A qualitative exploration of how patients conceptualise their acupuncturists: Technicians, caring professionals, and wise healers.

OBJECTIVES: To explore how patients conceptualise acupuncturists, the meanings ascribed to the therapeutic relationship and valued therapeutic behaviours. DESIGN: Qualitative study. Semi-structured face-to-face interviews explored patients' experiences of acupuncture. A diverse sample of 35 participants took part; they had used acupuncture for a variety of predominantly chronic conditions. Inductive thematic analysis was used to identify themes. SETTING: Southern England. RESULTS: Participants conceptualised acupuncturists in three ways: technician, caring professional, and wise and gifted healer. Each conceptualisation had different implications for patient health. For example, lifestyle advice from a wise healer was seen as inspirational wisdom, while lifestyle advice from a caring professional was seen as evidence of caring. Participants inferred empathy when acupuncturists took a detailed history, took notes during treatment, and provided therapeutic commentaries. Participants inferred knowledge and/or wisdom when acupuncturists made changes to treatments over time, provided explanatory frameworks for their symptoms, and made effective recommendations concerning lifestyle and health behaviours. CONCLUSIONS: The findings provide novel insights into how patients view acupuncturists, suggesting acupuncture-specific models that do not directly map onto conventional models of doctor-patient relationships. Understanding how patients think about their acupuncturist and make sense of clinical interactions could help acupuncturists to hone their therapeutic skills.

"Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England.

STUDY DESIGN: A qualitative study in south-west England primary care. OBJECTIVE: To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care. SUMMARY OF BACKGROUND DATA: Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians' perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice. METHODS: We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis. RESULTS: Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology-"non-specific LBP"-unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments. CONCLUSION: The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients. LEVEL OF EVIDENCE: N/A.

Patients' treatment beliefs in low back pain: development and validation of a questionnaire in primary care.

Choosing the most appropriate treatment for individual patients with low back pain (LBP) can be challenging, and clinical guidelines recommend taking into account patients' preferences. However, no tools exist to assess or compare patients' views about LBP treatments. We report the development and validation of the Low Back Pain Treatment Beliefs Questionnaire (LBP-TBQ) for use across different treatments in clinical practice and research. Using qualitative data, we developed a pool of items assessing perceived credibility, effectiveness, concerns about, and individual "fit" of specific treatments. These items were included in a survey completed by 429 primary care patients with LBP, of whom 115 completed it again 1 to 2 weeks later. We performed psychometric analyses using nonparametric item response theory and classical test theory. The 4 subscales of the resulting 16-item LBP-TBQ showed good homogeneity (H = 0.46-0.76), internal consistency (α = 0.73-0.94), and stability (r = 0.63-0.83), confirmed most convergent and discriminant validity hypotheses, and had acceptable structural validity for 4 guideline-recommended treatments: pain medication, exercise, manual therapy, and acupuncture. Participants with stronger positive treatment beliefs were more likely to rank that treatment as their first choice, indicating good criterion validity (t values = 3.11-9.80, all P < 0.01, except pain medication effectiveness beliefs, t(339) = 1.35; P = 0.18). A short 4-item version also displayed good homogeneity (H = 0.43-0.66), internal consistency (α = 0.70-0.86), and stability (r = 0.82-0.85) and was significantly related to treatment choice (t values = 4.33-9.25, all P < 0.01). The LBP-TBQ can be used to assess treatment beliefs in primary care patients with LBP and to investigate the effects of treatment beliefs on treatment uptake and adherence.

Psychological covariates of longitudinal changes in back-related disability in patients undergoing acupuncture.

