Synonyms/Common Names/Related Substances:

• Acupoints stimulation, acupressure point K-D2, acustimulation, aromatic acupressure, Asian bodywork therapy, auricular acupressure, automated massage chair, barefoot shiatsu, Bodymind Acupressure™, finger acupressure, five element shiatsu, G-Jo acupressure, high touch acupressure, integrative eclectic shiatsu, Japanese shiatsu (aka Nippon shiatsu or Namikoshi shiatsu), Jin Shin acupressure, Jin Shin acutouch, Jin Shin Do®, Ki-shiatsu®, Korean hand acupressure, Korean hand acupressure point K-D2, macrobiotic shiatsu, Namikoshi shiatsu, nei-guan, neikuan, Nippon shiatsu, ohashiatsu, Oriental bodywork therapy, P6, P-6, Sea-Band®, seitei shiatsu, shiatsu anma therapy, Tao shiatsu, Tapas Acupressure Technique™, traditional Chinese medicine, tui na, tuina (tui na), tuina massotherapy, vaginal acupressure, Watsu™, Wu Shu, zen shiatsu.
• Not included in this review: Acupuncture, acutherapy, AMMA® Therapy, ampaku, Ampuku® therapy, anma (aka Amma), anmo (aka An-mo or An Mo), Ayurvedic (Marma) massage therapy, Chi Nei Tsang, Chinese reflexology, Hoshino Therapy®, Indian head massage, Jin Shin Jyutsu®, Kerala Kalari Massage, Okazaki restorative massage, point holding, Qi Gong Massage, SHEN® Therapy, Taoist pressing point massage, Tibetan massage (Ku Nye), Tibetan pulsing, and traditional Thai massage (aka Nuad Bo Rarn).

Clinical Bottom Line/Effectiveness

Brief Background:

• The practice of acupressure originated in traditional Asian medicine 5,000 years ago, predating the practice of acupuncture. Acupressure works with the same body points and meridians as acupuncture, but stimulates the sites with finger pressure rather than by fine needles. Traditionally, acupressure is directed to 14 meridians and 2,000 specific charted points all over the body. Today, acupressure is used in the prevention and treatment of many illnesses of both mind and body.
• Shiatsu means finger (shi) pressure (atsu) in Japanese. Shiatsu technique involves finger pressure at acupoints and along body meridians. It can incorporate palm pressure, stretching, and other manual techniques. Shiatsu practitioners commonly treat musculoskeletal and psychological conditions, including neck, shoulder, and lower back problems, arthritis, depression, and anxiety. Tuina (Chinese for "pushing and pulling") is similar to shiatsu but with more soft-tissue manipulation and structural realignment, via pressing, tapping, or kneading. Tuina is a common form of Asian bodywork used in Chinese-American communities.
• There is strong scientific evidence in support of acupressure's efficacy in the prevention and treatment of acute nausea of diverse etiology in both adult and pediatric populations: postoperative, intraoperative, chemotherapy-induced, and pregnancy-related (morning sickness).
• There is promising early evidence for the use of acupressure in the improvement of sleep and exercise performance, and in the treatment of pain (lower back and postoperative), headaches, paralysis (poststroke), pediatric enuresis, pediatric epilepsy, cerebral birth injuries in infants, menstrual concerns, respiratory disorders, and Parkinson's Disease. Although evidence is currently inconclusive, research suggests that acupressure may not be effective in the direct treatment of obesity, but may help to maintain weight loss.
• Acupressure can be a cost-effective treatment and is generally well tolerated when the appropriate amount of force is used. Those considering acupressure treatment should speak with a health care provider prior to beginning treatment.

Quality of Scientific Evidence:

Indication	Evidence Grade
Nausea (of various etiologies)	A
Anxiety	B
Pain (general)	B
Agitated behavior (in dementia)	C
Alertness	C
Asthma (quality of life)	C
Chronic obstructive pulmonary disease (COPD)	C
Depression	C
Drug addiction	C
Dysmenorrhea	C
Dyspnea (shortness of breath)	C
Enuresis (children)	C
Epileptic seizure (children)	C
Exercise performance	C
Facial spasm	C
Gastrointestinal motility	C
Headache	C
Hypertension	C
Pain (fracture)	C
Pain (labor)	C
Pain (lower back)	C
Pain (neck)	C
Pain (post-operative)	C
Pain (shoulder)	C
Palliative care	C
Parkinson's disease	C
Sexual dysfunction	C
Sleep apnea	C
Sleep quality	C
Smoking cessation	C
Stroke	C
Cervical spondylosis	D
Weight loss/obesity	D

Historical or Theoretical Uses That Lack Sufficient Evidence:

• Abuse (sexual, physical, psychological), angina, anorexia nervosa, apoplectic hemiplegia, arthritis, asthma, attention deficit hyperactivity disorder, Bell's palsy, bloating (after surgery), cancer treatment (for children), cancer treatment side-effects (other than nausea), carpal tunnel syndrome, cerebral birth injuries (infants) (1), childbirth facilitation/induction, chronic fatigue syndrome, colds/flu, congestion, constipation, cosmetic uses, dementia, edema, emotional problems, eye strain, fatigue, fibromyalgia, gag reflex abnormalities (for during dental procedures) (2), gastrointestinal disorders, gum disease, head injury, HIV/AIDS, hyperactivity, immune deficiency, intervertebral disc prolapse, itchiness, jet lag, joint inflammation, kidney disease (4), kidney infection (related pain), menopausal pain, multiple sclerosis, muscle tension/ache, optic atrophy, organ transplantation, phobias, poor circulation, post-herpetic neuralgia (3), post-traumatic stress disorder (PTSD), psoriasis, recurrent urinary tract infection, restless leg syndrome, Rett syndrome, sickle cell anemia pain (5), sinus problems, sports injuries, stress (6), sunburn pain, tendonitis, toothache, ulcer pain, weight gain (premature infants) (7).

Strength of Expert Opinion and Historic/Folkloric Precedent:

• Experts believe the practice of acupressure originated in traditional Asian medicine approximately 5,000 year ago. Today, acupressure therapies are growing in popularity in the United States and Europe and are widely practiced both professionally and informally throughout Asia for relaxation, wellness promotion, and the treatment of disease.
• A nationwide survey in the United Kingdom found that shiatsu practitioners most commonly treated musculoskeletal and psychological conditions (8).
• The majority of acupressure interventions are conducted by nurses in clinical trials (9). Integrating tuina acupressure into a holistic nursing practice has also been discussed by Dune (10).
• In Denmark, a combination of shiatsu, acupuncture, and lifestyle adjustments resulted in significant ($12,000) economic savings in angina patients over two years (11).

Brief Safety Summary:

• Likely safe: Acupressure is generally reported as a safe procedure when performed by an experienced practitioner. Reports of serious complications are lacking in the available literature, despite millions of treatments conducted every year. Self-administered acupressure is also considered to be likely safe with proper education and training of technique.
• Possibly unsafe: When acupressure bands are applied too tightly (12;​13;​14;​15). When used in patients who are hypotensive or are on antihypertensive medication, as acupressure may lower blood pressure. When used in patients taking CNS depressants or those driving or operating machinery, as acupressure may cause sedation and relaxation.
• Likely unsafe: When used in patients at risk for arterial dissection or nerve injury (16;​17;​18;​19).
• Note: A doctor or other qualified health care provider should be consulted prior to beginning treatment.

Dosing/Toxicology

Definition:

• Acupressure is an ancient healing art that uses finger pressure along predefined "acupuncture points" and "meridians."
• Shiatsu is a Japanese word which translates as finger (shi) pressure (atsu).
• A "local point" is a location where there is tension or pain in the body.
• In acupressure treatment, a trigger point is a distal point which, when stimulated, affects the local point.
• In acupressure treatment, a tonic point is a point thought to strengthen the body overall.
• In traditional acupressure practice, meridians are believed to be pathways that connect acupuncture points and the internal organs of the body. They are thought of as "master communication pathways" that circulate electrical energy. In shiatsu, a "tsubo" is an access point or gateway to the flow of energy in a meridian.
• Acupressure treatment is characterized by the pressing of acupuncture points and the manipulation of qi (20). Qi refers to the natural life-energy of the universe.
• The broad term acupuncture includes, but is not limited to, acupressure (21).

Therapeutic Technique:

• Firm pressure: A fundamental technique which uses thumbs, fingers, palms, the sides of the hands, or knuckles to apply steady stationary pressure.
• Slow motion kneading: Uses the thumbs, fingers, and the heels of the hands to squeeze large muscle groups firmly.
• Brisk rubbing: Uses friction to "stimulate blood and lymph."
• Quick tapping: Uses the fingertips to stimulate muscles on tender areas of the body (e.g., the face).
• Gentle holding: A technique of Jin Shin acupressure, which uses the whole hands with gentle pressure from the fingers.
• In traditional practice, there are 2,000 acupressure points on the body, each defined by a name and/or number.
• In the prevention and treatment of nausea, studies have focused on the use of three acupoints: P6 on the wrist, ST36 on the upper leg, and K-K9 on the fourth finger.
• Unlike contemporary Western massage, traditional acupressure does not involve the application of oils on the skin (though other forms, such as Ayurvedic, may). Treatments are typically given through the clothes.
• Practitioners may additionally teach or recommend to their patients particular exercises, self-administered acupressure, counseling, diet changes, herbal medicine, spiritual improvements, or other lifestyle changes.

Types of Therapies:

• Acupressure: The practice of applying finger pressure to specific acupoints throughout the body. Acupressure has been most widely studied with respect to pressure at P6 at the wrist for control of nausea. Auricular acupressure involves stimulating specific acupoints on the ear, noninvasively, through the application of seeds adhered to the surface of the ear, or the use of other devices. There is a lack of evidence from randomized controlled trials involving full-body acupressure treatments; however, one published case series has been identified (22).
• Shiatsu (Japanese for "finger pressure"): Shiatsu is a Japanese form of acupressure which, typically, emphasizes finger pressure not only on acupoints but along the meridian as a whole, and can also incorporate palm pressure, stretching, and other manual techniques. There is a lack of evidence from randomized controlled trials involving shiatsu; however, two published case series have been identified (23;​24).
• Tuina (Chinese for "pushing and pulling"): Tuina is a Chinese form of Asian bodywork therapy, similar to shiatsu but with a greater emphasis on soft-tissue manipulation and structural realignment methods. Tuina is the most common form of Asian bodywork practiced in Chinese-American communities. Although there is a lack of evidence from randomized controlled trials involving Tuina, one published case series has been identified (25).
• Traditional Thai Massage: Thai massage consists of a set series of acupressure, passive body movements and stretches. It is an integration of Indian Buddhist medicine and traditional Chinese medicine, and incorporates a spiritual dimension in its approach. There is a lack of evidence from randomized controlled trials involving this modality.
• Ayurvedic Massage: Ayurvedic massage is a traditional Indian variation of Asian bodywork therapy, based on the Ayurvedic health system. It involves oiled massage along specific energy lines and points of the body. There is a lack of evidence from randomized controlled trials involving this modality.
• Vaginal acupressure: Vaginal acupressure is generally practiced with great care by an experienced physician and involves stimulation through the vagina to aid with gynecological and sexological problems. There is a lack of evidence from randomized controlled trials involving this modality; however, a pilot study has been identified (26).

Dose/Response:

• Acupressure at the P6 acupoint is most commonly used for nausea, although other acupoints, such as ST36 on the upper leg and K-K9 on the fourth finger, have also been studied. Commercial wristbands with acupressure beads for placement at the P6 acupressure point are also available. Acupressure regimens appearing in the literature have been varied, though no optimal parameters have been identified. In general, the data suggest acupressure reduces nausea only during or immediately following treatment; delayed nausea is not readily prevented. Auricular acupressure has been more commonly studied for pain and anxiety, with some evidence suggesting benefits during treatment, although optimal time length has, again, not been determined.

Precautions/Contraindications

Allergy:

• Those styles of acupressure that feature the application of oils to the skin, such as Ayurvedic massage therapy or aromatic acupressure, may potentially result in allergic skin reactions in certain patients.

Adverse Effects/Post-Market Surveillance:

• General: Severe adverse effects attributed to acupressure are lacking in available clinical trials. Despite a few isolated case reports of adverse effects associated with shiatsu, acupressure is generally recognized as safe. Acupressure bands may occasionally be too tight for the patient (12;​13;​14;​15).
• Musculoskeletal: If applied too vigorously, acupressure could cause bruising in sensitive individuals (theoretical).
• Neurologic/CNS: Nerve injury in the hand was reported in one man following shiatsu (18). A case of shingles, possibly due to nerve trauma, was reported in one woman following an overly vigorous shiatsu treatment (19). Arterial dissection developed in a woman who had undergone shiatsu for five years (16;​17). In a case report, internal jugular vein thrombosis was associated with shiatsu treatment of the neck (27).
• Other: Acupressure bands may occasionally be too tight for the patient (12;​13;​14). Pain, numbness, soreness (15), and hand-swelling (15;​28) have been reported in patients using acupressure wristbands.

Precautions/Warnings/Contraindications:

• Use cautiously in patients who are hypotensive or are on antihypertensive medication, as acupressure may lower blood-pressure.
• Use cautiously in patients taking CNS depressants or those driving or operating machinery, as acupressure may cause sedation and relaxation.
• Acupressure bands should be used cautiously to avoid pain, numbness, soreness, hand-swelling, or other symptoms associated with securing bands too tightly.
• Avoid shiatsu in patients at risk for arterial dissection or nerve injury (16;​17;​18;​19).
• Note: Acupressure is generally reported as safe when performed by an experienced practitioner. Serious complications are lacking in the available literature, despite millions of treatments every year. Self-administered acupressure is believed to be safe with proper training.

Pregnancy & Lactation:

• Acupressure has been used in facilitating childbirth and reducing pain associated with labor (29); however, experts contraindicate specific points during pregnancy due to potential for induced miscarriage (theoretical).
• Acupressure has been used to alleviate nausea and vomiting associated with pregnancy, with apparent significant effect, according to a meta-analysis (30), and without evidence of harm, from clinical trials.
• Evidence from one clinical trial suggested that acupressure was not significantly different from vitamin B6 for treatment of pregnancy-related nausea and vomiting (31).

Interactions

Most herbs and supplements have not been thoroughly tested for interactions with other herbs, supplements, drugs, or foods. The interactions listed below are based on reports in scientific publications, laboratory experiments, or traditional use. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy.

Acupressure/Drug Interactions:

• Analgesics: In human study, acupressure has been shown to reduce pain, including that associated with neuralgia, fracture, muscles, and headache (3;​32;​33;​34;​35;​36).
• Anesthetics: In a meta-analysis by Lee et al. of the treatment of postoperative nausea via acupuncture, of the 19 trials analyzed, the two whose subjects underwent treatment during general anesthesia rather than during the recovery period failed to demonstrate efficacy (37); this lack of effect may extend to wrist-point acupressure (theoretical).
• Antiemetics: In human study, acupressure reduced nausea and vomiting associated with chemotherapy, pregnancy, and operations (30;​38;​39;​40). The effects of acupressure with antiemetic agents are not well understood.
• Antihypertensives: Based on anecdotal reports, acupressure may reduce blood pressure. Theoretically, concurrent use of acupressure with antihypertensive agents may cause additive blood pressure lowering.
• CNS depressants: Acupressure has been shown to promote sleep and relaxation and relieve dyspnea (35;​41;​42;​43;​44;​45;​46). Concurrent use of acupressure with CNS depressants may cause additive sedative and relaxant effects.
• Gastrointestinal agents, prokinetic: In human study, acupressure was observed to increase gastrointestinal motility (47).

Acupressure/Herb/Supplement Interactions:

• General: In traditional Chinese and Japanese medicines, herbal remedies are often combined with mind-body therapies (including acupressure). Aromatic essential oils are also occasionally used in combination with acupressure (48).
• Analgesics: In human study, acupressure reduced pain, including that associated with neuralgia, fracture, muscles, and headache (3;​32;​33;​34;​35;​36).
• Antiemetics: In human study, acupressure reduced nausea and vomiting associated with chemotherapy, pregnancy, and operations (30;​38;​39;​40). The effects of acupressure with antiemetic agents are not well understood.
• Flavanones: In human study, auricular acupressure increased absorption of the flavanones naringenin and hesperetin from Citrus aurantium (49).
• Gastrointestinal herbs and supplements: In human study, acupressure was observed to increase gastrointestinal motility (47).
• Hypotensives: Based on anecdotal reports, acupressure may reduce blood pressure. Theoretically, concurrent use of acupressure with antihypertensive agents may cause additive blood pressure lowering.
• Sedatives: Acupressure has been shown to promote sleep and relaxation and relieve dyspnea (35;​41;​42;​43;​44;​45;​46). Concurrent use of acupressure with CNS depressants may cause additive sedative and relaxant effects.

Acupressure/Food Interactions:

• Insufficient available evidence.

Acupressure/Lab Interactions:

• Blood pressure: Based on anecdotal reports, acupressure may reduce blood pressure.

Acupressure/Nutrient Depletion:

• Flavanones: In human study, auricular acupressure increased absorption of the flavanones naringenin and hesperetin from Citrus aurantium (49).

Mechanism of Action

Theories and Expert Opinion:

• According to traditional Chinese and Japanese medical philosophies, health is considered as a state of balance in the body, maintained by the flow of life energy (chi, qi, or ki) along specific meridians. The philosophy that disease is caused by imbalance has led to treatments directed at establishing balance through the manipulation of points along these meridians.
• This principle is reflected in many traditional health systems of other Asian countries. In these health systems, a disease state is believed to occur when there is a blockage in the flow of energy, or if energy flow is deficient or in excess. Acupressure aims to restore normal flow of life energy by means of finger pressure, palm pressure, stretching, and other techniques. Traditionally, acupressure practitioners have taught that there are 12 primary channels and eight additional pathways that circulate life energy through the body, maintaining the balance of yin and yang.
• Acupressure is believed to release muscle pain and tension, increase circulation, and release endorphins. As a point is pressed, experts report that the muscle tension yields to the finger pressure, enabling the fibers to elongate and relax, allowing for blood to flow freely and toxins to be released and eliminated.
• Owing to their similarity, it has been suggested that growing understanding of the effects and mechanisms of acupuncture may be applicable to acupressure. Stimulation of acupoints, whether with needles, moxa, or fingers, would theoretically evoke similar or identical mechanisms.
• Likewise, acupressure techniques which involve the manipulation of soft tissues may have a similar or identical mechanism of action as therapeutic massage.
• In a review by Ma et al., it was calculated that 97.2% of acupressure clinical trials found acupressure to deliver positive benefits; however, upon the removal of very low-quality studies and unspecific caring scope, less than half of the articles remained, suggesting the need for better-quality research (9).
• Traditional Asian medicine, including acupressure, has been reviewed by Yu et al. (50), while the practice of shiatsu has been reviewed by Yates (51). The use of shiatsu for cancer patients has also been reviewed by Argash et al. (52).

Scientific Research:

• General: For nausea and vomiting, there are a number of well-designed, randomized clinical trials investigating the therapeutic effect of acupressure. Most studies attempt blinding by use of sham points (alternative points with no known accepted acupressure point), or lack of acupressure (lack of bead). Acupressure instruments or placebo instruments are covered in tape so that the patient and data collector are not aware of which group they are in. In some cases, patients are told the purpose of the study is to compare two acupressure points but the location is hidden using covering tape. As more patients become familiar with acupressure, these deceiving mechanisms may become less effective. In general, the quality of studies in other indications is lacking, and further study is required.
• Potential mechanisms of action: One case series indicated that auricular acupressure may reduce lactic acid elevation and increase oxygen uptake following strenuous exercise, suggesting acupuncture's possible effect on the body's metabolism (53).
• Statistically significant changes in blood endorphin content were observed in 30 of 70 acupressure recipients in one trial (54). In separate study, acupressure on the "extra 1" point (between the eyes) had no effect on melatonin or beta-endorphin levels (55).
• In human study, shiatsu is associated with distant muscle relaxation and neurovegetative calming as determined by electromyogram results (56). Also, acupressure to the soles of the feet resulted in a significant reduction in heart rate and nonsignificant increases in electroencephalogram readings (57). These effects may explain some of the nonlocal, full-body effects associated with shiatsu. Similarly, the effect of abdominal or ankle acupressure on foot rotation suggests a nonlocal effect of such stimulation (58). Increased blood flow (by transcutaneous oximetry) has also been observed following acustimulation using acupressure (59).
• The benefits of vaginal acupressure for gynecological and sexological problems may be partially due to the feelings and emotional responses the treatment provokes (60).
• Auricular acupressure increased serum concentrations of catalase and superoxide dismutase (61).
• Select reviews: The use of acupressure has been reviewed by various authors (62;​63;​64). Pharmacological and nonpharmacological treatments for nausea and vomiting, including acupressure, have been reviewed by various authors (65;​66;​67).

History

• As Western medical knowledge and procedures were assimilated by these cultures in the late 1800s and early 1900s, Asian bodywork therapies declined in popularity among medical professionals, although they are still commonly used by traditional healers and for relaxation purposes. Since the 1950s, the People's Republic of China has maintained a national health policy that embraces both Western medicine and traditional Chinese medicine, including the practice of tuina treatment.
• Since the 1970s there has been a resurgence of interest in both Western and Eastern forms of bodywork in the United States and Europe. There are currently over 1,000 nationally certified Asian bodywork therapists in the United States, a majority of whom are practitioners of acupressure or shiatsu. By comparison, there are over 10,000 acupuncturists in the United States. Also, by comparison, there are 40,000 nationally certified massage therapists in the United States, most of whom are trained primarily in Western massage techniques.
• In a recent random sample of community-dwelling individuals in Japan, 7% of individuals used physical complementary and alternative medicine, including acupressure, compared with 30% who visited physicians, and 23% who resorted to dietary complementary and alternative medicine (CAM) therapies (69). In Sweden, complementary therapies, including shiatsu, are gaining popularity (70).

Evidence Table

Evidence Discussion

Introduction: Problems in Research

• Standardization of intervention: Standardization is a recurrent problem in acupressure research. Acupressure healers vary widely in the techniques they employ, variably using touch, massage, oils, beads, beans, and combinations thereof. There are also wide variations in regimen and length of the period being used to evaluate outcomes.
• Standardization of comparison conditions: Comparison conditions may include sham or placebo acupressure (e.g., nonbeaded bands or altered nonacupressure location), another complementary therapy, traditional therapy, or no treatment. This makes comparisons of acupressure and control conditions difficult to generalize.
• Blinding: Blinding poses a special challenge in acupressure, as true double blinding remains difficult. Bands without beads have been used although it is possible patients are aware of the lack of pressure. Acupressure in nonacupressure locations has also been attempted by placing tape over locations of stimulations. Most studies have not conducted tests to determine if the control they used was a valid placebo, and two studies involving both sham acupressure and a reference group show significant differences between the two outcomes (71;​72). As always, subject knowledge may play a confounding role. As public awareness of acupressure grows, it may become increasingly difficult to design a trial in which the patient is not able to discern whether they are in the treatment or placebo group.
• Practitioner differences: The practitioner is an integral and intangible aspect of acupressure. There are wide differences in the nature and quality of the interpersonal relationship between practitioner and subject. Also, some acupressure is self-administered. These factors are likely to influence outcomes.
• Technique: In order to generate reliable and reproducible results on the efficacy of acupressure in treating nausea and vomiting, the great majority of RCTs undertaken in this area have focused exclusively on the effect of acupressure on the P6 acupoint. However, in the professional practice of acupressure and other Asian bodywork therapies in the treatment of nausea, the therapist will usually give a far more comprehensive treatment, involving multiple acupoints, tailored to the individual patient.
• Outcome measures: Many trials have used subjective measures that, even when validated, make it difficult to compare across studies or to pool the results of numerous small trials.

Nausea (of various etiologies)

