Acupressure

Acupressure

PEP Topic 
Fatigue
Description 

Acupressure is a therapeutic technique of applying digital pressure (i.e., pressure applied by the digits or hands) in a specified way on designated points on the body. By applying pressure to one or more acupoints, practitioners correct imbalances by stimulating or easing energy flow. The acupoint most commonly investigated and accessible is P6, which is located on the anterior surface of the forearm, about three finger-widths from the wrist crease. Acupressure devices also have been developed; these are considered passive forms of pressure and differ from digital pressure. The Sea-Band® device is an example of a commercially available acupressure device; it is a plastic stud incorporated into a wrist band to exert pressure on the P6 acupuncture point. The H7 acupressure point at the wrist has been used to treat insomnia. Acupressure has been examined for its effect on anxiety, chemotherapy-induced nausea and vomiting, depression, fatigue, pain, and sleep-wake disturbances.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Lee, E. J., & Frazier, S. K. (2011). The efficacy of acupressure for symptom management: a systematic review. Journal of Pain and Symptom Management, 42, 589–603.

doi: 10.1016/j.jpainsymman.2011.01.007
Print

Purpose:

To systematically review randomized, controlled trials that investigated the efficacy of acupressure for the management of symptoms.

Search Strategy:

Databases searched were CINAHL, MEDLINE, and PubMed.

Search keywords were acupressure, clinical trial, human, and/or randomized.

Studies were included in the review if

  • They were randomized, controlled trials published from January 1, 2000 to January 31, 2010
  • They were published in English
  • They used acupressure as the sole intervention for one group
  • There were four or more studies of the efficacy of acupressure for that particular symptom.

Studies were excluded from the review if they

  • Had sample sizes of less than 30 patients
  • Used auricular or hand pressure, reflexology, shiatsu, and electronic or magnetic devices
  • Were unpublished studies and abstracts.

Literature Evaluated:

In total, 108 references were screened.

Each experimental study was evaluated for quality using the Cochrane risk of bias (RoB) tool. Articles were evaluated for the presence of each of the six domains, and one point was assigned for each domain present. Scores ranged from zero to six, with higher values indicating higher quality and less risk for bias. All trials were evaluated by two authors, and agreement between them was 100%. A significant likelihood of bias was found in the evaluation.  

Only six randomized, controlled trials included were performed to determine the efficacy of acupressure on the reduction of fatigue and improvement of sleep in adults in various populations. Fatigue and insomnia were grouped together because those investigations were typically studied simultaneously.  
 

Sample Characteristics:

  • The final number of studies included was 43.
  • The total sample size was 5,021 patients across all studies of all symptoms. For studies that specifically focused on fatigue and insomnia, the sample size was 211 patients.
  • The sample range across all studies was 36 to 739 for all studies of all symptoms.
  • Multiple diagnoses and symptoms were included:  nausea, pregnancy, chemotherapy, radiation, surgery, motion sickness, pain, dysmenorrhea, labor, back pain, fracture, trauma, dyspnea, asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, endstage renal disease (ESRD), and insomnia.

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Results:

Only three studies conducted included a measure of fatigue. Six studies concluded that acupressure was effective in improving fatigue and reducing insomnia. Multiple symptoms were discussed in topic areas; findings from other symptom reviews were not included in the summary.

Conclusions:

The review did not provide rigorous support for the use of acupressure for the efficacy of symptom management.

Limitations:

  • Significant bias existed according to the Cochrane RoB tool. 
  • Lack of fidelity to the intervention confounded the results and may have added bias to the studies.

Nursing Implications:

Well-designed randomized, controlled trials are needed to determine the utility and efficacy of acupressure to manage various symptoms in several patient populations. Issues exist when looking at fatigue and insomnia concurrently, such as determining whether fatigue is an intervening variable for insomnia or an outcome variable of insomnia or whether insomnia is an intervening variable for fatigue. A conceptual framework is needed to guide how concurrent or symptom clusters are studied.