OBJECTIVES: To identify psychological covariates of longitudinal changes in back-related disability in patients undergoing acupuncture. MATERIALS AND METHODS: A longitudinal postal questionnaire study was conducted with data collection at baseline (pretreatment), 2 weeks, 3, and 6 months later. A total of 485 patients were recruited from 83 acupuncturists before commencing acupuncture for back pain. Questionnaires measured variables from 4 theories (fear-avoidance model, common-sense model, expectancy theory, social-cognitive theory), clinical and sociodemographic characteristics, and disability. Longitudinal multilevel models were constructed with disability over time as the outcome. RESULTS: Within individuals, reductions in disability (compared with the person's individual mean) were associated with reductions in: fear-avoidance beliefs about physical activity (ß=0.11, P<0.01) and work (ß=0.03, P<0.05), catastrophizing (ß=0.28, P<0.05), consequences (ß=0.28, P<0.01), concerns (ß=0.17, P<0.05), emotions (ß=0.16, P<0.05), and pain identity (ß=0.43, P<0.01). Within-person reductions in disability were associated with increases in: personal control (ß=-0.17, P<0.01), comprehension (ß=-0.11, P<0.05) and self-efficacy for coping (ß=-0.04, P<0.01). Between individuals, people who were less disabled had weaker fear-avoidance beliefs about physical activity (ß=0.12, P<0.01), had more self-efficacy for coping (ß=-0.07, P<0.01), perceived less severe consequences of back pain (ß=0.87, P<0.01), had more positive outcome expectancies (ß=-0.30, P<0.05), and appraised acupuncture appointments as less convenient (ß=0.92, P<0.05). DISCUSSION: Illness perceptions and, to a lesser extent, self-efficacy and expectancies can usefully supplement variables from the fear-avoidance model in theorizing pain-related disability. Positive changes in patients' beliefs about back pain might underpin the large nonspecific effects of acupuncture seen in trials and could be targeted clinically.

Patients' preconceptions of acupuncture: a qualitative study exploring the decisions patients make when seeking acupuncture.

BACKGROUND: Like any other form of healthcare, acupuncture takes place in a particular context which can enhance or diminish treatment outcomes (i.e. can produce contextual effects). Patients' expectations of acupuncture might be an important component of contextual effects, but we know relatively little about the origins and nature of patients' expectations or wider preconceptions about acupuncture. Our aim was to identify the processes the underpin patients' decisions to try acupuncture and thus begin to tease out the origins and nature of patients' preconceptions. METHODS: One-off semi-structured interviews were conducted with a purposive, varied sample of 35 adults who had tried acupuncture for various conditions. Interviews explored people's experiences of acupuncture treatment and techniques from framework and inductive thematic analysis were used to relate the data to the research question. RESULTS: We identified four distinct processes within participants' accounts of deciding to try acupuncture: establishing a need for treatment, establishing a need for a new treatment, deciding to try acupuncture, and finding an acupuncturist. Family, friends and health care professionals played a role in these processes, providing support, advice, and increasing people's general familiarity with acupuncture. When they came to their first acupuncture appointment, participants had hopes, concerns, and occasionally concrete expectations as to the nature of acupuncture treatment and its likely effects. CONCLUSIONS: Existing theories of how context influences health outcomes could be expanded to better reflect the psychological components identified here, such as hope, desire, optimism and open-mindedness. Future research on the context of acupuncture should consider these elements of the pre-treatment context in addition to more established components such as expectations. There appears to be a need for accessible (i.e. well-disseminated), credible, and individualised, patient-centred materials that can allay people's concerns about the nature of acupuncture treatment and shape realistic hopes and expectations.

How patients choose osteopaths: a mixed methods study.

OBJECTIVES: To explore how patients choose individual osteopaths to consult; to test whether patients' preferences for osteopaths depend on gender, the osteopath's qualifications, and the cost of treatment; to explore patients' perspectives. DESIGN: An explanatory mixed methods design incorporating a quasi-experimental study administered by postal survey and a qualitative interview study. SETTING: One sample of patients at a private-sector complementary therapy clinic in the UK completed a survey; a second sample of patients recruited from osteopathy clinics took part in qualitative interviews. MAIN OUTCOME MEASURES: In the survey, male and female respondents (n=176) rated the likelihood of consulting each of 8 fictional osteopaths, representing all possible combinations of 3 factors (practitioner gender, biomedically qualified or not, working in a public sector or private clinic). Semi-structured qualitative interviews (n=19) about patients' experiences of osteopathy were analysed deductively and inductively. RESULTS: Survey respondents preferred osteopaths who were also biomedical doctors, F(1,174)=67.21, p<0.001, η(2)=0.28. Qualitative data showed that, when choosing an osteopath, patients valued personal recommendations from a trusted source and such recommendations overrode other considerations. First impressions were important and were based on patients' perceptions of an osteopath's competence, interpersonal fit, and immediate treatment effect. CONCLUSIONS: Word of mouth appears to be the primary mechanism by which patients choose individual osteopaths; in the absence of personal recommendations, some patients prefer biomedically qualified practitioners. Trustworthy and appropriate information about practitioners (e.g. from professional regulatory bodies) could empower patients to make confident choices when seeking individual complementary practitioners to consult.

