Acupuncture

Acupuncture

PEP Topic 
Lymphedema
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.) The needles are twirled or energized electronically or are warmed and left in place for 20–30 minutes. The acupuncture point P6 is most commonly used for treatment of nausea and vomiting (Gamaluddin & Kirchner, 2006). Acupuncture has been evaluated in regard to treatment of anxiety, chemotherapy-induced nausea and vomiting, dyspnea, pain, hot flashes, depression, lymphedema, sleep-wake disturbances, peripheral neuropathy, and fatigue.
 
Gamaluddin, S., & Kirchner, J.T. (2006). Acupuncture: What the evidence shows now. Family Practice Recertification, 28(9), 26–28,33–37.

Effectiveness Not Established

Research Evidence Summaries

Cassileth, B.R., Van Zee, K.J., Chan, Y., Coleton, M.I., Hudis, C.A., Cohen, S., . . . Vickers, A.J. (2011). A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society, 29(3),170–172.

doi:10.1136/aim.2011.004069
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Study Purpose:

To evaluate the safety and effectiveness of acupuncture in women diagnosed with chronic lymphedema

Intervention Characteristics/Basic Study Process:

Women with chronic lymphedema after breast cancer surgery received acupuncture twice a week for four weeks using Acupoint prescription, chosen by consensus from members of the Memorial Sloan Kettering Cancer Center Integrative Medicine Service certified acupuncturists.

Sample Characteristics:

  • The study sample (N = 9) was comprised of female patients aged 18 years or older.
  • Median age of patients was 54 years.
  • All patients had lymphedema (arm circumference greater than 2 cm in comparison to unaffected arm) for at least six months and no more than five years as a result of surgery or radiation therapy for breast cancer.
  • Patients were excluded from the study if they had previous acupuncture treatment for lymphedema or current use of diuretics.

Setting:

The study took place at the Integrative Medicine Service and Department of Epidemiology and Biostatistics at the Memorial Sloan-Kettering Cancer Center in New York.

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study used a prospective pilot design.

Measurement Instruments/Methods:

  • Upper extremity volume was measured at two places on both the affected and unaffected extremities. The site with the greater difference between the affected and unaffected arms was used to determine the baseline measurement and assess outcome by comparing changes in the baseline measures.
  • Positive response was considered to be 30% reduction in the difference in size between affected and unaffected upper extremities after four weeks of treatment.

Results:

After nine subjects were treated, four women demonstrated a 30% reduction in limb volume after four weeks of treatment, with no significant adverse events occurring. Some patients did experience minor toxicities, such as slight bruising or minor pain at acupuncture site shortly after treatment.

Conclusions:

The pilot study suggests that acupuncture for women with arm lymphedema may be practical and was not associated with significant adverse effects. Further research in this area to establish safety and begin to evaluate effectiveness is planned.

Limitations:

  • The sample size was small with less than 30 patients.
  • Sample characteristics present a risk of bias.
  • Measurements and methods were not well described.

Nursing Implications:

Additional robust randomized controlled trials are needed to evaluate the use of acupuncture for the treatment of lymphedema.

Cassileth, B.R., Van Zee, K.J., Yeung, K.S., Coleton, M.I., Cohen, S., Chan, Y.H., … Hudis, C.A. (2013). Acupuncture in the treatment of upper-limb lymphedema: Results of a pilot study. Cancer, 119, 2455–2461.

doi: 10.1002/cncr.28093
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Study Purpose:

To evaluate the safety and potential efficacy of acupuncture in the treatment of arm lymphedema in women with breast cancer-related lymphedema

Intervention Characteristics/Basic Study Process:

Each patient was given acupuncture treatment twice weekly for four weeks. Treatments lasted 30 minutes, as 14 needles were inserted at apecific points determined on the basis of history and consensus of experienced acupuncturists.  Arm circumference was measured before and after each treatment.

Sample Characteristics:

  • The study consisted of 33 patients with a mean age of 55 years.
  • All of the participants were female and had breast cancer-related arm lymphedema.
  • Time from surgery was a median of 3.9 years. 
  • Most patients were reported to be on standard lymphedema therapy prior to enrollment.

Setting:

This was a single-site, outpatient study conducted at Memorial Sloan-Kettering Cancer Center in New York.

Phase of Care and Clinical Applications:

This study has clinical applicability for late effects and survivorship.

Study Design:

This was a prospective trial.