• Summary: There is strong evidence from meta-analyses and randomized controlled trials to support the use of P6 wrist acupressure in the prevention and treatment of acute nausea and vomiting. These studies have found acupressure effective in alleviating postoperative nausea, intraoperative nausea (during spinal anesthesia), chemotherapy-induced nausea, and pregnancy-related nausea (morning sickness). Acupressure is noninvasive, easy to self-administer, has no observable side effects, has been found to appeal to medical practitioners, and potentially may provide a low-cost and safer alternative to antiemetic drugs. Effectiveness has been shown in both pediatric and adult populations. The use of P6 acustimulation in particular, including acupressure, has been the subject of numerous reviews (73;​74;​75). Although reduction in nausea, vomiting, retching, and use of antiemetics have all been shown, acupressure appears to be most useful for acute nausea and reducing the severity of nausea, with less of an effect on delayed nausea and vomiting. Although further studies in specific populations may expand understanding, in general, acupressure may be useful as a therapy or preventive tool, or as an adjunct to conventional antiemetic therapy.
• Meta-analyses: Dune et al. conducted a meta-analysis to determine the effects of several methods of acustimulation (acupressure, acupuncture, laser acupuncture, and electrical stimulation) on postoperative nausea and vomiting (PONV) in children (38). Randomized controlled trials from online databases were included up to May 2005. Reference lists of reviewed papers were also reviewed. Trials were evaluated for methodological quality using the Quality Reporting of Meta-analyses (QUOROM) guidelines, and results were pooled using the fixed-effects model. Twelve trials (N=921) were pooled for the vomiting outcome. Two trials (N=258) were identified for the nausea outcome. Compared with the control groups, all acustimulation modalities reduced vomiting (RR=0.69, 95% CI: 0.59-0.80, p<0.0001) and nausea (RR=0.59, 95% CI: 0.46-0.76, p<0.0001). Three acupressure trials were identified (76;​77;​78). Pooled RR was 0.69 (95% CI: 0.55-0.87, p=0.002), favoring acupressure. One study used the bilateral P6 point (76); the second used bilateral BL10, BL11, and GB34 (77); and the third used bilateral K-K9 (78). The study by Lewis et al. using the bilateral K-K9 point had the greatest impact on relieving postoperative vomiting (78). A combination study of acupressure (preanesthesia) and acupuncture (postanesthesia) was also identified (79).
• Ezzo et al. conducted a meta-analysis to examine the effectiveness of acupuncture point stimulation on acute and delayed chemotherapy-induced nausea and vomiting in cancer patients (39). Randomized controlled trials assessing the effect of acupuncture point stimulation by any method (needles, electrical stimulation, magnets, or acupressure) on chemotherapy-induced nausea or vomiting were included. Three studies using acupressure were included: one unpublished abstract and two published papers (80;​81). Data were provided by investigators of the original trials and pooled using a fixed effect model. Relative risks were calculated on dichotomous data. Standardized mean differences were calculated for nausea severity. Weighted mean differences were calculated for number of emetic episodes. Across the 11 trials included, of which three involved acupressure, a reduced incidence of acute vomiting, but not acute or delayed nausea, was observed. Acupressure reduced the mean acute nausea severity (SMD=-0.19; 95% confidence interval: -0.37 to -0.01, p=0.04) but not acute vomiting or delayed symptoms. This Cochrane review was discussed (73).
• Helmreich et al. conducted a meta-analysis to examine the effects of acustimulation (acupressure, acupuncture, and electrical stimulation) on the prevention of nausea and vomiting in pregnant women (30). Fourteen trials were included, eight randomized controlled trials and six crossover trials (N=1,655). Studies were evaluated for quality according to the QUORUM guidelines. Before treatment, 100% of women were nauseated, and 96.6% reported vomiting. After the treatment, acustimulation reduced the proportion of nausea (RR=0.47, 95% CI:0.35-0.62, p<0.0001) and vomiting (RR=0.59, 95% CI: 0.51-0.68, p<0.0001), as compared with controls. It was concluded that acupressure (applied by finger pressure or wristband) reduced nausea and vomiting in pregnancy. A placebo effect remained when results were compared with controls in reducing nausea (three trials, RR=0.63, 95% CI: 0.39-1.02, p=0.0479) and vomiting (five trials, RR=0.67, 95% CI: 0.50-0.91, p=0.0084).
• Shiao et al. conducted a meta-analysis to examine the effects of acustimulation (acupuncture, acupressure, and electrical stimulation) on nausea and vomiting symptoms in postoperative adult populations (40). Thirty-three randomized controlled trials were included, and the results were pooled. Twenty of these studies included acupressure (13;​71;​82;​83;​84;​85;​86;​87;​88;​89;​90;​91;​92;​93;​94;​95;​96;​97;​98;​99). Compared with controls, acupressure reduced nausea (relative risk [RR]=0.60, 95% confidence interval [CI]: 0.53-0.69, p<0.0001), vomiting (RR=0.54, 95% CI: 0.45-0.64, p<0.0001), and the use of rescue antiemetics (RR=0.62, 95% CI: 0.52-0.74, p<0.0001). No evidence of bias was indicated. These values may reflect a more realistic picture of acupressure's effect on nausea due to the large number of studies included in the analysis. Individual papers available on PubMed are discussed below.
• Lee et al. performed a well-designed meta-analysis of 19 trials on various methods of stimulation of the P6 acupoint for postoperative nausea and vomiting (37), of which six employed acupressure (78;​82;​86;​91;​93;​100). This analysis showed that these methods collectively were superior to placebo in preventing early nausea and vomiting in adults. Sensitivity analysis showed that these findings were not affected by the types of control (sham or no treatment) or by the sample size of studies pooled. Eight of the 19 trials indicated a significant reduction in the incidence of early nausea or vomiting compared to placebo groups; two of these used acupressure (82;​100). Five of the 19 trials evaluated the effect of P6 stimulation in the prevention of late vomiting did not show significant effects; three of these used acupressure (82;​86;​91). The Ho trial found prevention of nausea from epidural morphine given for cesarean section. The meta-analysis also evaluated four double-blinded pediatric studies on stimulating the P6 acupoint for postoperative nausea and vomiting, in which one (78) used acupressure; none showed significant benefit. The Lewis et al. study found that the incidence of nausea and vomiting was lower in acupressure-treated children postoperatively; however, the design of their study would detect only changes that were 50% significantly different.
• Evidence: Schultz et al. conducted a randomized, double-blind, placebo controlled study of 103 women (mean age 47.4) to evaluate the preoperative effectiveness of acupressure bands, droperidol, and the combination thereof, in reducing PONV in gynecologic inpatients (90). Inclusion criteria for the study were women 18 years of age or older who were able to read and write English, had a low risk of anesthesia issues, and were scheduled for an inpatient stay after gynecologic surgery. Surgical procedures included vaginal or total abdominal hysterectomy, laparoscopy, tubal ligation, tubal re-anastomosis, bladder suspension, Burch procedure, anterior-posterior repair, or myomectomy. Exclusion criteria were pregnancy (including tubal pregnancy); surgery, chemotherapy or radiation therapy for cancer within the previous five years; an antiemetic within 24 hours before this surgery; previous use of acupressure bands; or peripheral neuropathy. The subjects were randomized to one of four groups: droperidol/acupressure bands, droperidol/placebo bands, placebo drug/acupressure bands, and placebo drug/placebo bands. The acupressure bands for the study were provided by Sea-Bands®; the actual bands had a small, elevated button that contacted the P6 (Neiguan) acupressure point. The placebo had a flat button in the same place. Droperidol 1.25 mg was given intravenously. All subjects were anesthetized with propofol, followed by isoflurane with endotracheal intubation. No antiemetics were given during the operation. Nausea, vomiting, sedation, and pain measurements were recorded every 15-30 minutes in a postanesthesia care unit (PACU), every two hours during the immediate postoperative period on the surgical unit, and every four hours throughout the remainder of the hospital stay. Occurrences of vomiting and retching were also documented. In addition, subjects were asked to keep a home diary of episodes of nausea and vomiting, as well as pain, for up to seven days postsurgery. Acupressure was applied via commercial wristbands; however, the duration of acupressure was not consistent. No adverse effects of therapy were noted by the authors. Initially, 143 women enrolled in the study. However, 103 women completed the hospital phase of the study, and 62 women (61%) completed home diaries. The most frequent reasons for dropouts were nonadministration of the study drug, as well as a change in postoperative plans to same-day discharge. Outcome measures were the occurrence of nausea and vomiting. Overall, the nausea experienced by the droperidol/placebo band group was significantly less than in the other groups (p=0.0355). However, when the analysis was controlled for acupressure bands in place on day 1, the results became statistically insignificant (p=0.382). There was no statistically significant difference in the experience of vomiting among the women in the four groups (p=0.672). Women in the droperidol/acupressure bands group experienced more moderate-to-severe nausea than women in the other three groups on their day of surgery, although the results were not statistically significant (p=0.056). Significantly more women in the droperidol/acupressure bands group received rescue antiemetics (p=0.026). Twenty-three women of 62 who completed home diaries (37%) reported continuing episodes of nausea after discharge to home. There were no statistically significant differences in the experience of PONV between this study and previous histories of nausea; however, there were significantly more women with a previous history of PONV in the droperidol/acupressure bands group. The authors stated their disappointment that the results did not support their hypothesis that the combination of droperidol and acupressure bands would decrease moderate-to-severe PONV in the study population. In fact, the study showed just the opposite: more women receiving combination therapy experienced nausea, and their nausea was more severe than women in the other groups, including the control group. In addition, women who received the combination of droperidol and acupressure bands required more postoperative antiemetics. In the process of trying to explain their results, it was noted that all women who were randomized to receive actual acupressure bands had higher rates of nausea. In contrast, all women who received placebo bands experienced less nausea. This suggests a benefit of placebo bands greater than that of acupuncture bands. Indeed, in a recent study of acupuncture in women undergoing IVF, women who received placebo acupuncture had a higher pregnancy rate than women receiving real acupuncture. The authors also suggest that characteristics of women in the droperidol/acupressure bands group may partially explain their increased nausea. More women in the droperidol/acupressure bands group had abdominal surgery and required more opioid medications for pain control; in addition, more women (nonsignificantly) in this group had a previous history of PONV. Thus, while the groups were randomized, a flaw or infelicity in randomization may have affected the results. Also, study bands were in place longer before surgery in the droperidol/placebo band group. The length of time the bands were in place should most likely have been standardized. Women in this group experienced the least amount of nausea and vomiting on the operative day. The authors note that recruitment was "problematic," possibly owing to the use of placebo drug. One-third of the patients were lost to attrition, which further reduced the possibility of significant findings. It is noted in the text that the number of staff involved in this project also contributed to attrition (i.e., data could not be retrieved).
• Agarwal et al. conducted a randomized controlled trial to examine the effect of P6 acupressure on postoperative nausea and vomiting following urological surgery, in 200 patients (98). Consecutive patients undergoing surgery were included if they did not have cardiovascular disease, diabetes, or previous history of travel sickness. Patients were given an acupressure band or a sham band, and both were covered in tape so that they could not be distinguished. Bands were applied 30 minutes prior to anesthesia and were removed six hours postoperatively. The authors found no significant difference between the acupressure group and a sham acupressure group. The authors hypothesize that this may be due to the fact that urological surgery can send additional afferent stimuli for nausea and vomiting, as opposed to the different surgeries undertaken in connection with previous acupressure studies. This was a well-designed study with appropriate randomization and blinding.
• Bertalanffy et al. conducted a prospective, randomized, double-blinded trial to test the hypothesis that Korean hand acupressure at the K-K9 point reduces motion sickness during ambulance transport (101). A total of 100 geriatric patients with minor trauma were enrolled in the study. Patients were randomized into two groups: a K-K9 group (N=50) and a sham acupressure group (N=50). To achieve double-blinding, one paramedic applied the acupressure patch before the ride, sat with the patient during the ride, and removed the patch after the ride. A second paramedic (who did not see the patient with the patch at any time) then assessed the outcome measurements independently. The inclusion criteria were older age (60-100 years), a history of motion sickness or postoperative nausea and vomiting (PONV), medical need for ambulance transport, and estimated transport times of 20 minutes. The exclusion criteria were not being fluent in German, being unable to give informed consent, having neurological or psychiatric disorders, taking any sedatives, having gastrointestinal disorders or any malignancies, and having a pain visual analog scale (VAS) greater than 50 due to trauma. Subjects of the K-K9 group (Group 1) received bilateral stimulation of K-K9, an acupuncture point located on both hands in the middle phalanx of the fourth finger. Subjects of the sham group (Group 2) received bilateral acupressure at a sham point, an acupuncture point known to have no effect, located in the middle phalanx of the second finger. The subjects received the acupressure stimulation prior to getting in the ambulance. Acupressure stimulation was performed using hand patches consisting of a hard plastic ball fixed with a small bandage. All patients developed symptoms of motion sickness during the ambulance ride to the hospital. All enrolled subjects completed the study; no patient had to be treated as a dropout for technical or medical reasons. The outcome measures included visual analog scores (VAS) recorded for nausea and for the patient's overall satisfaction with the treatment, hemodynamic variables, and peripheral vasoconstriction. In Group 1 and Group 2, a significant increase (p<0.01) in nausea and perspiration in the hands was noted, and at the time of the patients' arrival in the hospital, these scores were significantly different (p<0.01) between Group 1 and Group 2, although values were not provided. Both Group 1 and Group 2 showed a significant increase (p<0.01) in the subjective sensation of strong heart beats and an increase in their subjective sensation of vertigo on the VAS, but the score did not significantly differ between the groups at the end of the ambulance ride. Although all patients had been vasoconstricted at the emergency site before treatment, there was a significant difference (p<0.01) in the number of vasoconstricted patients in the hospital between groups (in Group 1, four constricted and 46 dilated, and in Group 2, 48 constricted and two dilated). On arrival in the hospital, a significant difference (p<0.01) in heart rate was also noted between groups though neither group experienced a significant change in blood pressure. The patients' overall degree of satisfaction with the provided care was significantly higher (p<0.01) in Group 1 than in Group 2.
• Boehler et al. conducted a double-blinded, randomized, placebo controlled study to investigate the effectiveness of prophylactic Korean hand acupressure in preventing postoperative vomiting in women undergoing minor gynecological laparoscopic surgery (89). The study enrolled 80 women with similar baseline characteristics. The study included only patients in the premenstrual phase of the menstrual cycle and excluded patients with gastric or intestinal disease or with nausea or vomiting in the previous week and patients receiving any medical therapy immediately before surgery. The treatment group (N=40) received Korean hand acupressure on both hands at point K-K9 via special acupressure seeds while the remaining subjects (N=40) functioned as the placebo group, with the acupressure seeds fixed on points not defined in Korean hand acupuncture. The patients were blinded to the treatment by having opaque tape applied to both the K-K9 point (fourth finger) and a sham point (fifth finger). Furthermore, the anesthesiologist and the nursing staff were unaware of the group assignments. Acupressure was administered 30 minutes prior to anesthesia induction and was maintained for at least 24 hours. No subject complained of nausea or vomiting after eight hours after the laparoscopic procedure. Eight women who received acupressure and 15 women in the placebo group required tropisetron as antiemetic rescue therapy. The dropout rate was not mentioned in the study. In the first 24 hours after surgery, the incidence of nausea and vomiting was significantly less (p=0.006 and p=0.007) in the acupressure group (40% and 22.5%) than in the placebo group (70% and 50%). Dropouts were not discussed.
• Harmon et al. conducted a prospective, randomized, double-blind study to access the efficacy of acupressure at the P6 point in preventing nausea and vomiting during and after cesarean section (85). The study recruited 94 patients aged between 18 and 40 years, who were determined to be healthy or asymptomatic according to the American Society of Anesthesiology guidelines (ASA I status), and scheduled for elective cesarean section. Patients excluded from the study were those with previous postoperative nausea and vomiting history or nausea and vomiting in the past 24 hours, obesity (BMI >35), diabetes mellitus, or previous acupuncture or acupressure experience. The treatment group (N=47) received acupressure bands (Sea-Bands®) at the P6 point, while the control group (N=47) received the bands at a placebo stimulation point. In both groups, acupressure bands were positioned on the right forearm five minutes prior to anesthesia administration. Since the patients' arms were covered with surgical drapes, bands were not visible to the assessing anesthetist. The bands were removed by the nursing staff six hours after discharge to the ward. The anesthetic technique and postoperative analgesia were standardized. Patients using the acupressure bands had reported minor side effects, such as swelling and discomfort. Dropout rates were not discussed in the study. The outcome measures included nausea, vomiting, and antiemetic and analgesic requirements. During the operation, 23% in the acupressure group and 53% in the control group experienced nausea or vomiting (p=0.002). After the operation, 36% in the acupressure group and 66% in the control group experienced nausea or vomiting (p=0.003). There was a statistically significant reduction in nausea (p=0.018) only during operations in the acupressure group compared with control. After the operation, there was a statistically significant reduction in vomiting (p=0.011) in the acupressure group. In addition, opioid requirements during and after the operations were similar between the two groups. There was also a statistically significant difference (p=0.01) in antiemetic requirement during and after operations between the treatment and the control group (25% and 50%, respectively). This study was well designed although the method of randomization was not described. Blinding was conducted by removing wristbands prior to endpoint analysis by study nurses.
• Alkaissi et al. conducted a double-blind randomized controlled trial of 60 women to investigate the "true" and placebo effect of acupressure in preventing postoperative nausea and vomiting (PONV) (71). The study recruited women scheduled for minor gynecological surgery on an outpatient basis, and subjects were included after written and verbal informed consent. Active and placebo treatments involved Sea-Bands® positioned to apply pressure at selected acupressure or nonacupressure points. In the acupressure group (A), the Sea-Bands® were applied bilaterally to deliver pressure at P6. In the placebo group (P), bands were placed on placebo points. A third reference group (R) received no acupressure wristband, but were informed and anesthetized in the same way as the acupressure and placebo groups. The bands were applied just before surgery and worn until noontime the day after surgery. One patient in the acupressure group and one in the placebo group reported nausea 24 hours after surgery. Ten patients dropped out from the study. The dropouts were evenly distributed between the groups. There were two kinds of dropouts: one group originally scheduled for surgery under anesthesia but who were switched over to local anesthesia, and a second group in which the study protocol was violated by administration of prophylactic antiemetic during anesthesia. These dropouts were replaced by randomizing another 10 patients at the end of the study. The outcome measured was number of patients experiencing complete response, nausea (only), vomiting, need for rescue medication, and nausea after 24 hours. Complete response was similar between the groups (11, 11 and nine patients in groups A, P and R, respectively). Also, 22 patients had nausea before discharge home (nine, seven, and six, respectively, in groups A, P, and R), and 10 patients had nausea 24 hours after operation (one, one, and eight in groups A, P, and R, respectively). When comparing reports of nausea between the reference group and either the acupressure or placebo group 24 hours postoperatively, the difference was significant (p<0.05). When compared to placebo acupressure (two patients vomited and five needed rescue), significantly (p<0.05) fewer needed rescue antiemetic medication after acupressure at P6 (no vomiting or rescue medication). When compared to the observation group (five patients vomited and four needed rescue antiemetics), significantly fewer vomited after acupressure (p<0.05). Although the method of randomization was not discussed in this study, blinding was very good with use of the same acupressure band (Sea-Band®) at a slightly different location.
• Harmon et al. conducted a randomized controlled trial to study the efficacy of acupressure at the P6 point in the prevention of nausea and vomiting after laparoscopy in 104 patients (87). Patients who were included were undergoing infertility investigations and were not obese or diagnosed with diabetes, and did not have a history of postoperative nausea. The anesthetic technique and postoperative analgesia were standardized. Sea-Band® or placebo wristbands were applied directly before anesthesia for 20 minutes. Failure of treatment was defined as the occurrence of nausea or vomiting within the first 24 hours after anesthesia. The use of acupressure wristbands reduced the incidence of nausea or vomiting from 42% to 19% compared with placebo, with an adjusted risk ratio of 0.24 (95% CI: 0.08-0.62; p=0.005). Other variables were similar between groups. This study was well designed. Blinding was conducted by removing wristbands prior to endpoint analysis by study nurses. Patients were told acupressure location was being investigated.
• Ho et al. conducted a randomized, double-blind, placebo controlled trial to access the antiemetic effect of P6 acupressure in parturients given epidural morphine for post-cesarean section pain relief (82). The study enrolled 60 parturients. Subjects excluded from the study were those with previous carpal tunnel syndrome and those who had experienced nausea or vomiting within 24 hours prior to cesarean section. Parturients were randomized to receive either active or placebo acupressure before anesthetic administration. The treatment group (N=30) received Sea-Bands®, which were placed bilaterally at the P6 acupoint, while the control group (N=30) received placebo wristbands, which were also placed at the same P6 point. An anesthesiologist followed up all parturients independently. Subjects were asked to wear the bands for 48 hours. If the subjects experienced discomfort, they could remove the bands for 30 minutes every two hours. Study subjects tolerated the bands well, and no adverse effects were noted following use of either Sea-Bands® or placebo wristbands. However, two of the 30 parturients in the control group received intravenous metoclopramide for treatment of intractable vomiting, while the treatment group required no such treatment. All subjects completed the study. The outcome measures included: vital signs, visual analogue scale (VAS) pain score, all postoperative analgesic requirements, respiratory rate, and side effects, including pruritus, dizziness, herpes simplex labialis, nausea, and vomiting. The incidence of nausea and vomiting after epidural morphine in the acupressure group was significantly different (p<0.05) than in the control group (nausea: 3% vs. 43%; vomiting: 0% vs. 27%, respectively). There were no statistically significant differences between the two groups in the incidence of pruritus and dizziness. Neither respiratory depression nor herpes simplex labialis was noted. This study was well designed. The number of dropouts was not discussed.
• Belluomini et al. conducted a randomized, blinded study to evaluate the effectiveness of acupressure in reducing nausea and vomiting in pregnancy (102). The study included 90 pregnant women who were referred by physicians and midwife practitioners. The inclusion criteria were complaints of nausea with or without emesis and gestational age of 12 weeks or less by study completion. The exclusion criteria were: diagnosed hyperemesis gravidarum (5% weight loss, ketonuria, and proteinuria), diseases that produce nausea and emesis, molar and ectopic pregnancies, or current use of antiemetic medications. The treatment group would apply acupressure at point PC6, and the control group would apply acupressure at a placebo point. Subjects were taught how to locate and apply acupressure at the assigned point. Both the subjects and the referring practitioners were blinded to the group assignment. Subjects were asked to complete an assessment form describing the severity and frequency of symptoms that occurred during the 10 consecutive days. The first three days were considered pretreatment with no acupressure applied. Beginning on the morning of the fourth day, each subject used acupressure at the assigned point for 10 minutes four times a day. Data from day 4 were discarded to allow 24 hours for the treatment to take effect. Data from days 5 to 7 were used to measure treatment effect. Adverse effects were not mentioned in the study. Thirty subjects did not complete the study. These subjects failed to return the forms, returned incomplete forms, or were lost to follow-up (13 treatment, 12 control). The remaining dropouts were due to prescribed antiemetics, abdominal surgery, or voluntary exclusion (three treatment, two control). Overall, the dropout rates between the groups were similar (16 treatment and 14 control subjects) The Rhodes Index of Nausea and Vomiting Form-2 was used to measure duration of nausea, amount of vomitus, and frequency, as well as distress from nausea, vomiting, and retching. Sixty women completed the study. In the control group, of the patients who vomited, 67% reported vomiting once or twice a day and 33% more than twice a day. After treatment in this group, 75% reported vomiting once or twice a day and 25% more than twice a day. In the treatment group, of the patients who vomited, 75% reported vomiting once or twice a day and 25% more than twice a day. After treatment in this group, 81% reported vomiting once or twice a day and 19% more than twice a day. There were no differences in the severity or frequency of emesis between the groups. Pretreatment scores for nausea correlated significantly with maternal age (p=0.044), but emesis scores did not (p=0.28). Also, there was a significant positive correlation (p=0.044) between maternal age and severity of nausea. Data analysis of days 5 to 7 demonstrated that both groups improved significantly over time (p<0.0001), but that nausea improved more significantly in the treatment group than in the sham control group (p=0.0021). Data from days 8, 9, and 10 showed no significant differences between the treatment and control groups because nausea and vomiting in both groups had improved over time. One weakness of the study the authors mentioned was that since only 28 (47%) of the study subjects reported emesis when entering the study, the sample size may have been insufficient to establish a statistically significant correlation. This study was well designed with patients and referring practitioners blinded to treatment group and no study withdrawals.
• De Aloysio et al. conducted a randomized, controlled crossover study to evaluate the antiemetic effect of acupressure at the P6 point in pregnant women (103). Sixty women in early pregnancy with pregnancy-related nausea and vomiting were included. Subjects were excluded if they had used therapy within three days of the study. Over 12 days, women used an acupressure band (Sea-Band®) unilaterally, bilaterally, or at a placebo point, for three days each. Use of acupressure resulted in a significantly lower frequency of morning sickness compared with placebo treatment: 60% positive effect with unilateral and bilateral acupressure compared with an approximately 30% positive effect of placebo acupressure. There were no differences between unilateral and bilateral treatment. There were no noteworthy side effects. This study was appropriately randomized, although blinding methods were inadequately described.
• Lewis et al. conducted a randomized controlled trial to assess the efficacy of P6 (Neiguan) point acupressure as an antiemetic in children undergoing outpatient strabismus correction (78). The subjects were children 3-12 years old, ASA grade I-II, and undergoing surgery to correct strabismus. Potential subjects with anatomical or neurological abnormalities of the upper limbs were excluded from the study. This prospective, double-blind study was designed to detect a 50% difference (from previous studies' reports' 66% postoperative vomiting to 33%) in the incidence of postoperative vomiting between two groups, placebo and acupressure, with a 90% power of achieving a statistically significant result at the 5% level (two-tailed). The authors determined that 31 patients per group would be required. A total of 66 children were enrolled in the study. The subjects were randomized to either a placebo group or to an acupressure group. The acupressure group wore Sea-Bands®. The placebo group wore similar bands without studs; the bands in both groups appeared identical unless turned inside out. In both groups, the bands were applied one hour before operation and were removed on the day of discharge. If the children were vomiting during their hospital stays, they were given droperidol 0.02mg/kg intravenously at the discretion of blinded anesthesia staff. If the children were vomiting after discharge at home, they were given prochlorperazine 5mg suppositories at the discretion of their parents. The bands were applied one hour before operation and were removed on the day of discharge. Discharge was determined based on the patients' recovery (airway patency, vital signs, and level of consciousness), ability to ambulate, and self-reports as pain-free. No antiemetic medication was given to the children before the operation. Anesthesia was standardized. At the end of the operation, the stomach was emptied using a suction catheter. In both groups, children received lactated Ringer's solution intravenously during the perioperative period. According to the authors, the children tolerated the bands well, and none of the bands had to be removed. Also, they also reported no complications in each group. Out of the 66 enrolled subjects, only the results of 64 children were included because the results of two subjects in the acupressure group were considered incomplete. No further details were given. Interactions were not discussed. Outcome measures include incidence of postoperative nausea and vomiting. Retching was defined as "active efforts without expulsion of gastric contents" and was recorded as vomiting. The results or incidence of vomiting were analyzed using the chi-square test with Yates' continuity correction. Statistical significance was achieved at p<0.05. P6 acupressure did not reduce the incidence of postoperative vomiting in children undergoing strabismus surgery. There was no significant difference in the incidence of postoperative vomiting between the placebo group and the acupressure group: 58% vs. 58% before discharge from hospital (p=0.84). At home, there were also no differences in between the two groups (73% vs. 71%) in the first 24 hours after surgery (p=0.30). The wristbands were positioned by the same investigator that observed and recorded patient characteristics such as the child's age, weight, and sex; a different blinded investigator recorded events such as nausea and vomiting and that retching was marked as vomiting. One possible limitation to the study was the lack of a risk factor comparison between the two groups concerning such variables as intraoperative use of isoflurane, fentanyl, and glycopyrrolate, and postoperative use of patient-controlled analgesia with morphine. These factors may have contributed to nausea and vomiting. Also, it is unclear how the investigators classified nausea since the data reported are only for vomiting. Since the purpose of their study was to examine the use of acupressure as an antiemetic, it is unclear if the acupressure affected or reduced the patient's nausea as well. Other limitations noted by the authors include surgical manipulation of the eye, administration of morphine during surgery, and early ambulation, all of which may increase the incidence of vomiting.
• Dibble et al. conducted a randomized controlled trial to examine the effect of P6 acupressure on chemotherapy-induced nausea in women undergoing chemotherapy for breast cancer (104). One hundred sixty women beginning their second or third cycle of chemotherapy for breast cancer treatment and who had moderate nausea intensity scores with their previous cycles were included. Subjects were randomized to one of three groups: P6 acupressure, acupressure to SI3 point (placebo), or usual care only. Subjects applied the acupressure wrist device after being taught by assistants who were unaware of the active point in order to maintain double-blinding. Nausea and vomiting over the 21-day cycle were the main endpoints. There were no significant differences in acute nausea or emesis by treatment group. However the acupressure group had a statistically significant reduction in the amount of vomiting (t=3.13, p=0.002, odds ratio [OR]=1.3 and t=4.81, p<0.0001, OR=1.4) and the intensity of nausea over time, when compared with the placebo and control groups. Withdrawals and the method of randomization were not described in this study.
• Heazell et al. conducted a single-blind randomized study to examine the effect of P6 acupressure for severe nausea and vomiting in early pregnancy (105). Eighty patients with nausea and vomiting plus ketonuria before 14 weeks of gestation were included. Women who had nausea and vomiting associated with pregnancy (NVAP) on their first inpatient admission between five and 14 weeks of gestation were recruited for the study. To require inpatient admission, patients had at least 2C of ketonuria on urinalysis, an inability to tolerate oral fluids, and a requirement for antiemetic medication. Patients were excluded if they had prior knowledge of or use of acupressure, because they could not remain blind to the treatment. Women were also excluded if there was evidence of urinary tract or gastroenterological infection, due to the potential for exacerbating nausea and vomiting. Women who were unable to communicate with the medical team were also excluded, although patients who did not speak English as a first language were admitted to the study because the catchment area serves a diverse ethnic population, with 50% of pregnant patients of Asian origin, and the medical team included staff members who were able to speak Asian languages. Patients who were assigned to the treatment group wore acupressure bands (Sea-Bands®) on both wrists that consisted of a plastic bead contained within a woven elastic band. The acupressure bands were placed at the P6 meridian point on the forearm. Those assigned to the placebo group had the beads placed at a site on the dorsal aspect of the forearm that is not thought to be effective. Patients wore the wristbands for eight hours a day, from 9 a.m. to 5 p.m., for the length of their hospital stay (mean length of stay was 3.4 days). Adverse effects were not discussed. Endpoints were the use of medication, requirement for intravenous fluid, and length of hospital stay. There was no difference between length of hospital stay, amount of medication, or fluid required between the acupressure and placebo groups. Further analysis of the length of inpatient stay shows a small reduction in the number of patients who stayed four nights or more in the treatment group, from 18 to 11 women (p< 0.05; degrees of freedom, 1). There was no statistically significant difference in the number of patients who required second- or third-line antiemetic medication (p>0.1; degrees of freedom, 2). No dropouts were reported. Three patients were not included in the assessment of secondary outcomes due to insufficient information for data collection. It should be noted that this study was only single-blinded.
• Ho et al. conducted a randomized controlled trial to examine the effect of P6 acupressure for nausea and vomiting during spinal anesthesia for cesarean delivery (106). One hundred ten patients with ASA physical status I-II, aged 23-40 years, and who were scheduled for elective cesarean delivery were included. Women with a history of carpal tunnel syndrome and women who had experienced nausea or vomiting within 24 hours before cesarean delivery were excluded. Thirty minutes before initiation of spinal anesthesia, patients received acupressure bands (Sea-Bands®) or placebo bands bilaterally at the P6 point. The primary outcomes were the incidence of nausea or vomiting evaluated and recorded by an independent research nurse intraoperatively. Incidence rates for intraoperative nausea were 64% (acupressure group) and 71% (control group), and 22% and 27% for vomiting, respectively. These rates were not significantly different. No adverse effects were observed, and there were no dropouts. This study was not blinded. Other confounding variables may include the use of concomitant medications (intrathecal opioids).
• Alkaissi et al. conducted a randomized controlled trial to test whether P6 acupressure increases tolerance to nauseogenic motion stimulation in women at high risk for PONV (12). Sixty women with high and low susceptibilities for motion sickness, between the ages of 18-40, were included in this study. Women were excluded if they had previous experience with elements of the study, such as acupressure bands or chair rotation. Women with visual problems, gastrointestinal, oculomotor, vestibular, or central nervous system disorders were also excluded. A Sea-Band® that carried a plastic pearl was used to apply pressure on P6 on the dorsal side of both arms; this was covered with a dressing. It was unclear how long the bands were worn by the subjects. The placebo group was given bands that did not stimulate P6, but were covered in dressing. Another control group did not have a band at all and therefore was not blinded. Subjects were stratified based on susceptibility to nausea. Two subjects in the P6 acupressure group reported that their bands were uncomfortable and tight, while one subject in the placebo group reported swelling of hands. All participants completed the trial. To induce nausea, the women were placed in a rotation chair at a speed of 10 cycles per minute. This continued until the women reported moderate nausea. A seven-point scale was used to express the severity of nausea (0=no nausea and 6=worst possible nausea). The P6 acupressure group took longer to become nauseated, compared to the control group. The mean time to nausea in the P6 acupressure group was 352 seconds (259-445, 95% confidence interval), compared to a mean of 151 seconds (121-181, 95% confidence interval) for the control group. This difference was significant (p=0.006). No difference was found between P6 and placebo acupressure or placebo acupressure and control groups. The severity of motion sickness that was recorded earlier did not affect participants' nausea threshold (p=0.107). The number of symptoms differed between the three arms of the trial (p<0.05). Fewer symptoms were recorded in the P6 acupressure compared to the control group (p<0.009). Overall, P6 acupressure was slightly more effective than placebo acupressure. This study employed an improper method of randomization.
• Klein et al. conducted a prospective, randomized, double-blind, placebo controlled clinical trial to evaluate whether using acupressure bands would reduce postoperative nausea and vomiting after cardiac surgery (99). The study enrolled 152 patients undergoing primary coronary artery bypass graft or valvular surgery. The two groups had similar demographic data and surgical characteristics except for gender; the control group had significantly more women than the treatment group (17 vs. six, respectively), which was a random occurrence. Patients excluded from the study were those with a past history of hiatus hernia, heartburn, or gastric surgery, or who were morbidly obese, or taking antiemetic medication, H2-receptor antagonist, or proton pump inhibitors. The two groups had acupressure bands positioned on both wrists prior to anesthesia induction. The treatment group (N=77) received acupressure treatment with Sea-Band® bands containing spherical beads placed in contact with the P6 position, while the control group (N=77) received treatment with identical bands placed at the same position but without the beads. To ensure patient blinding, both groups had their bands covered by a soft cotton roll. All bands were removed 24 hours after extubation. Premedication was standardized to 2-4mg of lorazepam, taken sublingually one hour before surgery. Anesthesia was standardized to patient body weight. No patient in either group reported significant adverse effects. The authors did not mention the dropout rates. The outcome measures included: nausea, vomiting, pain scores during the first 24 hours of the postoperative period, and analgesic and antiemetic requirements. Assessments were made by nursing staff blinded to group assignments. The two groups showed similar results with respect to the incidence of nausea or vomiting and antiemetic requirements. Also, similar results were observed between the two groups with respect to mean pain scores for 24 hours, total dose of propofol, and total analgesic requirements. Since genders were not equally distributed between the groups, the authors performed a subgroup analysis. Subset analysis by gender demonstrated that female patients in the acupressure group required less antiemetic treatment than female patients in the control group. After controlling for sex differences between the two groups, a logistic regression analysis performed on all patients showed that acupressure therapy was not effective in preventing postoperative nausea and vomiting (PONV). However, female sex was a significant predictor (p=0.03) for PONV. Based on the consideration that generally 47% of patients develop PONV after cardiac surgery, the authors determined that a sample size of 75 patients per group would be sufficient to provide 80% power in order to detect a 40% reduction in the proportion of affected patients. It had been previously observed that women are at an increased risk of PONV after surgery; therefore, it was expected that there would be an increased incidence of PONV in the placebo group due to the sex differences between the two groups. Even so, after controlling for this uneven distribution of gender between the treatment and placebo groups, acupressure therapy was still not effective in preventing PONV. It should be noted that although double blinding was indicated, the lack of a bead in the band of the placebo group may have been obvious to the wearer.
• Samad et al. conducted a randomized, double-blind controlled trial to evaluate the effectiveness of acupressure applied at meridian P6 point for the prevention of nausea and vomiting in patients undergoing laparoscopic cholecystectomy (97). Fifty ASA I and II patients, males and females ranging in age from 18 to 60 and undergoing laparoscopic cholecystectomy, were included in the trial. Subjects who were excluded from study included obese patients weighing more than 80kg, diabetics, patients with a history of postoperative nausea and vomiting, patients receiving antiemetic medications, and patients receiving H2 antagonists. Acupressure was applied at P6 point for half an hour before surgery, with the pressure band kept on for six hours after the surgery. In the placebo group the acupressure band was tied on meridian P6 point. However, the plastic bead was placed on the dorsum of the right forearm away from meridian P6 point. Acupressure standardization was not mentioned throughout the article. There were no side effects or complications caused by placement of the acupressure band in either group. Patients were assessed for nausea and vomiting for 1-2 hours in the recovery room and for 4-5 hours in the wards. Overall, the results showed that the incidence of postoperative nausea and vomiting was 36% in the treatment group and 40% in placebo group (no p values given). It was concluded that acupressure at P6 point half an hour before induction of anesthesia does not alter the incidence of nausea or vomiting within six hours after surgery. It should be noted that certain data referenced in the text were not provided in the article.
• Agarwal et al. conducted a randomized, prospective, double-blind, double-dummy controlled trial to compare the effectiveness of acupressure and ondansetron (an antiemetic medication) for preventing postoperative nausea and vomiting (PONV) (94). Subjects included patients of either sex, between 18 and 60 years old, ASA grade I-II, who were undergoing laparoscopic cholecystectomy. Exclusion criteria were refusal to participate in the study, previous history of PONV, travel sickness, impaired renal function with increased urea and creatinine concentrations, diabetes mellitus, obesity, and patients receiving antiemetic medication or a histamine H2-receptor antagonist within 72 hours of surgery. The 150 patients were randomized into three groups of 50 each: control, ondansetron, and acupressure. Before induction of anesthesia, acupressure wristbands were placed on the patients' forearms in all groups. In the control and ondansetron groups, the wristbands were placed inappropriately on the posterior surface of both forearms. In the acupressure group, the bands were applied correctly at the P6 point on both forearms. Patients in the ondansetron group received ondansetron 4mg intravenously (IV), while the other group's patients received normal saline 1mL intravenously immediately before induction of anesthesia to maintain blinding. After the surgery, if patients vomited more than once, a 4mg intravenous dose of ondansetron was administered as a rescue antiemetic. The acupressure wristbands were applied 30 minutes before induction of anesthesia and then removed six hours after surgery. Patients were observed for PONV within six hours of the patient's arrival in the postanesthesia care unit and then at 24 hours after surgery by a blinded observer. Anesthesia was standardized, and acupressure (active or sham) was delivered via commercial acupressure bands. No antiemetic medication was given before or during the operation. No adverse effects or complications were observed. Dropouts and interactions were not discussed. The primary outcome measure evaluated was the incidence of PONV, described as none, mild, moderate or severe. Patients were observed for PONV within six hours and 6-24 hours following surgery by a blinded observer. The results were scored as none, nausea, or retching/vomiting. Patients who experienced both nausea and vomiting were assigned to the vomiting group. A secondary outcome measure was the requirement for rescue antiemetic medication. A Z-test was used to compare the incidence of PONV in all three groups. Statistical significance was achieved at p<0.05. The incidence of PONV and the requirement of rescue medication were significantly lower in both the ondansetron and acupressure groups during the first six hours after surgery compared to the control group. The incidences of PONV in the first six hours after surgery were as follows: 44% in the control group compared to the ondansetron and acupressure groups, who had significant decreases in the incidence of PONV (8% and 10%, respectively). There was no significant difference in PONV incidence 6-24 hours following surgery in all three groups. There was a significant decrease in the requirement for rescue antiemetic medication in groups II and III within six hours following surgery. Only four patients required rescue antiemetic medication, and all were in the control group. However, requirements for rescue antiemetic medication were similar in the three groups 24 hours following surgery. Following surgery, none of the patients in the three groups required the use of a rescue antiemetic medication. It should be noted that the method chosen to place the sham acupressure wristbands may not have achieved complete blinding, as the difference in location may have been visible. Also, the authors did not compare prolonged CO₂ insufflation, gall bladder surgery, intraoperative use of isoflurane, fentanyl and glycopyrrolate, and postoperative use of patient-controlled analgesia with morphine. These factors may have contributed to PONV, as the authors noted in their discussion.
• Norheim et al. conducted a randomized, double-blind, placebo-controlled study to determine the efficacy of acupressure wristbands in reducing nausea and vomiting in early pregnancy (107). In total, 97 pregnant women participated. The selection criteria included: the presence of nausea for at least one week before study enrollment, a lack of pre-existing diseases causing nausea and vomiting, having received no therapy for nausea at enrollment or during the study period, and having no abnormalities discovered at a regular pregnancy follow-up. Participants were randomized into receiving either an active acupressure wristband (Sea-Band®) or a placebo wristband. The active wristband and the placebo wristband were identical from the outside, but on the inside, the placebo-wristband had a felt patch while the acupressure wristband had a protruding button. The study subjects participated for a total of 12 days. Days 1-4 were considered a pretreatment period, days 4-8 were the actual intervention period, and days 8-12 were follow-up period. In the intervention period, participants wore wristbands on both arms at the "Neiguan" point during the day and night except when they took a bath or engaged in activities that could wet the wristband. When using the wristband, 63% of subjects in the active treatment group and 90% in the placebo group experienced problems including pain, numbness, soreness and hand-swelling (p=0.004). No other serious adverse events were noted, although three women (two with the acupressure wristband and one with the placebo wristband) reported that they felt sicker during the study period. Thirteen of the 97 women did not complete all of the registration forms during the study period, though their data were used in results analysis in order to maintain the intention-to-treat principle. The outcome measures included: nausea and vomiting based on the intensity, duration, and nature of complaints. The subjects were asked to make three recordings each evening for 12 consecutive days. Both the active treatment group and the placebo group reported less intensity of morning sickness (71% and 63%, respectively) and reduced duration of symptoms (71% and 59%, respectively). The active treatment group had a reduction in the hours of complaint as compared to the placebo group (p=0.018). Randomization was not adequately described, and blinding did not appear to be adequate. Although indicated as a double-blind study, the lack of a button on the placebo wristband may have been obvious to participants. Also, no mention was made of training of correct placement, though participants did remove wristbands to avoid them getting wet. This study appears to be the same as a second study published by the same first author in the same year (15).
