Pain Medicine 2017; 0: 1–11
doi: 10.1093/pm/pnx134
Original Research Article
Acupuncture Therapy in a Group Setting for
Chronic Pain
Benjamin Kligler, MD, MPH,* Arya Nielsen, PhD,*,†
Corinne Kohrrer, LAc, FNP,†,‡ Tracy Schmid, LAc,†
Eve Waltermaurer, PhD,* Elidania Perez, MS,*,† and
Woodson Merrell, MD†
*Department of Family Medicine, Icahn School of
Medicine at Mount Sinai, New York, New York; †Mount
Sinai Beth Israel Medical Center, New York, New
York; ‡Hunter-Bellevue School of Nursing, New York,
New York, USA
Correspondence to: Benjamin Kligler, MD, MPH, 421
Fifth Street, Brooklyn, NY 11215, USA. Tel:
2028219142; E-mail: benkligler@gmail.com.
Funding sources: This project was supported by a
grant from the Blavatnik Family Foundation (52404029).
Disclosure and conflicts of interest: None of the
authors had any conflicts of interest, and the funding
foundation had no input into study design or the
analysis or reporting of results.
Abstract
Objective. This project was designed to test the fea-
sibility and effectiveness of acupuncture therapy
given in a group setting for chronic pain.
Design. Nonrandomized, repeated measures quasi-
experimental trial.
Setting. Care was delivered in a primary care clinic
waiting area after clinic hours.
Subjects. Included were primary care patients
(18 years old) with chronic pain of the neck, back,
shoulder, or osteoarthritis of any site of at least
three months’ duration.
Methods. Subjects received eight weekly acupunc-
ture therapy sessions in a group setting.
Acupuncture therapy included a combination of pal-
pation, acupuncture needling, Tui na, Gua sha, and
auricular treatment. Baseline pain levels were
C 2017 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
V 1
established in a two- to four-week run-in; assess-
ment of the intervention impact on pain intensity,
mood, and functional status were made at the end
of the treatment period (eight weeks) and 16 weeks
after completion of intervention (24 weeks).
Results. Of the total 113 participants recruited for
the trial, 96 completed the 24-week protocol. We
found a statistically and clinically significant de-
crease in pain severity, pain interference, and de-
pression in our study population. There were no
serious adverse events.
Conclusions. Acupuncture therapy offered in the
group setting was effective in reducing pain sever-
ity, pain interference, and depression in patients
with chronic neck, back, or shoulder pain or osteo-
arthritis. Benefit persisted through the 24-week
measure despite no additional treatment. This find-
ing has potentially important implications for im-
proving access to effective acupuncture treatment
for patients with limited financial resources.
Key Words. Acupuncture, chronic pain, comple-
mentary medicine
Background
The prevalence of chronic pain problems in the general
adult US population is high; estimates have ranged from
10% to 40% in recent large surveys depending on the
specific sample [1–4]. Research has also documented a
positive association between pain and impairment in
physical and psychological functioning [5,6], lost work
productivity [7], and lower socioeconomic status [8].
There is substantial evidence that minority and poor
populations differ both in the prevalence and outcomes
of chronic pain [2,8–11]. In addition, race/ethnicity and
socioeconomic factors influence access to pain care
[10,12–14].
A great deal of evidence now supports the use of acu-
puncture therapy in the treatment of chronic pain condi-
tions [15,16], including shoulder pain [17,18],
osteoarthritis [19–23], neck pain [24–26], and low back
Kligler et al.
pain [26–28]. Acupuncture is recommended as a firstline
treatment by the American College of Physicians in their
2017 Clinical Practice Guidelines for acute and chronic
low back pain and by the National Institutes of Health
for low back pain and knee osteoarthritis [29,30].
Although the mechanism of action remains complex
and some studies find both “sham” (needles in nonacu-
puncture points) and real acupuncture to be effective,
studies also show that 40% to 50% of patients experi-
ence a reduction in pain with acupuncture treatment
with some evidence of persistence in pain reduction in
the long term from real acupuncture [31].
Most acupuncture therapy is delivered in individual
practitioner-patient sessions. Patients from lower socio-
economic groups are generally not able to access acu-
puncture treatment in the United States; services are
not generally reimbursed by insurers, and patients often
cannot afford the out-of-pocket expense. Therefore,
cost and access pose a major barrier to widespread im-
plementation in this patient population. Acupuncture
care delivered in a group or community setting has
been shown to be feasible for patients with chronic pain
including patients from lower socioeconomic groups
[32–34]. There is some evidence of effectiveness of acu-
puncture therapy in groups for knee osteoarthritis [35]
and peripheral neuropathy [36,37], but other chronic
