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. In contrast, most Western acupuncturists follow the principles of conventional medicine and would employ acupuncture only for specific conditions and symptoms, including cancer-related fatigue, particularly as some preliminary studies suggested beneficial effects.

  • Even though some positive evidence exists, the published data from twelve systematic reviews are either contradictory or too methodologically weak to allow firm conclusions about the effectiveness of acupuncture or acupressure for cancer-related fatigue.
  • Reported differences in effect between true acupuncture and sham have been less convincing than the differences in effect between acupuncture and usual care.
  • 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], http://cam-cancer.org/en/acupuncture-fatigue. June 3, 2021.

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 costs

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?

Twelve 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. Where positive results are reported, the differences between true and sham acupuncture are smaller than between acupuncture and usual care. This may be due to lack of blinding and a subjective outcome.

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

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 both 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.

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 (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.

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BMAS (British Medical Acupuncture Society). Code of Practice & Complaints Procedure. Version 10 2018. Available online. Accessed 24th February 2021.

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