Acupuncture

Acupuncture

PEP Topic 
Depression
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. 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.

Effectiveness Not Established

Research Evidence Summaries

Deng, G., Chan, Y., Sjoberg, D., Vickers, A., Yeung, K.S., Kris, M., . . . Cassileth, B. (2013). Acupuncture for the treatment of post-chemotherapy chronic fatigue: a randomized, blinded, sham-controlled trial. Supportive Care in Cancer, 21, 1735–1741.

doi: 10.1007/s00520-013-1720-z
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Study Purpose:

To determine if acupuncture reduced cancer-related fatigue (CRF) more effectively than did sham acupuncture.

Intervention Characteristics/Basic Study Process:

Patients were randomized to an acupuncture or sham control group. Treatments were given once a week over six weeks. In the acupuncture group, a total of 14 needles were inserted at defined points during each session. The needles were stimulated manually and retained for 20 minutes. Sham needles, used in the control group, were blunt-tipped, moved up inside their handles when pressed against the skin, and did not penetrate the skin. In the control group, sham needles were applied in the same number and using the same technique as were the needles in the acupuncture group. Outcome measures were obtained at two weeks and at one week prior to the start of interventions and again at 42 and 49 days after completion.

Sample Characteristics:

  • The study reported a sample of 74 patients (82% female, 18% male).
  • Mean patient age was 53.5 years (range 45–59).
  • Patients had multiple tumor types, and more than half had breast cancer.
  • All had completed a course of chemotherapy at least 60 days prior to the study.

Setting:

  • Single site
  • Outpatient
  • Memorial Sloan Kettering Cancer Center, New York City, NY

Phase of Care and Clinical Applications:

Patients were undergoing the transition phase after initial treatment.

Study Design:

The study was a double-blind, randomized, sham-controlled trial.

Measurement Instruments/Methods:

  • Brief Fatigue Inventory (BFI)
  • Hospital Anxiety and Depression Scale (HADS)
  • Functional Assessment of Cancer Therapy-General (FACT-G)

Results:

  • At least 87% of participants completed all sessions.
  • In both groups, total fatigue scores declined by approximately one point between baseline and follow-up.
  • There were no differences between groups.
  • Neither HADS nor FACT-G measures showed significant differences between groups.

Conclusions:

The study showed that acupuncture had no effect on the symptoms of fatigue, anxiety, or depression.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • The drop-out rate was greater than 24%.
  • The authors performed an intention-to-treat analysis, but they did not report their exact procedures.

Nursing Implications:

The study did not demonstrate that acupuncture had an effect on fatigue, anxiety, or depression. The study contributes to a growing body of research that shows conflicting results regarding the effectiveness of this intervention for the management of fatigue. It has been shown that symptoms such as fatigue and anxiety tend to decline over time among patients with cancer. It is unclear if the timing in this study affected the results; symptoms may have declined with or without the intervention.

Feng, Y., Wang, X. Y., Li, S. D., Zhang, Y., Wang, H. M., Li, M., . . . Zhang, Z. (2011). Clinical research of acupuncture on malignant tumor patients for improving depression and sleep quality. Journal of Traditional Chinese Medicine, 31, 199–202.

doi: 10.1016/S0254-6272(11)60042-3
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Study Purpose:

To study the effect of acupuncture on depression and insomnia in patients with malignant tumors. 

Intervention Characteristics/Basic Study Process:

One time per day for 20 to 30 minutes, over a course of 30 days, patients in the intervention group received acupuncture on these acupoints:  Fenglon (ST-40), Yinlingquan (SP-9), Xuehai (SP-10), Sanyinjiao (SP-6), Yintant (EX-HN3), Baihui (DU-20), Sishencong (EX-HN1), Neiguan (PC-6), and Shenmen (TF-4). Patients in the control group received fluoxetine, 20 mg/day. Depression scores and sleep ratings were collected before and after the three-day treatment.

Sample Characteristics:

  • The sample was comprised of 80 patients (66% male, 34% female) with malignant tumors:  40 patients were in the treatment group, which received acupuncture, and 40 were in the control group, which received 20 mg of fluoxetine daily.
  • Mean age was 63.8 years (standard deviation [SD] = 5.47 years; range 18–75 years).
  • All patients had a malignant tumor. Seven types of cancer were represented in the sample:  lung, gastric, breast, colorectal, lymphoma, cervical, and ovarian cancer. 
  • Depression was assessed according to the Chinese Classification of Mental Disorders, third edition (CCMD-3).
  • Patients with a functional disorder of the heart, liver, kidney, or spinal cord were excluded, as were those currently taking antidepressant medications.

Setting:

  • Single site
  • Beijing, China

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study was a randomized, controlled trial with intervention and control groups.

