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ORIGINAL RESEARCH

LESSONS FROM AN ACUPUNCTURE TEACHING CLINIC: PATIENT


CHARACTERISTICS AND PAIN MANAGEMENT EFFECTIVENESS
Kai-Yin Hsu, MAOM, MS-PREP, Lic Ac, Dip. OM, BSN,1# Julie E. Dunn, PhD,2 Ylisabyth S. Bradshaw, DO, MS,3
and Lisa Conboy, MA, MS, ScD1,4

Objectives: To understand the following about patients about 40 years old, white, not Hispanic or Latino, married,
using an acupuncture teaching clinic: (1) sociodemographic highly educated, and employed. Most patients were confident in
characteristics and main complaints and (2) self-reported level acupuncture treatment. Out of the 421 acupuncture patients,
of patient-centered outcomes regarding pain management. 68.2% wanted acupuncture in order to manage pain. Overall,
20.6% of the patients (59, N ¼ 287) who used acupuncture for
Methods/Design: Retrospective chart review.
pain management for diseases of the musculoskeletal system and/
Subjects: A total of 458 new patients at NESA clinic during or connective tissue or migraine or headache completed the
October 1, 2009 to July 31, 2010 were enrolled in the study. sixth-week follow-up MYMOP form. Of these patients, 57.6%
Interventions: A variety of styles of Oriental medicine, primar- (34, N ¼ 59) returned during week 6 of the semester for
ily Chinese and Japanese style acupuncture and also heat acupuncture treatment and reported clinical improvement in at
treatments (MOXA or heat lamps) and Tui Na (Asia bodywork). least one MYMOP severity score, and no score got worse.
Conclusions: The information about sociodemographic char-
Results: Results from Objective 1 were descriptive (n ¼ 421).
acteristic and patient-centered outcomes of pain management
Objective 2 focused on the 59 patients from the larger sample
can be used for service provision, future study planning, and
who completed both an initial and a follow-up Measure
marketing. Future studies should address the low follow-up rate,
Your Medical Outcome Profile (MYMOP) form and who
the quality of self-reported clinic data, and the reasons that
used acupuncture for pain management of (1) diseases of the
patients chose acupuncture treatments and teaching clinics.
musculoskeletal system and/or connective tissue or (2) migraine/
headache. Both the symptom severity and activity of daily living/ Key words: Acupuncture, complementary medicine, pain
well-being scales of the MYMOP showed over 15.8% improve- management, medical education and training, pain research,
ment from baseline to at least six weeks of treatment: 28.6% for patient-centered outcomes
Symptom 1, 19.4% for Symptom 2, 35.7% for activities of daily
living, and 25.0% for well-being. The relative majority for each (Explore 2014; 10:284-293 & 2014 Elsevier Inc. All rights
sociodemographic trait investigated were as follows: female, reserved.)

INTRODUCTION therapies according to the 2002 National Health Interview


Acupuncture is one of the most commonly used comple- Survey (NHIS)1 and is becoming more widely accepted by the
mentary and alternative medicine (CAM) interventions/ American public as well as federal policy makers.2–4 In the
United States, acupuncture is used in many medical special-
ties, for example, complementary and integrative care in
oncology,5 pain management,6,7 public health drug treatment
1 Department of Research, New England School of Acupuncture, and community-based HIV care,8,9 and primary care.10,11
150 California Street, Newton, MA 02458 Patients who use acupuncture in hospitals or CAM clinics in
2 Friedman School of Nutrition Science and Policy, Tufts University, the United States are likely to be females who are between the
Boston, MA
ages of 18 and 59 years, suffer from pain/musculoskeletal
3 Pain Research, Education and Policy Program (PREP), Department
complaints, and report reduction in pain and improvement in
of Public Health and Community Medicine, Tufts University,
School of Medicine Boston, MA quality of life.12–14
4 Beth Israel Deaconess Medical Center, Harvard Medical School, Many medical research and treatment leaders advocate
Boston, MA patient-centered care and patient-centered outcomes res-
Funding: This project was partially funded by the grant “New earch.15,16 Since traditional Chinese medicine (TCM) is natu-
England School of Acupuncture–Harvard Acupuncture Research rally practiced in an individualized, patient-centered manner, it
Collaborative” (NCCAM U19 AT002022-01) fits well into this focus. However, relatively little infor-
# Corresponding author: mative data has been obtained to date on the characteristics
e-mail: khsu@nesa.edu and patient-centered outcomes of users of TCM teaching clinics

