Acupuncture

Acupuncture

PEP Topic 
Chronic Pain
Description 

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

Effectiveness Not Established

Research Evidence Summaries

Bao, T., Cai, L., Giles, J.T., Gould, J., Tarpinian, K., Betts, K., . . . Stearns, V. (2013). A dual-center randomized controlled double blind trial assessing the effect of acupuncture in reducing musculoskeletal symptoms in breast cancer patients taking aromatase inhibitors. Breast Cancer Research and Treatment, 138, 167–174.

doi: 10.1007/s10549-013-2427-z
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Study Purpose:

To evaluate the effect of acupuncture on function and pain in women with aromatase inhibitor associated musculoskeletal symptoms (AIMSS) and the effect of serum hormones and proinflammatory cytokines to help clarify the molecular mechanism of action with the use of acupuncture

Intervention Characteristics/Basic Study Process:

Patients were randomized to eight weekly real or sham acupuncture sessions evaluated by the Health Assessment Questionnaire Disability Index (HAQ-DI) and pain visual analog scare (VAS) at baseline and after intervention. Serum hormones and proinflammatory cytokines were measured pre- and post-intervention.

Sample Characteristics:

  • N = 47  
  • AGE = 44–85 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Postmenopausal women with stage 0–III breast cancer that was estrogen-receptor-positive or progesterone-receptor-positive receiving a standard dose of a third-generation aromatase inhibitor for one month or longer and with documented AIMSS. Baseline HAQ-DI or pain using a 100-point VAS of 20 or more
  • EXCLUSION CRITERIA: Acupuncture treatment within the past 12 months

Setting:

  • SITE: Multi-site 
  • SETTING TYPE: Not specified; outpatient
  • LOCATION: Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins; the University of Maryland Greenebaum Cancer Center

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Multiple phases of care
  • APPLICATIONS: Elder care, palliative care

Study Design:

  • Randomized, controlled double-blind trial

Measurement Instruments/Methods:

  • HAQ-DI
  • Pain VAS

Results:

No significant difference was seen in HAQ-DI and VAS scores between the groups. A significant reduction of interleukin 17 was seen in both groups after eight weeks, and no significant changes were seen in other hormone/proinflammatory markers in either group. No significant difference were seen in AIMSS between the groups; however, after eight weeks of  treatment, HAQ-DI and VAS scores improved for both groups.

Conclusions:

This study does not appear to support acupuncture as a means to reduce musculoskeletal symptoms in patients with breast cancer taking aromatase inhibitors. Sham and real acupuncture seem to improve HAQ-DI and VAS scores and seem to lower baseline, as revealed by a 12-week follow-up after the study. Neither acupuncture nor sham acupuncture produced any adverse effects and seem to be safe as an option for patients with early-stage breast cancer with AIMSS.

Limitations:

  • Small sample (less than 100)
  • Findings not generalizable
  • The sample size limits the ability to generalize findings.
  • Acupuncture training is required to perform the intervention.

Nursing Implications:

This study does not support acupuncture over sham acupuncture for the treatment of AIMSS in women with early-stage breast cancer. That being said, acupuncture has helped to improve VAS and HAQ-DI scores, suggesting it as a positive intervention with no side effects for these patients. Education and training in acupuncture would be suggested prior to therapy, but this article suggests that sham acupuncture produces statistically similar results and improves scores.

Chen, H., Liu, T.Y., Kuai, L., Zhu, J., Wu, C.J., & Liu, L.M. (2013). Electroacupuncture treatment for pancreatic cancer pain: A randomized controlled trial. Pancreatology, 13, 594–597. 

doi: 10.1016/j.pan.2013.10.007
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Study Purpose:

To evaluate the analgesic effect of electroacupuncture on pancreatic cancer pain

Intervention Characteristics/Basic Study Process:

Patients were treated in a comfortable prone position. Disposable stainless steel filiform needles (40 mm in length and 0.3 mm in diameter) were inserted perpendicularly into the Jiaji points from T8 to T12 bilaterally to a depth of 25 mm. After de-qi sensation was achieved, the handles of the needles were respectively connected to a Han's acupoint nerve stimulator (HANS) at a frequency of 2/100 Hz and a current of 1 mA with a disperse-dense waveform. The needles remained in place for 30 minutes. The treatment was given once a day for three days. Sham acupuncture needles were used as a placebo and were put into the same points in the treatment group without inserting into the skin. The needles were then connected to the electric stimulator but with zero frequency and electric current. All patients were to maintain the same analgesic drug treatment.