• Warwick-Evans et al. conducted a randomized, double-blind, placebo controlled trial to evaluate the effectiveness of acupressure as a prophylaxis against motion sickness (108). This study was composed of 36 male undergraduate students, aged 18-25 years (mean 21.3 years), divided into four groups. First, participants were divided based on their susceptibility to nausea and then were randomized into an experimental or control group. In the experimental group, a Sea-band® was attached to the participants at the Neiguan P6 acupoint. The control group also received a Sea-band®, but it was attached to a point a few centimeters away from the studied acupoint. Subjects were reported as not being aware of the incorrect placement. After bands were secured, patients were placed in rotating chairs and asked to tilt their heads to induce nausea. Each subject completed a 10-minute nausea induction on a rotating chair. Groups were matched for nausea susceptibility and then randomized into the control or experimental group. The Sea-band® placements were photographed and independently verified for proper placement by an acupuncture expert. To equilibrate the subjects' level of expectation, all subjects were told that acupressure was widely believed to prevent motion sickness, but that this was the first controlled study of efficacy. They were unaware of a placebo treatment until after the study. Adverse effects were not discussed. All subjects completed the study. There were no significant interactions. Motion sickness was assessed after nausea induction using a scoring procedure developed by Graybiel et al. As expected, motion sickness was reported at a significantly higher levels by the high-susceptibility group than the low-susceptibility group (p<0.05). Acupressure did not provide any significant protection against motion sickness for either group. In contrast, a nonsignificant trend in opposition to the expected effect in each group was observed. Several possible explanations as to why the study failed to reject the null hypothesis exist. Firstly, it is possible that the nausea induction may have been strong enough to overcome the effects of acupressure. Also, as previous studies tested mostly women, compared to this study which tested only men, it is possible that gender differences in acupressure responsiveness may have affected results.
• Turgut et al. conducted a randomized controlled trial to examine the effect of P6 acupressure in preventing nausea and vomiting in patients undergoing gynecological operations and receiving a patient-controlled analgesia device (28). One hundred two patients between the ages of 40 and 65 years were included. Patients who were obese, diabetic, or had a history of motion sickness, postoperative nausea and vomiting, or smoking were excluded. Patients were treated with acupressure (bands placed on both wrists with the plastic bead positioned at the P6 point) or control (beads placed at a nonacupoint site). All patients received a standard general anesthetic and were treated postoperatively with morphine. Over the following 24 hours, 33% of patients in the acupressure group had nausea, compared with 63% of controls. The cumulative incidence of vomiting at 24 hours was 25% and 61%, respectively. Twenty-six percent of patients treated with acupressure received a rescue antiemetic compared with 66% of controls. Two patients were not included in the analysis due to use of ineligible medications (N=1) and swelling in the treated hand (N=1). There were no other reported adverse effects. It should be noted that the study was improperly randomized (using the envelope method) and, though it was indicated to be observer-blinded, the method of blinding was not described.
• Schlager et al. conducted a double-blind, randomized, placebo controlled study to investigate the effectiveness of Korean hand acupressure in preventing postoperative vomiting in children scheduled for strabismus surgery (77). The study examined 50 children between the ages of three and 12 years who were scheduled for strabismus surgery. All subjects had American Society of Anesthesiologists (ASA) physical status I or II. Children were excluded from the study for the following reasons: gastric or intestinal diseases, emesis and vomiting in the week before the surgery, or medical treatment prior to surgery. Acupressure was induced by placing a disc on the Korean hand acupressure point K-K9, located on the fourth finger on both hands. Acupressure was given 30 minutes before induction of anesthesia and continued for 24 hours. The placebo group was not given an acupressure disc at K-K9. Only tape was placed on the fourth finger, similar to the group receiving acupressure. The children and parents, as well as the anesthetist and nursing staff, were not informed as to which arm of the trial each participant had been assigned. Two children in the acupressure group required antiemetic rescue therapy, compared to 10 children in the placebo group. All participants completed the study. The number of times each participant vomited was recorded by a nurse 24 hours after induction of anesthesia. Less vomiting occurred in the acupressure group than the placebo group (p=0.001). In the acupressure group, 20% of the children vomited in the first 24 hours after surgery, compared to 68% in the placebo group. Nausea was not studied in this trial since it is difficult to evaluate with children. Randomization and blinding methods were not described adequately in this study.
• Price conducted a randomized, single-blind, controlled study to investigate the effect of acupressure as an antiemetic in cancer chemotherapy in 53 patients, with observed beneficial results (109).
• Steele et al. conducted a multicenter, randomized controlled trial of 138 subjects to determine the effect of continuous acupressure at P6, applied with Sea-Bands® with acupressure buttons, on the frequency and severity of nausea and vomiting during the first trimester of pregnancy (110). Subjects were included if they had reported at least one episode of pregnancy-related nausea or vomiting (NVP), were within the first trimester of pregnancy, and were able to read and speak English. Participants were randomly issued Sea-Band® wristbands either with or without acupressure buttons. Participants were told to continuously wear a wristband on each wrist for four days, except during bathing, and to maintain a standardized log for the intervention days and for 72 hours after removal. The 72-hour washout period allowed for each participant to act as her own control. The manufacturer provided both the acupressure wristbands and the placebo bands. Adverse effects were not discussed. Of the 138 women issued a set of wristbands and instructed on the study protocol, 110 returned completed logs to the investigators. The 28 who did not return all data were not included in the analysis. The study did not include a discussion of concurrent therapies other than vitamin supplementation. For each of the seven days of the study, participants completed a five-question modified and abbreviated version of the Rhodes Index of Nausea and Vomiting. The researchers analyzed the data using Mann-Whitney U procedures and Wilcoxon's matched-pairs, signed-rank test. The researchers acknowledged that their sample size was not large enough to sufficiently reduce the chance of a type 1 error occurring, although this may be irrelevant as there was a large difference between the active and placebo groups. The researchers did not ask participants to report any other treatments they used to alleviate their NVP or any other possible causes of nausea and vomiting. The participants who were issued the active wristbands were given additional instruction in the proper placement of the acupressure knob, which could remove the blinding.
• Allen et al. conducted a randomized controlled trial to access the efficacy of acupressure on postoperative nausea and vomiting (86). A total of 46 patients, all women undergoing gynecological surgery and receiving a tightly controlled anesthetic regimen, were enrolled in the study. The inclusion criteria were: patients aged between 18 and 65 years, ASA status I or II, required gynecological surgery involving a Pfannenstiel incision, and no previous experience with this form of acupressure. Two patients were excluded due to previous exposure to the elasticized wristbands for motion sickness prevention. The ages and weights of the patients in the two groups were comparable: acupressure: average age 41.6 years (SD 7.4), weight 70.7kg (SD 16.4); sham: average age 44.2 years (SD 11.2), weight 73.7kg (SD 17.1). Twenty-three patients received acupressure via Sea-Bands® placed over the P6 point on the dorsum of the dominant wrist. The remaining subjects received acupressure at a "sham" point on the dorsum of the wrist on the dominant arm. All patients received a standard dose of anesthetic. Prior to premedication, both the treatment and the control groups had Sea-Bands® positioned on their dominant wrists. At 24 hours, the anesthetist visited the patients to collect data and record the amount of prochlorperazine and morphine administered. It was noted that no subjects experienced any untoward adverse effects. All subjects completed the study. The outcome measure was the severity of nausea or vomiting and the number of prochlorperazine doses requested and administered by the nursing staff. There was a reduction in the requests for antiemetic therapy in the group receiving P6 acupressure, but there was no difference in the incidence of nausea and vomiting. Also, there was no difference in total morphine consumption between the two groups. The use of acupressure had no effect on the maximum nausea/vomiting scores in the first 24 hours, although the sham group received more doses of prochlorperazine. There was a significant decrease in the amount of prochlorperazine administered to patients receiving P6 acupressure (p=0.036). Only nine out of 46 patients in this study were nausea-free and did not require antiemetics. Thus 80% experienced nausea or vomiting. It was not clarified how these patients were distributed between the active and sham treatment groups. It should be noted that the study power may have been insufficient (75% to detect a 50% change in the incidence of nausea and vomiting) to detect an effect.
• In an equivalence study, Roscoe et al. examined the efficacy of acupressure wristbands compared with standard care alone, as well as combined therapy, in preventing severe nausea in 86 breast cancer patients receiving doxorubicin-based chemotherapy, and at high risk of experiencing severe nausea following treatment (111). Patients were treated with standard care, standard care with acupressure bands (Sea-Bands®), or standard care with an acustimulation band (Reliefband®). Duration was not provided. In the acupressure group, the proportion of patients who reported severe nausea following chemotherapy treatment was significantly less than both the standard care group and the acustimulation group (41% vs. 68% and 73%, respectively). Delayed nausea and medication use was not affected. This study was not double-blinded, and no sham acustimulation band was used.
• Roscoe et al. conducted a randomized controlled study to examine the effect of acupressure as an adjunct to standard antiemetics for the relief of chemotherapy-induced nausea and vomiting (81). Seven hundred thirty nine patients were randomized. Patients were assigned to bilateral acupressure bands (Sea-Bands®), a single acustimulation band (Reliefband®), or no band (control). Patients could wear acupressure bands on one or both wrists if they desired. Bands were provided prior to treatment and worn for five days. The main endpoints were nausea, vomiting, quality of life, and antiemetic use with treatment. Results were available for 700 patients; no reasons were provided for lack of information from the other subjects. Patients in the acupressure condition experienced less nausea on the day of treatment compared to controls (data not provided; p<0.05). However, there were no significant differences in delayed nausea or vomiting among the three treatment conditions. Some gender differences were noted with suggestions of superiority for the acustimulation band. Limitations to this study include the lack of blinding (the authors acknowledge a potential for placebo effects) and an undescribed method of randomization.
• Alkaissi et al. conducted a randomized controlled trial to investigate the effect of sensory stimulation of the P6 point on postoperative nausea and vomiting (PONV) after gynecological surgery (13). The study included 410 women undergoing general anesthesia for elective gynecological surgery. The treatment group received bilateral P6 acupressure (N=135), another group received similar pressure on bilateral nonacupressure points (N=139), and the remaining subjects (N=136) served as a reference group. Study subjects were postoperatively treated with Sea-bands®, which were postoperatively positioned on both wrists at either the P6 point or on a nonacupoint just before the administration of anesthesia. The subjects were asked to wear the band continuously for 24 hours. If the bands caused discomfort, they could be removed for 30 minutes every two hours. During the study, a total of 61 adverse events were reported. These events included: discomfort, reported production of red indentation or itching (N=15), headache and dizziness (N=1), or reported wrist pain and band tightness causing swelling or deep marks or blistering at the site of the button (N=45). Twenty-six patients were withdrawn from the study: 12 due to changes from general anesthesia to local anesthesia and 14 patients because they were given antiemetics without meeting the criteria for treatment of PONV. Other patients who were also withdrawn included one with malignant hyperthermia, two with latex allergy, and one patient who could not read Swedish. However, these patients were replaced by including another 30 at the end of the study period. The primary outcome measured in this study was complete response, defined as no nausea, vomiting, or rescue medication for 24 hours. Complete response was more frequent in the P6 acupressure group than in the reference group (p=0.0194). Conversely, the incidence of PONV was 46% in the reference group, 38% after pressure on a nonacupoint, and 33% after P6 acupressure. The decrease from 46% to 33% was statistically significant. When considering vaginal cases separately, the decrease in PONV was from 36% to 20% (p=0.0168). The corresponding decrease from 59% to 55% in the laparoscopic surgery group was not statistically significant. A significant decrease occurred following vaginal surgery (44%) but not after laparoscopic surgery (7%). The authors claim that the design of their study makes it possible to estimate both the placebo effect and the incidence of PONV in the study population; however, it should be noted that their means of randomization were inadequate and that they failed to describe their method of blinding.
• Ming et al. conducted a randomized controlled study to examine the effect of stimulating two acupressure points (P6 and H7) on the incidence of postoperative nausea and vomiting (PONV) (95). Patients over 18 years of age who were scheduled to receive functional endoscopic sinus surgery (FESS) under general anesthesia were recruited from a hospital in the Taipei metropolitan area. Exclusion criteria were pregnancy, history of hypertension, uremia, renal failure, diabetes or gastrointestinal obstruction, concurrent chemotherapy, loss of upper extremities, infection, bruising, bleeding, thromboendarteritis, or malignant tumor in the hands (where acupressure was to be applied). A total of 150 subjects were divided into three groups, with each group consisting of 50 subjects. The average age was 48.7 years; 58.7% were male, and 41.3% were female. Subjects were randomly assigned to a finger-pressing group, a wristband group, or a control group. Two acupoints were used: Neiguan (P6) and Shenmen (H7). In the finger-pressing group, each acupoint was pressed for five minutes individually and separately in a treatment course of 20 minutes. Each acupoint was pressed for six seconds each time; the initial application of pressure was during the first and second seconds, pressure was applied continuously during the third and fourth seconds, and a slow release of pressure was carried out during the fifth and sixth seconds. This cycle was continuously repeated in the five-minute period of treatment. For the wristband group, one hour before the operation, the buttons against the acupoints P6 and H7 were pressed. At two and 10 hours after the operation, the band was released for 30 minutes, during which time the patients were accompanied by staff for 20 minutes; the band was then removed 24 hours after surgery. In the control group, the patients received no therapy; however, they were accompanied by a staff member as were those in the other two groups. In the finger-pressing group, the subjects were treated with finger pressing therapy on three occasions, each of which lasted 20 minutes. The first treatment was given one hour before the operation, the second treatment was given immediately before the patient was moved from the recovery room to the ward, and the last treatment was given 10 hours after the operation. In the wristband-pressing group, the patients were similarly treated except that a buttoned wristband was fastened on the wrist to apply pressure in lieu of finger pressing. The wrist button bands were removed 24 hours after the operation. Information regarding the incidences of nausea and vomiting, the amount of vomitus, and discomfort was collected at random times during the 24 hours after the operation. The state of anxiety questionnaire was administered before and 24 hours after the operation. No adverse effects from the treatment were noted. Initially, 152 subjects scheduled for routine FESS were recruited for the study. Two decided not to participate, as they did not experience any discomfort with previous similar operations. The Index of Nausea, Vomiting, and Retching (INVR) was used to evaluate nausea and vomiting. The INVR provides information on times, severity, duration, and amount of vomiting, as well as degree of discomfort. The State Anxiety Inventory, a subscale of the State-Trait Anxiety Inventory, was used as a surrogate measure of the efficacy of vomiting prevention by measuring the patients' degree of anxiety. Within 24 hours after operation, there were 13 episodes of nausea among 10 subjects in the finger-pressing group (12.3%), 36 episodes of nausea among 21 subjects in the wristband group (34.0%), and 57 episodes of nausea in 37 subjects among the control group (53.7%). The difference between groups was statistically significant (F=9.06, p<0.001). Within the same 24 hours, there were two episodes of vomiting by two subjects in the finger-pressing group (2.7%), 31 episodes of vomiting among 12 subjects in the wristband group (41.9%), and 41 episodes of vomiting in 21 subjects among the control group (55.4%). The difference between the three groups was significant (F=8.82, p<0.001). Differences in the discomfort level following nausea or vomiting were statistically significantly (F=19.16; F=8.50, p<0.001). Using Scheffe's post hoc test, the discomfort level for the control group was the highest, followed by the wristband group and the finger-pressing group. The difference in the mean score of anxiety before and after the operation was not statistically significant among the three groups (p>0.05). The mean score of nausea and vomiting during the 24 hours following the operation was 1.28 for the finger-pressing group (standard deviation (SD)=3.35), 4.34 for the wristband group (SD=6.63), and 6.96 for the control group (SD=5.96). The difference between the three groups in nausea and vomiting two hours following the operation was statistically significant (F=3.77, p<0.05). Scheffe's post hoc test demonstrated that the nausea and vomiting scores for the control group was much greater than the finger-pressing group. In addition, the difference in nausea and vomiting from 2-10 hours and after 24 hours following the operation was statistically significant (F=11.77; F=13.36, p<0.001). Scheffe's post hoc test revealed that nausea and vomiting scores for the control group were far greater than that for the finger-pressing group, but also higher than that of the wristband group. However, the difference in nausea and vomiting in the period from 10-24 hours following the operation was not statistically significant among the three groups (p>0.05). The authors report that finger-pressure is effective in preventing PONV; however, they note that their study suffers a number of limitations. In particular, they cite restrictions on availability of time, personnel, and budget. Since the subjects were patients who received FESS under general anesthesia, the generalizations made in this study are limited to this group of patients; that is, these findings may not be applicable to patients suffering from PONV following other types of surgery. The authors state that additional research with larger samples and multivariate statistical analysis is required. In addition to these considerations, it should be noted that during the time between the second and 24th hours after the operation, subjects had to self-record information related to nausea and vomiting. Also, while group selection was random, treatment blinding was not possible.
• Werntoft et al. conducted a randomized controlled study in 60 pregnant women to examine the effect of P6 acupressure on morning sickness (14). Women were included if they were having healthy and normal pregnancies with nausea and vomiting. Use of other therapies for pregnancy-related nausea and vomiting was excluded. Eighty women received envelopes containing wristbands or no wristbands (control) although results were included only for the first 60 women to return questionnaires. Wristbands offered acupressure at P6 or at a placebo point (upper wrist). Women wore wristbands for 14 days unless showering. The questionnaire was filled in on days 1, 3, 6, and 14 of the study and then returned. Nausea and vomiting were determined using the visual analog scale. Dropouts were not relevant to this study design, although, of the first 60 women to return questionnaires, it was indicated that two women had suffered miscarriages and four women found the wristbands too tight. Not all women indicated on the form to which group they had been assigned. Nausea during pregnancy was significantly reduced in the acupressure group, as compared to placebo acupressure or no treatment, after 14 days of treatment (a score of 4.2 in the P6 group vs. 5.9 in the placebo group and 6.5 in the no-treatment group). Relief from nausea appeared one day after starting treatment in both the P6 and placebo groups but lasted for only six days in the placebo group and 14 days in the acupressure group. Although described as randomized and placebo controlled, the method of randomization was improper (use of envelopes) and double-blinding was not described.
• Windle et al. conducted a randomized clinical trial to examine acupressure as a potentially safe complement to traditional drugs to prevent or relieve nausea and vomiting in postoperative patients (PONV) (112). The study comprised 157 patients. Inclusion criteria dictated that subjects be over the age of 18, with informed consent, and having had received gynecological, plastic, and urological surgeries. Exclusion criteria were as follows: nonfluent English speakers, patients with nasogatric tubes and peripheral vascular disease, or signs of compromised circulation in the upper extremities. The participants were randomly assigned to five groups: group 1 (N=29, acupressure on both wrists), group 2 (N=34, acupressure on one wrist), group 3 (N=30, wristband with no acupressure), group 4 (N=35, wristband without acupressure on one wrist), or group 5 (N=29, no wristband). Bands were attached immediately upon admission to the postanesthesia care unit (PACU) and worn until discharge or seven days, whichever occurred first. Hospital staff members were told to remove wristbands from patients after being discharged. Adverse effects, interactions, and dropouts were not mentioned. Nursing staff assessed and documented incidence of PONV, nursing interventions, and pharmacological and nonpharmacological interventions. There were no significant differences in terms of nausea and vomiting found between all five groups, as determined by one-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA). The authors state that these findings must be viewed with caution, as a power analysis showed low effect sizes and an inadequate sample size. They go on to suggest that further research is recommended with a larger sample size. It should be noted that it is also possible that the length of time that bands were attached may have been insufficient to produce a measurable effect. The authors also recommend the use of a visual analog scale to measure nausea and a maximum of three researchers to standardize results. Blinding, adverse effects, and dropouts were not discussed in this study. The method of randomization was also not described.
• Dibble et al. compared differences in nausea experience and intensity in women undergoing chemotherapy for breast cancer between those receiving usual care plus acupressure training and treatment and those receiving only usual care (80). Seventeen women receiving chemotherapy participated in the study, if they had nausea with previous chemotherapy. The intervention was finger acupressure bilaterally at P6 and ST36 (wrist and knee) for a maximum of three minutes each morning and as required during the day, for one cycle of chemotherapy (approximately 21 days). Subjects were taught how to self-apply by study nurses. Nausea experience measured by the Rhodes Index of Nausea, Vomiting, and Retching, as well as nausea intensity, was the main endpoint. Incidence of nausea was significantly reduced and of a decreased intensity in the acupressure group during the first 10 days of the chemotherapy cycle (exact values not provided). Adverse effects were not discussed. This study was not blinded; control groups did not receive any sham acupressure.
• In a randomized controlled study, Fan et al. investigated the effect of P6 acupressure on postoperative nausea and vomiting in 200 patients (93). Healthy patients undergoing short surgical procedures were included, while those using H2-receptor antagonists within 72 hours of surgery, or tranquilizers, or those with hypertension were excluded. Patients were randomized to acupressure (N=108) or control (N=92) groups. Spherical beads of acupressure bands were placed at the P6 points of both forearms in the acupressure group and were placed inappropriately on the posterior surface in the control group. Bands covered in soft cotton wrapping were placed before induction of anesthesia and removed six hours following the operation. A blinded observer was responsible for recoding endpoints (nausea, vomiting, and use of antiemetic medications). Twenty-five of 108 patients (23%) had nausea and vomiting in the acupressure group. In the control group, 38 of 92 patients (41%) had nausea and vomiting. This was statistically significant (p=0.0058). Limitations to this study include an undescribed method of randomization. Although reported as double-blind, the patient would have been aware of pressure placement.
• Stein et al. conducted a randomized equivalence trial in 25 patients to compare the effect of P6 acupressure with metoclopramide on intraoperative nausea during spinal anesthesia for cesarean section (83). Subjects included were healthy patients undergoing elective cesarean section during spinal anesthesia. Patients received either acupressure bands and 2mL of intravenous saline, placebo wristbands and 10mg of metoclopramide by slow intravenous administration, or placebo wristbands and 2mL of intravenous saline. P6 acupressure (N=6 with nausea) gave significantly more relief for patients experiencing intra-operative nausea during spinal anesthesia for cesarean section than the placebo group (N=19) and slightly less relief than the group receiving metoclopramide (N=4). Limitations include an improper method of randomization, an undescribed method of blinding, and a failure to describe withdrawals.
• O'Brien et al. conducted a randomized controlled trial to investigate the efficacy of P6 acupressure in reducing or relieving symptoms of nausea with or without vomiting and retching during pregnancy (113). One hundred sixty one pregnant volunteers were included. These patients had no previous experience with acupressure and had pregnancy-related nausea. Participants were assigned to one of three groups: P6 acupressure (Sea-Bands®), placebo (incorrect placement of bands), or control. Bands were worn for three days. The main endpoint was the Rhodes Index for Nausea and Vomiting. One hundred forty nine women completed the study. Adverse effects were not discussed. All participants reported significant decreases in nausea and vomiting or retching. There were no significant effects between groups. This study was well designed although reasons for withdrawals were not discussed.
• Hu et al. conducted a randomized, placebo controlled trial to evaluate the effectiveness of acupressure at P6 point on nausea associated with visually induced motion sickness (114). The study recruited 64 undergraduate students (32 men and 32 women) between 18 and 25 years of age. These subjects reported no visual problems, central nervous system disorders, or gastrointestinal disease or symptoms. The 64 subjects were randomly divided into four groups with 16 subjects in each condition: a P6 acupressure (group 1), a dummy-point acupressure (group 2), a sham P6 acupressure (group 3), and a control (group 4). Motion sickness was simulated using a rotating optokinetic drum. During the drum rotation period, group 1 received manual pulse pressure with about one pulse per second at the left P6 acupuncture point, group 2 received manual pulse pressure at a dummy-point, group 3 received manual finger contact at P6 but did not get pulse pressure, and group 4 served as the control group. The experimenter applying the pressure sat outside of the drum. Each subject had only one experimental session. The tests were run in the morning, during which each subject sat in the optokinetic drum for a total of 24 minutes: 12 minutes baseline and 12 minutes drum rotation. Adverse effects were not discussed. Dropouts were not mentioned in the study. The outcome measures included cutaneous measurements of gastric electrical activity, or electrogastrograms (EGGs). Subjective symptoms of motion sickness (SSMS) including dizziness, headache, salivation, warmth, cold sweating, and stomach discomfort were also recorded. Group 1 reported significantly less nausea during the drum rotation period than groups 2, 3, and 4 (p<0.02, p<0.05, and p<0.02, respectively). There were no significant differences in reports of nausea among groups 2, 3, and 4. Based on the post hoc Tukey comparisons, the SSMS scores for group 1 were significantly lower than groups 3 and 4 (p<0.01 and p<0.01, respectively) while no other group comparisons were significant. Also, the results indicated that group 1 had significantly lower EGG ratios than those in groups 3 and 4 (p<0.02 and p<0.02, respectively), which means that the subjects in group 1 showed the least increase in gastric activity and tachyarrhythmia during drum rotation. Results did not differ significantly among the other group comparisons. However, the subjects who received dummy-point acupressure (group 2) did not report significantly fewer symptoms or show less tachyarrhythmia than those in groups 3 and 4. This study did not involve people naturally experiencing motion sickness, but used healthy subjects in an artificial, nauseogenic situation. This study was not blinded.
• Barsoum et al. conducted a randomized controlled trial to investigate the effect of acupressure bands on postoperative nausea and vomiting in 162 patients (91): Inclusion and exclusion criteria were not discussed. Patients were randomized, by envelope method, to acupressure using elasticated bands containing a plastic button that applied sustained pressure at the P6 (Neiguan) point (Sea-Bands®), control dummy bands without the pressure button, or antiemetic injections of prochlorperazine with each opiate given. All patients received papaveretum injections as required for pain, and additional prochlorperazine injections were prescribed if nausea was not controlled adequately in the test groups. One hundred fifty two patients completed the study. Reasons for noncompletion were not provided. The major endpoints included the severity of nausea as assessed by linear analogue scale. Postoperative nausea was significantly (p=0.002) reduced by acupressure up to two days following the operation, as compared with both the control band group and the medication-treated patients (on day 1, results were 1.2 for the acupressure group, 2.4 for the control group, and 3.1 for the antiemetic group). Postoperative vomiting and the need for unplanned antiemetic injections were not significantly reduced in the acupressure group. Limitations to this study include improper randomization (envelope method) and a lack of blinding.
• Hyde et al. conducted a randomized, controlled crossover trial to examine the efficacy of acupressure therapy for morning sickness (115). Sixteen subjects were included. Inclusion and exclusion criteria were not provided. Eight subjects used acupressure wristbands for five days, followed by five days without therapy, while eight did the reverse. The main endpoint was results from the Multiple Affect Adjective Checklist and Sickness Impact Profile over the ten days. Use of acupressure wristbands relieved morning sickness for 12 of 16 subjects (chi 2=5.31 with Yates' correction factor, df=1, p<0.025). Anxiety and depression also appeared to be improved during the five days while wristbands were worn. This study was not blinded, as no bands were worn during the control period. Reasons for withdrawals were not provided. Nausea was improved by only a small amount considering the potential for placebo effects.
• Dundee et al. conducted a randomized controlled trial to examine the efficacy of acupressure at the P6 acupuncture point, in preventing morning sickness (72). Three hundred fifty patients in early pregnancy were included. Inclusion and exclusion criteria were not provided. Patients had five minutes of daily pressure, repeated at four hourly intervals, at the P6 point, pressure at a point near the right elbow, or no treatment. The severity and frequency of sickness over a period of four consecutive days was recorded. Troublesome sickness was significantly less in both the genuine (23/119) and dummy (41/112) pressure groups, as compared with the control group (67/119). A significant reduction in sickness remained only for the acupressure group when data was weighted to compensate for the lower incidence of fully completed returns in the active treatment groups. There were no side effects. It should be noted that this study was nonblinded and that the method of randomization was not described. No mention of withdrawals, other than incomplete returns, was made.
• Molassiotis et al. conducted a randomized controlled trial to examine the effect of P6 acupressure on chemotherapy-induced nausea and vomiting (116). Fifty-four patients with breast cancer, no experience with chemotherapy, and with a life expectancy of greater than three months were included. Acupressure was applied using wristbands (Sea-Bands®) which patients in the experimental group wore for five days following chemotherapy administration. The control group wore no bands. The major endpoint was the assessment of nausea, retching, and vomiting over the five days. Thirty-six patients completed the study: 19 in the control group and 17 in the acupressure group. Reasons for withdrawals were not provided. Scores for experiencing nausea (1.46 vs. 2.5) and retching (0.13 vs. 0.50), and occurrence of nausea (1.20 vs. 1.94), vomiting (0 vs. 0.22), and retching (0 vs. 0.22), as well as distress, were all significantly lower in the experimental group compared to the control group (p<0.05). Vomiting experience was not significantly lower. This paper was limited by an improper randomization procedure (envelope method) and a lack of blinding between groups.
• Perkins et al. conducted a randomized, controlled pilot study to examine the effect of acupressure on nausea and vomiting in palliative care patients (117).
• Puangsricharem et al. conducted a randomized controlled trial to examine the effect of auricular acupressure on nausea and vomiting in early pregnancy in 98 women (118). Women with symptoms of nausea and vomiting in early pregnancy before 14 weeks of gestation were included. Patients were randomized to treatment (magnetic pellets at both auricles) or control, for four days. Outcome measurement was a Rhodes Index score for severity and frequency of nausea and vomiting, as well as the amount of antiemetic drug taken, on the last three days of auricular acupressure. Results were returned from 91 women. The Rhodes Index scores for nausea and vomiting were reduced in the acupressure group, but the mean reduction was not significantly different from the control group. Antiemetic use did not differ between groups.
• Sadighha et al. conducted a randomized controlled study to compare the effect of acupressure wristbands versus metoclopramide for the prevention of postoperative nausea and vomiting (119).
• Jamigorn et al. conducted a randomized study to compare the effects of P6 acupressure and vitamin B6 for outpatient treatment of nausea and vomiting in early pregnancy (31). Pregnant volunteers with symptoms of mild-to-moderate nausea and vomiting between six and 12 weeks' gestation participated. For seven days, participants received a device for acupressure therapy and placebo drug or an otherwise identical but nonstimulating placebo device and vitamin B6. The primary outcome measure was self-recorded symptoms according to the Rhodes Index. The mean change in the Rhodes Index was not significantly different between the two groups. This study is limited by the lack of a true negative control group.
• Shin et al. conducted a randomized controlled study to examine the effect of Nei-Guan point acupressure on nausea, vomiting, and ketonuria levels in 66 women diagnosed with hyperemesis gravidarum (120). Patients were randomized to Nei-Guan point acupressure, a placebo group, or a control group, which received only conventional intravenous treatment. The degree of nausea and vomiting was significantly lower in the Nei-Guan point acupressure group in comparison with the placebo and control groups. Ketonuria levels were also significantly reduced on days 3 and 4.
• Shin et al. conducted a randomized controlled trial to examine the effects of Nei-Guan (P6) acupressure on nausea and vomiting in 66 pregnant women having hyperemesis gravidarum (121). In the treatment group, women were given P6 acupressure for ten minutes. A second group was the placebo group and a third group was the control group. Nausea and vomiting were the main endpoints. Nausea and vomiting were significantly reduced in the group receiving acupressure (F=8.259, p=0.001).
• Duggal et al. conducted a randomized controlled trial to examine the effect of acupressure on the incidence of nausea and vomiting after cesarean section under spinal anesthesia with added intrathecal morphine (84). Patients wore acupressure or placebo wristbands during surgery and postoperatively for at least 10 hours. The primary endpoint was incidence of intra- or postoperative nausea. There were no significant differences between the two groups following treatment. The demand for antiemetic medication was also similar. In a subgroup of patients who gave a previous history of postoperative nausea or vomiting, there was a statistically significant reduction in postoperative nausea and vomiting or retching in the acupressure group.
• Ferrara-Love et al. conducted a randomized controlled study to examine the effect of acupressure on the incidence of postoperative nausea in 90 same-day surgery patients (92). Patients were randomly assigned to treatment (N=30), receiving bilateral elastic bands that exerted pressure on the appropriate location on the distal aspect of the wrist; placebo (N=30), receiving elastic bands incapable of acupressure; or a control group (N=30), receiving routine nursing and medical interventions. Prescribed antiemetics were used if required. The primary endpoint was the incidence of nausea or vomiting. The incidence of nausea and vomiting did not differ in the operating room. In PACU phase II, the incidence was 10% in the treatment group, 20% in the placebo group, and 50% in the control group (overall, p=0.0001). Nausea and vomiting were significantly reduced in both treatment and placebo groups.
• Non-randomized studies (not included in evidence table): Lee et al. conducted a controlled trial to examine the effect of a Nei-Guan acupressure wristband on postsurgical nausea and vomiting in 40 patients undergoing middle ear surgery (122). Patients were assigned to wristband (acupressure applied with a wristband on the P6 point at both wrists from 30 minutes before to 24 hours after anesthesia) or control (no band) groups. The main endpoints were nausea and vomiting. Nausea and vomiting were significantly reduced in the patients wearing wristbands (t=2.303, p=0.028). Use of antiemetics was not affected.
• Markose et al. conducted an observational study to evaluate the effectiveness of P6 acupressure in reducing nausea, vomiting, and dry retching in pregnant women (123). The study recruited 35 unmedicated pregnant women, between 23 to 34 years of age and under 12 weeks of gestation, who experienced nausea with or without vomiting. The 35 studied subjects were asked to perform acupressure on point P6 (located on the forearm, anteromedially at a three-finger distance from the wrist crease). The first three days served as a control phase, with patients asked to apply treatment for 10 minutes on each hand, beginning on the fourth day. Subjects were provided with score sheets to be completed and returned after 10 days. Adverse events were not mentioned in the study. Only 17 of the 35 study subjects returned the score sheets appropriately completed. Outcome measures included: nausea, vomiting, and dry retching using the Rhodes Index of Nausea, Vomiting, and Retching (INVR). Statistical analysis showed no significant difference (p>0.05) in the symptoms between the first and third day, which illustrated the similarities among the studied subjects. However, a significant reduction in nausea, vomiting, and retching (p=0.08, p=0.000, p=0.004, respectively) was seen for the third and the seventh days. There was no significant difference (p>0.05) in symptom decrease on days 8-10. However, a significant reduction in nausea, vomiting, and retching (p=0.08, p=0.000, p=0.004, respectively) was seen for the third and the seventh days. There was no significant difference (p>0.05) in symptom decrease on days 8-10. It should be noted that this study was not a randomized controlled trial, and was therefore more prone to selection bias. Also, the study was of a small sample size, and the authors failed to calculate if their study was adequately powered. In addition, only half of the study subjects returned score sheets appropriately complete, with an inadequate follow-up of dropouts.
• In a placebo controlled study, Gieron et al. investigated the effectiveness of acupressure on frequency of emesis in 60 patients undergoing gynecological operations of longer duration, (100). Female patients, 18 to 65 years old (ASA groups I and II), were recruited. Small metal bullets were fastened at the P6 acupressure point and left for 24 hours. Premedication anesthesia, postoperative analgesia, and antiemetic treatment were all standardized. Nausea and vomiting over a 24-hour period were considered the primary endpoints. Acupressure (77% reduction) significantly reduced nausea up to the sixth postoperative hour, as compared with the placebo group (47% reduction) (p=0.03).
• Eizember et al. conducted a preliminary prospective study to determine the effect of acupressure on charcoal-associated emesis (124). The first part of the study was designed to determine the incidence of emesis following activated charcoal (AC). However, the primary goal was to test whether or not acupressure bands are effective in preventing charcoal-associated emesis. Another part of the study was to determine if the duration of acupressure prior to AC is directly correlated with the effectiveness of acupressure. Consecutive overdose patients were enrolled in the study. The control group consisted of 81 patients, while 106 patients were in the experimental treatment group. Exclusion criteria were as follows: patients less than 18 years old, those endotracheally intubated, or those having received ipecac, ingested antiemetic drugs, or received antiemetic drug therapy prior to or concurrently with AC. In the second part of the study, inclusion and exclusion criteria were identical to those for the preliminary aim of the study with the additional exclusion of protocol violation. Patients who were awake and less than 18 years old received 1g/kg activated charcoal (orally or via nasogastric tube). The patients were then observed for one hour following AC administration. These patients served as controls for the second part of the study, where acupressure bands were placed on overdose patients at the Nei-Guan P6 point of both wrists prior to activated charcoal, followed by one hour of observation. Adverse effects of acupuncture were not mentioned, however, management of emesis in any patient following AC was at the discretion of the treating physician. Toxic effects and interactions were not mentioned. Initially, 96 patients were enrolled in the preliminary portion as the control group of the study. Out of 96 patients, 15 were excluded due to criteria such as patients age being <18 years old, antiemetic ingestion or therapy, or lost medical records. Inability to review patient medical records constituted post hoc exclusion from the study. Therefore, only 81 patients were retained in the control group. One hundred twenty four patients were enrolled in the acupressure treatment portion of the study. Eighteen patients were excluded due to previously described exclusion criteria. Protocol violations included giving AC prior to placing acupressure bands, failing to place bands on both arms, or failing to give AC. This left 106 patients for analysis in the experimental treatment group. Demographic data and occurrence of emesis were described with observational statistics. Physicians or nurses completed a data form that included the time that acupressure bands were placed, time that AC was given, and presence or absence of vomiting within the observation period. The incidence of emesis with or without acupressure was compared. Furthermore, the duration of prophylactic acupressure was also analyzed in patients that vomited vs. those that did not. During the observation period, 21 of 81 controls (25.9%) experienced AC-associated emesis. However, in the acupressure group only 15/106 (14.2%) of subjects vomited. The incidence of emesis was 46% lower in the treatment group (chi squared=4.10; p=0.043). Finally, for the absolute difference in proportions the 95% CI was 1-23%. In 98 cases (times were not determined in eight cases), the duration acupressure bands were put in place prior to AC administration was recorded. The median duration of acupressure prior to AC was calculated to be four minutes (range 0-20) in patients with emesis and five minutes (range 0-125) in those without emesis. However, the medians were found to not be different when using the Wilcoxon rank sum test. This study suffers from several limitations that make interpretation of its findings difficult. These limitations include: inadequate description of design, lack of serum drug content testing, nonblinded design, and a lack of a strict AC administration protocol (including a failure to record total volume of AC administered).
• Shin et al. conducted a study to examine the effect of acupressure on emesis control in 40 postoperative gastric cancer patients undergoing chemotherapy (125). Patients were receiving the first cycle of chemotherapy with cisplatin and 5-fluorouracil and were regularly administered antiemesis medication. Patients also received or did not receive acupressure training (finger acupressure maneuver for five minutes on P6 point), at least three times daily before chemotherapy and mealtimes or based on their needs. Both groups also received nursing visits and consultations. The main endpoint was reported nausea and vomiting (Rhode's Index of Nausea, Vomiting, and Retching). It was reported that acupressure reduced the severity of nausea and vomiting, the duration of nausea, and the frequency of vomiting. Thus study did not appear to be randomized.
• Dent et al. examined the effectiveness of continuous PC6 acupressure, as an adjunct to antiemetic drug therapy, in the prevention and control of nausea and vomiting in the first 24 hours after myocardial infarction, in 301 patients (126) . The study was considered to be "partially randomized and partially blinded." Two hundred five males were included. The first 125 patients recruited received no additional intervention. Subsequent patients were randomized to receive continuous PC6 acupressure or placebo acupressure. Outcome measures included incidence of postmyocardial infarction nausea or vomiting, severity of symptoms, and use of antiemetic drugs. There were no significant differences between the groups for the 24-hour period of interest. During the last 20 hours of this period, the PC6 acupressure group experienced significantly less nausea or vomiting (18% vs. 32% placebo and 43% control) (p<0.05). The severity of symptoms and the need for antiemetic drugs were not significantly reduced by acupressure.
• Miller et al. conducted a nonrandomized comparative study to compare the effects of Acuband™ (acupressure) and ReliefBand™ (acustimulation) for motion sickness in 77 subjects (127). Subjects were assigned to Acuband™ or ReliefBand™, respective control bands, or a placebo (bandage). The instruments were applied either by previously trained subjects or by untrained subjects based on package instructions. Subjects were exposed to a maximum of 20 minutes of optokinetic drum rotation. Endpoints included symptoms and gastric myoelectric activity. Symptoms of motion sickness increased in all patients; however, onset was reduced in subjects using the ReliefBand™, compared with the Acuband™. Proper use did not affect outcome. This study was indicated as being "semi-randomized," and blinding was incomplete.
• Stern et al. conducted an open label trial to determine the clinical effectiveness of Acuband™ (a commercially available wristband) in the treatment of motion sickness (128). Patients were prescreened for susceptibility to motion sickness for inclusion. Acuband™ was positioned on the wrist between two tendons at the Neiguan point (P6), three finger-widths' down from the wrist crease, or on the arm three finger-widths' down from the elbow crease on the top side of the forearm. The control was no Acuband™ use. Patients were treated during one visit in each treatment arm on a total of three visits. No adverse effects were reported. Patient data for 13 patients could not be used. The most common reason was not attending all three sessions or exhibiting no susceptibility to motion sickness throughout the study, despite passing initial screening. Endpoints included subjective symptoms of motion sickness, abnormal gastric activity as recorded through electrogastrography, and tachyarrhythmia. Of the 38 patients who enrolled, 13 were dropped; 25 patients completed. Fifteen of the completers were female, and were all university students aged 18-22. ECG readings were taken from each subject's upper abdominal wall approximated to the antrum. Subjects reported fewer symptoms of motion sickness on days wearing the product on either the wrist or the arm than on days with no Acuband™; group mean report symptom scores were 11.9 on control days, Acuband™-wrist 6.5, Acuband™-arm 7.8 (p<0.01). No significance was found between the two Acuband™ placements, though both were significantly better than control. The amount of tachyarrhythmia found in the three treatments varied between 24.2% in the control group, 20.6% in the Acuband™-wrist group, and 19.9% in the Acuband™-arm group (p<0.05). Both acupressure treatments were observed as superior to control. Although the authors report positive results, the open-label trial format of this study limits the impact of these positive results; patients knew what treatment they received and were not kept from learning more about the examined product. Also, excluding dropout data in the final analysis because certain patients did not experience motion sickness symptoms even after experiencing symptoms meeting inclusion criteria does not appear to be justified.
• Gardani et al. conducted an open before-and-after comparison study to examine the effect of acupressure on antiemetic therapy-resistant, chemotherapy-induced vomiting (129). Forty consecutive advanced cancer patients with untreatable chemotherapy-induced vomiting were included. Patients presented with various cancers, including colorectal cancer, lung cancer, and breast cancer. P6 acupressure was for at least six hours daily at the onset of chemotherapy. Vomiting was improved in 70% of patients (28/40).
• Promising results have also been presented in a before-and-after comparison using acupressure for chemotherapy-induced nausea (130), as well as in a case series (131).
• A case series of 27 pregnant women reported that nausea and vomiting were reduced by 50% by Sea-Bands®, and that effectiveness was greater the earlier their application (132).
• Select combination studies: Klaiman et al. conducted a double-blind, randomized controlled trial to examine the effect of magnetic acupressure in the prevention of postoperative nausea and vomiting in 58 patients (133). Thirty-three of the patients underwent ear, nose, and throat procedures, and twenty-five underwent gynecological procedures. Patients were randomized to a magnet patch or placebo patch, applied 15 minutes before surgery to the P6 point above the wrist. Anesthesia was standardized. The primary endpoints included nausea and vomiting scores and rescue antiemetic medication use. Secondary endpoints included pain scores, percentage of patients who required rescue analgesics, and satisfaction scores. Postoperative nausea and vomiting occurred in 50% of patients. There were no differences between groups in terms of incidence or scores of nausea and vomiting, satisfaction level, pain scores, or rescue medication use.
• Melchart et al. conducted a randomized, controlled crossover study to investigate whether a combination of acupuncture and acupressure is effective for reducing chemotherapy-induced nausea and vomiting (134). Twenty-eight patients receiving moderately or highly emetogenic chemotherapy and conventional, standard antiemesis therapy were included. For one chemotherapy cycle, patients were treated with a combination of acupuncture and acupressure at P6 and for one cycle at a nearby sham point. The main outcome measure was the daily nausea score. There was no difference between combined acupuncture and acupressure treatment at P6 as compared with the sham point for the nausea score. Overall, the level of nausea was very low. Due to the combination nature of this study, the effect of acupressure alone cannot be determined.

