Complementary Therapies in Medicine (2015) 23, 68—78
Available online at www.sciencedirect.com
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Effect of self-acupressure for symptom management: A systematic review Hyun Jin Song a, Hyun-Ju Seo b,∗, Heeyoung Lee c, Heejeong Son d, Sun Mi Choi e, Sanghun Lee e a
School of Pharmacy, Sungkyunkwan University, Suwon, South Korea Department of Nursing, College of Medicine, Chosun University, 309 Pilmum-daero, Dong-gu, Gwangju 501-759, South Korea c Public Health Medical Service, Seoul National University Bundang Hospital, Seongnam, South Korea d Graduate School of Public Health, Seoul National University, Seoul, South Korea e Korea Institute of Oriental Medicine, Daejeon, South Korea Available online 4 December 2014 b
KEYWORDS Acupressure; Self-administration; Signs and Symptoms
∗
Abstract Objectives: To assess the efficacy and safety of self-administered acupressure to alleviate symptoms of various health problems, including allergic disease, cancer, respiratory disease, dysmenorrhea, perceived stress, insomnia, and sleep disturbances. Methods: We searched core, Korean, Chinese, and Japanese databases, including Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), six representative electronic Korean medical databases, China National Knowledge Infrastructure (CNKI), and Japan Science and Technology Information Aggregator (J-STAGE). We included randomized controlled trials (RCTs) and quasi-RCTs that examined disease-specific effects or symptom relief, adverse reactions, and quality-of-life (QOL) for self-administered acupressure. Data collection and assessment of the methodological quality of the included studies were conducted by two independent reviewers. Results: Eight RCTs and two quasi-RCTs showed positive effects and safety of self-acupressure therapy in clinically diverse populations. Quality assessment revealed moderate quality for the RCTs, with 50% or more of the trials assessed as presenting a low risk of bias in seven domains. All of the selected 10 studies reported positive effects for primary outcomes of selfacupressure therapy for symptom management, including significant improvements in symptom scores in allergic disease, nausea and vomiting in cancer, symptom scores in respiratory disease, pain symptoms in dysmenorrhea, and stress/fatigue scores and sleep disturbances in healthy people.
Corresponding author. Tel.: +82 62 230 6320; fax: +82 62 230 6329. E-mail address: [email protected] (H.-J. Seo).
http://dx.doi.org/10.1016/j.ctim.2014.11.002 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
Effect of self-acupressure for symptom management: A systematic review
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Conclusions: Our findings suggest that self-administered acupressure shows promise to alleviate the symptoms of various health problems. Therefore, further research with larger samples and methodologically well-designed RCTs is required to establish the efficacy of self-administered acupressure. © 2014 Elsevier Ltd. All rights reserved.
Introduction Acupressure involves applying pressure to specific points on the body using the hands, fingers, thumbs, elbows, feet, or various devices.1—3 According to the meridian theory, acupressure increases the flow of energy (qi) in the body; therefore, it is effective for managing symptoms of disease.4 Acupuncture, which is considered a representative treatment of alternative and complementary medicine, uses fine needles inserted in specific points on the body. Acupressure utilizes application of pressure to acupoints without penetrating the skin.1,2 Acupressure is non-invasive and typically painless, and adverse reactions caused by insertion of fine needles can be avoided.3 Moreover, self-acupressure can be administered in any situation, regardless of time and place, and self-treatment can be conducted without expensive costs. Self-acupressure is acupressure performed by trained participants without treatment by practitioners or healthcare providers. Several systematic reviews of acupressure performed by practitioners have been reported.2,3,5 However, no systematic review of self-acupressure with its various advantages, such as economical and convenient use, has been published. In order to develop acupressure as a self-administered therapy, it was necessary to understand the evidence supporting self-acupressure. Thus, this systematic review aimed to estimate the efficacy and safety of self-acupressure to alleviate symptoms of various health problems.
Methods Data sources and searches We conducted an extensive and comprehensive literature search of core, Korean, Chinese, and Japanese databases. The core databases were Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Korean databases included KoreaMed, Korean Medical Database (KMbase), Korean Studies Information Service System (KISS), National Discovery for Science Leaders (NDSL), and Korea Institute of Science Technology Information (KISTI). We also utilized the Oriental Medicine Advanced Searching Integrated System (OASIS). Chinese and Japanese databases were included in our search, specifically China National Knowledge Infrastructure (CNKI) and Japan Science and Technology Information Aggregator (J-STAGE). The search was conducted from 28 April 2013 to 7 May 2013. The search terms used were ‘‘acupressure,’’ ‘‘self,’’ and ‘‘acupuncture.’’ Medical Subject Headings (MeSH) terms and text words were used to adjust the search characteristics for each database. The only search limitation was
intervention for high sensitivity, and there were no limitations on diseases, patients, or language.
Study selection The inclusion criterion was self-administered acupressure. The final treatment interventions were carried out by the participants after they received training in the intervention procedure. All studies related to self-administered acupressure were included, regardless of the acupressure techniques applied. The studies included in this systematic review were randomized controlled trials (RCTs) or studies with a quasi-RCT design. Comparisons were sham acupressure, standard of care, and no treatment. The participants came from the general population or were patients with any type of disease. The outcomes included disease-specific effects, symptom relief, adverse reactions, and quality of life. Studies with final interventions performed by practitioners or healthcare providers were excluded. Studies reporting a mixture of interventions were also excluded, as were those reporting non-human target populations and interventions other than acupressure. In addition, there was no a priori exclusion criterion based on publication language.
Data extraction and quality assessment Two researchers independently extracted the data using a predetermined extraction form. For papers where the major outcomes were presented in graphical form, the corresponding author was contacted. The intention-to-treat (ITT) analysis was used if both ITT and per-protocol (PP) analyses were presented in the study. Disagreements regarding extracted data were resolved by consensus with a third person. The extraction form included the study design, the number and characteristics of participants, follow-up periods, primary and secondary outcomes, country of publication, treatment regimens, main acupoints, and methods of teaching self-acupressure. The quality of the RCTs was assessed using the Cochrane Risk of Bias (RoB) tool.6 The RoB tool assessed seven dimensions: sequence generation, allocation concealment, blinding of participants, personnel and outcomes, incomplete outcome data, selective outcome reporting, and other sources of bias. In this study, funding sources were confirmed in order to assess other sources of bias. Quasi-RCTs were assessed using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), which evaluated selection of participants, confounding variables, measurement of intervention (exposure), blinding for outcome assessment, incomplete outcome data, and selective outcome reporting.7
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Figure 1
Study flow diagram.
Data synthesis and analysis Because the included studies were not limited to participants with a specific disease, the estimation of outcomes did not possess inherent homogeneity of patients and interventions. Therefore, outcomes were not combined quantitatively, but were presented descriptively in this study.
Results The search produced 793 potential articles from all databases. After reviewing the abstracts, 768 studies were excluded, and 25 potential studies were selected. Review of the full articles resulted in exclusion of an additional 15 studies.3,8—21 Studies were excluded because they did not report self-acupressure, did not directly compare acupressure and placebo/control, did not include extracted clinical outcomes, were duplicate studies, or were not original articles. At the end of the review process, 10 studies (eight RCTs and two quasi-RCTs) out of 793 articles were selected for inclusion in this review (Figure 1). Among the eight RCTs, 75% (6/8) of the studies were evaluated as having a low risk of bias for random sequence generation, blinding of participants, blinding of outcome assessment, and selective reporting (Figure 2). The percentage of RCTs assessed as having a low risk of bias for incomplete outcome data and funding source was 50% (4/8). In the case of allocation concealment, the percentage of low-risk studies was only 25% (2/8). One quasi-RCT was evaluated as having a low risk of bias for blinding for outcome assessment, incomplete outcome data, and selective outcome reporting. All other dimensions evaluated for the quasi-RCTs were found to have a high or unclear risk of bias (Figure 3).
The studies included in this review were all designed as head-to-head trials. Eight RCTs and two quasi-RCTs were selected, with one crossover study design among the RCTs. The total number of participants was 659. Two of the trials reported results for two comparative groups: placebo (sham acupressure or no acupressure) and/or usual care (Table 1). Clinical problems included atopic dermatitis, allergic rhinitis, breast cancer, stomach cancer, bronchiectasis, chronic obstructive pulmonary disease (COPD), dysmenorrhea, stress, sleep disturbance, and fatigue. Follow-up periods ranged from three days to three months. The research countries included three trials from the United States, two trials from South Korea, and one trial each from Taiwan, Iran, Japan, Hong Kong, and Australia. Selected acupoints varied depending on the disease. Even when the same disease was being treated, different acupoints were selected according to the trial’s methods (Table 2). Training for participants in the technique of self-acupressure encompassed a wide variety of teaching methods utilized by the investigators. Investigators in five of 10 trials conducted training using an Acupressure Teaching Booklet. Acupoints were marked using ink or tape in three trials. Participants completed training sessions in one trial, and participants practiced self-acupressure under direct observation by the practitioner in another trial.
