Abstract
Objective:
To examine the experience of low-income medically underserved patients receiving acupuncture and/or massage for chronic pain at a Federally Qualified Health Center in Washington, DC.
Methods:
Thirty-one patients with chronic pain who had at least four treatment sessions were identified by their primary care physicians. Utilizing funds from a Health Resources and Services Administration (HRSA) grant, three massage therapists and two acupuncturists were recruited by Non-Profit Access to Integrative Medicine to offer free integrative medicine services. English- or Spanish-speaking patients who received at least four treatments were recruited for one-on-one interviews as well as a focus group. Ultimately, 14 patients took part and their average age was 58 years. IRB approval was obtained from George Washington University. Participants were asked questions concerning their chronic pain and quality of life (QOL), their understanding of integrative medicine treatments, and their use and perceptions of medication to treat chronic pain.
Results:
Coding of the transcripts revealed positive QOL improvements from the acupuncture and massage treatments. All participants reported at least some improvement in their pain from the treatments and all indicated they would be interested in further acupuncture and/or massage treatments in the future. Their decisions for treatment focused primarily on a willingness to try more natural treatments that did not cause adverse side effects, and in some cases, desperation to find a treatment that helped manage pain after trying other interventions including medication and physical therapy. Additional positive effects included a deep sense of calm and relaxation participants felt during treatment, improvement in pain symptoms, as well as benefits experienced for conditions other than pain.
Conclusions:
Acupuncture and massage were overwhelmingly viewed as treatments that could improve pain symptoms and QOL. This study demonstrates the important role integrative approaches to pain can play and highlights the need to reduce access barriers for marginalized communities with chronic pain.
Introduction
As of 2019, 20.4% of adults in the United States suffer from chronic pain and 7.4% had chronic pain that frequently limited life or work activities in the past 3 months. 1 Minority populations are at higher risk of chronic pain as well as pain undertreatment.2–5 Furthermore, there is a strong association between pain and concomitant mental health disorders.6–8
Integrative therapies including massage and acupuncture show promising results for improving chronic pain. Lack of response to conventional treatment, fewer adverse effects, requests from patients, positive perceptions from health professionals, and documented efficacy all play a role in the increased interest in these treatments. 9 Acupuncture is specifically recognized by the World Health Organization (WHO) and incorporated into chronic pain treatments by state-regulated health insurance in Germany, Austria, and the United Kingdom. 9
In the United States, it is recommended by the Agency for Healthcare Research and Quality, American College of Physicians, and the Joint Commission as a treatment modality option for chronic pain. 9 Acupuncture has been shown to improve discomfort from osteoarthritis, neck pain, and low-back pain.10–15 Massage has shown efficacy as a treatment in a multimodal approach to chronic pain as well. In one recent study, participants discussed the treatment's relaxing effects as well as improved quality of life (QOL) associated with receiving massage therapy specifically for osteoarthritis. 16
Although acupuncture and massage have shown promising benefits for chronic pain, access in the United States is limited by a lack of insurance reimbursement, funding, institutional support, and trainees.17,18 However, in 2020, Centers for Medicare and Medicaid Services announced the decision to cover acupuncture for chronic low-back pain in patients with Medicare. 19 Recent studies have been conducted to better understand the barriers to accessing acupuncture, specifically for lower income patients with chronic pain.2,3,20–22 The barriers include transportation, time off work, cost, and lack of knowledge about these integrative options.
This retrospective study sought to better understand the experiences of underserved patients suffering from chronic pain who participated in a pilot program introducing acupuncture and massage treatments at a community-based clinic. This qualitative inquiry sought to improve chronic pain management services available in primarily low-income populations. Acupuncture and massage were chosen due to their efficacy and to allow patients to experience both treatments depending on their preference.
Methods
This qualitative study is part of a larger Health Resources and Services Administration (HRSA) funded grant. Utilizing funds from this grant, three licensed massage therapists and two licensed acupuncturists were recruited to provide free treatment to patients suffering from chronic pain. Patients were referred for treatment by their providers for various conditions (Table 1).
