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Abstract

[Objective] The age, the chief complaint, the number or period of the treatment of patients who receive acupuncture and herbal prescription in the USA are not satisfactorily investigated. The aim of this analysis is to clarify such information by reviewing clinical charts in affiliated acupuncture clinic of Meiji College of Oriental Medicine. This study would helps oriental medical practitioners, acupuncturists, educators, and students to understand the actual circumstances of Oriental medicine in the USA.
[Methods] This study performed the statistical analysis of 3,000 clinical charts (Male: 1,034, Female: 1,966) of patients who have visited the clinic as the new patients from January 1996 through December 1999 and have not appeared for more than six months from the final treatment until November 2000.
[Results] In both gender, more than 60% of the population aged from 20 to 40 and showed skewed distribution toward younger ages. The median age in total was 34 ( male;35, female;33). The age between male and female using non-parametric method demonstrated significant difference. Male were 34.5% and female were 65.5% in 3,000 patients. 2,235 patients complained their conditions as clinical symptom, 653 patients complained their conditions as certain disease name, and 112 patients explained ambiguous condition. Among those who explained their condition as clinical symptom, musculoskeletal pain (n=1008, 33.6%), other pain (n=224, 7.5%), fatigue (n=160, 5.3%), stress (n=107, 3.6%), and muscle stiffness (n=104, 3.5%) were found to be majorities. While those who told disease name complained allergy on sinus (n=61, 2.0%), asthma (n=53, 1.8%), common cold (n=42, 1.4%), musculoskeletal pain (n=41, 1.4%), insomnia (n=38, 1.3%). The proportion of patients who received only acupuncture treatment (AT), combined treatment of acupuncture and herbs (AHT), and those who used only herbal medication was 15.7%, 83.2% and 1.1%, respectively. The median of number of consultation and period for acupuncture session was 2 times and 12 days, while the number and period of herbal prescription (HP) was 2 times and 12 days in AHT group, respectively. There were significant statistical difference on the number and period of the AT between AT group and AHT group. Moreover, among different chief complaint groups demonstrated significant differences as the number of AT, period of AT, the number of HP, and period of HP in AHT group.
[Conclusion] It was suggested that patients expect to receive AHT more than only AT , and that the alleviation of the patients uncomfortable feeling is important in acupuncture and herbal treatment. Furthermore, it was suggested that the different chief complaint may need the different treatment frequency and period.

Key words: USA, acupuncture treatment, herbal treatment, actual condition survey

I. Introduction

Although interest and concern of oriental medicine such as Acupuncture and Chinese herbs in the USA or the other western country in past decades has been increasing 1- 8), the age, the chief complaint of patients, or the number and period of treatment in acupuncture clinic are not satisfactorily investigated. This kind of information shall be important for the oriental medical practitioners, acupuncturists, educators and students to know the actual circumstances of Oriental Medicine in the USA. This study described the analysis of patients who visited acupuncture clinic of Meiji College of Oriental Medicine (MCOM) which was used to be located Berkeley, California. The treatment theory utilized by acupuncture colleges in California is so called Traditional Chinese Medicine (TCM). As a scope of practice of acupuncturist in California, licensed acupuncturists have used both acupuncture and Chinese herbs. California, in which the officially licensed acupuncturist are allowed to prescribe herbs, is a kind of ideal environment to practice Oriental medicine because both acupuncture and herbal prescription are primarily essential factors of Traditional Chinese Medicine. Although some of the acupuncture or herbal treatment theory is western medical oriented, it shall be very useful to the society to know the demands of patients for Traditional Chinese Medicine.
Therefore, what we investigated in the present study are; age, chief complaint (by symptom or disease name), and the frequency (number) and period of treatment by reviewing clinical charts of 3,000 outpatients who consulted the acupuncture clinic in MCOM.

II. Methods

1. Subjects
A total of 3,000 clinical charts of patients who have consulted the clinic from January 1996 through December 1999 and have not appeared for more than six months from the final consultation.
The information we analyzed in the study are as following; age, gender, chief complaint(by symptom or disease name), kind of treatment used (acupuncture treatment including indirect moxibustion), or combined treatment with acupuncture (including indirect moxibustion and herbal medication), the frequency of the treatment , and period of the treatment.
The chief complaints are classified into three groups according to the expression by the patients as following:symptom, disease name, and ambiguous symptom.
The treatment style, frequency, and the additional herbal prescription were decided according to the agreement of patients. The acupuncture treatment and herbal prescription were performed no more than once a day.