Self-acupressure for allergic disease Xue et al. compared real ear acupoints (REAP) with sham ear acupoints (SEAP) in 63 patients with allergic rhinitis.22 REAP were Shenmen (TF 4), Neibi (TG 4), Fei (CO 14), Fengxi (SF 1, 2i), and Shenshangxian (TG 2p); SEAP were Lun 2 (HX 10), Jian (SF 4, 5), Suogu (SF 6), Zhen (AT 3), and Ya (LO 1). Outcomes for REAP were significantly better than for SEAP in total nasal symptom score (TNSS) (P = 0.02), global nasal/nonnasal symptom score (P = 0.04), sneezing score (P = 0.01), and regular activities at home and work (P = 0.04). However, there were no significant differences between groups for results of the standardized Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and medication use. Mild adverse reactions were reported by 29.0% of the patients in the REAP group and 21.9% of the patients in SEAP group (P = 0.51). Serious adverse reactions were not reported in either group. Lee et al. studied 15 adult patients with pruritic atopic dermatitis.23 Acupressure plus standard care was compared with standard care only. Acupressure was administered for 3 min to Quchi (LI 11), an acupoint located on the left arm lateral to the antecubital fossa, three times per week for 4 weeks. Standard care included prescription and over-the-counter medications or lotions. Acupressure plus standard care compared with standard care only resulted in significant decreases in the Visual Analogue Scale (VAS) score (P = 0.04), Investigator’s Global Assessment (IGA) score (P = 0.03), and Eczema Area and Severity Index (EASI) lichenification score (P = 0.03). There was no significant difference in the overall EASI score. No adverse reactions were reported in either group.
Study characteristics of acupressure trials.
First author and Clinical publication year problem
Randomized controlled trial Xue et al., Allergic rhinitis 2011
No. of patients
Follow-up
Country
Measures
Symptom score, medication use, quality of life Severity of itching and atopic dermatitis Chemotherapy induced nausea and vomiting (CINV) Decreased symptoms, improved health-related quality of life Relief of dyspnea and other symptoms
Control (usual care)
31
32
NA
54.0
8 weeks
Australia
Median 28.5 (range 19—79) 49.3 (9.4)
33.3
4 weeks
US
100.0
21 days
US
59.5 (11.5)
40.0
8 weeks
Taiwan
67.3 (8.2)
NA
6 weeks
US
20.0* [Acupressure group: 20.0 (1.0) Control group: 19.9 (0.9)] 21.8* [Acupressure group: 22.0 (0.9) Control group: 21.6 (0.7)] 28.9 (8.5)
100.0
5 days
Iran
Pain score
100.0
Hong Kong
Pain level, menstrual distress
37.5
3 months (3 days in one month) 2 weeks
Japan
Perceived stress
Atopic dermatitis Breast cancer
8
7
53
Maa et al., 2007
Bronchiectasis
11
31
Placebo 53 Usual care 54 Placebo 11 Standard care 13 31
88
84
Chronic obstructive pulmonary disease (COPD) Bazarganipour Dysmenorrhea et al., 2010
Female, %
Acupressure
Lee et al., 2012 Dibble et al., 2007
Maa et al., 1997
Mean age (SD)
Wong et al., 2010
Dysmenorrhea
19
21
Honda et al., 2012
Stress (college students)
12
12
Quasi-randomized controlled trial Kim & Youn, 25 Sleep 2004 disturbance, fatigue (clinical nurses) Shin et al., Stomach 20 2004 cancer
23
26.6* [Acupressure group: 26.8 Control group: 26.3]
NA
3 days
South Korea
Sleep disturbance score, fatigue score
20
50.0 [Acupressure group: 52.8 (10.9) Control group: 47.3 (6.8)]
30.0
5 days
South Korea
Chemotherapy induced nausea and vomiting (CINV)
Effect of self-acupressure for symptom management: A systematic review
Table 1
NA: not available * The mean age of total participants was not reported, so the weighted mean age applied number in each group was calculated.
71
72 Table 2
H.J. Song et al. Study protocols for acupressure trials.
First author and publication year
Main acupoints Acupressure
Placebo/control
Treatment regimen
Teaching methods of self-acupressure
Three times daily, both ears, alternating weekly; adhesive stainless steel press-pellets (Acuneeds, Australia) were pressed until participants felt heat and slight soreness at the points 3 min, 3 times per week, for 4 weeks; acupressure was performed using a 1.2 mm titanium acupellet (Lhasa OMS, Weymouth, Massachusetts, USA) Each morning; acupressure was applied using the thumb of the opposite hand
Participants were instructed to press stainless steel pellets until they felt heat and slight soreness at the acupoints
Randomized controlled trial Xue et al., 2011 Real ear acupoints: Shenmen (TF 4), Neibi (TG 4), Fei (CO 14), Fengxi (SF 1, 2i), and Shenshangxian (TG 2p)
Sham ear acupoints: Lun 2 (HX 10), Jian (SF 4, 5), Suogu (SF 6), Zhen (AT 3), and Ya (LO 1)
Lee et al., 2012
Quchi (LI 11), located on the left arm lateral to the antecubital fossa
No acupressure
Dibble et al., 2007
Neiguan (PC 6), located on both forearms
Placebo group: sham point (Houxi, SI 3)/Usual care only group
Maa et al., 2007
Zhongfu (LU 1), Chize (LU 5), Yuji (LU 10), Fenglong (ST 40) and Zusanli (ST 36). Each point is located bilaterally.
Sham acupressure: near real acupoints/Standard care
First one side of the body and then the other side, for 30 s to 2 min; acupoints were stimulated using the fingers to apply gentle but firm pressure
Maa et al., 1997
Zhongfu LU 1, Yunmen LU 2, Dazhui GV 14, Yuji LU 10, Laogong PC 8, Zusanli ST 36, Hegu LI 4
Sham acupressure: non-acupoints
Real acupoints for 6 weeks, followed by sham acupressure for 6 weeks; participants applied gentle but firm pressure to the acupoint at approximately a 90◦ angle to the skin surface, using one or two fingers
Participants were instructed by principal investigators to administer acupressure with a titanium acupellet
Participants were instructed to perform acupressure to PC 6 points every morning. When participants asked, ink marks were provided to make locating the points easier. A skilled instructor directly demonstrated acupressure for the participants. After that, participants were asked to perform acupressure by themselves to make sure of their acquisition of the technique. An instructional booklet explaining how to locate and stimulate acupoints was also provided. A skilled instructor explained the acupressure technique using the instruction booklet. Acupressure was performed for each participant by the instructor for teaching purposes. When necessary, acupoints were marked on the skin.
Effect of self-acupressure for symptom management: A systematic review Table 2
73
(Continued)
First author and publication year
Main acupoints
Treatment regimen
Teaching methods of self-acupressure
20 min for 3 to 7 days before the menstrual cycle, in a sitting position, applying pressure using the thumb 20 min during the first 3 days of their next 3 menstrual cycles; pressure was applied using the participant’s thumb
Participants were instructed to apply the acupressure protocol on the acupoints predetermined by the investigator. After an acupressure intervention by a practitioner, participants were taught to practice acupressure at home. An Acupressure Teaching Booklet was provided. Participants were asked to complete five self-acupressure sessions
Acupressure
Placebo/control
Bazarganipour et al., 2010
Simple pressure to the Taichong (LR 3) point (between the first and second toe)
Simple pressure to the placebo point (between the third and fourth toe)
Wong et al., 2010
Sanyinjiao (SP 6) acupressure
No acupressure
Honda et al., 2012
Three acupressure points (Wangu GB 12, Tianrong SI 17, Futu LI 18) on the left and right sides of the neck
No intervention
5 s, five sessions during the morning, midday, and night
No intervention
3 days, 4 times per day; acupressure was administered using two thumbs
Usual care
5 min before chemotherapy, mealtimes, and anytime sensations of nausea were felt; participants applied acupressure using their finger
Quasi-randomized controlled trial Kim and Youn, Wangu (GB 12), 2004 Shenmen (HT 7), and Sanyinjiao (SP 6) acupoints
Shin et al., 2004
Neiguan (PC 6) acupressure point
The investigator demonstrated acupressure using an Acupressure Teaching Booklet. After that, the participants performed acupressure by themselves to make sure they understood the technique. Acupoints were first marked with tape. After it was removed, the participants located acupoints following written instructions. Participants and their family in the ward were taught how to locate the acupressure point by investigators. Acupressure Teaching Booklets were distributed to the ward. Participants were asked to perform the technique on the investigators to assure they could locate the points and apply enough pressure.
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Figure 2 Risk of bias graph and summary of all included randomized controlled trials using Cochrane’s RoB assessment tool. (a) RoB graph (b) RoB summary. RoB: Risk of Bias; (+): low risk of bias; (−): high risk of bias; (?): unclear risk of bias.
