Acupuncture for fatigue

Description of included studies

Acupuncture/acupressure

A total of 12 systematic reviews have focused on acupuncture or interventions including acupuncture for cancer-related fatigue (Table 1).

Seven systematic reviews published up to 2018 presented mixed conclusions (He 2013, Zeng 2013, Grant 2015, Posadzki 2013, Ling 2014, Duong 2017, Zhang 2018). 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  reported some positive findings but the results were mixed in the first (He 2013) and, in the second (Zeng 2013) 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. Systematic reviews not including a meta-analysis concluded that the results were, at best, inconclusive (Posadzki 2013, Ling 2014).

One of the two more 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 control (Duong 2017) . 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 questionable (Zhang 2018).  There was a suggestion of a possible benefit from using acupuncture as an adjuvant therapy but, because of lack of blinding, it was not possible to confirm this (Zeng 2013, Zhang 2018). 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 evidence (Grant 2015).

Five systematic reviews published since 2018 include two that covered a range of interventions for cancer-related fatigue, two that assessed acupuncture for various side effects including fatigue and one that focused specifically on acupuncture for cancer-related fatigue.

Two of the reviews included the same four RCTs but came to different conclusions on effectiveness: one suggested moderate improvements and the other no significant differences (Pan 2018; Yuangqing 2020). Assessments of the quality of the evidence also differed.  One review included only one trial of acupressure (n=43) (Vannorsdall 2020) while the number of trials was not reported in the network meta-analysis (Wu 2019). Both reported positive results with the network meta-analysis rating acupuncture alongside cognitive behavioural therapy as the most effective interventions of those compared.

The remaining systematic review included 9 RCTs with 809 participants (Jang 2020). Six trials were low risk of bias and three at moderate risk. Acupuncture was reported to have potential benefit in cancer-related fatigue with Brief Fatigue Inventory scores 0.93 points lower 95% CI (−1.65, −0.20) in true acupuncture versus sham acupuncture and 2.12 points lower 95% CI (−3.21, −1.04) in true acupuncture versus usual care. While there was a statistically significant difference between true and sham acupuncture, the clinical significance of a 0.93 point reduction on an 11 point scale is not clear. The larger difference between acupuncture and usual care may be due to lack of blinding together with a self-reported subjective outcome.

Four RCTs have been published subsequently, three of which assessed acupressure and one which assessed acupuncture. Details of these trials are presented in Table 2. Overall, the results of these trials do not significantly add to the evidence from the systematic reviews.

Other forms of acupoint stimulation

Transcutaneous electrical acupoint stimulation (TEAS) and infrared laser moxibustion have also been assessed in RCTs (Hou 2017, Mao 2016). 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 required (Hou 2017).

The second trial (n=78) used an innovative intervention: moxibustion combined with an infrared laser device (Mao 2016). Further trials would also be required to confirm results from this single centre, small trial.

References