Acupressure

STUDY PURPOSE: To review randomized, controlled trials on the current evidence on the therapeutic effects of acupoints stimulation for patients with cancer with anxiety and depression

TYPE OF STUDY: Systematic review

• FINAL NUMBER STUDIES INCLUDED = 11
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,073
• SAMPLE RANGE ACROSS STUDIES: 30–302
• KEY SAMPLE CHARACTERISTICS: Six studies were of breast cancer; one, lung; one, gynecologic; and three involved more than two types of cancer. Eight had a two-arm design, and three had a three-arm design. All assessed anxiety and/or depression.

APPLICATIONS: Palliative care

Overall, the findings really did not support acupoints as a useful approach for managing anxiety and depression. Although it has limited risks, it may be useful in patients who do not tolerate oral medications. Results should be interpreted with caution because of the limitations identified. Still, much needs to be researched in this area. Study heterogeneity and lack of standardization of care and design are some of the major limitations to this meta-analysis. Further studies including controls for environmental as well as study site differences are needed before these results can be interpreted. Generalizability is not possible outside of the current study demographics, which should also be taken into account for future studies.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• High heterogeneity

Acupoints could be a safe intervention used in clinical practice for patients with cancer who experience anxiety and depression. No serious harm was reported, so it could be used as an alternative to medications when patients do not tolerate. Still, much research needs to be conducted in this area.

To investigate the effects of acupressure on anxiety in patients with cancer

Patients were randomly assigned to acupressure, sham acupressure, or control groups. Control group patients received usual care. The acupressure group had pressure applied at nine points for two minutes each by a research assistant. Sham acupressure was also given at nine different points on the body. Patients received 10 sessions of sham or actual acupressure. Study measures were obtained at baseline, after session 5, and after session 10.

• N = 85
• MEAN AGE = 48 years
• MALES: 54.1%, FEMALES: 45.9%
• KEY DISEASE CHARACTERISTICS: 51% had stage 4 disease
• OTHER KEY SAMPLE CHARACTERISTICS: The majority had prior surgery and chemotherapy

• SITE: Single site  
• SETTING TYPE: Inpatient  
• LOCATION: Iran

Double-blinded, sham-controlled, randomized trial

• Spielberger State/Trait Anxiety Inventory (STAI)

Mean anxiety scores in the acupressure group declined over the three study measurement periods (p = 0.001). Anxiety scores in the sham group also declined somewhat. Anxiety levels in the control group increased over time. An analysis of variance showed that acupressure was associated with a significant reduction in state anxiety scores and a significant difference in comparison to the control group patients (p < 0.0001). There was no significant difference between acupressure and sham acupressure changes.

Both sham and actual acupressure were associated with reductions in anxiety scores.

• Small sample (< 100)
• Other limitations/explanation: The timing of postintervention anxiety measurements were not clear, but it appears this was done immediately after the sham or acupressure interventions. The actual clinical relevance of an immediate short-term change is not clear.

The findings of this study suggest that acupressure may be of some benefit in the short-term management of anxiety among patients with cancer. The findings regarding the effects of sham acupressure suggest there may be a placebo effect involved. Additional well-designed research would be helpful to demonstrate the role of acupressure in the management of anxiety.

To determine the effects of acupressure applied to the pericardium 6 (P 6) acupuncture point on chemotherapy-induced nausea and vomiting (CINV) and anxiety in patients with breast cancer undergoing chemotherapy

Stage 1–3 patients with breast cancer who were receiving cycle two and more advance-cycle chemotherapy in an ambulatory setting were trained to apply P 6 acupressure. Patients were randomly selected from a sample that met the study inclusion criteria. An acupressure wrist band was utilized with the research group. Patients were taught how to use the band with repeat demonstration. Patients continuously wore the acupressure band on both wrists for five days. Antiemetic medications used for the experimental and control group were not described.

• N = 64 
• AVERAGE AGE: 51.21 years (research arm); 50.87 years (control arm)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Stage 1–3 breast cancer after cycle two and more advance-cycle chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Breast cancer, female patients

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Turkey

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care 

• Quasi-experimental with a control group.
• Patients selected via randomized sample

• Beck Anxiety Inventory (BAI)
• Index of Nausea, Vomiting and Retching (INVR)
• Patient information form

The authors concluded that acupressure wristbands applied at the P 6 point decreased patients' nausea occurrence and experience and the overall experience and occurrence of nausea, vomiting, and retching combined. There was no effect on the occurrence or experience of vomiting or retching. Acupressure is an inexpensive intervention that may be able to provide additional relief to patients above and beyond recommended antiemetic therapy. Effects on anxiety are unclear.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Findings not generalizable
• Other limitations/explanation: No discussion on why the researchers waited till cycle two to start intervention; prevention at the first cycle is key to good control; no sham band/possible placebo effect; significantly lower anxiety at baseline in the experimental group

Acupressure is inexpensive, is easy to use, and can be considered in conjugation with medication or CINV prophylaxis. Acupressure can be considered in addition to recommended antiemetic therapy for additional support of patients experiencing CINV.