284 & 2014 Elsevier Inc. All rights reserved. EXPLORE September/October 2014, Vol. 10, No. 5
ISSN 1550-8307/$36.00 http://dx.doi.org/10.1016/j.explore.2014.06.004
in the United States. This retrospective chart review, which was To investigate self-reported clinical outcomes for Objective
completed at a TCM teaching clinic, the New England School 2, we compared initial and follow-up MYMOP forms for the
of Acupuncture (NESA), reports patients' sociodemographic subset of patients seeking pain management who had com-
characteristics and self-reported level of pain and functioning pleted an initial and at least one follow-up MYMOP form
across a variety of domains. This article also reports symptom over the study observation period. We examined changes in
changes using a patient-centered measure used in a TCM symptom severity, physical activity, and well-being scores by
teaching clinic, offering evidence of treatment effectiveness that comparing initial and follow-up MYMOP scores.
can be used for health systems integration and support of
TCM use in the community. As acupuncture continues to
become a more common treatment option, information on use SETTING/LOCATION
patterns and patient-centered outcomes in teaching clinics by NESA is the oldest acupuncture school in the United States;
observational study can inform the decisions of acupuncture this project was completed at NESA's main teaching clinic in
consumers, healthcare providers, and investigators. Newton, MA. Annually, about 400 NESA interns give over
10,600 treatments for a variety of conditions at NESA's main
teaching clinic. NESA's teaching clinics are learning environ-
ments where student interns treat patients under the direct
OBJECTIVES supervision of experienced and licensed acupuncturists.
We chose two aspects to study. Objective 1 was to describe NESA is committed to making acupuncture and Oriental
the sociodemographic characteristics and self-reported main medicine affordable and accessible to the greater public,
complaints of all new patients (n ¼ 421) at the NESA main which results in a heterogeneous patient population in its
clinic who received acupuncture treatments from a sample clinics that is more representative of the surrounding area
time period: October 1, 2009–July 31, 2010. Objective 2 was than if treatments were full-cost. Patients receive Oriental
to describe the self-reported level of symptom severity and medical care at affordable prices while also participating in
functioning across a variety of domains by examining “Meas- the education and training of future acupuncturists. Patients
ure Your Medical Outcome Profile” (MYMOP) forms13 for a choose from Chinese or Japanese acupuncture styles, Chinese
subgroup of patients (n ¼ 59) from Objective 1 who used herbal medicine, or a combination approach.
acupuncture for pain management of diseases of the
musculoskeletal system and/or connective tissue or migraine
or headache. We chose to focus on pain management because DATA COLLECTION
the 2002 National Health Interview Survey12 data indicates Patients completed the health history and initial MYMOP
that the most common reasons for seeking acupuncture forms before their first treatment at the NESA clinic. Interns
treatment in the United States are to relieve low back pain (students in their final year of a 3.5-year training program)
(34%), joint pain (16%), neck pain (14%), and headache/ provided their subsequent acupuncture care under close
migraine (10%). In addition, the 2007 National Health supervision of a senior practitioner. Following an extensive
Interview Survey17 has shown that the number of patients intake interview, patients could receive treatment using a
who have ever used acupuncture increased from 4.2% to variety of techniques of Oriental medicine, including acu-
6.3% of the population. puncture, Chinese herbs, heat treatments (MOXA or heat
lamps), and massage. The interns discussed each of these
techniques with subjects prior to any treatment. The clinic
METHODS/DESIGN offered patients private treatment rooms. The treatment plans
We extracted study data from extant patient charts. Self- are individualized, patient-centered, and holistic inter-
reported health history forms (HHFs) and MYMOP forms ventions.
were (and still are) regularly completed as part of standard care Generally, subjects saw the same intern or intern pair
at NESA clinics. We abstracted patient data for this project (interns sometimes work in pairs if a time slot is popular)
from the health history and MYMOP forms (see Data each time. Within the first two appointments, interns recom-
Collection). To analyze patient demographics for Objective mended a treatment plan of specific dose and duration. To
1, we used HHFs from a complete survey of all subjects facilitate scheduling, the front desk staff tried to schedule
meeting eligibility requirements (see Subjects). We described appointments for the same day of the week, at the same time,
patients by the following sociodemographic variables: gender, until the intern-treater determined that it was time to dismiss
age, race, ethnicity, marital status, education, and employment subjects from treatment. Ideally, subjects would come in once
status. We also recorded the following variables of acupuncture a week, but sometimes they would skip some treatments or
treatment patterns: main complaint, prior exposure to stop treatment altogether. Subjects completed follow-up
acupuncture and Chinese herbal medicine, level of con- MYMOP forms when their subsequent visits fell on the sixth
fidence in acupuncture treatment, total number of visits in and the 12th week of every semester.
the study period, treatment duration (days between first and
last treatment), acupuncture style received in the teaching clinic Measure Your Medical Outcome Profile
(Chinese or Japanese), whether Chinese herbal medicine The MYMOP14 is a patient-centered outcome questionnaire,
treatment was also received for the main complaint, and self- first published in the British Medical Journal in 1996.
reported main complaints. Originally designed to measure the effects of CAM, use of