2. Classification of chief complaints
Chief complaints are classified into three categories, which are symptom, ambiguous complaint, and disease name. Symptom was classified as; musculoskeletal pain, other pain, fatigue, stress, and muscle stiffness. Other pain is defined as pain not due to musculoskeletal problem such as headache, stomachache, sore throat, abdominal pain, or chest pain. Disease name were classified as allergy on sinus, asthma, common cold, musculoskeletal pain (including rheumatoid arthritis, temporomandibular joint dysfunction pain, sciatica), insomnia. Ambiguous complaint is defined as a complaint that was not classified as certain symptom nor disease name (health maintenance, smoking cessation, experience acupuncture, etc). Ambiguous complaint was broadly classified as health maintenance and improving immune system.

3. Style of Treatment
Style of the treatment was classified into two groups. The patients who received only acupuncture treatment (including indirect moxibustion ) without herbal prescription through the treatment period were classified as acupuncture treatment (AT) group. The patients who were treated with combination of acupuncture and herbal prescription were classified as AHT (acupuncture and herb combined treatment) group. When herbal prescription was done once in the process when the patients received acupuncture treatment, it was regarded AHT.
The patients who were received only herbal prescription were classified as HM (herbal medication) group. The AT and AHT group include patients who received indirect moxibustion treatment.

4. The frequency and period of treatment
The period of the treatment are defined as the term between the date on which the treatment for the chief complaint was started and the date on which the final treatment for the complaint was performed. If chief complaint changed during treatment, we regarded the final treatment day before the chief complaint changed, when the chief complaint had not been expressed for more than 6 month by patient as the final treatment day. We also regarded the final treatment day when a patient did not appear for more than 6 month as the treatment finished.
The frequency of the treatment is the number of treatment from the initial consultation to the final consultation on each patient. Because acupuncture treatment and herbal prescription are not always combined in the AHT group, the total number of acupuncture treatment and the total number of herbal prescription were counted independently.
The number and period of the treatment were further analyzed among the AHT groups that were classified according to the difference of the chief complaint.

5. Method of statistical analysis
Stat View J-4.5 (Abacus Concepts Inc. U.S.A.) for Macintosh was used for the analysis. Data were expressed as median(minimum, maximum). Mann-Whitney U-test was applied for the comparison of the age between male and female patients, the number and period of acupuncture treatment between male and female, the number and period of herbal prescription between male and female in AHT. Furthermore, Mann-Whitney U-test was applied for the comparison to the frequency and period of acupuncture treatment or herbal prescription between AT group and AHT group. Kruskal - Wallis test was applied for the comparison to the number and period of the treatment on different chief complaints in AHT group. Differences were considered statistically significant when p-value was less than 0.05.

III. Results

1. Age of Patients
The age distribution in 3,000 patients is shown in Fig 1. Histogram demonstrated that patients from 20 to 40 years old occupied more than 60% in the clinic of the subjects. Male and female patients showed similar skewed distribution toward younger ages in the histogram. The median (minimum, maximum) of age of patients elicited 34 (4,90), demonstrating significant statistical difference between male and female patients (Table 1).

2. The proportion of the patient gender
Male patients were 34.5 % and female patient were 65.5 %. Female patients were more than half number of patients (Table 1).

3. Classification of chief complaints
Of the 3,000 patients, 2,235 (74.5%; 791 male and 1,444 female) expressed their chief complaint as clinical symptom (symptom group) , while 653 (21.8%; 202 male and 451 female) told disease name (disease group). Chief complaints of the other 112 patients (41 male and 71 female), which were not classified symptom or disease name, were categorized as ambiguous complaint (Table 1).
Table 2 shows five major chief complaints in each group. Musculoskeletal pain (including low back pain, neck pain, back pain and shoulder pain etc.) was the most frequent (45.1 %) in the symptom group. The proportion of patients who complained other pain (including headache, stomach pain, sore throat etc.) was 10.0%, showing 55% of the subjects complained are some kind of pain. Fatigue (7.2 %) and stress (4.8 %) followed symptoms of pain. Others in symptom group contain psychological problem (n=91, 4.1%), symptoms of otolaryngology (n=84, 3.8%) and weight control (n=73, 3.3%) etc.
Allergy on sinus was the most frequent (9.3 %) in the disease name group. The proportion of patients who complained asthma was 8.1%. Common cold (6.4 %) and musculoskeletal pain (6.3 %, including sciatica, temporomandibular joint dysfunction pain, and rheumatoid arthritis) followed. Others in disease name group contain acne (n=29, 4.4%), premenstrual syndrome (n=26, 4.0%) and tendonitis (n=25, 3.8%) etc.
The ambiguous complaint were classified into two kinds (Table 2). The major category in the group was health maintenance (93.8 %), the other one was immune system improvement (6.2%).

