Original paper
The experience of acupuncture care from the perspective of people with chronic low back pain: a grounded theory study N J Stomski,1,2 S F Mackintosh,1 M Stanley1
1
School of Heath Sciences, University of South Australia, Adelaide, South Australia, Australia 2 School of Health Professions, Murdoch University, Murdoch, Western Australia, Australia Correspondence to Dr N J Stomski, School of Health Professions, Murdoch University, 90 South St, Murdoch, W A 6150, Australia; [email protected] Received 14 October 2013 Accepted 3 April 2014 Published Online First 1 May 2014
To cite: Stomski NJ, Mackintosh SF, Stanley M. Acupunct Med 2014;32: 333–339.
ABSTRACT Objectives To explore the experience of acupuncture care from the perspective of people with chronic low back pain. Methods A grounded theory, qualitative study using indepth interviews was undertaken with 11 people who had received acupuncture care for chronic low back pain. Interviews were audiorecorded and transcribed verbatim. Initial, focused and theoretical coding were used to identify a core category and several other categories. Results The core category, Reclaiming Control, was related to the sense of well-being experienced by most of the participants as a result of undergoing acupuncture care. The other categories were Gaining Sanctuary, Gaining Trust and Working Together. These categories reflected the processes of participants entering an aesthetically appealing, calm and relaxing space; developing confidence in the acupuncturists’ ability to care for them; and negotiating strategies and sharing decisionmaking with acupuncturists about their care. Conclusions Clinicians using acupuncture as a management strategy for low back pain may elicit an immediate sense of calmness in patients with subsequent well-being benefits. A sense of calmness may also be enhanced through providing a relaxing physical environment. The transactional and interpersonal processes of establishing trust and rapport, and shared decision-making are important for clients. Shared decision-making can be improved by clinicians carefully considering the explanation of issues and plans to a particular patient, especially by developing an understanding of each patient’s worldview and using language that the suits each individual’s healthcare orientation. Our findings should be interpreted cautiously as the results may be generalisable only to private practice in affluent countries, and whether the
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
findings are representative beyond this setting remains unclear.
INTRODUCTION The 2010 Global Burden of Disease study reported that low back pain ranked as the leading cause of disability-adjusted life years.1 This results in a substantial socioeconomic burden in both direct medical costs and indirect costs such as work absence and decreased productivity.1 Hence, effective management of low back pain is an important issue for patients, clinicians and healthcare policy makers. Recent clinical guidelines recommend that acupuncture should be considered for the management of chronic low back pain, especially if no improvement occurs through using self-care strategies or people express a preference for acupuncture.2 3 Qualitative studies of acupuncture care for conditions other than chronic low back pain have established that people value diverse well-being outcomes and other broad outcomes such as changes in self-awareness regardless of the reason people sought acupuncture care.4–14 Only one previous study appears to have explored the experience of acupuncture care from the perspective of people with chronic low back pain, and the findings were mainly descriptive in nature.15 This study builds on that previous study by using a grounded theory approach to articulate how consultation processes influence the experience of acupuncture care from the perspective of people with chronic low back pain. Given the paucity of research in this area, this study was guided by the following research question: ‘What is people’s
333
Original paper experience of acupuncture consultations during an episode of care for chronic low back pain?’ METHODOLOGY A grounded theory approach was selected for this study as there was little published information about the processes involved with the phenomena under study15 and this approach allowed the researchers to develop an understanding of the consultation processes involved with acupuncture care from the perspective of people with chronic low back pain. The principal researcher has more than 10 years experience as an acupuncturist in clinical practice and recognises that it may have shaped the analysis of this study. The other two researchers have more than 20 years experience as Allied Health Practitioners (Physiotherapy and Occupational Therapy) and in academia but had no experience with acupuncture. Accordingly, a social constructivist epistemological position16 was taken in this study as it acknowledges that a researcher’s previous experience and beliefs inevitably influence gathering data and its interpretation.
