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.