Ling, W., Lui, L.Y.Y., So, W.K.W., & Chan, K. (2014). Effects of acupuncture and acupressure on cancer-related fatigue: A systematic review. Oncology Nursing Forum, 41, 581–592. 

doi: 10.1188/14.ONF.581-592
Print

Purpose:

STUDY PURPOSE: To critically examine the evidence for acupuncture and acupressure in the management of cancer-related fatigue (CRF) in adult patients with cancer
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: AMED, British Nursing Index, CINAHL, Evidence-Based Medicine Reviews, Embase, Journals@Ovid, MEDLINE, Physiotherapy Evidence Database, ProQuest, PubMed, ScienceDirect, SpringerLink, TRIP, Wiley Online Library, China Academic Journals Full-Text Database, and Wanfang Data China Online Journals
 
KEYWORDS: Fatigue, cancer, acupuncture, and acupressure
 
INCLUSION CRITERIA: Randomized, controlled trials (RCTs) of acupuncture and acupressure for CRF in adult patients with cancer regardless of the type of cancer, duration of disease, and type of treatment received. CRF was a key outcome to be clearly measured and reported. Only studies published in English or Chinese were included.
 
EXCLUSION CRITERIA: Articles whose sole target participants were patients with fatigue other than CRF were excluded. Studies using shiatsu or reflexology for therapeutic intervention also were excluded.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 716
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two reviewers independently appraised the methodologic quality of the full texts of all potentially eligible articles by means of the standard checklist for RCTs developed by the Scottish Intercollegiate Guidelines Network ([SIGN], 2014). The 10 appraisal criteria for internal validity in the SIGN checklist were equally weighted. Most studies were underpowered or consisted of small sample sizes.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 11
  • TOTAL PATIENTS INCLUDED IN REVIEW = 731
  • SAMPLE RANGE ACROSS STUDIES: 13–302 patients
  • KEY SAMPLE CHARACTERISTICS: Age range was 20–81 years; average age was 52–59 years; variety of diagnoses but mainly breast cancer

Phase of Care and Clinical Applications:

PHASE OF CARE: All phases

Results:

Seven out of eight acupuncture studies showed improvement in CRF, but only four reached statistic significance. All four acupressure studies showed significant improvement. The four studies that showed improvement during initial treatment determined that results could be maintained for as many as 12 weeks. However, the maintenance study did not determine any extra benefit. Three studies reported no side effects. In other studies, adverse events were identified as minor and transient. Four studies used acupressure. These showed positive results. However, three studies were underpowered, and the comparability of study groups was questionable.

Conclusions:

Acupuncture and acupressure may be helpful in reducing fatigue. However, because of multiple methodologic flaws in studies reviewed, no firm conclusions can be made regarding the effectiveness of these interventions.

Limitations:

  • Heterogeneity of the samples, sizes, types of cancer, treatments administered, length, dose, and intensity of treatment
  • Studies had multiple flaws

Nursing Implications:

Acupuncture and acupressure appear to be safe and may be effective. Therefore, this intervention may be suggested for patients with CRF. Additional research is needed to confirm their effectiveness.

Research Evidence Summaries

Tang, W.R., Chen, W.J., Yu, C.T., Chang, Y.C., Chen, C.M., Wang, C.H., & Yang, S.H. (2014). Effects of acupressure on fatigue of lung cancer patients undergoing chemotherapy: An experimental pilot study. Complementary Therapies in Medicine, 22, 581–591. 

doi: 10.1016/j.ctim.2014.05.006
Print

Study Purpose:

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

Intervention Characteristics/Basic Study Process:

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.

Sample Characteristics:

  • 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.

Setting:

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

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Three-group, sham controlled, randomized trial

Measurement Instruments/Methods:

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

Results:

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.

Conclusions:

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.

Limitations:

  • 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.

Nursing Implications:

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.

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