disabling pain when first electing to undertake acupuncture. Most participants still experienced low back pain, but it was generally intermittent and manageable. Six participants had seen traditional acupuncturists,17 and five had consulted western acupuncturists.18 In this study, traditional acupuncturists were defined as those who primarily: explained treatment using language reflective of traditional Chinese medicine theory; used traditional oriental diagnostic methods; and used both local and distal acupuncture points.17 Western acupuncturists were defined as those who primarily: explained treatment in pathophysiological terms; used western diagnostic techniques; and used only local acupuncture points.18 Ethical approval/issues
The University of South Australia’s Human Research Ethics Committee granted ethical approval. Formal consent was gained before all interviews. Participants were assigned pseudonyms to maintain anonymity and confidentiality. Data collection/analysis
METHODS Recruitment and eligibility
Letters were sent to acupuncturists in one State in Australia asking them to place recruitment notices in their clinics. Advertisements were also placed in local newspapers and on community notice boards. When a potential participant expressed interest in the study, an information sheet was sent and the principal researcher then rang the participant to determine eligibility. Participants were eligible to be included in the study if they were either currently undertaking acupuncture care or had concluded acupuncture care in the previous 6 months for chronic non-specific low back pain ( pain in the low back region persisting beyond 3 months). Information-rich cases were sought and identified either through acupuncturists’ recommendations about clients who had a firm understanding of acupuncture care or clients who appeared well informed during the initial telephone conversation. Participants
Of the 11 interviewees, six were women. All were white, middle-class Australians; seven were aged between 25 and 40 years, one was a young adult and three had recently passed 60 years of age. Most participants were well educated and were developing or had led professional careers. Seven of the participants had experienced low back pain for a substantial period of time. Of these participants, the period of time with low back pain was about 10 years, 20 years, 30 years, and in two cases about 40 years. Four participants had experienced low back pain for between 1 and 2 years, and the remaining two participants had experienced it for less than a year. All but one of the participants had experienced intense and often 334
In keeping with a grounded theory approach, data collection and analysis were undertaken concurrently from mid-2009 to early 2010.16 The first author undertook all of the interviews and was not a therapist for any of the participants. Open-ended questions were used throughout each indepth interview because they often elicit unexpected statements and personal accounts, and enable the study of individual experience. The open-ended questions were based on Charmaz’s16 examples and started with ‘Talk me through an acupuncture session.’ and ‘What brought you to an acupuncturist?’ After the initial two open-ended questions, probing questions were used to explore the responses further; these included: What happened next? How did you feel about…? How did you respond to…? Could you talk more about…? Can you explain that more? At the conclusion of each interview, the following questions were used: Is there anything else you would like to tell me about you acupuncture experience? Is there anything you would like to tell acupuncturists, or people thinking of using acupuncture, about acupuncture care for low back pain? That is all I would like to ask, is there anything else you would like to talk about or ask me? Indepth interviews were audio-recorded and transcribed verbatim. For the first coding phase of analysis, transcripts were considered line by line with initial codes, derived from the participants actual words, assigned to each event or circumstance.16 Focused coding was then used to form categories by grouping similar codes together.16 Next, the categories were refined through constant comparison, which involved comparing different categories against one another, and contrasting different instances of the
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper same category both across and within participants.16 The final stage of coding involved using theoretical coding to specify the relationships between the categories until a core category became evident through ongoing analysis.16 Throughout the coding processes, discussions were held between the authors to build depth in the categories and refine the relationships between the categories. Memos were used throughout to capture thoughts, preserve comparisons and relationships between categories, and refine questions and directions to follow through on.16 Rigour
Charmaz identified four criteria to evaluate the rigour of a study: credibility, originality, resonance and usefulness.16 In this study, credibility was addressed by detailing data collection and the sample, collecting sufficient data to support the propositions, making systematic comparisons between data, and ensuring the categories encompassed a broad range of observations. Originality was addressed through the study’s categories, significance, and findings being presented and compared with the existing literature. In this study, resonance is addressed in the Findings section through delineating the categories and using transcript excerpts to support their development. The usefulness of a study may be assessed by considering whether it: interprets the studied experience in a way that people may use in the everyday life; contributes to knowledge; and provides direction for additional research. The usefulness of this study is described in the Discussion section. Two other strategies were used to attend to the rigour of this study: reflexivity and attention to negative cases. Memos were used in part to address reflexivity through considering how a priori assumptions may have influenced the categories and conceptual model.16 Also, reflexivity was attended to in peer debriefing between the principal author and the other coauthors without acupuncture backgrounds. These debriefings occurred fortnightly over 6 months, and in the course of which all authors contributed to refining the codes, categories and theory. Attention to negative cases involves deliberately identifying examples of cases within the data which do not accord with the emerging analysis.19 During analysis, the researchers used negative cases to challenge and strengthen the categories and conceptual model. Examples of negative cases are presented throughout the Findings section. Findings
Analysis of the data has generated a theory which explicates how aspects of acupuncture care contributed to people with chronic low back pain regaining control over their health. In the following sections, the basic problem and core category are detailed, followed by a description of the three subcategories and their relationship to the core category.
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
The core category: Reclaiming Control
The main issue identified from the participants’ interviews revolved around losing control. Some participants felt as though they had lost control over their personal circumstances, which they believe led to developing chronic low back pain: There’s a certain tension you need in order to operate because you’re not in an environment that’s of your own choosing regarding your job. Something has to give eventually, and for me it was the back. [Margaret]
For others, the loss of control was experienced after their chronic low back pain commenced: Now there’s no time in the day when I don’t have chronic pain, and so that’s the main issue it pretty much affects everything. [Lynn]
However, losing control involved more than how chronic low back pain directly affected the participants’ lives as it was also associated with unfulfilling interactions with health professionals: I had a specialist who said you will just have to learn to live with it, and I got really angry about that because that was no advice at all. [Margaret]
Reclaiming Control related to the sense of wellbeing experienced by most participants as a result of undergoing acupuncture care. Interestingly, the wellbeing benefits were valued as much as pain alleviation and improvements in physical function. Indeed, although participants initially attended for back pain management, their focus soon shifted towards attaining well-being benefits. I felt like when I went to see him it was about my whole well-being, it wasn’t just about back pain. [Jane]
The focus on well-being by most participants was particularly remarkable to the principal researcher who, as a clinical acupuncturist, held the view that people with low back pain undertook acupuncture care primarily for pain management. The importance of the well-being benefits was highlighted by the passing reference some participants made to low back pain per se during the initial stages of the interview. Subsequently, in later interviews, the principal researcher enquired specifically about issues related to low back pain after about 40– 45 min if the participants had barely discussed them at that point. The well-being benefits experienced by the participants included: improved focus and clarity; improved eyesight; better sleep; reinvigoration; increased emotional resilience; improved digestion; and feeling calmer and happier. The experience of these wellbeing benefits appeared to be attributable to the needling effects, especially as they most commonly occurred when the needles were left in place for more than 15 min and both local and distal acupuncture 335