pain conditions have not been studied in a group set-
ting. Formalized auricular acupuncture given in a group
setting has been used extensively in the treatment of
substance abuse disorders [38,39]. This project was de-
signed to test the feasibility and effectiveness of group
acupuncture for the treatment of back pain, shoulder
pain, neck pain, and osteoarthritis. The goal of this proj-
ect was to develop and pilot a low-cost, effective inte-
grative intervention for chronic pain that, if found to be
effective, could be replicated easily in underserved set-
tings across the United States.
Methods
Setting and Subjects
This study was approved by the Icahn School of
Medicine at Mount Sinai Institutional Review Board. We
recruited outpatients with chronic pain from local pri-
mary care practices in New York City. Chronic pain was
defined as pain that persisted for at least three months’
duration. After a two- to four-week run-in period to es-
tablish average baseline pain levels, participants were
offered an eight-week, group-based acupuncture treat-
ment intervention. We evaluated the impact of this inter-
vention on pain intensity, mood, and functional status,
as well as the effects on analgesic use. Patients age
18 years or older were eligible to participate in this study
if they had chronic pain due to a qualifying diagnosis of
back pain, shoulder pain, neck pain, and/or osteoarthri-
tis. In addition, participants had to 1) understand
English 2) be able to provide phone numbers to facilitate
scheduling, 3) be available for up to eight weekly treat-
ments and 16 weeks of follow-up post-treatment, 4)
2
have not received acupuncture treatment within the
past three months, and 5) have no severe psychiatric
problems that could interfere with the ability to receive
treatment in a group setting.
Design
The study used a repeated measures quasi-
experimental design. The multiple pretreatment mea-
surement points during the run-in period allowed us to
document and monitor the typically variable patterns of
pain pre-intervention. This design optimized feasibility
and acceptability to patients and participating health
centers while still generating meaningful outcome data.
Specifically, we did not propose randomization within
the practices, rather allowing clinicians to offer the inter-
vention to all patients with target diagnoses who meet
eligibility criteria.
Intervention
The intervention consisted of eight weekly sessions of
acupuncture therapy in a group setting provided by li-
censed acupuncturists. Appointments were staggered
every 15 minutes; each subject was present for 40 to
60 minutes total, with the treatment lasting from 20 to
40 minutes. Group sessions were scheduled to accom-
modate up to eight subjects per session. Sessions were
conducted in the late afternoon and evening by the
same acupuncturist; the study care was delivered by
two acupuncturists (CK and TS), each with over
10 years’ clinical experience. Study sessions were often
assisted by a student acupuncturist or additional acu-
puncturist who helped greet patients but was not di-
rectly involved in patient care.
Our intervention manual was developed using a modi-
fied Delphi process over two months with a team of
acupuncturists experienced in individual and group acu-
puncture care for chronic pain including current and for-
mer fellows of the Acupuncture Fellowship for Inpatient
Care at Mount Sinai Beth Israel. Participants had trained
in the United States, China, and Vietnam. Our approach
consisted of real-world acupuncture therapy options
and combinations: assessment, palpation, Tui Na, Gua
sha, acupuncture needling, auricular treatment, and
simple diet and lifestyle recommendations based in tra-
ditional East Asian medicine allowing treatment to be
shaped to individual patients’ needs through time.
Common points were needled based on the patient’s
presentation, with optional points selected based on
palpation of channels. Points were needled to obtain
“de qi,” which can be felt by the patient and practi-
tioner, sometimes with fasciculation and/or a grabbing
of the needle as it is manipulated, representing fibril
“whorling” within the connective tissue and mechanical
propagation of the signal along channels or connective
tissue planes. Noncoated acupuncture needles were
used to maximize the connective tissue response and
analgesic effect [40–44].
 Acupuncture Therapy in a Group Setting for Chronic Pain
Non-needling techniques were also used in the ap-
proach, including Tui Na, manual therapy often used in
conjunction with acupuncture, particularly for muscle
and joint pain, and Gua sha, defined as instrument-
assisted closely timed unidirectional press-stroking of a
lubricated area of the body surface to intentionally create
transitory therapeutic petechiae called “sha,” represent-
ing extravasation of blood in the subcutis [45]. In Tui Na,
specific applications are used to stimulate, relax, warm,
and irrigate channels in or associated with painful areas