Patient preferences for technical skills versus interpersonal skills in chiropractors and physiotherapists treating low back pain.

BACKGROUND: Little is known about which characteristics of chiropractors and physiotherapists matter to patients and influence their preferences when seeking care. OBJECTIVE: To examine the impact of four factors (patient gender, practitioner gender, practitioner specialty-chiropractor or physiotherapist and practitioner reputation-technical ability or interpersonal skills) on patients' choice of therapist to treat low back pain. METHODS: Questionnaire-based vignette study in which participants sampled from the general population rated the likelihood of consulting eight fictional therapists. Each fictional therapist represented a different combination of the three practitioner factors (e.g. male chiropractor with reputation for good technical ability). The study was administered as a postal survey to a simple random sample of residences in one postal town in England. RESULTS: Respondents (n = 657) consistently reported that they considered a practitioner's qualifications and technical skills important when choosing either a physiotherapist or a chiropractor; and just less than a third thought it was important that a practitioner was a good listener. As hypothesized, female respondents preferred female practitioners and respondents had a general preference for physiotherapists over chiropractors. Contrary to our hypothesis, the practitioner's reputation had the largest effect on respondents' preferences and all practitioners with a reputation for technical ability were preferred over those with a reputation for interpersonal skills. CONCLUSION: Similar factors are important to patients whether they are choosing an individual chiropractor or physiotherapist; patients particularly value information about technical competence. An awareness of these factors should help primary care providers to direct patients to relevant information and support their decision-making.

Health-care sector and complementary medicine: practitioners' experiences of delivering acupuncture in the public and private sectors.

AIM: The aim was to identify similarities and differences between private practice and the National Health Service (NHS) in practitioners' experiences of delivering acupuncture to treat pain. We wished to identify differences that could affect patients' experiences and inform our understanding of how trials conducted in private clinics relate to NHS clinical practice. BACKGROUND: Acupuncture is commonly used in primary care for lower back pain and is recommended in the National Institute for Health and Clinical Excellence's guidelines. Previous studies have identified differences in patients' accounts of receiving acupuncture in the NHS and in the private sector. The major recent UK trial of acupuncture for back pain was conducted in the private sector. METHODS: Semi-structured qualitative interviews were conducted with 16 acupuncturists who had experience of working in the private sector (n = 7), in the NHS (n =3), and in both the sectors (n = 6). The interviews lasted between 24 and 77 min (median=49 min) and explored acupuncturists' experiences of treating patients in pain. Inductive thematic analysis was used to identify similarities and differences across private practice and the NHS. FINDINGS: The perceived effectiveness of acupuncture was described consistently and participants felt they did (or would) deliver acupuncture similarly in NHS and in private practice. In both the sectors, patients sought acupuncture as a last resort and acupuncturist-patient relationships were deemed important. Acupuncture availability differed across sectors: in the NHS it was constrained by Trust policies and in the private sector by patients' financial resources. There were greater opportunities for autonomous practice in the private sector and regulation was important for different reasons in each sector. In general, NHS practitioners had Western-focussed training and also used conventional medical techniques, whereas private practitioners were more likely to have Traditional Chinese training and to practise other complementary therapies in addition to acupuncture. Future studies should examine the impact of these differences on patients' clinical outcomes.

A feasibility study exploring the role of Chinese herbal medicine in the treatment of endometriosis.