Original paper points were used. It also seems likely that well-being benefits were associated with following self-care advice provided by the acupuncturists such as relaxation strategies, exercise programmes, dietary recommendations and general lifestyle advice. Relaxation strategies involved guided visualisations incorporated into the consultations, and a specific biofeedback technique. Exercise recommendations included walking, tai chi, yoga, structured stretching programmes, swimming, postural modifications, qi gong, and advice to keep active and avoid sedentary behaviour. The dietary recommendations were usually based on a combination of traditional oriental dietary principles, like yin/yang or hot/damp/cold food, and contemporary western dietary principles, and often included recommendations for nutritional supplements such as vitamins or minerals. Most participants said that the dietary recommendations were not prescriptive but rather took the form of information that they could use to determine themselves how to plan their daily diet. The general lifestyle advice focused on acupuncturists suggesting to participants that they should find time to relax and pursue personal interests and not be hard on themselves. When the participants began to lose the sense of well-being sometime after last receiving an acupuncture treatment, ‘things started to fall part’ which acted as an impetus to undertake further acupuncture care: So I think it’s time for another session when I get indicators… lower back twinges is one, eyesight curiously, if I’ve been flat maybe, and feeling scrambled. When I’ve got clarity, I’ll go ok these are the things you need to do let’s look at how were going to do this, whereas when I’m in the scrambled mode I get stressed by it. [Clare]
Gaining Sanctuary
Gaining Sanctuary was associated with regaining control and involved most participants entering an aesthetically appealing space which evoked a sense of comfort: There are a lot of things in the room that I find welcoming and attractive… it’s a very peaceful experience and it’s like stepping from the outside world into that is a really, it’s a very nice place to be. [Clare]
Within this space, participants were able to remove themselves from their busy lives, and find time to just sit, relax and focus on being well. This peaceful, unhurried experience was then enhanced when the insertion of needles evoked a sense of calmness accompanied by sensations of warmth and flowing energy which was unlike anything the participants experienced in everyday life: For me this is an intense moment of just being, its beautiful, its not an experience that I get in my daily life. [Clare]
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Participants also noted that it was not ever intrusive as there were no external distractions. After the needles were inserted, the participants were left undisturbed by the acupuncturists, which provided them with the opportunity to think about being well. At the end of the consultation, time was also made available to summarise what the participants and acupuncturists had done together and discuss what the participants should be working on between appointments. However, some participants experienced only slight relaxation or no evident change, and the sense of calmness and warm energy were typically contingent upon two conditions: retaining acupuncture for between 15 and 20 min, and using both local and distal (from the low back region) acupuncture points. When the participants experienced calmness during needle retention, they typically described leaving the consultations feeling rejuvenated, calm, clear and focused. Gaining Trust
Gaining Trust was associated with regaining control and refers to how the participants usually developed confidence in the acupuncturists’ ability to care for them. When participants experienced initial assessments that were comprehensive, the participants typically began to develop confidence in the acupuncturists’ clinical competency, but when it was less than comprehensive the participants usually were left feeling uncertain: Part of me was thinking she must know what she is doing otherwise she would of searched a bit more...I wasn’t convinced that she did know what she was doing at all. [Angela]
The assessments differed according to the acupuncturists’ orientation. Western acupuncturists tended to focus on pain patterns and diagnostic scans, whereas traditional acupuncturists typically enquired about all areas of the participants’ lives and relied more on traditional diagnostic techniques such as pulse palpation and tongue inspection. The traditional acupuncturists often reflected their impressions of pulse and tongue diagnosis, which frequently assisted in gaining the participants’ confidence as it was usually perceived as being accurate: That amazes me how you can feel with three fingers the pulse, and he moves it around, and from that he can ascertain, quite well, my emotional state, or physical state. [Margaret]
Another aspect of the acupuncturists’ manner which in general engendered confidence concerned how clear the explanations were about what contributed to the participants’ condition, its management and expected course. The western acupuncturists tended to couch their explanations in biomedical terms, while the traditional acupuncturists frequently used
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper traditional Chinese medicine terms. Most participants thought that the explanations seemed reasonable which usually helped consolidate the trust in the acupuncturists, especially as they typically believed that the acupuncturists knew what was happening with their bodies. However, when the acupuncturists failed to clearly explain the expected course of care, they usually lost the participants’ confidence. Working Together
Working Together was associated with regaining control related to how the participants and acupuncturists shared information and negotiated strategies to manage the participants’ low back pain and improve their well-being. Acupuncturists usually asked participants’ opinion about the assessment findings, acupuncture treatment and self-care recommendations. The participants indicated that they asked questions about any aspect of care and that the acupuncturists often responded enthusiastically. When the acupuncturists used oriental lay language, this often resulted in participants asking further questions: He explains it to me in a very lay person sort of way, but I actually ask more because I’m interested, I just find the whole yin/yang, the whole Chinese medicine philosophy thing so interesting. [Tony]
Regardless of the type of language used by the acupuncturists, most participants developed a clear understanding of what influenced either their chronic low back pain or well-being, and strategies they could use to maintain or improve them. This understanding in turn usually enabled participants to collaborate with their acupuncturists in negotiating the direction of care, and in particular allowed participants to voice their preferences for care which the acupuncturists typically respected:
than this as it was partially associated with the participants being able to decide when they would make appointments or, in other words, being able to Gain Sanctuary when it suited them. Also, through Gaining Trust the participants believed that the acupuncturists were acting in their best interests, which led to the participants entrusting control over the direction of care to the acupuncturist. Even so, the participants still felt as though they were in control since the acupuncturists, in Working Together, facilitated the development of health literacy which, along with respecting their preferences for care, enabled the participants to reclaim control over decisions about care. DISCUSSION This study was the first within the field of acupuncture to link the sense of control clients experience with Gaining Trust in their acupuncturists and their ability to access acupuncture care. Several of the other processes involved with regaining control in this study have also been reported, namely, the experience of symptom alleviation and enhanced well-being, and developing a new awareness of how to use self-care strategies.6 10 13 14 The way in which the sense of control was linked to participants actively using selfcare advice to change their lifestyles in both this study and three previous acupuncture studies10 13 14 differed from the finding of one other acupuncture study6 which associated the sense of control with the participants simply electing to use acupuncture care. Several implications for clinical practice may be drawn from the findings of this study. Perhaps clinicians should consider using needling strategies which elicit an immediate sense of calmness, and subsequent
He suggests different directions. So relaxation he tends to be quite big on as well, so as well the acupuncture we do relaxation sessions, and he was the one who suggested going to the masseuse as well, but he tends to be guided by me. [Clare]
In contrast, a few participants did not, or could not, ask questions either due to a language barrier, the acupuncturist’s attitude or because they were not so inclined. When this occurred, the participants tended to adopt a passive role: I sort of understood what they talking about, but I just wanted them to treat me and went along with whatever they were doing. [Derek] Deriving the theory from the interplay between the categories
Figure 1 illustrates the relationships between the categories. As previously described, Reclaiming Control involved the participants regaining a sense of wellbeing. Reclaiming Control, however, involved more
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Figure 1 Relationships between core category and other categories.