Self-acupressure for cancer Dibble et al. conducted a RCT with 160 breast cancer patients who were receiving chemotherapy.24 The experimental group used their thumbs to press the Neiguan (PC 6) acupoint located bilaterally on the forearm, while the placebo group pressed the Houxi (SI 3) acupoint located on the ulnar side of the hand. The control group was treated with only usual care. Patients in all groups received usual care consisting of antiemetic therapy prescribed by their physicians. Delayed nausea or emesis, as well as the amount
of vomiting and the intensity of nausea over time, was significantly decreased in the experimental group compared with both the placebo group (P = 0.002) and the control group (P < 0.0001). However, acute nausea or emesis was not significantly different among the three groups (P = 0.71). Shin et al. conducted a quasi-RCT of 40 stomach cancer patients receiving chemotherapy.25 Nausea and vomiting in the intervention and control groups was the primary outcome. All patients received antiemetic therapy (metoclopramide and ondansetron) as prescribed by their physicians as usual care. Patients in the intervention group
Effect of self-acupressure for symptom management: A systematic review
75
LU 10, Laogong PC 8, Zusanli ST 36, and Hegu LI 4) for 6 weeks, followed by sham acupressure for an additional 6 weeks. The other group performed sham acupressure for the first 6 weeks and real acupressure for the following 6 weeks. Sham acupressure was applied with the same technique to seven points that were not true acupoints. The real acupressure group had less dyspnea as measured by a VAS scale and lower decathexis scores compared with the sham acupressure group (P = 0.009 and P = 0.044, both onetailed). However, sham acupressure was more effective in reducing peripheral sensory symptoms than real acupressure (P = 0.002, two-tailed).
Self-acupressure for dysmenorrhea
Figure 3 Risk of bias graph and summary of all included quasirandomized controlled trials using the RoBA. NS tool. (a) RoBANS graph (b) RoBANS summary. RoBANS: Risk of Bias Assessment for Non-randomized Studies; (+): low risk of bias; (−): high risk of bias; (?): unclear risk of bias.
also performed acupressure treatment at the Neiguan (PC 6) acupoint for 5 min before chemotherapy, at mealtimes, and any time they experienced nausea. According to the Rhodes Index of Nausea, Vomiting, and Retching (INVR), outcomes in the intervention group were significantly better for severity of nausea and vomiting (P < 0.01), duration of nausea (P < 0.01), and frequency of vomiting (P < 0.01) when compared with the control group.
Self-acupressure for respiratory disease In 2007, Maa et al. compared acupressure plus standard care, sham acupressure plus standard care, and standard care only in 35 patients with bronchiectasis.26 The acupressure points were Zhongfu (LU 1), Chize (LU 5), Yuji (LU 10), Fenglong (ST 40) and Zusanli (ST 36), with each point located bilaterally. Sham acupressure was performed on nearby real acupoints, and standard care included oral medication and chest physiotherapy. Outcomes for the Saint George Respiratory Questionnaire (SGRQ) in the acupressure plus standard care group were significantly better when compared with the standard care only group (P = 0.01). However, there was no significant difference in outcomes between the sham acupressure plus standard care and standard care only groups. Maa et al. studied the effects of acupressure in 31 patients with COPD in a RCT with a crossover design.27 One group performed acupressure at seven bilateral acupoints (Zhongfu LU 1, Yunmen LU 2, Dazhui GV 14, Yuji
A study of 172 dysmenorrhea patients by Bazarganipour et al. compared simple pressure to the Taichong (LR 3) acupoint (between the first and second toe) with simple pressure to a placebo point.28 The Taichong acupressure group showed a significant decrease in dysmenorrhea severity (P < 0.01), and, by the fourth menstrual cycle, there was a significant difference in dysmenorrhea severity (P < 0.02) between the Taichong and placebo groups. Wong et al. studied acupressure in 40 dysmenorrhea patients divided into acupressure intervention and control groups.29 The intervention group performed acupressure at Sanyinjiao (SP 6) for 20 min upon waking and at bedtime during the first three days of three successive menstrual cycles. The Pain Visual Analogue Scale (PVAS) and ShortForm MacGill Pain Questionnaire (SF-MPQ), administered 20 min after acupressure, showed significant reductions in pain scores in the acupressure group compared with the control group (P = 0.008 and P = 0.012). Moreover, scores on the PVAS, SF-MPQ, and Short-Form Menstrual Distress Questionnaire (SF-MDQ) administered to the acupressure group were significantly different when compared with the control group at three months after the intervention (P = 0.008, P = 0.012, and P = 0.024, respectively).
Self-acupressure for healthy people Honda et al. studied the difference between acupressure intervention and no intervention in 24 college students.30 Acupressure was administered to three points (Wangu GB 12, Tianrong SI 17, Futu LI 18) on the left and right sides of the neck for 5 s. The stress score for the Japanese language version of the Rhode Island Stress and Coping Inventory (JRISCI) was significantly decreased in the acupressure group compared with the control group after 2 weeks (P < 0.05). Kim and Youn studied sleep disturbance and fatigue among 48 clinical nurses divided into acupressure and nointervention groups.31 The Wangu (GB 12), Shenmen (HT 7), and Sanyinjiao (SP 6) acupoints were pressed for three days at a frequency of four times per day. The sleep disturbance and fatigue scores were significantly lower in the acupressure group compared with the no-intervention group after three days (P < 0.01 and P < 0.01).
Discussion This systematic review was performed to investigate the efficacy and safety of self-administered acupressure therapy
76 to relieve symptoms of various health problems, including allergic disease, cancer, respiratory disease, dysmenorrhea, perceived stress, insomnia, and sleep disturbances. All of the selected 10 studies reported positive effects for primary outcomes of self-acupressure therapy for symptom management. That is, there were significant improvements in outcomes for allergic disease, chemotherapy-induced nausea and vomiting in cancer patients, respiratory disease, dysmenorrhea, and stress/fatigue scores and sleep disturbances in healthy people. However, some secondary outcomes such as QOL, medication use in allergic disease, and acute nausea or emesis induced by chemotherapy did not show a significant difference. There were no studies reporting severe adverse reactions to self-acupressure. The results of our quality assessment showed a relatively moderate risk of bias in the RCTs, while the risk of bias in the quasi-RCTs was at least 50% higher for most of the evaluated domains. The results of the present review were similar to those of previous reviews.2,3,5,16,32 All of the previous systematic reviews included studies of acupressure performed by both participants and practitioners.
Allergic disease Two RCTs for allergic disease were included in this review. Xue et al. found that the symptom score for rhinitis in a REAP group was significantly improved compared with a SEAP group.22 In the second trial, the atopic dermatitis score for patients receiving acupressure plus standard care was significantly improved in comparison with standard care only.23 The results of a review of acupuncture and acupressure for allergic rhinitis by Zhang et al. were similar to those of the present study.32 Inclusion criteria were not limited to self-administered acupressure or treatment by practitioner. Among the five included studies, three studies compared auricular acupressure with antihistamines or Chinese herbal medicine, and the symptom score for the auricular acupressure group was significantly improved in comparison with the control group.
Cancer We reviewed one RCT and one quasi-RCT showing that chemotherapy-induced nausea and vomiting in the self-acupressure groups was significantly decreased in comparison with the control groups.24,25 Lee and Frazier conducted a systematic review of acupressure, including self-acupressure and acupressure performed by practitioners, and found four RCTs reporting significantly less nausea and vomiting in the acupressure groups compared with the control groups.3 At the initiatory stage, symptom improvement was not significant in either of the two groups. The results of our study were similar to those of Lee and Frazier.
Respiratory disease Two RCTs for respiratory disease were included in this systematic review. The symptom scores for bronchiectasis and dyspnea in COPD were significantly improved in the
H.J. Song et al. acupressure groups in comparison with the control groups.26,27 The results of the present review were similar to those of Robinson et al., who conducted a systematic review of Shiatsu or acupressure, including self-acupressure and acupressure performed by practitioners.16 This review included three studies of COPD and two studies of bronchiectasis. They concluded that there was limited evidence for chronic respiratory conditions.
