Article Text


‘All in the same boat’: a qualitative study of patients' attitudes and experiences in group acupuncture clinics
  1. Anthea Asprey1,
  2. Charlotte Paterson2,
  3. Adrian WhiteA3
  1. 1Primary Care Research Group, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK
  2. 2School of Social and Community Medicine, University of Bristol, Bristol, UK
  3. 3Primary Care Research Group, Peninsula College of Medicine and Dentistry, University of Plymouth, Plymouth, UK
  1. Correspondence to Anthea Asprey, Primary Care Research Group, Peninsula College of Medicine and Dentistry, Smeall Building, Magdalen Road, Exeter EX1 2LU, UK; anthea.asprey{at}


Background Group acupuncture clinics have been introduced in a London hospital and in two general practices in Hertfordshire for the treatment of knee osteoarthritis (OA). Encouraging preliminary reports have been published of the efficacy of the treatment delivered in this setting but its acceptability to patients has not yet been established. The aim was to investigate the acceptability and perceived advantages and disadvantages of acupuncture delivered in the group setting for the treatment of knee OA.

Methods Semistructured interviews were conducted with 16 patients in their own homes and with four nurses over the telephone. Interviews were recorded, transcribed, fully anonymised and analysed thematically.

Results Group acupuncture was delivered with enthusiasm by nurses, was acceptable and popular with patients and recognised to be cost-efficient. Factors affecting acceptability were situational, interpersonal and intrapersonal. Situational factors included adequacy of the physical space used, flexibility of the appointment system and the changing and adaptable nature of the group. Interpersonal factors were mutual support, the exchange of information, the provision of mixed or single-sex sessions and the role of the acupuncture nurse. Intrapersonal factors that increased acceptability were less clear, but nurses expressed the view that the group setting was less suitable for patients with complex conditions or severe pain.

Conclusions Acceptability is very high and may be maximised by taking a number of factors into account: full information should be provided before treatment begins; flexibility should be maintained in the appointment system and different levels of contact between fellow patients should be fostered; sufficient space and staffing should be provided and single-sex groups used wherever possible.

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Acupuncture is provided in a group setting in nurse-led clinics to patients with osteoarthritis (OA) of the knee. This service is provided in secondary care at the Royal London Hospital for Integrated Medicine, and in primary care in St Albans, Hertfordshire, where the service was set up on a trial basis for patients who would otherwise be referred for an orthopaedic opinion. Treatment is part of the local health service (figure 1) initiative to reduce referrals to secondary care, reduce surgical interventions and offer care locally.1,,3 The treatment procedure was virtually identical in the clinics except that, in the London clinic, electroacupuncture (EA) was used for all patients except those with contraindications who received manual treatment only whereas, in the St Albans sessions, EA was only given when manual acupuncture was deemed to have been ineffective after the first four sessions or at any time thereafter that manual treatment was considered to be inadequate.2 ,3

Figure 1

Group acupuncture clinic.

The success of these group clinics in terms of symptom relief is being evaluated, and preliminary reports are encouraging.1 ,3 Group clinics appear to be acceptable to patients and it has been observed that more benefits are derived than from individual treatment.3 A small-scale study in Middlesex of women with breast cancer receiving auricular acupuncture for hot flushes found a high level of acceptability,4 but a full investigation of the acceptability of group clinics for patients with knee OA has not yet been undertaken.

The study reported here was designed to examine the acceptability of the group acupuncture clinics for patients with knee OA, and to identify the perceived advantages and disadvantages of this method of delivery. Patients were drawn from those attending clinics in the two general practices in St Albans and the Royal London Hospital for Integrated Medicine. In order to explore the experiences and perceptions of patients and nurses in depth and to develop some conceptual explanations for the findings, we chose qualitative methods and individual interviews.5


Sampling and data collection

We approached a purposive sample of patients and all the acupuncture nurses in the clinics were approached for an interview. The patient sample was obtained by asking the nurses in both clinics to give information packs to approximately the same number of men and women and to approach as wide an age range of patients as possible. All the patient participants who responded requested to be interviewed in their own homes and written consent was gained at the time of interview.

Patients were interviewed face-to-face using a semistructured approach with open questions and prompts to ensure that the same general topics were covered in each interview at the same time as allowing for flexibility and probing to elicit more thorough data. This approach allows the interviewer to discover the interviewee's own framework of meanings rather than imposing preconceived structures and assumptions,6 and was therefore deemed appropriate for this exploratory study. Nurses were interviewed over the telephone using the same approach.

