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

Discussion

Main Findings

This study found that the provision of osteopathy and acupuncture treatment for MSK pain is achievable in a GP surgery with diverse patient demographics, complex MSK pain issues, high incidence of self-reported psychosocial problems, and minimal GP preparation for the CAM service. Despite a short service set-up time of a few months, patient and practice satisfaction with the CAM service was high, and patients with varied experiences of pain reported clinical improvement in their MSK condition and more (e.g. improved mental health and quality of life and a reduction in medication use). These findings are in line with NICE guidelines for the early management of persistent low back pain which recommend that treatment strategies should reduce pain and its impact on a person's life.[6] Our findings suggest that it is possible for a GP surgery to quickly adapt to incorporate a CAM pain service. However, certain conditions need to be in place, our qualitative results suggest, including adequate negotiation with practice staff, skilled CAM practitioners, built up demand for a pain service, appropriate rooms and equipment, adequate appointment flexibility, and minimal referral waiting times.

Furthermore, our results reveal patients are enthusiastic about the benefits of CAM treatments for pain when expertly delivered. Certainly, the importance of the patient being 'at the centre of everything the NHS does' is highlighted by the government.[43] However, the current study shows how high patient approval and demand for effective CAM services can have unexpected results. One drawback of the service was that patients wanted more CAM provision than originally estimated. Ideally there should be a degree of flexibility of CAM therapists to provide more or less appointments depending on patient demand.

Our results are in line with more general evaluations of CAM provision, for a variety of conditions, within the NHS which report statistically significant improvements in patients' specific conditions after treatment, improvement beyond symptom reduction (e.g. self-management behaviours, QoL), high levels of GP and patient satisfaction, reduced medication use, and that NHS provision allowed patients to access CAM services who would otherwise be unlikely to use such services [e.g. [4,23–27]]. They are also in line with other primary care based therapy-led service evaluations for MSK problems [e.g.,[44]] which show such interventions are both feasible and acceptable to patients.

It is important to note the high levels of anxiety and depression among patients in this study. Anxiety and depression are common among chronic pain patients and can exacerbate pain,[45–47] making mental health an important factor to address when treating these patients. BQ data showed patients in this study improved on all biopsychosocial dimensions of pain, including anxiety and depression. This suggests that holistic approaches like osteopathy and acupuncture may have added advantages for patient groups with relatively poor mental health. However, cognitive-behavioural and stress-management techniques may need to be considered alongside these therapies for patients who have psychological barriers to recovery.[45,48,49]

Strengths and Limitations of the Study

The results of this evaluation are important because osteopathy and acupuncture for MSK pain have not been evaluated together before, despite NICE guidelines recommending acupuncture and manual therapy as treatment options for patients with persistent low back pain. Whilst this evaluation does not address cause and effect, it provides important information for GPs considering a patient-centred osteopathy and acupuncture service for MSK problems. While it is always difficult to generalise from one specific GP practice to other practices, the site evaluated served a diverse population, suggesting that the results could have a degree of currency at different sites. In terms of limitations, it might be argued that some groups of patients were less well served by the service model provided (e.g. those who did not return surveys, those who did not respond as well to treatment). While this may well be true, patient questionnaires and clinical surveys had a patient response rate of 85% and 74% respectively, and few significant differences, demographically, between responders and non-responders. This suggests that we included a reasonably broad sample of respondents. In terms of ethnicity, our sample comprised 29% of patients from ethnic minorities; this is in contrast to 16% to 23% of ethnic minorities living in the wards that are served by the Victoria Medical Centre.[50] The additional percentage of ethnic minorities in our sample is predominantly accounted for by the number of Black/Afro-Caribbean participants; our sample comprised 12% Black/Afro-Caribbean participants in contrast to 4% to 6% living in the wards that are served by Victoria Medical Centre.[50] These figures suggest that ethnic minorities are well represented in this sample.

Given the number of statistical tests carried out, it is possible that type I errors may be evident. All patient outcomes that were statistically significant, however, remained significant after a Bonferroni correction was applied, hence the likelihood of type I errors is minimal.

GPs considered patient preference in their decision to refer to osteopathy or acupuncture, or another MSK service. This potentially resulted in patients with more positive attitudes towards acupuncture and osteopathy being referred. This may be considered a limitation of the study. However, the evaluation was intended to examine 'real world' conditions, in which GPs will consider patient preference when a number treatment options are available. Some patients saw the osteopath and acupuncturist, this was for a variety of reasons. Some patients were referred to one practitioner such as the osteopath and then went back to the GP to ask for further sessions with the acupuncturist and vice versa. On some occasions the osteopath referred the patient across to the acupuncturist and vice versa if they felt their colleague could treat the problem more effectively. Furthermore, as the demand for the service grew, having the referral route of both osteopathy and acupuncture was helpful for waiting list management.

When a new service is set up, waiting times can be artificially low as the service builds up to capacity. Although the evaluation did not commence until the third week of the service, it is likely that the waiting times at the beginning of evaluation do not reflect those recorded during the rest of the evaluation. Finally, it should be noted that although there were qualitative reports from patients of improved general health and well-being, quantitative data showed less change in this area, presumably because pain is not the only important factor to address for improved well-being.[51]

Implications for Future Research and Clinical Practice

With the new Coalition Government's health White Paper announcing that GPs will be assuming much of the commissioning responsibilities from PCTs, this study holds particular interest for commissioning consortia, as it demonstrates that it is possible to introduce treatment modalities into a GP surgery for patient benefit, even when the underlying philosophy (e.g. traditional Chinese medicine) differs to that of biomedicine. In addition, patients benefit from pain reduction and improvements in QoL, even after a relatively small number of treatments (less than 5). Nevertheless, flexibility of service provision does need to be considered. The experience of the service director (DP) suggests that there are a good number of suitably qualified osteopaths and acupuncturists available to work within the NHS.

This study reveals one mode of provision to be successful, but does not compare and contrast it with other modes, which may be more or less successful. Future research may wish to consider further the best way CAM services for MSK pain can be provided by the NHS and the extent to which these services should be integrated. For example, the service model examined by this study only represents CAM provision by the NHS. However, integration is not about merely providing CAM on the NHS; full integration of CAM services would involve conventional and CAM practitioners having a better understanding and appreciation of each others practices and working closely together for the benefit of the patient.[52] Future research may also wish to examine cost-effectiveness of osteopathy and acupuncture services, and longer-term patient outcomes to indicate the extent to which improvements are sustained.

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