Traditional acupuncture: exploring the rationale and theory of

280 Pages·2013·2.58 MB·English

Traditional acupuncture: exploring the rationale and
theory of change in the specific context of early breast
cancer and chemotherapy in research and practice

Sarah Price

Submitted in accordance with the requirements for the degree of
Doctor of Philosophy

The University of Leeds
School of Healthcare
September 2012
The candidate confirms that the work submitted is her own and that appropriate
credit has been given where reference has been made to the work of others.
This copy has been supplied on the understanding that it is copyright material and
that no quotation from the thesis may be published without proper
acknowledgement.

The right of Sarah Price be identified as Author of this work has been asserted by
her in accordance with the Copyright, Designs and Patents Act 1988
Acknowledgments

My thanks go firstly to the two acupuncturists and fourteen women with breast
cancer who took part in this study. Thanks also go to the oncologists and specialist
nurses who were open to the idea and made it happen most especially Professor
David Cameron who opened the doors of possibility onto this study. This study
would also not have been possible without the British Acupuncture Council who
funded the acupuncture treatment.

My special thanks go to Andrew Long and Mary Godfrey at the University of Leeds
and also to Kate Thomas who have supervised this project and have given so
generously of their time and their ideas. They have shown extraordinary patience
and kindness as I have travelled this long road. George Lewith also gave helpful
advice and support in the early days.

Lastly my thanks go to friends and family in Edinburgh especially Georgia and
Lauren and my two colleagues Trina Ward and Andrew Flower for their helpful
advice and comments and Wendy Faulkner for the same.

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Abstract

Acupuncture is an increasingly popular complementary therapy. Acupuncture research,
however, leaves uncertainty as to its effectiveness and raises question about what traditional
acupuncture (TA) is. This thesis aims to examine what acupuncture is, by using the Theory
of Change (ToC) as a novel approach to elucidate the pathways for change. Early breast
cancer (EBC) is used as a complex exemplar providing the TA practitioner with the
opportunity to utilise TA in all of its complexity.
A ToC framework was developed from the professional accrediting body of TA. This ToC
framework was applied to two sets of literature: firstly acupuncture research where validated
outcome measures were used; secondly research on the exploration of practitioner and
patients’ perceptions of TA. A longitudinal study was constructed to examine change over
time during the EBC experience. This study entailed interviewing 14 women before, during
and after chemotherapy while they received up to ten sessions of TA. The two practitioners
were also interviewed; they kept diaries and treatment logs of the process creating additional
data. Grounded theory methods were used to analyse the data.
The ToC was refined after analysis of all the data to provide a comprehensive insight into the
components of TA providing further weight to the idea that it is a complex intervention.
Treatment entails a continuous process with multiple pathways to change. TA offers great
flexibility in addressing chronic illness with acute features or daily fluctuations of a range of
problems. The concept of outcome patterns arose from this which is ripe for further
exploration. The therapeutic relationship is part of the intervention, used to engage the
individual with new insights into health and changing behaviour as well as to enable
disclosure leading to person-centred goals of treatment. Therapeutic befriending emerged
as a notion suitable for further exploration within CAM.

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Table of Contents
ACKNOWLEDGEMENTS I
ABSTRACT Ii
TABLE OF CONTENTS Iii
LIST OF BOXES, FIGURES AND TABLES X
GLOSSARY OF CHINESE MEDICINE TERMS Xiii

CHAPTER ONE 1
INTRODUCTION TO THE STUDY 1
Acupuncture in Practice………………………………………………………………. 2
Different Theories Underpin Practice……………………………………………….. 2
Acupuncture in Research – model validity…………………………………………. 4
Acupuncture – a simple or complex intervention?............................................... 5
Finding Appropriate Methods of Evaluation……………………………………….. 7
Early Breast Cancer as a Complex Exemplar…………………………………….. 7
Theory of Change…………………………………………………………………….. 7
Research Aim………………………………………………………………………….. 9
Research Question……………………………………………………………………. 9
Structure of Thesis……………………………………………………………………. 9
What might this PhD add?................................................................................. 10

CHAPTER TWO 12
EARLY BREAST CANCER AS AN EXEMPLAR 12
Introduction……………………………………………………………………………… 12
Background……………………………………………………………………………... 12
Early Breast Cancer as a Complex Medical Condition……………………………. 14
Cancer Related Fatigue………………………………………………………. 14
Symptom Clusters…………………………………………………………….. 15
Exploring the Experience of Breast Cancer…………………………………………. 17
Summary of Findings from the Qualitative Literature………………………………. 17
Time and the Illness Trajectory………………………………………………………. 29
Concluding Comments……………………………………………………………….. 32