Sampling
Pilot Program Overview
The qualitative study reported in this article is a retrospective assessment of a pilot program funded by the HRSA within the U.S. Department of Health & Human Services Administration (grant H80CS29002). The pilot program provided acupuncture and massage treatments to patients at no cost at a single Federally Qualified Health Center (FQHC) serving low-income patients in Washington, DC. The clinic is a multiservice operation providing medical care, legal representation, social services, and access to food and clothing to residents of the city.
Services were offered for 45-min individual massage therapy sessions and 1-h acupuncture sessions, an extra 15 min provided for instrument replacement and room setup. Any patients of this clinic who experienced chronic pain and received a referral from their provider were able to take part in this pilot program. To ensure equitable access to service, appointments were provided on a first-come, first-serve basis. Patients were encouraged to return for repeat visits and report changes in pain and QOL to providers.
Table 1 provides an overview of the number of patients who completed any acupuncture or massage treatments, the number of patients who completed at least four treatments and were eligible to participate in the retrospective qualitative study, and the final number of patients who consented to take part in the qualitative study.
Retrospective Study
After the pilot acupuncture and massage therapy treatments were complete, participants were invited to take part in a retrospective qualitative study to better understand their perceptions of these treatments toward managing chronic pain.
Participants and recruitment
Thirty-one patients (N = 31) who took part in at least four acupuncture and/or massage treatments at the clinic were invited to complete one-on-one interviews and a small focus group to discuss their experiences retrospectively. Participants who completed an interview were given a $10 grocery gift card and participants who completed both the interview and the focus group were given a $25 grocery gift card.
The initial pilot acupuncture and massage treatments were offered during a 1 year span between March 2018 and 2019. Interviews and the focus group were conducted between November 2020 and February 2021 and, due to the COVID-19 pandemic, took place through phone call or through Zoom. Table 2 provides an overview of the patients who took part in the qualitative study and includes how many treatments each completed.
Treatment Data
II, individual interview only; II+FG, individual interview and focus group.
Data collection
An interview protocol was used to guide discussion, but interviewers allowed participants to discuss any issues of concern and to deviate from the protocol when the conversations merited. Interviews were designed to understand how acupuncture and/or massage impacted patients' chronic pain and QOL, their thoughts on the integrative medical treatments, their use of and perceptions of medication to treat chronic pain, and their overall understanding of integrative and holistic medicine.
Participants completed a verbal consent before the interview and the focus group. Interviews were conducted by two members of the research team and lasted between 25 and 45 min. Interviews were audio recorded and transcribed verbatim by the research team. Once transcribed, the interview transcripts were uploaded to NVivo, a qualitative data analysis software tool for coding.
Data analysis
An inductive thematic analysis strategy was used to examine and categorize the data and identify emergent themes. To develop a comprehensive set of codes, three members of the research team individually read and coded a set of interviews following a process of grounded coding. To establish validity, the research team engaged in a process of peer debriefing wherein transcripts were individually reviewed and coded before the team met to review their independent work, identify overlap and unique coding categories, discuss current literature, and consult with the grant's principal investigator to arrive at a comprehensive codebook. The revised codes were then applied across all 14 interviews and the focus group and themes were identified.
Results
Ultimately, 14 patients (n = 14) enrolled in the qualitative study (45.16%). Eight participants completed an individual interview alone and six participants completed both the individual interview and a focus group discussion. Demographic information was collected from study participants to contextualize the qualitative data. Table 3 presents demographic data for the patients who participated in the study as well as details on the medical conditions that participants were diagnosed with before their acupuncture and/or massage treatments.
Aggregate Patient Data
PTSD, post-traumatic stress disorder.
Qualitative data were collected through individual interviews and a single focus group discussion facilitated by the research team. All 14 of the patients who completed at least four acupuncture and/or massage treatments, and who conducted an interview or took part in the focus group, reported improvement to their pain and expressed interest in further integrative medical treatments. No participants have received massage therapy in a clinical setting in the past and only one of the participants had experience with acupuncture before receiving treatment through this study.
Theme identification
Five distinct themes emerged through data analysis:
limited prior exposure to integrative medicine or holistic care, positive perception toward the treatment experiences, positive impact of integrative treatment on patient health and QOL, impact of integrative treatment on the use of medication, and desire for future integrative medical treatments.
