Written by Karen Pilkington, Edzard Ernst and the CAM-Cancer Consortium.
Updated December 16, 2015

Acupuncture for fatigue

Abstract and key points

  • Acupuncture usually entails the needling of specific points on the body surface.
  • The effectiveness of acupuncture for fatigue is not proven beyond reasonable doubt.
  • Serious complications of acupuncture exist but are probably very rare.

Acupuncture typically entails needling specific points of the body surface. According to Traditional Chinese Medicine (TCM) philosophy, illness is caused by imbalances of energies in the body and acupuncture is a treatment that re-balances energies. Therefore, it is claimed by TCM-practitioners to be helpful in most human condition. By contrast, most Western acupuncturists follow the principles of conventional medicine and would employ acupuncture only for specific conditions. Acupuncture might be advocated for a wide range of conditions and symptoms, including cancer-related fatigue, particularly as some preliminary studies suggested beneficial effects. Even though some positive evidence exists to support this claim, the published data are both too scarce and too methodologically weak for allowing firm conclusions about the effectiveness of acupuncture for cancer-related fatigue.

Mild adverse effects, e.g. pain or bleeding at the site of acupuncture can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.

Read about the regulation, supervision and reimbursement of acupuncture at NAFKAMs website CAM Regulation.

What is it?

Description

Acupuncture refers to the insertion of fine needles at specific points (acupuncture points or acupoints) on the body for the prevention or treatment of disease or the maintenance of health. The term ‘acupuncture’ is derived from Latin and means ‘piercing with a sharp instrument’. from Latinacus,‘needle’ (noun), andpungere,‘to prick or puncture’ (verb).

Ingredients/Components

Acupuncture is usually performed with fine, solid needles but many variations exist. ‘Acupoints’ might, for instance, be stimulated by electrical currents with or without needles (electro-acupuncture), by pressure (acupressure involving use of ‘press’ needles, studs or manual pressure), by heat (moxibustion) or laser light (laser-acupuncture). Techniques that do not involve the insertion of needles are not always classed as acupuncture.

Acupuncture is often part of a complex intervention that includes use of herbal mixtures, moxibustion (burning of herbs), and dietary and lifestyle advice.

Application and dosage

Acupuncture is applied to the body surface including the ears and scalp. The dosage (number of points stimulated, depth of needle insertion, duration of stimulation and frequency and duration of treatment sessions) depends on the condition treated. Sometimes only one acupoint is stimulated; more commonly several needles are applied. A specific area of the body (for example, ear-acupuncture) may be treated but, more commonly, several areas are needled. Needles are usually removed after a 30 minute treatment session but press needles and studs may be left for several days or, in some cases, weeks. Needles may be stimulated by manual manipulation or left unstimulated. Treatments may be repeated at regular intervals, for example once or twice weekly, or treatment can comprise of a single session.

The placement of needles is determined by the condition being treated and, to some extent, by the type of acupuncture being applied. In traditional Chinese or East Asian forms of acupuncture, acupoints are considered to be located along channels or ‘meridians’ through which a vital force or energy (‘Qi’) flows.1 Diagnosis is carried out using a number of methods including peripheral pulses, the appearance of the tongue, speech, history and overall impressions of the patient. The ‘symptom pattern’ and underlying ‘imbalances’ guide selection of points. In ‘Western medical’ acupuncture, points are selected according to contemporary neurophysiology and are considered to be sites where external stimuli result in a greater sensory stimulus, so-called ‘trigger points’.2,3

History/providers

The history of acupuncture can be traced to ancient China and its Taoist philosophy.4 It has been practised in China for more than 2000 years and in other East Asian countries including Japan ,Korea and Vietnam, for between 1000 to 2000 years arriving in Europe several hundred years ago.5 In traditional Chinese medicine (TCM), the life energy ‘Qi’ flowing through the body in meridians and the balance of ‘yin’ and ‘yang’ are thought to determine human health. Illness is seen as an imbalance of these energies and acupuncture is perceived to be one method for re-balancing the imbalance. Traditionally, acupuncture was not used primarily for specific problems such as pain control but to treat a wide range of symptoms or problems based on the pattern of diagnosis.5 Yet, in recent years, pain-control seems to have become its main purpose in many clinical settings.

Acupuncture became particularly popular outside Asia after the US president Richard Nixon visited China in 1971.4 Acupuncture treatments were originally provided by traditional acupuncturists but as interest in the technique extended, health professionals adopted and adapted the techniques, using acupuncture alongside conventional treatment.