BACKGROUND: Endometriosis is a common and disabling gynecologic condition affecting between 5% and 15% of women of childbearing age. Conventional medical intervention has unpleasant side-effects, and symptoms frequently return after treatment. Preliminary evidence suggests Chinese herbal medicine (CHM) may contribute to the treatment of endometriosis. OBJECTIVES: The aims of this study were to test the feasibility of a novel methodology for investigating individualized decoctions of CHM rigorously and to gather preliminary data on the treatment effect of CHM for a larger definitive trial. DESIGN: This was a 16-week prospective, double blinded, randomized controlled trial of 40 women with laparoscopically confirmed endometriosis. SETTINGS: The trial was conducted at a private CHM clinic in Hove (U.K.) and at a National Health Service outpatient clinic in London (U.K.). INTERVENTIONS: Participants were initially randomized to either wait-list control (WLC) or treatment groups to receive either individualized CHM decoctions or a therapeutically inert placebo decoction. OUTCOME MEASURES: Four 10-cm visual analogue scales (VAS) were used to measure menstrual pain, daily pain, and pain on intercourse and bowel movement; these measurements were recorded weekly. The Endometriosis Health Profile-30 (EHP-30) endometriosis-specific quality-of-life questionnaire was completed at the beginning and at the end of the trial. The Measure Yourself Medical Outcomes Profile (MYMOP) a patient-centered health questionnaire was completed monthly. Liver and renal function was measured at 0, 4, 8, and 16 weeks. RESULTS: Twenty-eight (28) women completed the trial. High dropout rates led to the suspension of the WLC. Randomization, double blinding, and allocation concealment was achieved successfully. Adjusted mean differences favored the active treatment in the EHP-30 and MYMOP scores. VAS scores favored the active treatment for relief of menstrual pain and the placebo group for reduction of daily pain. CONCLUSIONS: the methodology successfully allowed individualized CHM decoctions to be tested rigorously. There are nonspecific contextual effects from CHM that require further investigation. Provisional data were generated to warrant a larger, more-definitive study.

Acupuncture for low back pain: a survey of clinical practice in the UK.

OBJECTIVES: Acupuncture is recommended in official UK guidelines for persistent non-specific low back pain and is popular with patients. However, what UK-based acupuncturists actually do in every day clinical practice is poorly documented. We therefore conducted a survey of every-day clinical practice of acupuncture for low back pain in the UK. DESIGN: Cross-sectional postal survey. SETTING: Random samples of 100 acupuncturists from each of the three main UK societies for acupuncturists were sent questionnaires. MAIN OUTCOME MEASURES: A questionnaire designed (and pilot-tested) for this study asked about: training and professional identity, current work situation, and typical approach to treating a patient with low back pain. RESULTS: Completed questionnaires were received from 129 respondents (53% male), representing each society approximately equally. Work situation (e.g. weekly hours practicing acupuncture) differed across societies. Respondents reported needling 2-30 acupuncture points in an average treatment (median=8) and leaving needles in for 0-40 min (median=20 min). A large number of individual points (121) were named as 'typical'. CONCLUSIONS: There is huge variation in how acupuncture is used by UK practitioners to treat people with low back pain. This probably constitutes a difficult situation for patients when selecting an acupuncturist. It may also translate into large variation in clinical outcomes for patients receiving care from different acupuncturists as well as difficulty in developing acupuncture protocols for pragmatic and other trials. Such diversity reflects the ongoing debate within the acupuncture profession about good practice for common conditions.

Patients as healthcare consumers in the public and private sectors: a qualitative study of acupuncture in the UK.

