Results

The Effect of Acupressure

4.3 Results

The review of three databases revealed 25 articles from PubMed, 15 articles from MEDLINE, and 11 articles from CINAHL. Reference lists of these articles also were searched to fi nd other relevant studies. Among 51 articles, 38 articles were

Fig. 4.1 Sea band

Table 4.1 Effect size and quality of study Author (year) Measure Quality of study

Acupressure Control/placebo Effect size Con fi dence interval p Mean SD n Mean SD n Randomized controlled trial Roscoe et al. ( 2003 ) Severity of nausea (1–7) 2 2.6 No data 233 3 No data 232 <0.05 Molassiotis et al. ( 2007 ) Incidence of nausea at day 1 5 0.66 1.6 17 2.16 2.4 19 0.73 0.04–1.39 <0.05 Dibble et al. ( 2007 ) Incidence of emesis 1 No data No data <0.001 Jones et al. ( 2008 ) Total nausea prevention (0–10) 2 2.7 2.9 18 3.4 3.0 18 0.23 −0.42 to 0.89 NS Roscoe et al. ( 2010 ) Mean number of anti- emetic pills at home 4 12.6 6.6 36 18.5 9.1 32 1.21 0.70–1.73 <0.05 Suh ( 2012 ) IVNR score at day 4 5 5.48 3.84 25 10.76 7.54 23 0.89 0.29–1.47 0.001 Genç et al. ( 2013 ) Incidence of nausea, vomiting, retching 1 No data No data 67 No data No data 53 – – NS Quasi-experimental study Shin et al. ( 2004 ) Severity of nausea and vomiting at day 4 NA 3.05 2.91 20 9.5 8.95 20 0.95 0.3–1.6 <0.001 Taspinar and Sirin ( 2010 ) Severity of nausea (0–10) at day 3 NA 2.47 2.57 34 4.32 2.78 34 0.68 0.09–1.17 0.01 SD standard deviation, NA not applicable, n number, NS not signifi cant

excluded due to: duplicates ( n = 24), non-English text ( n = 2), nausea not caused by chemotherapy ( n = 4), non-acupressure intervention ( n = 6), secondary analysis ( n = 2) (Roscoe et al. 2006 ; Lee et al. 2010 ) , and non-availability of full text ( n = 1) (Fig. 4.2 ). This search resulted in twelve articles that were eligible for review: seven randomized controlled trials, two quasi-experimental studies, and three systematic reviews. Randomized controlled trials use randomization for group assignment to reduce bias and control groups to compare effectiveness between groups, while quasi-experimental studies use pre-post measures but do not use randomization or a control group. Quasi-experimental designs are used when: (1) the ef fi cacy of the intervention has been established and randomization might create ethical concerns; (2) it is dif fi cult to randomize subjects; (3) it is dif fi cult to randomize by location (e.g. by wards); and (4) only a small sample size is available. The limitation of quasi-experimental designs is the risk of bias (Harris et al. 2006 ) . The quality of the studies and effect sizes are summarized in Table 4.1 . Roscoe and his colleagues ( 2003 ) and Dibble and her colleagues ( 2007 ) did not provide data such as mean and standard deviation for each group to calculate effect size. The characteristics of randomized trials and quasi-experimental studies are summarized in Table 4.2 . Jones and colleagues ( 2008 ) , Taspinar and colleagues ( 2010 ) , Roscoe and colleagues ( 2010 ) , and Genç and colleagues ( 2013 ) did not provide the intervention time for acupressure. Total number of patients from seven studies is 1,341 and 89% of the patients were female. Children under 19 years old made up 1.3% of the subjects.

Key words: acupressure, nausea, cancer

Total 27

(25 from PubMed, 15 from MEDLINE and 11 from CINAHL, 0 from hand searching)

7 randomized controlled trials 3 systematic reviews

2 quasi-experimental studies

Not English (n = 2)

Not chemotherapy-induced nausea (n = 4) Not acupressure (n = 6)

Not full text (n = 1) Secondary analysis (n = 2)