Anxiety

• Summary: Standard, as well as auricular, acupressure has been investigated for the reduction in anxiety associated with pain, operation, and medical transportation. While preliminary evidence is promising, well-designed studies of high methodological strength are required before recommendations can be made in this indication.
• Evidence: Kober et al. conducted a prospective, randomized, blinded study to investigate the effectiveness of auricular acupressure during ambulance transport on stress and anxiety (135). A total of 36 patients were enrolled in this study. Patients were 23-89 years old and were being transported by ambulance to local hospitals for anticipated gastrointestinal procedures. Patients were excluded if they could not give informed consent, were not fluent in German, had neurological or psychiatric disorders, chronically used sedatives, or reported visual analog pain ratings greater than 80. Patients were randomized after baseline assessment by opening a sealed envelope with the predetermined group assignment. Seventeen subjects were randomized into the relaxation group. These patients received bilateral auricular acupressure at a relaxation point at the superior lateral wall of the triangular fossa. A small (1mm in diameter) plastic ball was pressed onto this point and fixed in place with an opaque ear patch for the duration of the ambulance ride. The sham group consisted of 19 patients who received bilateral auricular acupressure at the tip of the concha, a point that is reported to achieve homeostasis of the stomach and is not documented to have any relaxation or antianxiety effects. A small (1mm in diameter) plastic ball was pressed onto this point and fixed in place with an opaque ear patch for the duration of the ambulance ride. The patients were treated with acupressure for the duration of their ambulance ride to the hospital. A small (1mm) plastic ball was affixed to the randomly assigned pressure point with an opaque patch in both groups. Treatment and data collection were conducted separately; one paramedic performed treatment, while another took baseline and post-treatment data. The two were separated during this process to ensure blinding. The paramedic performing treatment did not know one point was a sham point; he was simply told that researchers were comparing the effectiveness of two points in order to prevent bias. No adverse effects were mentioned. The study was completed by all enrolled patients. No interactions were noted. The effectiveness of treatment was measured by self-assessment using the visual analog scale. Patients rated their anxiety on a scale of 0-100, with 100 being extreme anxiety. Patients were also asked four questions in an anticipation questionnaire, which consisted of questions about the waiting period for treatment, pain that was anticipated during treatment, the patient's attitude toward physicians, and treatment outcomes to investigate the patient's anticipation of medical treatment. Each question was rated with the visual analog scale of 0-100, with 0 being maximal satisfaction, 100 being absolute dissatisfaction. Patients receiving acupressure at the relaxation point reported significantly lower anxiety scores after treatment than patients in the sham group (p=0.002). Anticipation of pain during treatment was significantly lower in patients with acupressure at the relaxation point (p=0.006). Patients in the relaxation group were significantly more optimistic about their treatment outcomes after the intervention as compared to the sham group (p=0.014). Significant differences were not found in the estimation of waiting times for treatment (p=0.83), attitude toward the physicians (p=0.53), blood pressure or heart rate. The authors note the limitation of using the visual analog scale to measure anxiety, as it is less appropriate than the Spielberger state trait anxiety inventory; however, the latter test takes approximately 10 minutes to complete and was impractical under the parameters of the study.
• Kober et al. conducted a prospective, randomized, double-blinded clinical trial to evaluate whether acupressure could decrease pain and anxiety and increase patient satisfaction in patients with minor trauma (35). The study included 60 patients ranging from ages 19-99 with minor trauma or small injuries such as simple fractures, small wounds, and contusions. The study excluded patients who were not fluent in German, were unable to give informed consent, were taking any analgesics for chronic pain disorders, had a history of neurological or psychiatric disorders, or had a pain visual analog scale (VAS) score >8. Study subjects were randomly assigned to three groups. Group 1 ("true acupressure") received acupressure stimulation at points Di4 (Hegu), KS9 (Zhongchong), KS6 (Neiguan), BL60 (Kunlun), and LG20 (Baihui). Group 2 ("false acupressure") received acupressure stimulation at sham points. Group 3 ("no acupressure group") served as the control group. Stimulation involved using the paramedic's finger, and data were collected by an independent observer that was blinded to the group assignments. The subjects were treated according to group assignment for approximately three minutes. For Group 3, treatment consisted of waiting. No treatment-related adverse effects were observed or reported, and all patients completed the study. The outcome measures included: pain and anxiety reduction (using visual analogue scales), hemodynamic variables such as heart rate and blood pressure, and overall patient satisfaction. The results demonstrated that Group 1 had a significant (p<0.01) reduction in pain while Groups 2 and 3 remained unchanged. Anxiety was also significantly reduced (p<0.01) in Group 1, in 68% of the patients. However, in Group 2 and Group 3, the decrease in anxiety was insignificant (p=0.64 and p=0.56, respectively). Heart rate scores showed trends similar to pain scores, Group 1 showing a significant (p<0.01) heart rate reduction (observed in 89% of the cases) while in Group 2 and Group 3 heart rates remained unchanged. There were no significant changes in blood pressure, either among the groups or within the groups before and after treatment. Lastly, patient satisfaction scores after treatment were significantly (p<0.01) better in Group 1 than in Group 2 and Group 3. All patients had similar baseline characteristics which minimized the potential introduction of confounding variables.
• Mora et al. conducted a randomized, double-blind, placebo controlled trial to evaluate the effectiveness of auricular acupressure as a treatment for anxiety during transport to hospital in elderly patients with renal calculi (136). The study recruited 100 patients aged 65-90. The inclusion criteria were renal or urethral calculi, previous painful Extracorporeal Shock Wave Lithotripsy® (ESWL®), and social insurance. Exclusion criteria were inability to converse in German, inability to give informed consent, neurological or psychiatric disorders, chronic sedative intake, acute renal colic, a score higher than zero on the visual analog scale (VAS) for pain, analgesic drug intake within 48 hours of the study, or kidney stones larger than 2cm. Patients in the treatment group received bilateral acupressure with a plastic ball affixed with an opaque patch at the superior lateral wall of the triangular fossa. Patients in the sham group received bilateral acupressure with a 1mm plastic ball affixed with an opaque patch at the tip of the concha, a point that has been reported to improve homeostasis in the stomach. The treatment was used one time, during ambulance transport to the hospital. Both the sham and acupressure treatments were similar in appearance. The randomized treatment was performed by one paramedic, while data collection was performed by another paramedic blinded to the randomization. There were no patients that dropped out of the study. The visual analog scale for anxiety, a self-assessment tool to rate anxiety on a scale of 0-100 (0=no anxiety, 100=extremely anxious), was used to evaluate anxiety levels of patients before and after intervention. A four-item questionnaire was also used to evaluate the patient's feelings on the estimated waiting time until treatment, anticipated pain, attitude toward physicians, and potential treatment outcomes. Blood pressure and heart rate were also measured. The 100 patients included in the study had similar baseline characteristics, and were randomly assigned to treatment (50 patients) or sham (50 patients). After the intervention, patients in the treatment group had significantly less anxiety than patients in the sham group (VAS score 15.4 ± 9.8 vs. 49.8 ± 28.9, p=0.001). Acupressure patients also had significantly less anticipation of pain (VAS score 9.5 ± 4.1 vs. 33.8 ± 25.2, p=0.001) and were more optimistic about treatment outcomes (VAS score 11.1 ± 7.4 vs. 51.5 ± 25.5, p=0.001) as compared to the control group. There was no significant difference found between the groups in terms of estimation of waiting times, attitude toward physicians and acupuncture, blood pressure, or heart rate. The authors note that the visual analog scale may not have been the best measure to assess anxiety. The STAI is considered the gold standard in the acute setting; however, it takes approximately 10 minutes to complete and may not have been appropriate in this study.
• Agarwal et al. conducted a prospective, randomized, placebo controlled study of 76 adults undergoing elective surgery to assess the effects of acupressure on preoperative anxiety and bispectral index (BIS) values (43). Male and female patients, aged 18-50 years old, with ASA physical status I and II and undergoing elective surgical procedures were enrolled in the study. Patients taking any sedative, tranquilizer, or acupressure or acupuncture therapy were excluded from the study. Patients were allowed to relax for 15 minutes in the preoperative area. Then, depending on the group to which they were randomized, acupressure was applied to the "extra 1 point," located between the two eyebrows at the root of the nose. Placebo was considered to be acupressure applied 2cm laterally and horizontally from the lateral end of the left eyebrow. The treatments (acupressure and control) were given by the same investigator by applying acupressure by the pulp of the right thumb in a rotary fashion at 20-25 cycles per minute for 10 minutes. Following this, patients were observed for 30 minutes. The total study period lasted 40 minutes. Adverse effects were not discussed. The primary outcome was anxiety, measured on a visual stress scale (VSS). Bispectral index (BIS) values were also measured. The VSS decreased significantly from baseline in both groups following acupressure for 10 minutes (five vs. eight in the acupressure and seven vs. eight in the control group; p<0.001). However, anxiety returned to baseline in both groups 30 minutes after the release of pressure (p>0.05). Reduction of anxiety in the acupressure group was considered significant as compared to reduction of anxiety in the control group at the end of 10 minutes (five vs. seven). Another outcome was bispectral index (BIS) values. At two, five, and 10 minutes of pressure application, the BIS values were lower than baseline in both groups (p<0.05). During pressure application, BIS values were lower in the acupressure group as compared to the control group (p<0.05). Limitations of this study include nondisclosure of the loss of four patients; 76 patients were randomized but results are only reported for 72. Adverse events were also not discussed.
• Wang et al. conducted a randomized, sham-controlled pilot study to test if acupressure at the Yingtang point would decrease anxiety in parents of surgical patients (137). The study comprised 61 parents of children who were scheduled to undergo elective surgery. Subjects were ASA physical status I or II, with no history of psychiatric illness, and no previous experience with acupuncture. Both groups were treated with an acupressure bead (Helio, San Jose, CA) secured by tape covering. The experimental group received an acupressure bead at the Yingtang point found between the two eyebrows. The control group received a bead at a sham point found on the top left side of the left eyebrow. The beads were applied by the first author, a trained licensed acupuncturist. Twenty minutes after the bead was applied, outcomes were measured and the bead was removed. Participants were randomized based on a computer-generated randomization table. Adverse effects were not discussed. According to the authors, no protocol violations occurred during the study. Anxiety was measured using state trait anxiety inventory. Heart rate and blood pressure was also measured. Changes in sedation were also measured using a bispectral index monitor. At baseline, there were no differences between the two groups in terms of anxiety. At 20 minutes post-application, the acupuncture group was significantly less anxious (37 ± 10 vs. 45 ± 13, p=0.03). There were no differences found between the groups regarding the bispectral index , heart rate and blood pressure.
• Fassoulaki et al. conducted a randomized crossover trial to examine the effects of pressure on the "extra 1" acupuncture point on stress, tension, and bispectral index values (138). Twenty-five male and female patients were included in the study. Subjects were ASA physical status I or II and nonsmokers. Patients were excluded if they were taking sedatives, analgesics, or other drugs, if they had been exposed to acupuncture, or if they believed in traditional Chinese medicine. Twenty-five volunteers received pressure on the Yintang, or "extra 1" point (located midway between the medial ends of the two eyebrows at the root of the nose), and on a control point (located 2cm from the lateral end of the left eyebrow) in a randomized manner and on different days. Data were recorded by a blinded anesthesiologist. The pressure on the extra 1 point was applied by the thumb for 10 minutes while performing circular movements every 20-25 minutes. The duration of pressure on the control point was limited to five minutes, because volunteers found it to be an unpleasant feeling. All patients received both the treatment and control interventions. No adverse effects were noted, other than the unpleasant feeling caused by the control acupressure. No patients dropped out of the study. To record data, an electrode was attached to the patient for five minutes to obtain stable bispectral index (BIS) values. At the end of each 30-second period, the median of three BIS values was recorded. When the treatment was completed, BIS values were recorded for three minutes in the patients receiving acupressure to the extra 1 point, and the average of values recorded during this time was calculated. After BIS measurements were taken, each patient was asked to score his or her stress, tension, and anxiety on a scale of 0-10. A Friedman test was done and showed a significant difference among baseline BIS values, the values found during pressure application on the "extra 1" point for 2.5, 5.0, 7.5, and 10 mins., and the values after pressure release (p<0.001). A difference was also found between the BIS values obtained before and 2.5 minutes and 5.0 minutes into the pressure application on the control point also differed (p<0.001). There was a significant decrease in the BIS values during pressure on the extra 1 point at all time points when compared with the baseline values (p<0.001). During pressure application, BIS values were lower than those obtained after pressure release (p<0.001). When pressure was applied to the control point, BIS values were reduced after 2.5 and 5.0 min (p<0.001 for both). The baseline values of BIS were similar for the extra 1 and control point but the extra 1 point was significantly lower during the 2.5- and 5.0-minute period of pressure application (p<0.001 for both). The verbal stress scale values were reduced by 50% after pressure on the extra 1 point (p<0.001) and by 14% after pressure application on the control point (p<0.001). No study limitations were noted by the authors; however, there were an uneven number of men and women in the study (four men and 21 women). A letter to the editor (139) suggested that the control point chosen in this study was inappropriate, as it corresponds to the extra meridian point Taiyang. This letter also called attention to the fact that the control point caused pain to the patients, enough that the control and test pressures could not be done at the same time. This pain could have aroused the patient instead of providing a sedative effect, skewing the results. The study authors justified their selection of this control point as it was the only feasible point close to the BIS sensor, so any interference of pressure application with the BIS sensor and signal could be perceived in both the treatment and the control groups. Another letter to the editor (140) noted that the intensity of acupressure was not standardized and that the study authors did not have a nonintervention group. It is also pointed out that the control point used did not lie in the same dermatome and may not have comparable innervation as the true acupressure point. The study authors countered that pressure could not feasibly be standardized due to the variable pain thresholds from individual to individual and that a nonintervention group would not control for any interference problems with the BIS sensor. Furthermore, the authors cited the inherent difficulty in determining "comparable density" of innervation.
• Wang et al. conducted a randomized controlled trial to examine the effect of acupressure at the extra 1 point on anxiety in 52 children undergoing endoscopic procedures (141). Children received acupressure beads at the extra 1 point or at a sham point. The main endpoint was anxiety scores. Children in the test group experienced reduced anxiety (-9%) and children in the sham group experienced increased anxiety (2%) (p<0.05). Total intraprocedural propofol requirements did not differ between groups.