Claims of efficacy/alleged indications

According to TCM concepts, acupuncture is a therapy for most symptoms and diseases. Modern Western concepts are centred around conditions likely to be influenced through effects on neurotransmitters, such as musculoskeletal pain and nausea and vomiting.3,7

Mechanisms of action

Considerable research effort has been focused on finding physiological or histological evidence of the existence of concepts postulated within TCM acupuncture such as Qi, meridians and specific acupuncture points but conclusive proof has not been obtained.6 Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins.7

Prevalence of use

In many countries, acupuncture is now one of the most popular forms of CAM. Most modern pain clinics and many oncology centres across the world routinely offer acupuncture as one of several therapeutic options. Exact prevalence figures vary from country to country and from setting to setting. A survey of cancer patients in Europe reported use of acupuncture by between 2 to 4% of patients before and after diagnosis but use varied by cancer type and acupuncture was used by up to 17% of gynaecological cancer patients.8,9

Legal issues

In most countries, acupuncture can be administered by both medically-trained and statutorily regulated health professionals (e.g. doctors, physiotherapists, nurses, midwives) and by non-medically-trained acupuncturists. The regulation of acupuncture varies from one country to another. In the UK, there is voluntary rather than statutory regulation and local authorities can regulate hygiene of acupuncture practice.1

Cost and expenditures

In the UK, average costs are £40-£70 for the first session, with ordinary appointments of between 30-60 minutes between £25-£50.1 One series of treatments would normally comprise 5-20 sessions. In Germany, costs of acupuncture for some conditions are covered by public health insurers.

Does it work?

Several feasibility studies ascertained that acupuncture-trials for cancer fatigue were feasible and that the subject was worthy of further investigation.10-12

Systematic reviews

Five systematic reviews of trials of acupuncture for cancer-related fatigue have presented mixed conclusions.13-17 While the methods used differed, a similar set of clinical trials were selected for these reviews and this included a number of pilot trials. The only meta-analysis that has been conducted showed no significant difference between acupuncture and sham acupuncture, or between acupuncture and no treatment or wait-list control or between acupuncture and acupressure or self-acupuncture.14 The only significant difference was between acupuncture plus education intervention versus usual care. There is a suggestion of a possible benefit from using acupuncture as an adjuvant therapy but, because of lack of blinding, it is not possible to confirm this. It has also been suggested that the dose used in trials was suboptimal and the heterogeneity of the interventions added to the lack of conclusive evidence.

Narrative reviews

Several non-systematic reviews of acupuncture for cancer-related fatigue are available and tend to arrive at cautious conclusions stating that “acupuncture may help”18 or that “insufficient data exist”.19

Randomised controlled trials

In addition to the RCTs included in the systematic reviews, two further trials have been conducted. One of these assessed the effectiveness of electroacupuncture for fatigue related to aromatase inhibitor-related arthralgia.20 Electroacupuncture was compared with sham acupuncture and a wait list control group and effects on fatigue, sleep and psychological distress measured.  Electroacupuncture appeared the most effective treatment but acupuncture was individualised to address a range of symptoms and it is difficult to separate the effects on each of these interlinked outcomes. Thus, the results can be considered preliminary and indicative of a possible benefit only.

A second trial investigated the effects of acupressure on fatigue during chemotherapy in lung cancer patients.21 Acupressure with and without essential oils was tested against sham acupressure at non-acupoints, all treatments being provided daily for 5 months. Changes in fatigue were not significantly different between the acupressure and sham groups.

Is it safe?

Adverse events

In about 8-10% of all patients, acupuncture causes mild, transient adverse effects such as pain, haematoma or bleeding at the site of needling.22,23 In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record.24 Risk of cross-infection of blood borne disease, particularly hepatitis B, is minimised by the use of sterile disposable needles, and immunisation of acupuncturists. Rare cases of fatalities after acupuncture treatment have been reported although causality was not confirmed in many of these reports.25

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy.1, 26 Bleeding abnormalities and anticoagulant treatment, oedema, epilepsy, pregnancy and needle phobia are among those conditions that have been suggested as relative, or in some cases absolute, contra-indications. Some points are considered ‘forbidden’ or not to be used for acupuncture needling.

Interactions

None known, except for electro-acupuncture where the electrical current might interfere with pacemakers and is used with caution in epilepsy.26

Warnings

Strict asepsis and use of sterile disposable needles are mandatory to avoid infections. Some patients faint during acupuncture and should thus be treated lying down.

Citation

Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for fatigue [online document]. http://cam-cancer.org/The-Summaries/Mind-body-interventions/Acupuncture-for-fatigue. December 16, 2015.

Document history

Summary fully revised and updated in December 2015 by Karen Pilkington.
Summary first published in March 2013, authored by Edzard Ernst.

References

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