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CHAPTER THREE 34
METHODOLOGY 34
Introduction…………………………………………………………………………………… 34
Theory of Change……………………………………………………………………………. 34
Applying the Theory of Change Approach……………………………………….. 37
A Longitudinal Study Using a Broadly Interpretative Approach……………………….. 38
Interpretive Naturalistic Approach…………………………………………………. 38
Qualitative Research……………………………………………………………….. 39
Rigour………………………………………………………………………………… 39
Reflexivity…………………………………………………………………... 40
Researcher’s Epistemological Position…………………………………. 41
Ethics……………………………………………………………………….. 42
Concluding Comments…………………………………………………………………….. 42

CHAPTER FOUR 43
METHODS 43
Introduction……………………………………………………………………………………. 43
1. Exploring Two Models of Acupuncture Comparing Theory, Practice and Research 43
Developing a Framework that Articulates the ToC ......................................... 43
Textbooks for Cross Reference…………………………………………… 46
2. Applying the ToC Framework to the Clinical Acupuncture Research Literature 50
Search Strategy……………………………………………………………………… 50
Sampling Strategy…………………………………………………………………… 50
3. Exploring the Literature for Patient and Practitioner Experiences of TA…………… 52
Search Strategy for the Qualitative Literature Review…………………………... 52
4. A Longitudinal Qualitative Study………………………………………………………… 54
Inclusion and Exclusion Criteria……………………………………………………. 54
Sampling……………………………………………………………………………… 54
Acupuncture Treatment and Setting……………………………………………… 54
Access to women with EBC (participants)………………………………. 54
Access to acupuncturists………………………………………………….. 54
In-depth Interviews………………………………………………………………….. 54
i) Topic guides for interviews with EBC participants…………………… 55
Interviews with breast cancer participants……………………………… 57

ii) Topic guides for interviews with the Acupuncturists………………… 57
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Interviews with acupuncturists…………………………………………… 58
Reflective Diaries……………………………………………………………………. 59
Acupuncture Treatment Log……………………………………………………….. 59
Safety Data and Satisfaction with Treatment……………………………………. 59
Demographic Data………………………………………………………………….. 60
Ethical Approval……………………………………………………………………… 60
Funding for the Study……………………………………………………………… 60
Analysis for the Longitudinal Qualitative Study Using Grounded Theory……. 60
Managing data………………………………………………………………. 61
Process of analysis………………………………………………………… 64
i) Open coding and memo writing…………………………………. 64
ii) Focused coding……………………………………………………. 65
iii) Vignettes……………………………………………………………. 65
iv) Developing categories…………………………………………….. 66
v) Time………………………………………………………………… 67
The Inclusiveness and Consistency of the Data………………………………… 68
Reflexivity and Grounded Theory………………………………………………… 68
Sensitising Concepts………………………………………………………………. 68
Theoretical Sampling………………………………………………………………. 69
5. Analysis of Acupuncture Data Using the ToC Framework…………………………… 70
Interpretation of the Data……………………………………………………………………. 70
Concluding Comments………………………………………………………………………. 70

CHAPTER FIVE 72
THEORY OF CHANGE IN CLINICAL TRIALS OF ACUPUNCTURE FOR 72
SYMPTOMS COMMON DURING BREAST CANCER TREATMENT
Introduction…………………………………………………………………………………… 72
Aim of this Review…………………………………………………………………………… 72
Results………………………………………………………………………………………… 73
Adherence to a Theoretical Model…………………………………………………. 73
TA Model……………………………………………………………………………… 73
MA Model…………………………………………………………………………….. 74

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Unclassifiable……………………………………………………………………….. 76
Exploration by Symptom…………………………………………………………………… 76
Vasomotor Symptoms……………………………………………………………… 76
Fatigue……………………………………………………………………………….. 77
Depression, Anxiety, Insomnia Symptoms………………………………………. 78
Nausea and Vomiting……………………………………………………………….. 78
What are the Gaps in the Knowledge?.......................................................................... 78
Concluding Comments………………………………………………………………………. 79

CHAPTER SIX 81
SURFACING THE THEORY OF CHANGE: TA PRACTITIONER AND PATIENT 81
PERSPECTIVES
Introduction…………………………………………………………………………………… 81
Practitioner Perspectives and Theory of Change………………………………………… 81
Patient Perspectives on Experiences of TA………………………………………………. 85
Theory of Change…………………………………………………………………………… 96
Concluding Comments…….……………………………………………………………….. 99

