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Manual acupuncture as an adjunctive treatment
of nausea in patients with cancer in palliative care
– a prospective, observational pilot study
Elisabeth Nystrom, Gunilla Ridderstrom, Ann-Sofie Leffler
Abstract Elisabeth Nystrom
Background Good clinical evidence has been reported for the effect of PC6 acupuncture in preventing or registered
physiotherapist
attenuating postoperative and pregnancy related nausea. Our primary aim was to examine whether PC6
acupuncture during a period of chemotherapy could complement pharmacological treatment of nausea in cancer Gunilla Ridderstrom
registered
patients in the palliative stage of their disease.
physiotherapist
Method We conducted a prospective observational pilot study to measure changes in nausea, and also
explored the relationship between nausea, pain and constipation. Twelve patients suffering from nausea and Advanced home health-
care
four nausea free patients participated in the study. The nausea free patients were included because they had Solna Sundbyberg
been troubled by nausea in a previous course of chemotherapy, despite medication with antiemetic drugs, and Solna, Sweden
were about to start a new course of treatment. The patients rated their intensity of nausea, pain and constipation Ann-Sofie Leffler
on a numerical rating scale before each of 10 treatment sessions with PC6 acupuncture over the course of three registered
weeks, and at two follow ups during the following week. physiotherapist
Section of Clinical Pain
Results Fifteen patients completed the study. Compared to before treatment, the patients scored a significantly
Research
reduced intensity of nausea before the last treatment session (P<0.01) and at the first follow up (P<0.05). Three Department of
out of four nausea free patients were still nausea free before the last treatment session with acupuncture. No Molecular Medicine and
Surgery
relationship could be found between nausea, pain and constipation before, during or after the treatment
Karolinska Institute
period had finished. University Hospital
Conclusion The study demonstrated that acupuncture treatment in cancer patients can be associated with a Solna, Stockholm
Sweden
significantly reduced intensity of nausea during a period of chemotherapy in their final phase of life.
Correspondence:
Keywords Ann-Sofie Leffler
Acupuncture stimulation, nausea, cancer, palliative care, prospective observational pilot study. [email protected]
Introduction and feelings of discomfort. After weeks of nausea
Nausea has been defined as an unpleasant but not and vomiting, patients may come to regard the whole
painful experience, usually localised in the throat life situation as hopeless, and this may give rise to
and the upper part of the stomach, which gives an suicidal thoughts.2
obvious sensation that vomiting might be imminent.1 Since nausea can be triggered by several causes,
In palliative care, nausea is a common symptom and eg the cancer itself, 3 the cancer treatment, 4;5
it has been reported that approximately 40-70% of the constipation, or oropharyngeal candidiasis, it is
patients with a diagnosed cancer suffer from constant desirable to investigate the possible causes of the
or intermittent nausea in the final phase of life.1;2 nausea as far as possible, and to give causal
Nausea has obvious consequences on the quality of treatment.2 In the final phase of life this is not always
life, and it is not unusual for patients to experience possible, and therefore the treatment in this phase
nausea as a greater problem than pain.2 During the often concentrates on symptom relief. Despite the
early stages, nausea is dominated by a loss of appetite development of modern antiemetic agents, we have
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observed that some patients in our clinic using these position. All treatments had to fit in with the normal
new antiemetic medications still experience nausea. care procedures of ASIH and were performed either
Since the Swedish National Health Board approved two or three times a week, with two follow up
acupuncture for treatment of nausea in 1993, assessments the following week. At each treatment
acupuncture has been available to patients with cancer session, the patient was asked to rate the intensity
as a complement or an alternative to pharmacological of nausea and pain together with constipation prior to
treatment. insertion of the acupuncture needle. The intensity of
The main purpose of the present prospective nausea and pain, respectively, were rated on a 0-10
observational pilot study was to investigate whether point numerical rating scale (NRS), where the left
acupuncture to PC6 could complement extreme indicated no nausea or pain (0) and the right
pharmacological treatment of nausea in patients with end the worst imaginable nausea or pain (10). The
cancer in a palliative stage who are undergoing degree of constipation was rated from 0 to 2, where
chemotherapy. In addition, we also looked for a 0 indicated none, 1 moderate, and 2 troublesome
relationship between nausea, pain and constipation. intensity of constipation.
