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Acupressure: An Overview of Systematic Reviews

Open AccessPublished:September 03, 2010DOI:https://doi.org/10.1016/j.jpainsymman.2010.07.003
      To the Editor:
      Acupressure is a commonly used treatment for a wide range of conditions. Different experts have suggested different definitions (Table 1),
      • Segen J.C.
      Dictionary of alternative medicine.
      • Jonas W.B.
      Mosby's dictionary of complementary and alternative medicine.
      • Kayne S.B.
      Complementary therapies for pharmacists.
      • Yuan C.-S.
      • Bieber E.J.
      • Bauer B.A.
      Textbook of complementary and alternative medicine.
      most of which stress that its concepts are similar to those of acupuncture. The main difference is that, instead of needle insertion, pressure is used for stimulation of acupuncture points. Normally this pressure is applied manually.
      Table 1Definitions of Acupressure
      Author (Reference)Definition (Quote)
      Segen
      • Segen J.C.
      Dictionary of alternative medicine.
      A 4000-year-old Oriental technique that combines massage and features of acupuncture
      Jonas
      • Jonas W.B.
      Mosby's dictionary of complementary and alternative medicine.
      A technique used to release blocked Qi by applying finger pressure to points on meridians
      Kayne
      • Kayne S.B.
      Complementary therapies for pharmacists.
      A form of acupuncture in which fingers, thumbs, and elbows are used to stimulate the body's acupuncture points
      Yuan et al.
      • Yuan C.-S.
      • Bieber E.J.
      • Bauer B.A.
      Textbook of complementary and alternative medicine.
      A form of bodywork based on traditional Chinese meridian theory in which acupuncture points are pressed to stimulate the flow of energy or Qi
      Although acupressure is often recommended as a symptomatic treatment for a wide range of conditions, for example, arthritis, claustrophobia, the common cold, gastrointestinal problems, gynecological complaints, insomnia, laryngitis, neuralgia, sciatica, renal disease, stuttering, sweating, tinnitus, and vertigo,
      • Segen J.C.
      Dictionary of alternative medicine.
      its clinical effectiveness remains uncertain.
      • Ernst E.
      • Pittler M.H.
      • Wider B.
      • Boddy K.
      The desktop guide to complementary and alternative medicine.
      Many clinical trials have emerged, but their results are contradictory. Systematic reviews assessing the totality of this evidence might bring clarification, but several such articles have been published, and their conclusions also are contradictory.
      This overview is aimed at summarizing and critically evaluating all systematic reviews of acupressure as a symptomatic treatment for any condition. Our ultimate goal is to provide clinicians with clearer guidance as to the value of this approach.