Lessons from an Acupuncture Teaching Clinic EXPLORE September/October 2014, Vol. 10, No. 5 285
this evaluation tool in primary care has become popular in NESA clinic, (ii) who received acupuncture treatments, (iii)
both biomedicine and CAM literature.13,18–20 It is problem-/ who were in the observation period: October 1, 2009–July 31,
symptom-specific, asking patients to report two symptoms 2010, and (iv) who completed HHFs (N ¼ 421) (Figure 1).
that are the most bothersome and to rate the severity of those The study population for Objective 2 included all patients
two symptoms. The MYMOP form requires the respondent, from Objective 1 whose (i) records included an initial and at
with some guidance, to specify one or two symptoms that least one follow-up MYMOP form and (ii) HHF Complaints
concern them the most and for which they are seeking indicated they wanted pain management for (1) diseases of
treatment and one activity of daily living that is restricted the musculoskeletal system and/or connective tissue or (2)
or prevented by these symptoms. The respondent then scores migraine or headache (Figure 1).
these items on a seven-point scale, 0–6, with 6 being “as bad Confidentiality was carefully preserved. The study was
as it could be” and 0 being “as good as it could be,” according approved and oversight was provided by the New England
to perceived severity in the last week. Subjects also score their Institutional Review Board (NEIRB). Earlier stages of the
general feeling of well-being over the last week on a similar study were also approved by the Tufts University Health
scale of 0–6. Science Campus' IRB. Subjects could choose to skip parts or
The MYMOP form is applicable to all patients who present all of the HHF and MYMOP forms if they wished not to
with physical, emotional, or social symptoms. It is brief and provide the information.
simple to administer. Follow-up forms are completed without
help, and the original health concerns are asked about again.13
NESA began implementing the MYMOP form in teaching STATISTICAL ANALYSIS
clinics in 2008. At follow-ups, the patients are given a new Descriptive statistics were generated for both objectives using
MYMOP form that already contains the two symptoms given EXCEL 2003 (Microsoft Corp.) and SPSS 22 (IBM Corp.).
previously and are asked to rate the severity of those two Initial (baseline), week six, and week 12 MYMOP scores
symptoms, allowing for the evaluation of changes in the (Symptoms 1 and 2, activity of daily living, and well-being)
patients' top two symptoms over time. NESA chose to collect were summarized by their means and standard deviations. We
follow-up MYMOP forms for subsequent (not initial) visits calculated changes of each MYMOP score by taking the sixth-
falling on the sixth and the 12th week of every semester. and the 12th-week scores and subtracting the corresponding
Trained work-study students regularly entered the data initial (baseline) scores, so that a negative change denotes
from all the HHFs and MYMOP forms into an analyzable improvement. Each MYMOP score's percentage change is
database. A research assistant with an RN license mapped the calculated by taking mean changes divided by corresponding
HHF complaints and MYMOP symptoms to ICD-9-CM initial mean scores. Paired t-tests were used and assessed by
codes.21 The database was then queried to select relevant data SPSS 22 for comparing the sixth- and the 12th-week scores to
for Objectives 1 and 2. initial MYMOP scores. The change in medication use was
calculated for patients who had recorded this data. Mapping
Important Note About HHF and MYMOP to ICD-9-CM codes was completed prior to any statistical
In addition to a requested MYMOP form, patients are also analysis, to avoid bias in the mapping.
required to fill out a HHF, which collects a more complete
medical history; the interns use this form to determine diagnosis
RESULTS
and treatment. A part of this form requests a main and a
Figure 1 is a flowchart showing attrition.
secondary complaint for seeking treatment. For any particular
patient, the main and secondary complaints gathered by the
HHF did not always overlap with the MYMOP forms' first and Characteristics of Patients at Objective 1 (baseline)
second symptoms, henceforth referred to as the HHF Main and Payment records identified 458 acupuncture patients as poten-
Secondary Complaints and MYMOP Symptoms 1 and 2, tially new to the NESA main clinic during the study period. In
respectively. For example, a patient might say his or her HHF this survey, 14 patients turned out not to be seen in the study
Main Complaint is lower back pain, whereas their MYMOP period, 18 patients were missing entire medical records, and five
Symptom 1 is weakness in the right leg. This distinction between patients were missing entire HHFs. Therefore, 421 patients were
Complaints and Symptoms is explained further in Discussion. included in the final Objective 1 sample (Table 1).
We chose to use HHF Main and Secondary Complaints to Subjects were mostly female (72.0%). Their mean age was
describe and categorize our sample for Objective 1 because 42.5 years and median age was 39.0 years. Subjects were
these complaints were what motivated the patients to seek predominantly white (82.4%), not Hispanic or Latino
treatment. We also used this HHF data to select the subsample (49.4%), and married (41.6%). Almost half (47.5%) of the
for Objective 2. At that point, however, we used MYMOP respondents had received at least college education and most
Symptoms 1 and 2 to consider changes due to treatment were employed (78.9%). A sizeable minority (46.1%) had
because these MYMOP items offer a quantitative severity rating. prior exposure to acupuncture or Oriental medicine. Almost
four-fifths (79.1%) had moderate or greater confidence in
acupuncture treatment. Regarding treatment styles, 57
SUBJECTS patients (13.5%) received Japanese acupuncture styles (JAS),
The population for Objective 1 was all patients meeting our 296 patients (70.3%) received Chinese acupuncture styles
four eligibility requirements: (i) who were new patients at the (CAS), and 68 patients (16.2%) received both JAS and CAS