Dysmenorrhea Pain scores for dysmenorrhea patients performing selfacupressure were significantly decreased compared with scores for patients in the control groups.28,29 Lee and Frazier reported three RCTs showing pain scores that significantly decreased in the acupressure group in comparison with the control group.3 Jiang et al. conducted a meta-analysis of acupressure performed by participants or by practitioners and reported that the VAS, SF-MPQ, and SF-MDQ scores in the acupressure group were significantly better than in the control group.5
Healthy people One RCT showed that self-administered acupressure in healthy college students significantly lowered stress levels, and a quasi-RCT reported that self-acupressure reduced sleep disturbances and fatigue in healthy nurses, both in comparison with a control group.30,31 Lee and Frazier found one RCT that reported that acupressure for insomnia was significantly better than control for symptom improvement, while another RCT reported no significant difference between acupressure and control.3 Lee and Frazier also identified three RCTs reporting that acupressure reduced fatigue. Yeung et al. conducted a systematic review of acupressure for insomnia and included studies of acupressure performed by both participants and practitioners.2 Results from six RCTs showed that acupressure was significantly better than sham acupressure for insomnia. In outcomes for medication use, seven of 10 RCTs showed a significant reduction in the acupressure group compared with the control group, while three of 10 RCTs found no significant difference between the acupressure and control groups. This study is the first systematic review estimating the effects of self-acupressure. Systematic reviews reporting both self-acupressure and practitioner-administered acupressure have been published; however, no systematic review for self-acupressure alone has been reported. Furthermore, this study identifies a range of diseases that can be treated by self-acupressure. The search strategy included only the intervention (with no limitation for disease) so that the search could be conducted with a highly sensitive search strategy. The present study included RCTs and quasi-RCTs for various conditions, including cancer, respiratory disease, dysmenorrhea, and symptom management in healthy persons. In addition, we conducted an extensive search of databases, including Eastern databases. Many studies of alternative and complementary treatments have been conducted in Eastern countries. Therefore, we expanded our search strategy to include Korean and Japanese databases
Effect of self-acupressure for symptom management: A systematic review as well as core and Chinese databases. Previous systematic reviews only searched core and Chinese databases.2,3,5 Interpretation of the results of this study should take into account its limitations. First, we could not perform a meta-analysis of the selected studies because of diversity in participants, intervention methods, and medical results. Even when the same disease was studied in different trials, the outcome measures were not standardized. Consequently, we opted to present a narrative description of the efficacy and safety of self-acupressure. Second, we found it difficult to judge the evidence for self-acupressure. The results of the quality assessment of risk of bias in the trials were not good, and efficacy was not clearly estimated. Moreover, the teaching methods for the self-administered intervention were not standardized, suggesting a high probability of inconsistency in the administration of selfacupressure.
Conclusions Even though most of the trials of self-acupressure therapy showed some effect, it was difficult to draw conclusions about specific intervention methods or their effects because the interventions and effect indicators in each study were different. Furthermore, the evidence level for selfacupressure was difficult to evaluate due to the moderate quality of the studies and the disparities in teaching methods for the self-administered intervention. High-quality RCTs with larger samples are necessary to establish the evidence for self-acupressure as an effective intervention.
Conflict of interest The authors have no conflicts of interest that are directly relevant to the content of this article.
Acknowledgments This study was performed as part of the Infrastructure Development Project for Traditional Knowledge-based Remedy (K12210) funded by the Korea Institute of Oriental Medicine (KIOM) in South Korea. The results of this project were subjected to the KIOM appraisal process. No other sources of funding were used to assist in the preparation of this article.
References 1. Beal WM. Acupuncture and acupressure application to women’s reproductive health care. J Nursemidwifery 1999;44:217—30. 2. Yeung WF, Chung KF, Poon MM, Ho FY, Zhang SP, et al. Acupressure, reflexology, and auricular acupressure for insomnia: a systematic review of randomized controlled trials. Sleep Med 2012;13:971—84. 3. Lee EJ, Frazier SK. The efficacy of acupressure for symptom management: a systematic review. J Pain Symptom Manage 2011;42:589—603. 4. National Cancer Institute. Acupuncture. http://www.cancer. gov/cancertopics/pdq/cam/acupuncture/HealthProfessional.; 2007 [accessed 21.11.13]. 5. Jiang HR, Ni S, Li JL, Liu MM, Li J, Cui XJ, et al. Systematic review of randomized clinical trials of acupressure therapy for primary dysmenorrhea. Evid Based Complement Alternat Med 2013;2013:169692 [Epub 2013 Aug 18].
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6. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. The Cochrane Collaboration. 2011. http://handbook.cochrane.org/. [accessed 21.11.13]. 7. Kim SY, Park JE, Lee YJ, Seo HJ, Sheen SS, Hahn S, et al. Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. J Clin Epidemiol 2013;66:408—14. 8. Chao HL, Miao SJ, Liu PF, Lee HH, Chen YM, Yao CT, et al. The beneficial effect of ST-36 (Zusanli) acupressure on postoperative gastrointestinal function in patients with colorectal cancer. Oncol Nurs Forum 2013;40. E61-68. 9. Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. J Adv Nurs 2004;48:380—7. 10. Fritz DJ, Carney RM, Steinmeyer B, Ditson G, Hill N, Zee-Cheng J. The efficacy of auriculotherapy for smoking cessation: a randomized, placebo-controlled trial. J Am Board Fam Med 2013;26:61—70. 11. Lee JS, Lee MS, Min K, Lew JH, Lee BJ. Acupressure for treating neurological disorders: a systematic review. Int J Neurosci 2011;121:409—14. 12. Lu MJ, Lin ST, Chen KM, Tsang HY, Su SF. Acupressure improves sleep quality of psychogeriatric inpatients. Nurs Res 2013;62:130—7. 13. Maa SH, Sun MF, Hsu KH, Hung TJ, Chen HC, Yu CT, et al. Effect of acupuncture or acupressure on quality of life of patients with chronic obstructive asthma: a pilot study. J Altern Complement Med 2003;9:659—70. 14. Noroozinia H, Mahoori A, Hasani E, Gerami-Fahim M, Sepehrvand N. The effect of acupressure on nausea and vomiting after cesarean section under spinal anesthesia. Acta Med Iran 2013;51:163—7. 15. Rerksuppaphol L. Efficacy of auricular acupressure combined with transcutaneous electrical acupoint stimulation for weight reduction in obese women. J Med Assoc Thai 2012;95(Suppl. 12):S32—9. 16. Robinson N, Lorenc A, Liao X. The evidence for Shiatsu: a systematic review of Shiatsu and acupressure. BMC Complement Altern Med 2011;11:88. 17. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev 2011;7:CD009232. 18. Wu HS, Wu SC, Lin JG, Lin LC. Effectiveness of acupressure in improving dyspnoea in chronic obstructive pulmonary disease. J Adv Nurs 2004;45:252—9. 19. Yang MH, Wu SC, Lin JG, Lin LC. The efficacy of acupressure for decreasing agitated behaviour in dementia: a pilot study. J Clin Nurs 2007;16:308—15. 20. Yeh CH, Chien LC, Balaban D, Sponberg R, Primavera J, Morone NE, et al. A randomized clinical trial of auricular point acupressure for chronic low back pain: a feasibility study. Evid Based Complement Alternat Med 2013:196978. 21. Yip YB, Tse SH. The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med 2004;12:28—37. 22. Xue CC, Zhang CS, Yang AW, Zhang AL, Li Y, Xia J, et al. Semi-self-administered ear acupressure for persistent allergic rhinitis: a randomised sham-controlled trial. Ann Allergy Asthma Immunol 2011;106:168—70. 23. Lee KC, Keyes A, Hensley JR, Gordon JR, Kwasny MJ, West DP, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunct Med 2012;30:8—11. 24. Dibble SL, Luce J, Cooper BA, Israel J, Cohen M, Nussey B, et al. Acupressure for chemotherapy-induced nausea and vomiting: a randomized clinical trial. Oncol Nurs Forum 2007;34:813—20. 25. Shin YH, Kim TI, Shin MS, Juon HS. Effect of acupressure on nausea and vomiting during chemotherapy cycle for
78 Korean postoperative stomach cancer patients. Cancer Nurs 2004;27:267—74. 26. Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH. Selfadministered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. J Clin Nurs 2007;16:794—804. 27. Maa SH, Gauthier D, Turner M. Acupressure as an adjunct to a pulmonary rehabilitation program. J Cardiopulm Rehabil 1997;17:268—76. 28. Bazarganipour F, Lamyian M, Heshmat R, Abadi MA, Taghavi A. A randomized clinical trial of the efficacy of applying a simple acupressure protocol to the Taichong point in relieving dysmenorrhea. Int J Gynaecol Obstet 2010;111:105—9.