Pain (general)

• Summary: Acupressure using aromatic essential oils (lavender) may reduce pain intensity, stiffness, and stress in patients with neck pain for up to one month. Auricular acupressure may reduce pain and anxiety among hip fracture patients. Acupressure may also aid in the improvement of hemiplegic shoulder pain and motor power among stroke patients. Further well-qualified studies of strong design are needed to confirm these findings.
• Evidence: Kober et al. conducted a prospective, randomized, blinded study to investigate the effectiveness of auricular acupressure during ambulance transport on stress and anxiety (135). A total of 36 patients were enrolled in this study. Patients were 23-89 years old and were selected for having been transported by ambulance to local hospitals for anticipated gastrointestinal procedures. Patients were excluded if they could not give informed consent, if they were not fluent in German, if they had neurological or psychiatric disorders, if they had chronic sedative use, or if they reported visual analog pain ratings greater than 80. Patients were randomized after baseline assessment by opening a sealed envelope with the predetermined group assignment. Seventeen subjects were randomized into the relaxation group, and these patients received bilateral auricular acupressure at a relaxation point at the superior lateral wall of the triangular fossa. A small (1mm in diameter) plastic ball was pressed onto this point and fixed in place with an opaque ear patch for the duration of the ambulance ride. The sham group consisted of 19 patients who received bilateral auricular acupressure at the tip of the concha, a point that is reported to achieve homeostasis of the stomach and is not documented to have any relaxation or antianxiety effects. A small (1mm in diameter) plastic ball was pressed onto this point and fixed in place with an opaque ear patch for the duration of the ambulance ride. The patients were treated with acupressure for the duration of their ambulance ride to the hospital. A small (1mm) plastic ball was affixed to the randomly assigned pressure point with an opaque patch in both groups. No adverse effects were mentioned. The study was completed by all enrolled patients. No interactions were noted. The effectiveness of treatment was measured by self-assessment using the visual analog scale. Patients rated their anxiety on a scale of 0-100, with 100 being extreme anxiety. Patients were also asked four questions in an anticipation questionnaire, which consisted of questions about the waiting period for treatment, pain that was anticipated during treatment, the patient's attitude toward physicians, and treatment outcomes, to investigate the patient's anticipation of medical treatment. Each question was rated with the visual analog scale of 0-100, with 0 being maximal satisfaction, 100 being absolute dissatisfaction. Patients receiving acupressure at the relaxation point reported significantly lower anxiety scores after treatment than patients in the sham group (p=0.002). Anticipation of pain during treatment was significantly lower in patients with acupressure at the relaxation point (p=0.006). Patients in the relaxation group were significantly more optimistic about their treatment outcomes after the intervention as compared to the sham group (p=0.014). Significant differences were not found in terms of estimation of waiting times for treatment (p=0.83), attitude toward the physicians (p=0.53), blood pressure, or heart rate. One paramedic performed treatment, while another took baseline and post-treatment data; the two were separated during this process to ensure blinding. The paramedic performing treatment did not know one point was a sham point; he was simply told researchers were comparing the effectiveness of two points in order to prevent bias. The authors noted the limitation of using the visual analog scale to measure anxiety, as it is less appropriate than using the Spielberger state trait anxiety inventory; however, this inventory takes 10 minutes to complete and was therefore impractical in this study.
• Kober et al. conducted a prospective, randomized, double-blinded clinical trial to evaluate whether acupressure could decrease pain and anxiety and increase patient satisfaction in patients with minor trauma (35). The study included 60 patients ranging from ages 19-99 with minor trauma or small injuries such as simple fractures, small wounds, and contusions. The study excluded patients who were not fluent in the German language, unable to give informed consent, taking any analgesics for chronic pain disorders, had a history of neurological or psychiatric disorders, or had a pain visual analog scale (VAS) score of >8. Study subjects were randomly assigned to three groups. Group 1 ("true acupressure") received acupressure stimulation at points Di4 (Hegu), KS9 (Zhongchong), KS6 (Neiguan), BL60 (Kunlun), and LG20 (Baihui). Group 2 ("false acupressure") received acupressure stimulation at sham points. Group 3 ("no acupressure group") served as the control group. Stimulation was performed with a finger of the paramedic, and data were collected by an independent observer that was blinded to the group assignments. The subjects were treated according to group assignment for approximately three minutes. For Group 3, this consisted of waiting. No treatment-related adverse effects were observed or reported, and all patients completed the study. The outcome measures included: pain and anxiety reduction (using visual analogue scales), hemodynamic variables such as heart rate and blood pressure, and overall patient satisfaction. The results demonstrated that Group 1 had a significant (p<0.01) reduction in pain while Groups 2 and 3 remained unchanged. Anxiety was also significantly reduced (p<0.01) in Group 1, in 68% of the patients. However, in Group 2 and Group 3, anxiety decrease was insignificant (p=0.64 and p=0.56, respectively). Heart rate scores showed similar trends, as pain scores in Group 1 showed a significant (p<0.01) heart rate reduction (observed in 89% of the cases), but in Group 2 and Group 3 heart rate remained unchanged. There were no significant changes in blood pressure, either among the groups or within the groups before and after treatment. Lastly, patient satisfaction scores after treatment were significantly (p<0.01) better in Group 1 than in Group 2 and Group 3. All patients had similar baseline characteristics which minimized the potential introduction of confounding variables.
• Arai et al. conducted a randomized controlled trial to examine the effect of acupressure applied at the extra 1 point on the pain of needle insertion in 22 healthy females (142). Patients were given acupressure at the extra 1 point or at a sham point. The main endpoint was the score of pain on needle insertion using a verbal rating scale, as well as heart rate variability. Acupressure at the extra 1 point significantly reduced, and acupressure at the sham point significantly increased, the score on the verbal rating scale. Heart rate variability was also reduced in the treatment group.
• Wang et al. conducted a randomized comparative study to contrast the effects of Tuigua manipulation combined with quadriceps exercise and tuina for treating degenerative arthritis in 48 patients (143). Patients were treated with Tuigua manipulation combined with quadriceps exercise or tuina, for three courses of treatment, with each course lasting ten days. Endpoints included pain, joint range of motion, function, and muscle power. There were no statistically significant differences between the numbers of knees cured in each group. Pain and joint range of motion improved equally in both groups. Knee function and quadriceps muscle power improved more in the Tuigua group.

Agitated behavior (in dementia)

• Summary: While acupressure has been used traditionally to alleviate anxiety, its effect on agitation associated with dementia has also been investigated in a pilot study. Although acupressure was found to reduce agitation in this patient group, methodological weaknesses such as a lack of randomization and blinding limit the strength of these findings. Further study is required before recommendations can be made.
• Evidence: Yang et al. conducted a controlled pilot study to investigate the efficacy of acupressure in decreasing agitated behaviors associated with dementia (45). A total of 31 patients were recruited from the Ning-Yen long-term care facility. Participants were men and women, 65-86 years of age, who met the DSM-IV standard for dementia as diagnosed by psychiatrists or neurologists, scored 40 or above on the Cohen-Mansfield Agitation Inventory (CMAI), which is defined as severe agitation (Cohen-Mansfield et al. 1989), expected to be in the nursing home for at least 13 weeks, and possessed no broken skin or infection around the acupressure points (head and extremities). Subjects received acupressure treatment or control treatment; subjects served as their own controls. Five acupoints were used to treat agitation: Fengchi (GB20), Baihui (Du20), Shenmen (He7), Niguan (Pe6) and Sanyinjiao (Sp6). After a five-minute warm-up period (holding, rubbing and pressing the palms and finger joints on the hands), pressure was applied to each acupoint for two minutes. Acupressure treatments were 15 minutes in duration and were applied twice daily in weekly cycles (five days of treatment with two days off), for four weeks. This was followed by a four-week control period, consisting of companionship and conversation. There was a treatment-free washout week between the acupressure period and control periods. Acupressure was performed by the principal investigator at five specific acupuncture points with force set at 3-4kg with a time difference in application of <5 seconds. The investigator was observed for accuracy by acupuncture specialists and tested for consistency two times a week. Adverse effects, allergies, and toxic effects were not discussed. Eleven subjects dropped out of the study due to discharge from the facility or hospitalization. Interactions were not discussed. Outcome measures included the Cohen-Mansfield Agitation Inventory (CMAI) and daily agitation records of physical, verbal, nonverbal, and nonphysical attacks. The difference between pre- and post-treatment results for CMAI for acupressure was 19.45 and for control was -2.15 with a paired t-test of 6.517 (p<0.001). The F-value from daily agitation records was 13.402 for physical attack, 12.432 for verbal attack, 14.198 for nonphysical attack I, 16.29 for nonphysical attack II, and 7.798 for nonverbal attack (p<0.001). The small sample size did not allow for a crossover study design. Other limitations of the study were a high dropout rate with reasons for dropout possibly due to treatment. Additionally, the study was nonblinded, as the principle investigator administered treatment. Also, patients were not of similar cognitive function or psychotropic drug use. Finally, there was no true control group, and the "control treatment" (companionship and conversation) may not be an accurate control; acupressure at nonacupoints may have been more appropriate.

Alertness

• Summary: While acupressure has been used traditionally to treat sleep disorders and fatigue, its effect on alertness in has not been widely investigated. In one study, stimulation acupressure was associated with less fatigue and increased alertness; however, methodological weakness prevents strong conclusions from being drawn. Further study is required before general recommendations can be made in this indication.
• Evidence: Harris et al. conducted a crossover (two treatments; three periods), single-blinded, equivalence trial of 39 subjects to determine whether two different acupressure treatments have opposing effects on alertness in a full-day classroom setting (144). Study subjects had to be at least 18 years of age, a member of the Michigan School of Public Health class being studied (CRDSA cohort XI), and be present during the May 2004 CRDSA session. Study subjects were excluded if they had prior experience with acupuncture or acupressure. Subjects in Sequence I self-administered acupressure in the following order: stimulation (day 1), relaxation (day 2), and relaxation (day 3); subjects in Sequence II self-administered acupressure in the order: relaxation (day 1), stimulation (day 2), and stimulation (day 3). Treatments were for 15-minute sessions daily, administered over a period of three days (three minutes at each of five separate points). Instructors taught all study participants the same method, location, and intensity of acupressure to be used. Adverse effects were brief, not clinically significant for individuals, and not statistically significantly different between sequences. Muscle cramps (N=5), muscle aches (N=5), headaches (N=6), and fatigue (N=7) were the most common adverse effects. Dropouts were not discussed. The primary outcome was the difference between afternoon and morning scores on the Stanford Sleepiness Scale (afternoon-morning score). The least-square means for the stimulation and relaxation acupressure treatments were 0.570 and 1.127, respectively, with a significant difference in change in alertness scores between the two acupressure treatments. After including outliers' responses in the results, the adjusted least square means for the stimulation and relaxation treatments were 0.736 and 1.196, respectively, with a trend toward less fatigue with stimulation acupressure. Overall, the study showed that a stimulation acupressure regimen induced a statistically significant reduction in sleepiness and improvement in alertness, as measured by the Stanford Sleepiness Scale, compared to a relaxation acupressure treatment. Limitations of this study include the possible subject discernment of assigned treatment arms; the inability to apply the study findings to the general population; and the inherent design of the acupressure treatment arms. It is not clear whether the treatment regimens were optimal in pressure, duration, or location to produce the greatest effect, and the method of self-administration may have introduced inconsistencies among subjects. Further studies are needed in other populations to determine the scope of observed effects, to optimize acupressure regimens, and to determine if acupressure not only affects perceived fatigue but also quantitative measures of sleepiness.

Asthma (quality of life)

• Summary: Acupressure has been studied for its purported ability to improve both quality of life and respiratory symptoms associated with respiratory disorders such as asthma. Preliminary evidence suggests some improvement in chronic obstructive asthmatics on scores for the St. George's Respiratory Questionnaire, although further study in required before recommendations can be made.
• Evidence: Maa et al. conducted a randomized, controlled pilot study to compare acupuncture or acupressure with standard care, over standard care alone, on quality of life and symptoms of asthma in 70 adult asthma patients (41). Seventy patients with chronic obstructive asthma were enrolled. Inclusion and exclusion criteria were not provided. Patients were randomly assigned to receive acupuncture (20 treatments over eight weeks at Zhongfu, Dazhui, Dingchuan, Neiguan, and Zusanli points) in addition to standard care (N=26), acupressure (self-administered daily whenever needed or at least once daily at Zhongfu, Dazhui, Dingchuan, Neiguan, and Zusanli points) and standard care (N=23), or standard care alone (N=21) for eight weeks. Only 41 subjects completed the study. It was reported that many patients failed to make appointments. The major endpoints included the six-minute walking test, the Dyspnea Visual Analogue Scale, the modified Borg scale, St. George's Respiratory Questionnaire (SGRQ), and the Bronchitis Emphysema Symptom Checklist (BESC). As compared with control subjects, the total SGRQ score improved 18.5-fold in subjects treated with acupuncture and 6.57-fold in subjects treated with acupressure (p<0.05). The irritability domain score determined by the BESC improved (nonsignificantly) by 11.8-fold in the acupressure group. Limitations include inadequate description of randomization, blinding, and withdrawals, especially in the control group. Side effects were not discussed.

Chronic obstructive pulmonary disease (COPD)

• Summary: Acupressure has been studied for its ability to improve mood and respiratory symptoms associated with respiratory disorders such as asthma and chronic obstructive disorders. Preliminary evidence suggests improvement in scores for dyspnea in some studies, although further study in well-designed and reported studies is still required before recommendations can be made.
• Evidence: Maa et al. performed a randomized controlled trial to evaluate the effects of acupressure in patients with bronchiectasis on their perceived health-related quality of life (145). Forty-nine patients were included in the study after meeting the following criteria: age 40-70; bronchiectasis diagnosis for at least three years; at least four weeks of regular treatment with anticholinergic inhaled agents, inhaled corticosteroids, theophylline, or prednisolone; no current or past cardiac dysfunction, systemic disease, or disability; ability to speak Chinese or Taiwanese; and ability to learn to self-administer acupressure. Patients were randomly assigned by random number table to receive standard care with acupressure for eight weeks (N=16), standard care with sham acupressure for eight weeks (N=17), or standard care alone (N=16). Standard care consisted of patients continuing to utilize their current treatment regimen. The acupressure group received bilateral pressure at five acupoints: Zhongfu, Chize, Yuji, Fenglong, and Zusanli. The sham points used were located near real acupoints-over the sternum, on the elbow, at the junction between the thumb and the wrist, and on the anterior tibia and external ankle-but where no acupoints are known to exist. Participants were taught to administer acupressure on their own. The treatment was used for eight weeks. Data was only calculated on the 35 patients who completed the study (11 acupressure, 11 sham, and 13 control). The overall attrition rate was 29%. Twelve patients withdrew at week 4, one due to upper respiratory infection and 11 voluntarily. Two subjects dropped out at week 8: one patient died and the other withdrew voluntarily. Most of the voluntary dropouts did so due to nonmedical reasons. The following outcome measurements were taken at baseline and after four and eight weeks: sputum amounts, sputum self-assessment or effort to clear sputum, six-minute walking distance (6-MWD), breathing difficulty using the dyspnea visual analogue scale (DVAS), and health-related quality of life using the Saint George's Respiratory Questionnaire (SGRQ). Participants recorded the total volume (in ml) of daily sputum throughout the study. Baseline values did not differ significantly across the three groups. After eight weeks of treatment, the daily sputum amount improved in all participants. However, sputum self-assessment and SGRQ scores showed benefits from both acupressure and sham acupressure treatments. Of note, the sputum self-assessment scores for the sham treatment were significantly better than control (p=0.03), indicating a strong placebo effect. Compared to the control group, SGRQ activity scores for the acupressure were lower by 11.81 (p=0.01), indicating that acupressure had a significant effect in easing activities daily living activities. Other independent variables were not significantly improved. Further multivariate analysis also showed no significance. The data suggest that eight weeks of self-administered acupressure may be useful to reduce the effects of bronchiectasis on activities of daily living. However, the strong placebo effect observed may be due to the fact that acupuncture and acupressure are well received in Asian populations.
• Wu et al. conducted a randomized, controlled, double-blind, block experimental design study to determine if standardized acupressure would lessen dyspnea and associated depression in patients with COPD (146). Subjects diagnosed with COPD were chosen from one medical center and three regional hospitals in Taipei, Taiwan. To maintain comparability, subjects were divided into categories of age, gender, pulmonary function, steroid use, and smoking. These categories were used to match similar patients prior to dividing into true acupressure or sham acupressure groups. The true acupressure group received an acupressure program that used acupoints that have been shown to improve dyspnea: Great Hammer, Celestial Chimney, Lung Transport, Kidney Transport, and Fish Border. The sham acupoints used were Shang Hill, Supreme White, and Large Pile. Both real and sham acupressure treatments were administered over four weeks and comprised 16-minute sessions given five times a week for a total of 20 sessions. Five experts, either physicians or associate professors in Chinese medicine, independently rated the correctness of selected acupoints, the techniques and procedure, and the amount of time pressure was applied on a four-point scale with "proper" and "very proper" being assigned to the highest possible scores. All acupoints selected scored a rating of "proper" or "very proper" and received approval from the study investigator. Each measurement was performed using the same place and height. The manipulations of both the true and sham acupressure groups were video-recorded. The intervention completion rate for the four weeks was 100%. The study dropout rate was 19.4% (the authors citing a high initial refusal rate). No washout was required for this study. Antidepressant medications were not initiated or allowed in the 63% of patients suffering from depression in the trial, as identified by their physicians. The Geriatric Depression Scale (GDS) and Dyspnea Visual Analogue Scale (DVAS) were administered prior to the program as a baseline, and again following the completion of the four-week program. Oxygen saturation and other physiological indicators were measured before and after each session. Secondary outcome measures (oxygen saturation, systolic and diastolic blood pressure, respiratory rate, and heart rate) were collected before and after each session. The results of this study showed that Geriatric Depression (GDS) scores, Dyspnea Visual Analogue Scale (DVAS) scores, oxygen saturation, and physiological indicators of the true acupressure group were significantly improved, compared to those of the sham acupressure group. The participant ratio favored males (81.8%) that lived with their children and had families (80%). Results showed that the consistency of acupressure manipulation in both groups (sham and actual) was 100%. Following intervention, the true acupressure group declined 2.09 in GDS scores as compared with the sham group, which increased by 0.14 points (p<0.005). Significant differences were also observed between groups for DVAS scores. The real acupressure group decreased by 1.6 while the sham group increased by 0.69 (p<0.005). The intervention effects between pre- and post-intervention for SBP, RR, and HR in the two groups were also significantly different (p<0.001), although DBP and oxygen saturation differences did not reach significance. A high dropout rate (~20%) without clear explanation is suggestive of a potential limitation of the internal validity of the study. Also, the short, 15-item form of the Chinese version of the GDS was used as opposed to the more complete, full version (COPD-induced lack of energy was cited as a rationale). It should also be noted that only one out of three patients eligible to enroll did so, which may have introduced some selection bias and led to the disproportionate demographics ratio favoring males (81.8%) that lived with their children (80%).
• Wu et al. conducted a randomized controlled trial with block experimental design to compare outcomes of sham acupoints vs. true acupoints on dyspnea in 44 COPD patients (42). Subjects were included if they had COPD or dyspnea, were on steroid medication (<10mg daily), had not received pulmonary rehabilitation in last six months, and spoke Chinese or Taiwanese. Matching factors were used including age, sex, pulmonary function, smoking, and steroid use. Patients were randomly assigned either to a true acupressure acupoint or a sham pressure point for 16 minutes per session. The true acupressure regimens were as follows: (1) effleurage (holding, rubbing, and pressing the neck and shoulders for two minutes), (2) pressing and rubbing the Great Hammer (GV14) point for three minutes, (3) pressing the Celestial Chimney (CV22) point for 1-5 minutes, (4) pressing and rubbing the Lung Transport (B13) points simultaneously for three minutes, (5) pressing and rubbing the Kidney Transport (B23) points simultaneously for 1-5 minutes, (6) pressing and rubbing the Fish Border (L10) point for three minutes. Points 2-6 were pressed or rubbed once per second; after rubbing or pressing for five seconds, they were released for one second and rotated for the remainder of the treatment time. The sham acupressure regimens employed acupoints at meridians and ganglionic sections distinct from the "true" acupoints tested. These included the Shang Hill (Sp5) point, the Supreme White (Sp3) point, and the Large Pile (Liv1) point. Subjects in both groups received five 16-minute sessions over four weeks, for a total of 20 sessions. Adverse effects, dropouts, and interactions were not discussed; however, data were reported for all 44 subjects. Physiological outcome measures included pulmonary function and dyspnea scores, six-minute walking distance measurements, state anxiety scale scores, and oxygen saturation and respiratory rate measurements. The pulmonary function and dyspnea scores, six-minute walking distance measurements, state anxiety scale scores, and physiological indicators of the true acupoint acupressure group improved significantly compared with those of the sham group (all p<0.001). Besides the common limitations with sham acupressure, other methodological concerns raised in this study include the use nonstandardized measurements among the hospitals, resulting in nongeneralizable findings. In addition, an oximeter was used to measure oxygen saturation, which does not provide as much information as spirometry measurements (of arterial blood gases and chest X-rays) concerning the effectiveness of acupressure in lessening dyspnea in COPD patients.
• Maa et al. conducted a single-blind, randomized, controlled, crossover trial to examine the effect of acupressure on dyspnea in 31 patients with COPD (147). Patients were randomly assigned to one of two groups. Patients in group 1 were taught acupressure and practiced it daily at home for six weeks, followed by six weeks of sham acupressure. In group 2, the order of acupressure and sham acupressure was reversed. Endpoints included dyspnea, other symptoms associated with COPD, activity tolerance, lung function, and functional exercise capacity. Acupressure resulted in a greater reduction in dyspnea vs. sham acupressure as determined by visual analog scale (p=0.009). Decathexis was also relieved but to a lesser extent. Sham acupressure was more effective than real acupressure for reducing peripheral sensory symptoms (p=0.002).

Depression

• Summary: Acupressure, including auricular acupressure, has been studied for its ability to improve mood associated with substance withdrawal, obstructive pulmonary disease, and hemodialysis treatment. Preliminary evidence suggests improvement in scores for depression in at least some of these patient groups, although further study is still required before recommendations can be made.
• Evidence: Tian et al. conducted a placebo controlled pilot study of 17 subjects, mainly Hispanic males, to examine the efficacy of auricular acupressure in addition to usual care, on depression and substance craving, in substance abuse treatment (148). To be included in the study, an individual had to be at least 18 years of age; self-report primary drug of choice as one of alcohol, marijuana, cocaine, heroin, or methamphetamines; not be pregnant or planning to become pregnant during the treatment phase of the study; not be receiving acupuncture or acupressure treatment or have received acupuncture or acupressure in the past 30 days; and not be clinically identified as at risk for suicide. In addition to usual care, participants received specific auricular acupressure treatment and placebo auricular acupressure treatment. The three treatment arms were the specific acupressure group (auricular acupressure specifically for substance abuse in addition to usual care), placebo control group (stimulation at nonacupoints of the auricles in addition to usual care), and usual care only (control). Auricular acupressure was applied at five points on each side of the auricles that have been identified for treating substance abuse. A Cow soapwort seed was placed at each of these five points and replaced after each week of the program. Each point was massaged by the researcher for one minute during treatment sessions and again by participants for three minutes before bed and 1-2 minutes when experiencing a craving. The acupressure treatment was offered once a week for six consecutive weeks. The acupuncture protocol followed the National Acupuncture Detoxification Association Auricular Acupuncture protocol. The acupressure was performed by a researcher who taught the participants to self-administer the treatments. This same technique was used for the placebo acupressure treatments, although it was done at nonacupoints. Adverse effects were not discussed. A total of 13 (76.5%) participants completed the entire six-week treatment phase. One participant in the specific acupressure group was discharged by the counseling center and sent back to jail in the second week of the study because of probation violations. Two participants in the placebo acupressure group dropped out of the study. One withdrew after the first treatment, reporting that the acupressure gave him a headache. The other was considered a dropout because of not showing for acupressure treatment for two consecutive weeks. One participant from the nonacupressure group was considered a dropout for not showing for two consecutive weeks of counseling. The main outcome measures included the Hopkins Symptom Checklist (SCL-20) Depression Scale, which was administered before and after six weeks of treatment to assess changes in emotional distress. The Brief Substance Craving Scale was used at baseline and weekly for six weeks to assess changes in craving. No significant differences in baseline scores of the SCL-20 were noted among the three groups (p=0.6788). Participants from all three groups showed reduced emotional distress over the six-week time period. Compared with their baseline results, the specific acupressure group scored 37.16% lower at the end of the sixth week, whereas the placebo and usual-care-only group scored 34.63% and 63.51% lower, respectively. The reduction in emotional distress was found to be statistically significant within the specific acupressure group (p=0.0567) and usual-care-only (non-acupressure) group (p=0.0208), but not in the placebo group (p=0.2150). No significant differences on the Brief Substance Craving Scale (BSCS) were noted at baseline across the three groups (p=0.9329). The specific acupressure group had a steady and significant reduction in craving throughout the treatment period, with a 73.79% reduction of craving at the end of treatment (p=0.0009). The placebo group also showed reduced craving (p=0.0183); however, the craving fluctuated with an increase during the second week of the treatment period compared to baseline scores. The change of craving from baseline to the end of the sixth week among the three groups was also significantly different, with the largest difference noted between the specific acupressure group and the usual-care-only (nonacupressure) group (p=0.0006). Limitations of this study include: small sample size, short treatment phase, and no follow-up assessments. The randomization method was also not described. However, the study is one of few randomized, placebo controlled trials on auricular acupressure, and the findings suggest further research is warranted.
• Tsay et al. conducted a randomized controlled trial to compare the effectiveness of acupressure and transcutaneous electrical acupoint stimulation (TEAS) on fatigue, sleep quality, and depression in 106 patients receiving routine hemodialysis treatment (149). Adult patients with end-stage renal disease were included if they had been treated with hemodialysis for at least three months, had complaints of fatigue symptoms with Pittsburgh Sleep Quality Index (PSQI) scores of at least five points, and had Beck Depression Inventory (BDI) scores of 10 points or higher. Patients with lower-extremity amputations, co-morbid diagnoses of psychiatric disorders, congestive heart failure, chronic obstructive pulmonary disease, insulin-dependent diabetes, neuromuscular disease, systemic lupus erythematosus, rheumatoid arthritis, or cancer, or who used steroids or antihypertensive agents, were excluded. Patients were randomized to acupressure (15 minutes three times weekly for one month at K1, St36, GB34, and Sp6 sites), TEAS (15 minutes three times weekly for one month), or control groups (routine care). Endpoints included the revised Piper Fatigue Scale (PFS), the Pittsburgh Sleep Quality Index, and the Beck Depression Inventory. As compared with control, but not each other, levels of fatigue (22% reduction in acupressure group), sleep quality (12% improvement in acupressure group), and depression (24% improvement in acupressure group) scores all improved with acupressure and TEAS. This study was not blinded.
• Wu et al. conducted a randomized, controlled, double-blind, block experimental design study to determine if standardized acupressure would lessen dyspnea and associated depression in patients with COPD (146). Subjects diagnosed with COPD were chosen from one medical center and three regional hospitals in Taipei, Taiwan. To maintain comparability, subjects were divided into categories of age, gender, pulmonary function, steroid use, and smoking. These categories were used to match similar patients prior to dividing into true acupressure or sham acupressure groups. The true acupressure group received an acupressure program that used acupoints that have been shown to improve dyspnea: Great Hammer, Celestial Chimney, Lung Transport, Kidney Transport, and Fish Border. The sham acupoints used were Shang Hill, Supreme White, and Large Pile. Treatments extended over four weeks and consisted of 16-minute sessions given five times weekly, for a total of 20 sessions. Both real and sham acupressure treatments were administered over four weeks and comprised 16-minute sessions given five times a week for a total of 20 sessions. Five experts, either physicians or associate professors in Chinese medicine, independently rated the correctness of selected acupoints, the techniques and procedure, and the amount of time pressure applied on a four-point scale, with "proper" and "very proper" being assigned to the highest possible scores. All acupoints selected scored a rating of "proper" or "very proper" and received approval from the study investigator. Each measurement was performed using the same place and height. The manipulations of both the true and sham acupressure groups were video-recorded. The intervention completion rate for the four weeks was 100%. The study dropout rate was 19.4% (the authors citing a high initial refusal rate). No washout was required for this study. Antidepressant medications were not initiated or allowed in the 63% of patients suffering from depression in the trial, as identified by their physicians. The Geriatric Depression Scale (GDS) and Dyspnea Visual Analogue Scale (DVAS) were administered prior to the program as a baseline, and again following the completion of the four-week program. Oxygen saturation and other physiological indicators were measured before and after each session. Secondary outcome measures (oxygen saturation, systolic and diastolic blood pressure, respiratory rate, and heart rate) were collected before and after each session. The results of this study showed that Geriatric Depression (GDS) scores, Dyspnea Visual Analogue Scale (DVAS) scores, oxygen saturation, and physiological indicators of the true acupressure group significantly improved, compared to those of the sham acupressure group. The participant ratio favored males (81.8%) that lived with their children and had families (80%). Results showed that the consistency of acupressure manipulation in both groups (sham and actual) was 100%. Following intervention, the true acupressure group declined 2.09 in GDS scores as compared with the sham group, which increased by 0.14 points (p<0.005). Significant differences were also observed between groups for DVAS scores. The real acupressure group decreased by 1.6, while the sham group increased by 0.69 (p<0.005). The intervention effects between pre- and post- intervention for SBP, RR, and HR in the two groups were also significantly different (p<0.001), although DBP and oxygen saturation differences did not reach significance. A high dropout rate (~20%) without clear explanation is suggestive of a potential limitation of the internal validity of the study. Also, the short, 15-item form of the Chinese version of the GDS was used as opposed to the more complete, full version (COPD-induced lack of energy was cited as a rationale). It should also be noted that only one out of three patients eligible to enroll did so, which may have introduced some selection bias and led to the disproportionate demographics ratio favoring males (81.8%) that lived with their children (80%).

