Zick SM, Sen A, Wyatt GK, Murphy SL, Arnedt JT, Harris RE. Investigation of 2 types of self-administered acupressure for persistent cancer-related fatigue in breast cancer survivors: a randomized clinical trial. JAMA Oncol. 2016;2(11):1470-1476.
To determine the efficacy of self-administered relaxing acupressure versus stimulating acupressure or usual care in decreasing fatigue and improving sleep and quality of life in breast cancer survivors.
Phase III randomized, single-blind clinical trial
This study analyzed 288 female participants ages 32-65 years old (mean 60.0±10.4 STD) with a history of breast cancer between stages 0 and III who had completed all cancer treatment (except hormone-blocking therapy) and been cancer-free for at least 12 months before study enrollment. Eligible women must have reported persistent fatigue with onset since their cancer diagnosis and had a score ≥4 on their Brief Fatigue Inventory (BFI). Participants were recruited from 6 Michigan counties and received diagnosis of breast cancer between January 1, 2006 and December 31, 2010.
Participants were randomized to receive 6 weeks of relaxing acupressure, stimulating acupressure, or usual care, followed by 4 weeks of washout. Usual care consisted of any treatment participants received from healthcare providers for fatigue during the study.
Persistent fatigue itself may be an independent risk factor associated with earlier recurrence and shorter overall survival.
Following randomization, participants in the acupressure arms were taught self-administration of acupressure by one of 13 trained acupressure educators who were all trained by the same National Certification Commission for Acupuncture and Oriental Medicine–certified acupuncturist.
Acupressure was performed for 27 minutes once daily for 6 weeks, by applying 3 minutes of pressure on each point in a circular motion. Points used for relaxing acupressure were yin tang, anmian, heart 7, spleen 6, and liver 3. Points used for stimulating acupressure were du 20, conception vessel 6, large intestine 4, stomach 36, spleen 6, and kidney 3. In both protocols, any points not located along the midline were done bilaterally.
The researchers randomized 288 women, and 228 completed the 6-week course of care: 74 in the relaxing acupressure group, 70 in the stimulating acupressure group, and 84 in the usual care group.
Study Parameters Assessed
The severity and effect of fatigue in the preceding 24 hours was assessed using the Brief Fatigue Inventory (BFI). Sleep disturbance in the past month was evaluated using the Pittsburgh Sleep Quality Index (PSQI). Functional impairment and its impact on quality of life over the preceding month were assessed using the Long-Term Quality of Life Instrument (LTQL).
These surveys were administered at 3 time points: baseline, week 6, and week 10 (following a 4-week washout period during which time no acupressure was performed).
Primary Outcome Measure
Change in BFI score between baseline and at the end of 6 weeks of acupressure or usual care, and after an additional 4 weeks during which no acupressure was performed.
At week 6, normal fatigue levels (BFI<4) were achieved in 66.2% (49/74) of participants in the relaxing acupressure group, 60.9% (42/70) in the stimulating acupressure group, and 31.3% (26/84) in the usual care group. This was a mean reduction of 34%, 27% and -1% in the respective groups from baseline fatigue. At week 10, normal fatigue levels were maintained in 56.3% (40/71) of participants in the relaxing acupressure group, 60.9% (42/69) in the stimulating acupressure group, and 30.1% (25/83) in the usual care group. Results were statistically significant in comparing acupressure to usual care (P<0.001) in both time points, with no significant difference seen between the 2 acupressure groups.
Significant improvement in sleep quality was seen in relaxing acupressure vs usual care at week 6 (P=0.03). Improvement achieved with relaxing acupressure at week 6 was still sustained at week 10.
Significant improvement in 3 out of 4 quality of life subscales at both time points was seen in the relaxing acupressure group as compared to usual care. The 3 subscales were somatic, fitness, and social support (P=0.03, 0.04, and 0.03 respectively).
Stimulating acupressure was not found to be significantly different from usual care or relaxing acupressure in assessment of sleep or quality of life at any time point.
Six adverse events related to acupressure self-administration were reported, all of which consisted of mild bruising at an acupressure site.