H.J. Song et al. 29. Wong CL, Lai KY, Tse HM. Effects of SP6 acupressure on pain and menstrual distress in young women with dysmenorrhea. Complement Ther Clin Pract 2010;16:64—9. 30. Honda Y, Tsuda A, Horiuchi S. Effect of a four-week selfadministered acupressure intervention on perceived stress over the past month. Open J Med Psychol 2012;1:20—4. 31. Kim WI, Youn HM. The effect of self-acupressure of Qangol (G12), Shinmun (H7), Samumgyo (Sp6) on clinical nurses’ sleep pattern disturbance and fatigue. Kor J Meridian Acupoint 2004;21:81—93. 32. Zhang CS, Yang AW, Zhang AL, Fu WB, Thien FU, Lewith G, et al. Ear-acupressure for allergic rhinitis: a systematic review. Clin Otolaryngol 2010;35:6—12.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Effect of self-acupressure for symptom management: A systematic review Hyun Jin Song a, Hyun-Ju Seo b,∗, Heeyoung Lee c, Heejeong Son d, Sun Mi Choi e, Sanghun Lee e a
School of Pharmacy, Sungkyunkwan University, Suwon, South Korea Department of Nursing, College of Medicine, Chosun University, 309 Pilmum-daero, Dong-gu, Gwangju 501-759, South Korea c Public Health Medical Service, Seoul National University Bundang Hospital, Seongnam, South Korea d Graduate School of Public Health, Seoul National University, Seoul, South Korea e Korea Institute of Oriental Medicine, Daejeon, South Korea Available online 4 December 2014 b
KEYWORDS Acupressure; Self-administration; Signs and Symptoms
∗
Abstract Objectives: To assess the efficacy and safety of self-administered acupressure to alleviate symptoms of various health problems, including allergic disease, cancer, respiratory disease, dysmenorrhea, perceived stress, insomnia, and sleep disturbances. Methods: We searched core, Korean, Chinese, and Japanese databases, including Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), six representative electronic Korean medical databases, China National Knowledge Infrastructure (CNKI), and Japan Science and Technology Information Aggregator (J-STAGE). We included randomized controlled trials (RCTs) and quasi-RCTs that examined disease-specific effects or symptom relief, adverse reactions, and quality-of-life (QOL) for self-administered acupressure. Data collection and assessment of the methodological quality of the included studies were conducted by two independent reviewers. Results: Eight RCTs and two quasi-RCTs showed positive effects and safety of self-acupressure therapy in clinically diverse populations. Quality assessment revealed moderate quality for the RCTs, with 50% or more of the trials assessed as presenting a low risk of bias in seven domains. All of the selected 10 studies reported positive effects for primary outcomes of selfacupressure therapy for symptom management, including significant improvements in symptom scores in allergic disease, nausea and vomiting in cancer, symptom scores in respiratory disease, pain symptoms in dysmenorrhea, and stress/fatigue scores and sleep disturbances in healthy people.
Corresponding author. Tel.: +82 62 230 6320; fax: +82 62 230 6329. E-mail address: [email protected] (H.-J. Seo).
http://dx.doi.org/10.1016/j.ctim.2014.11.002 0965-2299/© 2014 Elsevier Ltd. All rights reserved.
Effect of self-acupressure for symptom management: A systematic review
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Conclusions: Our findings suggest that self-administered acupressure shows promise to alleviate the symptoms of various health problems. Therefore, further research with larger samples and methodologically well-designed RCTs is required to establish the efficacy of self-administered acupressure. © 2014 Elsevier Ltd. All rights reserved.
Introduction Acupressure involves applying pressure to specific points on the body using the hands, fingers, thumbs, elbows, feet, or various devices.1—3 According to the meridian theory, acupressure increases the flow of energy (qi) in the body; therefore, it is effective for managing symptoms of disease.4 Acupuncture, which is considered a representative treatment of alternative and complementary medicine, uses fine needles inserted in specific points on the body. Acupressure utilizes application of pressure to acupoints without penetrating the skin.1,2 Acupressure is non-invasive and typically painless, and adverse reactions caused by insertion of fine needles can be avoided.3 Moreover, self-acupressure can be administered in any situation, regardless of time and place, and self-treatment can be conducted without expensive costs. Self-acupressure is acupressure performed by trained participants without treatment by practitioners or healthcare providers. Several systematic reviews of acupressure performed by practitioners have been reported.2,3,5 However, no systematic review of self-acupressure with its various advantages, such as economical and convenient use, has been published. In order to develop acupressure as a self-administered therapy, it was necessary to understand the evidence supporting self-acupressure. Thus, this systematic review aimed to estimate the efficacy and safety of self-acupressure to alleviate symptoms of various health problems.
Methods Data sources and searches We conducted an extensive and comprehensive literature search of core, Korean, Chinese, and Japanese databases. The core databases were Ovid-MEDLINE, Ovid-EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Korean databases included KoreaMed, Korean Medical Database (KMbase), Korean Studies Information Service System (KISS), National Discovery for Science Leaders (NDSL), and Korea Institute of Science Technology Information (KISTI). We also utilized the Oriental Medicine Advanced Searching Integrated System (OASIS). Chinese and Japanese databases were included in our search, specifically China National Knowledge Infrastructure (CNKI) and Japan Science and Technology Information Aggregator (J-STAGE). The search was conducted from 28 April 2013 to 7 May 2013. The search terms used were ‘‘acupressure,’’ ‘‘self,’’ and ‘‘acupuncture.’’ Medical Subject Headings (MeSH) terms and text words were used to adjust the search characteristics for each database. The only search limitation was
intervention for high sensitivity, and there were no limitations on diseases, patients, or language.
Study selection The inclusion criterion was self-administered acupressure. The final treatment interventions were carried out by the participants after they received training in the intervention procedure. All studies related to self-administered acupressure were included, regardless of the acupressure techniques applied. The studies included in this systematic review were randomized controlled trials (RCTs) or studies with a quasi-RCT design. Comparisons were sham acupressure, standard of care, and no treatment. The participants came from the general population or were patients with any type of disease. The outcomes included disease-specific effects, symptom relief, adverse reactions, and quality of life. Studies with final interventions performed by practitioners or healthcare providers were excluded. Studies reporting a mixture of interventions were also excluded, as were those reporting non-human target populations and interventions other than acupressure. In addition, there was no a priori exclusion criterion based on publication language.
Data extraction and quality assessment Two researchers independently extracted the data using a predetermined extraction form. For papers where the major outcomes were presented in graphical form, the corresponding author was contacted. The intention-to-treat (ITT) analysis was used if both ITT and per-protocol (PP) analyses were presented in the study. Disagreements regarding extracted data were resolved by consensus with a third person. The extraction form included the study design, the number and characteristics of participants, follow-up periods, primary and secondary outcomes, country of publication, treatment regimens, main acupoints, and methods of teaching self-acupressure. The quality of the RCTs was assessed using the Cochrane Risk of Bias (RoB) tool.6 The RoB tool assessed seven dimensions: sequence generation, allocation concealment, blinding of participants, personnel and outcomes, incomplete outcome data, selective outcome reporting, and other sources of bias. In this study, funding sources were confirmed in order to assess other sources of bias. Quasi-RCTs were assessed using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS), which evaluated selection of participants, confounding variables, measurement of intervention (exposure), blinding for outcome assessment, incomplete outcome data, and selective outcome reporting.7
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Figure 1
Study flow diagram.
Data synthesis and analysis Because the included studies were not limited to participants with a specific disease, the estimation of outcomes did not possess inherent homogeneity of patients and interventions. Therefore, outcomes were not combined quantitatively, but were presented descriptively in this study.
Results The search produced 793 potential articles from all databases. After reviewing the abstracts, 768 studies were excluded, and 25 potential studies were selected. Review of the full articles resulted in exclusion of an additional 15 studies.3,8—21 Studies were excluded because they did not report self-acupressure, did not directly compare acupressure and placebo/control, did not include extracted clinical outcomes, were duplicate studies, or were not original articles. At the end of the review process, 10 studies (eight RCTs and two quasi-RCTs) out of 793 articles were selected for inclusion in this review (Figure 1). Among the eight RCTs, 75% (6/8) of the studies were evaluated as having a low risk of bias for random sequence generation, blinding of participants, blinding of outcome assessment, and selective reporting (Figure 2). The percentage of RCTs assessed as having a low risk of bias for incomplete outcome data and funding source was 50% (4/8). In the case of allocation concealment, the percentage of low-risk studies was only 25% (2/8). One quasi-RCT was evaluated as having a low risk of bias for blinding for outcome assessment, incomplete outcome data, and selective outcome reporting. All other dimensions evaluated for the quasi-RCTs were found to have a high or unclear risk of bias (Figure 3).
The studies included in this review were all designed as head-to-head trials. Eight RCTs and two quasi-RCTs were selected, with one crossover study design among the RCTs. The total number of participants was 659. Two of the trials reported results for two comparative groups: placebo (sham acupressure or no acupressure) and/or usual care (Table 1). Clinical problems included atopic dermatitis, allergic rhinitis, breast cancer, stomach cancer, bronchiectasis, chronic obstructive pulmonary disease (COPD), dysmenorrhea, stress, sleep disturbance, and fatigue. Follow-up periods ranged from three days to three months. The research countries included three trials from the United States, two trials from South Korea, and one trial each from Taiwan, Iran, Japan, Hong Kong, and Australia. Selected acupoints varied depending on the disease. Even when the same disease was being treated, different acupoints were selected according to the trial’s methods (Table 2). Training for participants in the technique of self-acupressure encompassed a wide variety of teaching methods utilized by the investigators. Investigators in five of 10 trials conducted training using an Acupressure Teaching Booklet. Acupoints were marked using ink or tape in three trials. Participants completed training sessions in one trial, and participants practiced self-acupressure under direct observation by the practitioner in another trial.
