SHIATSU

Areviewoftheevidence

ProfessorNicolaRobinsonJulieDonaldson AvaLorenc
October2006

CommissionedandfundedbytheShiatsuSocietyUKwww.shiatsusociety.org

Thisreportwascommissionedandfundedby:
ShiatsuSocietyUK
EastlandsCourt
StPetersRoad
Rugby
CV213QP
Tel:08451304560
Email: info@shiatsusociety.org
Web: www.shiatsusociety.org

CentreforComplementaryHealthcare&IntegratedMedicineCCHIM
FacultyofHealthandHumanSciences
ThamesValleyUniversity
WalpoleHouse
1822BondStreet
Ealing
LondonW55AA,UK

Tel.02082805172
Email: nicky.robinson@tvu.ac.uk
www.cchim.com
1

Contents
Glossaryofterms.............................................................................................................................. 1
Nomenclatureofpoints ..................................................................................................................... 5
1. ExecutiveSummary ................................................................................................................... 6
2. Introduction ................................................................................................................................ 7
4. Objective..................................................................................................................................... 8
5. Methodsandsearchstrategy .................................................................................................... 8
5.1
5.2
5.3
5.4

6.

Databases..................................................................................................................................................... 8
Definitionofsearchterms............................................................................................................................ 9
Assessmentoftheevidence........................................................................................................................ 9
Figure1:Flowchartofevidencereviewprocess...................................................................................... 10

ResultsandAnalysis...............................................................................................................11

6.1
6.2
6.2.1
6.2.2
6.2.3
6.2.4
6.2.5
6.2.6
6.2.7

Shiatsu ........................................................................................................................................................ 12
Acupressure................................................................................................................................................ 13
Pain......................................................................................................................................................................... 13
Nausea&vomiting................................................................................................................................................. 16
RenalSymptoms .................................................................................................................................................... 18
Chronicobstructivepulmonarydisease/asthma ................................................................................................... 19
Anxiety/stress/sleepproblems ............................................................................................................................... 20
Anaesthesia/consciousness................................................................................................................................... 21
Otherconditions...................................................................................................................................................... 22

7. Discussion................................................................................................................................24
8. Conclusions..............................................................................................................................27
9. Recommendations ...................................................................................................................27
Appendix1SearchTermsanddefinitions ...................................................................................28
Appendix2Databasesearchesandtermsused .........................................................................29
Appendix3Screeningofsearchresults ......................................................................................30
Appendix4SecondMEDLINEMeSHtreeandsubsequentsearches ........................................32
Appendix5Abstractscreeningform............................................................................................34
Appendix6Initialsearchresults ..................................................................................................35
Appendix7Retrievedpublicationsforscreening .......................................................................37
Appendix8CriticalAppraisalchecklist .......................................................................................38
Appendix9Evidencetablesstudiesincluded.............................................................................39
Appendix10Excludedfromreview..............................................................................................91
10.1
10.2

Shiatsu ........................................................................................................................................................ 91
Acupressure................................................................................................................................................ 93

Appendix11Backgroundreview................................................................................................ 101
11.1
11.2

Shiatsu ...................................................................................................................................................... 101

Acupressure.............................................................................................................................................. 106

Appendix12Evidencetablesreferences ................................................................................... 113

12.1
12.2

Shiatsu ...................................................................................................................................................... 113

Acupressure.............................................................................................................................................. 113

Appendix13Excludedfromreviewreferences ........................................................................ 116

13.1
13.2

Shiatsu ...................................................................................................................................................... 116

Acupressure.............................................................................................................................................. 116

Appendix14Backgroundreviewreferences ............................................................................. 120

14.1
14.2

Shiatsu ...................................................................................................................................................... 120

Acupressure.............................................................................................................................................. 121

Appendix15ResultsfromIndextoThesesandZETOCsearches........................................... 123
15.1
15.2
15.3

Shiatsusearchresults.............................................................................................................................. 123
Acupressuresearchresults ..................................................................................................................... 124
ZETOC(BritishLibraryElectronicTableofContents)search .............................................................. 125

