit, it was felt that the service was helpful for the practice's patients in terms of reducing their pain, increasing their flexibility and movement, improving general well-being, providing an explanation for their pain, and helping them to understand and manage their condition. In addition, GPs particularly valued having the service on site, this meant they were aware that their patients were having CAM treatment and were able to access details of patient appointments on the practice's computerised system and communicate with CAM practitioners easily. GPs also welcomed the relatively short waiting time for appointments and having an extra referral option.

"Very good, very prompt and the patients love it, you can't ask for more." GP4
"From referral to seeing patient, to appointment to getting feedback, I think it's worked very smoothly, there's been no logistical problem. It's very easy to do." GP3

Despite the favourable opinions of the service some problems emerged. Firstly, the popularity of the service needed to be managed. Interestingly, the service reached capacity very quickly. This high demand sometimes resulted in CAM practitioners being unable to treat their patients on a weekly basis, and there had been a period where GPs had been unable to refer to osteopathy. In addition, patients' expectations needed to be managed in terms of the total number of sessions they could receive. Secondly, CAM practitioners felt they could have benefited from more feedback regarding service provision from GPs and other members of staff.

"If you see them [GPs] in the corridor they're very nice and say 'hi', but they're rushed off their feet, so there's virtually no time to have any interaction." Practitioner1

Thirdly, there were issues regarding high numbers of referrals of chronic patients to the clinic. CAM practitioners were happy to try and treat any patient, but had to alter their expectations regarding the kind of success that was likely to be achieved with some patients.

"Some [patients] have been very long-term and difficult, but I guess that's just the demographic you're just going to see here. From my point of view you just have to accept that and get on with it." Practitioner2
"… we're so desperate to get some of these heart sink patients to be seen by somebody. And part of it is the therapy and part of it is the time they're spent with. And perhaps those types of patients were not quite so appropriate, but on the other hand you can't just pick up the easiest patients." GP1

Finally, there had initially been some practical problems regarding appropriate room space and equipment availability (e.g. couches) for practitioners. These issues had taken time to resolve and practitioners felt they should have been organised prior to their arrival.

In summary, data suggest that successful provision of osteopathy and acupuncture services for MSK pain within General Practice is achievable. However, some issues with provision will arise and need to be managed in order to provide as efficient a service as possible.

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