Sample Characteristics:

  • N = 60  
  • AGE RANGE = 18–75 years
  • MALES: 63.3% treatment arm (66.7% control arm), FEMALES: 36.7% treatment arm (33.3% control arm)
  • KEY DISEASE CHARACTERISTICS: Histologically confirmed advanced pancreatic cancer at stages III–IV in the staging system of the Union for International Cancer Control
  • OTHER KEY SAMPLE CHARACTERISTICS: Pain intensity of 3–6 on numeric rating scale (0–10), stable dose of analgesics at least 72 hours before randomization, estimated survival time greater than one month, never been treated by acupuncture, no other causes of pain (e.g., rheumatoid arthritis, disc disease), no contraindications for acupuncture (e.g., bleeding risk, infectious dermatosis, ulcer or scar at acupuncture points) or history of cerebrovascular accident (CVA) or spinal cord injury, study completed before treatment for pancreatic cancer

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Not specified    
  • LOCATION: Fudan University Shanghai Cancer Center (FUSCC)

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Mutliple phases of care
  • APPLICATIONS: Palliative care 

Study Design:

Pain intensity as assessed using a numeric rating scale of 0–10 after subjects were given an explanation of the rating scale. Ratings were done before treatment, after one to three treatments, and at one and two days after the completion of the treatments.

Measurement Instruments/Methods:

  • Numeric rating scale from 0–10
  • Analgesic record
  • Adverse events

Results:

Pain intensity decreased compared with baseline after each of the three treatments in the acupuncture group. There was little change in the level of pain in the control group. The difference between the treatment arm and the control arm was statistically significant after each of the three treatments. Follow-up during the two days after treatment also showed a significant reduction in pain intensity in the treatment arm compared to the control arm. No infections at the treated points were noted during the trial, and there were no adverse events.

Conclusions:

Pain intensity significantly decreased compared to baseline in the electroacupuncture group, a result that was significantly different than the result for those in the control arm of the study. There was no significant difference in the level of pain at any of the time points for those in the control arm of the study.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding)
  • Findings not generalizable
  • Other limitations/explanation: The study only included mild to moderate levels of pain. Pain was only assessed for two days after the treatment.

Nursing Implications:

Pain is a significant problem for individuals diagnosed with pancreatic cancer. Standard treatment options include opioids, radiotherapy, and celiac plexus neurolysis; however, these are not always effective and may be limited due to their side effects. Nurses need to be aware of potential pain management options for patients with pancreatic cancer-associated pain in order to improve the patients' quality of life.

Garcia, M.K., Driver, L., Haddad, R., Lee, R., Palmer, J.L., Wei, Q., . . . Cohen, L. (2014). Acupuncture for treatment of uncontrolled pain in cancer patients: A pragmatic pilot study. Integrative Cancer Therapies, 13, 133–140.

doi: 10.1177/1534735413510558
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Study Purpose:

To test the hypotheses that acupuncture would be feasible, safe, and effective adjunct for pain management

Intervention Characteristics/Basic Study Process:

Patients were recruited from referrals to a pain management center. Patients received individualized acupuncture treatments one to three times per week. Treatments were provided by two licensed and experienced acupuncturists. The points used in the treatments are described, and standard techniques for point location were used. Needles were left in place for about 25 minutes. Electrical stimulation was added at the discretion of the practitioner. Study measures were obtained at baseline and after the last acupuncture session. Patients were dropped from the analysis if pain control medications were changed during the course of the study.

Sample Characteristics:

  • N = 41  
  • MEAN AGE = 54 years (range = 33–88 years)
  • MALES: 29%, FEMALES: 71%
  • KEY DISEASE CHARACTERISTICS: Multiple tumor types (breast was most common); patients had varied stages of disease
  • OTHER KEY SAMPLE CHARACTERISTICS: Pain scores were > 4 on a numeric rating scale at study entry, and mean duration of pain management we 31 months. There were varied locations of pain with low back, neck, and shoulder being the most common. Most patients had multiple locations of pain.