Measurement Instruments/Methods:

  • Arm circumference was measured.
  • The percent change in lymphedema was calucated by taking the largest pretreatment difference between arms minus the same site posttreatment difference and dividing that number by the largest pretreatment difference.

Results:

  • Just more than three-fourths of the patients (76%) received all intervention sessions. Of these, 33% showed reduction of 30% or more in lymphedema and 55% showed reduction of 20% or more. Mean reduction in the extent of lymphedema was 0.90 cm (95% confidence interval [CI], 0.72–1.07, p < 0.0005). 
  • A segment of patients (12%) reported sustained improvement for four months during follow up; however, the method of obtaining this information was not clearly described. 
  • Additionally, 36.4% of patients reported mild bruising or minor pain or tingling in the arm or shoulder at least once. One patient experienced a transient increase in lymphedema.

Conclusions:

Findings suggest that acupuncture can be safely provided to patients with arm lymphedema. However, the benefit is unclear because of study design limitations and the fact that the mean change in lymphedema was very small.

Limitations:

  • The sample size was small with fewer than 100 patients.
  • A risk of bias exists because no control group, blinding, or random assignment was used.
  • Unintended interventions or applicable interventions that were not described could have influenced results.
  • The measurement methods were not well described.
  • The measurement validity and reliability was questionable.
  • The method of lymphedema measurement was not as rigorous as possible. The actual “standard” treatments used are not described, and it is not known if any changes occurred in the standard approaches during the study period, such as activity changes. 
  • The report of duration of effect on follow-up was not clearly described.

Nursing Implications:

This study provides insufficient evidence to support efficacy of acupuncture for lymphedema management.

Smith, C.A., Pirotta, M., & Kilbreath, S. (2014). A feasibility study to examine the role of acupuncture to reduce symptoms of lymphoedema after breast cancer: A randomised controlled trial. Acupuncture in Medicine. Advance online publication. 

doi: 10.1136/acupmed-2014-010593
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Study Purpose:

To determine the feasibility, acceptability, and safety of acupuncture to treat arm lymphedema in women following treatment for breast cancer

Intervention Characteristics/Basic Study Process:

This was a randomized, controlled trial of acupuncture compared to usual treatment. Twenty women with stable, unilateral, intransient lymphedema that was present for at least six months prior were recruited. Ten participants were in the control group. The remaining 10 received 12 acupuncture treatments administered to body and arm points on the nonlymphedematous limb over eight weeks, twice weekly for four weeks then once weekly for four weeks. Clinical outcomes were assessed at baseline and again after eight weeks.

Sample Characteristics:

  • N = 17  
  • MEAN AGE = 57 years (control, SD = 8.4 years), 63.4 years (acupuncture, SD = 7.4 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer-related lymphedema
  • OTHER KEY SAMPLE CHARACTERISTICS: Had lymphedema for at least six months

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Outpatient    
  • LOCATION: Clinic in Sydney, Australia

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Late effects and survivorship
  • APPLICATIONS: Palliative care 

Study Design:

Randomized, controlled trial

Measurement Instruments/Methods:

  • Bioimpedance spectroscopy (BIS) and arm circumference measure (SFB7 instrument)
  • Lymphoedema Symptom Intensity and Distress Survey–Arm and Trunk (LSIDS-AT)
  • Measure Yourself Medical Outcome Profile (MYMOP)

Results:

Compliance with the treatment protocol was high; 37 women were recruited and 20 were included in the trial. Three women withdrew from the trial. Participants reported an average of two symptoms associated with treatment. Acupuncture did not worsen lymphedema in the intervention group. The change in BIS measurements ranged from a 0.01 increase to a 0.3 decrease in the control group. The intervention group’s BIS measurements saw an increase of 0.28 and a decrease or 0.43. No increases in swelling greater than 10% occurred. No changes in quality of life or other patient-reported outcome measures related to lymphedema were reported.

Conclusions:

Acupuncture did not cause any significant changes in limb volume for women with arm lymphedema. It may stabilize lymphedema symptoms. No major safety concerns were identified.

Limitations:

  • Small sample (< 30)
  • Key sample group differences that could influence results
  • Subject withdrawals ≥ 10%
  • Other limitations/explanation: The control and intervention groups were chosen randomly, but the women in the acupuncture group had symptoms for a significantly longer period of time.

Nursing Implications:

Acupuncture did not improve or exacerbate lymphedema in women who were breast cancer survivors. At this time, there is not enough research to promote the use of acupuncture as an effective intervention for the reduction of arm volume in this population.


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