      Study

      Electronic literature searches were carried out in April 2010 using Medline, Embase, Amed, CINAHL, the Cochrane Library, six Korean medical databases and Chinese databases, without restrictions as to time or language. The search terms were acupressure, shiatsu, acupuncture point stimulation, systematic review, and meta-analysis. In addition, our departmental files were hand-searched. Abstracts of reviews thus located were inspected by the authors, and those appearing to meet the inclusion criteria were retrieved and read in full by both authors. Reviews were defined as systematic if they included an explicit and repeatable methods section describing the search strategy and explicit inclusion/exclusion criteria.
      To be included, a systematic review had to be concerned specifically with the effectiveness of acupressure and include evidence from at least two controlled clinical trials. Systematic reviews evaluating acupressure together with acupuncture, without evaluating the two approaches separately, were excluded. Reviews that were not systematic
      • Roscoe J.A.
      • Matteson S.E.
      Acupressure and acustimulation bands for control of nausea: a brief review.
      • Collins K.B.
      • Thomas D.J.
      Acupuncture and acupressure for the management of chemotherapy-induced nausea and vomiting.
      • Hickman A.G.
      • Bell D.M.
      • Preston J.C.
      Acupressure and postoperative nausea and vomiting.
      were excluded.
      Data were extracted independently by both authors, using predefined criteria (Table 2).
      • Ernst E.
      Acupressure for nausea: a best evidence analysis.
      • Harris P.E.
      Acupressure: a review of the literature.
      • Klein J.
      • Griffiths P.
      Acupressure for nausea and vomiting in cancer patients receiving chemotherapy.
      • Ma H.W.
      • Chang M.L.
      • Lin C.J.
      A systematic review of acupressure for the application on nursing practice.
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      • Lee J.
      • Dodd M.
      • Dibble S.
      • Abrams D.
      Review of acupressure studies for chemotherapy-induced nausea and vomiting control.
      • Nunley C.
      • Wakim J.
      • Guinn C.
      The effects of stimulation of acupressure point p.6 on postoperative nausea and vomiting: a review of literature.
      • Cho S.H.
      • Hwang E.W.
      Acupressure for primary dysmenorrhoea: a systematic review.
      • Zhang C.S.
      • Yang A.W.
      • Zhang A.L.
      • et al.
      Ear-acupressure for allergic rhinitis: a systematic review.
      Judgments about the quality of the primary studies were adopted from the respective systematic reviews. The Overview Quality Assessment Questionnaire was used to evaluate the methodological quality of all included systematic reviews.
      • Jadad A.R.
      • McQuay H.J.
      Meta-analyses to evaluate analgesic interventions. A systematic review of their methodology.
      • Oxman A.D.
      • Guyatt G.H.
      Validation of an index of the quality of review articles.
      The score ranges from 1 to 7; a score of three or less was considered as indicative of major flaws and a score of five or more as suggesting only minor flaws. Both authors did these assessments independently, and discrepancies were settled by discussion.
      Table 2Systematic Reviews of Acupressure
      First Author (Year)ConditionNumber of Trials IncludedMeta-analysisQuality of Primary StudiesQuality of Review (OQAQ)
      The overall score is from 1 to 7. OQAQ≤3: having extensive or major flaw; OQAQ≥5: having minor or minimal flaw.
      Author's Conclusion (Quote)Direction of ResultsComment
      Ernst
      • Ernst E.
      Acupressure for nausea: a best evidence analysis.
      (1996)
      Nausea18NoVariable1“…compared to sham interventions, P6 acupressure was significantly more effective in reducing nausea”[+]Only two databases searched—no clear inclusion/exclusion criteria.
      Harris
      • Harris P.E.
      Acupressure: a review of the literature.
      (1997)
      Any17NoVariable1“PC6 is more effective than placebo in reducing feelings of nausea…”[+]Only one database (CISCOM) was searched.
      Klein
      • Klein J.
      • Griffiths P.
      Acupressure for nausea and vomiting in cancer patients receiving chemotherapy.
      (2004)
      Chemotherapy-induced nausea and vomiting2NoVariable3“Acupressure may decrease nausea”[+]Five databases were searched.
      Ma
      • Ma H.W.
      • Chang M.L.
      • Lin C.J.
      A systematic review of acupressure for the application on nursing practice.
      (2007)
      Any71NoVariable, mostly poor3“The effects of acupressure led to the positive results”[+]Medline and four Chinese databases were searched. Not all studies were controlled clinical trials.
      Allen
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      (2008)