All patients were stimulated with manual
Methods acupuncture bilaterally on PC6 located in the anterior
Sixteen consecutive patients, 12 women and four forearm, approximately 35mm or 2 cun (1 cun
men, admitted to advanced home healthcare in Solna corresponds to the breadth of the patient’s thumb)
Sundbyberg, Sweden (ASIH) to receive palliative proximal to the wrist between the tendons of extensor
care, participated in the study. The inclusion criterion carpi radialis and palmaris longus. One patient with
was a diagnosis of incurable cancer. The patients lymphoedema in her arm after a breast cancer
were given verbal and written information about the operation was treated unilaterally on the unaffected
study, in which it was carefully pointed out that their side. The needles were inserted approximately 10-
collaboration was totally voluntary and could be 15mm deep and treatment lasted for 10 minutes, with
interrupted at any time without this affecting their manual stimulation of the needle, repeated after five
ongoing care in any way. Before the start, the patients minutes and just before the removal of the needle
were requested to answer a questionnaire regarding (Seirin No.3 – 0.20x15mm). Stimulation refers to
their: nausea (intensity); vomiting (yes or no); pain manual rotation of the needle until a de qi sensation
(intensity); constipation (none, moderate or was obtained. The de qi sensation has been described
troublesome); use of antiemetic and other as a sensation of mild muscular discomfort,
medications; and they were asked whether tenderness, numbness, stinging, pain or heat.6
preparations were in place for chemotherapy (yes or
no), or radiotherapy (yes or no) treatment. In addition, Results
the patients were asked about their attitude to being During a period of chemotherapy treatment, 15
treated with acupuncture for nausea patients, 11 women and 4 men, between the ages of
(considerable/large interest, moderate or low interest). 40 and 82 years, with a diagnosis of cancer in a
Patients were also requested to keep a diary during palliative stage and registered in the care of the ASIH
the treatment period, to record the number of were included in the study. Table 1 gives the
vomiting episodes and their general wellbeing, ie if background data on the patients and overall changes
the cancer had any impact on their overall status (yes in their nausea scores. One patient interrupted the
or no). All patients gave their informed consent to treatment after the first acupuncture session because
participation. of pain from the needle stimulation.
The same investigators (EN and GR) who are Eleven patients reported nausea despite
registered physical therapists specialised in medication with antiemetic drugs. Four patients who
acupuncture performed all study assessments and reported no nausea were included in the study at the
acupuncture treatments. start of their chemotherapy, since they had been
During a period of three weeks, a total of 10 troubled by nausea in previous treatment with
acupuncture treatments were given in the patient’s chemotherapy, despite medication with antiemetic
home or at the ASIH clinic, in a sitting or lying drugs, and were about to start a new course of
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Table 1 Background information and nausea intensity scores
Patient Cancer Interest in Effect on Nausea score (scale 0-10)
no sex diagnosis Vmt CT RT acup? wellbeing? O – before acup; X before 10th session of PC6 acup
0 1 2 3 4 5 6 7 8 9 10
1 chest no no yes mod no X O
2 rectal no yes no large yes O X
3 breast yes yes no large no X O
4 pancreas yes yes no mod no O X
5 intestine yes yes no large yes O X
6 prostate yes no no mod no X O
7 prostate yes yes no mod yes X O
8 ovary yes no no mod no X O
9 lung yes yes yes large yes OX
10 uterus no no no low no X X
11 breast yes yes no mod no X O
12 breast no yes no large yes X O
13 breast no yes no large yes OX
14 breast no yes no large yes OX
15 lung no yes yes large yes X O
Nausea intensity scores rated on a 0-10 point numerical rating scale, in 15 patients with a cancer disease. Nausea intensity scores before PC6 acupuncture are
marked with an O, and before the tenth treatment with a X.
Abbreviations: Vmt – vomiting; CT – chemotherapy; RT – radiotherapy; acup – acupuncture.