286 EXPLORE September/October 2014, Vol. 10, No. 5 Lessons from an Acupuncture Teaching Clinic
Figure 1. Chart selection for Objective 1 and Objective 2.

(Table 2). The mean duration of treatment was 52.7 days, Treatment Outcomes (Objective 2)
with a range of zero (one treatment only) to 274 days. The Of the 421 patients, 287 indicated in HHF Main and/or
median duration of treatment was 28 days, but there was a Secondary Complaints that they sought pain management for
sharp drop off after three weeks (Table 3). diseases of the musculoskeletal system and/or connective tissue or
Using the ICD-9-CM coding system, the top six main migraine or headache. Only 59 patients completed both an initial
complaints for acupuncture visits were the following: Diseases and at least one follow-up MYMOP form. Records obtained
of the musculoskeletal system and connective tissue; mental from these patients were used to compare pre- and post-treatment
disorders; symptoms, signs, and ill-defined conditions; nerv- MYMOP scores. (However, recall from Important Note about
ous system and sense organs; digestive system; and genito- Outcome Measures: do not conflate HHF Main and Secondary
urinary system (Table 4). Complaints with MYMOP Symptoms 1 and 2.)

Lessons from an Acupuncture Teaching Clinic EXPLORE September/October 2014, Vol. 10, No. 5 287
Table 1. Baselines and Follow-Up Characteristics of Study Patients Table 1 (continued)
Undergoing Acupuncture Treatment
Characteristic N ¼ 421 % N ¼ 59 %
Characteristic N ¼ 421 % N ¼ 59 %
Missing 17 4.0% 3 5.1%
Gender
Female 303 72.0% 46 78% Prior exposure to
Male 118 28.0% 13 22% acupuncture or
Oriental medicine
Age (mean, 42.46 y/o 39 y/o 47.84 y/o 51 y/o Yes 194 46.1% 27 45.8%
median) No 220 52.3% 31 52.5%
0–20 17 4.0% 2 3.4%
21–30 112 26.6% 10 16.9% Patients' confidence
31–40 88 20.9% 11 18.6% level for TCM
41–50 65 15.4% 6 10.2% treatment
51–60 73 17.3% 15 25.4% Not confident 9 2.1% 1 1.7%
61–70 45 10.7% 11 18.6% Slightly 45 10.7% 7 11.9%
71–100 19 4.5% 4 6.8% confident
Moderately 131 31.1% 18 30.5%
Race confident
American Indian 1 0.2% 0 0% Confident 141 33.5% 22 37.3%
or Alaska native Very confident 61 14.5% 10 16.9%
Asian 26 6.2% 2 3.4%
Black or African 11 2.6% 3 5.1% Use herbs for main
American complaint
Native Hawaiian 1 0.2% 1 1.7% Yes 108 25.7% 17 28.8%
or other Pacific No 310 73.6% 42 71.2%
Islander For other 3 0.7% 0 0%
White 347 82.4% 52 88.1% complaint
Note: Totals may not add up to 421 or 59 because of missing data.
Ethnicity
Hispanic or 24 5.7% 1 1.7%
Latino Table 5 shows treatment outcomes; totals are less than 59
Not Hispanic or 208 49.4% 31 52.5% because when we reviewed these 59 MYMOP forms, we
Latino found missing data in some survey questions. In order to gain
better information, Table 5 breaks down MYMOP Symptoms
Marital status 1 and 2 to two ICD-9 categories and a catchall for everything
Married 175 41.6% 26 44.1% else: diseases of the musculoskeletal system and/or connective
Never married 157 37.3% 16 27.1% tissue; migraine or headache; and all other ailments, such as
Widowed 15 3.6% 1 1.7% stress, vertigo, cough, fatigue, chest tight, and constipation.
Divorced or 61 14.5% 13 22% Table 1 includes the characteristics of these 59 patients.
separated There were no statistical differences (p o .05) on any baseline
measure between patients qualifying for Objective 2 and the
Education 228 patients dismissed from Objective 2.
Grammar 10 2.4% 0 0% MYMOP Symptom 1 severity, MYMOP Symptom
school 2 severity, activity of daily living that MYMOP Symptoms
High school 54 12.8% 12 20.3% 1 or 2 prevent or interfere with, and well-being scales all
showed at least a 13.2% improvement from baseline to six
College 200 47.5% 22 37.3%
weeks (Table 5). Four symptoms showed the minimal
Masters 116 27.6% 20 33.9%
important clinical difference13 of 1.4: week six change score
Doctorate 24 5.7% 2 3.4% in Symptom 1—headache or migraine; week 12 change score
in Symptom 1—musculoskeletal pain; and week 12 change
Employment status
scores in Symptom 1—others and Symptom 2—others. The
Employed 332 78.9% 45 76.3% mean score changes in MYMOP Symptoms 1 and 2 from
Unemployed 29 6.9% 5 8.5% baseline to six weeks vary very little across the ICD-9
Retired 41 9.7% 8 13.6% categories. About half of the patients (30, N ¼ 59) were
Disabled 9 2.1% 1 1.7% taking medication for MYMOP Symptom 1 at their initial

288 EXPLORE September/October 2014, Vol. 10, No. 5 Lessons from an Acupuncture Teaching Clinic
Table 2. Style of Treatment by Number of Visit than number of treatments as a control for natural history.
More recently, NESA added a three-week data collection
Number of Visit in 10 Months Patient Numbers (%) (N ¼ 421) point due to the observation that the median treatment
JAS CAS duration is under a month. This new schedule balances