The interview schedules were developed by the researcher in consultation with the two other team members who were, respectively, a practising acupuncturist physician and researcher and a physician with long-term experience of research into complementary medicine. The interview schedule was refined after a pilot interview with a patient representative.

A sequential questioning method was adopted to help patients and nurses recall their experiences.7 This involves asking questions about events in the way they unfold so, for example, patients were first asked about their past experiences of acupuncture treatment, then how they were offered the group acupuncture and what were their expectations, experiences and views of the very first clinic they attended. Subsequent questions addressed their ongoing experiences and views of the group clinic.

Data analysis

Interviews were transcribed verbatim by the researcher to start the process of familiarisation with and interpretation of the data.8 Data collection and analysis occurred concurrently and continued until no new major themes were occurring. Scripts were coded using the NVivo specialist computer-aided qualitative analysis package (NVivo Version 2.0). Codes were developed iteratively—that is, interview scripts were continually revisited in the light of subsequent scripts to ensure that the codes were comprehensively applied.9 ,10 Blind double coding was undertaken on an early sample of scripts and discussions were held by the research team to verify that codes had been applied systematically, accurately and appropriately and that no important issues had been overlooked. Some codes arose directly from answers to interview questions, such as those used for descriptions of how the clinics were conducted, whether nurses introduced patients to each other and so on, but an inductive approach was also used to identify concepts emerging directly from the data.11 ,12 The data were then analysed thematically to identify salient themes.13 The themes developed by the principal researcher were also checked by other members of the research team to ensure that an accurate and balanced interpretation of the data was achieved.


All those who responded were interviewed (16 patients, 4 nurses). Equal numbers of patients were obtained from each clinic and the final sample consisted of 16 patients (10 women and 6 men) aged 48–89 years, with equal numbers in each of the three clinics. A wide variety of individuals was obtained in terms of present or previous occupation: 10 interviewees were retired but had pursued a variety of occupations in the past including teaching, clerical work and building; those who were currently employed included a medical secretary and an architect. Four of the six nurses involved in acupuncture clinics (3 women, 1 man) volunteered to participate.

Factors influencing the acceptability of group acupuncture clinics sometimes appeared to reside in the situation itself and sometimes in the nature of the interaction that occurred within the situation; salient factors were also identified that resided within the individual patient. Themes derived from the data will therefore be presented under three main categories: situational, interpersonal and intrapersonal.

Situational themes

There was evidence to suggest that the particular way in which group clinics are organised contributes to their acceptability. The usual treatment pattern in the group clinics was an initial series of weekly sessions (usually four) followed by appointments at gradually increasing intervals until a 6-week interval was reached. Each week the clinic session therefore comprised a different combination of individuals, as patients attended at varying intervals. Second, appointments were staggered across the 2 or 3 h of the clinic so that people arrived at different times, stayed for 30–40 min and then left. The choice provided by this structure was used by some people to ‘meet the same people’ whereas others valued seeing different people, which was good ‘because you would run out of conversation’. Most patients described how they liked a mixture of contacts in the clinics, some people who were familiar and others who were new: ‘I usually go at four o'clock, you know, you get to see the same ones and it's “Oh hello, how are you?”, you know. And then sometimes you meet a different one and then it's quite nice to talk to them, and if you've been going longer they ask me how I've found it.' (Woman in her 60s)

The opportunity to make stronger ties with others attending the clinic was less likely to occur in the London clinic, which served a much larger and more densely populated area, than in those taking place in Hertfordshire.

Another aspect of group sessions that contributed to acceptability was the greater flexibility they offered to patients compared with individual treatment. Because each clinic can accommodate a flexible number of people, it is possible to give extra appointments when requested because of increased pain or other personal reasons. In addition, it is possible to alter the intervals between treatments on a more formal but still flexible basis without substantially disrupting the system. One woman, for example, who had had arthritis since early childhood and experienced very intense pain had been offered more frequent appointments to accommodate her specific needs: ‘I've gone back to 3 weeks because the 3 weeks I can manage … I went to 4 and I tried 5, and at 5 I was horrendous and even at 4 I wasn't good, so that's why I've gone back on to 3 … She (the nurse) is very flexible and, you know, it does help.' (Woman in her 50s)