Self-acupressure for allergic disease Xue et al. compared real ear acupoints (REAP) with sham ear acupoints (SEAP) in 63 patients with allergic rhinitis.22 REAP were Shenmen (TF 4), Neibi (TG 4), Fei (CO 14), Fengxi (SF 1, 2i), and Shenshangxian (TG 2p); SEAP were Lun 2 (HX 10), Jian (SF 4, 5), Suogu (SF 6), Zhen (AT 3), and Ya (LO 1). Outcomes for REAP were significantly better than for SEAP in total nasal symptom score (TNSS) (P = 0.02), global nasal/nonnasal symptom score (P = 0.04), sneezing score (P = 0.01), and regular activities at home and work (P = 0.04). However, there were no significant differences between groups for results of the standardized Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and medication use. Mild adverse reactions were reported by 29.0% of the patients in the REAP group and 21.9% of the patients in SEAP group (P = 0.51). Serious adverse reactions were not reported in either group. Lee et al. studied 15 adult patients with pruritic atopic dermatitis.23 Acupressure plus standard care was compared with standard care only. Acupressure was administered for 3 min to Quchi (LI 11), an acupoint located on the left arm lateral to the antecubital fossa, three times per week for 4 weeks. Standard care included prescription and over-the-counter medications or lotions. Acupressure plus standard care compared with standard care only resulted in significant decreases in the Visual Analogue Scale (VAS) score (P = 0.04), Investigator’s Global Assessment (IGA) score (P = 0.03), and Eczema Area and Severity Index (EASI) lichenification score (P = 0.03). There was no significant difference in the overall EASI score. No adverse reactions were reported in either group.
Study characteristics of acupressure trials.
First author and Clinical publication year problem
Randomized controlled trial Xue et al., Allergic rhinitis 2011
No. of patients
Follow-up
Country
Measures
Symptom score, medication use, quality of life Severity of itching and atopic dermatitis Chemotherapy induced nausea and vomiting (CINV) Decreased symptoms, improved health-related quality of life Relief of dyspnea and other symptoms
Control (usual care)
31
32
NA
54.0
8 weeks
Australia
Median 28.5 (range 19—79) 49.3 (9.4)
33.3
4 weeks
US
100.0
21 days
US
59.5 (11.5)
40.0
8 weeks
Taiwan
67.3 (8.2)
NA
6 weeks
US
20.0* [Acupressure group: 20.0 (1.0) Control group: 19.9 (0.9)] 21.8* [Acupressure group: 22.0 (0.9) Control group: 21.6 (0.7)] 28.9 (8.5)
100.0
5 days
Iran
Pain score
100.0
Hong Kong
Pain level, menstrual distress
37.5
3 months (3 days in one month) 2 weeks
Japan
Perceived stress
Atopic dermatitis Breast cancer
8
7
53
Maa et al., 2007
Bronchiectasis
11
31
Placebo 53 Usual care 54 Placebo 11 Standard care 13 31
88
84
Chronic obstructive pulmonary disease (COPD) Bazarganipour Dysmenorrhea et al., 2010
Female, %
Acupressure
Lee et al., 2012 Dibble et al., 2007
Maa et al., 1997
Mean age (SD)
Wong et al., 2010
Dysmenorrhea
19
21
Honda et al., 2012
Stress (college students)
12
12
Quasi-randomized controlled trial Kim & Youn, 25 Sleep 2004 disturbance, fatigue (clinical nurses) Shin et al., Stomach 20 2004 cancer
23
26.6* [Acupressure group: 26.8 Control group: 26.3]
NA
3 days
South Korea
Sleep disturbance score, fatigue score
20
50.0 [Acupressure group: 52.8 (10.9) Control group: 47.3 (6.8)]
30.0
5 days
South Korea
Chemotherapy induced nausea and vomiting (CINV)
Effect of self-acupressure for symptom management: A systematic review
Table 1
NA: not available * The mean age of total participants was not reported, so the weighted mean age applied number in each group was calculated.
71
72 Table 2
H.J. Song et al. Study protocols for acupressure trials.
First author and publication year
Main acupoints Acupressure
Placebo/control
Treatment regimen
Teaching methods of self-acupressure
Three times daily, both ears, alternating weekly; adhesive stainless steel press-pellets (Acuneeds, Australia) were pressed until participants felt heat and slight soreness at the points 3 min, 3 times per week, for 4 weeks; acupressure was performed using a 1.2 mm titanium acupellet (Lhasa OMS, Weymouth, Massachusetts, USA) Each morning; acupressure was applied using the thumb of the opposite hand
Participants were instructed to press stainless steel pellets until they felt heat and slight soreness at the acupoints
Randomized controlled trial Xue et al., 2011 Real ear acupoints: Shenmen (TF 4), Neibi (TG 4), Fei (CO 14), Fengxi (SF 1, 2i), and Shenshangxian (TG 2p)
Sham ear acupoints: Lun 2 (HX 10), Jian (SF 4, 5), Suogu (SF 6), Zhen (AT 3), and Ya (LO 1)
Lee et al., 2012
Quchi (LI 11), located on the left arm lateral to the antecubital fossa
No acupressure
Dibble et al., 2007
Neiguan (PC 6), located on both forearms
Placebo group: sham point (Houxi, SI 3)/Usual care only group
Maa et al., 2007
Zhongfu (LU 1), Chize (LU 5), Yuji (LU 10), Fenglong (ST 40) and Zusanli (ST 36). Each point is located bilaterally.
Sham acupressure: near real acupoints/Standard care
First one side of the body and then the other side, for 30 s to 2 min; acupoints were stimulated using the fingers to apply gentle but firm pressure
Maa et al., 1997
Zhongfu LU 1, Yunmen LU 2, Dazhui GV 14, Yuji LU 10, Laogong PC 8, Zusanli ST 36, Hegu LI 4
Sham acupressure: non-acupoints
Real acupoints for 6 weeks, followed by sham acupressure for 6 weeks; participants applied gentle but firm pressure to the acupoint at approximately a 90◦ angle to the skin surface, using one or two fingers
Participants were instructed by principal investigators to administer acupressure with a titanium acupellet
Participants were instructed to perform acupressure to PC 6 points every morning. When participants asked, ink marks were provided to make locating the points easier. A skilled instructor directly demonstrated acupressure for the participants. After that, participants were asked to perform acupressure by themselves to make sure of their acquisition of the technique. An instructional booklet explaining how to locate and stimulate acupoints was also provided. A skilled instructor explained the acupressure technique using the instruction booklet. Acupressure was performed for each participant by the instructor for teaching purposes. When necessary, acupoints were marked on the skin.
Effect of self-acupressure for symptom management: A systematic review Table 2
73
(Continued)
First author and publication year
Main acupoints
Treatment regimen
Teaching methods of self-acupressure
20 min for 3 to 7 days before the menstrual cycle, in a sitting position, applying pressure using the thumb 20 min during the first 3 days of their next 3 menstrual cycles; pressure was applied using the participant’s thumb
Participants were instructed to apply the acupressure protocol on the acupoints predetermined by the investigator. After an acupressure intervention by a practitioner, participants were taught to practice acupressure at home. An Acupressure Teaching Booklet was provided. Participants were asked to complete five self-acupressure sessions
Acupressure
Placebo/control
Bazarganipour et al., 2010
Simple pressure to the Taichong (LR 3) point (between the first and second toe)
Simple pressure to the placebo point (between the third and fourth toe)
Wong et al., 2010
Sanyinjiao (SP 6) acupressure
No acupressure
Honda et al., 2012
Three acupressure points (Wangu GB 12, Tianrong SI 17, Futu LI 18) on the left and right sides of the neck
No intervention
5 s, five sessions during the morning, midday, and night
No intervention
3 days, 4 times per day; acupressure was administered using two thumbs
Usual care
5 min before chemotherapy, mealtimes, and anytime sensations of nausea were felt; participants applied acupressure using their finger
Quasi-randomized controlled trial Kim and Youn, Wangu (GB 12), 2004 Shenmen (HT 7), and Sanyinjiao (SP 6) acupoints
Shin et al., 2004
Neiguan (PC 6) acupressure point
The investigator demonstrated acupressure using an Acupressure Teaching Booklet. After that, the participants performed acupressure by themselves to make sure they understood the technique. Acupoints were first marked with tape. After it was removed, the participants located acupoints following written instructions. Participants and their family in the ward were taught how to locate the acupressure point by investigators. Acupressure Teaching Booklets were distributed to the ward. Participants were asked to perform the technique on the investigators to assure they could locate the points and apply enough pressure.
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H.J. Song et al.
Figure 2 Risk of bias graph and summary of all included randomized controlled trials using Cochrane’s RoB assessment tool. (a) RoB graph (b) RoB summary. RoB: Risk of Bias; (+): low risk of bias; (−): high risk of bias; (?): unclear risk of bias.