Measurement Instruments/Methods:

  • Zung Self-Rating Depression Scale (SDS)    
  • Hamilton Rating Scale for Depression (HRSD)
  • Pittsburgh Sleep Quality Index (PSQI)

Results:

Pretreatment SDS scores of the treatment and control groups were 64.12 (SD = 5.34) and 64.24 (SD = 4.98), respectively, with no significant difference (p > 0.05). After treatment, SDS scores of the treatment and control groups were 43.64 (SD = 5.28) and 50.76 (SD = 5.42), which showed significant difference (p < 0.05). HRSD scores of both groups showed no significant difference before treatment (p > 0.05); however, after-treatment scores were 9.88 (SD = 1.27) in the treatment group and 13.72 (SD = 2.05) in the control group (p < 0.05). These results indicate that both acupuncture and fluoxetine were effective in reducing depression scores in these patients, with acupuncture showing greater effectiveness. PSQI scores of the treatment group, before and after treatment, were 14.48 (SD = 1.71) and 7.92 (SD = 1.22), respectively, with a significant difference (p < 0.001). The control group's PSQI scores, 13.92 (SD = 2.59) and 11.44 (SD = 1.89), did not reach significance (p > 0.05). Results indicate that acupuncture improved sleep quality in more patients than did fluoxetine.

Conclusions:

Both acupuncture and fluoxetine were associated with reduced depression scores and some improvement in sleep. Due to the lack of a real control group and no control over cancer type and treatment phase, drawing a conclusion about the effectiveness of the intervention is difficult.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • The age range was small.
  • The study was conducted at a single site, and the measurement tools were self-report instruments.
  • Fluoxetine may take more than 30 days to reach therapeutic effectiveness.
  • The study compared a fluoxetine-using group to an acupuncture-using group; the study included no real control group.
  • The sample included diverse cancer types, and patients were at different phases of treatment. These factors may confound the findings.
  • The authors did not analyze the differences between groups in regard to posttreatment PSQI scores. 
  • The study did not include an attentional control or consider the possible placebo effect of acupuncture.
     

Nursing Implications:

Acupuncture is a nonpharmacologic intervention that shows promise in reducing depression and improving sleep quality in patients with cancer and depression.

Mao, J.J., Farrar, J.T., Bruner, D., Zee, J., Bowman, M., Seluzicki, C., . . . Xie, S.X. (2014). Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: A randomized trial. Cancer, 23, 3744–3751. 

doi: 10.1002/cncr.28917
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Study Purpose:

To examine electroacupuncture (EA) compared to sham acupuncture (SA) and a waitlist control (WLC) group to determine effectiveness on fatigue, sleep disturbance, depression, and anxiety in postmenopausal breast cancer survivors who reported joint pain, or arthralgia, related to aromatase inhibitors (anastrazole, letrozole, exemestane)

Intervention Characteristics/Basic Study Process:

Acupuncture interventions were administered by two licensed acupuncturists (not physicians). Ten treatments were administered over eight weeks with two treatments during each of the first two weeks followed by one treatment per week for the following six weeks. The EA and SA treatments were administered by the same two acupuncturists. Procedures for the two groups differed in the placement of the acupuncture needles and actual versus sham electrical stimulation using a transcutaneous electrical nerve stimulation (TENS) unit. The same timing and duration of treatments was used for each group.

Sample Characteristics:

  • N = 67 (159 were screened; 76 were enrolled; 9 were excluded during the next round of evaluations; 4 were lost to follow-up by time 2 [4 weeks] and 4 more were lost to follow-up by time 3 [12 weeks])  
  • MEAN AGE: 59.7 years (range = 41–76 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Breast cancer survivors being treated with aromatase inhibitors (AIs) for 3–56 months. 66% of participants were being treated with an AI at the time of the study. At baseline, there were significant correlations between baseline pain (as measured by the Brief Pain Inventory) and fatigue, sleep, and depression, but there was no correlation with anxiety. Most participants (71.6%) were white and 23.9% were black; greater than 75% reported college education. Disease: 48%–50% were at disease stage I, 30–36 % were at disease stage II, and 14%–22 % were at disease stage III.  
  • OTHER KEY SAMPLE CHARACTERISTICS: Most participants (71.6%) were white and 23.9% were black; greater than 75% held some college education. Inclusion criteria: Women with histories of stages I–III breast cancer currently taking an AI, current complaints of joint pain times three months, attributes pain to AI, current-week pain rating of 4 or greater on an 11-point rating (0–10), complaints of pain at least 15 days within the last 30 days. 

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Not specified    
  • LOCATION: The Abramson Cancer Center of the Hospital of the University of Pennsylvania

Phase of Care and Clinical Applications:

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

Study Design:

Three-group randomized controlled trial comparing EA, SA, and WLC.