4. The proportion of AT group and AHT group
The proportion of patients who received only acupuncture treatment (AT), combined treatment of acupuncture and herbs (AHT), and those who used only herbal prescription was 15.7 %, 83.2 % and 1.1 %, respectively (Table 1).

5. The frequency and period of treatment session (Table 3)
Median of acupuncture treatment number of the overall patients was 2 (1,96) times (male; 2 (1,96) and female; 2 (1,89)). Median of treatment period was 12 (1,935) days in 2,967 patients (male; 8(1,772), female; 15(1,935)). There were significant differences between male and female in the number and period of acupuncture treatment in 2,967 patients including AT group and AHT group. Furthermore, there were significant differences in acupuncture treatment number and period between AHT group and AT group (P<0.01).

6. The frequency and period of herbal prescription in AHT group (Table 3)
The total number of herbal prescription in AHT group was 2 (1,60) times (male;2(1,58), 2 (1, 60)). The period of herbal prescription was 12(1,960) days in AHT group (male;8 (1,772), female;15(1,960)). There were significant differences between male and female in the number and period of herbal prescription (P<0.05).

7. The frequency and period of acupuncture treatment by type of symptoms
The acupuncture treatment number and period in each five major categories of symptom group and disease name group, and two major categories of ambiguous complaint group were shown in Table 4 and 5.
There was significant difference in the acupuncture treatment number and period of musculoskeletal pain and stress between male and female (P<0.05) in symptom group (Table 4). There was no significant difference in the acupuncture treatment number and period between male and female in disease name and ambiguous complaint group (Table 5).

8. The frequency and period of herbal prescription among symptom group, disease name group, and ambiguous complaint group
The number and period of herbal prescription by five major categories of symptom group, disease name group, and two major categories of ambiguous complaint group were shown in Table 6 and 7. There was significant difference in the number and period of herbal prescription between male and female who complained musculoskeletal pain (P<0.05, Table 6). There was no significant difference in the herbal prescription number and period between male and female in disease name and ambiguous complaint group (Table 7).

9. The frequency and period of acupuncture treatment or herbal prescription by different chief complaints.
These statistics were performed among 5 major symptoms (symptom group), 5 major disease names (disease name group), and health maintenance (ambiguous group). There were significant differences in the number and period of acupuncture treatment among different complaints (p<0.01). Furthermore, there were significant differences in the number and period of herbal prescription among different complaints (p<0.01).