[46]. In traditional East Asian medicine, acupuncture
channels or meridians represent both the vertical and
horizontal pathways connecting the surface of the body
to internal tissues and organs. Acupuncture channels
and points have more recently been associated with
connective tissue planes [44], and their stimulation to a
global physiologic network [47]. Tui Na can be especially
useful if the subject is new to acupuncture therapy and/
or has a fear of needles. Gua sha is used to resolve the
condition known as “blood stasis” in Chinese medicine,
which is associated with persistent, fixed, or recurring
pain. Gua sha mechanically stretches the subcutaneous
fascia, and the production and resolution of “sha pete-
chiae” upregulates heme oxygenase-1 (HO-1), producing
an anti-inflammatory and immune protective effect locally
and systemically over a period of days following treat-
ment [26,48–50]. Gua sha was delivered using single-
use disposable metal caps [51] and a plain nonmedi-
cated balm. Auricular treatment included ear needling
and pressure applied to points on the ear with pretaped
seeds or sphere magnets retained between sessions.
Auricular therapy has been shown to be an effective
treatment for acute and chronic pain [52,53].
We instructed patients to arrive for treatment hydrated
and having eaten something within the last hour to re-
duce the incidence of presyncope. We asked patients
to wear loose clothing so that the neck, shoulders, up-
per back, forearms, and forelegs were accessible to
touch. Our sessions were conducted in a comfortable
clinic waiting area after clinic hours. Patients were either
seated in soft chairs or on a couch.
Data Collection
We had two primary outcome measures. The Brief Pain
Inventory–Short Form (BPI) [54] is a nine-item measure
that asks patients to indicate, over the past 24 hours,
the level of pain they are feeling, the intensity of pain,
and how their pain influences select aspects of their ev-
eryday life, that is, mood, walking, sleep, and their ability
to work. The Center for Epidemiological Studies–
Depression Scale (CES-D) [55] is a well-validated,
20-item measure of depressive symptoms. Secondary
outcome measures included the Patient Global
Impression of Change (PGIC), a single-question seven-
point categorical scale that captures a patient’s experi-
ence of treatment at baseline and follow-up points and
pain-free days, a self-report measure used in previous
pain research. Patients were asked to report the number
of pain free days in the previous two weeks. We also
Table 1 Data collection
Pre Week Week Week Week
Measure Baseline 1 1 8 12 24
BPI X X X X X X
CES-D X X X X X
Pain-free days X X X X X X
PGIC X X X
Demographics X
Medication use X X X X
BPI ¼ Brief Pain Inventory–Short Form; CES-D ¼ Center for
Epidemiological Studies–Depression Scale; Pre ¼ pre-acu-
puncture; Week 1 ¼ first acupuncture visit.
examined medication utilization, asking participants at
baseline and week 1, week 8, and week 24 to report
their use of pain medications over the prior two-week
period. Measures were collected over the 24-week
study period as per the schedule in Table 1.
Analysis
Pain severity was measured using four BPI questions re-
lated to worst, least, average, and current pain. Each
question was scaled from 0 (no pain) to 10; the answers
were summed to form the scale pain severity measure.
The multiple baseline (pre-intervention) measures were
averaged for a single baseline measure. Pain
interference was measured using four BPI questions re-
lated to worst, least, average, and current pain. Each
question was scaled from 0 (no pain) to 10, and these
were summed to form the scale pain interference mea-
sure. The multiple baseline (pre-intervention) measures
were averaged for a single baseline measure. For the
BPI, we also measured percent change from baseline to
24 weeks to identify those with at least a 30% change
over that period. Depression was measured as the sum
of the 20 CES-D questions (scored 0–10).
Sociodemographic factors and baseline health indica-
tors were examined comparing those patients who
completed the 24-week follow-up (N ¼ 96) with those
who initiated treatment but either withdrew from or were
lost to follow-up (N ¼ 9) using the Fisher exact test for
proportion and t test to compare means. Patients who
enrolled in the study but never initiated treatment were
omitted entirely from the analysis (N ¼ 8). To compare
average pain severity, pain interference, and depression
scores over time, repeated measures GLM were used
applying a Greenhouse-Geisser correction when the
spherocity assumption was violated by the data.
Additionally, baseline and 24-week outcomes were
compared using repeated measures t tests. Data were
entered, coded, and analyzed in SPSS v. 24. As there
were no statistically significant differences between the
eight- and 12-week outcomes on any of the measures,
we have presented the data as baseline, midpoint, and
end point to maximize the number of patients included
3
Kligler et al.