      Preventing nausea and vomiting under neuraxial anesthesia6NoGood5“The finding is not consistent”[+/−]Four databases were searched.
      Lee
      • Lee J.
      • Dodd M.
      • Dibble S.
      • Abrams D.
      Review of acupressure studies for chemotherapy-induced nausea and vomiting control.
      (2008)
      Chemotherapy-induced nausea and vomiting10NoVariable1“Acupressure should be strongly recommended…”[+]Only three databases were searched, none of which specialized on the Asian literature.
      Nunley
      • Nunley C.
      • Wakim J.
      • Guinn C.
      The effects of stimulation of acupressure point p.6 on postoperative nausea and vomiting: a review of literature.
      (2008)
      Postoperative nausea and vomiting9NoVariable1“…acupressure [has] shown antiemetic effectiveness for prevention of PONV”[+]No clear inclusion/exclusion criteria. Other treatments were reviewed as well.
      Cho
      • Cho S.H.
      • Hwang E.W.
      Acupressure for primary dysmenorrhoea: a systematic review.
      (2010)
      Dysmenorrhea4NoPoor3“Acupressure alleviates pain”[+]Asian literature was included.
      Zhang
      • Zhang C.S.
      • Yang A.W.
      • Zhang A.L.
      • et al.
      Ear-acupressure for allergic rhinitis: a systematic review.
      (2010)
      Allergic rhinitis5NoPoor3“Benefit…is unknown”[+/−]21 databases were searched. Trials comparing ear acupressure or herbal medicine with body acupuncture were included.
      OQAQ=Overview Quality Assessment Questionnaire; +=positive, that is, acupressure is effective or likely to be effective; +/−=inconclusive.
      a The overall score is from 1 to 7. OQAQ3: having extensive or major flaw; OQAQ5: having minor or minimal flaw.
      We located 147 potentially relevant articles, of which nine met the above inclusion criteria (Fig. 1). Key data are summarized in Table 2.
      • Ernst E.
      Acupressure for nausea: a best evidence analysis.
      • Harris P.E.
      Acupressure: a review of the literature.
      • Klein J.
      • Griffiths P.
      Acupressure for nausea and vomiting in cancer patients receiving chemotherapy.
      • Ma H.W.
      • Chang M.L.
      • Lin C.J.
      A systematic review of acupressure for the application on nursing practice.
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      • Lee J.
      • Dodd M.
      • Dibble S.
      • Abrams D.
      Review of acupressure studies for chemotherapy-induced nausea and vomiting control.
      • Nunley C.
      • Wakim J.
      • Guinn C.
      The effects of stimulation of acupressure point p.6 on postoperative nausea and vomiting: a review of literature.
      • Cho S.H.
      • Hwang E.W.
      Acupressure for primary dysmenorrhoea: a systematic review.
      • Zhang C.S.
      • Yang A.W.
      • Zhang A.L.
      • et al.
      Ear-acupressure for allergic rhinitis: a systematic review.
      Figure thumbnail gr1
      Fig. 1Flowchart of publication selection process.
      The systematic reviews had been published between 1996 and 2010. Most were published after 2000. They included between two and 71 sets of primary data, which, in many cases, were methodologically flawed. The majority related to the treatment of nausea and vomiting.
      • Ernst E.
      Acupressure for nausea: a best evidence analysis.
      • Klein J.
      • Griffiths P.
      Acupressure for nausea and vomiting in cancer patients receiving chemotherapy.
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      • Lee J.
      • Dodd M.
      • Dibble S.
      • Abrams D.
      Review of acupressure studies for chemotherapy-induced nausea and vomiting control.
      • Nunley C.
      • Wakim J.
      • Guinn C.
      The effects of stimulation of acupressure point p.6 on postoperative nausea and vomiting: a review of literature.
      There was considerable overlap in terms of the primary studies included. Other reviews evaluated acupressure's effectiveness for any condition,
      • Harris P.E.
      Acupressure: a review of the literature.
      • Ma H.W.
      • Chang M.L.
      • Lin C.J.
      A systematic review of acupressure for the application on nursing practice.
      dysmenorrhea,
      • Cho S.H.
      • Hwang E.W.
      Acupressure for primary dysmenorrhoea: a systematic review.
      and allergic rhinitis.
      • Zhang C.S.
      • Yang A.W.
      • Zhang A.L.
      • et al.
      Ear-acupressure for allergic rhinitis: a systematic review.
      The methodological quality of the systematic reviews was generally poor. Only one review scored five points, four scored three points, and four scored one point. The methodologically best article
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      arrived at an inconclusive overall result, whereas most of the other systematic reviews drew positive conclusions about the effectiveness of acupressure (Table 2).

