By Erica Benedicto, PA-C, MPH, YT

Founder, Shiny Healthy People, Austin, TX

Ms. Benedicto reports no financial relationships relevant to this field of study.

SYNOPSIS: Two different types of self-administered acupressure techniques were significant in reducing persistent cancer-related fatigue compared with standard of care, but only relaxing acupressure affected quality of sleep and life.

SOURCE: Zick SM, Sen A, Wyatt GK, et al. Investigation of 2 types of self-administered acupressure for persistent cancer-related fatigue in breast cancer survivors. JAMA Oncol 2016; Jul 7. doi: 10.1001/jamaoncol.2016.1867. [Epub ahead of print].

SUMMARY POINTS

  • Breast cancer survivors were randomized and assigned to one of three interventions: self-administered relaxing acupressure, stimulating acupressure, or usual care.
  • At the end of six weeks, 66.2% of relaxing acupressure, 60.9% of stimulating acupressure, and 31.3% in usual care achieved normal fatigue levels, meaning they had a Brief Fatigue Inventory score of < 4, indicating a statistically significant difference.

The prevalence of breast cancer is rising, with about one in eight U.S. women developing invasive cancer over her lifetime.1 One of the most common symptoms of breast cancer survivors is persistent fatigue, leading to decreased quality of life and poor sleep quality.2 Fatigue persists in approximately one-third of women up to 10 years after the end of breast cancer treatment.3

Although the rates of cancer-related fatigue remain high, the treatments for this symptom are limited.4 This is where inexpensive, easy-to-administer self-care techniques can fill a need for breast cancer survivors. Zick et al looked at persistent fatigue after breast cancer treatment and the benefits of self-administered acupressure vs. usual care.

Acupressure has shown promising benefits, particularly in treating cancer-related fatigue, decreasing patients’ symptoms of fatigue by approximately 45% to 70%.4 Participants in this study further benefited by initiating relaxing acupressure (which is typically used for insomnia) and stimulating acupressure (used to boost energy).

The study was a 10-week randomized, single-blind trial. The authors screened 424 women recruited from the Michigan Tumor Registry and randomized 288 women. Researchers divided the 288 women into three groups: relaxing acupressure, stimulating acupressure, and usual care. Usual care consisted of any treatment given by a healthcare professional for cancer-related persistent fatigue. Randomization (1:1:1) was computer generated by blocks of six and by county. Of the three groups, 72.4% of the relaxing acupressure, 73.4% of the stimulating acupressure, and 86.5% in usual care completed all study visits. There were no significant differences in any sociodemographic group or clinically between those who withdrew from the study and those who completed the study.

Participants who performed self-administered acupressure were taught by a trained acupressure educator at baseline. Women were taught point location, stimulation techniques, and pressure intensity. Participants in the relaxing acupressure group worked on five points, with four done bilaterally and one centrally. The stimulating acupressure group used six points, four done bilaterally and two centrally. Participants were instructed to perform acupressure once daily, stimulating each point in a circular motion for three minutes. Researchers assessed consistency and fidelity by testing participants on technique and duration at baseline, three weeks, and six weeks. Participants performed self-administered acupressure daily for six weeks. There was a four-week follow-up for all three groups. Women were ineligible if they had untreated major depressive disorder, other fatigue-causing comorbidities, or a cancer diagnosis other than breast or skin cancer within the previous 10 years. Also, they were not allowed to participate in the study if they were starting a new treatment, changing medication for cancer, taking medication for insomnia, or if they received acupressure or acupuncture within the six months prior to the study beginning.

Primary outcome measures were assessed using the Brief Fatigue Inventory (BFI) score, which was collected at baseline and weeks 1 to 10. The BFI looks at nine different items measuring fatigue on a scale from 0 to 10. A score of 4 or higher is considered clinically relevant for fatigue and a three-point change and drop below 4 is considered a clinically meaningful change. Secondary outcome looked at the Pittsburgh Sleep Quality Index (PSQI) and Long-Term Quality of Life Instrument, which were administered at baseline and weeks 6 and 10. Eligible women had to report persistent fatigue starting on or after their cancer diagnosis with a score of 4 or higher on the BFI.

Usual care was considered any treatment given to a patient by a healthcare professional for fatigue. The three groups consisted of 98 self-administering relaxing acupressure, 94 stimulating acupressure, and 96 allocated to usual care. After six weeks, 74 completed relaxing acupressure, 70 completed stimulating acupressure, and 84 completed usual care. At the four-week follow-up with no acupressure, there were 71 from the relaxation group, 69 from the stimulating group, and 83 from the usual care group.