To explore the effects of acupressure on fatigue and other symptoms in patients with lung cancer undergoing chemotherapy

Patients were hospitalized for four days. On day 1, a research assistant (RA) taught patients how to self-administer acupressure, and patients received a handbook including an acupoint map and acupressure methods. On days 2–4 and in subsequent hospitalizations for chemotherapy, an RA assisted patients in acupressure and confirmed their accuracy. Three acupoints were used, and the intervention was done once daily every morning for five months. Patients were instructed to do the acupressure at home each day. Patients were randomly assigned to one of three groups by a coin toss; group A received acupressure with essential oils, group B received only acupressure, and group C received sham acupressure using three sham acupoints. Study data were collected one day before starting chemotherapy, on day 1 of the third chemotherapy cycle, and on day 1 of the sixth chemotherapy cycle. Data were collected 30 minutes after the acupressure intervention.

• N = 45  
• MEAN AGE = 58.3 years
• MALES: 57.9%, FEMALES: 42.1%
• KEY DISEASE CHARACTERISTICS: All had lung cancer, the majority were stage IV
• OTHER KEY SAMPLE CHARACTERISTICS: Education level was varied with most patients having a sixth grade or less education. 70%–80% were married.

• SITE: Single-site    
• SETTING TYPE: Multiple settings    
• LOCATION: Taiwan

• PHASE OF CARE: Active antitumor treatment

Three-group, sham controlled, randomized trial

• Tang Fatigue Rating Scale 
• Eastern Cooperative Oncology Group (ECOG) Performance Status rating
• Hospital Anxiety and Depression (HADS) scale 
• Pittsburgh Sleep Quality Index

Adherence rates to acupressure varied significantly across groups – for group A, 93%, group B, 91.9%, and group C, 77.3%. Only subscale scores for fatigue in daily activity were lower for the two acupressure groups on day 1 of the third chemotherapy cycle. There were no other significant differences between groups for fatigue. There were no significant differences between groups in anxiety or depression scores. Sleep scores were lower for group A at one time point and group B at another time point compared to the sham control group (p < .05). However, these differences were not consistent across all study time points, and there were no other differences between groups in sleep results.

Potential benefits of acupressure for fatigue and sleep disturbance among patients receiving chemotherapy for lung cancer are not clear in this study. Differences in patient outcomes were not consistent across study time points according to the study group. No effect was demonstrated on anxiety or depression scores.

• Small sample (< 100)
• Risk of bias (no blinding)
• Key sample group differences that could influence results
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The sham control group was significantly older than the other study groups. 21% were lost to follow-up for various reasons; no ITT analysis was described. Data were collected only 30 minutes immediately after acupressure when the patient was in the hospital, so response duration is not known. Repeated use of the same tools may have resulted in testing effect. Adherence was much lower in the control group, so actual group differences due to acupressure cannot be determined.

This study does not provide strong evidence in support of the effectiveness of acupressure for management of fatigue, sleep disturbance, anxiety, or depression. The study did show that self-administration of acupressure was feasible and had no associated adverse effects in patients with advanced lung cancer. This is a low-risk, low-cost intervention that some patients may be interested in using.

The purpose was to evaluate the effect of therapeutic care (TC) with acupressure on fatigue in patients with breast cancer receiving chemotherapy.

Patients were randomized to the intervention or sham control arm. The intervention consisted of acupressure to three points related to energy in the human body (bilateral Hegu, Zusanli, & Sanyinjiao) administered 30 minutes per day, 10 minutes per point, 3 days a week for 12 weeks. Sham control included three points reported to have no relationship to alleviate cancer-related fatigue, first metacarpal head, patella, and inner ankle with same treatment administration, frequency, and duration. Fatigue, anxiety, depression, and sleep were measured at baseline, 6 weeks, and 12 weeks.

• N = 48 
• AGE: Mean age of the intervention group was 51.8 years (SD = 9.6) and control was 52.4 years (SD = 9.3).
• FEMALES: 100% 
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Breast cancer, actively receiving chemotherapy    
• OTHER KEY SAMPLE CHARACTERISTICS: s/p lumpectomy or mastectomy, did not take herbs or supplements, and did not report medication-related fatigue

• SITE: Single site
• SETTING TYPE: Not specified    
• LOCATION: China

PHASE OF CARE: Active antitumor treatment

Randomized control trial

Multidimensional fatigue inventory (MFI), Hospital Anxiety and Depression Scale (HADS), and Pittsburgh Sleep Quality Index (PSQI)

For those in the intervention group, fatigue improved statistically (p < 0.01) at 6 weeks and maintained improvement at 12 weeks (p < 0.01). Anxiety, depression, and sleep quality improved at 12 weeks (p < 0.01).

Acupressure may be an effective method or type of complementary and alternative therapy in improving fatigue, anxiety, depression, and sleep in patients with breast cancer receiving chemotherapy.

• Small sample (< 100)
• Subject withdrawals ≥ 10%  
• Other limitations or explanation: Single site, all Chinese patients

Acupressure focused on points known to help energy may be useful in treating cancer-related fatigue, anxiety, depression, and sleep quality.