Setting:

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

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Mutliple phases of care
  • APPLICATIONS: Palliative care 

Study Design:

Single-arm prospective trial

Measurement Instruments/Methods:

  • Brief Pain Inventory (BPI)
  • MD Anderson Symptom Inventory (MASI)

Results:

The average number of treatments was eight (range = 2–10) over five weeks excluding drop-outs. 71% of patients received auricular acupuncture and 71% received electroacupuncture. Pain severity and interference scores declined significantly (p < .0011) using the BPI. A significant reduction in both of these aspects was also seen with the MASI (p < .002). Intent-to-treat analysis using the replacement of missing values with group means showed the same results. For 44% of patients, pain medications remained the same as those at baseline. Fewer patients required opioids at follow-up compared to baseline, and the prevalence of use of other medications for pain such as nonopioid analgesics, antidepressants, and other adjuvant medications declined. 87% of patients stated that the course of acupuncture treatment met their expectations very or extremely well. There were no adverse effects of acupuncture reported.

Conclusions:

Findings suggest that the use of acupuncture as an adjunctive therapy for chronic pain management is feasible, is safe, and can be beneficial in reducing pain.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Unintended interventions or applicable interventions not described that would influence results
  • Subject withdrawals ≥ 10%  
  • Other limitations/explanation: Although it was stated that patients were not to have pain medication changed during the study, substantial changes in various medications occurred and were reported. There was a 21% drop-out rate with about 40% of these due to changes in pain medication.

Nursing Implications:

Findings suggest that acupuncture treatment as an adjunctive pain management approach can be beneficial for some patients. Interpretation of findings is difficult due to the individualization of the treatment regimen, study design limitations, and the likelihood that there is a placebo effect with acupuncture. For those patients who wish to try acupuncture for pain management, it appears to be feasible and safe when provided by appropriate practitioners.

Lim, J.T., Wong, E.T., & Aung, S.K. (2011). Is there a role for acupuncture in the symptom management of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led supportive care. Acupuncture in Medicine, 29(3), 173–179.

doi: 10.1136/aim.2011.004044
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Study Purpose:

To document changes in symptoms after acupuncture or nurse-led supportive care in patients with incurable cancer and to determine the feasibility of carrying out a randomized trial in acupuncture for patients with advanced incurable cancer

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to either an acupuncture group or a nurse-led supportive care group. In the acupuncture group, traditional Chinese medical acupuncture was performed by the principle investigator, a radiation oncologist, and a certified medical acupuncturist. The acupuncture points were chosen based on the symptoms experienced. The acupuncture needles were connected to an electric stimulator, and a 0.3 ms duration, 4 Hz alternating current was delivered. The needles were stimulated for 20 minutes and then removed.

In the nurse-led supportive care group, patients met for 20–30 minutes with an experienced palliative care nurse weekly for four weeks, comparable to the time spent in acupuncture. The nurse explored their most troubling symptoms and discussed medications and nonpharmacologic therapies such as relaxation therapy, professional counseling, exercise, or judicious rest. The patient’s interpretation of the causes of the symptoms and how they could be ameliorated were discussed. The nurse also addressed issues such as improving the scheduling and dosing of the medications and alternative therapies to drugs, such as foods for managing constipation. Useful strategies for coping with daily activities and emotional support were discussed.

Sample Characteristics:

  • The study reported on a final sample of 18 patients.
  • Mean patient age was 55 years in the acupuncture group and 64.9 years in the nurse-led supportive care group.
  • Males represented 11% of the intervention group and 6% of the nurse-led supportive care group. Females represented 44% of the intervention group and 39% of the nurse-led supportive care group.
  • Cancer sites were breast, rectum, endometrium, cervix, oropharynx, bladder, kidney, lung, cecum, and esophagus, in addition to leukemia and myeloma.

Setting:

  • 80 clinics
  • Outpatient setting
  • BC Cancer Agency at the Vancouver Island Centre in Victoria (Pain and Symptom Clinic for palliative management of cancer and treatment-related symptoms)

Phase of Care and Clinical Applications:

  • Patients were receiving end-of-life care.
  • The study has clinical applicability for end-of-life and palliative care.

Study Design:

This pilot study was a single-blind, randomized controlled trial.

Measurement Instruments/Methods:

The Edmond Symptom Assessment System (ESAS) was used to measure any changes in the symptoms experienced by patients before and after the intervention.