Measurement Instruments/Methods:

Four measurement tools were used: the Brief Pain Inventory (BPI); the Brief Fatigue Inventory (BFI); the Pittsburgh Sleep Quality Index (PSQI); and the Hospital Anxiety and Depression Scale (HADS). A priori primary outcome reported pain intensity and interference. A priori secondary outcome reported fatigue, sleep, and psychological distress (anxiety, depression).

Results:

Measurements were repeated at weeks 4, 8, and 12. There was significant (p = 0.0095) improvement in the fatigue score after EA, no improvement with SA, and greater reduction in fatigue than the WLC group. There were nonsignificant improvements in sleep in the EA and SA groups compared to the WLC group. There was significant (p = 0.04) improvement in the EA group but the SA group on the HADS anxiety score compared to the WLC group; a nonsignificant improvement continued in the EA group at week 8, whereas week 12 showed a significant (p = 0.006) improvement in the EA and WLC groups. EA and SA group improvements in depression scores were significant (p = 0.015 and p = 0.0088, respectively) compared with the WLC group; EA and SA significantly (p = 0.0031m and p = 0.0056, respectively) improved scores at week 8, and scores did not change at week 12.

Conclusions:

EA produced improvements by reducing fatigue, anxiety, and depression scores. SA produced improvements in depression scores only. Acupuncture with electronic stimulation may be an effective treatment for pain and the nonpain symptoms of fatigue, sleep disturbance, and depression associated with AIs. Additional research is encouraged.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no blinding). There was no blinding but the risk of bias is low because each arm of the study required specific treatment limited to administration by just two acupuncturists.

 

Nursing Implications:

Acupuncture with electrical stimulation should be considered a viable treatment option for patients with breast cancer taking AIs who complain of joint pain. Large, randomized, controlled research studies are needed to develop evidence for the efficacy of EA in breast and other cancers. Drug and symptom cluster correlations must be deconstructed.

Molassiotis, A., Bardy, J., Finnegan-John, J., Mackereth, P., Ryder, D. W., Filshie, J., . . . Richardson, A. (2012). Acupuncture for cancer-related fatigue in patients with breast cancer: a pragmatic randomized controlled trial. Journal of Clinical Oncology, 30, 4470–4476.

doi: 10.1200/JCO.2012.41.6222
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Study Purpose:

To assess the effectiveness of acupuncture for cancer-related fatigue (CRF) in women with breast cancer.

Intervention Characteristics/Basic Study Process:

Women were randomly assigned to acupuncture or enhanced usual care groups. Usual care enhancement consisted of providing a booklet about CRF, diet, exercise, and sleep. The intervention group was offered six acupuncture treatments over six weeks. Sessions lasted 20 minutes each and involved unilateral or bilateral needles at three points. No rotation or flicking of needles was performed. Patients were followed for 18 weeks. Outcome measures were recorded at six weeks.

Sample Characteristics:

  • The sample was comprised of 246 participants.
  • Mean age was 52.5 years (range 25–80).
  • All participants were female.
  • All participants had breast cancer with no distant metastases. 
  • All participants had completed antitumor treatment within one month to five years prior to enrollment. 
  • All participants had a baseline fatigue of at least 5 on an 11-point screening scale. 
  • Average time since diagnosis was 20.5 months.
  • Mean duration of fatigue was 16.5 months.
  • Participants were predominantly white, married, and had at least a college education.

Setting:

  • Multisite
  • Outpatient
  • United Kingdom

Phase of Care and Clinical Applications:

The study has clinical applicability for late effects and survivorship.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Multidimensional Fatigue Inventory (MFI)
  • Hospital Anxiety and Depression Scale (HADS)
  • Functional Assessment of Cancer Therapy-Breast (FACT-B)
     

Results:

The difference score between the control and acupuncture groups for fatigue was –3.11 (95% confidence interval [CI] [–3.97, –2.25]; p < 0.001). Intention-to-treat (ITT) analysis, using an assumption of no improvement for patients whose week six outcome data were missing, continued to show a significant difference (–2.49; p < 0.001). Week six outcomes, as reflected in HADS and FACT-B scores, were significantly improved from baseline in patients who received acupuncture (p < 0.001).

Conclusions:

Findings showed that acupuncture as provided was effective in reducing fatigue over a six-week period among survivors of breast cancer.

Limitations:

  • The study had a risk of bias due to no blinding.
  • Data were missing for 20.3% of the acupuncture group and 13.3% of the control group. The authors performed conservative ITT analysis to account for the missing data. For the intervention group, the authors reported complete data only.
  • The authors did not discuss data relative to anxiety or depression.

Nursing Implications:

Findings showed that acupuncture was helpful in reducing fatigue in patients with breast cancer who had completed antitumor treatment. The study supports the effectiveness of acupuncture for the treatment of fatigue.

