Acupuncture for breathlessness | Cam-Cancer

Acupuncture for breathlessness

Abstract and key points
  • Acupuncture usually entails the needling of specific points located on the body surface.
  • The effectiveness of acupuncture for cancer-related breathlessness is uncertain; few trials are available and effects on breathlessness have not been confirmed although potentially beneficial effects on anxiety and morphine use in breathlessness warrant further investigation. 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 to be helpful in for many health-related problems. Many providers advocate it for a wide range of conditions and symptoms, including cancer-related breathlessness.

Few clinical trials have been carried out. These have not demonstrated a clear effect of acupuncture on breathlessness but have indicated there may be beneficial effects in reducing morphine requirements and reducing anxiety related to breathlessness. These preliminary findings do require further confirmation.Mild adverse effects can be expected in about 10% of all cases, and serious complications, such as pneumothorax and hepatitis, seem to be very rare.

Document history

Revised and updated in July 2018 by Karen Pilkington.
Revised and updated in July 2015 by Karen Pilkington.
Summary first published in July 2013, authored by Edzard Ernst.

Citation

Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for breathlessness [online document], http://cam-cancer.org/en/acupuncture-breathlessness, July 14, 2018.

What is it?

Scientific name/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’) flows1. 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 philosophy4. 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 ago5. 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 diagnosis5. 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 19714. 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, such as musculoskeletal pain and nausea and vomiting, that are likely to be influenced through effects on neurotransmitters3,7.

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 obtained6. Neurophysiological theories to explain acupuncture’s modes of action in pain have been developed, e.g. gate-control mechanism, and effects on neurotransmitters like endorphins7.

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 patients8,9.  Acupuncture was found to be the therapy most frequently provided by integrative oncology centres across Europe with 55% of 47 centres providing acupuncture10.

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 practice1.

Cost and expenditures

In the UK, average costs are £40-£70 for the first session, with subsequent appointments of between 30-60 minutes costing from £25 to £501. 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?

Systematic reviews

Two systematic reviews of various interventions for breathlessness in advanced stages of malignant and non-malignant diseases located five RCTs of acupuncture/acupressure including a single RCT in cancer (reference 13 as described below)11,12. The reviews concluded that there was not enough evidence to recommend the routine use of acupuncture/acupressure. One of these reviews12 was published in 2008 and the planned update has now been withdrawn24.

Randomised controlled trials

One RCT involved the treatment of 47 patients suffering from advanced breast or lung cancer and breathlessness13. They received a single session of real or sham acupuncture in addition to standard drug treatments. Semi-permanent studs were subsequently inserted for twice daily self-treatments. Follow-up was one week. The results show a slight but not statistically significant advantage in terms of symptomatic relief for the real acupuncture group. The authors concluded that the acupuncture technique used in this trial is unlikely to have effects on dyspnoea (breathlessness) 'importantly larger than placebo' for patients with advanced cancer.

In a subsequent RCT, acupuncture was compared with morphine and with acupuncture combined with morphine25. The 173 patients treated were suffering from breathlessness associated with advanced non-small cell lung cancer and mesothelioma. Acupuncture treatment included semi-permanent intrastuds for massaging when symptomatic. Response was based on patients achieving >1.5 improvement in VAS dyspnoea at 4 h. This was achieved in 74%, 60% and 66% of patients treated with acupuncture, morphine and the combination respectively. No statistically significant difference in overall response was observed between the 3 groups. The groups were similar at baseline but the trial was slightly underpowered to detect a difference in effects. Details of the randomisation process are limited (e.g. who carried allocation out) and blinding was not feasible due to the type of interventions. Fewer patients, however, treated with acupuncture required at least one morphine dose (p<0.0001) and acupuncture was linked with less adverse effects than morphine.

Auricular acupressure involving application of Vaccaria segetalis (a small seed) to the ear, was assessed in a small 3-arm randomised pilot study26. Advanced lung cancer patients were randomised to standard care plus auricular acupressure at non-specific points, to acupressure at points considered specific to lung function plus standard care, or to standard care alone. The Cancer Dyspnea Scale and oxygen saturation were used to assess effects. Significant effects were reported but, as only 11 patients in total were involved and blinding could not be fully achieved, these results are preliminary and need further confirmation.

Uncontrolled clinical trials

An open, uncontrolled pilot study included 20 cancer patients with severe breathlessness at rest. They were treated with one acupuncture session, and subsequently 14 patients reported marked symptomatic relief14. The authors concluded that the therapeutic value of acupuncture in the management of breathlessness requires further evaluation. A second small uncontrolled trial involved 10 weekly semi-standardised acupuncture sessions for 12 patients with dyspnoea due to lung cancer27. Mean scores improved at the end of treatment and at 4 week follow-up. Ten patients completed treatment and acupuncture was well-tolerated but the lack of a control group together with a potential confounding effect of the treatment on anxiety means that further confirmation of these reported effects is required.