Other patients with less pain reported negotiating longer periods between appointments, up to 12 weeks. Such flexibility was greatly appreciated by the patients and also valued by the nurses: ‘The situation we faced with just doing one-to-one clinics was someone would perhaps have a course of acupuncture, maybe have six sessions or something, and then they’d be booked in for a follow-up and they wouldn't get seen for another 7 months … and that was very frustrating for the patients and it was ineffective healthcare from us.' (Nurse)

Acceptability was also influenced by the availability of a suitably large physical space for the clinic rather than using smaller consulting rooms. Small rooms were more difficult for the nurses in terms of monitoring several patients at once, and could also feel socially uncomfortable for patients: ‘I think once I had it done, she was in tiny rooms and there was two of us in a room, and whoever I was with wasn’t very chatty and I found it quite a long time, whereas when it's in the big room, even if you're not talking, you can listen to the others' conversations, you know.' (Woman in her 60s)

It appeared that the space available affected the group dynamics and that most patients were more relaxed with each other in a larger space. The following quotation is from another interviewee who subsequently withdrew from the group sessions: ‘Most of the people were nice, but there was one particular woman … and I thought “I can’t come any more, I can't sit with her!” … She was over the top and really pushing us all and bullying about what we should believe and what we should do … it was such a small room anyway, and it was just so full on, and I felt very intimidated.' (Woman in her 60s)

The use of EA was very compatible with the group situation and afforded benefits to both nurses and patients. The patients appeared to enjoy being allowed to control the strength of the pulse without supervision. This was of necessity as the nurse did not have sufficient time in a group clinic to always be in control of each machine being used. Patients sometimes described this in the interviews and were positive about the experience: ‘They said, “You control it, this is how the machine works” … well, basically everybody’s got different tolerance levels, anyway, to pain, haven't they? I mean, what I would feel was painful, maybe to somebody else it would feel like a scratch so, you know, I do think it's important that you control, the individual patient actually controls how much vibration is going on, really.' (Woman in her 50s)

Interpersonal themes

The supportive environment that may develop in the group clinic appeared to contribute significantly to the acceptability of receiving acupuncture in this setting. One of the most striking themes to emerge from the interview data was the encouragement, comfort and support that patients derived from attending a regular event with other people who had comparable physical difficulties: ‘We always know we’re not the only one in that boat … when you're in a lot of pain you think, “Oh, I don't know, is it just me, am I exaggerating, is it mental?”, like this. And you see how everyone else suffers and how they cope with it.' (Woman in her 50s)

The nurses were aware of this dynamic in the group, which they felt helped patients to feel more ‘normal’. Two of the male interviewees, however, distanced themselves from the idea of mutual support: ‘From my point of view I wouldn’t have to rely on somebody else's support, I don't think.' (Man in his 70s) ‘I would say that it (social element of the session) doesn’t have any significant importance for me at all … I mean, it's just because you're there for half an hour, you might pass the odd comment on something, but you're not establishing an ongoing friendliness.' (Man in his 60s)

This response did not, however, appear to prevent these patients from gaining benefit from the clinic and both spoke positively of the group sessions. Indeed, the last speaker, who maintained throughout the interview that, as far as the group was concerned, he could ‘take it or leave it’, made the following comment at the end of the interview which suggests that this very kind of ‘normalisation’ had indeed taken place: ‘Well, it was quite nice being in the group. Because you kind of think, well other people have got the same sort of problems, you’re not completely weird!'

Patients also sometimes expressed the view that this shared experience liberated them to discuss the difficulties associated with arthritis more openly, as they sometimes found this difficult in their everyday lives: ‘It’s just the fact that somebody else knows what you're going through. And most of the other people I know are much younger than me, so they haven't got a clue what I’m on about.' (Woman in her 50s)

The nurses were aware that they were unable to provide this kind of support themselves: ‘That’s the benefit for them, from the patients' point of view, I think, seeing other patients going through the same problems as themselves would make them feel almost they're supporting each other and they think, “Oh, I’m not the only one!” … and, because I don't have the condition myself, I can't give that insight that they can give to each other.' (Nurse)