Fatigue measured by the BFI score from baseline to six weeks was significantly greater in relaxing and stimulating acupressure compared to usual care (mean [SD], - 2.6 [1.5] for relaxing acupressure, -2.0 [1.5] for stimulating acupressure, and -1.1 [1.6] for usual care; P < .001 for both acupressure groups compared to usual care). At week 10, the change in BFI score from baseline was higher in the relaxing acupressure group vs. the stimulating group compared with usual care. The mean percentage fatigue reductions at 6 weeks were 34% for relaxing, 27% for stimulating, and -1% for usual care (P < 0.001 for both acupressure arms and usual care). Participants who managed to achieve normal fatigue levels with a BFI score of < 4 at week 6 were 66.2% in relaxing, 60.9% in stimulating, and 31.3% in usual care. These benefits continued into the follow-up period at 10 weeks, with 56.3% in relaxing acupressure, 60.9% in stimulating acupressure, and 30.1% in usual care having normal fatigue levels.

Sleep quality was measured on a 19-item PSQI, which measures sleep disturbance over one month. A score of 8 or higher indicates poor sleep quality; if the score drops below 8 or changes more than 3 points, it is considered clinically significant. Those in the relaxing acupressure group had PSQI scores that were significantly lower. Those in the stimulating group did not have any significant clinical changes. There was no significant difference in the three arms at the 10-week follow-up. Participants in the relaxing acupressure arm had an improved measure of long-term quality of life for three of the four subscales, including somatic, fitness, and social support at six and 10 weeks. Stimulating acupressure was not significantly different from usual care for any subscale. Six adverse events were recorded during the research, which consisted of mild bruising at acupressure sites.

Table 1: Relaxing vs. Stimulating Acupressure

Relaxing Acupressure

Stimulating Acupressure

Done Bilaterally

  • anmian
  • heart 7
  • spleen 6
  • liver 3

Done Bilaterally

  • large intestine 4
  • stomach 36
  • spleen 6
  • kidney 3

Done Centrally

  • yin tang

Done Centrally

  • du

COMMENTARY

According to this study, cancer-related fatigue can be reduced with self-administered relaxing and stimulating acupressure compared to usual care. Both relaxing and stimulating arms demonstrated significant improvements in fatigue, and the relaxing arm showed improved quality of life and sleep compared with usual care. These results are interesting for several reasons, one of which is that the research shows that the etiology of persistent fatigue can be from various mechanisms. Recent studies suggest persistent fatigue stems from central nervous system dysfunction and possibly is linked to elevations in specific neurotransmitters and metabolites, including elevations in glutamate levels; acupressure provided benefits despite a lack of stratification by etiology.5-8 Acupuncture has been proven to alter brain physiology, chemistry, and function, and the researchers from this study posit that self-administration of acupressure may have the same effects.

The study had a few limitations, including too few minority women. Breast cancer is more common in African-American women than white women younger than 45 years of age. African-American women also have a higher rate of death from breast cancer.1 There were also concerns about self-administered acupressure being too time consuming and, therefore, leading to discontinuation of participation. However, dropout rates were not overtly affected by randomization to the treatment groups, perhaps indicating a minimal time-disincentive.

Educating and empowering patients to take control of their health is becoming a common trend in healthcare. Providing patients with the tools and resources encourages independence and autonomy. Self-administered relaxing acupressure can be added to the toolbox of healthcare professionals treating breast cancer patients to target persistent fatigue. As part of the comprehensive care plan for patients with breast cancer, this may be a feasible addition in decreasing cancer-related fatigue and improving quality of sleep and life.

REFERENCES

  1. U.S. Breast Cancer Statistics. Breast Cancer.org. Available at: http://www.breastcancer.org/symptoms/understand_bc/statistics. Updated Sept. 30, 2016. Accessed Oct. 16, 2016.
  2. Reinertsen KV, Cvancarova M, Loge JH, et al. Predictors and course of chronic fatigue in long-term breast cancer survivors. J Cancer Surviv 2010;4:405-414.
  3. Minton O, Stone, P. How common is fatigue in disease-free breast cancer survivors: A longitudinal investigation. Cancer 2006;106:751-758.
  4. Berger AM. National comprehensive cancer network. Cancer-Related Fatigue, Version 2.2015 J Natl Compr Canc Netw 2015;13:
    1012-1039.
  5. Ling WM, Lui LY, So WK, Chan K. Effects of acupuncture and acupressure on cancer-related fatigue: A systematic review. Oncol Nurs Forum 2014;41:581-592.
  6. Zick SM, Alrawi S, Merel G, et al. Relaxation acupressure reduces persistent cancer-related fatigue. Evid Based Complement Alternat Med 2011:2011:142913.
  7. Zick SM, Zwickey H, Wood L, et al. Preliminary differences in peripheral immune markers and brain metabolites between fatigued and non-fatigued breast cancer survivors: A pilot study. Brain Imaging Behav 2014;8:506-516.
  8. Hampson JP, Zick SM, Khabir T, et al. Altered resting brain connectivity in persistent cancer related fatigue. Neuroimage Clin 2015;8:305-313.