BACKGROUND: The aim of this study was to compare patients' experiences of public and private sector healthcare, using acupuncture as an example. In the UK, acupuncture is popular with patients, is recommended in official guidelines for low back pain, and is available in both the private sector and the public sector (NHS). Consumerism was used as a theoretical framework to explore patients' experiences. METHODS: Semi-structured face-to-face interviews were conducted in 2007-8 with a purposive sample of 27 patients who had recently used acupuncture for painful conditions in the private sector and/or in the NHS. Inductive thematic analysis was used to develop themes that summarised the bulk of the data and provided insights into consumerism in NHS- and private practice-based acupuncture. RESULTS: Five main themes were identified: value for money and willingness to pay; free and fair access; individualised holistic care: feeling cared for; consequences of choice: empowerment and vulnerability; and "just added extras": physical environment. Patients who had received acupuncture in the private sector constructed detailed accounts of the benefits of private care. Patients who had not received acupuncture in the private sector expected minimal differences from NHS care, and those differences were seen as not integral to treatment. The private sector facilitated consumerist behaviour to a greater extent than did the NHS, but private consumers appeared to base their decisions on unreliable and incomplete information. CONCLUSIONS: Patients used and experienced acupuncture differently in the NHS compared to the private sector. Eight different faces of consumerist behaviour were identified, but six were dominant: consumer as chooser, consumer as pragmatist, consumer as patient, consumer as earnest explorer, consumer as victim, and consumer as citizen. The decision to use acupuncture in either the private sector or the NHS was rarely well-informed: NHS and private patients both had misconceptions about acupuncture in the other sector. Future research should evaluate whether the differences we identified in patients' experiences across private and public healthcare are common, whether they translate into significant differences in clinical outcomes, and whether similar faces of consumerism characterise patients' experiences of other interventions in the private and public sectors.

How the psychosocial context of clinical trials differs from usual care: a qualitative study of acupuncture patients.

BACKGROUND: Qualitative studies of participants' experiences in randomised clinical trials (RCTs) suggest that the psychosocial context of treatment in RCTs may be quite different to the psychosocial context of treatment in usual practice. This is important, as the psychosocial context of treatment is known to influence patient outcomes in chronic illness. Few studies have directly compared the psychosocial context of treatment across RCTs and usual practice. In this study, we explored differences in psychosocial context between RCT and usual practice settings, using acupuncture as our model. METHODS: We undertook a secondary analysis of existing qualitative interviews with 54 patients. 27 were drawn from a study of western and traditional acupuncture in usual practice (for a range of painful conditions). 27 were drawn from a qualitative study nested in an RCT of western acupuncture for osteoarthritis of the hip or knee. We used qualitative analysis software to facilitate an inductive thematic analysis in which we identified three main themes. RESULTS: In usual practice, starting acupuncture was more likely to be embedded in an active and ongoing search for pain relief, whereas in the RCT starting acupuncture was opportunistic. Usual practice patients reported few uncertainties and these had minimal consequences for them. In the RCT, patients experienced considerable uncertainties about their treatment and its effectiveness, and were particularly concerned about whether they were receiving real (or fake) acupuncture. Patients stopped acupuncture only at the end of the fixed course of treatment in the RCT, which was similar to those receiving acupuncture in the public sector National Health Service (NHS). In comparison, private sector patients re-evaluated and re-negotiated treatments particularly when starting to use acupuncture. CONCLUSIONS: Differences in psychosocial context between RCTs and usual practice could reduce the impact of acupuncture in RCT settings and/or lead to under-reporting of benefit by patients in trials. New trial designs that ensure participants' experiences are similar to usual practice should minimise differences in psychosocial context and help attenuate these potentially confounding effects.

How patients choose acupuncturists: a mixed-methods project.

OBJECTIVES: Patients can have difficulties choosing acupuncturists in the United Kingdom because acupuncturists are not all subject to statutory regulation. Research has identified factors that influence patients' choice of general practitioner. However, how patients choose acupuncturists has not been studied. The aim was to investigate how patients choose acupuncturists and to identify which factors might influence this choice. DESIGN: A mixed-methods design used an exploratory qualitative study followed by a quantitative study. The qualitative study explored patients' experiences of acupuncture. The quantitative vignette study investigated the impact of patient gender and practitioner factors (gender, training location, and qualifications) on choice of acupuncturist. METHODS: In the qualitative study, 35 acupuncture patients (recruited through maximum variation sampling from seven clinics and the community) participated in semistructured interviews about their acupuncture experiences. In the quantitative study, 73 participants imagined wanting to consult an acupuncturist for back pain. They rated 8 fictional acupuncturists; ratings were analyzed using analysis of covariance. RESULTS: Patients wanted qualified, personable acupuncturists and valued recommendations from trusted others. Without such recommendations, potential patients preferred female acupuncturists (F(1,69)=4.504, p<0.05) and those with medical qualifications (F(1,69)=44.832, p<0.01). CONCLUSIONS: The decision to consult a particular acupuncturist is not straightforward. Acupuncturists' trustworthiness and technical competence are important to (potential) patients; practitioner gender also influenced preferences. Patients need to be informed about proposals concerning statutory regulation in CAM and its implications; conventional practitioners might be able to better support their patients wanting to consult acupuncturists.