Table 2 Individual nausea intensity scores
Patients Treatment sessions Follow up
1 2 3 4 5 6 7 8 9 10 1 2
1 9 6 1 0 0 0 0 0 0 0 0 3
2 3 2 4 1 0 0 4 2 4 4 4 7
3 4 8 7 0 0 0 0 0 0 0 4 0
4 5 0 0 0 3 3 8 9 3 7 5 7
5 0 0 0 0 3 4 1 1 1 1 0 0
6 7 7 6 5 6 6 6 2 1 1 0 0
7 1 0 0 0 0 1 5 0 0 0 0 0
8 6 3 4 4 3 3 2 3 1 1 5 5
9 0 0 0 0 0 0 0 0 0 0 3 7
10 5 0 0 0 0 0 0 0 0 0 0 0
11 3 6 6 4 0 1 1 0 2 2 6 2
12 2 1 2 3 5 2 2 1 1 1 0 0
13 0 0 0 0 0 0 0 1 0 0 0 0
14 0 0 0 0 0 0 0 0 0 0 0 0
15 4 3 4 5 3 0 0 0 0 0 1 5
Nausea intensity was scored on a 0-10 point numerical rating scale before PC6 acupuncture treatment on 10 sessions over three weeks,
and at follow up assessments in the following week, in 15 patients with cancer. Patients’ numbered 5, 9, 13 and 14 were nausea free
patients at start.
treatment. In addition to pharmacological treatment, acupuncture. The patients with considerable interest
these patients were treated with acupuncture point included those who were about to start a new period
stimulation. Three patients received radiotherapy for of chemotherapy. In addition, patients with a
pain relief during the treatment period. considerable interest reported that the cancer did not
The diary notes showed that, before the tenth have any effect on their general wellbeing.
treatment, eight patients were troubled by vomiting Before acupuncture, patients suffering from
to varying degrees. The interest in attending treatment nausea reported a median nausea intensity of 4.5,
with acupuncture varied and was not dependent on with a range of 1-9. Nine patients with nausea
the cancer diagnosis, whether the patient was troubled reported a lower intensity, and three reported a higher
with vomiting, or whether the patient also received intensity, before the tenth treatment. Compared to
radiotherapy. One patient showed low, six moderate before treatment, the intensity of nausea had
and eight considerable interest in receiving decreased significantly before the tenth treatment
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Figure 1 Nausea intensity scores, rated on a 0-10 point numerical rating scale at the start (blue column)
and before the tenth treatment (white column) of PC6 acupuncture in 15 patients with cancer undergoing
chemotherapy.
(Mann-Whitney U test, P<0.01) and remained to an interest in non-pharmacological treatments.5
significantly decreased at the first follow up (two to To our knowledge, no study has examined the effect
three days after the end of the treatment period) on nausea of PC6 stimulation with acupuncture in
(Mann-Whitney U test, P<0.05) but not the second patients with a diagnosis of cancer, in the palliative
follow up (one week after the end of the treatment stage, during a period of chemotherapy. Palliative
period). Three out of four patients with no nausea care has been defined as ‘The active, total care of
prior to the start were still nausea free at the tenth patients whose disease is not responsive to any
treatment. curative treatment’. Although all patients in this study
The intensity of pain at baseline was reported were in a state where the cancer disease was gradually
by seven patients, with a median value of 4 and a deteriorating, a significant reduction of nausea was
range of 1-6. Prior to the tenth treatment, these reported for some days.