      Comment

      Our overview shows that several systematic reviews of acupressure have been published. The fact that most of them were recent indicates that the scientific interest in acupressure is growing. Most of the reviews are of poor quality, are based on few and often less than rigorous clinical trials, and arrive at overall positive conclusions.
      For the treatment of nausea and vomiting, there are four reviews.
      • Ernst E.
      Acupressure for nausea: a best evidence analysis.
      • Klein J.
      • Griffiths P.
      Acupressure for nausea and vomiting in cancer patients receiving chemotherapy.
      • Lee J.
      • Dodd M.
      • Dibble S.
      • Abrams D.
      Review of acupressure studies for chemotherapy-induced nausea and vomiting control.
      • Nunley C.
      • Wakim J.
      • Guinn C.
      The effects of stimulation of acupressure point p.6 on postoperative nausea and vomiting: a review of literature.
      They are all positive but invariably of poor quality and based on mostly poor-quality primary studies. Thus, it might be wise to err on the safe side and consider acupressure not solidly evidence based for that indication.
      For the prevention of nausea and vomiting, only one systematic review exists.
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      It is of relatively high quality and includes six mostly rigorous trials. These primary studies report highly contradictory findings. Allen and Habib
      • Allen T.K.
      • Habib A.S.
      P6 stimulation for the prevention of nausea and vomiting associated with cesarean delivery under neuraxial anesthesia: a systematic review of randomized controlled trials.
      rightly conclude that “the evidence is not consistent.” Therefore, it would be erroneous to consider acupressure an evidence-based treatment for the prevention of nausea and vomiting.
      The other two systematic reviews relate to dysmenorrhea
      • Cho S.H.
      • Hwang E.W.
      Acupressure for primary dysmenorrhoea: a systematic review.
      and allergic rhinitis.
      • Zhang C.S.
      • Yang A.W.
      • Zhang A.L.
      • et al.
      Ear-acupressure for allergic rhinitis: a systematic review.
      Both are of poor quality and both rely on a small number of flawed studies. It seems fair to say that the value of acupressure is not well documented for either of these conditions.
      In essence, this means that the effectiveness of acupressure is currently not well documented for any condition. This is in sharp contrast to the many claims made by the proponents of this therapeutic modality.
      • Yuan C.-S.
      • Bieber E.J.
      • Bauer B.A.
      Textbook of complementary and alternative medicine.
      • Roscoe J.A.
      • Matteson S.E.
      Acupressure and acustimulation bands for control of nausea: a brief review.
      • Collins K.B.
      • Thomas D.J.
      Acupuncture and acupressure for the management of chemotherapy-induced nausea and vomiting.
      • Hickman A.G.
      • Bell D.M.
      • Preston J.C.
      Acupressure and postoperative nausea and vomiting.
      • Ellis N.
      Acupuncture in clinical practice.
      The intriguing question arises: Does acupressure require a rigorous scientific evaluation at all? It is a safe and pleasant treatment and, if patients want it, appreciate it and pay for it, why not? This stance seems certainly reasonable, and we might agree with it. Yet, if proponents of any therapy make therapeutic claims that go beyond the notion of “a pleasant experience,” we need data to support these claims. In the case of acupressure, many such claims are being made (see above). We feel, therefore, that given the lack of sound evidence, such claims might not be responsible.
      Our overview has several important limitations. Although our search strategy seemed thorough, we cannot totally exclude the notion that relevant articles were missed. By evaluating systematic reviews rather than clinical trials, important details of the primary studies may have been lost. Most crucially, the poor quality of the primary data and the systematic reviews is regrettable. Collectively, these limitations limit the conclusiveness of our findings.
      In conclusion, although nine systematic reviews of acupressure are currently available, the effectiveness for this treatment has not been conclusively demonstrated for any condition.

      Acknowledgments

      Dr. Lee was supported by KIOM ( KIO251 ).

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