A grounded theory study of homeopathic practitioners' perceptions and experiences of the homeopathic consultation.

Research into the homeopathic consultation has largely focused on patients' experiences, although the practitioner is a crucial component of the therapeutic context and may have an important part in optimizing health outcomes. Therefore the aim of this qualitative research was to gain an in-depth understanding of homeopathic practitioners' perceptions and experiences of the consultation. Medical and non-medical homeopaths were sampled from the registers of the Faculty and Society of Homeopaths. Two phases of data collection were employed. Phase 1 used in depth face-to-face interviews enabling the development of an initial model of the homeopathic consultation. Phase 2 involved observations of homeopathic consultations and practitioner reflective diaries in order to confirm, refute, or enlarge the model. Using the constant comparative method of grounded theory five main categories emerged, exploring the journey, finding the level, responding therapeutically, understanding self, and connecting, forming a model entitled "a theoretical model of a UK classical homeopathic consultation" which describes how homeopaths view and enact the consultation process. This study suggests that the process of identifying and prescribing the remedy is embedded in the consultation, highlighting the interconnectedness of the whole homeopathic consultation and aspects of the consultation that are unique and specific to homeopathy.

The development and validation of an outcome measure for spiritual healing: a mixed methods study.

BACKGROUND: Spiritual healing, probably the oldest documented paramedical intervention, is a neglected area of research. In order to conduct further research into the effects of healing, a valid and reliable outcome measure is needed that captures the experience of individuals receiving healing (healees) and is not burdensome to complete. We aimed to develop such a measure. METHODS: A mixed methods design was used. Focus groups and cognitive interviews were used to generate and refine questionnaire items grounded in the experiences and language of healees (Study 1). The resulting questionnaire was tested and its formal psychometric properties were evaluated (Study 2). Participants were recruited from a spiritual healing sanctuary and via individual healers (including registered spiritual healers, Reiki practitioners, healers affiliated with churches). RESULTS: In Study 1, 24 participants took part in 7 focus groups and 6 cognitive interviews. 29 common effects were identified and grouped into 7 discrete dimensions that appeared to characterize potentially sustainable effects reported by participants following their experiences of spiritual healing. In Study 2, 393 participants returned completed baseline questionnaires, 243 of whom completed the questionnaire again 1-6 weeks later. Exploratory factor analysis generated 5 subscales, based on 20 of the items: outlook, energy, health, relationships and emotional balance. These subscales demonstrated acceptable internal consistency, convergent validity and test-retest reliability. Three of the subscales and the whole questionnaire demonstrated good sensitivity to change. CONCLUSIONS: We have produced a psychometrically sound healing impact questionnaire that is acceptable to healees, healers and researchers for use in future evaluations of spiritual healing.

Traditional Chinese Medicine for treatment of fibromyalgia: a systematic review of randomized controlled trials.

BACKGROUND: Traditional Chinese Medicine (TCM) is popular for treatment of fibromyalgia (FM) although there is a lack of comprehensive evaluation of current clinical evidence for TCM's therapeutic effect and safety. OBJECTIVE: To review systematically the beneficial and harmful effects of TCM therapies for FM. METHODS: We searched six English and Chinese electronic databases for randomized clinical trials (RCTs) on TCM for treatment of FM. Two authors extracted data and assessed the trial quality independently. RevMan 5 software was used for data analyses with an effect estimate presented as mean difference (MD) with a 95% confidence interval (CI). RESULTS: Twenty-five RCTs were identified with 1516 participants for this review. Seven trials (28%) were evaluated as having a low risk of bias and the remaining trials were identified as being as unclear or having a high risk of bias. Overall, ten trials were eligible for the meta-analysis, and data from remaining 15 trials were synthesized qualitatively. Acupuncture reduced the number of tender points (MD, -3.21; 95% CI -4.23 to -2.11; p < 0.00001, I(2) = 0%), and pain scores compared with conventional medications (MD, -1.78; 95% CI, -2.24 to -1.32; p < 0.00001; I(2) = 0%). Acupuncture showed no significant effect, with a random-effect model, compared with sham acupuncture (MD, -0.55; 95% CI, -1.35-0.24; p = 0.17; I(2) = 69%), on pain reduction. A combination of acupuncture and cupping therapy was better than conventional medications for reducing pain (MD, -1.66; 95% CI, -2.14 to -1.19; p < 0.00001; I(2) = 0%), and for improving depression scores with related to FM (MD, -4.92; 95% CI, -6.49 to -3.34; p < 0.00001; I(2) = 32%). Other individual trials demonstrated positive effects of Chinese herbal medicine on pain reduction compared with conventional medications. There were no serious adverse effects reported that were related to TCM therapies in these trials. CONCLUSIONS: TCM therapies appear to be effective for treating FM. However, further large, rigorously designed trials are warranted because of insufficient methodological rigor in the included trials.