IV. Discussion

This study demonstrates the statistical analysis of patients who consulted at acupuncture clinic of MCOM, Berkeley California. When we consider the population in USA, it would not reflect the exact information. But, this report should be one of valuable information when one try to suppose what is the demands for Oriental Medicine by the society. Oriental Medicine in the USA may be a developing medicine, but it is the tradition in Asian countries. This might explain that patients at the clinic are much younger than patients who visit acupuncture clinic in Japan.
Because the sample size in the present study was large (3,000 total), there were significant difference in age between male and female, but the median of difference was less meaningful (approximately 2 year). Proportion of gender showed that female (65.5%) was higher than male patients (34.5%). The result suggests that female is more likely to use oriental medicine than male.
Although it was very difficult to classify the chief complaint into disease name group or symptom group, most new patients is presumed to complain symptom because this study demonstrated that about 21.8% of the new patients complained disease name, and about 74.5% complained symptom. Acupuncturist should be able to play a role of primary care practitioner, because 74.5% patients complained symptom according to our study. Furthermore, patients may expect oriental medicine to alleviate uncomfortable symptom, which is caused by some essential problems. If this hypothesis is correct, it is presumed that it is very important in Oriental Medicine to be able to improve uncomfortable symptoms or feelings. However this study does not demonstrate that Oriental Medicine can give a better result than Occidental Medicine. Psychological effect, satisfaction, or rapport between patient and the oriental medical practitioner may influence on patients happiness or satisfaction if many patients are attracted to visit oriental medical clinics, because it takes longer time for a session of oriental medical treatment or consultation than occidental medicine, generally speaking. The musculoskeletal pain showed the largest number in total chief complaints (33.6 % of 3,000 patients). This suggests that the society may expect or recognize that oriental medicine is useful for alleviation of pain; as a result, many patients who visit acupuncture clinic may expect to alleviate its pain symptom. Therefore, acupuncturists should be able to take care of pain well. Although allergy on sinus elicited only 2.0 % of 3,000 patients and asthma elicited 1.7 % of 3,000 patients, these showed the first and the second large number in the category. Authors presume that patients might have started to expect the effects of Oriental Medicine for allergy in USA. Others of symptom group occupied 21.1 % of 3,000 patients, others in disease name group occupied 13.9 % of 3,000 patients. This result demonstrates that acupuncture clinic accepts patients who have so much miscellaneous chief complaints in the various kinds of medical fields. Simple convenience for visiting clinic may useful for current demand, because oriental medical treatment is presumably much lower cost comparing to the general Occidental Medicine today.
Patients who expect health maintenance were classified into ambiguous complaint group. It occupied 3.5 % of 3,000patients, which was more than allergy on sinus (2.0 %), and the largest percentage of the ambiguous complaint group. Health maintenance, a medical science that focuses on preventing health troubles or diseases, is called preventive medicine. Therefore we suppose that it should be emphasized to study Oriental Medicine in the future from the view of preventing medicine, also.
Although it is not clear why AHT group elicited 83.2 % on the contrary to AT group elicited 15.7 %, it is presumed that patients who visited acupuncture clinic desired to receive acupuncture and herbal treatment. Because acupuncturists in this clinic do not basically decide a treatment style dogmatically and it is decided with the agreement with a patient.
The median of the number of acupuncture treatment was 2 times, and the period was 12 days. The median of the number of herbal prescription was 2 times, and the period was 12 days in AHT group. This demonstrates that patients visited the clinic 2 times during approximately 2 weeks if we do not consider whether patients were cured or not.
We consider there are mainly four reasons in the treatment frequency and period; (1) alleviation of the symptom, (2) no effect, (3) financial reason, (4) changed clinic. But the aim of this investigation did not find clear reason why patients visit the clinic 2 times. We need more investigation about that factor.
Both the acupuncture treatment number and period elicited significant differences between AT group and AHT group. AHT group demonstrated longer the number of treatment and period than AT group. One reason is presumed that only acupuncture treatment is applied on acute or not serious symptoms, and acupuncture and herbal treatment was applied on chronic or serious symptoms. Furthermore, the acupuncture treatment and herbal prescription number and period among the different chief complaints elicited significant differences suggest the possibility that the effect of acupuncture treatment or herbal prescription might be different according to the each chief complaints.
This study indicated only the analysis of patients who visited the clinic (MCOM) without regarding they were alleviated or not. Therefore, we need to investigate whether AT or AHT is effective or not on the miscellaneous chief complaints. We should know how many treatment number and how long it takes the period for cure or alleviation of the symptom or disease through acupuncture treatment or acupuncture and herbal treatment.

V. Conclusion

We investigated patients in affiliated acupuncture clinic of Meiji College of Oriental Medicine by the clinical charts regarding the age, gender, chief complaint, AT only or AHT, the frequency and period of AT or HP. We took below results.
(1) The median of age was 34 (male: 35, female: 33). Patients from 20 to younger than 40 years old occupied more than 60% in the clinic. Female occupied 65.5 % and male occupied 34.5 % in 3,000 patients.
(2) 2,235 patients complained symptom, 653 patients complained disease name, and 112 patients complained ambiguous complaint.
(3) Musculoskeletal pain was most popular chief complaint in symptom group. Allergy on sinus was most popular in disease name group. Health maintenance was most popular in ambiguous complaint group.
(4) Patients who accepted AHT were 2,496 (male: 829, female: 1,667). Patients who accepted AT were 471 (male: 202, female: 269).
(5) The median of the frequency of AT was 2 times (male: 2, female: 2), and period was 12 days (male: 8, female: 15). The median of the frequency of HP was 2 times (male: 2, female: 2), and period was 12 days (male: 8, female: 15). There was significant difference between male and female in the frequency and period of treatment. The AT frequency and period of musculoskeletal pain were 2 (male: 2, female: 2) and 8 (male: 8, female: 13), and herbal prescription frequency and period were 2 (male: 2, female: 2) and 8 (male: 8, female: 12), respectively.
(6) There were significant differences on the frequency and period of acupuncture treatment between AT group and AHT group.
(7) There were significant differences on the frequency and period of acupuncture treatment and herbal prescription in different chief complaint.
These results suggested that many patients might expect to receive both acupuncture and herbal treatment. According to many patients complained symptom than disease name, it is important that oriental medical practitioner rapidly alleviate patients uncomfortable symptom. Further, it was suggested that the different chief complaint might need the different treatment frequency and period.

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