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 needling17,18. In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record19. 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 reports20.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,21. 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 epilepsy20.

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.

References
  1. BAcC (British Acupuncture Council) website: accessed 23rd July 2018. Top 10 Things to Know is accessible via the homepage
  2. Filshie, J., Cummings, M. Western medical acupuncture. In: Ernst, E., White, A.  (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 31-59.
  3. White A; Editorial Board of Acupuncture in Medicine. Western medical acupuncture: a definition. Acupunct Med. 2009 27(1):33-5.
  4. White A, Ernst E. Introduction. In: Ernst, E., White, A. (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp1-10.
  5. Birch S, Kaptchuk T. History, nature and current practice of acupuncture: an East Asian perspective. In: Ernst, E., White, A.  (Eds). Acupuncture: A Scientific Appraisal. 1999. Butterworth-Heinemann, Oxford. pp 11-30.
  6. Ahn AC, Colbert AP, Anderson BJ, Martinsen OG, Hammerschlag R, Cina S, Wayne PM, Langevin HM. Electrical properties of acupuncture points and meridians: a systematic review. Bioelectromagnetics. 2008 29(4):245-56.
  7. Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Prog Neurobiol 2008; 84(4):355-375.
  8. Molassiotis A, Browall M, Milovics L, Panteli V, Patiraki E, Fernandez-Ortega P. Complementary and alternative medicine use in patients with gynecological cancers in Europe. Int J Gynecol Cancer. 2006 16 Suppl 1:219-24.
  9. Molassiotis A, Fernadez-Ortega P, Pud D, Ozden G, Scott JA, Panteli V, Margulies A, Browall M, Magri M, Selvekerova S, Madsen E, Milovics L, Bruyns I, Gudmundsdottir G, Hummerston S, Ahmad AM, Platin N, Kearney N, Patiraki E. Use of complementary and alternative medicine in cancer patients: a European survey. Ann Oncol. 2005 16(4):655-63.
  10. Rossi E, Vita A, Baccetti S, Di Stefano M, Voller F, Zanobini A. Complementary and alternative medicine for cancer patients: results of the EPAAC survey on integrative oncology centres in Europe. Support Care Cancer. 2015 23(6):1795-806. doi: 10.1007/s00520-014-2517-4.
  11. Ben-Aharon I, Gafter-Gvili A, Paul M et al. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008; 26: 2396-404.
  12. Bausewein C, Booth S, Gysels M et al. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008; 2: CD005623.
  13. Vickers AJ, Feinstein MB, Deng GE et al. Acupuncture for dyspnea in advanced cancer: a randomized, placebo-controlled pilot trial. BMC Palliat Care 2005; 4: 5.
  14. Filshie J, Penn K, Ashley S et al. Acupuncture for the relief of cancer-related breathlessness. Palliat Med 1996; 10: 145-50.
  15. Jobst K, Chen JH, McPherson K et al. Controlled trial of acupuncture for disabling breathlessness. Lancet 1986; 2: 1416-9.
  16. Lewith GT, Prescott P, Davis CL. Can a standardized acupuncture technique palliate disabling breathlessness: a single-blind, placebo-controlled crossover study. Chest 2004; 125: 1783-90.
  17. Coyle ME, Shergis JL, Huang ET, Guo X, Di YM, Zhang A, Xue CC. Acupuncture therapies for chronic obstructive pulmonary disease: a systematic review of randomized, controlled trials. Altern Ther Health Med. 2014; 20(6):10-23.
  18. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
  19. Witt CM, Pach D, Brinkhaus B, Wruck K, Tag B, Mank S, Willich SN. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed. 2009;16(2):91-7.
  20. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
  21. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
  22. BMAS (British Medical Acupuncture Society): Code of Practice, version 9 December 2009. Accessed 23rd July 2018.
  23. Rossi E, Vita A, Baccetti S, Di Stefano M, Voller F, Zanobini A. Complementary and alternative medicine for cancer patients: results of the EPAAC survey on integrative oncology centres in Europe. Support Care Cancer. 2015;23(6):1795-806.
  24. Bausewein C, Booth S, Gysels M, Higginson IJ. WITHDRAWN: Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2013;11:CD005623.
  25. Minchom A, Punwani R, Filshie J, Bhosle J, Nimako K, Myerson J, et al. A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma. Eur J Cancer 2016; 61:102-10pp.
  26. Strong RA, Georges JM, Connelly CD. Pilot Evaluation of Auricular Acupressure in End-Stage Lung Cancer Patients. Journal of palliative medicine. 2016;19(5):556-8.
  27. Bauml J, Haas A, Simone CB, 2nd, Li SQ, Cohen RB, Langer CJ, et al. Acupuncture for Dyspnea in Lung Cancer: Results of a Feasibility Trial. Integrative cancer therapies. 2016;15(3):326-32.

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