Acupuncture for chronic pain and depression in primary care : a programme of research

Abstract Background There has been an increase in the utilisation of acupuncture in recent years, yet the evidence base is insufficiently well established to be certain about its clinical effectiveness and cost-effectiveness. Addressing the questions related to the evidence base will reduce uncertainty and help policy- and decision-makers with regard to whether or not wider access is appropriate and provides value for money. Aim Our aim was to establish the most reliable evidence on the clinical effectiveness and cost-effectiveness of acupuncture for chronic pain by drawing on relevant evidence, including recent high-quality trials, and to develop fresh evidence on acupuncture for depression. To extend the evidence base we synthesised the results of published trials using robust systematic review methodology and conducted a randomised controlled trial (RCT) of acupuncture for depression. Methods and results We synthesised the evidence from high-quality trials of acupuncture for chronic pain, consisting of musculoskeletal pain related to the neck and low back, osteoarthritis of the knee, and headache and migraine, involving nearly 18,000 patients. In an individual patient data (IPD) pairwise meta-analysis, acupuncture was significantly better than both sham acupuncture (p < 0.001) and usual care (p < 0.001) for all conditions. Using network meta-analyses, we compared acupuncture with other physical therapies for osteoarthritis of the knee. In both an analysis of all available evidence and an analysis of a subset of better-quality trials, using aggregate-level data, we found acupuncture to be one of the more effective therapies. We developed new Bayesian methods for analysing multiple individual patient-level data sets to evaluate heterogeneous continuous outcomes. An accompanying cost-effectiveness analysis found transcutaneous electrical nerve stimulation (TENS) to be cost-effective for osteoarthritis at a threshold of £20,000 per quality-adjusted life-year when all trials were synthesised. When the analysis was restricted to trials of higher quality with adequate allocation concealment, acupuncture was cost-effective. In a RCT of acupuncture or counselling compared with usual care for depression, in which half the patients were also experiencing comorbid pain, we found acupuncture and counselling to be clinically effective and acupuncture to be cost-effective. For patients in whom acupuncture is inappropriate or unavailable, counselling is cost-effective. Conclusion We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed. When all trials are analysed, TENS is cost-effective. Promising clinical and economic evidence on acupuncture for depression needs to be extended to other contexts and settings. For the conditions we have investigated, the drawing together of evidence on acupuncture from this programme of research has substantially reduced levels of uncertainty. We have identified directions for further research. Our research also provides a valuable basis for considering the potential role of acupuncture as a referral option in health care and enabling providers and policy-makers to make decisions based on robust sources of evidence

An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain : A randomized trial (ATLAS)

OBJECTIVES: To assess the cost-effectiveness of acupuncture and usual care, and Alexander Technique lessons and usual care, compared with usual GP care alone for chronic neck pain patients. METHODS: An economic evaluation was undertaken alongside the ATLAS trial, taking both NHS and wider societal viewpoints. Participants were offered up to twelve acupuncture sessions or twenty Alexander lessons (equivalent overall contact time). Costs were in pounds sterling. Effectiveness was measured using the generic EQ-5D to calculate quality adjusted life years (QALYs), as well as using a specific neck pain measure-the Northwick Park Neck Pain Questionnaire (NPQ). RESULTS: In the base case analysis, incremental QALY gains were 0.032 and 0.025 in the acupuncture and Alexander groups, respectively, in comparison to usual GP care, indicating moderate health benefits for both interventions. Incremental costs were £451 for acupuncture and £667 for Alexander, mainly driven by intervention costs. Acupuncture was likely to be cost-effective (ICER = £18,767/QALY bootstrapped 95% CI £4,426 to £74,562) and was robust to most sensitivity analyses. Alexander lessons were not cost-effective at the lower NICE threshold of £20,000/QALY (£25,101/QALY bootstrapped 95% CI -£150,208 to £248,697) but may be at £30,000/QALY, however, there was considerable statistical uncertainty in all tested scenarios. CONCLUSIONS: In comparison with usual care, acupuncture is likely to be cost-effective for chronic neck pain, whereas, largely due to higher intervention costs, Alexander lessons are unlikely to be cost-effective. However, there were high levels of missing data and further research is needed to assess the long-term cost-effectiveness of these interventions

Community, connection, caring : towards a Christian feminist practical theology of older women