Glossaryofterms
Attritionrate: Therateatwhichparticipantsarelostduringthecourseofastudy.(Alsocalledloss
to follow up). Participants that are lost during a study are often called dropouts and are usually
untraceable.
Bias:Whenapointofviewpreventsimpartialjudgmentonissuesrelatingtothesubjectofthatpoint
ofview.Inclinicalstudies,biasiscontrolledbyblindingandrandomisation.
Asystematicdistortionofresearchresultsduetothelackofobjectivity,fairness,orimpartialityonthe
partoftheevaluatororassessor.Alternatively,therearedisparitiesinresearchortestresultsdueto
usingimproperassessmenttoolsorinstrumentsacrossgroups.
Asystematicerrorordeviationinresultsorinferencesfromthetruth. Instudiesoftheeffectsofhealth
care, the main types of bias arise from systematic differences in the groups that are compared
(selection bias),thecarethatisprovided,exposuretootherfactorsapartfromthe interventionof
interest(performancebias),withdrawalsorexclusionsofpeopleenteredintoastudy(attritionbias)
orhowoutcomesareassessed(detectionbias).Reviewsofstudiesmayalsobeparticularlyaffected
byreportingbias,whereabiasedsubsetofalltherelevantdataisavailable.
Blindedstudy: Astudydoneinsuchawaythatthepatientsorsubjectsdonotknow(isblindedasto)
whattreatmenttheyarereceivingtoensurethattheresultsarenotaffectedbyaplaceboeffect(the
powerofsuggestion).
Blinding: Theprocessofpreventingthoseinvolvedinatrialfromknowingtowhichcomparisongroup
aparticularparticipantbelongs.Theriskofbiasisminimisedwhenasfewpeopleaspossibleknow
who is receiving the experimental intervention and who the control intervention. Participants,
caregivers,outcomeassessorsandanalystsareallcandidatesforbeingblinded.Blindingofcertain
groupsisnotalwayspossible,forexamplesurgeonsinsurgicaltrials.
BonferronicorrectionforType1error: Thisisanexampleofamultiplecomparisontechniques.It
adjuststheType1errorleveltocompensateformultiplecomparisonsbetweenthreeormoregroups
ortwoormoreresponsevariables.
Carryover effect: The persistence, into a later period of treatment, of some of the effects of a
treatmentappliedinanearlierperiod.
Controlgroup:Thesubjectsinacontrolledstudywhodonotreceivethetreatment.
Controlledstudy: Astudythatusesthemethodofcomparisontoevaluatetheeffectofatreatment
by comparing treated subjects with a control group, who do not receive the treatment. (See also
uncontrolledstudy)
Conveniencesample: Agroupofindividualsbeingstudiedbecausetheyareconvenientlyaccessible
insomeway.Thiscouldmakethemparticularlyunrepresentative,astheyarenotarandomsampleof
the whole population. A convenience sample, for example, might be all the people at a certain
hospital,orattendingaparticularsupportgroup.Theycoulddifferinimportantwaysfromthepeople
whohaven'tbeenbroughttogetherinthatway:theycouldbemoreorlesssick,forexample.
Doubleblind: In a doubleblind study, neither the subjects nor the people evaluating the subjects
knowwhoisinthetreatmentgroupandwhoisinthecontrolgroup.Thismitigatestheplaceboeffect
andguardsagainstconsciousandunconsciousprejudicefororagainstthetreatmentonthepartof
theevaluators.

Duplicatebias:Astudythathasbeenpublishedmorethanonceusingthesamedatabutwrittenasa
separatestudy.
Hawthorneeffect/bias: Thiscanbesummarizedas"Individualbehavioursmaybealteredbecause
theyknowtheyarebeingstudied."Thismeansthattheactofmeasurement,itself,impactstheresults
ofthemeasurement.Inscience,dippingathermometerintoavialofliquidcanaffectthetemperature
oftheliquidbeingmeasured.Inthesameway,theactofcollectingdata,wherenonewascollected
beforecreatesasituationthatdidnotexistbefore,therebyaffectingtheresults.
Intention to treat analysis: A strategy for analysing data from a randomised controlled trial. All
participants are included in the arm to whichtheywereallocated,whetheror not they received (or
completed)theinterventiongiventothatarm.Intentiontotreatanalysispreventsbiascausedbythe
loss of participants, which may disrupt the baselineequivalenceestablishedby randomisationand
whichmayreflectnonadherencetotheprotocol.Thetermisoftenmisusedintrialpublicationswhen
someparticipantswereexcluded.
Interrater reliability: The degree of stability exhibited when a measurement is repeated under
identicalconditionsbydifferentraters.Reliabilityreferstothedegreetowhichtheresultsobtainedby
ameasurementprocedurecanbereplicated.Lackofinterraterreliabilitymayarisefromdivergences
betweenobserversorinstabilityoftheattributebeingmeasured.
Interventiongroup:Agroupofparticipantsinastudyreceivingaparticularhealthcareintervention.
Parallelgrouptrialsincludeatleasttwointerventiongroups.
Intrarater reliability: The degree of stability exhibited when a measurement is repeated under
identicalconditionsbythesamerater.Reliabilityreferstothedegreetowhichtheresultsobtainedby
ameasurementprocedurecanbereplicated.Lackofintraraterreliabilitymayarisefromdivergences
betweeninstrumentsofmeasurement,orinstabilityoftheattributebeingmeasured.
Language bias:Exclusion, in a metaanalysis of controlled trials, of those published in languages
otherthanEnglish.
Mean:Thesumofalistofnumbers,dividedbythenumberofnumbers.Thisisalsooftenreferredto
astheaverage.
Metaanalysis: A statistical procedure to combine a number of existing studies. Through such a
procedure, effects which are hard or impossibleto discernin the originalstudies because ofa too
small sample size can be made visible, as the metaanalysis is (in the ideal case) equivalent to a
singlestudywiththecombinedsizeofalloriginalstudies.Aweaknessofthemethodisthatproblems
with any of the studies will affect the result of the metaanalysis, so a good metaanalysis of bad
studieswillstillresultinbaddata.
Nullhypothesis:Astatementconcerningoneormoreparameter(s)thatissubjectedtoastatistical
testastatementthatthereisnorelationshipbetweenthetwovariablesofinterestthebeliefthatany
apparentrelationshipbetweenoramongvariablesinoneormoreresearchsampleshasbeencaused
bysamplingerrorthehypothesisthatistestedwhenseekingtogainstatisticalsupportforaresearch
hypothesis.
Ordereffects: Wheretheeffectsoftwodifferentinterventions(A,B)arebothbeingstudiedforall
participantsdividedintotwogroups(1,2).Theorderinwhichtheseinterventionsareadministered
mayhaveaneffectontheoutcomee.g.group1hasinterventionAfollowedbyBandgroup2has
interventionBfollowedbyA.