CHAPTER SEVEN 101
EXPLORING EXPERIENCE AND CONCERNS: A MAELSTROM OF 101
CHANGE
Introduction………………………………………………………………………………….. 101
1. Before Chemotherapy……………………………………………………………………. 102
Shock of Diagnosis………………………………………………………………… 102
Keeping Everything Normal……………………………………………………….. 102
2. During Chemotherapy…………………………………………………………………… 110
Carrying On As Normal……………………………………………………………... 111
Consequences of ‘keeping everything normal’…………………………………………… 115
i) Limiting Support…………………………………………………………………… 115
ii) A Limbo State…………………………………………………………………… 115
iii) Suffering and Isolation………………………………………………………….. 116
3. Looking Back……………………………………………………………………………… 116
4. Meaning and Significance of EBC………………………………………………………. 119
5. Suffering…………………………………………………………………………………… 121
Physical Suffering…………………………………………………………………… 121
Emotionality………………………………………………………………………….. 123
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Mental Anguish………………………………………………………………………. 124
Loss…………………………………………………………………………………… 125
i) Loss of the independent self……………………………………………. 125
ii) Loss of the confident self……………………………………………….. 126
iii) Loss of intimacy…………………………………………………………. 127
iv) Loss of peace of mind…………………………………………………. 127
Concluding Comments……………………………………………………………………… 129

CHAPTER EIGHT 132
OUTCOMES 132
Introduction……………………………………………………………………………………. 132
1. Practitioner Perspectives…………………………………………………………………. 133
Treatment Logs……………………………………………………………………… 133
Diaries………………………………………………………………………………… 135
Practitioner Intended Outcomes…………………………………………………… 135
i) Fortify and Strengthen…………………………………………………… 137
ii) Pre-empt Side-effects…………………………………………………… 139
iii) Resolve Outcome Patterns…………………………………………….. 140
iv) Enable Coping and Wellness…………………………………………. 142
2. Women’s Perceptions of Perceived Benefits and Valued Outcomes………………. 144
Perceived Benefits…………………………………………………………………. 144
General Benefits……………………………………………………………………. 145
i) Feeling more relaxed……………………………………………………. 145
ii) ‘It made me more open’………………………………………………… 146
Specific Benefits……………………………………………………………………. 146
Anticipatory Benefit…………………………………………………………………. 147
Enabling Coping…………………………………………………………………… 148
Therapeutic Relationship and Therapeutic Befriending…………………………………. 150
Concluding Comments……………………………………………………………………… 154

CHAPTER NINE 157
TRADITIONAL ACUPUNCTURE: THEORY OF CHANGE IN PRACTICE 157
Introduction…………………………………………………………………………………. 157

Information Gathering……………………………………………………………………… 158
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Signs and Symptoms……………………………………………………………… 158
History of the Person……………………………………………………………… 159
Silent Information………………………………………………………………….. 159
Continuous Process………………………………………………………………. 160
Individualised Treatment………………………………………………………….. 162
Root and Branch……………………………………………………………………………. 165
Treat According to the Zang Fu and Balance of Qi……………………………………… 166
Therapeutic Relationship…………………………………………………………………… 168
Building Rapport……………………………………………………………………. 168
A Warm and Genuine Attachment………………………………………………… 169
Mutually Enhanced with Acupuncture……………………………………………. 169
Whole Person Approach……………………………………………………………………. 171
Concluding Comments……………………………………………………………………… 171

CHAPTER TEN 173
REFLEXIVITY 173
Introduction………………………………………………………………………………….. 173
My Standpoint……………………………………………………………………………….. 173
My Journey from Practitioner to Practitioner-researcher……………………………….. 174
Reflections on the Nature of the Encounter with Participants………………… 174
Reflections on the Discussion of the Therapeutic Relationship………………. 178
Reflections on the Encounter with Practitioners………………………………. 179
Reflections on Methodology……………………………………………………… 180
Reflections on Methods…………………………………………………………… 180
Case Studies……………………………………………………………………………….. 181
A counter case……………………………………………………………………. 181
A case to demonstrate ToC and the outcome of changing perspectives…… 182
Concluding Comments…………………………………………………………………… 186

CHAPTER ELEVEN 187
DISCUSSION 187
Introduction…………………………………………………………………………………. 187
1. Meeting the Objectives of the Thesis………………………………………………… 190
2. Intended Effects, Perceived Benefits What to Measure…………………………….. 191
Whole Systems Research………………………………………………………… 192
Symptom Clusters and Outcome Patterns……………………………………… 192
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