0 296 (70.3) 57 (13.5) improved quality and quantity of data with time spent to
1–6 95 (22.6) 261 (62.0) obtain such data: Collecting a follow-up every third or every
other visit incurs too much bookkeeping overhead and overly
7–12 22 (5.2) 73 (17.3)
frequent follow-ups risk patients remembering or learning the
13–18 6 (1.4) 19 (4.5)
questions.
19–24 2 (0.5) 6 (1.4) The majority of acupuncture patients wanted pain manage-
25–30 0 3 (0.7) ment at this TCM teaching clinic. Baseline MYMOP scores
430 0 2 (0.5) showed no statistical differences between those who com-
JAS: Japanese acupuncture style; CAS: Chinese acupuncture style. pleted a sixth-week follow-up and those who did not (sixth-
week data could be missing because the subject had no
visit. After six weeks, 10 patients reported taking medication treatment that week, stopped coming in, or skipped filling
for MYMOP Symptom 1, but data were missing for seven out the follow-up MYMOP form). However, the Objective
patients. Many symptoms improved with statistical signifi- 2 analysis supports that after six weeks of acupuncture
cance as determined by unpaired Student's t-tests of pre- treatments, most patients reported improvement in MYMOP
versus post-treatment sample means (Table 5). Symptoms 1 and 2 (when each involved the musculoskeletal
system and/or connective tissue), symptom-related activity
limitations, and general well-being. There were too few
patients for us to evaluate changes in MYMOP symptoms
DISCUSSION
about other issues (neither the musculoskeletal system nor
This project offers a clear profile of acupuncture patients at a
connective tissue). However, a low follow-up rate limited
TCM teaching clinic. The relative majority for each socio-
what could be deduced about pain management effectiveness
demographic trait investigated was as follows: female, 40 years
from this study. Of the patients seeking pain management,
old or younger, white, not Hispanic or Latino, married,
their follow-up MYMOP forms show that at least one in 10
highly educated, and employed. Most patients had confi-
(34/287 is 11.8%) patients returned during week 6 of the
dence in acupuncture treatment. Diseases of the musculoske-
semester for acupuncture treatment and reported clinical
letal system and/or connective tissue were the most common
improvement in MYMOP severity scores.
category treated by acupuncture at the TCM teaching clinic.
The patients' sociodemographic characteristics and condi-
Acupuncture therapy had a mean of six visits and a mean
tions seen in our clinic are similar to other descriptive studies
treatment duration of 53 days. The median duration of
of acupuncture use at teaching clinics,22,23 at regional private
treatment was 28 days. Most patients had one acupuncture
practices,24,25 and nationally1,12,17,26: mostly female, mostly
treatment every nine days.
white, mostly with college undergraduate degree or higher,
When NESA introduced the MYMOP forms, we did not
and mostly seeking treatment for diseases of the musculoske-
know the optimal schedule for administering follow-up
letal system and connective tissue. The primary race in our
forms, so we designed collection timing on semesters (which
clinic reflected the race distribution in Massachusetts, which
are used for intern rotations) and collected follow-up
was comprised of 83.7% whites in 2012.27 Our patients' mean
MYMOP forms at the sixth and the 12th week of every
age was 42.5 ! 16.0 years, which is similar to other
semester. We collected MYMOP forms by timeline rather
findings.22,23 Our data shows that 52.3 % of patients had
not previously experienced TCM, which again is similar to
Table 3. Treatment Duration results from other teaching clinics.22,23 Like us, Marx et al.
Duration (days) Patient Numbers (%) measured confidence in TCM treatment on a five-point scale,
(N ¼ 421) but with different categories, complicating comparison.
Almost half (48.0%) of our patients were “confident” or “very
r21 204 (48.5) confident” and 31.1% were “moderately confident” in TCM
22–42 54 (12.8) treatment, whereas Marx et al.23 found that 70.5% of patients
43–63 27 (6.4) were at least “a bit confident” or “confident.”
64–84 42 (10.0) Besides geographic differences in popularity and/or accept-
85–105 18 (4.3) ance of CAM therapies,28 referrals by students are one of the
106–126 12 (2.9) factors promoting teaching clinics.22 Unfortunately, we do
127–147 16 (3.8) not know how patients in our sample found our teaching
148–168 19 (4.5) clinic. The comparatively low cost of our acupuncture
services is probably one factor. Although NESA is not a
169–210 14 (3.3)
community acupuncture clinic, our treatment fee is equal to
211–252 9 (2.1)
or lower than national acupuncture users' average payment
253–294 6 (1.4) each time. The treatment fee is under $40 at NESA teaching