Placebo: An inactivesubstance orprocedureadministered toaparticipant,usuallytocompareits

effectswiththoseofarealdrugorotherintervention,butsometimesforthepsychologicalbenefitto
theparticipantthroughabeliefthats/heisreceivingtreatment.Placebosareusedinclinicaltrialsto
blind people to their treatment allocation. Placebos should be indistinguishable from the active
interventiontoensureadequateblinding.
Placebo effect: The belief or knowledge that one is being treated can itself have an effect that
confounds with the real effect of the treatment. Subjects given a placebo as a painkiller report
statisticallysignificantreductionsinpaininrandomisedstudiesthatcomparethemwithsubjectswho
receive no treatment at all. This very real psychological effect of a placebo, which has no direct
biochemicaleffect,iscalledtheplaceboeffect.Administeringaplacebotothecontrolgroupisthus
importantinstudieswithhumansubjectsthisistheessenceofablindexperiment.
Poweredsamplesize:Thesamplesizecalculatedforastudywillensurethatitissufficientinorder
todetectasignificantdifference.
Practiceeffect:Theeffectofreceivinganinterventionforasecondtime.Thiscanalsobereferredto
asalearningeffect.Whenyousplitthesubjects,thegroupthatgetsthecontrolfirsthasthepractice
effect added to the intervention, whereas the groupthat gets the intervention firsthas the practice
effectaddedtothecontroltreatment.Sowhenyouaveragethedifferencescores,thepracticeeffect
disappearsandyouareleftwiththetreatmenteffect,providedthetwogroupshavethesamenumber
ofsubjects.
Pragmatic design: A trial that aims to test a treatment policy in a 'real life' situation, when many
peoplemaynotreceiveallofthetreatment,andmayuseothertreatmentsaswell.Thisisasopposed
to an explanatory trial, which is done under ideal conditions and is trying to determine whether a
therapyhastheabilitytomakeadifferenceatall(i.e.testingitsefficacy).
Pvalue: The probability (ranging from zero to one) that the results observed in astudy (or results
more extreme) could haveoccurredbychance if inreality thenullhypothesis was true.In ameta
analysis,thePvaluefortheoveralleffectassessestheoverallstatisticalsignificanceofthedifference
between the intervention groups, whilst the Pvalue for the heterogeneity statistic assesses the
statisticalsignificanceofdifferencesbetweentheeffectsobservedineachstudy.
Probabilitysamples: Samplesinwhicheachelementinthepopulationhasaknownchanceofbeing
selectedintothesample.
Purposive sample:A nonprobabilitysampling technique whereininvestigators usetheirjudgment
andpriorknowledgetochoosepeopleforthesamplewhowouldbestservethepurposesofthestudy.
RandomSample: Arandomsampleisasamplewhosemembersarechosenatrandomfromagiven
populationinsuchawaythatthechanceofobtaininganyparticularsamplecanbecomputed.The
numberofunitsinthesampleiscalledthesamplesize,oftendenotedasn.
Randomised block experiment: This study design splits the experiment into a number of "mini
experiments" or blocks for convenience, or to increase power. Typically, each block has one
experimental
unit
of
each
treatment.
Randomised control trial (RCT): A clinical trial in which chance is deliberately introduced in
assigningsubjectstothetreatmentandcontrolgroups.Forexample,writeanidentifyingnumberfor
eachsubjectonaslipofpaper,stiruptheslipsofpaper,anddrawslipswithoutreplacementuntilhalf
of them have been drawn. The subjects identified on the slips drawn could then be assigned to
treatment,andtheresttocontrol.Randomisingtheassignmenttendstodecreaseconfoundingofthe
3