Theme one: limited prior exposure to integrative medicine and holistic care
The first significant finding was the disconnect between the language used by clinicians and researchers to discuss integrative medicine or holistic care and patient understanding of these treatment modalities. None of the participants in this study had ever heard the terms integrative medicine or holistic care before taking part in this study. Instead, they used terms such as “natural medicine” and “Eastern medicine.” Through further discussion, the authors learned that nine participants have had some exposure to integrative treatments (e.g., yoga, tai chi, and chiropractic care) and alternative nonpharmacologic measures of pain relief or health management (e.g., turmeric supplements and medicinal teas) but did not use the same language as clinicians to describe these treatments.
Theme two: positive perception toward the treatment experience
Thirteen patients expressed positive feelings toward the integrative treatment they received at the clinic, in terms of both clinical care from the therapists and the environment in the treatment rooms. One patient who suffers from chronic pain in addition to anxiety and depression noted,
I feel very welcome there as an indigenous person and as a queer person and as a disabled person. … I would continue to come there and, if other services are offered that could be of use for me, I would absolutely try them (Participant 4—II).
Other patients alternatively described the therapists as “caring individuals with … a large amount of respect for others,” “really nice,” and “professional, but also a very caring person.” The participants had similarly positive things to say about the treatment rooms, describing them as “a safe place,” “serene and peaceful,” “soothing,” and “relaxing.”
Only one participant expressed negative feelings about both the acupuncture treatment and the massage treatment. This individual was seeking treatment for chronic pain as a result of nerve damage. He ultimately discontinued acupuncture because he found the treatments painful and did not like the massage because he was uncomfortable with a male therapist providing treatment. This second point specifically highlights the importance of developing a comfortable treatment environment wherein all patients feel safe.
Theme three: positive impact of integrative treatment on health and QOL
In addition to the positive perception of the therapists and the treatment rooms, participants expressed varying positive impacts of the integrative treatments on their health conditions and QOL represented in four primary domains: (1) temporary pain improvement, (2) improved flexibility and movement, (3) improvement to daily activities and QOL, and (4) benefits to mental health. Of note, there were no participants who expressed any negative side effects or poor progression in their conditions after either treatment.
Temporary pain improvement
According to 13 participants, the most significant impact of the acupuncture and massage treatment was a temporary improvement to their pain.
At the time back when I was coming [to Clinic], and when the needles had been set in my body … when the nice doctor was doing [the treatment], I would just feel the pain melting in waves out of me. It would relieve me … (Participant 9—II).
For one patient, the pain relief was sustained but they had difficulty in scheduling follow-up appointments due to the popularity of this service. “When I did the treatment, I felt better for like two weeks … and after that, it was very hard to get back to the appointments actually because there were a lot of people wanting the service” (Participant 10—II). This experience lends further support to recommendation for increased access to affordable integrative medical treatment to low-income patient populations.
When asked about their expectations regarding care, only two of the participants identified pain relief as an anticipated outcome. Three patients noted that they believed acupuncture would be painful and the remaining participants either expressed having no expectations related to the effectiveness of integrative treatment or an expectation that the treatment may provide some stress relief unrelated to pain.
Improved flexibility and movement
In addition to short-term pain relief, nine participants expressed an improvement in flexibility and to their ability to move comfortably. For one patient, this change was immediately apparent,
After the acupuncture I was using the stairs … even my will power clearly increases to do activities. I was using the stairs! When I came in [to Clinic] I was using the elevator … when going back, I was able to use the stairs down from the second floor (Participant 7—II).
Other patients identified improved range of motion in their neck, decreased muscle tension, relief of shoulder and back pressure, and improved feeling in their legs and feet after treatment. One patient worked as a health care aid to individuals with disabilities and noted an improved ability to stand for long periods of time and less difficulty when lifting patients from their beds. Five participants noted that these improvements were temporary and began to experience difficulty in moving after their treatments ended. For one patient, the temporary benefit of acupuncture was particularly profound on her pain,
I have severe lower back pain, which may reach about eight to nine and the pain scale. After the acupuncture really, it went away for a while … The most painful condition I had was the lower back pain, which was improved by the acupuncture and the massage therapy I got from [the Clinic]. So I definitely believe that acupuncture and massage therapy helped us a lot … (Participant 6—FG).