Results:

The treatment was well tolerated with no significant unexpected side effects. The compliance rate was 90% for acupuncture and 80% for nurse-led supportive care. All nine symptoms (pain, tiredness/fatigue, nausea, depression, anxiety, drowsiness, loss of appetite, lack of well-being, and shortness of breath) were improved immediately after acupuncture, with improvement continuing in six of these symptoms after six weeks. Six symptom scores improved immediately following nurse-led supportive care visits, with all nine symptoms showing improvement after six weeks. Total symptoms were reduced by an average of 22% after each acupuncture visit and by 14% after each nurse-led supportive care visit. ESAS scores at the end of the follow-up period were reduced by 19% for the acupuncture group and 26% for the nurse-led supportive care group. At six weeks after acupuncture, symptoms of pain, nausea, and loss of appetite did not maintain improvement. Only 48% of eligible patients consented to the study, and it was closed due to poor recruitment.

Conclusions:

The study suggests that patients can benefit from incorporating acupuncture and supportive interventions to help with symptom management in advanced incurable cancer. Findings suggest that nurse attention provided over the long term benefited patients and that acupuncture may provide some immediate symptom improvements.

Limitations:

  • The study had a small sample size, with less than 30 patients.
  • No patient blinding with self-report outcome measures may be subject to validity threats.

Nursing Implications:

Nurse-led supportive care can improve symptoms in these patients. These improvements can likely be attributed to increased attention and quality feedback being provided from the nurse to the medical team, who were able to initiate positive changes in medication and other supportive measures.

Mao, J.J., Xie, S.X., Farrar, J.T., Stricker, C.T., Bowman, M.A., Bruner, D., & DeMichele, A. (2014). A randomised trial of electro-acupuncture for arthralgia related to aromatase inhibitor use. European Journal of Cancer, 50, 267–276.

doi: 10.1016/j.ejca.2013.09.022
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Study Purpose:

To test the hypothesis that electroacupuncture (EA) would improve function and reduce arthralgia compared to usual care

Intervention Characteristics/Basic Study Process:

Patients were randomized to wait-list control, EA, or sham acupuncture (SA) groups. Acupuncture was given twice a week for two weeks, then weekly, for a total of 10 treatments over eight weeks. SA treatment frequency and duration were the same as for EA. Study assessments were done at baseline, after eight weeks, and at week 12.

Sample Characteristics:

  • N = 36
  • MEAN AGE = 59.67 years
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: All received aromatase inhibitors ranging from 19.5–31.1 months across groups. Duration of joint pain ranged from 43.4–62.9 on average. Duration was highly variable across groups.

Setting:

  • SITE: Single site 
  • SETTING TYPE: Outpatient 
  • LOCATION: Pennsylvania

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

  • Double-blind, placebo-controlled RCT

Measurement Instruments/Methods:

  • Brief Pain Inventory (BPI)
  • Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
  • Quick Disability of Arm Shoulder Hand (DASH)
  • Physical Performance Test (PPT)

Results:

At week 8  and week 12, the EA group had a greater reduction in pain severity and pain interference compared to the wait-list control group (p < .001). The EA group also had greater improvement in DASH scores and outcomes, as measured by the WOMAC index compared to controls. The SA group also had a significantly greater reduction in pain severity and interference compared to controls at week 8 and week 12 (p < .005). No significant differences were seen between the SA and EA groups.

Conclusions:

EA and SA were associated with reduction in arthralgia pain severity and interference and improvement in joint disability measures.

Limitations:

  • Small sample (less than 100)
  • Subject withdrawals 10% ore more
  • No information is provided regarding pain medication use.
  • Withdrawals were high, suggesting that the intervention may not be acceptable or practical for many patients.

Nursing Implications:

Findings suggest that EA and placebo acupuncture resulted in reduced pain from arthralgia in patients receiving aromatase inhibitors. Although this study was well designed, the sample size was small, and a substantial number of participants dropped out. Placebo effects of acupuncture or SA may help to alleviate arthralgia pain in these patients, and this approach may be acceptable or preferred by some patients.

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
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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
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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.

Hopkins Hollis, A.S. (2010). Acupuncture as a treatment modality for the management of cancer pain: The state of the science. Oncology Nursing Forum, 37, E344–E348.

doi: 10.1188/10.ONF.E344-E348
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Purpose:

To explore the current state of the science regarding acupuncture as a treatment modality for cancer pain

TYPE OF STUDY: Systematic review

Search Strategy:

Databases searched were PUBMED and CINAHL, in addition to websites from the National Cancer Institute, the National Institute of Health's Complementary and Alternative Medicine Program, and the American Cancer Society.