treatmenteffectwithotherfactors,bymakingthetreatmentandcontrolgroupsroughlycomparablein
allrespectsbutthetreatment.
Samplewithlowattritionrate: Thisindicatesthattherewasalowlevelofdropoutsfromthegroup
ofstudyparticipants(SeeAttritionrate)
Single blindstudy:A study inwhichone party,eithertheinvestigatororparticipant,isunawareof
whatmedicationtheparticipantistakingalsocalledsinglemaskedstudy.
Singlegrouppretestposttestdesign: Thereisnocontrolgroupinthistypeofstudy.Theresults
arethereforemeasuredby:
Pretest a means to measure existing knowledge or ability prior to the implementation of an
instructionalactivity,innovationorprogram
Posttest a means to measure knowledge or ability after an instructional activity, innovation or
program is implemented, using one or more research methods . Also sometimes referred to as a
"postassessment."
Three armed RCT: A randomised clinical trials where there are three groups receiving different
treatments/interventionsforcomparison.
TypeIerror: Errorthatoccurswhenthenullhypothesisisrejectedwhenatruerelationshipbetween
variablesdoesnotexistalsocalledalpha()error.
tdistribution: Astatisticaldistributiondescribingthedistributionofthemeansofsamplestakenfrom
apopulationwithunknownvariance.
ttest:The ttest employs the statistic (t) to testagiven statisticalhypothesis aboutthe mean of a
population(oraboutthemeansoftwopopulations).Themostcommonttestisatestforadifference
oftwomeans
Uncontrolled study: A study in which there is no control group i.e., in which the method of
comparison is not used: the experimenter decides whogetsthetreatment,but the outcome of the
treatedgroupisnotcomparedwiththeoutcomeofacontrolgroupthatdoesnotreceivetreatment.

Nomenclatureofpoints
Itisnecessaryinanacademicreportofthiskindtonamepointsstrictlyastheyappearinpublishedpapers.This
iswhythesamepointsappearwithdifferentabbreviationsacrossthisreportforexamplePericardium6appears
asP6,PC6,Pc6andHP6.
Thevariousabbreviationsastheyappearinthereportarelistedbelow:
Heartmeridianpointsareabbreviatedas:HtHT
SmallIntestinemeridianpointsareabbreviatedas:SiSI
Pericardium meridian (also known as Heart Protector, Heart Governor and Heart Constrictor) points are
abbreviatedas:PPcPCHP
TripleHeatermeridian(alsoknownasTripleWarmer)pointsareabbreviatedas:THTW
Spleenmeridianpointsareabbreviatedas:SpSP
Stomachmeridianpointsareabbreviatedas:STSt
Lungmeridianpointsareabbreviatedas:LLULu
LargeIntestinemeridianpointsareabbreviatedas:LILi
Kidneymeridianpointsareabbreviatedas:KKIKi
Bladdermeridian(alsoknownastheUrinaryBladder)pointsareabbreviatedas:UBBLBlB
Livermeridianpointsareabbreviatedas:LivLIVLR
GallBladdermeridianpointsareabbreviatedas:GB
ConceptionVesselmeridian(alsoknownasRenMai)pointsareabbreviatedas:RenCV
GoverningVesselmeridian(alsoknownasDuMai)pointsareabbreviatedas:DuGV
Chinesepointnamesaregiveninsomeabstractsandthemeridian/numberformathasbeeninsertedwhere
appropriate.
The Third Eye Point between the medial ends of the eyebrows on the bridge of the nose has no
meridian/numberformatassociatedwithit.Itisnamedinthefollowingwaysinthetext:YintangExtra1