Lessons from an Acupuncture Teaching Clinic EXPLORE September/October 2014, Vol. 10, No. 5 289
Table 4. Top Six Main Complaint for Acupuncture Visits on Health History Form
Number of
ICD-9 Major Disease Categories (21) Self-Reported Signs and Symptoms Examples Subjectsa (%)
Diseases of the musculoskeletal system “Arm tingling,” “sciatic (sic),” “bursitis,” “arthritis,” “fibromyalgia,” and “SLE” 244 (58.0)
and connective tissue (710–739) (systemic lupus erythematosus)
Mental disorders (290–319) “Stress,” “anxiety,” “stress-related insomnia [sic],” “reduce craving cocaine 97 (23.0)
(sic),” “hyperactivity,” “attention,” “smoking,” and “metaphysical tension”
Symptoms, signs, and ill-defined “Over eating (sic),” “high cholesterol,” “insomnia,” “weight loses (sic),” 70 (16.6)
conditions (780–799) “fatigue,” “lack of energy,” “nausea,” “muscular eye coordination (sic),”
“ringing in ears,” and “fecal incontinence”
Diseases of the nervous system “Migraines,” “headache,” “Bells palsy (sic),” “bruxism,” “clenching and 57 (13.5)
and sense organs (320–389) grinding,” “vertigo,” “Meniere's disease,” “eyes,” “carpal tunnel (sic),” and
“Parkinson's disease”
Diseases of the digestive system (520– “Gastro-sour (sic),” “locked jaw,” “TMJ (temporomandibular joint disorder),” 41 (9.7)
579) “low abdominal function,” “GB (gallbladder),” “wall edema (probably
abdominal wall edema),” “may be passed a stone (sic),” “colitis,”
“constipation,” “IBS ( irritable bowel syndrome),” and “gluten intolerance”
Diseases of the genitourinary system “Fertility (sic),” “menopause,” “prolonged heavy menstrual bleeding,” “PMS 41 (9.7)
(580–629) (premenstrual syndrome),” “induction of labor,” “UTI ( urinary tract infection),”
“menstrual problem (clotting, cramp, and irregular bleeding) (sic),”
“endometriosis,” “Candida,” “BPH (benign prostatic hyperplasia),” and
“impotence”
a
Total number of subjects exceeds N ¼ 421 due to multiple self-reported signs and symptoms per person.