patients rated their pain with an intensity median Four patients with no nausea at the start were
value of 5 with a range of 2-7. One patient who was included in the study, as described. Between courses
pain free at the start reported a pain intensity of 3 of chemotherapy, these patients were free from
before the tenth treatment. nausea. Since three of these patients did not
None of the patients reported constipation at the experience any nausea at the end of the treatment
start, during the treatment period or at the follow period with acupuncture, and the fourth only reported
ups. light nausea (intensity score of 1), it is possible that
stimulation of PC6 in combination with antiemetic
Discussion drugs reduced or prevented their chemotherapy-
Despite positive results obtained from studies of the related nausea. Previous studies of postoperative7
effect of reducing nausea and vomiting by modern and chemotherapy-induced nausea4;5 support the use
antiemetic drugs, the need for additional relief has led of PC6 stimulation prior to therapy.7;4;5
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It is well known that different chemotherapy the study focused on investigating only the effect on
medications can cause nausea with different nausea. Manual acupuncture point stimulation was
intensity,5; 8 and that chemotherapy induced nausea chosen, as a systematic review reported that
may be either acute or delayed.5 Although there were electroacupuncture had a greater effect on vomiting.12
questions in the questionnaire about concurrent Bilateral stimulation was used in all patients except
chemotherapy, the patients were not requested to one with lymphoedema – who also reported reduced
name the medication they were being treated with. nausea after unilateral stimulation. A previous study
Therefore, it is possible that the patients in this study investigating the effect of unilateral or bilateral
were treated with chemotherapy medications causing stimulation on pregnancy related nausea and vomiting
different degrees of intensity of nausea, as well as did not show any significant difference between these
different time courses (acute or delayed). two stimulation methods.13 We chose to use a 0-10
Constipation is common among cancer patients point numerical rating scale for intensity ratings of
and studies have shown that constipation can give nausea and pain in order to be able to follow even
rise to nausea.2 None of the patients in the study minor changes in these experiences.4
reported any constipation during the whole treatment In conclusion, the patients in this clinical
period, as they were routinely treated with laxatives, observational pilot study rated a significant
successfully. The incidence of pain in patients with reduction in the intensity of nausea, lasting for
a cancer diagnosis in palliative care has been several days, following treatment with PC6
estimated to be approximately 75%.9 Pain control acupuncture stimulation as an adjunct during a
with acupuncture has been examined in many course of chemotherapy. In addition, it is possible
randomised trials, whereas the value of acupuncture that the acupuncture given before chemotherapy
in reducing cancer related pain of different aetiology in four patients, in conjunction with antiemetic
remains to be evaluated.10 However, nausea as a result drugs, prevented or reduced the incidence of nausea.
of pain has been reported to be rare in cancer No relationship between nausea, pain and
patients. 2 The finding of reduced nausea in constipation could be seen before, during or after
conjunction with no influence on the pain intensity the treatment. Further studies are required to
supports a benefit from acupuncture point stimulation ascertain whether treatment of nausea with PC6
of PC6 for nausea but not pain in the these patients. acupuncture in the final phase of life is only an
Evidence has been presented showing that the adjunct to pharmacological treatment, or whether it
incidence and severity of nausea and vomiting are is sufficient to provide an alternative treatment for
linked to pathological and temporal alterations in this symptom, which fundamentally disturbs
the hormone balance, this being seen both in patients’ wellbeing.
pregnancy related nausea and vomiting and in the
influence of the menstrual cycle day on postoperative Summary points
nausea and vomiting.3 Female cancer patients are
There is uncertainty over the effectiveness of acupuncture
sometimes medicated with hormone preparations or on nausea from chemotherapy during the palliative stage of
have a cancer that influences their hormonal balance cancer
pathologically. Therefore it has been proposed that This series of 15 cases showed either useful reductions in
women may suffer from nausea more often than nausea, or avoidance of anticipated nausea, in several
men, and that treatment with acupuncture could patients
reduce nausea among women to a greater extent.11 It is not possible currently to predict which patients are
However, we did not have sufficient information to likely to respond
perform a subgroup analysis of the effect of PC6
acupuncture point stimulation on the female patients Acknowledgements
in this study who suffered from nausea that might This study was supported by grants from Stockholm
be triggered, at least partially, by alterations in the County Council and the Karolinska Institute.
hormonal balance.
Since we have observed that patients experience Conflicts of interest
nausea significantly more frequently than vomiting, None declared.
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Manual acupuncture as an adjunctive
treatment of nausea in patients with cancer in
palliative care − a prospective, observational
pilot study
Elisabeth Nystrom, Gunilla Ridderstrom and Ann-Sofie Leffler
Acupunct Med 2008 26: 27-32
doi: 10.1136/aim.26.1.27
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