Stimulated by McKee et al 2020.
We called it HVAC (“H-vac”), the high-volume acupuncture clinic that was set up at RLHH after its refurbishment in the early noughties. RLHH stood for the Royal London Homeopathic Hospital, but now it is called the Royal London Hospital for Integrated Medicine (RLHIM). The term H-vac can still be heard used around its corridors, since it rolls off the tongue easily, but the official term adopted was Group Acupuncture Clinics, which cannot be shortened to a nice crisp acronym.
High volume was the point though, and the group element simply facilitated the volume, treating as many patients as we could in one clinical session and giving them all the best treatment (ie 30 minutes of electroacupuncture). Although later there was discussion of utilising group interaction, this was never achieved in the setting. We started with OA knee because the data was promising (specifically Jorge Vas’s paper in the BMJ in 2004), it required limited exposure, and there would be little argument over the best protocol. Indeed, the only possible argument was over the exclusion of Xiyan – the eyes of the knee.
An early audit of chronic knee pain demonstrated modest benefits, but more importantly paved the way for rapid expansion despite the CG59 hiccup, recommending against the use of EA in osteoarthrosis.[4–6] The H-vac clinics were a roaring success, particularly with patients, and soon incorporated other body regions, including facial pain, the back and eventually headache.
One of my colleagues was drafted in to help at the increasingly busy H-vac. He was a heavily accented German doctor with very good sense of humour and a disarmingly unassuming yet highly perceptive take on the world. He referred to himself as Yo-acupuncturist, after the sushi establishment were the food circulates on a conveyer belt. He felt frustrated that there was no time for anything more than placing and removing needles, and he knew that needles alone were not the solution to the existential suffering of his patients. Indeed they weren’t, but they did more than might have been expected in the circumstances, and for some, perhaps, they were “anchor points for hope”.
Now it is some 15 years later, and we have a study from the US (n=779) comparing individual and group acupuncture provided in 6 primary care centres in the Bronx, New York. The group sessions involved up to 6 patients sitting on chairs in a large room, with patients scheduled every 15 (follow-ups) or 20 (new) minutes. The patients having individual treatment were scheduled every half an hour and the practitioner ran two rooms simultaneously. This individual approach is just like the London Teaching Clinic, and the group sessions we used to run scheduled patients every 10 minutes in a room with 5 plinths. Two nurses would regularly see up to 26 patients in a half day session, many of whom might receive 20 or 30 minutes of EA.
The individual treatment was marginally better in most outcomes, although the difference was not statistically significant. Non-inferiority was not established for group over individual treatment, since the upper CI (confidence interval) of the difference just exceeded the minimum clinically relevant improvement of 10%.
37.5% (individual) or 30.3% (group) participants achieved a 30% or greater reduction in pain interference (the primary outcome) at 12 weeks. This was the ITT analysis, with the figures being slightly higher, as would be expected, in the PP (per protocol) analysis. The percentages were still good at 24 weeks (35.0% and 28.7%).
The response rates were much lower than those in a pilot study (n=113) of group acupuncture in a similar setting (68%), and lower than we achieved in our first chronic knee pain H-vac (53%, most similar outcome; n=87). We also saw patients at a much higher rate in H-vac (3-4 per hour per practitioner) compared with this study in the Bronx (1.9 per hour).
So what does the future hold for this approach? I would be happy to see a conveyor belt system, but I think I would still retain the human element despite the brevity, rather than transition to what my German colleague imagined himself becoming – his Yo acupuncturist was a robot!
1 McKee MD, Nielsen A, Anderson B, et al. Individual vs. Group Delivery of Acupuncture Therapy for Chronic Musculoskeletal Pain in Urban Primary Care—a Randomized Trial. J Gen Intern Med 2020;:1–11. doi:10.1007/s11606-019-05583-6
2 Vas J, Méndez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ 2004;329:1216. doi:10.1136/bmj.38238.601447.3A
3 Berkovitz S, Cummings M, Perrin C, et al. High Volume Acupuncture Clinic (Hvac) for Chronic Knee Pain – Audit of a Possible Model for Delivery of Acupuncture in the National Health Service. Acupunct Med 2008;26:46–50. doi:10.1136/aim.26.1.46
4 NICE guideline on osteoarthritis: the care and management of osteoarthritis in adults. http://guidance.nice.org.uk/CG59. 2008.
5 Cummings M. Why recommend acupuncture for low back pain but not for osteoarthritis? A commentary on recent NICE guidelines. Acupunct Med 2009;27:128–9. doi:10.1136/aim.2009.001214
6 Cummings M. NICE, electroacupuncture, and osteoarthritis. Int Musculoskelet Med 2014;36:47–9. doi:10.1179/1753614614Z.00000000068
7 Cummings M. The Development of Group Acupuncture for Chronic Knee Pain Was All about Providing Frequent Electroacupuncture. Acupunct Med 2012;30:363–4. doi:10.1136/acupmed-2012-010260
8 Kligler B, Nielsen A, Kohrherr C, et al. Acupuncture Therapy in a Group Setting for Chronic Pain. Pain Med 2018;19:393–403. doi:10.1093/pm/pnx134