Acupuncture for fatigue | Cam-Cancer

Acupuncture for fatigue

Abstract and key points

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 conditions. 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 from seven systematic reviews are either contradictory or too methodologically weak to allow firm conclusions about the effectiveness of acupuncture for cancer-related fatigue. There is only preliminary evidence for transcutaneous electrical acupoint stimulation and infrared laser moxibustion from one trial, respectively.

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.

Document history

Summary last revised and updated in July 2019 by Karen Pilkington.
Summary fully revised and updated in December 2015 by Karen Pilkington.
Summary first published in March 2013, authored by Edzard Ernst.

Citation

Karen Pilkington, Edzard Ernst, CAM-Cancer Consortium. Acupuncture for fatigue [online document]. July 10th, 2019.

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’) 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 likely to be influenced through effects on neurotransmitters, such as musculoskeletal pain and nausea and vomiting3,7.

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 patients8,9Acupuncture was the therapy most frequently provided by integrative oncology centres across Europe, being provided by 55% of 47 centres10 .

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. For regulation of acupuncture in European countries please visit the CAM Regulation website.

Cost and expenditures

In many European countries, the cost of acupuncture ranges between EUR 35 and 95 for the first session (60-90 mins) and EUR 35-75 for ordinary appointments of 30-60 mins. One series of treatments would normally comprise 5-20 sessions. Please see CAM Regulation for coverage of cost by public health insurers across Europe.

Does it work?

Seven systematic reviews of acupuncture/acupressure for cancer-related fatigue report contradictory results, particularly when acupuncture is compared against sham, and several reviews are too methodologically weak to allow firm conclusions.

There is only preliminary evidence for transcutaneous electrical acupoint stimulation and infrared laser moxibustion from one trial, respectively.

Acupuncture/acupressure

Seven systematic reviews of trials of acupuncture for cancer-related fatigue have presented mixed conclusions11-17. While the methods used differed, a similar set of clinical trials were selected for these reviews and this included a number of feasibility studies and pilot trials. Several meta-analyses have been carried out involving similar but not identical sets of studies. The two earlier meta-analyses both reported some positive findings but the results were mixed in the first11 and, in the second12 the only significant difference was between acupuncture plus education intervention versus usual care; however no significant difference were found between acupuncture and sham acupuncture, or between acupuncture and no treatment or wait-list control, or between acupuncture and acupressure or self-acupuncture.

One of the two most recent meta-analyses combined results of acupuncture and acupressure (7 RCTs, 462 patients) against all controls and found no significant difference nor a difference between acupuncture and control16 .The other claimed that acupuncture is effective but several of the trials in the meta-analysis were at high risk of bias and the methods themselves were questionable17.  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 this12,17.

Systematic reviews which did not include a meta-analysis concluded that the results were, at best, inconclusive14,15.

A further systematic review focused on the quality of acupuncture interventions in fatigue trials suggested that the dose used is suboptimal and the heterogeneity of the interventions adds to the lack of conclusive evidence13.

In addition to the RCTs included in the systematic reviews, one small (n=28) pilot study was published after the most recent systematic review#ref1818. While beneficial effects of acupuncture compared with sham were indicated, the main aim of the study was to assess feasibility and compliance. Both were demonstrated but further appropriately powered studies are needed to confirm these preliminary findings.

Other forms of acupoint stimulation

Transcutaneous electrical acupoint stimulation (TEAS) and infrared laser moxibustion have also been assessed in RCTs19,20. TEAS involves electrical, non-invasive stimulation of acupoints (as opposed to electroacupuncture which involves needling). Positive results were reported in one RCT (n=162) for TEAS when compared to a sham or usual care but further confirmation of the results from this single study is required19. The second trial (n=78) used an innovative intervention: moxibustion combined with an infrared laser device20. Further trials would also be required to confirm results from this single centre, small trial.

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 needling22,23Most commonly reported problems are local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%)23.  In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record24. 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 reports25.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy1,26 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 epilepsy26.