Molassiotis, A., Bardy, J., Finnegan-John, J., Mackereth, P., Ryder, W. D., Filshie, J., . . . Richardson, A. (2013). A randomized, controlled trial of acupuncture self-needling as maintenance therapy for cancer-related fatigue after therapist-delivered acupuncture. Annals of Oncology, 24, 1645–1652.

doi: 10.1093/annonc/mdt034
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Study Purpose:

To determine if maintenance acupuncture is beneficial in sustaining improvements in fatigue after a course of acupuncture.

Intervention Characteristics/Basic Study Process:

Patients in a previous six-week acupuncture trial were rerandomized to three groups:  maintenance self-acupuncture, therapist-delivered maintenance acupuncture, or a control group receiving usual care. Maintenance therapy lasted for four weeks. Standard acupuncture points were used, and sessions were weekly. Data were collected at the end of four weeks and at 12 weeks after rerandomization.

Sample Characteristics:

  • The study reported a sample of 151 women with breast cancer.
  • Mean age was 53 years.
  • Patients had undergone surgery, and the majority had received prior chemotherapy and radiotherapy.
  • Mean time since completion of treatment was 20 months.
  • The majority of patients were married and employed full- or part-time.

Setting:

  • Single site
  • Multiple settings
  • United Kingdom

Phase of Care and Clinical Applications:

Patients were undergoing the transition phase of care after active treatment.

Study Design:

The study was a randomized, controlled trial.

Measurement Instruments/Methods:

  • Multidimensional Fatigue Inventory (MFI)
  • Hospital Anxiety and Depression Scale (HADS)
  • Functional Assessment of Cancer Therapy-Breast (FACT-B)
  • Patients' logs of self-needling

Results:

Results showed a trend of fatigue improvement in the combined acupuncture groups compared to the control; the trend was not significant. In regard to results reflecting anxiety or depression, the study showed no differences between groups. Patients' logs indicated that patients performed self-needling as planned.

Conclusions:

Findings suggested that it is feasible for patients to maintain acupuncture treatment through self-needling. Compared to symptom improvement in patients in the control group, symptom improvement in patients undergoing maintenance acupuncture through self-needling or through delivery by a therapist was not significant.

Limitations:

  • The study had risks of bias due to no blinding and no appropriate attentional control condition.
  • The authors did not discuss other treatments or interventions aimed at fatigue. If the authors used additional management approaches, the approaches are unknown.

Nursing Implications:

The study showed that patients can be taught to deliver their own acupuncture treatments effectively by self-needling. The study did not demonstrate that ongoing acupuncture, or maintenance acupuncture, had any effect on fatigue, anxiety, or depression.

Systematic Review/Meta-Analysis

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
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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.

Haddad, N.E., & Palesh, O. (2014). Acupuncture in the treatment of cancer-related psychological symptoms. Integrative Cancer Therapies, 13, 371–385. 

doi: 10.1177/1534735413520181
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Purpose:

STUDY PURPOSE: To summarize existing research on acupuncture in the treatment of symptoms and quality of life in patients with cancer
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: PubMed
 
KEYWORDS: Acupuncture, cancer, depression, anxiety, sleep, insomnia, quality of life
 
INCLUSION CRITERIA: ​Studies in adults using acupuncture in which at least one of the outcomes was reported as a primary or secondary study outcome
 
EXCLUSION CRITERIA: Pediatric patients and review articles

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: Not reported
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Standards for reporting interventions in clinical trials of acupuncture guidelines were used, but there were no specific methods of study quality evaluation overall.

Sample Characteristics:

FINAL NUMBER STUDIES INCLUDED = 12
 
TOTAL PATIENTS INCLUDED IN REVIEW = 923
 
SAMPLE RANGE ACROSS STUDIES: 10–302 patients
 
KEY SAMPLE CHARACTERISTICS: Studies included perioperative use and patients in hospice care; most of the studies were of patients with breast cancer and breast cancer survivors.

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Elder care   

Results:

The studies included 11 quantitative and one qualitative study. Their findings showed positive effects on sleep in two studies, one of which was a single-arm, nonrandomized study. Positive effects were shown on anxiety in three studies, one of which was single-arm. Four studies showed positive effects on depression, one of which was single-arm. Five studies did not show acupuncture to have any effects. It was noted that acupuncture methodology was inconsistently reported. There also was a lack of data such as standard deviations and change scores.

Conclusions:

This review showed mixed results for the effects of acupuncture on sleep, depression, and anxiety. The current evidence has several study design and reporting limitations.

Limitations:

  • There was inconsistent reporting of methods and statistical results.
  • There was no quality evaluation of individual studies.
  • No information was provided regarding whether baseline anxiety or depression scores were clinically significant.
  • In many trials, the practitioner delivering the intervention was not reported.

Nursing Implications:

There is no strong evidence to support the use of acupuncture for the treatment of anxiety, depression, or sleep disturbances.


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