Self-acupressure for cancer Dibble et al. conducted a RCT with 160 breast cancer patients who were receiving chemotherapy.24 The experimental group used their thumbs to press the Neiguan (PC 6) acupoint located bilaterally on the forearm, while the placebo group pressed the Houxi (SI 3) acupoint located on the ulnar side of the hand. The control group was treated with only usual care. Patients in all groups received usual care consisting of antiemetic therapy prescribed by their physicians. Delayed nausea or emesis, as well as the amount
of vomiting and the intensity of nausea over time, was significantly decreased in the experimental group compared with both the placebo group (P = 0.002) and the control group (P < 0.0001). However, acute nausea or emesis was not significantly different among the three groups (P = 0.71). Shin et al. conducted a quasi-RCT of 40 stomach cancer patients receiving chemotherapy.25 Nausea and vomiting in the intervention and control groups was the primary outcome. All patients received antiemetic therapy (metoclopramide and ondansetron) as prescribed by their physicians as usual care. Patients in the intervention group
Effect of self-acupressure for symptom management: A systematic review
75
LU 10, Laogong PC 8, Zusanli ST 36, and Hegu LI 4) for 6 weeks, followed by sham acupressure for an additional 6 weeks. The other group performed sham acupressure for the first 6 weeks and real acupressure for the following 6 weeks. Sham acupressure was applied with the same technique to seven points that were not true acupoints. The real acupressure group had less dyspnea as measured by a VAS scale and lower decathexis scores compared with the sham acupressure group (P = 0.009 and P = 0.044, both onetailed). However, sham acupressure was more effective in reducing peripheral sensory symptoms than real acupressure (P = 0.002, two-tailed).
Self-acupressure for dysmenorrhea
Figure 3 Risk of bias graph and summary of all included quasirandomized controlled trials using the RoBA. NS tool. (a) RoBANS graph (b) RoBANS summary. RoBANS: Risk of Bias Assessment for Non-randomized Studies; (+): low risk of bias; (−): high risk of bias; (?): unclear risk of bias.
also performed acupressure treatment at the Neiguan (PC 6) acupoint for 5 min before chemotherapy, at mealtimes, and any time they experienced nausea. According to the Rhodes Index of Nausea, Vomiting, and Retching (INVR), outcomes in the intervention group were significantly better for severity of nausea and vomiting (P < 0.01), duration of nausea (P < 0.01), and frequency of vomiting (P < 0.01) when compared with the control group.
Self-acupressure for respiratory disease In 2007, Maa et al. compared acupressure plus standard care, sham acupressure plus standard care, and standard care only in 35 patients with bronchiectasis.26 The acupressure points were Zhongfu (LU 1), Chize (LU 5), Yuji (LU 10), Fenglong (ST 40) and Zusanli (ST 36), with each point located bilaterally. Sham acupressure was performed on nearby real acupoints, and standard care included oral medication and chest physiotherapy. Outcomes for the Saint George Respiratory Questionnaire (SGRQ) in the acupressure plus standard care group were significantly better when compared with the standard care only group (P = 0.01). However, there was no significant difference in outcomes between the sham acupressure plus standard care and standard care only groups. Maa et al. studied the effects of acupressure in 31 patients with COPD in a RCT with a crossover design.27 One group performed acupressure at seven bilateral acupoints (Zhongfu LU 1, Yunmen LU 2, Dazhui GV 14, Yuji
A study of 172 dysmenorrhea patients by Bazarganipour et al. compared simple pressure to the Taichong (LR 3) acupoint (between the first and second toe) with simple pressure to a placebo point.28 The Taichong acupressure group showed a significant decrease in dysmenorrhea severity (P < 0.01), and, by the fourth menstrual cycle, there was a significant difference in dysmenorrhea severity (P < 0.02) between the Taichong and placebo groups. Wong et al. studied acupressure in 40 dysmenorrhea patients divided into acupressure intervention and control groups.29 The intervention group performed acupressure at Sanyinjiao (SP 6) for 20 min upon waking and at bedtime during the first three days of three successive menstrual cycles. The Pain Visual Analogue Scale (PVAS) and ShortForm MacGill Pain Questionnaire (SF-MPQ), administered 20 min after acupressure, showed significant reductions in pain scores in the acupressure group compared with the control group (P = 0.008 and P = 0.012). Moreover, scores on the PVAS, SF-MPQ, and Short-Form Menstrual Distress Questionnaire (SF-MDQ) administered to the acupressure group were significantly different when compared with the control group at three months after the intervention (P = 0.008, P = 0.012, and P = 0.024, respectively).
Self-acupressure for healthy people Honda et al. studied the difference between acupressure intervention and no intervention in 24 college students.30 Acupressure was administered to three points (Wangu GB 12, Tianrong SI 17, Futu LI 18) on the left and right sides of the neck for 5 s. The stress score for the Japanese language version of the Rhode Island Stress and Coping Inventory (JRISCI) was significantly decreased in the acupressure group compared with the control group after 2 weeks (P < 0.05). Kim and Youn studied sleep disturbance and fatigue among 48 clinical nurses divided into acupressure and nointervention groups.31 The Wangu (GB 12), Shenmen (HT 7), and Sanyinjiao (SP 6) acupoints were pressed for three days at a frequency of four times per day. The sleep disturbance and fatigue scores were significantly lower in the acupressure group compared with the no-intervention group after three days (P < 0.01 and P < 0.01).
Discussion This systematic review was performed to investigate the efficacy and safety of self-administered acupressure therapy
76 to relieve symptoms of various health problems, including allergic disease, cancer, respiratory disease, dysmenorrhea, perceived stress, insomnia, and sleep disturbances. All of the selected 10 studies reported positive effects for primary outcomes of self-acupressure therapy for symptom management. That is, there were significant improvements in outcomes for allergic disease, chemotherapy-induced nausea and vomiting in cancer patients, respiratory disease, dysmenorrhea, and stress/fatigue scores and sleep disturbances in healthy people. However, some secondary outcomes such as QOL, medication use in allergic disease, and acute nausea or emesis induced by chemotherapy did not show a significant difference. There were no studies reporting severe adverse reactions to self-acupressure. The results of our quality assessment showed a relatively moderate risk of bias in the RCTs, while the risk of bias in the quasi-RCTs was at least 50% higher for most of the evaluated domains. The results of the present review were similar to those of previous reviews.2,3,5,16,32 All of the previous systematic reviews included studies of acupressure performed by both participants and practitioners.
Allergic disease Two RCTs for allergic disease were included in this review. Xue et al. found that the symptom score for rhinitis in a REAP group was significantly improved compared with a SEAP group.22 In the second trial, the atopic dermatitis score for patients receiving acupressure plus standard care was significantly improved in comparison with standard care only.23 The results of a review of acupuncture and acupressure for allergic rhinitis by Zhang et al. were similar to those of the present study.32 Inclusion criteria were not limited to self-administered acupressure or treatment by practitioner. Among the five included studies, three studies compared auricular acupressure with antihistamines or Chinese herbal medicine, and the symptom score for the auricular acupressure group was significantly improved in comparison with the control group.
Cancer We reviewed one RCT and one quasi-RCT showing that chemotherapy-induced nausea and vomiting in the self-acupressure groups was significantly decreased in comparison with the control groups.24,25 Lee and Frazier conducted a systematic review of acupressure, including self-acupressure and acupressure performed by practitioners, and found four RCTs reporting significantly less nausea and vomiting in the acupressure groups compared with the control groups.3 At the initiatory stage, symptom improvement was not significant in either of the two groups. The results of our study were similar to those of Lee and Frazier.
Respiratory disease Two RCTs for respiratory disease were included in this systematic review. The symptom scores for bronchiectasis and dyspnea in COPD were significantly improved in the
H.J. Song et al. acupressure groups in comparison with the control groups.26,27 The results of the present review were similar to those of Robinson et al., who conducted a systematic review of Shiatsu or acupressure, including self-acupressure and acupressure performed by practitioners.16 This review included three studies of COPD and two studies of bronchiectasis. They concluded that there was limited evidence for chronic respiratory conditions.