Drug addiction

• Summary: Acupressure has been used historically to decrease anxiety and depression. In preliminary trials, it has been studied for its ability to improve substance abuse withdrawal, and mood changes associated with that process. Results from a pilot study suggest auricular acupressure has no effect over placebo acupressure on substance craving during withdrawal. Further study in well designed and reported studies is required before recommendations can be made.
• Evidence: Tian et al. conducted a placebo-controlled pilot study of 17 subjects, mainly Hispanic males, to examine the efficacy of auricular acupressure in addition to usual care, on depression and substance craving, in substance abuse treatment (148). To be included in the study, an individual had to be at least 18 years of age; self-report primary drug of choice as one of alcohol, marijuana, cocaine, heroin, or methamphetamines; not be pregnant or planning to become pregnant during the treatment phase of the study; not be receiving acupuncture or acupressure treatment or have received acupuncture or acupressure in the past 30 days; and not be clinically identified as at risk for suicide. In addition to usual care, participants received specific auricular acupressure treatment and placebo auricular acupressure treatment. The three treatment arms were the specific acupressure group (auricular acupressure specifically for substance abuse in addition to usual care), placebo control group (stimulation at nonacupoints of the auricles in addition to usual care), and usual care only (control). Auricular acupressure was applied at five points on each side of the auricles that have been identified for treating substance abuse. A Cow soapwort seed was placed at each of these five points and replaced after each week of the program. Each point was massaged by the researcher for one minute during treatment sessions and again by participants for three minutes before bed and 1-2 minutes when experiencing a craving. The acupressure treatment was offered once a week for six consecutive weeks. The acupuncture protocol followed the National Acupuncture Detoxification Association Auricular Acupuncture protocol. The acupressure was performed by a researcher who taught the participants to self-administer the treatments. This same technique was used for the placebo acupressure treatments, although it was done at nonacupoints. Adverse effects were not discussed. A total of 13 (76.5%) participants completed the entire six-week treatment phase. One participant in the specific acupressure group was discharged by the counseling center and sent back to jail in the second week of the study because of probation violations. Two participants in the placebo acupressure group dropped out of the study. One withdrew after the first treatment, reporting that the acupressure gave him a headache. The other was considered a dropout because of not showing for acupressure treatment for two consecutive weeks. One participant from the nonacupressure group was considered a dropout for not showing for two consecutive weeks of counseling. The main outcome measures included the Hopkins Symptom Checklist (SCL-20) Depression Scale, which was administered before and after six weeks of treatment to assess changes in emotional distress. The Brief Substance Craving Scale was used at baseline and weekly for six weeks to assess changes in craving. No significant differences in baseline scores of the SCL-20 were noted among the three groups (p=0.6788). Participants from all three groups showed reduced emotional distress over the six-week time period. Compared with their baseline results, the specific acupressure group scored 37.16% lower at the end of the sixth week, whereas the placebo and usual-care-only group scored 34.63% and 63.51% lower, respectively. The reduction in emotional distress was found to be statistically significant within the specific acupressure group (p=0.0567) and usual-care-only (nonacupressure) group (p=0.0208), but not in the placebo group (p=0.2150). No significant differences on the Brief Substance Craving Scale (BSCS) were noted at baseline across the three groups (p=0.9329). The specific acupressure group had a steady and significant reduction in craving throughout the treatment period, with a 73.79% reduction of craving at the end of treatment (p=0.0009). The placebo group also showed reduced craving (p=0 .0183); however, the craving fluctuated with an increase during the second week of the treatment period compared to baseline scores. The change of craving from baseline to the end of the sixth week among the three groups was also significantly different, with the largest difference noted between the specific acupressure group and the usual-care-only (nonacupressure) group (p=0.0006). Limitations of this study include: small sample size, short treatment phase, and no follow-up assessments. The randomization method was also not described. However, the study is one of few randomized, placebo controlled trials on auricular acupressure, and the findings suggest further research is warranted.

Dysmenorrhea

• Summary: Acupressure has been historically used to decrease anxiety and pain. In randomized and nonrandomized studies, acupressure has been observed to reduce pain associated with dysmenorrhea. One study suggests equivalent pain reduction to ibuprofen, indicating the potential for a cost-effective and safe mechanism for dealing with dysmenorrhea. Further well-designed studies are required before recommendations can be made.
• Systematic review: White et al. conducted a systematic review of controlled trials to review the effectiveness of acupressure and acupuncture in gynecological conditions (150). MEDLINE, EMBASE databases, and the Cochrane Library were searched using the terms acupuncture or acupressure, dysmenorrhea, infertility, mastalgia (mastodynia), menopause, menorrhagia, pelvic pain, premenstrual pain, and vulvodynia. In addition, files in the author's office were searched. The search was restricted to European languages. The full article was retrieved for any reference that appeared, from the title or abstract, to report a controlled trial. Predetermined trial data for 10 trials were extracted into a table for evaluation. Traditional, electro-, auricular, self-, and formula acupuncture or acupressure were used. Frequency and time of acupressure or acupuncture varied between studies from 12 weeks up to six months. Follow-ups ranged from 0-1 year. Nonstandardized pooling of mixed data included a range from traditional, electro-, auricular, self-, and formula acupunctures. Dropout data were not presented, although acupuncture treatment historically has a very low side-effect profile. Acupressure was only studied with respect to dysmenorrhea. For dysmenorrhea studies, menstrual symptom score, menstrual pain, blood loss, menstrual pain diary, pain VAS score, and dysmenorrheal pain were measured. In patients who wore an acupressure garment, there was a significant improvement in dysmenorrhea symptoms over patients receiving usual care for dysmenorrhea (p<0.05) (151). In a group of schoolgirls, self-acupressure and ibuprofen were superior to sham acupressure (p<0.0001) (152). Limited numerical data were presented, with some p-values not being presented when called for. No controlled trials were locatable or included for mastalgia, menorrhagia, or pelvic pain. A limited number of trials were presented with varying quality and focus. Placebo effects were possible, as studies had varying and often nonexistent levels of blinding.
• Evidence: Jun et al. conducted a nonrandomized controlled trial to determine the efficacy of using San Yin Jiao acupressure in the treatment of dysmenorrhea as well as to evaluate temperature changes in two related acupoints (153). Patients included in this study were 58 healthy female college students, aged 18-28 years, with regular menstrual cycles accompanied by moderate-to-severe pain (VAS score of four or more) who were not pregnant and were not diagnosed with secondary dysmenorrhea. Patients had to avoid the use of intrauterine devices and oral contraceptives during the entire length of the study, and nonsteroidal anti-inflammatory drugs (NSAIDs) or other pain medications with prostaglandin synthetase-inhibiting activity for seven days before the expected onset of their menstrual period. After completing a survey, skin temperature was measured at the CV2 and CV12 acupoints while the patient was lying down. The researcher then located the SP6 site three cun (a unit equivalent to four fingerbreadths, or approximately 4cm) above the inner malleous and marked it. Accuracy of SP6 identification was validated with the Pyunjac Electro Acupointer, identified by a change of color from red to green on the readout at the correct point. The experimental treatment involved the researcher placing both thumbs on the SP6 site of both legs and applying strong vertical pressure for 10 second cycles (eight seconds of acupressure and two seconds of rest) for 120 cycles. The control group received light placement of the researcher's thumb on the SP6 sites without applying any pressure for the same 10-second cycle, completed 120 times. Acupressure or pressureless touch was administered for 20 minutes, and dysmenorrhea was evaluated immediately after treatment, then at 30 minutes and one, two, and three hours after treatment. Both the experimental and treatment groups received treatment at the SP6 sites of both legs. No allergies or adverse effects were noted. Personal circumstances were the reason for three patients dropping out of the study. The effectiveness of acupressure was assessed by measuring the severity of dysmenorrhea and skin temperature. Severity of dysmenorrhea was measured with a visual analog scale (VAS); patients rated their pain on a scale of 0 (no pain) to 10 (most severe pain). Immediately after and 30 mins. after acupressure or touch, the participants were asked to rate the severity of dysmenorrhea. Dysmenorrhea was also rated at home at one, two, and three hours after treatment. Skin temperature was measured before, and 30 minutes after, treatment with a strip skin thermometer at the CV2 and CV12 acupoints. Measurements were take over one minute, after the participant had been lying down for 15 mins. under constant temperature (20°C) and humidity (50-60%) to assess increases in blood flow to the lower abdomen. The severity of dysmenorrhea in the experimental group decreased from 5.3 to 2.73 following treatment. The control group reported a decrease in severity of dysmenorrhea from 5.14 to 4.21. All time periods were assessed using ANCOVA, and significant differences were observed immediately after acupressure (p=0.000, F=18.50), 30 mins. after acupressure (p=0.004, F=12.29), one hour after acupressure (p=0.004, F=12.37), and two hours after acupressure (p=0.032, F=8.04). No difference was observed between the two groups at three hours after acupressure (p=0.063, F=6.66). Skin temperature at the CV2 acupoint was significantly different between the two groups; temperature increased 0.92°C in the treatment group and 0.68°C in the control group (p=0.03, F=4.87). No significant difference was found between the experimental and control groups with respect to the skin temperature at the CV12 acupoint. The researchers noted several limitations to their study including the group assignment protocol. Patients were assigned to the control group if they enrolled in May or June and were assigned to the experimental group if enrolled in July or August (an improper method of randomization). The authors go on to mention that this seasonal difference may have influenced findings, as there is research that reports the severity and incidence of dysmenorrheal may be influenced by seasonal effects. It should also be noted that the author administered all acupressure or touch techniques to the patients to reduce error from using multiple people to administer the technique. The same researcher questioned the patient on the severity of dysmenorrhea and was not blinded as to which patient received which treatment. However, the skin temperature was measured by a research assistant who was blinded.
• Taylor et al. conducted a randomized controlled trial to evaluate the safety and effectiveness of an acupressure device in treating pain and symptom distress associated with dysmenorrhea (151). The inclusion criteria for this trial consisted of women 20-40 years of age experiencing regular menstrual cycles (26-32 days for a period of six months). The women were required to not be on any oral contraceptives for the previous three months, not pregnant or lactating, and not currently taking medications that could alter hormonal or pain levels. Other exclusion criteria were diagnosis of endometriosis, chronic pelvic pain, infertility, pelvic inflammatory disease, menstrual cramps onset occurring on more than one premenstrual day, or current treatment for vaginal or cervical infection or dysplasia, and women who reported a pain intensity rating of 3.5 or more over their last menstrual period. In total, 127 women were eligible for inclusion; however, 66 either declined to participate or did not complete the pretreatment procedure. Of the 61 women completing the pretreatment data collection, only 58 completed both treatment phases. The Relief Brief contained acupads that applied frontal pressure at CV2, CV4, K11, ST30, SP12, and SP13. In the back, the acupads applied pressure at GV4, BL23, BL25, and BL27. Participants were randomized to wear an acupressure garment called "The Relief Brief" or to a control group (their regular medication). The Relief Brief is a cotton Lycra panty brief with a fixed number of lower abdominal and lower back acupads, which provide pressure to dysmenorrhea-relieving Chinese acupressure points. The garment was to be worn from the onset of menstrual flow for as long as possible without experiencing discomfort, for a maximum of three days. The investigators attempted to control for significant confounding variables such as pressure, acupressure dose, and point specificity. A licensed and experienced acupuncturist provided technical assistance with acupad placement. A sham panty was not used because of economic constraints. No serious adverse effects were reported. However, 84% of the women experienced feelings of tightness, and 29% reported physical symptoms when wearing the Relief Brief. The authors mentioned three participants either dropped out or were lost to follow-up; no further details were provided. Menstrual pain severity, pain medication use, and adverse effects were analyzed to assess the outcome of acupressure on dysmenorrhea. Assessments were taken at baseline and at two points during treatment. The analysis of pain medication use and pain measures revealed statistically significant (p<0.05) group main effects, time main effects, and group x time interactions. Also, the median pain medication use dropped from six tablets daily to only two tablets for the Relief Brief group; however, it remained at six pills for the control group at the second treatment cycle (p<0.05). The results of the trial surpassed the predicted clinical significance. Ninety percent of women wearing the Relief Brief obtained at least a 25% reduction, consisting of a 2-3 point drop in menstrual pain severity compared to only 8% of the control group (p<0.05). Also, the Relief Brief garment produced at least a 50% decline in menstrual pain symptom intensity in more than two-thirds of the subjects. The authors conclude that, based on the data obtained from this trial, with design alteration, the Relief Brief could be used as an alternative treatment for women who suffer pain and symptom distress associated with dysmenorrhea. A limitation to this randomized controlled trial is the lack of standardization for the regular medication used, as well as the lack of appropriate blinding. However, this trial provided promising results for a safe and efficacious treatment for dysmenorrhea.
• Chen et al. conducted a controlled clinical trial to examine the effects of acupressure at Sanyinjao (SP6) on 69 adolescents' pain perception, anxiety, and mental distress syndromes during dysmenorrhea (154). Inclusion criteria included being younger than 20 years old, a dysmenorrhea pain score higher than five, no history of gynecological disease or secondary dysmenorrhea, and no pain medication within the last four hours prior to the clinical trial. Participants received acupressure at the Sanyinjiao acupoint for two complete five-minute cycles of pressure on each leg, for a total of 20 minutes, or control (rest with no acupressure). The force applied to each point increased from 1-21kg to 3-53kg. Participants were told to apply pressure to this acupoint before their next menstrual cycle. Adverse effects were not discussed. Twelve participants did not finish the study due to one of the following reasons: seeking alternative medical advice, physical discomfort, withdrawal, or falling asleep. Patients were assessed for pain based on the VASP (Visual Analog Scale for Pain) scale, which consisted of a 10cm scale. A score shifted all the way to the left indicated no pain while a score shifted all the way to the right indicated the worst possible pain. The Short-Form McGill Pain Questionnaire also helped evaluate patients' pain. The Menstrual Distress Questionnaire evaluated patients on three categories: pain, autonomic reactions, and water retention. Patients were also evaluated on a scale for anxiety. Initially, acupressure at Sanyinjiao reduced the pain and anxiety typical of dysmenorrhea. In the self-treatment follow-up, acupressure at Sanyinjiao significantly reduced menstrual pain but not anxiety. Thirty-one (87%) of the 35 participants reported that acupressure was helpful, and 33 (94%) were satisfied with acupressure in terms of pain relief and psychological support during dysmenorrhea. Several limitations to this study were discussed by the authors. Difficulty conducting a blind study was a potential source of bias, as participants knew who was and was not receiving acupressure treatment. Furthermore, once a participant received acupressure, there was also no way to prevent the subjects from performing self-treatment. Participants also knew that the acupressure treatments were being studied for efficacy and may have simply reported psychosomatic effects. Additionally, since the treatment was self-administered, there was no way to standardize or regulate the treatment.
• Pouresmail et al. conducted an equivalence study to compare the effects of acupressure and ibuprofen on symptoms of dysmenorrhea in 216 high school students (152). Girls were treated with acupressure, sham acupressure, or ibuprofen. All techniques reduced the pain; however, acupressure and ibuprofen were both significantly more effective than sham acupressure.

Dyspnea (shortness of breath)

• Summary: Acupressure has been studied for its ability to improve mood and respiratory symptoms associated with respiratory disorders such as asthma and chronic obstructive disorders. Preliminary evidence suggests improvement in scores for dyspnea in some studies as well, although further study in well-designed and reported studies is still required before recommendations can be made.
• Systematic review: Bausewein et al. conducted a systematic review to examine the effect of nonpharmacological and noninvasive interventions to relieve breathlessness in participants suffering from the five most common conditions causing breathlessness in advanced disease (155). The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, British Nursing Index, PsycINFO, Science Citation Index Expanded, AMED, The Cochrane Pain, Palliative and Supportive Care Trials Register, The Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness were searched in June 2007 for relevant studies. Various websites and reference lists of relevant articles and textbooks were also searched. Papers were included if they described randomized controlled or controlled clinical trials assessing the effects of nonpharmacological and noninvasive interventions to relieve breathlessness in participants described as suffering from breathlessness due to advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease, chronic heart failure, or motor neuron disease. Due to heterogeneity of studies, meta-analysis was not attempted. Forty-seven studies with 2532 participants were included. These studies investigated the effect of interventions such as walking aids, distractive auditory stimuli, chest wall vibration, relaxation, neuroelectric muscle stimulation, fan, counseling and support, breath training, psychotherapy, and acupuncture or acupressure (N=5 studies combined). Two of these studies investigated the use of acupressure (42;​147). The authors concluded that there was a "low strength of evidence" that acupuncture or acupressure was helpful.
• Evidence: Maa et al. performed a randomized controlled trial to evaluate the effects of acupressure in patients with bronchiectasis on their perceived health-related quality of life (145). Forty-nine patients were included in the study after meeting the following criteria: age 40-70; bronchiectasis diagnosis for at least three years; at least four weeks of regular treatment with anticholinergic inhaled agents, inhaled corticosteroids, theophylline, or prednisolone; no current or past cardiac dysfunction, systemic disease, or disability; the ability to speak Chinese or Taiwanese; and the ability to learn to self-administer acupressure. Patients were randomly assigned by random number table to receive standard care with acupressure for eight weeks (N=16), standard care with sham acupressure for eight weeks (N=17), or standard care alone (N=16). Standard care consisted of patients continuing to utilize their current treatment regimen. The acupressure group received bilateral pressure at five acupoints: Zhongfu, Chize, Yuji, Fenglong, and Zusanli. The sham points used were located near real acupoints-over the sternum, on the elbow, at the junction between the thumb and the wrist, and on the anterior tibia and external ankle-but where no acupoints are known to exist. Participants were taught to administer acupressure on their own. The treatment was used for eight weeks. Data was only calculated on the 35 patients who completed the study (11 acupressure, 11 sham, and 13 control). The overall attrition rate was 29%. Twelve patients withdrew at week 4, one due to upper respiratory infection and 11 voluntarily. Two subjects dropped out at week 8: one patient died and the other withdrew voluntarily. Most of the voluntary dropouts did so due to nonmedical reasons. The following outcome measurements were taken at baseline and after four and eight weeks: sputum amounts, sputum self-assessment or effort to clear sputum, six-minute walking distance (6-MWD), breathing difficulty via dyspnea visual analogue scale (DVAS), and health-related quality of life via Saint George's Respiratory Questionnaire (SGRQ). Participants recorded the total volume (in ml) of daily sputum throughout the study. Baseline values did not differ significantly across the three groups. After eight weeks of treatment, the daily sputum amount improved in all participants. However, sputum self-assessment and SGRQ scores showed benefits from both acupressure and sham acupressure treatments. Of note, the sputum self-assessment scores for the sham treatment were significantly better than control (p=0.03), indicating a strong placebo effect. Compared to the control group, SGRQ activity scores for the acupressure were lower by 11.81 (p=0.01), indicating that acupressure had a significant effect in easing activities daily living activities. Other independent variables were not significantly improved. Further multivariate analysis also showed no significance. The data suggest that eight weeks of self-administered acupressure may be useful to reduce the effects of bronchiectasis on activities of daily living. However, the strong placebo effect observed may be due to the fact that acupuncture and acupressure are well received in Asian populations.
• Wu et al. conducted a randomized, controlled, double-blind, block experimental design study to determine if standardized acupressure would lessen dyspnea and associated depression in patients with COPD (146). Subjects diagnosed with COPD were chosen from one medical center and three regional hospitals in Taipei, Taiwan. To maintain comparability, subjects were divided into categories of age, gender, pulmonary function, steroid use, and smoking. These categories were used to match similar patients prior to dividing into true acupressure or sham acupressure groups. The true acupressure group received an acupressure program that used acupoints that have been shown to improve dyspnea: Great Hammer, Celestial Chimney, Lung Transport, Kidney Transport, and Fish Border. The sham acupoints used were Shang Hill, Supreme White, and Large Pile. Both real and sham acupressure treatments were administered over four weeks and comprised 16-minute sessions given five times a week for a total of 20 sessions. Five experts, either physicians or associate professors in Chinese medicine, independently rated the correctness of selected acupoints, the techniques and procedure, and the amount of time pressure was applied on a four-point scale with "proper" and "very proper" being assigned to the highest possible scores. All acupoints selected scored a rating of "proper" or "very proper" and received approval from the study investigator. Each measurement was performed using the same place and height. The manipulations of both the true and sham acupressure groups were video-recorded. The intervention completion rate for the four weeks was 100%. The study dropout rate was 19.4% (the authors citing a high initial refusal rate). No washout was required for this study. Antidepressant medications were not initiated or allowed in the 63% of patients suffering from depression in the trial, as identified by their physicians. The Geriatric Depression Scale (GDS) and Dyspnea Visual Analogue Scale (DVAS) were administered prior to the program as a baseline, and again following the completion of the four-week program. Oxygen saturation and other physiological indicators were measured before and after each session. Secondary outcome measures (oxygen saturation, systolic and diastolic blood pressure, respiratory rate, and heart rate) were collected before and after each session. The results of this study showed that Geriatric Depression (GDS) scores, Dyspnea Visual Analogue Scale (DVAS) scores, oxygen saturation, and physiological indicators of the true acupressure group were significantly improved, compared to those of the sham acupressure group. The participant ratio favored males (81.8%) that lived with their children and had families (80%). Results showed that the consistency of acupressure manipulation in both groups (sham and actual) was 100%. Following intervention, the true acupressure group declined 2.09 in GDS scores as compared with the sham group, which increased by 0.14 points (p<0.005). Significant differences were also observed between groups for DVAS scores. The real acupressure group decreased by 1.6 while the sham group increased by 0.69 (p<0.005). The intervention effects between pre- and post-intervention for SBP, RR, and HR in the two groups were also significantly different (p<0.001), although DBP and oxygen saturation differences did not reach significance. A high dropout rate (~20%) without clear explanation is suggestive of a potential limitation of the internal validity of the study. Also, the short, 15-item form of the Chinese version of the GDS was used as opposed to the more complete, full version (COPD-induced lack of energy was cited as a rationale). It should also be noted that only one out of three patients eligible to enroll did so, which may have introduced some selection bias and led to the disproportionate demographics ratio favoring males (81.8%) that lived with their children (80%).
• Wu et al. conducted a randomized controlled trial with block experimental design to compare outcomes of sham acupoints vs. true acupoints on dyspnea in 44 COPD patients (42). Subjects were included if they had COPD or dyspnea, were on steroid medication (<10mg daily), had not received pulmonary rehabilitation in last six months, and spoke Chinese or Taiwanese. Matching factors were used including age, sex, pulmonary function, smoking, and steroid use. Patients were randomly assigned either to a true acupressure acupoint or a sham pressure point for 16 minutes per session. The true acupressure regimens were as follows: (1) effleurage (holding, rubbing, and pressing the neck and shoulders for two minutes), (2) pressing and rubbing the Great Hammer (GV14) point for three minutes, (3) pressing the Celestial Chimney (CV22) point for 1-5 minutes, (4) pressing and rubbing the Lung Transport (B13) points simultaneously for three minutes, (5) pressing and rubbing the Kidney Transport (B23) points simultaneously for 1-5 minutes, (6) pressing and rubbing the Fish Border (L10) point for three minutes. Points 2-6 were pressed or rubbed once per second; after rubbing or pressing for five seconds, they were released for one second and rotated for the remainder of the treatment time. The sham acupressure regimens employed acupoints at meridians and ganglionic sections distinct from the "true" acupoints tested. These included the Shang Hill (Sp5) point, the Supreme White (Sp3) point, and the Large Pile (Liv1) point. Subjects in both groups received five 16-minute sessions over four weeks, for a total of 20 sessions. Adverse effects, dropouts, and interactions were not discussed; however, data were reported for all 44 subjects. Physiological outcome measures included pulmonary function and dyspnea scores, six-minute walking distance measurements, state anxiety scale scores, and oxygen saturation and respiratory rate measurements. The pulmonary function and dyspnea scores, six-minute walking distance measurements, state anxiety scale scores, and physiological indicators of the true acupoint acupressure group improved significantly compared with those of the sham group (all p<0.001). Besides the common limitations with sham acupressure, other methodological concerns raised in this study include the use nonstandardized measurements among the hospitals, resulting in ungeneralizable findings. In addition, an oximeter was used to measure oxygen saturation, which does not provide as much information as spirometry measurements (of arterial blood gases, and chest X-rays) concerning the effectiveness of acupressure in lessening dyspnea in COPD patients.
• Maa et al. conducted a single-blind, randomized controlled, crossover trial to examine the effect of acupressure on dyspnea in 31 patients with COPD (147). Patients were randomly assigned to one of two groups. Patients in group 1 were taught acupressure and practiced it daily at home for six weeks, followed by six weeks of sham acupressure. In group 2, the order of acupressure and sham acupressure was reversed. Endpoints included dyspnea, other symptoms associated with COPD, activity tolerance, lung function, and functional exercise capacity. Acupressure resulted in a greater reduction in dyspnea vs. sham acupressure as determined by visual analog scale (p=0.009). Decathexis was also relieved but to a lesser extent. Sham acupressure was more effective than real acupressure for reducing peripheral sensory symptoms (p=0.002).
• Select combination studies (not included in table): Tsay et al. conducted a two-group experimental design study with repeated measures of 52 patients (25 men, 27 women) to investigate the effects of acupressure therapy on dyspnea, anxiety, and physiological indicators of heart rate and respiratory rate in patients with chronic obstructive pulmonary disease on mechanical ventilation support (156). Participants were required to be alert, to be mentally competent and able to communicate, to be medically stable, to be diagnosed with COPD and receiving mechanical ventilation assistance over 21 days, to be aged 60 years or above, to have reported symptoms of dyspnea, to require FiO₂ <50% of the time, and to have a resting arterial PaO₂ >60mmHg, serum albumin >2.5mg/dL, and hemoglobin >10mg/dL. Those with active heart or neuromuscular diseases, hearing problems, or psychiatric diagnoses, or those using steroids, neuromuscular blocking agents, or tranquillizers were excluded. All patients received regular treatment with inhaled bronchodilators. Three acupoints, Neiguan (PC6) and Hegu (LI4) in both hands, and Shenmen (HT7) on both ears, were selected for treatment. Each acupressure therapy was limited to 15 minutes, consisting of three minutes of massage on the shoulders and both arms to relax the person and 12 minutes of acupoints massage (four minutes per acupoint). Patients in the experimental group received acupressure therapy every day for 10 days at mid-afternoon. To ensure standardization among all the treatments, a trained TMC nurse therapist administered the protocol in the experimental group. The reliability and validity of acupressure treatment was assessed by confirmation of application of consistent pressure on the correct acupoints. Two TMC experts, who confirmed with 100% accuracy and agreement, evaluated the accuracy of acupoint selection. Adverse effects were not discussed. Based on data reported, there were no withdrawals, though this was not discussed by the authors. The primary outcome measures were the visual analogue scales for dyspnea and anxiety, and physiological indicators of heart rate and respiratory rate. Dyspnea (p=0.009), anxiety (p=0.011) and physiological indicators (p < 0.0001) in the acupressure group improved significantly over time as compared to the control group. Some study limitations include: a lack of a double-blinded design (although it is difficult to have double-blinding in acupressure studies); a limited subject population, and the administration of additional massage, thereby making the effect of acupressure alone unclear.