Fig. 4.2 Flow chart of study selection

Table 4.2 The description of acupressure studies Author (year) Sample n Acupressure point Tool Time per day Days Measures Roscoe et al. ( 2003 ) Breast cancer (85%) 739 PC6 Sea band 24 h 5 Severity, frequency of nausea and vomiting, expected ef fi cacy of the wristband Shin et al. ( 2004 ) Stomach cancer 40 PC6 Finger 15–20 min 5 Rhodes index of nausea, vomiting, and retching Molassiotis et al. ( 2007 ) Breast cancer 36 PC6 Sea band 24 h 5 Rhodes index of nausea, vomiting, and retching Dibble et al. ( 2007 ) Breast cancer 160 PC6 Finger 6–9 min 21 Rhodes index of nausea, vomiting, and retching, state-trait anxiety inventory Jones et al. ( 2008 ) Children with cancer 18 PC6 Sea band No data 1–5 Morrow assessment of nausea and emesis Roscoe et al. ( 2010 ) Breast cancer 74 PC6 Sea band No data 5 Severity of nausea (1–7), mean number of anti-emetic pills at home Taspinar and Sirin ( 2010 ) Gynecologic cancer 34 PC6 Sea band No data 5 Severity of nausea (0–10) Suh ( 2012 ) Breast cancer 120 PC6 Sea band No data 5 Rhodes index of nausea, vomiting, and retching Genç et al. ( 2013 ) Lung, breast, or gynecological cancer 120 PC6 Sea band No data 5 Rhodes index of nausea, vomiting, and retching, functional assessment of cancer therapy general

4.3.1 Randomized Controlled Trials (RCTs)

4.3.1.1 Acupressure Point

All studies used acupoint PC6. PC6 is located at the middle of the inner side of the forearm three fi ngers width above the wrist crease (World Health Organization 2012b ) (Fig. 4.3 ).

4.3.1.2 Outcome Measures

To measure nausea, studies used the Rhodes index of nausea, vomiting, and retching (Rhodes et al. 1987 ; Rhodes and McDaniel 1999 ) , the Morrow assessment of nau- sea and emesis (Morrow 1992 ) , severity of nausea, and a patient report diary (Carey and Burish 1988 ) .

To measure other factors related to nausea, studies used the Functional assessment of cancer therapy scale-general (Cella et al. 1993 ) , expected ef fi cacy of the wrist bands (Roscoe et al. 2003 ) , and the State-trait anxiety inventory (Spielberger 1983 ) .

4.3.1.3 Quality of Studies

The average risk of bias score was 2.85 for the RCTs which indicated that the risk of these studies was moderate to high. Of seven RCTs: the sequence generation was not clear in four studies (Roscoe et al. 2003 ; Dibble et al. 2007 ; Jones et al. 2008 ; Genç et al. 2013 ); allocation concealment was not clear in four studies (Roscoe et al. 2003 ; Dibble et al. 2007 ; Jones et al. 2008 ; Genç et al. 2013 ); blinding of participants, personnel, and outcomes was not clear or not used in four studies

Fig. 4.3 Acupressure at PC6

(Roscoe et al. 2003 ; Dibble et al. 2007 ; Molassiotis et al. 2007 ; Genç et al. 2013 );

incomplete outcome data in three studies (Roscoe et al. 2010 ; Dibble et al. 2007 ; Genç et al. 2013 ), selective outcome reporting in four studies (Roscoe et al. 2003,

2010 ; Jones et al. 2008 ; Genç et al. 2013 ); and other sources of bias such as no report of attrition rate and reason, fi delity, and side effects in four studies (Roscoe et al. 2003 ; Dibble et al. 2007 ; Jones et al. 2008 ; Genç et al. 2013 ) .

4.3.1.4 Description of Studies

Acupressure using sea bands continuously for fi ve days signi fi cantly decreased nausea and vomiting on the fi rst day of chemotherapy compared to the control group, which received standard care ( n = 739, p < 0.05). However, there was no signi fi cant difference on the second to fi fth day of chemotherapy compared to the control group. Females made up 92% of the subjects. In addition, 85% of subjects had breast cancer and 10%

of subjects had hematologic neoplasms. This study did not report the mean age of patients and standard deviation for each group (Roscoe et al. 2003 ) . In another study, the use of acupressure with sea bands continuously for fi ve days signi fi cantly decreased nausea, vomiting, and retching in patients with breast cancer receiving chemotherapy when compared to a control group receiving standard care ( n = 36, p < 0.05). The mean age of patients was 49.5 ± 10.5 (Molassiotis et al. 2007 ) . Dibble and her colleagues ( 2007 ) randomized patients with breast cancer to the acupressure group, the placebo acupressure group or the usual-care group. The acupressure group used PC6 and the placebo group used Houxi (SI3). There was no signi fi cant difference in acute nausea (chemotherapy day 1) among three groups after acupressure. However, there was a signi fi cant difference in delayed nausea (chemotherapy days 2–11) and the incidence of vomiting among the acupressure group, the placebo group ( t = 3.3, p = 0.002, odds ratio = 1.3), or the usual-care group ( t = 4.91, p < 0.0001, odds ratio = 1.4, n = 150). The acupressure group was most effective when compared to the placebo and usual-care groups. The participants performed acupressure for 6–9 min/day for three weeks.

