Acupuncture for breathlessness | Cam-Cancer

Acupuncture for breathlessness

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. Many providers advocate it for a wide range of conditions and symptoms, including cancer-related breathlessness.
  • Few trials have been carried out and the findings of systematic reviews are based on one or more of these trials.
  • Two randomised controlled trials (RCT) of acupuncture, an RCT of acupressure and a small randomised pilot study of acupressure are available.
  • These have not demonstrated a clear effect of acupuncture on breathlessness as results have been non-significant or the clinical significance is unclear.
  • One trial suggested possible beneficial effects of acupuncture in reducing morphine requirements and reducing anxiety related to breathlessness. These preliminary findings 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.

Citation

Karen Pilkington, Edzard Ernst and the CAM Cancer Consortium. Acupuncture for breathlessness [online document], February 15, 2021

Document history

Revised and updated in February 2021 by Karen Pilkington.
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.

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 acus, ‘needle’ (noun), and pungere, ‘to prick or puncture’ (verb).

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.

Background and prevalence

The history of acupuncture can be traced to ancient China and its Taoist philosophy (White 1999). 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 (Birch 1999). 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 (Birch 1999). 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 (White 1999). 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.

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, for example, acupuncture was used by up to 17% of gynaecological cancer patients (Molassiotis 2006, Molassiotis 2005). Acupuncture was the therapy most frequently provided by integrative oncology centres across Europe, being provided by 55% of 47 centres (Rossi 2015).

Application and providers

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 (BAcC  2019). 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’ (Filshie 1999, White 2009).

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 (White 2009,  Zhao 2008).

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 (Ahn 2008). 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 (Zhao 2008).

Legal issues and cost

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. Information on the regulation of acupuncture in European countries can be found on websites such as that of the European Traditional Chinese Medicine Association (ETCMA).

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. See the ETCMA website (above) for coverage of cost by public health insurers across Europe. 

Does it work?

No systematic reviews have focused specifically on acupuncture for breathlessness due to cancer. One systematic review focuses on acupuncture for breathlessness due to various disease states including cancer (van Trott 2020). Three systematic reviews that assessed acupuncture for breathlessness in cancer alongside other interventions have found insufficient evidence for firm conclusions (Ben Aharon 2008, Bausewein 2008, Dy 2020. Few trials have been carried out and the findings of systematic reviews are based on one or more of these trials.

  • Two randomised controlled trials (RCT) of acupuncture (Minchom 2016, Vickers 2005), an RCT of acupressure (Dogan 2020) and a small randomised pilot study of acupressure (Strong 2016) are available.
  • These have not demonstrated a clear effect of acupuncture on breathlessness as results have been non-significant or the clinical significance is unclear.
  • One trial suggested possible beneficial effects of acupuncture in reducing morphine requirements and reducing anxiety related to breathlessness. These preliminary findings require further confirmation.

Description of included systematic reviews of acupuncture/acupressure

One systematic review has been published that focuses on acupuncture for breathlessness in diseases including cancer (von Trott et al 2020). Searches were carried out up to 2019 and 12 studies were found, only two of which were in cancer. As results of trials in conditions other than cancer were merged with those in cancer, it is difficult to interpret the results. The two cancer trials only contributed to one analysis and, although the results favoured acupuncture compared with control, there was a very high degree of heterogeneity. Each of the two trials in question (Vickers 2005; Minchom 2016) is discussed in more detail below.

Three reviews have assessed acupuncture along with other interventions for breathless in advanced cancer. 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 (Vickers 2005 as described below). Both reviews concluded that there was not enough evidence to recommend the routine use of acupuncture/acupressure. One of these (Bausewein 2008) was a Cochrane review and the planned update has now been withdrawn (Bausewein 2013). The second review (Ben-Aharon 2008) has been updated but the more recent version of the review does not mention acupuncture (Ben-Aharon 2013).

The third systematic review that includes acupuncture is a comparative effectiveness review of interventions for breathlessness in patients with advanced cancer published by the US Agency for Healthcare Research and Quality (Dy 2020). It has also been published as a journal paper (Gupta 2020). This review refers to three trials of acupuncture and/or acupressure.  The first was a trial of acupuncture versus sham acupuncture (Vickers 2005 as described below) which was judged to provide insufficient evidence of any effect. The second trial mentioned was a trial of acupressure versus usual care (Dogan 2020 as described below). Results of this trial were combined with those of a trial of reflexology, therefore, the conclusion of low evidence of an improvement compared with usual care is difficult to interpret. The third trial included in this review was a 3-armed trial of acupuncture, morphine and combined acupuncture plus morphine (Minchom 2016 as described below). This was judged to provide insufficient evidence due to study limitations and imprecise results.

Description of included RCTs of acupuncture

One RCT involved the treatment of 47 patients suffering from advanced breast or lung cancer and breathlessness (American Thoracic Society Breathlessness score 2 or higher) (Vickers 2005). They received a single session of real or sham acupuncture (needling at non-specific points) in addition to standard drug treatments. Semi-permanent studs were subsequently inserted for twice daily self-treatments. Follow-up was one week. Forty-five patients were followed up using a 0-10 breathless scale. 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. The methodology including allocation and blinding was rigorous.

In a subsequent RCT, acupuncture was compared with morphine and with acupuncture combined with morphine (Minchom 2016). 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. A subsequent conference abstract suggested that acupuncture had an anxiolytic effect in this situation (Minchom 2017)

Description of included RCTs of acupressure

Auricular acupressure involving application of Vaccaria segetalis (a small seed) to the ear, was assessed in a small 3-arm randomised pilot study (Strong 2016). 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.

A recent trial conducted in a university hospital in Turkey compared acupressure to usual care in 60 patients with advanced lung cancer (Dogan, 2020). Acupressure was applied twice daily for 4 weeks by patients after an initial instruction session. A modified Borg scale and the St George’s Respiratory Questionnaire were used to measure effects along with walking distance before and after the 6-minute walk test. A statistically significant between group difference was reported in median breathlessness scores, both before a 6 minute walking test (p=0.004) and after a 6 minute walking test (p=0.018). It is unclear if the difference was clinically relevant. Trial methods were rigorous but acupressure was self-administered and blinding was not possible.

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 (Coyle 2014, White 1997, Witt 2009). Most commonly reported problems are local pain (3.3%), bruising (3.2%), minor bleeding (1.4%), and orthostatic problems (0.5%) (Melchart 2004).   In addition, in rare cases complications due to tissue trauma, pneumothorax, cardiac tamponade or infection are on record (White 2004). 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 (Ernst 2010).

Safety incidents have been assessed that were linked to acupuncture treatments received in a healthcare setting (UK National Health Service) (Wheway 2012). The 325 incidents over a 3 year period included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse reactions (12%). The majority (95%) of the incidents were categorised as low or no harm.

Contraindications

Professional bodies for acupuncture vary somewhat in defining contraindications, particularly in relation to pregnancy (BAcC 2019, BMAS 2019). 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 (Filshie 1999).

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.

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 practice (Zia 2017). 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

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BAcC (British Acupuncture Council) website: accessed 15th February 2021. Top 10 Things to Know is accessible via the homepage.

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.

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.

Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol. 2012 Nov;51(8):996-1008. doi: 10.3109/0284186X.2012.709638. Epub 2012 Aug 30. PMID: 22934558.

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BMAS (British Medical Acupuncture Society): Code of Practice, version 10 August 2018. Accessed 26th January 2021.

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