Acupuncture

Acupuncture

PEP Topic 
Acute Pain
Description 

Acupuncture is a method of producing analgesia or altering a body system's function by inserting wire-thin needles into acupoints along a specific meridian. (Meridians are body channels that transport energy.) The needles, which are about the diameter of a strand of hair, are twirled, energized electronically, or warmed and then left in place for 20–30 minutes. The acupuncture point P6 is most commonly used for the treatment of nausea and vomiting. Acupuncture has been evaluated as a treatment for anxiety, chemotherapy-induced nausea and vomiting, dyspnea, pain, hot flashes, depression, lymphedema, sleep-wake disturbances, peripheral neuropathy, and fatigue.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Bardia, A., Barton, D.L., Prokop, L.J., Bauer, B.A., & Moynihan, T.J. (2006). Efficacy of complementary and alternative medicine therapies in relieving cancer pain: A systematic review. Journal of Clinical Oncology, 24, 5457–5464.

doi: 10.1200/JCO.2006.08.3725
Print

Purpose:

To evaluate the efficacy of various complementary and alternative medicine (CAM) therapies to reduce cancer pain

The type of article is systematic review.

Search Strategy:

  • Databases searched were MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine (AMED), and the Cochrane Library up to August 2005. Investigators also searched reference lists from articles to identify relevant studies.
  • Search keywords were cancer, pain and alternative medicine, and neoplasm, as well as terms for major individual CAM therapies.
  • Studies were included in the review if they were randomized clinical trials (RCTs) that had a CAM intervention for cancer pain.
  • Exclusion criteria were not cited.

Literature Evaluated:

The initial search identified 101 articles, of which investigators excluded 85. Investigators included an additional two articles, which were found through manual scans of reference lists. Investigators appraised articles by using the Jadad scale.

Sample Characteristics:

  • The final sample included 18 studies reporting on 1,499 patients.
  • The average sample included less than 100 patients; median sample size was 54 patients.

Results:

  • Acupuncture: Investigators evaluated three trials, of which one was a high-quality study that used auricular acupuncture to treat 90 patients. Compared to the placebo group, the treatment group had a significant decrease in pain intensity that lasted two months.
  • Mind-body interventions: Investigators assessed five trials. Two of these were trials of intermediate quality in which support groups were effective in decreasing pain. Interventions included group supportive psychotherapy, hypnosis, and support groups. Two trials concluded that relaxation and imagery were effective in reducing pain. Researchers obtained no greater relief by adding cognitive behavioral therapy to relaxation or imagery.
  • Music: Assessment revealed that the three trials were of poor quality. Results were mixed. Effects measured were of very short duration.
  • Herbal mixtures: Two trials examined different herbal supplements. Both trials were of poor quality, and one did not report actual statistical results. Authors could draw no meaningful conclusions from this information.
  • Massage therapy: The four trials involving massage therapy had mixed results in terms of efficacy. Most of these trials had very small sample sizes, and none found intervention effects that lasted longer than four weeks.
  • Healing touch or Reiki: Two trials involved these interventions. Results did not warrant conclusions about effectiveness.

Conclusions:

The result of this systematic review was that none of these interventions can be recommended as effective. The most promising therapies appear to be mind-body interventions. In particular, hypnosis and relaxation might have some effect in decreasing cancer pain. Effect may be limited by cognitive impairment caused by cancer or cancer treatment. Support groups may have some positive effects. Whether these benefits are due to increased patient awareness, with more frequent visits to care providers, better compliance with medication regimens, or as a result of group interaction and social or emotional support is unclear. One study found that benefit occurred only in those patients who were more distressed at baseline. It is possible that effect sizes of therapies may be more discernible among patients with higher pain ratings, demonstrating a floor effect related to the symptom of pain.

Limitations:

  • Most trials were of low quality, with missing data and incomplete reporting. This fact made extracting sufficient usable information difficult.
  • Few studies in the analysis examined a specific intervention.

Nursing Implications:

Current evidence does not support the efficacy of the cited CAM interventions in the management of pain of patients with cancer. Methodologically strong research that incorporates appropriate attentional and sham controls, sufficient sample sizes, and longer duration of follow-up is needed.