1. ExecutiveSummary
Theaimofthisevidencereviewwastoidentifyandappraisescientificpublicationsonthepracticeof
ShiatsuinordertodeterminethedirectionoffutureresearchfortheShiatsuprofession.
Comprehensivesearcheswereconducted(Feb1990June2006)ofdatabasesMEDLINE,Cochrane,
EMBASE,CINAHL,AMED,PsycINFO,BNI,BlackwellSynergy,Ingenta,ScienceDirectandIndexto
Theses. Acupressure and Shiatsu usethe samepoints andare based onthe meridian system of
Traditional Chinese Medicine, but Shiatsu techniques cover more than just acupressure. On this
basis,itwasagreedthatacupressurestudiesshouldbeincludedinthereview.
Initialsearchresultsidentified602studies.Afterapplyingexclusioncriteriaandqualityassessment,5
Shiatsu and 41 acupressure publications remained for review and appraisal. The Shiatsu studies
comprised three uncontrolled studies and two quasiexperimental studies. For acupressure, three
weresystematicreviews,23randomisedcontrolledtrials(RCTs),14quasiexperimentalstudiesand
oneuncontrolledstudy.
TheShiatsustudiesprovide verylimitedevidenceonadiverserangeofhealthissues(angina,low
backpain,fibromyalgia,chemotherapysideeffects/anxietyandinducinglabour).Themethodological
qualityofthesestudieswasgenerallypoor.
Studiesonacupressureprovidedfairlystrongevidenceforitsuseinthetreatmentofpain.Evidence
for acupressure for nausea and vomiting was inconsistent, with the strongest evidence for post
operativenausea.WeakevidenceforrenalsymptomsandCOPD/asthmawasfound.Theremaining
acupressure studies provided evidence of variable quality on psychosocial health issues,
consciousness/anaesthesiaandotherdisparatehealthissues.
The methodological quality of studies and the health issues investigated were heterogeneous and
therefore study results could not be pooled. The main methodological limitations of the studies
identifiedincluded:smallsamplesizes,insufficientdetailsonsamplingandfollowup,highdropout
rates,uncontrolleddesign,andlackofblinding.
TheresearchbaseforShiatsuisverymuchinitsinfancyandtheprofessionwillneedtoworkclosely
withitspractitionersandresearchersinordertobuildupevidenceofeffectiveness.Welldesigned
efficacystudiesareneededonShiatsuasanintervention.
Recommendationsfollowingthisreviewinclude:
ConductfurtherresearchontheeffectivenessofShiatsuasanintervention
Encouragepractitionerstoengageinresearchusingwelldesignedstudies
ClarificationoftherelationshipbetweenShiatsuandacupressureformarketingandpublic
awareness
ConsiderthedevelopmentandpilotingofanadverseeventreportingsystemforShiatsu
ExploreclinicalandthecosteffectivenessofShiatsuinanintegratedsetting
Identifyspecifictopicareasforinitialresearchinvestment
DevelopanevaluativeframeworkforintegratedShiatsupractice
Developaresearchresourcefortheprofession
InvestigatetheappropriatenessofvariousresearchmethodologiesforShiatsuresearch

2. Introduction
The word SHIATSU is Japanese and means pressure ("ATSU") with fingers ("SHI"), i.e. "finger
pressure". The termhas beenusedoverthelast 200years todescribethe practice of amassage
therapywhich incorporatesgentlemanipulationsand stretchescombinedwithpressuretechniques
exertedthroughthefingers,thumbs,elbows,kneesandfeet.Shiatsuisanorientalmedicinewhich
has its roots in Chinese medicine and may even have predated acupuncture. It embraces the
philosophyofYinandYang,theenergymeridians,thefiveelementsandtheconceptofKi,orenergy.
Practitionersusepointsonthemeridianstorebalancethebodysenergy.Thesepressurepointsare
knownastsubosinJapaneseandarepointsthatallowthetherapisttoactontheenergymeridians.
The conceptofaffectingthebalanceofenergythroughtsubosonthemeridiansissimilartothatof
acupuncturewhere needles areplacedat thesespecific points orwhere heat isapplied tochosen
pointsonthemeridians,andinShiatsuwherepressureisappliedonbothpointsandmeridians.
However,morerecentlyShiatsuisknownasaformofbodyworkwhichprimarilydevelopedinJapan.
IthasbeenrecognizedbytheJapaneseGovernmentasatherapyinitsownrightduringthelast50
years1. It is now practiced in many European countries and was one of eight nonconventional,
complementarymedicinedisciplinesnamedintheCollinsReport.2
Shiatsuhasanumberofdifferentstyles,philosophicalapproachesandtheoreticalbases.TheShiatsu
SocietyUKencouragesaneclecticoutlooksothatpractitionersandstudentsbecomefamiliarwithand
respectthedifferentformsandstylesofShiatsu,TheapproachesmostcommonlyfoundinBritainare
Zen Shiatsu (most common), Macrobiotic Shiatsu, Healing Shiatsu, Tao Shiatsu, Seiki, Namikoshi
ShiatsuandHaraShiatsu.
Shiatsuaimsistobalance,restoreandmaintainthebodysenergybalanceandpreventthebuildup
of stress. It is used to treat a wide range of conditions, from specific injuries to more general
symptoms of poor health, and is a deeply relaxing experience. Shiatsu is complementary to
mainstreamWesternmedicine,notanalternative.Someofthemostcommonsyndromeswhichmay
be amenable to treatment by Shiatsu include: headaches migraine stiff necks and shoulders
backachescoughscoldsmenstrualproblemsrespiratoryillnessesincludingasthmaandbronchitis
sinustroubleandcatarrhinsomniatensionanxietyanddepressionfatigueandweaknessdigestive
disorders and bowel trouble circulatory problems rheumatic and arthritic complaints sciatica and
conditionsfollowingsprainsandinjuries.
Acupressure is the treatment through massage of specific pressure points as defined within with
meridian systemof TraditionalChineseMedicine (TCM). Acupressure isembeddedwithinShiatsu
training, theory andpractice. Shiatsupractitioners are trainedinthe anatomicallocation,functions
andusesofover150pressurepointsonthebody.Shiatsuandacupressurearenotidentical,since
Shiatsutraining andpracticecoversmore than acupressureandincludesdiagnosisfromtheHara,
andthetreatmentofentiremeridiansaswellaspoints.However,Shiatsuincorporatesacupressure,
andthereisanargumenttobemadethatevidencefortheefficacyofacupressurecanvalidlybeused
tosupportclaimsabouttheefficacyofShiatsuforspecificconditions.3