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Original paper well-being benefits, as both effects were highly valued by the participants in this study. This sense of calmness may also be enhanced through providing a relaxing physical environment. In addition, clinicians could take note of the transactional and interpersonal processes described in this study and include them in their care approach as they were also linked to the beneficial outcomes the participants in this study experienced. Of particular importance to the participants were establishing trust and rapport, shared decision-making, and enabling self-care through following advice for the management of low back pain. Notably, the cognitive aspect (shared decision-making/ provision of advice) of these processes has been associated with enablement, improved symptoms, higher satisfaction and reduced use of healthcare.20 A recent systematic review reported that self-care had a small effect on reducing pain and disability in people with low back pain. That review questioned the value of self-care given its minimal impact on low back pain, although the similarity in effect between self-care and other more costly interventions was noted. However, rather than considering the value of self-care solely in the context of treatment effect, its importance may be better reflected in the sense of control the participants experienced when adopting self-care strategies.21 To enable informed decision-making, clinicians should carefully consider how they explain issues and plans to a particular client.22 23 Traditional Chinese medicine terms confused some of the participants and biomedical explanations resonated with some participants. This suggests that acupuncturists may want to develop an understanding of each client’s worldview and engage in shared decision-making through using language that suits each individual‘s healthcare orientation. The findings have implications for education both at undergraduate and continuing professional developments levels. Communication skills of acupuncturists are important as effective communication and the facilitation of medical literacy were integral to the beneficial outcomes experienced by the participants in this study. Shared decision-making material should be embedded throughout the curriculum at the undergraduate level as shared decision-making has been recognised as an important component of contemporary clinical practice.22 23 For professional development, information about shared decision-making would be most effectively disseminated in interactive workshops, given that studies of educational initiatives have shown passive strategies, such as journal articles or didactic lectures, have little influence on clinical practice.24 25 It is clear that acupuncture care for chronic low back pain involves more than inserting needles to alleviate pain. Hence, future researchers need to consider evaluating interpersonal and transactional aspects of 338
acupuncture care, and diverse well-being outcomes, to establish the full extent of the way in which acupuncture care may improve the quality of life for people with chronic low back pain. Limitations
The participants of this study were well-educated, middle-class Australians and whether the experience of acupuncture care would be similar for people from other socioeconomic backgrounds remains unclear. Moreover, our findings should be interpreted cautiously as the results may be generalisable only to private practice in affluent countries, and whether the findings are representative beyond this setting is uncertain. Finally, time constraints within a doctoral programme resulted in uncertainty that the categories were theoretically saturated. It is possible that if more participants were interviewed, other categories may have emerged.19 CONCLUSIONS People who had under taken acupuncture for chronic low back reported that needling strategies elicited a sense of calmness and well-being, which may be enhanced through a relaxing physical environment. Establishing trust and shared decision-making are particularly important to clients and careful consideration of each client’s worldview may tailor treatment to each individual’s healthcare orientation. Through skilled application of both acupuncture and communication, clients with chronic low back pain may be enabled to reclaim control and to experience well-being.
Summary points ▸ We interviewed 11 patients on their experience in private acupuncture clinics for treatment of chronic low back pain. ▸ The core category of their experience was regaining control they had previously lost. ▸ Improvement in sense of wellbeing was valued as much as improvement of symptoms and function. ▸ The sanctuary of clinic, and trust in and collaboration with the practitioner were significant components of the benefit.
Correction notice This article has been corrected since it was published Online First. The word ‘Sancturay’ in Figure 1 has been amended to read ‘Sanctuary’. Contributors All authors contributed to the conception and design of the study, acquisition of data, analysis and interpretation of data, were involved in drafting the manuscript, and have given final approval of the version to be published. Competing interests None. Ethics approval University of South Australia HREC.