Choi, T.Y., Lee, M.S., Kim, T.H., Zaslawski, C., & Ernst, E. (2012). Acupuncture for the treatment of cancer pain: A systematic review of randomised clinical trials. Supportive Care in Cancer, 20, 1147–1158.

doi: 10.1007/s00520-012-1432-9
Print

Purpose:

To perform a combined systematic review and meta-analysis to assess the effectiveness of acupuncture for treating cancer pain

Search Strategy:

  • Databases searched were MEDLINE, Allied and Complementary Medicine Database (AMED), EMBASE, CINAHL, PsycINFO, the Cochrane Library 2011, Korean Studies Information, DBpia (a database of Korean publications), Korean Institute of Science and Technology Information, Research Information Centre for Health Database, KoreaMed, Korean National Assembly Library, Chinese Medical Database of the China Academic Journal, and China Doctor/Master’s Dissertations.  
  • Search keywords were the English terms that follow and their Korean and Chinese equivalents: (acupuncture OR electro-acupuncture OR auricular acupuncture OR scalp acupuncture OR needle OR acupuncture point OR meridian OR acupoint OR acupuncture treatment OR acupuncture therapy) AND (cancer OR tumour OR neoplasm OR pain).
  • Studies were included if
    • Acupuncture was used as the sole intervention or as an adjunct to another standard treatment for any cancer pain.
    • The control group received the same concomitant treatments as the acupuncture group.
    • They were controlled by means of a placebo or they controlled against a drug-therapy or no-treatment group.
  • Studies were excluded if they were nonrandomized trials, were trials with designs that did not allow the effectiveness of acupuncture to be evaluated, adopted comparison treatments or groups that were expected to have effects similar to acupuncture or used herbal medicines, were trials that studied cancer pain mixed with other types of pain, were trials that were conducted on patients during or a few days after an operation on malignant tumors, or were trials in which outcome measures were irrelevant to cancer pain.

Literature Evaluated:

  • The search retrieved 494 references published through April 2011.
  • Two independent reviewers read all articles. Reviewers extracted data from the articles according to predefined criteria. Risk of bias was assessed using criteria from the Cochrane classification.
  • Nine studies were included in the meta-analysis. Data were pooled for a meta-analysis by using a random-effects model.

Sample Characteristics:

  • The final number of studies included was 15; all were randomized controlled trials (RCTs).
  • Total sample size was 1,157.
  • Fourteen studies were conducted in China; these studies included a total of 1,070 participants. One study was conducted in France; this study included 87 participants.
  • Three RCTs contained cases of liver cancer, one RCT contained at least one case of stomach cancer, and one RCT contained at least one late-stage cancer. 
  • The focus of the meta-analysis was traditional Chinese acupuncture.

Phase of Care and Clinical Applications:

The study has clinical applicability for palliative care.

Results:

Most of the studies involved manual acupuncture based on traditional Chinese medicine. In regard to effect on cancer pain, the majority of the studies found the effects of acupuncture and conventional drug therapy to be comparable; however, equivalence of effects is unclear in those studies reporting no differences between acupuncture and conventional drug therapies.

Conclusions:

Acupuncture may be an effective intervention for controlling pain; however, due to the small number of RCTs, low methodological quality, and small sample sizes, the results of the meta-analysis did not provide strong evidence of such effectiveness.

Limitations:

  • All the RCTs had a high risk of bias.
  • Because all the research evaluated was published in China, authors were uncertain of the accuracy of the findings.

Nursing Implications:

Further research is needed to evaluate this nonpharmacologic intervention for relieving cancer pain.

Garcia, M. K., McQuade, J., Haddad, R., Patel, S., Lee, R., Yang, P., . . . Cohen, L. (2013). Systematic review of acupuncture in cancer care: a synthesis of the evidence. Journal of Clinical Oncology, 31, 952–960.

doi: 10.1200/JCO.2012.43.5818
Print

Purpose:

To evaluate the effectiveness of acupuncture for symptom control in patients with cancer.

Search Strategy:

Databases searched were MEDLINE, EMBASE, CINAHL, Cochrane Collaboration, Scopus, and PubMed through December 2011.

Search keywords were acupuncture, electroacupuncture, moxibustion, Chinese medicine, Asian medicine, and keywords that included cancer and cancer symptoms.

Studies were included in the review if they

  • Were randomized, clinical trials (RCTs)
  • Involved acupuncture with needle insertion
  • Compared acupuncture to control, placebo, or sham acupuncture.

Studies were excluded from the review if they

  • Compared two active acupuncture forms, acupressure, or other interventions similar to acupuncture that did not involve needle insertion
  • Did not measure the effect of acupuncture on symptoms
  • Were considered gray literature (i.e., not generally accessible).

Literature Evaluated:

In total, 3,494 references were retrieved and evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions.

Sample Characteristics:

  • The final number of studies included was 41.
  • The authors did not provide the sample range across studies, total number of patients, disease types, or characteristics.