3. Aim
TheaimofthisreportwastosystematicallyreviewthecurrentevidencebaseforShiatsubyidentifying
relevantscientificpublicationsandappraisingthequalityoftheresearchpublishedtodate.

Lundberg.P(1992)TheNewBookofShiatsu.NewYork:FiresideBooks.
EuropeanParliament(1997).TheCollinsReport,ResolutionontheStatusofNonConventionalMedicine.Strasbourg
(disseminatedbytheEuropeanParliament,May1999).
3
BewleyD(2006)DirectorShiatsuSociety,lettertoCommitteeofAdvertisingPractice,June2006.
2

4. Objective
ToinformfutureresearchdirectionsfortheShiatsuprofessioninordertobuildtheirevidencebase.
Tosupportevidencedrivenpractice,marketingandadvertisingofShiatsu.
TosupportthedevelopmentofShiatsutrainingandeducation.

5. Methodsandsearchstrategy
5.1 Databases
ComprehensivesearcheswereconductedforpublicationsfromFebruary1990toJune2006.Nodate
restrictionsweresetthereforeinitialresultsincludedpublicationspriortothisdate.Theinitialsearches
were conductedin February2006.TheMEDLINEsearcheswereupdatedin March,AprilandJune
2006withafinalupdateinAugust2006inpreparationforreviewingtheevidence.Allsearchresults
werecollatedinindividualReferenceManagerdatabasesforreview.
Searchenginesandjournaldatabasesaccessedarelistedbelow(Table1)
Table1Searchenginesandjournaldatabasesaccessed:
ViaPubMed:
MEDLINE
ViaOVID:
EBMreviews(includesallCochraneLibraryresources)
AlliedandComplementaryMedicine(AMED)
BritishNursingIndex(BNI)
CumulativeIndex toNursing&AlliedHealthLiterature(CINAHL)
EMBASE
MEDLINEinprocess&nonindexed
OVIDMEDLINE
PsycINFO
Journaldatabases:
ScienceDirect
BlackwellSynergy
IngentaSelect
WileyInterscience
Thefollowingdatabaseswerealsosearched:
1.IndextoTheses
http://www.theses.com/
2.ZETOC(BritishLibraryelectronictableofcontents)
TheShiatsuSocietyUKprovidedacopyofacommissionedreport4

MackayH&LongA(2003)TheExperienceandEffectsofShiatsu:FindingsfromaTwoCountryExploratoryStudy.
UniversityofSalford,UK
8

In addition, information and unpublished data was collected from the Shiatsu Society UK. The
references of retrieved information were checked to identify any further studies. Any duplicates
identifiedbysystematicallysearchingthedatabasewereremoved.

5.2 Definitionofsearchterms
Shiatsu was used as the main search term for most searches as it is included in the MeSH term
acupressureinMEDLINE.MeSHistheNationalLibraryofMedicines(NLM)controlledvocabulary
usedforindexingpublicationsforMEDLINE/PubMed.MeSHterminologyprovidesaconsistentwayto
retrieveinformationthatmayusedifferentterminologyforthesameconceptsSeeAppendix1
MoreinformationonMeSHMedicalSubjectHeadingscanbefoundat:
http://www.nlm.nih.gov/mesh/meshhome.html
ThefulldetailsofsearchescarriedoutaregiveninAppendix2.