Dysmenorrhea Pain scores for dysmenorrhea patients performing selfacupressure were significantly decreased compared with scores for patients in the control groups.28,29 Lee and Frazier reported three RCTs showing pain scores that significantly decreased in the acupressure group in comparison with the control group.3 Jiang et al. conducted a meta-analysis of acupressure performed by participants or by practitioners and reported that the VAS, SF-MPQ, and SF-MDQ scores in the acupressure group were significantly better than in the control group.5
Healthy people One RCT showed that self-administered acupressure in healthy college students significantly lowered stress levels, and a quasi-RCT reported that self-acupressure reduced sleep disturbances and fatigue in healthy nurses, both in comparison with a control group.30,31 Lee and Frazier found one RCT that reported that acupressure for insomnia was significantly better than control for symptom improvement, while another RCT reported no significant difference between acupressure and control.3 Lee and Frazier also identified three RCTs reporting that acupressure reduced fatigue. Yeung et al. conducted a systematic review of acupressure for insomnia and included studies of acupressure performed by both participants and practitioners.2 Results from six RCTs showed that acupressure was significantly better than sham acupressure for insomnia. In outcomes for medication use, seven of 10 RCTs showed a significant reduction in the acupressure group compared with the control group, while three of 10 RCTs found no significant difference between the acupressure and control groups. This study is the first systematic review estimating the effects of self-acupressure. Systematic reviews reporting both self-acupressure and practitioner-administered acupressure have been published; however, no systematic review for self-acupressure alone has been reported. Furthermore, this study identifies a range of diseases that can be treated by self-acupressure. The search strategy included only the intervention (with no limitation for disease) so that the search could be conducted with a highly sensitive search strategy. The present study included RCTs and quasi-RCTs for various conditions, including cancer, respiratory disease, dysmenorrhea, and symptom management in healthy persons. In addition, we conducted an extensive search of databases, including Eastern databases. Many studies of alternative and complementary treatments have been conducted in Eastern countries. Therefore, we expanded our search strategy to include Korean and Japanese databases
Effect of self-acupressure for symptom management: A systematic review as well as core and Chinese databases. Previous systematic reviews only searched core and Chinese databases.2,3,5 Interpretation of the results of this study should take into account its limitations. First, we could not perform a meta-analysis of the selected studies because of diversity in participants, intervention methods, and medical results. Even when the same disease was studied in different trials, the outcome measures were not standardized. Consequently, we opted to present a narrative description of the efficacy and safety of self-acupressure. Second, we found it difficult to judge the evidence for self-acupressure. The results of the quality assessment of risk of bias in the trials were not good, and efficacy was not clearly estimated. Moreover, the teaching methods for the self-administered intervention were not standardized, suggesting a high probability of inconsistency in the administration of selfacupressure.
Conclusions Even though most of the trials of self-acupressure therapy showed some effect, it was difficult to draw conclusions about specific intervention methods or their effects because the interventions and effect indicators in each study were different. Furthermore, the evidence level for selfacupressure was difficult to evaluate due to the moderate quality of the studies and the disparities in teaching methods for the self-administered intervention. High-quality RCTs with larger samples are necessary to establish the evidence for self-acupressure as an effective intervention.
Conflict of interest The authors have no conflicts of interest that are directly relevant to the content of this article.
Acknowledgments This study was performed as part of the Infrastructure Development Project for Traditional Knowledge-based Remedy (K12210) funded by the Korea Institute of Oriental Medicine (KIOM) in South Korea. The results of this project were subjected to the KIOM appraisal process. No other sources of funding were used to assist in the preparation of this article.
References 1. Beal WM. Acupuncture and acupressure application to women’s reproductive health care. J Nursemidwifery 1999;44:217—30. 2. Yeung WF, Chung KF, Poon MM, Ho FY, Zhang SP, et al. Acupressure, reflexology, and auricular acupressure for insomnia: a systematic review of randomized controlled trials. Sleep Med 2012;13:971—84. 3. Lee EJ, Frazier SK. The efficacy of acupressure for symptom management: a systematic review. J Pain Symptom Manage 2011;42:589—603. 4. National Cancer Institute. Acupuncture. http://www.cancer. gov/cancertopics/pdq/cam/acupuncture/HealthProfessional.; 2007 [accessed 21.11.13]. 5. Jiang HR, Ni S, Li JL, Liu MM, Li J, Cui XJ, et al. Systematic review of randomized clinical trials of acupressure therapy for primary dysmenorrhea. Evid Based Complement Alternat Med 2013;2013:169692 [Epub 2013 Aug 18].
77
6. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. The Cochrane Collaboration. 2011. http://handbook.cochrane.org/. [accessed 21.11.13]. 7. Kim SY, Park JE, Lee YJ, Seo HJ, Sheen SS, Hahn S, et al. Testing a tool for assessing the risk of bias for nonrandomized studies showed moderate reliability and promising validity. J Clin Epidemiol 2013;66:408—14. 8. Chao HL, Miao SJ, Liu PF, Lee HH, Chen YM, Yao CT, et al. The beneficial effect of ST-36 (Zusanli) acupressure on postoperative gastrointestinal function in patients with colorectal cancer. Oncol Nurs Forum 2013;40. E61-68. 9. Chen HM, Chen CH. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. J Adv Nurs 2004;48:380—7. 10. Fritz DJ, Carney RM, Steinmeyer B, Ditson G, Hill N, Zee-Cheng J. The efficacy of auriculotherapy for smoking cessation: a randomized, placebo-controlled trial. J Am Board Fam Med 2013;26:61—70. 11. Lee JS, Lee MS, Min K, Lew JH, Lee BJ. Acupressure for treating neurological disorders: a systematic review. Int J Neurosci 2011;121:409—14. 12. Lu MJ, Lin ST, Chen KM, Tsang HY, Su SF. Acupressure improves sleep quality of psychogeriatric inpatients. Nurs Res 2013;62:130—7. 13. Maa SH, Sun MF, Hsu KH, Hung TJ, Chen HC, Yu CT, et al. Effect of acupuncture or acupressure on quality of life of patients with chronic obstructive asthma: a pilot study. J Altern Complement Med 2003;9:659—70. 14. Noroozinia H, Mahoori A, Hasani E, Gerami-Fahim M, Sepehrvand N. The effect of acupressure on nausea and vomiting after cesarean section under spinal anesthesia. Acta Med Iran 2013;51:163—7. 15. Rerksuppaphol L. Efficacy of auricular acupressure combined with transcutaneous electrical acupoint stimulation for weight reduction in obese women. J Med Assoc Thai 2012;95(Suppl. 12):S32—9. 16. Robinson N, Lorenc A, Liao X. The evidence for Shiatsu: a systematic review of Shiatsu and acupressure. BMC Complement Altern Med 2011;11:88. 17. Smith CA, Collins CT, Crowther CA, Levett KM. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev 2011;7:CD009232. 18. Wu HS, Wu SC, Lin JG, Lin LC. Effectiveness of acupressure in improving dyspnoea in chronic obstructive pulmonary disease. J Adv Nurs 2004;45:252—9. 19. Yang MH, Wu SC, Lin JG, Lin LC. The efficacy of acupressure for decreasing agitated behaviour in dementia: a pilot study. J Clin Nurs 2007;16:308—15. 20. Yeh CH, Chien LC, Balaban D, Sponberg R, Primavera J, Morone NE, et al. A randomized clinical trial of auricular point acupressure for chronic low back pain: a feasibility study. Evid Based Complement Alternat Med 2013:196978. 21. Yip YB, Tse SH. The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med 2004;12:28—37. 22. Xue CC, Zhang CS, Yang AW, Zhang AL, Li Y, Xia J, et al. Semi-self-administered ear acupressure for persistent allergic rhinitis: a randomised sham-controlled trial. Ann Allergy Asthma Immunol 2011;106:168—70. 23. Lee KC, Keyes A, Hensley JR, Gordon JR, Kwasny MJ, West DP, et al. Effectiveness of acupressure on pruritus and lichenification associated with atopic dermatitis: a pilot trial. Acupunct Med 2012;30:8—11. 24. Dibble SL, Luce J, Cooper BA, Israel J, Cohen M, Nussey B, et al. Acupressure for chemotherapy-induced nausea and vomiting: a randomized clinical trial. Oncol Nurs Forum 2007;34:813—20. 25. Shin YH, Kim TI, Shin MS, Juon HS. Effect of acupressure on nausea and vomiting during chemotherapy cycle for
78 Korean postoperative stomach cancer patients. Cancer Nurs 2004;27:267—74. 26. Maa SH, Tsou TS, Wang KY, Wang CH, Lin HC, Huang YH. Selfadministered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. J Clin Nurs 2007;16:794—804. 27. Maa SH, Gauthier D, Turner M. Acupressure as an adjunct to a pulmonary rehabilitation program. J Cardiopulm Rehabil 1997;17:268—76. 28. Bazarganipour F, Lamyian M, Heshmat R, Abadi MA, Taghavi A. A randomized clinical trial of the efficacy of applying a simple acupressure protocol to the Taichong point in relieving dysmenorrhea. Int J Gynaecol Obstet 2010;111:105—9.
H.J. Song et al. 29. Wong CL, Lai KY, Tse HM. Effects of SP6 acupressure on pain and menstrual distress in young women with dysmenorrhea. Complement Ther Clin Pract 2010;16:64—9. 30. Honda Y, Tsuda A, Horiuchi S. Effect of a four-week selfadministered acupressure intervention on perceived stress over the past month. Open J Med Psychol 2012;1:20—4. 31. Kim WI, Youn HM. The effect of self-acupressure of Qangol (G12), Shinmun (H7), Samumgyo (Sp6) on clinical nurses’ sleep pattern disturbance and fatigue. Kor J Meridian Acupoint 2004;21:81—93. 32. Zhang CS, Yang AW, Zhang AL, Fu WB, Thien FU, Lewith G, et al. Ear-acupressure for allergic rhinitis: a systematic review. Clin Otolaryngol 2010;35:6—12.
