Dose and Relationships, What Matters?

In the latest issue of British Medical Acupuncture Society's newsletter 'The Point' Adrian White provides a very interesting review of a presentation given at the Society's Autumn Scientific meeting.
The presentation was given by Petra Bauemler who works in Dominic Irnich's pain unit in Munich, Germany and discussed the findings of a mixed methods study she had recently completed look at the different approaches taken when treating neck pain.
In the presentation she describes how 14 patients with neck pain were treated in Argentina, China and Germany and the findings where as follows:
  • In Argentina patients received up to 10 needles in individualised points over 10 visits, one or twice per week. 
  • In China patients received up to 52 needles, mostly in fixed standard points and have to go for daily treatment for up to 30 visits.
  • In Germany patients receive treatment which falls somewhere in between.
What was interesting is that the outcome on neck pain and range of movement was the same in all three treatment settings!
Adrian White's comment was that this fits well into the overall view that is developing in that precise details of dose and schedule of acupuncture, maybe as long as they exceed some minimal threshold of stimulation, only contribute a small amount to its overall effect.
From clinical experience I would agree, but would also suggest there is a maximum threshold of stimulation, which may be unique to each patient, beyond which the effects of acupuncture may be less effective, or indeed generate a adverse effect.
In other words, a certain minimum level of input is required but it may also be important not to overstimulate more sensitive patients for example.
What does interest me is that despite receiving what may be considered high dose treatment according to the STRICTA guidelines, the cohort of patients from China did not seem to react negatively to acupuncture as a whole, in fact quite the opposite. This may be in part due to cultural factors related to expectation and convention. I suspect that if similarly high dose treatment was given to Western patients, the overall treatment effect may not be as positive. Perhaps those in China expect very regular treatment using a large number of needles and may not feel they have been properly treated if this approach is not taken.
Another interesting finding was the view that the patients had about the therapeutic relationship with the acupuncture practitioner. In Argentina this should be based on love, and without love for the practitioner they would not get better. In Germany they wanted a relationship based on trust, and in China it was how famous the acupuncture practitioner was that mattered!
I'd be very interested to hear of your experiences in dose control and to what extent your therapeutic relationship may affect your clinical outcomes?
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