Improvement to daily activities and QOL
The most meaningful impacts that the patients described after their treatments were directly related to heightened QOL and their improved ability to successfully complete activities of daily life. Before receiving treatment, many patients expressed a low QOL due to their pain and other health issues. For one patient, their chronic pain impacted every part of their life. “There's not a single part of my life that has not been affected by it. Like, I don't feel like myself anymore. I would feel like I'm nothing but a walking ball of pain and trauma and misery” (Participant 4—II).
This sentiment was shared by another seven participants who expressed a negative perception of their QOL and difficulty in completing basic daily activities such as dressing in the morning, cleaning their home, commuting to and from work, and playing with children.
Other patients noted that they began to feel hopeful about their medical conditions given the benefits that they experienced after treatment. These patients noted that they were more committed to seeking regular care since the benefits of acupuncture and massage were so profound. One patient who suffers from chronic pain reported that the treatments significantly changed her QOL.
I was overjoyed. I was like, this is my one opportunity to prayerfully have a shot at some sort of quality of life…. I was just so overjoyed because I know that it can help with so many things: daily life, mental health, physical health… (Participant 3—II).
Benefits to mental health
Nine of the 14 participants had at least one comorbid mental health diagnosis and 8 participants identified benefits to their mental health after integrative medical treatments. These benefits were varied, but patients commonly identified reduced anxiety, improvement to symptoms of post-traumatic stress disorder (PTSD), and reduced symptoms of depression. The positive mental health benefits of the integrative medical treatment were best described by a patient who suffers from chronic pain as well as PTSD as a result of surviving domestic violence.
I'm a survivor of domestic violence so I was exposed to so many stresses on the daily … so, [during the treatment] […] I would feel so relaxed, not so tense […] Having to have massage therapy loosens up all that stress that I get during the week and the … acupuncture was very beneficial for me (Participant 8—FG).
Theme four: impact of integrative treatment on use of medication
The fourth theme that emerged was decreased use of medication after integrative treatments at the clinic. Five patients identified decreased reliance on pain medication, including ibuprofen, aspirin, tylenol, and tramadol: all common non-steroidal anti inflammatory medications (NSAIDs) used to reduce pain. In addition to NSAIDs, one patient also indicated that they were able to discontinue the use of a muscle relaxant while they were actively in treatment.
A number of participants expressed some hesitancy toward using prescription medications, especially opioids used in pain management, out of concern for their addictive qualities and their physical side effects (e.g., fogginess, lethargy, etc.). For this group of patients, the ability to reduce their use of medicine was a particularly strong benefit.
Theme five: desire for future integrative medical treatment at the clinic
The final theme that appeared commonly across the data was a desire for continued integrative treatments and an expansion of services to include other treatments such as reiki or tai chi. As all of the interviews and the focus group were conducted in the middle of the COVID-19 pandemic, a number of patients specifically discussed how disappointed they were by the reduced clinical operations and the end of acupuncture and massage therapy. Another patient specifically discussed how they put off seeking integrative care as it was not readily and affordably available before this study and how disappointed they were when the therapist had to leave.
People have been recommending it [integrative treatments] to me because of my pain and I was looking for it … I never knew it was available however. So, when I heard that the doctor was coming [to the Clinic] to treat us, I was very happy. I had this idea in me that I would soon be pain-free. But, unfortunately [the therapist] didn't have enough time to take us all to the end of treatment. He had to go somewhere else (Participant 9—II).
Discussion
Overall, this study demonstrated the importance of integrative holistic modalities into treating chronic pain while also highlighting the challenges to implementing integrative treatment. Although the majority of patients were unable to provide the technical definition of integrative medicine or holistic care, and interpretations included thoughts of “natural medicine” and “Eastern Medicine,” this did not limit their interest in continuing treatments. Some patients had exposure to integrative treatments such as tai chi or chiropractic care, but they did not associate these modalities with integrative medicine.
Limited health knowledge is a studied reason for nonuse of integrative medicine modalities. 23 The data in this study represent an important disconnect between the language used by clinicians to discuss holistic care and the ways patients experience or express their alternative attempts at pain management. A lack of shared language may lead to miscommunications between patients and providers and so it remains important for clinicians to use direct language, provide examples, and clearly explain health benefits when discussing possible complementary integrative treatments.
None of the research participants had exposure to massage therapy in a clinical setting and only one had prior exposure to acupuncture. Through interviews it was apparent that some participants had interest in these services; however, did not know where to access them.