Table 2 Study demographics

Completed (N ¼ 96) LTFU (N ¼ 9) P

No. (%) No. (%)

Ethnicity Hispanic 25 (26.0) 2 (22.2) 1.00

Non-Hispanic 70 (72.9) 7 (77.8)
Missing 1 (0.1) 0 (0.0)
Race Asian 8 (8.3) 1 (11.1) 0.41
Black/African American 13 (13.5) 3 (33.3)
Other 18 (18.7) 1 (11.1)
White 53 (55.2) 4 (44.4)
Missing 4 (4.2) 0 (0.0)
Education Did not graduate high school 2 (2.1) 0 (0.0) 0.62
High school graduate 6 (6.3) 1 (11.1)
Some college 16 (16.7) 2 (22.2)
College graduate or greater 71 (74.0) 6 (66.7)
Missing 1 (1.0) 0 (0.0)
Work status Full time 56 (58.3) 6 (66.7) 0.37
Part time 9 (9.4) 0 (0.0)
Retired 17 (17.7) 0 (0.0)
Student 2 (2.1) 0 (0.0)
Disabled 4 (4.2) 1 (11.1)
Unemployed 5 (5.2) 1 (11.1)
Missing 3 (3.1) 1 (11.1)
Income <$20,000 10 (10.4) 2 (22.2) 0.86
$20,000–$49,000 26 (27.0) 1(11.1)
$50,000þ 45 (46.9) 5 (55.6)
Don’t know/refused/missing 15 (15.6) 1 (11.1)
Receiving routine medical care Yes 85 (88.5) 9 (100.0) 0.59
No 11 (11.5) 0 (0.0)
Insurance type Private 57 (59.4) 7 (77.8) 0.77
Fee-for-service 1 (1.0) 0 (0.0)
Medicaid 12 (12.5) 0 (0.0)
Medicare 17 (17.7) 2 (22.2)
N/A or missing 9 (9.4) 0 (0.0)
Disability Yes 6 (6.3) 1 (11.1) 0.48
No 89 (92.7) 8 (88.9)
Missing 1 (1.0) 0 (0.0)
Mean (SD) Mean (SD)
Age, years 54.0 (15.5) 44.7 (12.8) 0.09
Baseline pain severity 5.0 (1.7) 5.3 (2.0) 0.59
Baseline pain interference 3.7 (2.1) 4.7 (2.1) 0.13
Baseline 2-week pain-free days 1.5 (2.1) 1.7 (3.5) 0.75
Baseline depression 13.7 (9.0) 17.6 (12.2) 0.23

LTFU ¼ Lost to Follow Up.

in the analysis. For subjects (N ¼ 85) who had both
eight- and 12-week data, we averaged the values for
analysis. To compare self-reported past two-week pain
medication use from baseline to eight weeks and base-
line to 24-week post-treatment, we used Pearson’s chi-
square test of proportions.
Results
We recruited a total of 113 participants for the trial, 96
of whom completed the 24-week protocol. Eight
patients never initiated the study intervention. Of the re-
maining nine subjects, two patients withdrew, one pa-
tient moved away after three sessions, one had surgery
and could not complete the study, and five could not
be reached for the 24-week follow-up. Our average age
was 54.4 years, and the ethnic makeup of our study
sample was representative of the New York City popula-
tion. There were no significant differences between
study completers and noncompleters in any category,
including pain severity or depression at baseline. The
majority of our participants were insured, with 30.6% of