Warnings

Recommendations from the US National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology in 2017 indicate that “oncology acupuncture” is a specialty area of practice27. Specific concerns include higher risks of infection and bleeding due to neutropenia and thrombocytopenia and possibility for hemodynamic instability due to dehydration and malnutrition. It was proposed that clinical practice guidelines are followed that take into account lab values such as absolute neutrophil and platelet counts.

References
  1. BAcC (British Acupuncture Council) website. Ten Top Things to Know. Available online. Accessed 2nd July 2019.
  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.
  11. He, X. R., Q. Wang and P. P. Li. Acupuncture and moxibustion for cancer-related fatigue: a systematic review and meta-analysis. Asian Pac J Cancer Prev 2013 14(5): 3067-3074.
  12. Zeng, Y., T. Luo, J. Finnegan-John and A. S. Cheng. Meta-Analysis of Randomized Controlled Trials of Acupuncture for Cancer-Related Fatigue. Integr Cancer Ther 2013 13(3): 193-200.
  13. Grant, S. J., C. A. Smith, N. de Silva and C. Su. Defining the Quality of Acupuncture: The Case of Acupuncture for Cancer-Related Fatigue. Integr Cancer Ther 2015 14(3): 258-270.
  14. Posadzki, P., T. W. Moon, T. Y. Choi, T. Y. Park, M. S. Lee and E. Ernst. Acupuncture for cancer-related fatigue: a systematic review of randomized clinical trials. Support Care Cancer 2013 21(7): 2067-2073.
  15. Ling, W. M., L. Y. Lui, W. K. So and K. Chan. Effects of acupuncture and acupressure on cancer-related fatigue: a systematic review. Oncol Nurs Forum 2014 41(6): 581-592.
  16. Duong N, Davis H, Robinson PD, Oberoi S, Cataudella D, Culos-Reed SN, et al. Mind and body practices for fatigue reduction in patients with cancer and hematopoietic stem cell transplant recipients: A systematic review and meta-analysis. Critical reviews in oncology/hematology. 2017;120:210-6.
  17. Zhang Y, Lin L, Li H, Hu Y, Tian L. Effects of acupuncture on cancer-related fatigue: a meta-analysis. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 2018;26(2):415-25.
  18. Cheng CS, Chen LY, Ning ZY, Zhang CY, Chen H, Chen Z, et al. Acupuncture for cancer-related fatigue in lung cancer patients: a randomized, double blind, placebo-controlled pilot trial. Supportive care in cancer. 2017;25(12):3807‐14
  19. Hou L, Zhou C, Wu Y, Yu Y, Hu Y. Transcutaneous electrical acupoint stimulation (TEAS) relieved cancer-related fatigue in non-small cell lung cancer (NSCLC) patients after chemotherapy. Journal of thoracic disease. 2017;9(7):1959‐66.
  20. Mao H, Mao JJ, Guo M, Cheng K, Wei J, Shen X, et al. Effects of infrared laser moxibustion on cancer-related fatigue: a randomized, double-blind, placebo-controlled trial. Cancer. 2016;122(23):3667‐72
  21. White A, Hayhoe S, Ernst E. Survey of Adverse Events Following Acupuncture Acupunct Med. 1997; 15:67-70.
  22. 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 Apr;16(2):91-7.
  23. Melchart D, Weidenhammer W, Streng A., et al. Prospective investigation of adverse effects of acupuncture in 97 733 patients. Arch Intern Med. 2004;1641:104–105.
  24. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004; 22(3):122-123.
  25. Ernst E. Deaths after acupuncture: a systematic review. Int J Risk Safety 2010; 22(3):131-136.
  26. BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 9 December 2009. Available online. Accessed 2nd July 2019.
  27. Zia FZ, Olaku O, Bao T, et al. The National Cancer Institute's Conference on Acupuncture for Symptom Management in Oncology: State of the Science, Evidence, and Research Gaps. J Natl Cancer Inst Monogr. 2017;2017(52).

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