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper Provenance and peer review Not commissioned; externally peer reviewed. 12
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The experience of acupuncture care from the perspective of people with chronic low back pain: a grounded theory study N J Stomski,1,2 S F Mackintosh,1 M Stanley1
1
School of Heath Sciences, University of South Australia, Adelaide, South Australia, Australia 2 School of Health Professions, Murdoch University, Murdoch, Western Australia, Australia Correspondence to Dr N J Stomski, School of Health Professions, Murdoch University, 90 South St, Murdoch, W A 6150, Australia; [email protected] Received 14 October 2013 Accepted 3 April 2014 Published Online First 1 May 2014
To cite: Stomski NJ, Mackintosh SF, Stanley M. Acupunct Med 2014;32: 333–339.
ABSTRACT Objectives To explore the experience of acupuncture care from the perspective of people with chronic low back pain. Methods A grounded theory, qualitative study using indepth interviews was undertaken with 11 people who had received acupuncture care for chronic low back pain. Interviews were audiorecorded and transcribed verbatim. Initial, focused and theoretical coding were used to identify a core category and several other categories. Results The core category, Reclaiming Control, was related to the sense of well-being experienced by most of the participants as a result of undergoing acupuncture care. The other categories were Gaining Sanctuary, Gaining Trust and Working Together. These categories reflected the processes of participants entering an aesthetically appealing, calm and relaxing space; developing confidence in the acupuncturists’ ability to care for them; and negotiating strategies and sharing decisionmaking with acupuncturists about their care. Conclusions Clinicians using acupuncture as a management strategy for low back pain may elicit an immediate sense of calmness in patients with subsequent well-being benefits. A sense of calmness may also be enhanced through providing a relaxing physical environment. The transactional and interpersonal processes of establishing trust and rapport, and shared decision-making are important for clients. Shared decision-making can be improved by clinicians carefully considering the explanation of issues and plans to a particular patient, especially by developing an understanding of each patient’s worldview and using language that the suits each individual’s healthcare orientation. Our findings should be interpreted cautiously as the results may be generalisable only to private practice in affluent countries, and whether the
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
findings are representative beyond this setting remains unclear.
INTRODUCTION The 2010 Global Burden of Disease study reported that low back pain ranked as the leading cause of disability-adjusted life years.1 This results in a substantial socioeconomic burden in both direct medical costs and indirect costs such as work absence and decreased productivity.1 Hence, effective management of low back pain is an important issue for patients, clinicians and healthcare policy makers. Recent clinical guidelines recommend that acupuncture should be considered for the management of chronic low back pain, especially if no improvement occurs through using self-care strategies or people express a preference for acupuncture.2 3 Qualitative studies of acupuncture care for conditions other than chronic low back pain have established that people value diverse well-being outcomes and other broad outcomes such as changes in self-awareness regardless of the reason people sought acupuncture care.4–14 Only one previous study appears to have explored the experience of acupuncture care from the perspective of people with chronic low back pain, and the findings were mainly descriptive in nature.15 This study builds on that previous study by using a grounded theory approach to articulate how consultation processes influence the experience of acupuncture care from the perspective of people with chronic low back pain. Given the paucity of research in this area, this study was guided by the following research question: ‘What is people’s
333
Original paper experience of acupuncture consultations during an episode of care for chronic low back pain?’ METHODOLOGY A grounded theory approach was selected for this study as there was little published information about the processes involved with the phenomena under study15 and this approach allowed the researchers to develop an understanding of the consultation processes involved with acupuncture care from the perspective of people with chronic low back pain. The principal researcher has more than 10 years experience as an acupuncturist in clinical practice and recognises that it may have shaped the analysis of this study. The other two researchers have more than 20 years experience as Allied Health Practitioners (Physiotherapy and Occupational Therapy) and in academia but had no experience with acupuncture. Accordingly, a social constructivist epistemological position16 was taken in this study as it acknowledges that a researcher’s previous experience and beliefs inevitably influence gathering data and its interpretation.
disabling pain when first electing to undertake acupuncture. Most participants still experienced low back pain, but it was generally intermittent and manageable. Six participants had seen traditional acupuncturists,17 and five had consulted western acupuncturists.18 In this study, traditional acupuncturists were defined as those who primarily: explained treatment using language reflective of traditional Chinese medicine theory; used traditional oriental diagnostic methods; and used both local and distal acupuncture points.17 Western acupuncturists were defined as those who primarily: explained treatment in pathophysiological terms; used western diagnostic techniques; and used only local acupuncture points.18 Ethical approval/issues
The University of South Australia’s Human Research Ethics Committee granted ethical approval. Formal consent was gained before all interviews. Participants were assigned pseudonyms to maintain anonymity and confidentiality. Data collection/analysis
METHODS Recruitment and eligibility
Letters were sent to acupuncturists in one State in Australia asking them to place recruitment notices in their clinics. Advertisements were also placed in local newspapers and on community notice boards. When a potential participant expressed interest in the study, an information sheet was sent and the principal researcher then rang the participant to determine eligibility. Participants were eligible to be included in the study if they were either currently undertaking acupuncture care or had concluded acupuncture care in the previous 6 months for chronic non-specific low back pain ( pain in the low back region persisting beyond 3 months). Information-rich cases were sought and identified either through acupuncturists’ recommendations about clients who had a firm understanding of acupuncture care or clients who appeared well informed during the initial telephone conversation. Participants
Of the 11 interviewees, six were women. All were white, middle-class Australians; seven were aged between 25 and 40 years, one was a young adult and three had recently passed 60 years of age. Most participants were well educated and were developing or had led professional careers. Seven of the participants had experienced low back pain for a substantial period of time. Of these participants, the period of time with low back pain was about 10 years, 20 years, 30 years, and in two cases about 40 years. Four participants had experienced low back pain for between 1 and 2 years, and the remaining two participants had experienced it for less than a year. All but one of the participants had experienced intense and often 334