Moderate to severe cancer-related fatigue is thought to affect approximately one-third of women up to 10 years into breast cancer survivorship.1-3 In addition to decreasing quality of life, it is reported to be one of the main obstacles to maintaining physical activity in the breast cancer survivorship population,4,5 which is particularly concerning given that reduced or lack of physical activity has been associated with increased risk of mortality.6 Persistent fatigue itself though may also be an independent risk factor associated with earlier recurrence and shorter overall survival.7
While etiology is not entirely clear, persistent cancer-related fatigue is likely multifactorial and, at least in part, associated with dysfunction in the central nervous and immune systems, including involvement of elevated creatine, glutamate and pro-inflammatory cytokines.8-10 Acupuncture has been shown to affect brain physiology11-13 and immune function.14-16 It is likely that acupressure may as well. Preliminary data suggest that acupressure may be affecting neural-immune signaling, resulting in decreased expression of pro-inflammatory cytokines such as IL-1 beta, IL-2, and IL-6, while increasing anti-inflammatory cytokines such as IL-4.17
Other studies have also documented the effects of acupressure in cancer-related fatigue.18-23 In one study, also published by Zick et al, 43 cancer patients were randomized to 12 weeks of relaxing acupressure, high-dose stimulating acupressure, or low-dose acupressure. All three protocols showed a significant improvement in fatigue, with relaxing acupressure showing the greatest benefit (P<0.05). Participants in this study overall experienced 45% to 70% decrease in fatigue levels from baseline.19
In another study, 31 patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization (TACE) showed significant improvement in fatigue over the control group (N=31) after receiving auricular acupressure daily for 5 days during their period of hospitalization for the TACE treatment (P<0.001).20
After completion of chemotherapy treatment, 47 cancer patients were randomized to receive acupuncture, self-administered acupressure, or self-administered sham acupressure 6 times, for 20 minutes each over a 2-week period. At the end of the 2-week period, a 36% reduction in fatigue from baseline was seen in the acupuncture group, a 19% reduction was seen in the acupressure group, and 0.6% reduction was seen in the sham acupressure group.21
In 57 lung cancer patients undergoing chemotherapy treatment who were randomized to receive 6 minutes of acupressure plus essential oil, acupressure alone, or sham acupressure daily for 5 months, lower fatigue scores were seen in the acupressure plus essential oil and acupressure alone groups than in the sham acupressure group; however, the difference did not reach statistical significance. In subscale analysis, however, significant difference was achieved in fatigue experienced during daily activities midway through the chemotherapy regimen.22
This recent study by Zick et al in breast cancer survivors found that the use of either acupressure protocol was effective in significantly reducing fatigue; however, only relaxing acupressure was effective in also significantly improving sleep and quality of life. These effects are consistent with why one might select these points in an acupuncture protocol. According to Traditional Chinese Medicine theory, points used in the relaxing protocol were calming to the spirit (yin tang, anmian, heart 7), involved in the smooth flow of qi and emotions (liver 3), and involved in the formation of qi and blood (spleen 6).23 Several of these points are commonly used in the treatment of insomnia. The stimulating protocol included the point involved in the formation of qi and blood (spleen 6) but also included points to stimulate generation of qi and blood (stomach 36), restore yang (large intestine 4), tonify qi/kidney/yang (conception vessel 6, kidney 3) and raise yang (du 20).23 Several of these points are commonly used to increase energy and endurance.
In this study, Zick et al found that 11.9% of the women felt self-administering the daily acupressure was too time-consuming and therefore discontinued the study. The study also found that on average at least 70% of the acupressure sessions were performed, according to daily logs completed by the participants.
Considering the financial burden our patients face with cancer treatment,24 as well as the cost of acupuncture and/or supplements, which may be prohibitive for patients with lower incomes and assets, self-administration of acupressure offers an empowering way our patients can potentially improve their quality of life and overall survival. One might also consider making a short video as a teaching tool. Additionally, evidence suggests other populations outside of the breast cancer survivorship cohort may also benefit from acupressure self-administration such as caregivers,25 patients in active treatment,21,22 and pediatric oncology patients.26 However, more research is certainly needed in these areas.
In the meantime, devoting 15 minutes to teach a patient or a group of patients a simple easy-to-learn acupressure protocol that they can self-administer on their own is a safe, low-cost, no-pill, noninvasive strategy which may provide them with significant improvement in their energy level, quality of life, and possibly even overall survival.
- Bower JE, Ganz PA, Desmond KA, et al. Fatigue in long-term breast carcinoma survivors: a longitudinalinvestigation. Cancer. 2006;106(4):751-758.
- Minton O, Stone P. How common is fatigue in disease-free breast cancer survivors? a systematic review of the literature. Breast Cancer Res Treat. 2008;112(1):5-13.
- Harrington CB, Hansen JA, Moskowitz M, Todd BL, FeuersteinM. It’s not over when it’s over: long-term symptoms in cancer survivors: a systematic review. Int J Psychiatry Med. 2010;40(2):163-181.
- Brunet J, Taran S, Burke S, Sabiston CM. A qualitative exploration of barriers and motivators to physical activity participation in women treated for breast cancer. Disabil Rehabil. 2013;35(24): 2038-2045.