Results:

Studies addressed potential management of the following symptoms:

  • Pain:  Eleven RCTs met the criteria for analysis. No large trials reported positive results or were of good quality.
  • Chemotherapy-Induced Nausea and Vomiting (CINV):  Eleven RCTs met the criteria for analysis. One large study with a low risk of bias showed between-group effect sizes for acupuncture versus sham (0.80) and for acupuncture versus usual care (1.10).
  • Fatigue:  Three RCTs met the criteria for analysis. All had high risks of bias, and two had negative outcomes.
  • Hot Flashes:  Seven RCTs met the criteria for analysis. None had a low risk of bias.
  • Anxiety or Depression:  Five of the six RCTs analyzed showed positive results. All five had high risks of bias.
  • Sleep:  Three RCTs met the criteria for analysis, and all three reported positive outcomes and had high risks of bias.

Conclusions:

The strongest evidence that the study produced showed that acupuncture may be effective for the management of CINV. The study did not show acupuncture to be efficacious in the treatment of other symptoms.

Limitations:

The studies included were of low quality.

Nursing Implications:

Available evidence, which was limited, did not support the claim that acupuncture is effective in alleviating various adverse symptoms in adults with cancer. Additional research is needed to determine the efficacy. The findings of this analysis suggested that patients with uncontrolled CINV may be appropriate candidates for acupuncture referral. For the treatment of other symptoms, the efficacy is undetermined.

Lee, H., Schmidt, K., & Ernst, E. (2005). Acupuncture for the relief of cancer-related pain—A systematic review. European Journal of Pain, 9, 437–444.

doi: 10.1016/j.ejpain.2004.10.004
Print

Purpose:

To summarize a systematic review of existing evidence regarding the effect of acupuncture on cancer-related pain

Search Strategy:

Databases searched were MEDLINE, EMBASE, CINAHL, Allied and Complementary Medicine Database (AMED), PsycINFO, British Nursing Index, the Cochrane Library, and databases relative to Journal of Korean Society for Acupuncture and Moxibustion and Journal of Korean Oriental Medicine. Investigators performed manual searches of department files and the reference lists of all located articles.

Search keywords were acupuncture, electroacupuncture, cancer, neoplasm, and tumor.

Studies were included if they were

  • Published in any language
  • Prospective clinical studies that used manual acupuncture, ear acupuncture, or electroacupuncture for the treatment of cancer-related pain in humans.

Studies were excluded if they related to laser acupuncture, acupressure, or moxibustion or used transcutaneous electrical nerve stimulation or other cointerventions that were complementary or alternative medicine modalities; were case series, case reports, or  abstracts with no details about the intervention; and involved acupuncture for postoperative pain in patients with cancer.

Literature Evaluated:

Investigators reviewed 29 studies initially and chose 7 for analysis. Two authors, working independently, read all articles in full and extracted data about trial methods, study design, participants, interventions, type of pain, pain outcomes, and adverse effects. Authors used a modified Jadad scale to rate the studies. (The study summary cites rating criteria.) Authors met to reach consensus, and discrepancies were settled by discussion with the third author. The Jadad scale was modified because of the near impossibility of blinding the acupuncturist to the treatment.

Sample Characteristics:

  • The total sample size was not reported.
  • The sample range across studies was 12–92.
  • Characteristics of the sample were all cancer types (heterogeneous), neuropathic nociceptive (> 30/100), abdominal, back, and not specified.

Results:

  • The studies of acupuncture for cancer-related pain were not evidence-based. Visual analog scale and patient’s verbal assessment were the primary pain-related measures. One study used the plasma leucine-enkephalin level as a measure.
  • The quality of the included studies was lacking—only three of the seven studies were randomized controlled trials.

Conclusions:

Data from this study do not support the use of acupuncture as an effective analgesic adjunctive method for the treatment of cancer pain. Note that 2003 is the most recent date of an article in this systematic review; articles excluded were published 1974–2003.

Nursing Implications:

Appropriately powered randomized controlled trials that investigate the efficacy of acupuncture are needed.

Paley, C.A., Johnson, M.I., Tashani, O.A., & Bagnall, A.M. (2011). Acupuncture for cancer pain in adults. Cochrane Database of Systematic Reviews, 1, CD007753.

doi: 10.1002/14651858.CD007753.pub2
Print

Purpose:

To evaluate the efficacy of acupuncture for the relief of cancer-related pain in adults

Search Strategy:

Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Allied and Complementary Medicine Database (AMED), SPORTDiscus, and PsycINFO.

Search keywords included acupuncture therapy, Medicine East Asian traditional, acupressure or acupoint*, traditional Chinese medicine, pain, neoplasm or cancer. All databases were searched from their inception to October 2010. Authors provided an extensive list of search terms and the strategy per database. In addition, to identify further references for analysis, investigators searched the reference lists of eligible studies as well as lists associated with previous systematic reviews.

Studies were included if they

  • Were randomized controlled trials (RCTs).
  • Evaluated any type of invasive acupuncture. (Both Western-style and traditional Chinese acupuncture were included in the search.)
  • Involved patients who had cancer-related pain as defined by commonly used rating scales or questionnaires.
  • Involved patients 18 years of age or older.