In keeping with a grounded theory approach, data collection and analysis were undertaken concurrently from mid-2009 to early 2010.16 The first author undertook all of the interviews and was not a therapist for any of the participants. Open-ended questions were used throughout each indepth interview because they often elicit unexpected statements and personal accounts, and enable the study of individual experience. The open-ended questions were based on Charmaz’s16 examples and started with ‘Talk me through an acupuncture session.’ and ‘What brought you to an acupuncturist?’ After the initial two open-ended questions, probing questions were used to explore the responses further; these included: What happened next? How did you feel about…? How did you respond to…? Could you talk more about…? Can you explain that more? At the conclusion of each interview, the following questions were used: Is there anything else you would like to tell me about you acupuncture experience? Is there anything you would like to tell acupuncturists, or people thinking of using acupuncture, about acupuncture care for low back pain? That is all I would like to ask, is there anything else you would like to talk about or ask me? Indepth interviews were audio-recorded and transcribed verbatim. For the first coding phase of analysis, transcripts were considered line by line with initial codes, derived from the participants actual words, assigned to each event or circumstance.16 Focused coding was then used to form categories by grouping similar codes together.16 Next, the categories were refined through constant comparison, which involved comparing different categories against one another, and contrasting different instances of the
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper same category both across and within participants.16 The final stage of coding involved using theoretical coding to specify the relationships between the categories until a core category became evident through ongoing analysis.16 Throughout the coding processes, discussions were held between the authors to build depth in the categories and refine the relationships between the categories. Memos were used throughout to capture thoughts, preserve comparisons and relationships between categories, and refine questions and directions to follow through on.16 Rigour
Charmaz identified four criteria to evaluate the rigour of a study: credibility, originality, resonance and usefulness.16 In this study, credibility was addressed by detailing data collection and the sample, collecting sufficient data to support the propositions, making systematic comparisons between data, and ensuring the categories encompassed a broad range of observations. Originality was addressed through the study’s categories, significance, and findings being presented and compared with the existing literature. In this study, resonance is addressed in the Findings section through delineating the categories and using transcript excerpts to support their development. The usefulness of a study may be assessed by considering whether it: interprets the studied experience in a way that people may use in the everyday life; contributes to knowledge; and provides direction for additional research. The usefulness of this study is described in the Discussion section. Two other strategies were used to attend to the rigour of this study: reflexivity and attention to negative cases. Memos were used in part to address reflexivity through considering how a priori assumptions may have influenced the categories and conceptual model.16 Also, reflexivity was attended to in peer debriefing between the principal author and the other coauthors without acupuncture backgrounds. These debriefings occurred fortnightly over 6 months, and in the course of which all authors contributed to refining the codes, categories and theory. Attention to negative cases involves deliberately identifying examples of cases within the data which do not accord with the emerging analysis.19 During analysis, the researchers used negative cases to challenge and strengthen the categories and conceptual model. Examples of negative cases are presented throughout the Findings section. Findings
Analysis of the data has generated a theory which explicates how aspects of acupuncture care contributed to people with chronic low back pain regaining control over their health. In the following sections, the basic problem and core category are detailed, followed by a description of the three subcategories and their relationship to the core category.
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
The core category: Reclaiming Control
The main issue identified from the participants’ interviews revolved around losing control. Some participants felt as though they had lost control over their personal circumstances, which they believe led to developing chronic low back pain: There’s a certain tension you need in order to operate because you’re not in an environment that’s of your own choosing regarding your job. Something has to give eventually, and for me it was the back. [Margaret]
For others, the loss of control was experienced after their chronic low back pain commenced: Now there’s no time in the day when I don’t have chronic pain, and so that’s the main issue it pretty much affects everything. [Lynn]
However, losing control involved more than how chronic low back pain directly affected the participants’ lives as it was also associated with unfulfilling interactions with health professionals: I had a specialist who said you will just have to learn to live with it, and I got really angry about that because that was no advice at all. [Margaret]
Reclaiming Control related to the sense of wellbeing experienced by most participants as a result of undergoing acupuncture care. Interestingly, the wellbeing benefits were valued as much as pain alleviation and improvements in physical function. Indeed, although participants initially attended for back pain management, their focus soon shifted towards attaining well-being benefits. I felt like when I went to see him it was about my whole well-being, it wasn’t just about back pain. [Jane]
The focus on well-being by most participants was particularly remarkable to the principal researcher who, as a clinical acupuncturist, held the view that people with low back pain undertook acupuncture care primarily for pain management. The importance of the well-being benefits was highlighted by the passing reference some participants made to low back pain per se during the initial stages of the interview. Subsequently, in later interviews, the principal researcher enquired specifically about issues related to low back pain after about 40– 45 min if the participants had barely discussed them at that point. The well-being benefits experienced by the participants included: improved focus and clarity; improved eyesight; better sleep; reinvigoration; increased emotional resilience; improved digestion; and feeling calmer and happier. The experience of these wellbeing benefits appeared to be attributable to the needling effects, especially as they most commonly occurred when the needles were left in place for more than 15 min and both local and distal acupuncture 335
Original paper points were used. It also seems likely that well-being benefits were associated with following self-care advice provided by the acupuncturists such as relaxation strategies, exercise programmes, dietary recommendations and general lifestyle advice. Relaxation strategies involved guided visualisations incorporated into the consultations, and a specific biofeedback technique. Exercise recommendations included walking, tai chi, yoga, structured stretching programmes, swimming, postural modifications, qi gong, and advice to keep active and avoid sedentary behaviour. The dietary recommendations were usually based on a combination of traditional oriental dietary principles, like yin/yang or hot/damp/cold food, and contemporary western dietary principles, and often included recommendations for nutritional supplements such as vitamins or minerals. Most participants said that the dietary recommendations were not prescriptive but rather took the form of information that they could use to determine themselves how to plan their daily diet. The general lifestyle advice focused on acupuncturists suggesting to participants that they should find time to relax and pursue personal interests and not be hard on themselves. When the participants began to lose the sense of well-being sometime after last receiving an acupuncture treatment, ‘things started to fall part’ which acted as an impetus to undertake further acupuncture care: So I think it’s time for another session when I get indicators… lower back twinges is one, eyesight curiously, if I’ve been flat maybe, and feeling scrambled. When I’ve got clarity, I’ll go ok these are the things you need to do let’s look at how were going to do this, whereas when I’m in the scrambled mode I get stressed by it. [Clare]