clinics, which is low for the Boston area but not uncommon is intriguing, but hard to interpret without additional data and
nationally; from the NHIS 2007 report, 45% of acupuncture further study. Was acupuncture effective against not only pain
users paid an average of $40 or less for treatments.24 Finding but also associated symptoms or were the associated symptoms
patients' motivation for choosing this teaching clinic for their relieved without much impact on pain?
first TCM treatment is an objective in future studies. Ours is a unique study that not only reports HHF Main
Chao et al.24 found that community acupuncture patients Complaints by category (ICD-9) but also breaks down
are more likely to receive frequent acupuncture treatments MYMOP outcomes by the same categories. (Many studies
(defined as 10 or more treatments in the prior 12 months) use SF-3630 rather than MYMOP forms, which makes
compared to national acupuncture users, regardless of age, comparisons with their results less than straightforward.)
sex, income, education, and health status (48% versus 15%). Some studies used the MYMOP form to measure outcomes,
Frequent use at our clinic appears to be less than for but neither reported Main Complaints for acupuncture
community clinic clients but more than national users: in treatment nor categorized MYMOP Symptoms 1 or 2.31,32
the 10 months of the study period, only 26.8% of patients Many studies equated MYMOP Symptoms 1 and/or 2 to Main
had eight or more treatments, but 21.9% patients already had Complaints and categorized them (they used their own system,
10 or more. not ICD-9) but then did not use those categories to break
The MYMOP form was easy to administer, acceptable to down scores for MYMOP Symptoms 1 and 2 when reporting
patients and clinic staff, and provided useful and detailed treatment outcomes.23,33,34 Hull et al.35 used insurance billing
quantitative and qualitative patient-centered outcome data. codes to categorize patients' Main Complaint for acupuncture
This matches the experience of other studies.29 treatment, but they did not break down scores for MYMOP
One discovery we consider very interesting is that the Symptoms 1 and 2. Since our study breaks down both HHF
MYMOP form allowed patients to provide more detailed/ Main Complaints and MYMOP Symptoms by ICD-9 codes,
targeted explanations when their HHF Main or Secondary patterns in each category become analyzable or at least
Complaints showed they sought pain management for diseases suggestive despite the small sample size.
of the musculoskeletal system and/or connective tissue or Another important distinction of our study is our choice for
migraine or headache. Such patient-centered outcomes allow Objective 1 to categorize not MYMOP Symptoms 1 or 2 but
patients to describe in their own words the problems they the HHF Main Complaint, the “main problem you would like
considered the most bothersome, and patients provided a wide us to help you with.” We also used the HHF Main Complaint
variety of MYMOP Symptoms 1 and 2 besides pain, such as to select our subjects for Objective 2. We believed that the HHF
poor appetite, anxiety, insomnia, or lower energy. The improve- Main Complaint captures the reasons patients sought acupunc-
ment of scores for the catchall category for MYMOP Symptoms ture treatment more accurately than MYMOP Symptoms. So,

290 EXPLORE September/October 2014, Vol. 10, No. 5 Lessons from an Acupuncture Teaching Clinic
Table 5. Clinical Outcomes From 59 Complete MYMOP Forms
MYMOP Scores at Initial and at Follow-Up

Scale: 0 ¼ “As Good As It Could Be”; 6 ¼ “As Bad As It Could Be”

Initial Week Six Week 12 Paired Mean Change Paired Mean Change Scorea
Follow-Up Follow-Up Scorea (Week Six/Initial) (Week 12/Initial)

Score Mean Score Mean Score Mean Meanb Meanb


N (SD) N (SD) N (SD) N (SD) % Change c
N (SD) % Change c

d e
Symptom 1 57 4.2 (1.1) 55 3.0 (1.5) 12 2.2 (1.3) 55 "1.2 28.6 12 "2.0 47.6
(1.6) (1.5)
Musculoskeletal 40 4.3 (1.1) 39 3.1 (1.4)d 6 2.3 (1.5) 39 "1.1 26.2 6 "1.5 39.5
pain (1.6) (1.9)
Headache or 5 4.8 (1.6) 5 3.0 (2.2) 1 3.0 5 "1.8 37.5 1 "3.0 50.0
migraine (1.6)
Others 12 3.9 (0.8) 11 2.7 (1.6)f 5 1.8 (1.1)f 11 "1.3 32.5 5 "2.4 57.1
(1.8) (1.1)