Enuresis (children)

• Summary: While there is preliminary evidence that acupressure may reduce enuresis in children, methodological weaknesses in the available literature prevent recommendation. Stronger trials are needed to further assess the therapeutic benefit of acupressure in the treatment of pediatric enuresis.
• Evidence: Yuksek et al. conducted a comparison study to contrast the effects of acupressure and oxybutinin for treating nocturnal enuresis in 24 patients (157). Children with organic urinary tract disorders, or those that used medication which would affect bladder function, were excluded from the study. Only those with diagnosed nocturnal enuresis were included. In the acupressure group (N=12), treatment was administered to the patients by their parents, who had been taught the technique. Pressure was applied at the following acupuncture points; Gv4, Gv15, Gv20, B23, B28, B32, H7, H9, St36, Sp4, Sp6, Sp12, Ren2, Ren3, Ren6, K3, and K5. In the oxybutinin group (N=12), patients received 0.4mg/kg of oxybutinin. Endpoints included parental records of bed-wetting and completed questionnaires. Complete and partial responses after six months of treatment were 83.3% and 16.7%, respectively, in patients treated with acupressure, and 58.3% and 33.3% in children using oxybutinin. These results were not significantly different. This study was poorly presented, with no indication of randomization or blinding. The effect of acupressure is unclear as a large placebo effect may have been evident in both groups. Side effects were not discussed.
• Bartocci et al. conducted a case series in 15 pediatric patients (aged 4-13) suffering from night enuresis who had not benefitted from other therapies (therapies unnamed) (158). Of these patients, 10 received acupuncture treatments on seven acupoints and five patients received "micromassage" on two acupoints on the fifth finger. Subjects' parents repeated the therapy every night for ten minutes for an average of 20 days. In the acupuncture group, seven recovered completely, two recovered partially, and one exhibited a negative result. In the micromassage group, two subjects recovered completely, and one recovered partially. Parental compliance and performance were not discussed, and no control group or randomization was used.

Epileptic seizure (children)

• Summary: There is preliminary evidence to support the use of acupressure in the acute treatment of epileptic seizures; however, further research is required before any recommendation can be made.
• Evidence: In a case series, Pothmann et al. reported that acupressure was effective in the acute treatment of cerebral convulsions in epileptic children aged 2-14 years old (159). This was a case series of 62 different cerebral fits treated by strong manual manipulation of the nasal philtrum. Nearly all (91%) of the convulsions, including convulsions leading to unconsciousness (grand mal), were found to be successfully treated within 30 seconds. Other types of fits did not respond to this acupressure treatment.
• Select combination studies (not included in table): Wu et al. conducted a randomized controlled (crossover) trial to examine the effect of a combination of acupuncture, tuina, and rehabilitation on baseline seizure frequency in 116 children with cerebral palsy (160). The control group received rehabilitation (physiotherapy, occupational therapy, and hydrotherapy) only. Sessions lasted for 12 weeks with a four-week washout period between treatment crossover. Acupuncture was administered for five days each week. The main endpoint was change in seizure frequency during treatment. The authors observed that there was no increase in seizure frequency with treatment. Thirty-three children did not complete the study.

Exercise performance

• Summary: There is promising early evidence from one small case series to support the use of acupressure in exercise performance. This trial found that auricular acupressure may reduce muscle fatigue and lactic acid production. Larger, controlled trials are needed to further assess the use of acupressure in exercise performance.
• Evidence: Jaung-Geng et al. conducted a case series involving 12 healthy male volunteers aged 19-25, whose lactic acid and oxygen intake levels were monitored five and thirty minutes after vigorous exercise (53). In the first experiment, subjects were given auricular acupressure treatments using vaccaria seeds taped to five acupoints and pressed for five minutes. Three days later, in a control experiment with the same subjects, seeds were taped to the same acupoints but were not pressed. Results indicated that auricular acupressure significantly reduced lactic acid elevation and increased oxygen uptake following strenuous exercise, suggesting a reduction in muscle fatigue.

Facial spasm

• Summary: preliminary evidence suggests the combination of acupuncture with pressure on otopoints is preferable to simple acupuncture and simple pressure on otopoints in patients with facial spasm. Well-designed study is required before recommendations can be made in this field.
• Select combination studies (not included in table): In a controlled study, the combined method of acupuncture with pressure on otopoints (the combination group) was used to treat 86 patients with facial spasm; simple acupuncture and simple pressure on otopoints were applied separately in two other groups of patients as controls (161). The total effective rates of the combination group, the acupuncture group, and the pressure-on-otopoints group were 95.4%, 92.1% and 62.5%, respectively, while the cure rates were 38.4%, 15.8% and 5%, respectively. The authors note that the differences in results of the three groups show statistical significance, indicating that the therapeutic effectiveness of the combined method of acupuncture with pressure on otopoints was better than the other two therapeutic methods.

Gastrointestinal motility

• Summary: There is promising preliminary evidence to suggest improvements in gastrointestinal motility in response to acupressure. However, further higher-quality research is needed before a recommendation can be made.
• Evidence: Chen et al. conducted a randomized controlled trial to examine the effect of acupressure on gastrointestinal motility in 41 women after trans-abdominal hysterectomy (47). Inclusion and exclusion criteria were not provided. Patients were randomly assigned to acupressure-three minutes at each of Neiguan (PC-6), Zusanli (ST-36), and Sanyinjiao (SP-6) points, which involved repeated procedures of five seconds of pressure, five seconds of kneading, and two seconds of rest-or a control group-three minutes of acupressure on sham points, which involved repeated procedures of five seconds of pressure, five seconds of kneading, and two seconds of rest. Acupressure was first administered five hours following the operation to allow for recovery and then performed twice daily thereafter. The main endpoints included patients' satisfaction and gastrointestinal contractions (stethoscope and visual analog scale). Acupressure significantly increased gastrointestinal motility (p<0.05). Using a stethoscope to measure GI contractions, it was determined that acupressure increased gastrointestinal motility by 7.10 points from the first to the third day, as compared with 1.89 points in the sham group. Food intake did not differ between groups. Limitations include a lack of double-blinding. Side effects were not discussed.
• Wang et al. conducted a randomized comparison trial to compare the effects of massage and tuina treatment on infantile diarrhea in 275 infants (162). Infants were randomized to massage "for supplementing qi" (N=137) or tuina (N=138), for seven days. Total cure was the main endpoint. The cured rate was observed to be significantly less in the tuina group vs. the massage group (69.6% vs. 83.2%, p<0.05) and the time to cure shorter in the massage group
• Lower-quality evidence (not included in table): In a controlled study, Chang et al. investigated the difference in bowel sounds and passing of gas in 142 abdominal hysterectomy patients treated for five minutes or ten minutes with SP6 acupressure (163). The main endpoints were time when bowel sounds were heard and passing of gas. The time when bowel sounds were heard was significantly shorter in both experimental groups compared to the control group (F=10.29, p=0.000). The time when gas was passed was also significantly shorter in the group treated for ten minutes as compared to the control group (F=4.68, p=0.011).
• Two case reports (one being the author's personal experience and the other a patient with the same condition of postlaparotomy intestinal obstruction) by Saito (24) described a marked unblocking of intestinal obstruction and improvement in pain levels following shiatsu massage in the mid-back.

Headache

• Summary: There is early evidence from one large case series to support the use of acupressure in the treatment of headaches; however, studies of more powerful design are needed to confirm these findings.
• Evidence: Kurland et al. conducted a large case series involving over 200 patients with significant headache symptomology, who were treated by self-administered manual acupressure on four acupoints on the head, neck, and hands (32). Treatment was reported to abort or partially abort migraine or histamine cephalgia attacks when administered in the predromal phase. It was also able to reduce the pain of acute, subacute, and chronic migraine and tension headaches. However, no patient surveys or quantitative measurement of these effects were presented.

Hypertension

• Summary: Despite wide anecdotal claims of benefit in the treatment of hypertension with acupressure, high-quality primary evidence is lacking. A report by Yu et al. comparing auriculoacupressure with composite hypotensive tablets reported a positive effect on hypertension (164). Evidence from a weight-loss study by Allison et al., however, found no effect (165). Further study emphasizing blood pressure as an endpoint are needed to confirm these findings.
• Evidence: Allison et al. reported a randomized, placebo controlled, single-blind study (N=48) to determine the efficacy of an auricular acupressure device on weight loss in obese patients (165). Subjects were randomized to either treatment (auricular acupressure device) or control (wrist acupressure device). Testing occurred over 12 weeks with weight, body fat, and blood pressure measured every two weeks. The auricular acupressure device applied pressure on six ear acupoints. There were no significant differences between the two groups regarding weight loss, fat loss, or blood pressure reduction. However, the study had a 27% noncompletion rate, and the authors failed to conduct tests to determine if the wrist acupressure device was a valid placebo.

Pain (fracture)

• Summary: Recent studies suggest that pain due to bone fracture may be reduced following auricular acupressure during transportation. Whether this is due to actual pain reduction or anxiety reduction is not clear. Although available studies were described as randomized, improper randomization procedure and an overall lack of methodological description make it difficult evaluate these findings. Further well-qualified studies of strong design are needed to confirm these findings.
• Evidence: Barker et al. conducted a randomized, double-blind, sham control trial of 38 elderly patients with acute hip fracture to assess the effects of auricular acupressure on anxiety and pain (34). The study included patients aged 80-95 years, with ASA physical status II or III, who experienced an isolated hip fracture without any additional trauma. Patients were excluded who did not speak fluent German, had ear deformities, severe neurologic or psychiatric disorders, or were taking sedatives or analgesics on a long-term basis. Subjects either received true bilateral auricular acupressure at three auricular acupressure points for hip pain, or sham auricular acupressure, with 1mm acupressure plastic beads. The subject's pain and anxiety were evaluated before and after the intervention. Acupressure beads were secured by paramedics during the ambulance ride to the hospital. Adverse effects were not discussed. There were no dropouts in either the treatment or the sham groups. The primary outcomes were pain and anxiety, measured before and after the intervention. The visual analog scale (VAS) with scale of 0-100mm was used before and after treatment. VAS-Pain, VAS-Anxiety, and VAS-Satisfaction were administered and self-reported by the patients. Blood pressure and heart rate were analyzed as well. Subjects in the true intervention acupressure group had significantly lower anxiety scores on arrival at the hospital as compared with individuals who received the sham control intervention. Similarly, a two-way repeated-measures analysis of variance that examined the levels of pain found a time effect (p=0.0001) and a group x time intervention (F=28, p=0.0001). That is, subjects in the true intervention group experienced significantly less pain on arrival at the hospital. Subjects were also found to have lower heart rate on arrival at the hospital (F=18, p=0.0001). There were no differences in systolic blood pressure (repeated measure, F=3.1, p=0.093) and diastolic blood pressure (F=0.9, p=0.34) between the true intervention and sham control groups. Limitations of this study may include the method of randomization, as it was not discussed. Otherwise, this study was well-designed to maintain blinding and avoid bias. The duration acupressure beads were secured was unspecified.
• Lang et al. performed a prospective, randomized, double-blind study to evaluate the effectiveness of acupressure at the Baihui and Hegu points on pain relief during transport of patients with distal radial fracture (166). The study evaluated 32 patients, aged 19-99 years, with an isolated fracture of the distal radius and visible axial deviation and dislocation. Patients were excluded if they could not speak German well enough to give informed consent, if they had any neurologic or psychiatric disorders, if they were currently using analgesics for chronic pain, or if they had a visual analog pain scale (VAS) rating of 80 or greater. Acupressure was applied for three minutes at each acupressure point. Fifteen patients were randomized to the treatment group by sealed envelopes opened by the paramedic assigned to perform the acupressure treatment. The treatment group was given acupressure at the points GV20 (Baihui) and LI4 (Hegu). Sixteen patients were randomized to the control group and were sham stimulated at points BL17 (Geshu)-indicated for chronic anemia-and TE14 (Jianliao)-indicated for chronic shoulder arthrosis. The LI4 (Hegu) and TE14 (Jianliao) points were given pressure on the contralateral arm to avoid close proximity to the injured area. This treatment was given once en route to the hospital after injury. Sham points were used in the control group for comparison. One patient in the treatment group dropped out of the study; this patient withdrew his consent before study completion for unknown reasons. The visual analog scale was used to rate pain, anxiety, and overall satisfaction on a scale of 0-100 before acupressure and after emergency transport. Blood pressure and heart rate were also measured at the accident site and on arrival at the hospital. Patients overall satisfaction was also measured on the VAS (0-100). When the patients arrived at the hospital, those assigned to the treatment group had significantly lower pain (36.6 ± 11.0) compared to the control group (56.0 ± 13.3). Anxiety was significantly lower in the treatment group (34.9 ± 22.2) compared to the control group (53.4 ± 19.7). Patients in the treatment group also had significantly lower heart rates than those in the control group (69.9 ± 12.5 vs. 90.4 ± 6.2 beats/min.). No significant difference was found in blood pressure readings. General satisfaction with medical care was significantly higher in the treatment group than the control group (25.1 ± 22.6 vs. 41.8 ± 19.6). The authors noted several limitations in their study, such as the lack of a null group, which may have shown whether the presence of a rescue team and anticipated prompt arrival at the hospital may have alleviated pain on its own. Also, points BL17 (Geshu) and TE14 (Jianliao), chosen for the control group, are not located in the same dermatome as those in the treatment group. The authors explain that these points were selected randomly because they were easy to find and are not purported to have effects in acute injury.

Pain (labor)

• Summary: Early evidence from studies investigating acupressure in other forms of pain has suggested that acupressure may have positive effects in labor pain reduction. However, primary research investigating acupressure in this indication remains scarce; a recent meta-analysis (167) identified only two studies. Further investigation is necessary before a recommendation can be made.
• Meta-analysis: Smith et al. conducted a meta-analysis examining the effects of complementary and alternative therapies for pain management in labor (167). Papers were searched in the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), and CINAHL (1980 to February 2006). Unpublished and published randomized controlled trials comparing complementary and alternative therapies, including acupressure, were selected; only two acupressure papers with 172 patients were included (36;​168). The meta-analysis was performed using relative risks for dichotomous outcomes and mean differences for continuous outcomes, such as maternal satisfaction and use of pharmacological pain relief. Results from the two individual studies suggest the potential for a reduction in pain associated with labor, although firm conclusions could not be drawn.
• Evidence: Lee at al. conducted a double-blinded, randomized clinical trial to evaluate the effects of SP6 acupressure on labor pain and delivery time (36). The study comprised 84 women in labor, without oxytocin augmentation or analgesic administration. They were recruited at the outpatient department in a general hospital. To be included in the study, the women must have been pregnant for more than 36 weeks, without any specific diseases, in good health, and planning on a vaginal delivery. Exclusion criteria were as follows: possible diagnosis of multiple fetuses, identifiable gynecologic conditions (i.e., inflammatory diseases, uterine myoma, or precancerous lesions), and use of psychotherapeutic drugs. The subjects were randomly assigned to experimental and control groups. The experimental group received acupressure at SP6 on both legs while the control group only received a touch at these acupoints. While the control group received no pressure at SP6, the experimental group received pressure ranging from 1911-2150mmHg. The intervention was administered by a nurse who had been trained in acupressure 18 months prior to the study. Deep breaths and relaxation were also encouraged during the process. During each uterine contraction, pressure was held at SP6 for thirty minutes. Before delivering, each woman was assigned to either SP6 acupressure (experimental) or SP6 touch (control). The groups were matched for the following characteristics: parity, cervical dilation, status of rupture of amniotic membrane, childbirth preparation, and husband's attendance. Each patient was told she was receiving a treatment to alleviate pain but was not aware of her placement in the study. Nurses were also blinded to their patients' assignments in the study. No treatment-related adverse effects were mentioned. Originally, 89 women agreed to participate; however, only 75 women completed the study. Five women delivered via cesarean section and were excluded based on birth route criteria. Nine were excluded because of incomplete data or withdrawal from the study. Patient's pain and anxiety was measured using a visual analog scale which ranged from 0-10 (no pain/anxiety to worst possible pain/anxiety). Pain was measured before and immediately after patient's received acupressure as well as thirty and sixty minutes afterward. Duration of labor to delivery was measured as two time periods. The first was from 3cm dilated to full cervical dilation, and the second was from full dilation to birth. Anxiety level was significantly lower in the SP6 acupressure group than in the SP6 touch group (p=0.030). Significant differences were found between the groups in labor pain scores at all time points following the intervention: immediately after the intervention (p=0.012); 30 minutes after the intervention (p=0.021); and 60 minutes after the intervention (p=0.012). Total labor time (3cm dilatation to delivery) was significantly shorter in the acupressure experimental group than in the control group (p=0.006). Although the authors claim that the double-blinded design of the study removed the potential for bias from the patient and the practitioner, it is unclear how patients were blinded to assignment.
• Chung et al. conducted a randomized controlled trial to determine the effectiveness of acupressure on points BL67 and LI4 in the first stage of labor on labor pain and uterine contractions (168). The subjects were pregnant women carrying one fetus with an estimated gestational age of 37-42 weeks. Patients had to be able to interact verbally in Chinese. Exclusion criteria were high-risk pregnancy, use of medications during labor (such as oxytocin for induction or epidural block), and cesarean sections. There were 127 patients randomized to receive acupressure, effleurage, or no treatment. Acupressure patients received thumb pressure to the right and left LI4 pressure points for five minutes each (25 cycles; 10 seconds of pressure followed by two seconds of rest in each cycle), They also received pencil-eraser pressure to the right and left BL67 pressure points for five minutes each (25 cycles as described above). Effleurage patients received light skin stroking up and down the left and right upper-outer arm for 10 minutes each, with each stroke in accordance with breathing patterns (12-30 strokes per minute). For patients receiving no treatment, the nurse-midwife simply stayed in the room and took notes or conversed with the patients and their families. Each subject was treated for 20 minutes during the first phase of labor. Five nurse-midwives were trained extensively in the technique of acupressure and effleurage. The midwives performed the techniques on the women and were responsible for data collection as well. No allergies or adverse effects were noted. There were 23 patients (seven acupressure patients, eight effleurage patients, and eight control patients) who dropped out of the study, most commonly due to decisions to use medications for pain relief, to induce labor, or to deliver by cesarean section. Labor pain was measured before and after treatment with the visual analog scale during the three phases of the first stage of labor: latent, active and transitional. The effectiveness of uterine contractions was measured in Montevideo Units. There was a significant decrease in labor pain among the three groups during the active phase of the first stage of labor (p=0.041); no significant difference was found among the three groups during the latent or transitional phases. During the active phase, there was no significant difference in labor pain between the acupressure and effleurage groups (p=0.109) or between the effleurage and control groups (p=0.268); a significant difference was detected between the acupressure and control groups (p=0.017). There was no significant difference found among the three groups in any phase of the first stage of labor in terms of effectiveness of uterine contractions. The authors also looked at the duration of the first stage of labor in all three groups; a significant difference was found among the three groups (p=0.019), and the acupressure group had a shorter duration than the control group. There was no difference found between the effleurage group and the acupressure group. The p value for labor pain among the three groups in the latent phase was 0.051, very close to the level of significance (0.05). The authors noted that external fetal monitoring may not have been as accurate as internal fetal monitoring in measuring the effect of treatment on uterine contractions. They further note that their small sample size limited quantitative analysis, especially in the transitional phase of labor, and that they should have also measured endorphin and oxytocin serum levels as more objective monitoring parameters.
• Select combination studies (not included in table): Ingram et al. conducted a pilot audit on the use of shiatsu techniques, as taught by hospital midwives, on the progress of post-term labors and deliveries, for the purpose of informing practice (169). The audit occurred at St. Michael's Hospital, Bristol, from March to July 2000. Sixty-six women who attended a consultant clinic hospital appointment at 40 weeks' gestation were taught the massage techniques by one midwife who had completed the shiatsu course. Seventy-six comparison women attended similar clinics when the midwife was not on duty. The audit extracted outcome information from the Stork hospital database including induction, type of delivery, length of labor, and analgesia used. Post-term women who used shiatsu were significantly more likely to labor spontaneously than those who did not (p=0.038). Of those who had used shiatsu, 17% more went into spontaneous labor compared to those who were not taught shiatsu.

Pain (lower back)

• Summary: Acupressure has been explored as a possible treatment for the alleviation of lower back pain (170;​171). There is promising early data to suggest that acupressure techniques may be useful in this indication. Larger, well-controlled studies, with adequate descriptions of methods, would strengthen the case for acupressure's use in lower back pain.
• Evidence: Hsieh et al. conducted a randomized controlled comparative trial of 129 patients with chronic low back pain to evaluate the effectiveness of acupressure on disability, pain scores, and functional status (33). Eligible patients were aged 18 years and older, had chronic low back pain for more than four months as diagnosed by a senior orthopedic specialist, had chronic low back pain that was not caused by systemic or organic diseases, cancers, or psychiatric diseases, were not pregnant, had no acute severe pains needing immediate treatment or surgery, and had no contraindication to acupressure (that is, no open wound). Patients received either acupressure or physical therapy, although methodology was inadequately described. Each patient received six sessions in one month. Acupressure was administered by one acupressure therapist to "standardize" treatment. Physical therapy was administered by different therapists, the authors rationalizing that the methodology was considered standardized, as physical therapy is well established in orthodox, Western medicine. Adverse effects were not discussed. Dropouts were discussed in both groups. There were two patients in the acupressure group who refused treatment and two patients who changed to the physical therapy group. There were also two patients lost to follow-up after one month and nine lost to follow-up after six months. There were five patients in the physical therapy group who refused treatment and two patients who changed to the acupressure group. The number of patients lost to follow-up after one month was six and the number of patients lost to follow-up after six months was 11. The primary outcome was the Roland and Morris disability questionnaire. Other outcomes were pain visual analog scale, core outcome measures, and the Oswestry disability questionnaire. The mean total Roland and Morris disability questionnaire score after treatment was significantly lower in the acupressure group than in the physical therapy group, regardless of the difference in absolute score (-3.8, 95% confidence interval: -5.7 to -1.9) or mean change from baseline (-4.64, -6.39 to -2.89). Acupressure conferred an 89% (95% confidence interval: 61%-97%) reduction in significant disability compared with physical therapy after adjustment for degree of disability at baseline. It should be noted that there was no placebo used in this study. Also, 15.5% of patients were lost to follow-up, and missing data for these patients was substituted with baseline or post-treatment data. The authors note that this could have been ameliorated by using an intent-to-treat method that included patients lost to follow-up in the analysis.
• Hsieh et al. conducted a randomized, controlled clinical trial to compare the efficacy of acupressure with that of physical therapy in reducing low back pain in 146 participants (172). The inclusion criteria were as follows: lower back pain (LBP) not caused by severe systematic diseases, no contraindications to acupressure or physical therapy (such as open wounds), no severe pain, and no previous recommendations of surgery for LBP treatment. Acupressure was performed by a "senior therapist"; no further information was provided. Each session lasted 15 minutes. All participants received six treatments over a four-week period. Clinicians responsible for the evaluation of pain were blinded and unaware of which arm each participant was in. A research assistant who interviewed each patient after treatment was also blinded and was unaware which arm each participant was in. No adverse effects were mentioned in this study. All participants were analyzed using the "intent to treat" approach, and 25 patients were lost to follow-up after six months due to "migration" (13 in the acupressure group, 12 in the control group). To measure pain, a Chinese version of Short-Form Pain Questionnaire (SF-PQ) was developed, which scaled pain from 0-3. A score of zero corresponded to no pain, and a score of three corresponded to severe pain. No significant differences in baseline characteristics were found among patients. After four weeks of treatment, pain scores (2.28, SD=2.62) in the acupressure group were significantly lower than the physical therapy group's scores (5.05, SD=5.11) (p=0.0002). Even after six months, the pain scores in the acupressure group (1.08, SD=1.43) were still significantly lower than the physical therapy group's scores (3.15, SD=3.62) (p=0.0004). All participants were treated by the same therapist, which provided internal validity to the study but may have affected the study's external validity. Other limitations inherent in this study include the lack of double-blinding and a described acupressure methodology.
• Case series: In a case series, Brady et al. investigated the effect of shiatsu on lower back pain in 66 individuals complaining of lower back pain (23). Each individual was measured using the State-Trait Anxiety Inventory and self-reported their pain levels using the Visual Analogue Scale (VAS) before and after four shiatsu massage treatments over an eight-week period. Each subject was then called two days following each treatment and asked again to quantify the level of pain using VAS. Both pain and anxiety decreased significantly over time. Extraneous variables such a gender, age, gender of therapist, length of history with lower back pain, previous experience with shiatsu, and medications taken for lower back pain were not found to alter the results.
• Select combination studies (not included in table): Peng et al. conducted an open study to examine the combined therapy of intradermal needle therapy and tuina on lumbar disc herniation in 150 patients (173). In these patients tuina therapy was followed by intradermal needle embedding at local Ashi points, and at Shenshu (BL23), Yaoyangguan (GV3), Zhibian (BL54), Fengshi (GB31), Yanglingquan (GB34). The treatment was given once every other day, for two courses of five treatments. The main endpoint was cure rate. It was indicated that 102 cases were cured, 22 cases were effective, 18 cases were improved, and eight cases were ineffective. The effect of tuina alone is not clear in this study.
• Yip et al. conducted a randomized controlled trial to assess the effect of acupoint stimulation with lavender aromatic essential oil on pain relief, and enhancing physical functional activities among adults with subacute or chronic nonspecific low back pain (174). Inclusion criteria were as follows: over the age of 18, nonspecific subacute low back pain for most days within the past four weeks, having not received acupuncture, physiotherapy or manipulative therapy in the past week, and understanding the study and comprehending the directions. Patients were excluded if they (1) had low back pain caused by specific entities such as infection, metastases, neoplasm osteoporosis, fractures, spine deformity, or prolapsed intervertebral disc; (2) had undergone surgery or had discoloration, fracture, neurological deficits, spinal disease, varicose vein, blood dyscrasia, cancer, or systemic disorders, (3) were pregnant, (4) were allergic to natural lavender aromatic oil, (5) had a wound at any of the acupoints at the back or on the lower limb, or (6) had had a surgical intervention within the last three months. Acupressure massage consisted of light-to-medium finger press with 3% aromatic natural lavender oil on eight acupoints for two minutes each. The acupoints were San-Jiao-Shu (UB22), Shen-Shu (UB23), Da-Chang-Shu (UB 25), and Wei-Zhong (UB40). Acupressure was performed by a nurse trained in Chinese medicine. Conventional treatment was also included. The control group received conventional treatment alone. Participants were treated for 35-45 minutes eight times over a three-week period. Participants were randomly placed into the intervention or control group by a research team. No adverse effects were reported. Out of the 61 participants enrolled in the study, 51 completed. Dropouts could not complete the trial for various reasons (busy, not interested, or started a new job). There was no difference between the 51 participants and the 10 dropouts except for age. Dropouts were significantly older and had more difficulty with daily activities. The two groups were similar in terms of gender, education, pre-retirement occupation, pain intensity, and duration of LBP. A nurse collected outcome measures via a face-to-face interview and body measurements. These measurements occurred before the acupressure and one week after treatment. Pain intensity, pulse, and blood pressure were also recorded to measure relaxation. Pain intensity was measured via a visual analog scale. Some secondary outcomes were also recorded. They include: range of motion of lateral spine flexion, walking time for fifteen meters, and interference in daily activities. A week after treatment, the intervention group had 39% greater reduction in pain intensity than the control group (p=0.0001), improved walking time (p=0.05), and greater lateral spine flexion range (p=0.01). A statistical significance was found between the two groups in walking time and flexion range; however, these differences were only two seconds and two centimeters, respectively. These values are likely not clinically relevant. It should also be noted that this study was not blinded. The participants were aware of their own treatment as well as their fellow participants' treatments. No control or sham acupressure group was conducted to in this study, which may have contributed to placebo effects.

Pain (neck)

• Summary: Early evidence from a study investigating the combined effects of acupressure with lavender essential oil suggests some potential for improvement in neck pain and stiffness following acupressure treatment; however, further research exploring the effects of acupressure alone are necessary before any recommendation can be made.
• Select combination studies (not included in table): Yip et al conducted a randomized controlled trial to assess the efficacy of acupressure using an aromatic essential oil (lavender) as an adjunct therapy for relieving pain and enhancing physical function among adults with subacute nonspecific neck pain (48). The study enrolled patients 18 years or older with nonspecific subacute neck pain for most days in the preceding two weeks and who also had not received acupuncture, physiotherapy, or manipulative therapy in the same time period. Patients were also required to understand the explanation of the study along with the instructions and complete an interview. The study excluded subjects with neck pain due to specific conditions (such as infection, metastases, neoplasm osteoporosis, fractures, radicular cervical syndrome, segmental instability, or spine deformity). Patients who were possibly pregnant or allergic to natural lavender aromatic oil, had wounds or contagious skin conditions at any of the acupoints at the neck or the shoulder, or who had surgical interventions in the preceding three months were also not eligible. During manual acupressure, 3% lavender oil (Lavandula angustifolia, VIE AROME) in olive oil was used as the massage lubricant. The massage consisted of the application of a light-to-medium finger press with oil on 20 fixed acupoints for two minutes each. The acupoints consisted of 10 fixed relaxation points along with 10 fixed body points. The ten relaxation acupoints (five bilateral points) were Shousanli, Quchi, Naoshu, Tianliao, and Tianzhu. The ten fixed body acupoints (four bilateral and two unilateral points) were Yamen, Fengfu, Fengchi, Jianjing, Jianwaishu and Tianyou. Willing participants who qualified were randomly assigned to a manual acupressure group (MAG) or control group (CG). The MAG received eight sessions of acupressure massage with natural aromatic lavender oil along with conventional treatment. Each session included local region acupressure and relaxation. Subjects in the CG received conventional treatment alone, but were offered manual acupressure treatment after completing the study. The ''conventional treatment'' received by both control and intervention groups was the standard treatment given by the general outpatient department or family practitioner. Participants were treated eight times for 35-40 minutes over three weeks. On arrival, clients were instructed to sit and relax for 5-10 minutes and to empty their bladders. Subjects in the manual acupressure massage group were then given 30 minutes of neck pain acupressure massage. The oil consisted of 3% aromatic natural lavender oil in olive oil base. The same supply of oil and dilution was used throughout the trial. One participant reported discomfort caused by the acupressure. Toxic side effects were not discussed. Of the 32 participants enrolled in this study, 28 subjects (88.0%) completed the study. Fourteen were in the Manual Acupressure Group (MAG) and 18 were in the Control Group (CG.). Four clients failed to return (MAG: 3 and CG: 1) in the one-month follow-up for various reasons, such as being busy or out of town. One participant discontinued the study due to discomfort caused by acupressure. Data were obtained at four time points during the study. The first data were collected before the intervention, then immediately after the intervention. Results were also collected one week and one month following treatment completion for all groups. Both neck stiffness and stress level were assessed by a standard 10cm horizontal VAS. Neck flexion and extension were quantified by the distance in centimeters between the tip of chin and supra-sternal notch. Also, neck lateral flexion was assessed by the distance in centimeters between mastoid process of skull to the acromion process of shoulder. Interference in daily activities was measured by the Neck Pain and Disability Scale (NPDS). The number of pain killers taken was also noted. The baseline VAS score for the manual acupressure group and control groups were collected as 5.12 and 4.91, respectively, out of 10 (p=0.72). One month after the end of treatment, the manual acupressure group had, compared to the control group, 23% reduced pain intensity (p=0.02), 23% reduced neck stiffness (p=0.001), 39% reduced stress level (p=0.0001), improved neck flexion (p=0.02), neck lateral flexion (p=0.02), and neck extension (p=0.01). However, improvements in functional disability level were found in both the manual acupressure group (p=0.001) and the control group (P=0.02). It should be noted that this was a nonblinded experimental study design, as the interviewers were aware of the assignment of the participants to their groups. Another limitation to this study was the lack of placebo control or sham acupressure groups to control for possible placebo effects. Also, as aromatic lavender oil is popular in Hong Kong, patients' expectations of the effect of lavender oil may have inflated the effects of the intervention.