Gaining Sanctuary
Gaining Sanctuary was associated with regaining control and involved most participants entering an aesthetically appealing space which evoked a sense of comfort: There are a lot of things in the room that I find welcoming and attractive… it’s a very peaceful experience and it’s like stepping from the outside world into that is a really, it’s a very nice place to be. [Clare]
Within this space, participants were able to remove themselves from their busy lives, and find time to just sit, relax and focus on being well. This peaceful, unhurried experience was then enhanced when the insertion of needles evoked a sense of calmness accompanied by sensations of warmth and flowing energy which was unlike anything the participants experienced in everyday life: For me this is an intense moment of just being, its beautiful, its not an experience that I get in my daily life. [Clare]
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Participants also noted that it was not ever intrusive as there were no external distractions. After the needles were inserted, the participants were left undisturbed by the acupuncturists, which provided them with the opportunity to think about being well. At the end of the consultation, time was also made available to summarise what the participants and acupuncturists had done together and discuss what the participants should be working on between appointments. However, some participants experienced only slight relaxation or no evident change, and the sense of calmness and warm energy were typically contingent upon two conditions: retaining acupuncture for between 15 and 20 min, and using both local and distal (from the low back region) acupuncture points. When the participants experienced calmness during needle retention, they typically described leaving the consultations feeling rejuvenated, calm, clear and focused. Gaining Trust
Gaining Trust was associated with regaining control and refers to how the participants usually developed confidence in the acupuncturists’ ability to care for them. When participants experienced initial assessments that were comprehensive, the participants typically began to develop confidence in the acupuncturists’ clinical competency, but when it was less than comprehensive the participants usually were left feeling uncertain: Part of me was thinking she must know what she is doing otherwise she would of searched a bit more...I wasn’t convinced that she did know what she was doing at all. [Angela]
The assessments differed according to the acupuncturists’ orientation. Western acupuncturists tended to focus on pain patterns and diagnostic scans, whereas traditional acupuncturists typically enquired about all areas of the participants’ lives and relied more on traditional diagnostic techniques such as pulse palpation and tongue inspection. The traditional acupuncturists often reflected their impressions of pulse and tongue diagnosis, which frequently assisted in gaining the participants’ confidence as it was usually perceived as being accurate: That amazes me how you can feel with three fingers the pulse, and he moves it around, and from that he can ascertain, quite well, my emotional state, or physical state. [Margaret]
Another aspect of the acupuncturists’ manner which in general engendered confidence concerned how clear the explanations were about what contributed to the participants’ condition, its management and expected course. The western acupuncturists tended to couch their explanations in biomedical terms, while the traditional acupuncturists frequently used
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper traditional Chinese medicine terms. Most participants thought that the explanations seemed reasonable which usually helped consolidate the trust in the acupuncturists, especially as they typically believed that the acupuncturists knew what was happening with their bodies. However, when the acupuncturists failed to clearly explain the expected course of care, they usually lost the participants’ confidence. Working Together
Working Together was associated with regaining control related to how the participants and acupuncturists shared information and negotiated strategies to manage the participants’ low back pain and improve their well-being. Acupuncturists usually asked participants’ opinion about the assessment findings, acupuncture treatment and self-care recommendations. The participants indicated that they asked questions about any aspect of care and that the acupuncturists often responded enthusiastically. When the acupuncturists used oriental lay language, this often resulted in participants asking further questions: He explains it to me in a very lay person sort of way, but I actually ask more because I’m interested, I just find the whole yin/yang, the whole Chinese medicine philosophy thing so interesting. [Tony]
Regardless of the type of language used by the acupuncturists, most participants developed a clear understanding of what influenced either their chronic low back pain or well-being, and strategies they could use to maintain or improve them. This understanding in turn usually enabled participants to collaborate with their acupuncturists in negotiating the direction of care, and in particular allowed participants to voice their preferences for care which the acupuncturists typically respected:
than this as it was partially associated with the participants being able to decide when they would make appointments or, in other words, being able to Gain Sanctuary when it suited them. Also, through Gaining Trust the participants believed that the acupuncturists were acting in their best interests, which led to the participants entrusting control over the direction of care to the acupuncturist. Even so, the participants still felt as though they were in control since the acupuncturists, in Working Together, facilitated the development of health literacy which, along with respecting their preferences for care, enabled the participants to reclaim control over decisions about care. DISCUSSION This study was the first within the field of acupuncture to link the sense of control clients experience with Gaining Trust in their acupuncturists and their ability to access acupuncture care. Several of the other processes involved with regaining control in this study have also been reported, namely, the experience of symptom alleviation and enhanced well-being, and developing a new awareness of how to use self-care strategies.6 10 13 14 The way in which the sense of control was linked to participants actively using selfcare advice to change their lifestyles in both this study and three previous acupuncture studies10 13 14 differed from the finding of one other acupuncture study6 which associated the sense of control with the participants simply electing to use acupuncture care. Several implications for clinical practice may be drawn from the findings of this study. Perhaps clinicians should consider using needling strategies which elicit an immediate sense of calmness, and subsequent
He suggests different directions. So relaxation he tends to be quite big on as well, so as well the acupuncture we do relaxation sessions, and he was the one who suggested going to the masseuse as well, but he tends to be guided by me. [Clare]
In contrast, a few participants did not, or could not, ask questions either due to a language barrier, the acupuncturist’s attitude or because they were not so inclined. When this occurred, the participants tended to adopt a passive role: I sort of understood what they talking about, but I just wanted them to treat me and went along with whatever they were doing. [Derek] Deriving the theory from the interplay between the categories
Figure 1 illustrates the relationships between the categories. As previously described, Reclaiming Control involved the participants regaining a sense of wellbeing. Reclaiming Control, however, involved more
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Figure 1 Relationships between core category and other categories.