4
 Acupuncture Therapy in a Group Setting for Chronic Pain
those on Medicaid or Medicare. Outcome results below
represent the 96 study participants who completed the
24-week term of the trial. Demographics for the two
groups are presented in Table 2.
We had complete data on a total of 95 subjects on pain
severity, 94 on pain interference, and 95 on the depres-
sion outcome. Using the generally accepted definition of
a clinically significant change in pain being a 30% de-
crease from baseline, we found a statistically and clini-
cally significant decrease in both pain severity and pain
interference in our study population. This difference not
only persisted beyond the eight-week end-of-treatment
time point, but continued to increase through the 24-
week measure despite no additional treatment. Pain se-
verity decreased from 4.92 (95% confidence interval [CI]
¼ 4.58–5.26) at baseline to 2.72 (95% CI ¼ 2.19–3.32;
P < 0.01) at 24 weeks. Pain interference decreased from
3.59 (95% CI ¼ 3.17–4.01) at baseline to 1.87 (95% CI
¼ 1.38–2.37; P < 0.01) at 24 weeks. Fifty-five out of 95
patients (57.8%) showed at least a 30% reduction in
pain severity, and 64 out of 94 patients (68.0%) showed
at least a 30% reduction in pain interference. The aver-
age number of acupuncture sessions completed was
6.7. Changes in pain severity and pain interference are
shown in Figures 1 and 2.
The number of pain-free days in the past two weeks
also increased significantly during the course of the
study from 1.4 (95% CI ¼ 1.0–1.8); P < 0.01) at baseline
to 4.8 (95% CI ¼ 3.7–5.8; P < 0.01) at 24 weeks.
Change in pain-free days is shown in Figure 3.
We also found a statistically and clinically significant de-
crease in depression from baseline to 24 weeks as
BPI pain severity
Estimate marginal means
Baseline
Figure 1 Brief Pain Inventory–Short Form pain severity. BPI ¼ Brief Pain Inventory–Short Form.
measured by the CES-D. The mean score at baseline
was 13.47 (95% CI ¼ 11.67–15.27) as compared with
9.79 (95% CI ¼ 7.61–11.97; P < 0.01) at 24 weeks. The
clinical significance of this change is less clear than with
the pain measure as a cutoff of 16 on the CES-D is
usually used as a threshold indicating a risk for clinical
depression. As with the pain measures, the benefit in
depression was maintained through the 24-week end
point despite the fact that no additional treatment was
offered after week 8. Depression results are shown in
Figure 4.
The PGIC measure decreased over the study period
though the change did not reach clinical significance.
Regarding medication use, we found that the proportion
of subjects taking any type of pain medication over the
previous two weeks fell from 87% at baseline to 65% at
the 24-week mark (P < 0.01). However, the self-
reported data on this outcome were too inconsistent to
allow for analysis of specific medication categories.
There were no serious adverse effects reported in this
study and only infrequent minor adverse effects such as
needle site irritation and bleeding and tiredness after
treatment.
Discussion
Pain is a primary symptom that prompts health care
seeking including for care by acupuncturists. Low back
and neck pain were the leading causes of disability in
2015 in most countries [6], and approximately 12% of the
US population age 25 to 74 years has clinically defined
osteoarthritis (OA) of some joint [56]. There is evidence
that acupuncture is effective for chronic pain including
headache [57] and migraine [58], temporomandibular
Midpoint End point
5
Kligler et al.

BPI pain interference

6.00

5.00
Estimate marginal means

4.00

3.00

2.00

1.00

0.00
Baseline Midpoint End point

Figure 2 Brief Pain Inventory–Short Form pain interference. BPI ¼ Brief Pain Inventory–Short Form.

Pain-free days over the past 2 weeks

14.00

12.00
Estimate marginal means

10.00

8.00

6.00

4.00

2.00

0.00
Baseline Midpoint Endpoint

Figure 3 Pain-free days.

disorders [59] shoulder pain [17,18], pain of the lower
back and neck, and osteoarthritis of the knee [15,16,19–
30,60,61]. A 2016 meta-analysis of acupuncture trials for
neck, lower back and shoulder pain, knee OA pain, and
headache/migraine show that relief persists for 50% to
90% of patients even at 12 months’ post-treatment [31].
These trials, however, are of acupuncture given in individ-
ual sessions. The cost and lack of universal insurance
coverage for acupuncture creates a significant barrier to
access to individual acupuncture for patients from under-
served and low–socioeconomic status populations; offer-
ing acupuncture therapy in the group setting is a
potential solution to this access problem.
Depression and other mental health comorbidities often
contribute to disability and reduced quality of life in