Another aspect of this support was directly related to the acupuncture treatment itself. The next two quotations illustrate the importance of this in both starting and persisting with acupuncture: ‘I was just a little apprehensive at first, but I saw all the other brave ladies there not flinching or anything, so I thought, “Oh well, it can’t be too bad”.' (Woman in her 80s) ‘I think that there is a sharing of how effective the treatment is for individuals. Um, some people are surprised by the long-term effect, if you like, the 4-week or 6-week effect of the acupuncture, when they’re still on a 2-week cycle.' (Man in his 60s)

Nine of the interviewees were able to compare the group setting with previous experiences of individual acupuncture treatment and appeared to prefer group sessions because of the element of mutual support and companionship: ‘Yeah, it’s beneficial in a group from the point of view you've got someone to talk to, you've got an exchange of ideas or problems or whatever. Whereas if you sit there on your own you're basically just waiting for the clock to tick round to say, “Well I’m finished now”.' (Man in his 70s)

There was evidence that the conversations that occurred in the clinic could be both pleasant and useful. Often the content of the conversation was reportedly fairly insubstantial but nevertheless enjoyable and sometimes humorous: ‘We just sit there talking about things, really. Discussing the family and shopping and where we’re going, are we going on holiday and just have a general chit-chat really … I enjoy meeting the other people, it's quite nice to know things, you know.' (Woman in her 80s) ‘It was also like a bit of an old git’s thing, you know, all our varicose veins and our knobbly knees, “Oh they're lovely! Oh I wish I’d shaved my legs!”, you know, it's all about keeping it light, in a way.' (Woman in her 50s)

Additionally, there was evidence that participants shared useful information with each other, particularly about managing the arthritis on a daily basis: ‘Or somebody says, “Oh well, I find if I lay this way or do that it eases it” and, of course, it all helps everybody … so you’re picking up the information.' (Woman in her 70s) ‘Somebody perhaps will go swimming, so they’ll say, “This was a nice swimming pool and it was easy to get to,” so it sort of spreads into all sorts of things. And how the shop-mobility works in certain places and all sorts of things really, which you wouldn't actually have if you were sat on your own in a cubicle.' (Woman in her 50s)

The nurses confirmed that this kind of information exchange took place among the patients, including discussions about the advice and treatment they had been given by different healthcare professionals: ‘They would exchange ideas, their own experiences, how long they’d had the condition, how, you know, how much support locally they had, or not (laughs) and, yes, often it's about the condition and their management of the condition and exchanging ideas … and often they would say, “Which doctor do you see here? My doctor says this,” because they might see different consultants in this hospital so, yeah, in terms of their overall treatment plan, they might, you know, exchange ideas.' (Nurse) ‘There’s a sort of certain socio-educational aspect to it as well, which is supportive … and they'll discuss other therapies such as chondroitin or that sort of thing … there's quite an exchange of information going on.' (Nurse)

A number of the patients mentioned that they had reduced their use of pain killing drugs as a result of participating in the acupuncture clinics: ‘I took it upon myself to reduce the medication … I have reduced it by 50% so, you know, that is a big difference, but ultimately I want to not be taking diclofenac at all. So, we’ll see. It (acupuncture) is definitely better than dosing yourself up on pain killers.' (Woman in her 40s)

This behaviour is not, of course, directly associated with the group nature of the treatment, although patients who try this strategy may share it with others in the group and thus encourage them to do the same.

Being treated in a group inevitably means that patients are largely deprived of the opportunity to be private. Acupuncture for OA of the knee, however, involves exposing only the knee, and no interviewee expressed any serious difficulties with doing this: ‘Well, it was only my knee, you know, it’s not like you've got to strip off everything else, so, that would be slightly different (laughs), but yes, I felt fine … You're just rolling your trouser leg up … it's quite acceptable.' (Woman in her 50s)

One of the clinics offered the option of having curtains pulled around each patient and all the patients interviewed from this clinic had experienced having curtains open and closed around them at different times, and preferred them open: ‘Now they sort of closet everybody off, you have the curtains drawn around your bed, but at the time it was more open, there were no curtains … everybody could see and there was quite a bit of interchange as well which I actually preferred … I don’t know why it happened, but I think it is better when we're in a room and we can exchange glances, laughs, the social aspect of it.' (Woman in her 50s)

Another interpersonal aspect of the group situation which may affect acceptability is whether the clinic is mixed or single sex. One clinic used single-sex groups in separate rooms while the other two were mixed. Both were acceptable: ‘There aren’t very many men that are around during the day when these sessions take place, and if there are, they're the older gents and, you know, you can have a chat with them … and I think, well, if it was segregated, it wouldn't make a lot of difference because I’d still chat to them.' (Woman in her 40s)

A mixed-sex situation could be problematic, however, for some groups such as some Muslim women.