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Original paper well-being benefits, as both effects were highly valued by the participants in this study. This sense of calmness may also be enhanced through providing a relaxing physical environment. In addition, clinicians could take note of the transactional and interpersonal processes described in this study and include them in their care approach as they were also linked to the beneficial outcomes the participants in this study experienced. Of particular importance to the participants were establishing trust and rapport, shared decision-making, and enabling self-care through following advice for the management of low back pain. Notably, the cognitive aspect (shared decision-making/ provision of advice) of these processes has been associated with enablement, improved symptoms, higher satisfaction and reduced use of healthcare.20 A recent systematic review reported that self-care had a small effect on reducing pain and disability in people with low back pain. That review questioned the value of self-care given its minimal impact on low back pain, although the similarity in effect between self-care and other more costly interventions was noted. However, rather than considering the value of self-care solely in the context of treatment effect, its importance may be better reflected in the sense of control the participants experienced when adopting self-care strategies.21 To enable informed decision-making, clinicians should carefully consider how they explain issues and plans to a particular client.22 23 Traditional Chinese medicine terms confused some of the participants and biomedical explanations resonated with some participants. This suggests that acupuncturists may want to develop an understanding of each client’s worldview and engage in shared decision-making through using language that suits each individual‘s healthcare orientation. The findings have implications for education both at undergraduate and continuing professional developments levels. Communication skills of acupuncturists are important as effective communication and the facilitation of medical literacy were integral to the beneficial outcomes experienced by the participants in this study. Shared decision-making material should be embedded throughout the curriculum at the undergraduate level as shared decision-making has been recognised as an important component of contemporary clinical practice.22 23 For professional development, information about shared decision-making would be most effectively disseminated in interactive workshops, given that studies of educational initiatives have shown passive strategies, such as journal articles or didactic lectures, have little influence on clinical practice.24 25 It is clear that acupuncture care for chronic low back pain involves more than inserting needles to alleviate pain. Hence, future researchers need to consider evaluating interpersonal and transactional aspects of 338
acupuncture care, and diverse well-being outcomes, to establish the full extent of the way in which acupuncture care may improve the quality of life for people with chronic low back pain. Limitations
The participants of this study were well-educated, middle-class Australians and whether the experience of acupuncture care would be similar for people from other socioeconomic backgrounds remains unclear. Moreover, our findings should be interpreted cautiously as the results may be generalisable only to private practice in affluent countries, and whether the findings are representative beyond this setting is uncertain. Finally, time constraints within a doctoral programme resulted in uncertainty that the categories were theoretically saturated. It is possible that if more participants were interviewed, other categories may have emerged.19 CONCLUSIONS People who had under taken acupuncture for chronic low back reported that needling strategies elicited a sense of calmness and well-being, which may be enhanced through a relaxing physical environment. Establishing trust and shared decision-making are particularly important to clients and careful consideration of each client’s worldview may tailor treatment to each individual’s healthcare orientation. Through skilled application of both acupuncture and communication, clients with chronic low back pain may be enabled to reclaim control and to experience well-being.
Summary points ▸ We interviewed 11 patients on their experience in private acupuncture clinics for treatment of chronic low back pain. ▸ The core category of their experience was regaining control they had previously lost. ▸ Improvement in sense of wellbeing was valued as much as improvement of symptoms and function. ▸ The sanctuary of clinic, and trust in and collaboration with the practitioner were significant components of the benefit.
Correction notice This article has been corrected since it was published Online First. The word ‘Sancturay’ in Figure 1 has been amended to read ‘Sanctuary’. Contributors All authors contributed to the conception and design of the study, acquisition of data, analysis and interpretation of data, were involved in drafting the manuscript, and have given final approval of the version to be published. Competing interests None. Ethics approval University of South Australia HREC.
Stomski NJ, et al. Acupunct Med 2014;32:333–339. doi:10.1136/acupmed-2013-010477
Original paper Provenance and peer review Not commissioned; externally peer reviewed. 12
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