Christian feminist theologians state that community, connection, and caring are the means by which women live their lives and through which women understand and express their faith. These theologians also claim that their theologies are based on women's expeniences. In this thesis I ask, are the ideas of community, connection, and caring proposed by these theologians relevant to older women in Britain today? Are older women's experiences reflected in Christian feminist theologies? Should there be a separate theology of older women based on these concepts? I explore these questions first by considering ideas of community, connection, and caring put forward by feminists and Christian feminist theologians and then by comparing these ideas with the lived experiences of older women themselves. These experiences are gathered from the field of social gerontology as well as from new empirical research: semi-structured interviews with 40 churchgoing Methodist and Anglican women in York, aged 65 and over. Data analysis indicates that community, connection, and caring are important and desirable aspects of older women's lives, and that the family and the local church are significant sources of these entities and processes. In this respect, older women's experiences are reflected in Christian feminist theologies, although this appears to be more by default than by design. In addition, their experiences (for example, of being a newcomer to a church congregation or of working to maintain an identity as a carer in a society that views them as recipients of care only) are not universally positive, adding dissenting voices to the largely enthusiastic assertions of the theologians. Consequently, I propose a move towards a Christian feminist practical theology of older women-a theology based on older women's experiences of community, connection, and caring and calling for informed, committed praxis by the churches, suggestions for which are offered. Such a feminist theology would complement other developing theologies and spiritualities of older women. At the same time, it would be flexible and provisional, taking on board new developments and data as they arise-particularly as succeeding generations of women age-and intentionally incorporating them

Gender and Creativity: Female Artist Subplots From Hawthorne to Fowles

223 p.Thesis (Ph.D.)--University of Illinois at Urbana-Champaign, 1988.Gender and Creativity is a dialogic study of five novels. The introduction briefly summarizes the characteristics of the artist plot. Chapter One examines the disruptive textual interplay between female artist subplots and the centripetal finalizing force of a dominant romance plot. In the novels examined, plot, setting, and character double to tell two &quot;warring&quot; stories. Each character is both a minor character in a romance plot and the protagonist questing for independence in the artist plot. The settings are double: both traditional societies and the forbidden worlds of bohemia are represented. The plots contain contradictory logics--the logic of the romance which works to affirm social order and of the Kunstlerroman trying to subvert it. Even the discourse is double-edged or split, at once talking about both sexuality and creativity, consisting of metaphors which pit female against male creativity. Chapter Two focuses on Hawthorne's Ivory Tower artist, Hilda (The Marble Faun), her relationship with the old Italian masters, and her marriage to Kenyon. Chapter Three studies Faulkner's &quot;still life&quot; artist Charlotte Rittenmeyer (The Wild Palms), her status as social renegade and, finally, the politics of her death. In Chapter Four, Gudrun Brangwen (Women in Love) and her dealings with both the continental bohemias and industrial societies are examined. John Fowles's two artist heroines--Sarah Woodruff (The French Lieutenant's Woman) and Diane (The Ebony Tower)--are the subjects of Chapter Five. The conclusion, &quot;Restoring Interpretive Center,&quot; discusses the different interpretations produced by reading for plot and for subplot. Although each of these novels has been read as a text which challenges the conservative ideology of the marriage plot, a critique from the point of view of the artist subplot illuminates the opposite perspective. Though the authors early on challenge, they ultimately reject bohemian life and affirm social values and tradition. Finally, I argue that reading for subplots forces us to read from multiple perspectives, to see what is imagined but not acted on in texts, and to identify the ideological forces that block these imaginings. Reading for subplots allows us to see what has been relegated to the margins of the text and, more importantly, why.U of I OnlyRestricted to the U of I community idenfinitely during batch ingest of legacy ETD

Literate Zeal Gender and the Making of a New Yorker Ethos

Intro -- Contents -- Preface: Haute Literacy -- Introduction: Literacy, Gender, and the Rhetorical Work of Editing -- One: Between the Sheets: Editing and the Making of a New Yorker Ethos -- Two: "The Precision of Knives," or More Than Just Commas -- Three: Mademoiselle, the New Yorker, and Other Women's Magazines -- Conclusion: Lady Editors, Katharine White, and the Embodiment of Style -- Afterword: Katharine White's Bequest, or Ruminations on an Archive -- Notes -- Works Cited -- IndexDescription based on publisher supplied metadata and other sources.Electronic reproduction. Ann Arbor, Michigan : ProQuest Ebook Central, YYYY. Available via World Wide Web. Access may be limited to ProQuest Ebook Central affiliated libraries