Prevalence of complementary medicine use in pediatric cancer: a systematic review.

CONTEXT: Complementary and alternative medicine (CAM) is used by pediatric patients with cancer, but the actual frequency of CAM use is undetermined. OBJECTIVE: In this systematic review we summarize the current evidence on the prevalence of CAM use in pediatric patients with cancer and assess the reported quality of included studies. METHODS: We systematically searched 6 major electronic databases, reference lists of existing reviews, and personal files. We included full articles about primary research studies (without language restriction) that reported the prevalence of CAM use if all or a defined subsample of participants were pediatric patients with cancer. Detailed information regarding methods and results was extracted from the original articles. A quality-assessment tool was rigorously developed on the basis of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement and used to assess reported study quality. Formal tests of interrater agreement were conducted. RESULTS: We included 28 studies with survey data (collected from 1975 to 2005) from 3526 children. In 20 studies with 2871 participants, the prevalence of any CAM use (since cancer diagnosis) ranged from 6% to 91%; considerable heterogeneity across studies precluded meta-analysis. Study quality was mixed and not correlated with CAM prevalence. Herbal remedies were the most popular CAM modality, followed by diets/nutrition and faith-healing. Commonly reported reasons for CAM use included to help cure or fight the child's cancer, symptomatic relief, and support of ongoing use of conventional therapy. There was little evidence of an association between CAM use and patients' sociodemographic characteristics. CONCLUSIONS: Many pediatric patients with cancer use CAM. It is important that pediatricians be aware of this fact and encourage open communication with patients and their parents. Using standardized survey methods and CAM definitions in future studies could improve their quality and help generate comparable data. Our quality-assessment tool could prove valuable for other reviews of prevalence studies.

Why consumers maintain complementary and alternative medicine use: a qualitative study.

OBJECTIVES: Although research evidence exists to suggest why consumers use complementary and alternative medicine (CAM), there remains a need to distinguish between factors and processes involved in the initial uptake of therapies and those involved in their subsequent maintenance. We therefore conducted a qualitative study to explore and describe consumers' reasons for maintaining or stopping CAM use. METHODS: This was a qualitative study. We interviewed 46 CAM consumers and 9 CAM practitioners, in two high-street CAM clinics in the UK. The interviews were analyzed thematically using techniques from grounded theory. RESULTS: Consumers described and evaluated their CAM experiences along four dimensions: interpersonal (e.g., interactions with practitioners), physical (e.g., sensations such as touch or pain during treatment), affective (e.g., empowerment), and cognitive (e.g., beliefs about treatment). They evaluated their experiences in relation to their individual needs and expectations; financial considerations could limit maintenance of CAM use. Practitioners emphasized the effectiveness of treatment and themselves as contributing to consumers maintaining treatment, and recognized the role of financial considerations in decisions to stop CAM use. CONCLUSIONS: This study suggests that experiences of conventional medicine are of limited importance after the decision to initiate CAM. Experiences of CAM were foremost in our consumers' decisions to maintain or stop specific CAM therapies. Maintenance of CAM could occur even if consumers' experiences were not entirely positive. Our findings provide novel, systematic insights that will be of particular interest to practitioners who want to support consumers as they decide whether to maintain CAM use.