‘I suppose the Asian ladies are always a bit wary so we’re always very careful with them to say that there will only be ladies there and, you know … we have quite a few Asian patients and you just can't do it. Either you lose them altogether or you do it separately.' (Nurse)

Most of the patients attending the clinic with single-sex groups felt this arrangement was the most desirable way to run the sessions, regardless of religious or cultural considerations: ‘I think that as a group you wouldn’t be nearly so relaxed if the fellas were there … I wonder whether some of the conversations we have, whether we'd have them if there was a man there. I really don't know.' (Woman in her 70s) ‘I prefer it being all men. I would think it would be difficult for ladies in there with their legs bared up to here and … It’s typical men's clubbiness, isn't it, really? Not that it's the sort of club that you'd wish to join (laughter).' (Man in his 70s)

Another aspect of acceptability was the interaction between patients and nurses. In most cases the patients spoke very highly of the nurses, and this clearly added to their enjoyment of the group sessions: ‘I felt apprehensive the first time about having it done, but then she was so – she just chats as though she’s known you for a long time, puts you at ease.' (Woman in her 60s)

There was some evidence, however, that explanations given by the nurses (as recalled by the patients) were inconsistent and sometimes incomplete, which could cause difficulties. Patients were not always clear, for example, about if and when they had been told that the acupuncture treatment was to be offered in a group, that it was a mixed-sex group or what clothing was most appropriate. Some people thought they had been told in advance, but others indicated that it had been a complete surprise when they arrived for the first session and in some cases this had caused embarrassment: ‘It (mixed-sex clinic) wasn’t something I was expecting, wasn't something I was told about before I went in … you know, we're not all beautiful shapes or whatever, and it's sort of a bit embarrassing.' (Woman in her 50s)

When the nurses introduced patients to each other, patients appeared to be grateful for this and appreciated the effort made to remember them personally: ‘She just used to introduce us by our Christian names, I think that’s why it's relaxed, it's very informal, isn't it?' (Woman in her 60s)

Nurses gave plenty of individual attention where it was needed, and it was also noted that the attention of the nurse, although divided between several patients, was more likely to be sustained in the group situation, though less necessary as time went on: ‘If they’re newer people she stays a bit longer with them, you know, but us old hands she just leaves us to get on with it really … she doesn't need to keep coming back to you really.' (Woman in her 80s)

Intrapersonal themes

It seems intuitively likely that the group situation would be more acceptable to a more gregarious type of personality than to the more private individual, but the interview data did not support this hypothesis. The interviewees appeared to vary considerably as personalities and sometimes defined themselves overtly either as private or sociable people. Some of the more private people appeared to be content to read a book or newspaper or to listen to others rather than to join in with the interaction: ‘I can only really remember a couple of occasions (when he talked at any length with other patients), very, very rare. I would normally have my book and I would be reading.’ (Man in his 60s)

This contrasted with the behaviour of those who appeared to be more chatty and sociable: ‘I’m quite a blabbermouth, from the point of view that I will talk to people rather than not talk to them.' (Woman in her 40s)

Despite these differences, however, there was a generally positive and often very enthusiastic attitude towards the group sessions.

Interviewees were grateful that they had been offered this treatment free of charge by the NHS. They appreciated that this was an efficient use of resources and put a high value upon it, particularly as it resulted in more frequent access to treatment: ‘But what you’ve got to understand is, if they want to go for single sessions, like I used to do … you wait 3 months for each session. So if they see six people instead of one every 40 min, they see a hell of a lot more people in a day, and it's a lot more cost-effective because they're using the same nurses as they would use for one person.' (Man in his 60s)

On the other hand, the nurses felt group clinics were not likely to be suitable for certain individual patients. They felt that patients with complex conditions or those who had extreme pain, for example, were more easily treated individually: ‘I think more of the reason why I sometimes take people out of the high volume (group) setting is where they are a bit too complex, too much stuff, and then I will often see them one-to-one in another clinic, and I have up to an hour then with the patient.’ (Nurse) ‘I have had one lady who was in pain, and she didn’t feel like being chatty and socially interacting, and I put her in a sort of smaller area … and she since has dropped out of the clinic and has been helped in other ways.' (Nurse)