Keywords were acupuncture for cancer pain and cancer pain management acupuncture.

Studies that focused on cancer pain and acupuncture using human participants, were English language, and described attitudes associated with acupuncture or complementary and alternative medicine were included in the search.

Studies that focused on postoperative pain and studies that combined acupuncture with other modalities, such as massage, were excluded from the search.

Literature Evaluated:

A total of 130 studies from  2000 to 2009 were retrieved.

Sample Characteristics:

  • A final number of 11 studies were included in the review.
  • The 11 studies included 3 randomized controlled trials, 1 pilot study, 1 meta-analysis, 1 case-control study, 1 prospective cohort study, and 4 expert reviews.

Results:

  • Level I evidence: The administration of true acupuncture resulted in decreased pain when compared to the sham acupuncture and the control group (p < 0.05). No long-term difference in pain improvement was noted among groups.
  • Level III evidence: The low statistical power of this study and the lack of attempts to control for confounding variables affected the external validity.
  • Level V evidence: A decrease in pain was reported at one month for 16 of the 34 patients treated with acupuncture (p < 0.05) and at the six-month follow-up for 14 of the 34 patients treated with acupuncture (p < 0.05).

Conclusions:

The use of acupuncture as a complementary treatment for the management of cancer pain may have the potential to improve the quality of life of patients with cancer. Benefits of the addition of acupuncture for cancer pain management must be supported by evidence of safety and effectiveness. A synthesis of the current evidence reveals a lack of level I and level II studies pertaining to acupuncture as an intervention for the management of cancer pain. The nonexperimental studies cannot adequately infer causality.

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
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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.

Guideline/Expert Opinion

National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf

http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf
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Type of Resource/Evidence-Based Process:

These guidelines do not provide any information about search strategy or any specific evaluation of evidence. Notes state that most direct evidence is of low quality, but recommendations do result from unanimous consensus.

Guidelines & Recommendations:

The guidelines provide detailed recommendations regarding:

  • Screening and assessment
  • Management of pain in opioid-naive as well as opioid-tolerant patients
  • Ongoing care of adult patients with cancer and related pain management
  • Comprehensive pain assessment and use of pain ratings
  • Interventions for specific types of pain syndromes
  • Opioid prescribing, titration, and ongoing management
  • Management of adverse effects related to opioids
  • Psychosocial support and patient and family education
  • Nonpharmacologic interventions.

Limitations:

In general, opioids are first-line interventions. The NCCN guidelines suggest that antidepressants and anticonvulsants can be first-line treatments for adjuvant pain, although the recommendation for using them as such is still based on anecdotal experience or guidelines relating to patients who do not have cancer.

Nursing Implications:

The NCCN guidelines provide comprehensive algorithms for pain management, from screening to ongoing maintenance. The guidelines recommend considering a variety of nonpharmacologic interventions. Psychosocial support, including coping-skills training, is recommended, as is comprehensive patient and family education. The guidelines provide useful information and an overview of the full range of pain management. The work points to the ongoing need to consider multiple adjuvant and supportive interventions to achieve pain relief that works for the individual patient.

Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Jr., Cross, J.T., Jr, Owens, D.K., . . . Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146.

doi: 10.7326/0003-4819-148-2-200801150-00009
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Purpose & Patient Population:

Objectives were to

  • Present evidence that will contribute to the improvement of palliative care at the end of life.
  • Answer questions regarding critical elements.
  • Identify patients who could benefit from palliative approaches.
  • Identify treatment strategies that work for pain, dyspnea, and depression.
  • Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

Type of Resource/Evidence-Based Process:

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

Results Provided in the Reference:

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

  • Pain
    • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
    • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
    • Palliative care teams may be moderately beneficial in providing pain management.
  • Dyspnea
    • Evidence shows a valuable effect of morphine.
    • Nebulized opioids show no additional benefit over oral opioids.
    • Evidence regarding the use of oxygen is equivocal.
    • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
  • Depression
    • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
    • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
    • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

Guidelines & Recommendations:

The following were graded as strong recommendations with moderate quality of evidence.

  • Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
  • For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
  • Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
  • Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
  • Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

Limitations:

  • Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
  • Financial support for this guideline was entirely from the American College of Physicians.

Nursing Implications:

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.


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