Symptom 2 50 3.7 (1.3) 44 2.9 (1.2)d 10 1.8 (1.3)f 44 "0.7 19.4 10 "1.3 40.6
(1.2) (1.6)
Musculoskeletal 28 3.6 (1.3) 26 2.8 (1.2)f 6 1.8 (1.2) 26 "0.7 20.0 6 "1.0 35.7
pain (1.3) (1.9)
Headache or 1 3.0 1 1.0 0 1 "2.0 66.7 0
migraine
Others 21 3.8 (1.2) 17 3.2 (1.1) 4 1.8 (1.7) 17 "0.6 15.8 4 "1.7 48.6
(1.1) (1.3)

Activity of daily living 48 4.2 (1.2) 43 2.7 (1.5)d 8 2.3 (0.7)f 43 "1.5 35.7 8 "1.5 39.5
(1.6) (1.4)
Well-being 55 3.2 (1.4) 47 2.4 (1.1)d 9 2.7 (1.3)f 47 "0.8 25.0 9 "1.1 28.9
(1.4) (0.9)
Taking medication 30 13 5
Treatment numbers 51 4.6 (2.2) 12 9.2 (3.4)
a
Note: Six- and 12-week paired mean change scores represent change from initial (baseline).
b
Note: Negative change scores indicate improvement.
c
Note: Percentage change calculated from paired mean change score divided by paired mean initial scores.
d
p o .0001.
e
p o .001.
f
p o .05.

despite the smaller sample size, the quality should be better than The small sample size in Objective 2 is especially disappoint-
expected from just using MYMOP forms. ing, since we would like to get outcomes broken down into
Although our observational study design does not have the ICD-9 categories, or even finer distinctions such as major
internal validity of randomized clinical trials, it provides real- disease categories in each ICD-9 category, e.g., low back pain
world evidence about the use of acupuncture and preliminary and neck pain. Nevertheless, our results are still interesting
evidence of its effectiveness for pain management. This study and, we believe, meaningful. Firstly, ours is a singular study
supplies actionable information to healthcare providers, patients, that breaks down both HHF Main Complaints and also
and investigators about characteristics of acupuncture patients at MYMOP outcomes into categories. Secondly, we (sub)cate-
a TCM teaching clinic; further, it illustrates patients' acupunc- gorize HHF Main Complaints rather than MYMOP Symp-
ture treatment experiences for pain management effectiveness. toms. Thirdly, and finally, our sample is likely representative
of users of teaching acupuncture clinics. The first two points
Limitations were already elaborated upon earlier in Discussion. We go
Limitations of this project include the unavoidable aspects of into more detail for the third point below.
pilot studies in real-world situations: small sample size, Our sample, because we used a census, is likely very
quality issues for clinic data, and uncontrolled study design. representative of users of acupuncture teaching clinics.

Lessons from an Acupuncture Teaching Clinic EXPLORE September/October 2014, Vol. 10, No. 5 291
Further, our treatment fee schedule is much more reasonable addition to the sixth and 12th weeks to better capture
(about 50.0% lower) than other acupuncture clinics in the follow-up data.
Greater Boston community, which increases potential patient 3. Future research could explore how confidence in CAM
diversity. Last, while the sample is self-selected, and thus the affects outcomes, and whether it means more aggressive
percentage of patients who believe in acupuncture may be treatment would be welcome and more effective.
higher than the general population, the belief structure of our 4. Future studies should address the low follow-up rate, the
sample is probably very similar to populations of users of quality of self-reported clinic data, and the reasons that
other acupuncture teaching clinic services. So again, we patients chose acupuncture treatment and teaching clinics.
should expect reasonably good results from analyzing our 5. Future work will include a larger, longer-term, and stand-
sample, despite its small size. ardized data collection to look at sociodemographic
Why was our sample so small? A major factor is that we characteristics and patient-centered outcomes of acupunc-
had a relatively small fraction of patients who completed ture in TCM teaching clinical settings.
follow-up MYMOP forms. Only 59 patients (20.6%) com-
pleted the sixth-week follow-up MYMOP form out of 287
patients who used acupuncture for pain management for
Acknowledgments
diseases of the musculoskeletal system and/or connective
tissue or migraine or headache. Unfortunately, we do not
have data for those who discontinued treatment prior to six We would like to thank Tufts and NESA faculty and
weeks. Was it because they got better or because they did not? students, NESA patients, Thomas Yan, Lucy Chen, and
We need further research to understand this. However, this Kenneth Kwan Ho Chui.
low follow-up rate is similar to other observational study
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