Effectiveness of Acupuncture Modalities for Cancer-Related Sleep Disturbance

People with cancer experience difficulties with many bodily systems. Sleep disturbance is nearly 3 times more prevalent in patients with cancer (36% to 59%) than in the general population. Acupuncture and acupressure have been used to manage treatment-related side effects such as fatigue, pain, nausea, and vomiting.

Denise Shuk Ting Cheung, BNurs, PhD, RN, and colleagues at the University of Hong Kong, undertook a systematic review and Bayesian network meta analysis to explore the effectiveness of these modalities on sleep in patients with cancer. 

For this analysis, acupressure was defined as applying mechanical pressure on body acupoints or auricular points using fingers, vaccaria seeds, magnetic beads, or other devices; manual acupuncture as inserting acupuncture needles at acupoints on the body (body acupuncture) or on the ear lobe (auricular acupuncture); and electroacupuncture as using an electro stimulator to deliver weak electrical current to body acupoints via pairs of electrodes attached to the handle of inserted needles.

Sham acupuncture resembles acupuncture but pressure or stimulation is applied to nonacupoints or acupoints not relevant to the intended results. It is often used in double-blind studies to control for nonspecific effects of acupuncture treatment in research.

Acupoints are specific points on the body — on the skin surface or underneath — at which physiologic and/or bodily dysfunction are believed to be reflected. Manipulation of acupoints may release substances or incur changes that adjust dysfunction, maintaining homeostasis.² Traditional Chinese medicine (TCM) theory centers on stimulation of acupoints as the mechanism of acupuncture and acupressure to restore health and treat disease.

In this analysis, the researchers searched 6 key English databases (PUBMED, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, DINAHL, and Sociological Abstracts) and 2 important Chinese databases (Wanfang and China National Knowledge Infrastructure). Search terms were related to cancer (cancer, tumor, neoplasm, malignant), modality (acupuncture, acupressure, acupoint, electroacupuncture), and type of study (randomized controlled trial, clinical trial).

Some studies often embed sleep in the quality-of-life assessments, so initial searches were not limited to sleep. Complete reports of randomized clinical trials describing acupuncture or acupressure used for sleep in adults (older than 18 years) who had cancer were included.

Inclusion criteria were trials on acupuncture — manual, auricular or electroacupuncture — or acupressure — body acupressure or auricular acupressure — as the only intervention or used along with another standard treatment. Type of cancer or stage of treatment were not limited. Trials that combined acupuncture or acupressure with treatments such as herbal medicine or massage were not included in this analysis.

Six categories of study arms were identified: acupressure, manual acupuncture, electroacupuncture, enhanced supportive care, no treatment, and sham.

Twenty-eight studies met the inclusion criteria. Sample sizes ranged from 30 to 288 participants, and 14 studies focused on patients with breast cancer. Most studies were conducted in China (East Asia) and the United States (western countries).

Acupuncture

Six studies tested manual acupuncture: 5 tested body acupuncture and 1 tested auricular acupuncture. Three studies tested electroacupuncture. During the testing, participants received acupuncture once or twice a week over a 4- to 12-week period. The shortest intervention period was 30 days, and the longest intervention period was 6 months.

The control group interventions were wait list control, usual care, drug treatment, sham acupuncture, and sham electroacupuncture.

Acupressure

The remaining 19 trials tested acupressure: 9 tested auricular acupressure and 10 tested body acupressure. Auricular acupressure was self-administered by patients massaging acupoints on their external ears where vaccaria seeds, magnetic pellets, or crystal pellets were taped on.

In half of the studies on body acupressure, researchers, nurses, or practitioners administered the intervention. In the other studies, participants were taught to self-administer acupressure by the instructors. Self-administered acupressure sessions were performed 2 to 3 times a day for 2 to 6 weeks.

The most common control group interventions were usual care and sham acupressure.

Conclusions

Standardized mean differences were greatest for acupressure (−2.67; 95% credible interval [CrI], −3.46 to −1.90), followed by acupuncture (SMD, −1.87; 95% CrI, −2.94 to −0.81) and electroacupuncture (SMD, −1.60; 95% CrI, −3 to −0.21) compared with enhanced supportive care.

In comparison with no treatment, a significant effect was observed only with acupressure (SMD, −1.06; 95% CrI, −1.70 to −0.42). No significant effect was observed with acupuncture or electroacupuncture.

None of the interventions were significantly better than sham, with all SMDs within 95% CrI.

Comparisons between control interventions showed sham had a better effect than did enhanced supportive care (SMD, −1.99; 95% CrI, −2.95 to −1.06), as did no treatment (−1.61; 95% CrI, −2.54 to −0.69).

The results of this study demonstrated that acupressure, manual acupuncture, and electroacupuncture were more effective than enhanced supportive care in improving sleep disturbance in patients with cancer, with acupressure the most effective of the 3 modalities. However, the researchers suggest that more rigorous trials are needed to confirm whether different forms of acupuncture or acupressure have different effects on sleep disturbance in these patients.

References

1. Cheung DS, Xu X, Smith R, et al. Invasive or noninvasive? A systematic review and network meta-analysis of acupuncture and acupressure to treat sleep disturbance in cancer patients. Worldviews Evid Based Nurs. Published online December 21, 2022. doi:10.1111/wvn.12617
2. Li F, He T, Xu Q, et al. What is the acupoint? A preliminary review of acupoints. Pain Med. 2015;16(10):1905-1915. doi:10.1111/pme.12761