This research supports preliminary reports from the group clinics that this method of delivery is acceptable to patients.1 ,3 ,4 The clear advantage of group acupuncture sessions, apart from their cost-effectiveness, is their sociable nature. The shared experience of OA and its associated physical difficulties engenders a supportive and empathetic environment in the clinic which seems to act as a ‘normaliser’ for some participants, who may feel alienated and ‘abnormal’ in other social situations. In addition, helpful information may be shared, such as details of local accessible facilities, how to manage arthritis on a daily basis, what medical advice has been given and what other treatments have been tried. In addition, interaction between patients in the sessions can vary from superficial convivial contact to more useful and supportive interaction, accommodating a wide range of individuals and preferences. It was also clear that the use of EA was particularly manageable in the group situation and that patients appreciated this method of delivery.

There was also evidence from the study that seeing others in the clinic who had attended for some time and hearing about their experiences could encourage new patients to persist with the acupuncture treatment. Such patients might not have continued in other circumstances such as attending individual acupuncture sessions, thus affecting the efficacy of the treatment as well as contributing to its acceptability. For maximum success, care needs to be taken to ensure that patients are given sufficient information in advance of the sessions and that the clinic is adequately staffed and provided with enough space. In addition, it seems likely that single-sex group clinics offer a more acceptable environment for most people.

By obtaining in-depth information from patients attending group acupuncture clinics and the nurses who run them, it was possible to identify a range of factors that influence the acceptability of this method of delivery. The three clinics in the sample contrasted in a number of ways, which enabled us to identify the relative advantages of different ways of organising the sessions. There were a number of limitations to the study, however. First, as we did not undertake a systematic comparison with acupuncture delivered individually, the advantages of the group situation had to be inferred from patients' reports. Second, selection bias is likely. For example, despite repeated efforts to locate patients who had dropped out of a group clinic, only one such interview was obtained so it was not possible to investigate fully the possible disadvantages that some patients might experience. It could also be argued that the positive group effect reported here is likely to have been influenced by the fact that those who do not gain benefit drop out, leaving only patients with a positive experience. As the team was also unsuccessful in recruiting patients from an ethnic minority background, it was also not possible to identify any potential differences that might be experienced by these groups. As this research was concerned only with patients with OA of the knee, our findings may not apply to patients with other medical conditions.

In summary, the data gathered in this research study suggest that group acupuncture clinics for patients with OA of the knee are both successful and highly acceptable, even to people with very different attitudes or personalities. Patients recognised that group clinics were a cost-efficient method of providing acupuncture. Group clinics have the perceived advantages of flexibility of appointment, encouragement to persist with the treatment and the opportunity to share symptoms, difficulties and information about how to manage pain. Potential disadvantages are the limited use for conditions that require treatment to personal areas of the body, particularly with mixed clinics, and embarrassment when very small groups are forced to sit together for the duration of the treatment.


The authors thank the British Acupuncture Society and the Ann Hill Research Trust for funding this study. They also gratefully acknowledge the substantial help offered by Marion Richardson, Pam Richmond and Rieko Ito, the nurses who led the group acupuncture clinics in the Parkbury House and Midway surgeries in St Albans and the Royal London Hospital for Integrated Medicine (RLHIM), who shared their experiences, allowed the researcher to observe their clinics and subsequently helped with the recruitment of patients for interviews. Additionally, Chris Perrin, the Nurse and Therapist Manager at the RLHIM, participated in an interview. Finally, the authors would like to thank the patients who generously gave their time and willingly shared their experiences with us.

View Abstract


  • Funding British Medical Acupuncture Society and Ann Hill Research Trust.

  • Competing interests AA, AW and CP have been paid lecture fees and travel expenses from the British Medical Acupuncture Society (BMAS). AW is paid by the BMAS as Editor of the journal Acupuncture in Medicine and receives royalties on books on acupuncture. The Peninsula College of Medicine and Dentistry received a research grant from the BMAS and Ann Hill Research Trust for the present study.

  • Patient consent Obtained.

  • Ethics approval The study was approved by the South West NHS Research Ethics Committee (10/H0206/6).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Considering the nature of the original data, they will not be made publically available.

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