The response to the practice of acupuncture and massage was positive in this retrospective study. The experience was generally described as relaxing and soothing with praise given to the acupuncturists and massage therapists. Improved QOL and pain reduction were highlighted in every interview. Furthermore, discussion of improvement in mental health is an important finding. The link between chronic pain and mental health has been extensively studied, and this research demonstrates that integrative modalities can have a twofold effect on improving participant's chronic pain and mental health.6,8
Hsu et al. have explored the complicated relationship between expectations, hope, and experience with complementary and alternative medicine, and this complexity is illustrated in some of this study's patient interviews. 24 Only two patients predicted some form of pain relief and some were expecting the acupuncture to be painful. There were more patients who had no or low expectations, but still had hope for any kind of pain or QOL improvement. This study offered both acupuncture and massage to provide options and alternatives for patients.
One patient reported feeling uncomfortable with a male administering the massage therapy, illustrating the utility and necessity in offering multiple different kinds of integrative modalities with a variety of providers. This is an important concept for future implementation of integrative medicine into FQHCs or other clinics.
The data supported the initial hypothesis that the inclusion of acupuncture and massage would decrease patients' need to take opioids or other NSAIDs to manage their chronic pain. These data are encouraging from a public health standpoint and further illustrate the utility of offering integrative medicine to all populations. The results of this study show that the patients benefited from the free acupuncture and massage therapies offered at their home clinic where they receive primary care and other services.
There is an increased advantage in having integrative medicine modalities administered in a safe location, such as the familiar community medical home. Patients appreciated being able to obtain all of their care at one facility and the familiarity aided in their comfort with trying something new. Similar studies have demonstrated the feasibility of offering these services in a community medical home.2,22 Patients reported their delight in finding out that these services, which are often difficult to afford out-of-pocket, were going to be offered. One patient stated,
This was the only place I saw acupuncture and massage therapy, I mean in the clinics, in the nonprofit area. So if we get the chance, I think it will be more helpful and people may get a benefit out of [acupuncture and massage] (Participant 7—FG).
Limitations
This study used interview data that required participants to recall thoughts and feelings about past experiences. There was no data collected before starting therapies or during the course of treatments. Due to the limitations of the pandemic, there was an extended timeframe between discontinuation of services and time of interview. Therefore, data are subject to recall bias and have no baseline information for comparison. As this was a retrospective analysis of a pilot program at a single FQHC, additional prospective trials should be implemented in similar contexts. This retrospective study may help to inform future studies.
There may be bias involved in study recruitment. It is unknown whether the people who chose not to complete the interviews did so because they did not enjoy or find benefit in the therapies or declined because they did not have time for the interview. As part of the study design, patients with less than four visits were excluded. Data on why they only attended three or fewer sessions were not collected; therefore, it is also unknown whether they quit because they did not find benefit, or whether another unrelated conflict arose and prevented them from attending sessions.
There were also access limits, as only so many patients could be served per week given limited time and budgeting. Services were offered two times a week during business hours. This meant that people who had to work during regular hours had no access. Since the FQHC serves a primarily low-income population who do not have flexible jobs, many patients were unable to seek services due to work.
Conclusion
The results of this study highlight the important role integrative approaches to pain can play and the need to reduce barriers to integrative treatments for marginalized communities with chronic pain. It is important to note that these modalities can have a long-term impact on reducing overall cost to the health care system due to chronic pain management. There is also the added benefit of suffering reduction on behalf of the patients. There is a clear advantage in having integrative medicine modalities administered in a safe location, such as a community clinic.
This study aligns with similar studies and demonstrates the feasibility of offering acupuncture and massage in an urban community health center. It also demonstrates an interest in the services from a lower income medically underserved population despite lack of previous exposure to these modalities.
Footnotes
Authors' Contributions
The majority of writing and research was conducted by L.H., J.O., and P.C. R.A. was the clinical lead at the FQHC site and helped with coordinating of the treatments as well as coordinating data collection and article editing. M.K. was the PI, assisting with the project the whole way through and providing editing guidance.
Acknowledgment
Partial data from this project were presented at ICIMH May 2022.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The project was funded through an HRSA grant (H80CS29002) as well as funds from the Non-Profit Access to Integrative Medicine EIN: 46-5542911.