They kept a daily log for three weeks and did not report any side effects. The mean age of patients was 49.3 ± 9.4. This study did not report fi delity and outcome such as the number for each group and the score on the nausea scale for each group. Jones and his colleagues ( 2008 ) used a crossover randomized clinical trial design to examine the effect of acupressure on chemotherapy-induced nausea in 18 children with cancer.

The effect of acupressure using sea bands was not signi fi cantly different compared to the placebo and control groups. The mean age of patients was 11.7 ± 4.2. The types of cancer varied such as acute lymphoblastic leukemia ( n = 4), rhabdomyosarcoma ( n = 5), Ewing sarcoma ( n = 4), medulloblastoma ( n = 2), and osteosarcoma ( n = 3). Roscoe et al. ( 2010 ) reported that patients with high expectancy of acupressure ( n = 36) took fewer anti-emetic pills at home compared to patients with lower expectancy ( n = 32, p < 0.05). In this study, patients performed acupressure using sea bands for fi ve days.

The mean age was 51.5 (28–74) in 74 patients with breast cancer.

4.3.2 Quasi-experimental Study

Taspinar and Sirin ( 2010 ) reported that acupressure using sea bands for fi ve days decreased nausea compared to nausea before acupressure in 34 patients with gynecologic cancer ( p = 0.01). The mean age of the participants was 50.55 ± 10.55.

This study did not use a control group. Seventy six percent of the patients had ovarian cancer. In addition, 23.55% of patients had cancer of the endometrium, cervix, or fallopian tubes. The dosage of anti-emetic medication was reduced signi fi cantly after acupressure. Shin and her colleagues ( 2004 ) reported that acupressure for 15–20 min per day for fi ve days reduced nausea compared to the control group who received standard care in patients with stomach cancer ( n = 40, p < 0.001). Seventy percent of the patients were male and the mean age of patients was 52.75 ± 10.91.

4.3.3 Systematic Reviews

Chao and his colleagues ( 2009 ) reviewed randomized controlled trials which examined the effect of acupuncture, acupressure, or any other acupuncture point stimulation method for the management of therapy-related adverse events in patients with breast cancer. Chao and his colleagues ( 2009 ) included a paper which was written in Chinese. They concluded (based on the positive results of 10 out of 11 studies) that acupuncture, acupressure, electroacupuncture (EA), and drug injection at acupuncture points signi fi cantly improved chemotherapy- induced nausea in 761 patients with breast cancer. Chao and his colleagues included four studies which examined the effect of acupressure on chemother- apy-induced nausea (Dibble et al. 2000, 2007 ; Molassiotis et al. 2007 ) . Dibble and her colleagues ( 2000 ) found that a daily 9-min acupressure at PC6 and zusanli (ST36) for 21 days did not reduce acute nausea and vomiting on the day of chemotherapy, but did decrease nausea and vomiting from day 2 to 11 when compared to the control (standard care) and placebo groups (acupressure in inappropriate locations) in 17 patients with breast cancer. Lee and her col- leagues ( 2008 ) reviewed ten clinical trials to compare the effect of acupressure modalities such as sea bands and fi nger acupressure on chemotherapy-induced nausea. Four of seven studies using sea bands supported the positive effects and all three studies using fi nger acupressure supported the positive effects.

Sea bands decreased acute nausea, whereas fi nger acupressure decreased delayed nausea and vomiting. Lee and her colleagues ( 2008 ) included two unpublished papers and one abstract. Klein and Grif fi ths ( 2004 ) reviewed two randomized controlled trials (Dibble et al. 2000 ; Ho 2006 ) . Klein and Grif fi ths ( 2004 ) found that acupressure decreased chemotherapy-induced nausea in 482 patients with cancer.