- Blaney JM, Lowe-Strong A, Rankin-Watt J,Campbell A, Gracey JH. Cancer survivors’ exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire-survey. Psychooncology. 2013;22(1):186-194.
- Ammitzbøll G, Søgaard K, Karlsen RV, Tjønneland A, Johansen C, Frederiksen K, et al. Physical activity and survival in breast cancer. Eur J Cancer. 2016;66:67-74.
- Groenvold M, Petersen MA, Idler E, Bjorner JB, Fayers PM, Mouridsen HT. Psychological distress and fatigue predicted recurrence and survival in primary breast cancer patients. Breast Cancer Res Treat. 2007;105(2):209-219.
- Hampson JP, Zick SM, Khabir T,Wright BD, Harris RE. Altered resting brain connectivity in persistent cancer related fatigue. Neuroimage Clin. 2015;8:305-313.
- Zick SM, Zwickey H,Wood L, et al. Preliminary differences in peripheral immune markers and brain metabolites between fatigued and non-fatigued breast cancer survivors: a pilot study. Brain Imaging Behav. 2014;8(4):506-516.
- Alschuler, L, Gazella K. Natural Interventions for Posttreatment Cancer-related Fatigue: Spotlight on ginseng, Rhodiola, and medicinal mushrooms. Natural Medicine Journal. 2014; 6(11).
- Xing GG, Liu FY, Qu XX, Han JS,Wan Y. Long-term synaptic plasticity in the spinal dorsal horn and its modulation by electroacupuncture in rats with neuropathic pain. Exp Neurol. 2007;208(2):323-332.
- Harris RE, Sundgren PC, Pang Y, et al. Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia. Arthritis Rheum. 2008;58(3):903-907.
- Napadow V, Lee J, Kim J, et al. Brain correlates of phasic autonomic response to acupuncture stimulation: an event-related fMRI study. Hum Brain Mapp. 2013;34(10):2592-2606.
- Jeong HJ, Hong SH, Nam YC, Yang HS, Lyu YS, Baek SH, et al. The effect of acupuncture on proinflammatory cytokine production in patients with chronic headache: a preliminary report. Am J Chin Med. 2003;31(6):945-954.
- Wei Y, Dong M, Zhong L, Liu J, Luo Q, Lv Y, et al. Regulation of hypothalamic-pituitary-adrenal axis activity and immunologic function contributed to the anti-inflammatory effect of acupuncture in the OVA-induced murine asthma model. Neurosci Lett. 2016 Nov 2. pii: S0304-3940(16)30840-0.
- Lim HD, Kim MH, Lee CY, Namgung U. Anti-Inflammatory Effects of Acupuncture Stimulation via the Vagus Nerve. PLoS One. 2016 Mar 18;11(3):e0151882.
- Lin WC, Yeh CH, Chien LC, Morone NE, Glick RM, Albers KM. The Anti-Inflammatory Actions of Auricular Point Acupressure for Chronic Low Back Pain. Evid Based Complement Alternat Med. 2015;2015:103570.
- Ling WM, Lui LY, So WK, Chan K. Effects of acupuncture and acupressure on cancer-related fatigue: a systematic review. Oncol Nurs Forum. 2014;41(6):581-592.
- Zick SM, Alrawi S, Merel G, et al Relaxation acupressure reduces persistent cancer-related fatigue. Evid Based Complement Alternat Med. 2011; 2011:142913.
- Lan SC, Lin YE, Chen SC, Lin YF,Wang YJ. Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study. Evid Based Complement Alternat Med. 2015;2015:496485.
- Molassiotis A, Sylt P, Diggins H. The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: a randomised controlled trial. Complement Ther Med. 2007;15(4):228-237.
- Tang WR, ChenWJ, Yu CT, et al. Effects of acupressure on fatigue of lung cancer patients undergoing chemotherapy: an experimental pilot study. Complement Ther Med. 2014;22(4):581-591.
- Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. East Sussex, England: Journal of Chinese Medicine Publications; 1998.
- Zafar SY. Financial Toxicity of Cancer Care: It's Time to Intervene. J Natl Cancer Inst. 2015 Dec 11;108(5).
- Tiwari A, Lao L, Wang AX, Cheung DS, So MK, Yu DS, et al. Self-administered acupressure for symptom management among Chinese family caregivers with caregiver stress: a randomized, wait-list controlled trial. BMC Complement Altern Med. 2016;28;16(1):424.
- Bastani F, Khosravi M, Borimnejad L, Arbabi N. The effect of acupressure on cancer-related fatigue among school-aged children with acute lymphoblastic leukemia. Iran J Nurs Midwifery Res. 2015;20(5):545-51.