6
 Acupuncture Therapy in a Group Setting for Chronic Pain
Depression
20.00
18.00
Estimate marginal means
16.00
14.00
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Baseline
Figure 4 Center for Epidemiological Studies–Depression Scale results. CES-D ¼ Center for Epidemiological
Studies–Depression Scale.
patients with chronic pain. Although studies are ongoing
regarding the impact of acupuncture on depression, a
2010 systematic review with meta-analysis found acu-
puncture’s benefit to be similar to that of antidepressant
medications [62]. A 2012 systematic review found that
acupuncture alone was comparable with antidepres-
sants or psychotherapy alone in the treatment of de-
pression [63], and a 2013 systematic review found a
high level of evidence to support the use of acupuncture
in treating major depressive disorders in pregnancy [64].
A large-scale 2013 trial found that acupuncture and
counseling can provide long-term benefits for many pa-
tients with ongoing depression in primary care [61,65].
Acupuncture is also shown to improve quality of life in
patients with depression [66].
Group acupuncture (also known as “community acu-
puncture”) sessions and clinics have increased in the
United States and in other countries to meet the
demand for care by those who cannot afford out-of-
pocket fees associated with individual session care.
By group acupuncture here, we mean treating
patients in turn in a shared setting, primarily seated in
chairs proximal to one another. Patients may or may
not interact with one another, but can hear conversa-
tion between other patients or between other patients
and the practitioner. Although there are no official
statistics on the number of community/group acu-
puncture clinics, as of 2012 at least 200 such pro-
grams were operating around the country, and this
number has certainly grown at this point [67]. Group
acupuncture has been studied for feasibility and qual-
ity of patient experience [67–70] for knee OA
[34,35,70], for cancer pain, for peripheral neuropathy
and digestive symptoms [36], to relieve radiation-
Midpoint End point
induced xerostomia [71], and for pain and peripheral
neuropathy in HIV patients [37]. However, no large-
scale effectiveness trials of group acupuncture for
chronic pain have been published to date.
In previous work, we found it feasible and effective to de-
liver individual acupuncture sessions in an underserved
primary care setting [32,33]. In this study, we confirm
that acupuncture therapy in a group setting is feasible
and effective in a primary care clinic in New York City.
We found a significant reduction of chronic pain and de-
pression over eight weeks of treatment. Perhaps more
importantly, we found that this benefit was sustained
through 24 weeks with no additional intervention despite
the fact that our treatment intervention was only eight
weeks long as opposed to the 12- to 16-week duration
more common in clinical trials. These findings clarify that
acupuncture therapy customarily given in an individual
setting can reduce chronic pain and depression in pa-
tients with chronic pain when given in a group setting as
well. Group acupuncture may therefore be considered a
safe and effective option for chronic pain patients.
Although our patient sample in this study was not exclu-
sively drawn from a low-income or underserved popula-
tion, there is no reason to assume that the pain
outcomes we demonstrated here would not apply to
these populations, potentially addressing the access is-
sue that impacts those of a lower socioeconomic status.
Limitations
Our trial used a quasi-experimental design and did not
have a control group. While acupuncture has been
shown to be effective for chronic pain and depression in
controlled trials, because of the lack of control group,
7
Kligler et al.
we cannot definitively say that the acupuncture therapy
was the discrete cause of the benefit to subjects here,
as opposed to the nonspecific treatment effects of care
or of participating in a group research project. A more
ideal design would randomize between group and indi-
vidual acupuncture, and in fact our current Patient-
Centered Outcome Research Institute (PCORI)–funded
effort, the Acupuncture Approaches to Decrease
Disparities in Pain Treatment (AADDOPT-2) trial, is tak-
ing this approach in a randomized study of 700 patients
receiving acupuncture at community health centers in
the Bronx, New York. A second limitation in the present
study was the lack of an effective strategy for collecting
data on medication use, which is another important out-
come potentially impacted by acupuncture treatment.
Conclusions
Weekly acupuncture therapy offered in the group setting
for eight weeks was effective in reducing pain severity,
pain interference, and depression in patients with
chronic neck, back or shoulder pain, or osteoarthritis.
Benefit persisted through the 24-week measure despite
no additional treatment. This finding has potentially im-
portant implications for improving access to effective
acupuncture treatment for patients with limited financial
resources.
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