5.3 Assessmentoftheevidence
Thestages used toassess the evidencearegivenin Appendix3 andareshowngraphicallyinthe
FlowChartFigure1.Abstractswereretrievedandreviewedagainsttheinclusioncriteria(Appendix3)
andifacceptedintothereviewtheywereretrievedforclassificationandappraisal.Studiescouldbe
classifiedintooneofthefollowing:asystematicreview,randomizedcontrolledtrial,anduncontrolled
studies.Tworeviewersindependentlycategorizedtheevidenceandanindependentadjudicatorused
iftherewasanydisagreementaboutinclusion.
As part of the review process, the references of any systematic or literature reviews and meta
analyseswerecheckedagainstthesearchresultstoensureaccuracyofsearches.Itwasduringthis
process, thatitwasfoundthatasmallnumberofthesereferences,relatingtoacupressurestudies
thathadnotbeencapturedinanyoftheabovesearches.ByobtainingMEDLINEabstractsincitation
format,itbecameclearthatacupressurewasalsoincludedinasecondMeSHtreeandthereforenot
all of the acupressure citations in MEDLINE had been included in the initial searches in February
2006.SeeAppendix4forthesecondMeSHtreedescriptionandsubsequentsearchdetails.
Allrelevantstudieswereappraisedandtheirmethodologicalqualityassessed.Thecategorisationof
thequality,weightanddirectionofevidenceforeachstudywasgradedusingcriteriadevelopedand
adaptedfromWaddell5.
Category1:
Category2:
Category3:

Generally consistent finding in a range of evidence from welldesigned experimental

studies
Either basedonasingleacceptablestudy,oraweakorinconsistentfindinginsome
multipleacceptablestudies.
Limitedscientificevidence,whichdoesnotmeetallthecriteriaofacceptablestudies,or
anabsenceofdirectlyapplicablestudiesofgoodquality.Thisincludespublishedand
unpublishedexpertopinion.

Relevant information was extracted independently by 2 reviewers using a standardised extraction

form.SeeAppendix5andFigure1.

WaddellG,FederG,McIntoshA,LewisM,HutchinsonA.(1996)ClinicalGuidelinesforManagementofAcuteLow
BackPain(LowBackPainEvidenceReview).RoyalCollegeofGeneralPractitioners.London.
9

5.4 Figure1:Flowchartofevidencereviewprocess

Medlineandotherdatabasesearches9th
Feb 2nd August2006,keywordsShiatsu
andacupressureas applicable

n= 602 results

Remaining 523screened(byShiatsu
SocietyDirectorand1reviewer)

First exclusions donefromreferences,

notabstracts:
PriortoFeb1990
Duplicatesbetweendatabases
Obviousfromtitlethatadevicehadbeen
used
Newspaperarticles,bookreviews,
comments,letters,
n= 79

Second exclusionsfromabstractsand/
orfulltextifavailable
Foreignlanguagepapers
UseofKoreanpoints/meridians
Devices/plasters/wristbandsused
Auricularacupressure
Comments,letters
All but3ShiatsuSocietyNews(SSN)and
healthmagazinereferences
n= 377 (include 122 SSN refs)
Thisleft 146toassessforreview allfull
textsobtained.
Notreviewedasevidenceanddonot
provideanyusefulinformationand
thereforeexcluded n= 61

Notreviewedasnotevidencebutprovide
usefulinformationanddirectionfor
evidencebasen= 41

Includedforreviewfrominitialsearches n= 44
plus 2fromsecondMeSHtreesearches,n= 46

Shiatsu
n= 5

Acupressure
n= 41

10

6.