Pain (postoperative)

• Summary: Preliminary evidence is conflicting regarding the use of acupressure in pain postoperatively. Further well-designed studies are required before recommendations can be made.
• Evidence: Sakurai et al. conducted a randomized controlled study to examine the effect of minute sphere acupressure on postabdominal surgery pain and analgesic requirements in 71 surgical patients (96). Patients with conditions in which pain perception was affected and or who used preoperative analgesics and were scheduled for regional anesthesia were excluded. Patients were given standardized desflurane and fentanyl anesthetic and were treated postoperatively with a patient-controlled morphine pump. On completion of surgery, patients were randomly assigned to control (untreated) or minute sphere acupressure at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points. Sites were covered with dressings so that patients could not determine their assignments. The main end points were pain and opioid consumption on the first postoperative morning. Fifty-three patients (30 controls) completed the study. The authors state that side effects were not the reason for withdrawals. Morphine requirements and pain scores were not significantly different between groups. This study was well designed, with surgeons and patients blinded to treatment.
• Heping et al. conducted a before-and-after comparison study involving 70 randomly selected operative patients treated by auricular manual "pressing pills" on multiple acupoints, and 40 operative patients treated with Dolantin or Rutundin (54). There was no statistically significant difference between the two groups in age distribution or type of illness prompting surgery. Among those undergoing acupressure, 66 out of 70 reported pain relief after two treatments, compared with 37 of the 40 receiving relief in the analgesic group after two injections. Statistically significant changes in blood endorphin content were observed in 30 of the 70 acupressure recipients, and in those in the analgesic group who received relief. It should be noted that the study is unclear on if the comparison group was randomly selected, and it employed no quantitative mechanism for comparing pain relief.

Pain (shoulder)

• Summary: There is preliminary evidence from a randomized controlled trial that the addition of aromatherapy to acupressure might increase its pain-reducing effects in patients with shoulder pain. However, the lack of a nontreatment or sham-treated control makes it difficult to determine the effect of acupressure alone. Preliminary evidence suggesting reduced pain following acupressure in patients with fractures and low back pain indicate that there is a need for well-designed studies in this field before recommendations can be made.
• Select combination studies (not included in table): Shin et al. conducted a randomized, before-and-after equivalence study of 30 stroke patients with hemiplegic shoulder pain (HSP) to evaluate the effectiveness of aromatherapy and acupressure, compared to acupressure alone, in reducing HSP and improving motor power in stroke patients (175). Patients with HSP, with Grade 3 or lower in motor power of the hemiplegic upper extremity, and with no allergy to aromatherapy, were included. Patients with pain conditions other than HSP were excluded. Thirty subjects were randomized to receive either aromatherapy and acupressure or acupressure alone. The acupressure was performed on acupoints related to shoulder pain: Large Intestine (LI) 15 (Jian Yu), Small Intestine (SI) 9 (Jian Zhen), Triple Energizer (TE) 14 (Jian Liao), Gallbladder (GB) 21 (Jian Jing), SI11 (Tian Zong), and SI12 (Tian Zong). The aromatherapy employed essential oils of rosemary, lavender, and peppermint in a 2:1:1 ratio diluted to 3% in jojoba oil, at the same points. Twenty-minute sessions were performed twice daily for two weeks. Adverse effects and interactions were not discussed. All 30 subjects completed the two-week treatment. Outcome measures included shoulder pain and motor power, measured before and after treatment. The pain scores were markedly reduced in both groups at post-treatment, compared to pretreatment (both aromatherapy-and-acupressure and acupressure-only groups, p<0.001). Pain score differed significantly between the two groups at post-treatment (p<0.01). Motor power was also significantly improved at post-treatment, compared to pretreatment, in both groups (p<0.005). The intergroup differences were not significant. Limitations of this study include a small sample size, some reliance on subjective outcome measures, the heterogeneity of shoulder pain in stroke patients, and the short-term nature of treatment. It should also be noted that the study did not employ a control group.

Palliative care

• Summary: There is preliminary evidence from a case series suggesting shiatsu therapy might improve energy, relaxation, confidence, mobility, symptom control, and clarity of thought in patients attending hospice day services. However, the lack of a nontreatment or sham-treated control make it difficult to determine the effect of acupressure alone. Well-designed studies are required before recommendations can be made.
• Evidence: Cheesman et al. conducted a case series to evaluate the effects of shiatsu therapy on clients attending hospice day services (176). Eleven clients with advanced progressive disease received five therapy sessions each at weekly intervals. Data were collected through five unstructured interviews with each client. Four of these were conducted before, during, and shortly after the therapy regime, and the fifth was undertaken four weeks after treatment ended. All the interviews were tape-recorded, transcribed, and subject to content analysis. The results of this analysis revealed significant improvements in energy levels, relaxation, confidence, symptom control, clarity of thought, and mobility. These benefits were of variable duration, in some instances lasting a few hours but in others extending beyond the five-week treatment regime. Data validity were ensured by keeping research journals (to provide an audit trail), conducting member checks, and using peer debriefing. The study involved three overlapping cohorts of participants in a data collection period that took approximately six months.

Parkinson's disease

• Summary: There is promising early evidence from one small case series to support the use of tuina massage in the treatment of Parkinson's Disease. Symptomology was noted to improve under "FSR" style tuina massage in this study. Larger controlled trials are required before any recommendation can be made.
• Evidence: Walton-Hadlock et al. conducted a controlled case series involving 12 patients with Parkinson's disease and 12 without Parkinson's disease receiving "Yin-type" or "FSR" style tuina massage once a week for a minimum of four sessions (25). Certain patients also received acupuncture. All of the subjects in the Parkinson's group reported a decrease in symptoms ranging from improved ability to move head from side to side to decreased dyskinesia, tremor, rigidity, cogwheeling, as well as improved gait, speech, and circulation. Four subjects reported cessation of all Parkinson's symptoms. Limitations to this study include the lack of a placebo group and the possible confounding effect of acupuncture.

Sexual dysfunction

• Summary: There is promising early evidence from a small case series to support the use of vaginal acupressure for women with a history of sexual problems. The clinical use of vaginal acupressure has been reviewed by the same author (60). Larger controlled trials utilizing this type of acupressure are still required before recommendations can be made.
• Evidence: Ventegodt et al. conducted an open pilot study to examine the effect of vaginal acupressure in 20 female patients with a long history of sexual problems (26). Other than a long history of sexual problems, inclusion and exclusion criteria were not provided. It should be noted that vaginal acupressure technique was not clearly described. Endpoints included quality of life and reduction in symptoms. Overall, 56% of patients experienced positive effects. None reported setbacks. Most (89%) patients said the treatment was of high quality and valuable. Problems appeared less serious and general quality of life improved. Seventeen percent of subjects reported minor or temporary side effects (feelings of shame or guilt, bleeding, reopening of scars, and genital soreness). Chronic genital pains, lack of desire or orgasm, pain or discomfort during intercourse, and subjective sexual insufficiency all significantly improved with treatment (p<0.05). Self-evaluated physical and mental health, relationship with partner, subjective sexual ability, and quality of life were also significantly improved. This study is limited by several methodological weaknesses including a lack of randomization, controls, and blinding.

Sleep apnea

• Summary: There is preliminary evidence from one randomized controlled trial to suggest that auricular acupressure may be of benefit to those with sleep apnea, with treatment resulting in reduced apnea and improvements in blood oxygen saturation. However, further research is required before recommendations can be made in this indication.
• Evidence: Wang et al. conducted a randomized controlled study to examine the effect of auricular acupressure for the treatment of sleep apnea syndrome in 45 patients (177). Patients were randomly divided to acupressure (N=30) or control (N=15). Endpoints included changes in clinical symptoms, apnea-hypopnea index, apnea index, hypopnea index, and minimum blood oxygen saturation (mSaO₂) during the night before and after treatment with multiple-channel polysomnography. As compared with control, acupressure significantly improved clinical symptoms, with significant reductions in apnea-hypopnea index, apnea index, and hypopnea index, and increased mSaO₂ (p<0.01). No improvements occurred in the control group.

Sleep quality

• Summary: There is promising early evidence from randomized controlled trials to support the use of acupressure for sleep quality in the elderly, although data are inconsistent in patients with end-stage renal disease (ESRD). Further trials in both the elderly and other populations are needed to clarify the effect of acupressure on quality of sleep.
• Evidence: Tsay et al. conducted a well-designed randomized, controlled trial to examine the effect of acupressure on sleep in 98 patients with end-stage renal disease (44). ESRD patients who scored five points or higher on the Pittsburgh Sleep Quality Index were included. Patients were assigned to acupressure (hand shenmen HT7, ear shenmen HT7, and yung chuan K11), sham acupressure, and control groups. Acupressure or sham acupressure were administered three times a week during hemodialysis treatment for a total of four weeks. The main endpoints included the Pittsburgh Sleep Quality Index, sleep log, and the SF-36. Acupressure resulted in improvements in all indices as compared with control, but not compared with sham acupressure. This study was well designed, although the abstract does not include the observed lack of difference between sham and true acupressure groups and falsely supports positive results.
• Tsay et al. conducted a randomized controlled trial to compare the effectiveness of acupressure and transcutaneous electrical acupoint stimulation (TEAS) on fatigue, sleep quality, and depression in 106 patients receiving routine hemodialysis treatment (149). Adult patients with end-stage renal disease were included if they had been treated with hemodialysis for at least three months, had complaints of fatigue symptoms with Pittsburgh Sleep Quality Index (PSQI) scores of at least five points, and had Beck Depression Inventory (BDI) scores of 10 points or higher. Patients with lower-extremity amputations, co-morbid diagnoses of psychiatric disorders, congestive heart failure, chronic obstructive pulmonary disease, insulin-dependent diabetes, neuromuscular disease, systemic lupus erythematosus, rheumatoid arthritis, cancer, or a history of steroid or antihypertensive use were excluded. Patients were randomized to acupressure (15 minutes three times weekly for one month at K1, St36, GB34, and Sp6 sites), TEAS (15 minutes three times weekly for one month), or control groups (routine care). Endpoints included the revised Piper Fatigue Scale (PFS), the Pittsburgh Sleep Quality Index, and the Beck Depression Inventory. As compared with control (but not each other), levels of fatigue (22% reduction in acupressure group), sleep quality (12% improvement in acupressure group), and depression (24% improvement in acupressure group) scores all improved with acupressure and TEAS. This study was not blinded.
• Tsay et al. conducted a randomized controlled study to examine the efficacy of acupressure in alleviating fatigue in 106 patients with end-stage renal disease (178). Adult patients with end-stage renal disease were included if they had been treated with hemodialysis for at least three months, had complaints of fatigue symptoms with Pittsburgh Sleep Quality Index (PSQI) scores of at least five points, and Beck Depression Inventory (BDI) scores of 10 points or higher. Patients with lower-extremity amputations, co-morbid diagnoses of psychiatric disorders, congestive heart failure, chronic obstructive pulmonary disease, insulin-dependent diabetes, neuromuscular disease, systemic lupus erythematosus, rheumatoid arthritis, cancer, or history of steroid or antihypertensive use were excluded. Patients were randomized to acupressure (15 minutes three times weekly for one month at K1, St36, GB34, and Sp6 sites), sham acupressure, (different points), or control groups (routine care). Endpoints included the revised Piper Fatigue Scale (PFS), the Pittsburgh Sleep Quality Index, and the Beck Depression Inventory. Acupressure resulted in significantly lower fatigue scores vs. control; however, there were no differences compared with placebo. It should be noted that this study was not completely blinded.
• Tsay et al. conducted a randomized controlled trial to examine the effect of acupressure on sleep quality of 105 end-stage renal disease patients (179). Adult ESRD patients undergoing afternoon dialysis with no other major illnesses were included. Patients were assigned to acupressure (hand shenmen HT7, ear shenmen HT7, and yung chuan K11), sham acupressure, or control groups. Acupressure or sham acupressure were administered three times a week during hemodialysis treatment for a total of four weeks. The main outcomes included the Pittsburgh sleep quality index and a sleep log. Acupressure resulted in improvements in all indices as compared with control, but not as compared with sham acupressure. This study was very similar to another study conducted by the same first author (44). Randomization and double-blinding were not adequately described.
• Chen et al. conducted a randomized, single-blinded study involving 124 elderly people suffering from sleep disturbance (46). However, the study had only a 66% completion rate. Of those remaining in the study, 28 subjects were in each of three groups: an acupressure group receiving manual treatment on five acupoints, a sham acupressure group, and a nontreatment group. Using the Pittsburgh Sleep Quality Index (PSQI), the study found that there was a significant improvement in sleep among those receiving acupressure. This study is limited by its singly blinded design.
• Sok et al. conducted a study to examine the effects of auricular acupuncture on insomnia in 50 Korean elderly (180). Subjects were aged 65 years and over. Auricular acupuncture was applied five times, for three days each time. Sleep scores were the main endpoints. Acupressure resulted in significantly higher sleep scores vs. control (p=0.001), as well as higher self-satisfaction scores on sleep vs. control group (p=0.001).

Smoking cessation

• Summary: There is, at this time, little evidence to support the use of auricular acupressure as an aid for smoking cessation. Well-designed clinical trials are required before any recommendations can be made.
• Systematic review: White et al. performed a systematic review of 24 randomized trials to compare effectiveness of acupuncture, acupressure, laser therapy, or electrostimulation with either no intervention, a sham form of the intervention, or another intervention, for smoking cessation (181). The authors wanted to determine if these therapies are more effective than waiting list or no intervention for smoking, have a specific effect in smoking cessation beyond placebo effects, and are more effective than other interventions of known effect for smoking cessation. Secondary objectives were to evaluate whether these therapies have a specific effect in smoking cessation when they are used as adjuncts to another active treatment and to evaluate whether any particular acupuncture approach is more effective than any other. The trials included were all randomized controlled trials comparing acupuncture, acupressure, laser therapy, or electrostimulation with either no intervention, a sham form of the intervention, or another intervention, for smoking cessation. Participants were tobacco smokers of any age who wished to stop smoking. It appears that only one study directly examined acupressure, although this is not clear from the review (182). The primary analysis included all forms of stimulation, and thus the effect of acupressure alone was not discussed.
• Evidence: White et al conducted an open, randomized, controlled pilot study to evaluate the design of a study testing acupressure as an adjunct to one, currently offered antismoking treatment, for the purpose of determining whether the design could feasibly detect the effects of acupressure on smoking withdrawal (183). Smokers were eligible for the study if they smoked 10 or more cigarettes daily, were aged 18 years or over, intended to stop smoking on the quit date, chose nicotine replacement therapy (NRT) rather than bupropion, and gave informed consent. Forty-nine smokers were recruited for the study. Subjects were excluded if they had a history of current otitis externa or other pathological condition of the ear, history of a poorly controlled relevant medical condition, history of allergy to adhesive dressing, were currently taking antidepressant or antipsychotic medication, were possibly pregnant, or were already participating in a research project. Of the 49 smokers who attended four clinics, 24 agreed to participate. This study was conducted within a six-week group program offered by the Smoking Advice Service in Plymouth, UK. All participants received the usual treatment with NRT and group behavioral therapy and were randomized into three groups: group A with two auricular acupressure beads placed on Lung and Shenmen points of the ear, group B with only one bead placed at lung point of the ear, or group C with no additional therapy. Participants were taught to press the beads when they experienced cravings. They were given oral and written instructions on how to tap, press, or squeeze the beads repeatedly for up to a minute each time a craving occurred. Beads were worn in one ear for four weeks, replaced as necessary. Subjects were also advised to bring their empty packets of NRT to assigned clinics, allowing for direct assessment of NRT consumption. For the majority of time, discomfort experienced by the subjects from the bead was scored as "none" to "slight." However, two participants, both in group A, reported the discomfort as being "somewhat" on days 3-4. Two other patients also reported "soreness" from the beads. No participant reported removing the bead due to soreness. No toxic side effects were mentioned throughout the study. Of the 24 subjects randomized on the quit date, one decided against using NRT and was therefore excluded from analysis. Also, four participants did not attend the week following the quit date and so were presumed not to have quit. Thus, only 19 of the 24 patients (39% of those invited) remained in the study for at least one week after quitting. Only 7 of 24 (14%) remained throughout the study period. At week 3, one subject withdrew from the study due to lack of perceived effect of acupressure, but continued to attend the clinic. Subjects who dropped out of the study were slightly older (47.5, SD 11.5, against 41.7, SD 14.0 years), and reported a median of two previous quit attempts in comparison to six in those who stayed (z=2.175, p=0.030, Mann-Whitney U test). Furthermore, subjects did not report higher daily consumption of cigarettes compared to participants who remained in the study, and were similar in nicotine dependence scores, measured expired carbon monoxide concentration, and prescribed form of NRT. Any interactions with the treatment were not mentioned. The effects of acupressure on nicotine dependence were measured by the report of NRT consumption and nicotine withdrawal symptoms. The consumption of NRT (patch, gum, micro tablets, lozenges or inhalator) was measured in two ways: by counting used packs at each attendance and from reports in daily diaries. Withdrawal symptoms were assessed by a seven-item Mood and Physical Symptoms Scale (MPSS). The secondary outcome was quit rate at four weeks, defined as self-reported cessation. This was validated by carbon monoxide concentration in expired air of ≤9ppm. Relative level of discomfort due to beads was also measured using a five-point scale (none to extreme). This was recorded in the subjects' daily diaries. Participants were also asked to record how many times they stimulated the beads over a 24-hour period. They were to place results in five categories: none, <5, 5-9, 10-20, and over 20 times. At each clinic attendance, participants were interviewed by two authors and were asked whether they had experienced any adverse events during the previous week related to NRT or acupressure. This information, along with CO readings, was recorded in a clinic data sheet. No significant changes or differences between groups for any week were seen. This study was limited by a significant dropout rate. The dropout rate during the five-week study was 84%. From 49 smokers attending four clinics, only seven remained to the final week. Compliance was also poor . During the first week participants generally adhered to instructions on how to press the bead quite well; however, soon after, compliance deteriorated. Reporting of NRT consumption was also very poor, with large portions of data unreported or missing. It appears that any effects of acupressure on smoking withdrawal are unlikely to be detectable by the methods used in this study.
• Select combination studies (not included in table): Chen et al. conducted a controlled clinical trial to develop an Internet-assisted smoking cessation program accompanied with auricular acupressure and to compare the quit rate and self-efficacy of youth smokers receiving auricular acupressure with and without the Internet-assisted smoking cessation program (184). Students who smoked were recruited on a voluntary basis as subjects from two senior high schools. The exclusion criteria were not reported. A website was constructed to provide an Internet-assisted smoking cessation program. The contents of the website were divided into eight units: Impact of Smoking, Auricular Acupressure for Smoking Cessation, Critical Issues in Smoking Cessation, Online Questionnaire, Professional Counseling, Discussion Forum, Hot Topics, and Hyperlinked Websites. Group 1 received four weeks of auricular acupressure plus an Internet-assisted smoking cessation program, whereas Group 2 only received four weeks of auricular acupressure. The auricular points for smoking cessation that were used in this study include the Shenmen, Lung, Mouth, Stomach, and Endocrine points. The participants were instructed to press five auricular points for at least one minute, 3-5 times per day for four weeks. The adhesive patch with the ear seed was renewed weekly. Adverse effects, interactions, and dropouts were not mentioned. Data on demographic factors, serum cotinine, quitting rate, nicotine dependence, and self-efficacy of subjects were collected before and after a four-week intervention. Serum cotinine level served as a physical indicator for the efficacy of the smoking-cessation intervention. A serum cotinine concentration under 100ng/mL indicated that an individual did not use tobacco. Serum cotinine level was determined by enzyme-linked immunosorbent assay (ELISA). In addition, the Fagerstrom tolerance questionnaire (FTQ), developed by Fagerstrom et al., was used to evaluate participants' nicotine dependence. Self-efficacy served as a psychological indicator in this study and was assessed using a self-efficacy questionnaire developed by Liao et al. Before intervention, the mean serum cotinine level was 346.77ng/mL (SD=142.51) for Group 1 and 376.06ng/mL (SD=169.71) for Group 2. After intervention, the mean serum cotinine level was 342.29ng/mL (SD=182.70) for Group 1, and 379.73ng/mL (SD=187.68) for Group 2. In terms of quitting rate, six of 38 subjects (15.78%) in Group 1 displayed serum cotinine levels under 100ng/mL, whereas one of 39 subjects (2.56%) did in Group 2. After intervention, the quit rate was 15.78% in Group 1 and 2.56% in Group 2. Group 1 showed a statistically significant difference of nicotine dependence before and after intervention (z=-2.81, p<0.01), but Group 2 did not (z=-0.47, p>0.05). The improvement of self-efficacy between Groups 1 and 2 was significantly different. In Group 1, the difference between pretest and post-test values of self-efficacy was statistically significant (t=5.77, p<0.001). In Group 2, the difference between pretest and post-test values also was statistically significant (t=2.32, p<0.05). An independent t-test revealed that the improvement of self-efficacy score between the two groups was also significantly different (t=2.24, p<0.05). Dropouts, side-effects, and adverse events were not discussed. Certain elements of the study's design were also not discussed.

Stroke

• Summary: There is promising early data from one case series supporting the use of acupressure as an adjunct treatment in the recovery from poststroke paralysis. This study combined herbal and conventional medicine with full-body acupressure as the therapeutic intervention; however, a full analysis is not provided in the report. Future research is required before any recommendation can be made.
• Select combination studies (not included in table): Rongzhong et al. conducted a case series involving 42 patients with apoplectic hemiplegia (22). Twelve patients received a combination of herbal and Western medicine as well as full-body acupressure treatments every 1-2 days. Thirty patients refused medicine due to insignificant results and received only acupressure. Nine of the patients (21%) reported disappearance of hemiplegic symptoms within six months, and only four patients (10%) showed no effect. Unfortunately, methodological weaknesses such as the lack of a control or comparison group and the failure to account for whether receiving or not receiving medicine was a significant factor undermine the validity of these findings.

Cervical spondylosis

• Summary: Results from a meta-analysis do not suggest tuina as an effective treatment for the improvement of headache and vertigo in individuals with cervical spondylosis. Further study is required before any recommendations can be made.
• Meta-analysis: Wang et al. conducted a meta-analysis to examine the effect of tuina in the treatment of cervical spondylosis (185). Cochrane Library, PUBMED, MEDLINE, EBM Review, ProQuest Medical Bundle, and SCOPUS databases were searched. Chinese research papers were also searched. Papers investigating tuina as a stand-alone modality in a parallel-group comparison design were included. Studies with an evidence rating of II-2 (fair or above) were included in this review. The direction of the effect size for the improvement of blood flow velocity of the vertebral artery and the basilar artery was not consistent across studies. Moreover, the pooled effect size was negligible. No evidence supported that tuina could improve headache and vertigo. However, a small effect of tuina on the viscosity of blood and plasma was found.

Weight loss/obesity

• Summary: The scientific evidence is currently unclear with respect to the use of acupressure for weight loss, though early data suggest the potential for improved weight maintenance following weight loss. Further study is required before recommendations can be made in either condition.
• Systematic review: Pittler et al. conducted a systematic review to examine the evidence from randomized controlled trials and systematic reviews of complementary therapies for reducing body weight (186). MEDLINE, EMBASE, AMED, and the Cochrane Library were searched through January 2004. Hand-searches of relevant medical journals and bibliographies of identified articles were also conducted. Six systematic reviews and 25 additional randomized controlled trials were included. Only one study (a systematic review) discussed the use of acupressure (187). Overall, it was concluded that for most complementary therapies, the weight of the evidence for reducing body is not convincing.
• Ernst systematically reviewed all placebo/sham-controlled studies on acupuncture or acupressure for weight reduction and found four studies and scored them according to their methodological quality (187). The results of the four studies were contradictory, although the two relatively rigorous trials showed no effect on body weight. It is not clear which of the included trials studied acupressure.
• Evidence: Elder et al. conducted a randomized, single-blinded controlled trial to evaluate two mind-body interventions and their efficacy in weight loss maintenance (188). Patients included in the study were men and women aged 18-80. Eligible women had a body mass index (BMI) of 25-35kg/m² at baseline, and men had a BMI of 25-40kg/m². Patients had to live in the Portland, Oregon, metropolitan area, complete the initial 12-week weight loss program, attend at least 75% of the weight loss sessions, and lose at least 3.5kg in the 12-week weight loss program. Patients were excluded from the study if they had medical conditions or treatments in which using a diet and exercise weight loss program is contraindicated (including cancer), if they had significant gastrointestinal disease, diabetes, congestive heart failure, or cardiovascular disease, if they were taking prescription medication for high blood pressure, high cholesterol, psychosis or manic depression, if they had a psychiatric hospitalization during the past two years, if they were taking weight loss medications currently or within the past six months, if they had liposuction in the past 12 months, or if they had a previous history of bariatric surgery. Other reasons for exclusion included a previous history of CAM weight loss treatment; current acupressure, qigong, or acupuncture treatment; consumption of more than 21 alcoholic drinks per week; weight change of more than 10 pounds during the six months prior to the baseline period; pregnancy, current breast-feeding or planning pregnancy before the end of the study; current participation in another clinical trial; or a household member of another participant in the study. Out of 223 subjects recruited, 101 were eligible for the study. After all participants completed a 12-week weight loss class, all patients that lost at least 3.5kg were included in the experimental phase of the study; in total, 92 were randomized to intervention and control groups. The sample size was limited to about 90 by available funding and practical considerations. Interventions were qigong (QI), Tapas Acupressure Technique (TAT) or a control group using self-directed support (SDS). The qigong techniques used in the study were shaking (five minutes; to begin opening the body's meridians and connect with universal energy), movements (18 minutes; to increased communication and exchange with universal energies, to enhance an individual's vitality) and harvesting the energy (five minutes; involved using basic qigong closing methods to consolidate and maintain the results of the exercises). The TAT technique combined acupressure with specific mental focuses, to alter energy patterns stored in the body. Patients were given general instructions to identify the belief or action that was hindering weight loss or maintenance and focus on that negative image while holding the TAT pose (pressure to acupuncture points GB21, BL1, and Yin Tang for 30 seconds). While continuing pressure to these points for another 30 seconds, patients were to transition the focus onto the opposite positive image, then focus on healing the origins of the problem and all parts of the body affected by it. Finally, patients were told to forgive everyone they blamed for the problem. Daily practice was advised. For the control group, written materials were provided to the patients with a general overview of weight loss maintenance strategies. Further sessions were participant-driven maintenance support groups in which the patients could ask questions of the class leader and share experiences. The initial weight loss period took place over 12 weeks. The post-randomization interventions were done in group sessions for 10 hours per week for 24 weeks. No allergies or adverse effects were noted. There were 11 patients who dropped out of the study (six in QI, two in TAT, and three in SDS group). Reasons for discontinuation were obtained from nine patients. Three patients either never attended or discontinued attending the weight loss maintenance sessions primarily due to scheduling conflicts. Six patients discontinued because of unclear expectations of the classes or discomfort with some aspect of the class. No interactions were noted. The primary outcome measure was weight change, with weight assessed at one, 12, and 24 weeks post-randomization. Weight was assessed with a high-quality digital scale while subjects were wearing light indoor clothes and no shoes. Other psychosocial constructs were measured prior to randomization to determine if the CAM interventions might have a potential impact on weight. These included absorption (openness to experiencing emotional and cognitive alterations across different situations, measured with the Tellegen absorption scale), expectancy (patients rated how helpful they thought each intervention would be prior to enrollment, rated on a scale of 1-5), social support (measured with a scale adapted from the medical outcomes study), depression (assessed using the Center for Epidemiologic Studies depression scale) and weight loss history. The TAT group had a small, insignificant improvement over the SDS group at 12 weeks. At 24 weeks, the TAT group did not regain any weight overall and showed benefit over the control group (p=0.09). The control group regained 1.5kg after an initial 5kg weight loss. The QI group increased in weight at both 12 and 24 weeks, regaining a total of 4.3kg of the 5.5kg initially lost, and showed significant differences from both other groups at both time points. The researchers noted that the qigong group should have been trained more extensively and given more time per week, as this technique requires more extensive training and time for use. It should also be noted that the exclusion of so many co-morbidities limits the generalizability of this study. Furthermore, the number of adjunct treatments make the effect of acupressure alone difficult to assess.
• Allison et al. reported a randomized, placebo controlled, single-blind study (N=48) to determine the efficacy of an auricular acupressure device on weight loss in obese patients (165). Subjects were randomized to either treatment (auricular acupressure device) or control (wrist acupressure device). Testing occurred over 12 weeks with weight, body fat, and blood pressure measured every two weeks. The auricular acupressure device applied pressure on six ear acupoints. There were no significant differences between the two groups regarding weight loss, fat loss, or blood pressure reduction. However, the study had a 27% noncompletion rate, and the authors failed to conduct tests to determine if the wrist acupressure device was a valid placebo.

Products Studied

Products/supplies/equipment of particular brands used in statistically significant trials:

• Sea-Band( wristband (examples) (71;​82;​83;​85;​87;​91;​103;​107;​110;​116).
• AcuBand( wrist strap (93).
• AB-Bong acupressure disc (77).

Author Information

• Authors/Editors: Julie Conquer, PhD (RGB Consulting); Jenna Hollenstein, MS, RD (Natural Standard Research Collaboration); Ramon Iovin, PhD, (Natural Standard Research Collaboration); Richard Isaac (Natural Standard Research Collaboration); Katie Nummy, BS (Northeastern University); Erica Rusie-Seamon, PharmD (Natural Standard Research Collaboration); Shaina Tanguay-Colucci, BS (Natural Standard Research Collaboration); Catherine Ulbricht, PharmD (Massachusetts General Hospital); Wendy Weissner, BA (Natural Standard Research Collaboration); Carolyn Williams Orlando, MA.
• Blinded Peer Review: Natural Standard Editorial Board.

References

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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