Studies were excluded if they were not RCTs or if they involved pain due to preexisting noncancer pathology or treatments (e.g., chemotherapy), neuropathic pain, or procedures such as surgery.

Literature Evaluated:

The initial search retrieved 253 articles. Of these, only three RCTs were appropriate for inclusion. None provided extractable data for meta-analysis. Investigators evaluated study quality by using the Jadad scale. Two of the three studies had low-quality scores (2 points out of 5).

Sample Characteristics:

The three studies included a total of 204 patients. Across studies, sample size range was 48–90. Authors reported no other sample characteristics.

Results:

  • One study compared the effects of auricular acupuncture at acknowledged acupuncture points to acupuncture at placebo points. Compared to the placebo group, the acupuncture group reported a significant decrease in pain intensity (p < 0.0001), compared to baseline, at two months.
  • One study concluded that the analgesic effect of acupuncture was greater than that of medication (p < 0.05). However, in this study researchers set a predetermined level of pain as the criterion for general effectiveness; researchers did not analyze actual pain data. The study did not report raw data or standard deviations.
  • One study reported that long-term effects were similar in groups treated with acupuncture and medication. The study provided no explanation regarding pain measurement.
  • The evidence from only one high-quality RCT was insufficient to provide the basis for a judgment about the efficacy of acupuncture. This study involved apparent inconsistencies in reporting and some inadequate acupuncture doses.

Conclusions:

This study provided insufficient evidence to determine the effectiveness of acupuncture for the relief of cancer-related pain.

Limitations:

Available evidence is inconclusive or of low quality.

Nursing Implications:

Acupuncture is being more widely used to treat cancer-related pain, but evidence is insufficient to support the effectiveness of this treatment. More well-designed studies of acupuncture are needed, and study designers should ensure adequate sample sizes, homogeneity of cancer pain conditions under study, consistent dosing of acupuncture, valid controls, and reliable pain outcomes measurement. The authors point out that guidelines for the use of acupuncture are available. They suggest that practitioners use such guidelines and remain aware of the limitations of acupuncture.

Research Evidence Summaries

Deng, G., Rusch, V., Vickers, A., Malhotra, V., Ginex, P., Downey, R., . . . Cassiletha, B. (2008). Randomized controlled trial of a special acupuncture technique for pain after thoracotomy. The Journal of Thoracic and Cardiovascular Surgery, 136(6), 1464-1469.

doi:10.1016/j.jtcvs.2008.07.053
Print

Study Purpose:

To determine whether use of intradermal acupuncture needles is superior to sham acupuncture in the treatment of acute and chronic pain after thoracotomy

Intervention Characteristics/Basic Study Process:

Patients were stratified according to use of epidural anesthesia and then randomized to receive acupuncture or a sham technique. Within 2 hours before the operation and before induction of anesthesia, 9 intradermal acupuncture needles were inserted on each side of the spine corresponding to BL-12 to BL-19 acupuncture points and to an extra point. These needles had the appearance of miniature thumbtacks, and a ring at the end of the needle keeps it from entering the skin completely. Needles were exchanged for new ones 1 week after initially placed. The duration of acupuncture was 4 weeks, with different needles removed at different time-points. Patients in the control group underwent the same procedure, except that dummy studs were used that had the same appearance and ring, but no needle. Sham studs were placed at areas to prevent tactile stimulation of acupuncture points. Pain was measured at days 10, 30, 60 and 90 post surgery.

Sample Characteristics:

Sample Size: 106 Mean age = 64, range = 57-72 Females: 51% Males: 49% Patients had cancer and were scheduled for unilateral thoracotomy that did not involve the chest wall, esophagectomy or extrapleural approaches. No other disease related information is provided. Patients were excluded if they had previous acupuncture or platelet counts< 20,000.

Setting:

Single site, Other Memorial Sloan Kettering

Study Design:

Randomized controlled trial

Measurement Instruments/Methods:

Brief Pain Inventory Medication Quantification Scale for opioid use

Results:

There were no differences between groups for any pain measures at any of the follow-up time points.

Conclusions:

Acupuncture as used here does not appear to be effective for the management of acute or chronic thoracotomy related pain

Limitations:

No information was provided regarding any background chronic pain among the sample, which may have also affected findings. Authors point out that the needles used here were shorter than those used in other studies. It is not clear how these factors and needle placement affect results.

Nursing Implications:

Findings suggest that perioperative acupuncture does not effectively prevent or reduce pain associated with the operation. Acupuncture techniques in terms of needle types, placement, frequency of replacement etc., vary among providers of this treatment. These aspects increase the complexity of research in this area.

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