ResultsandAnalysis

Aftercarryingouttheinitialdatabasesearches,atotalof602publicationswereidentifiedwhichhada
keywordofShiatsuand/oracupressure(Figure1)Afterduplicatesbetweendatabases,comments,
newspaper articles and letters were excluded (79), 523 publications were screened online using
published abstracts and full articles where available. A further second screening using agreed
exclusioncriteria(Appendix3)resultedin146publicationsforreview.Fulltextsofthe146publications
werefurtherscreenedbytworeviewers.
Afterapplyingexclusioncriteriaandqualityassessment,5Shiatsuand39acupressurepublications
remained for review and appraisal. Two acupressure studies were further added after the second
MeSHtermsearches,leavingatotalof46studiestoreview,5Shiatsuand41acupressure(Figure1
andAppendices,4,6,7.).The46includedstudieswerecriticallyappraisedbytworeviewersusing
the checklist in Appendix 8. Evidence tables of these publications were constructed (Appendix 9).
Datacollectedoneachstudyincluded:studydesign,setting,sample,healthissue,analysisofresults,
conclusionsandcommentsonquality.
Atotalof13Shiatsuand48acupressurepublicationswereexcludedasaresultofscreeningthe146
publications.DetailsoftheexcludedpublicationscanbefoundinAppendix10.Note:twoacupressure
publicationswereexcludedafterthesecondMeSHtreesearches.
Of the remaining 41 publications which were considered useful for background information, 22
referredtoShiatsuand19toacupressure.DetailsofthesecanbefoundinAppendix11.
ReferenceManagerdatabasesforincluded,excludedpublicationsandthoseprovidingbackground
informationwerealsoconstructed(Appendices12,13,14).Nofurtherpublicationswereincludedfor
review from the Indexto Theses andZETOC searches. Details ofthese searchescan be foundin
Appendix15.
The Shiatsu publications comprised three uncontrolled studiesand twoquasiexperimentalstudies
(without a randomised control group). For acupressure, three were systematic reviews, 23
randomised controlled trials (RCTs), 14 quasiexperimental studies (without a randomised control
group)andoneuncontrolledstudy.Themajorityofstudiesusedastandardisedacupressure/Shiatsu
procedure,onlyfivestudieswerepragmatic.
It was felt inappropriate to combine the Shiatsu and acupressure studies in case there were
differencesinthetechniques.Poolingofdataorametaanalysisofallincludedstudiescouldnotbe
carriedoutduetoheterogeneityinstudymethodology,therangeofhealthconditionsstudied,variety
ofinterventionsandoutcomemeasuresemployed.
Tables2and3givethenumberofincludedShiatsuandacupressurearticlesbyhealthissue.
Table2:Shiatsustudiesbyhealthissue
HealthIssue
Angina
Lowbackpain
Fibromyalgia
Chemotherapysideeffects/anxiety
Inducinglabour
Total

Numberofstudies
1
1
1
1
1
5

11

Table3:Acupressurestudiesbyhealthissue
Health Issue Initial search
results
Subsections
Pain
Dysmenorrhoea
3
Labourpain
3
Lowerbackpain
3
Minortrauma
1
Neckpain
1
Nausea&vomiting
Postoperative
4
Chemotherapy
3
Pregnancy
2
RenalSymptoms
Chronicobstructivepulmonarydisease/asthma
Anxiety/stress/sleepproblems
Measuresofanaesthesia/
Consciousness
Angina
Gastrointestinalmotility
Gagging
Nocturnalenuresis
Subtotal
HealthIssueSubsequentsearch
Angina
Nausea&vomiting(pregnancy)
Total

Numberof
studies

11

9
5
4
3
3
1
1
1
1
39
1
1
41

Full details of each included study, comprising methodology, design, sample, intervention, results,
conclusionandcriticalappraisalcomments,canbefoundinAppendix9.Anarrativesummaryofthe
studies is given below, which discusses the evidence found for Shiatsu and acupressure grouped
accordingtothehealthconditioninvestigated.

6.1 Shiatsu
TheShiatsustudiesidentifiedinvestigatedquiteseparatehealthissuesanddidnotusecomparable
methodology and therefore could not be pooled. These studies appear in alphabetical order in
Appendix9andarediscussedandsummarisedindividuallybelow.
Ballegaardetal(1996)investigatedtheeffectofShiatsu,withacupunctureandlifestyleadjustment,
onpatientswithanginapectoris.Thefocusofthisstudywasoncostbenefitratherthanefficacy.69
consecutive patients were treated and compared with those from a separate trial of two invasive
treatments for angina6. Incidence of death/myocardial infarction (MI) was 7% in this sample,
comparedto21%and15%inthecomparisongroup(undergoingcoronaryarterybypassgraftingand
percutaneoustransluminalcoronaryangioplastyrespectively).Therewasnosignificantdifferencein
painreliefbetweengroups.Additionallyacostsavingof$12000perpatientwasestimated.Thiswas
a convenience sample and was not powered. The main flaws were the absence of an equivalent
controlgroupandlackofblinding.ThecomparisongroupwerefromtheUSAandthestudywasdone
in Denmark, additionally 56% of the participants would have been excluded from the one of the
comparison groups. Also, due to the pragmatic design, it is difficult to isolate the effects of
acupressurefromcointerventionsofacupunctureandlifestyleadjustments.
6

KingSB,LemboNJ,WeintraubWSetal(1994)Arandomisedtrialcomparingcoronaryangioplastywithcoronary
bypasssurgery. NewEnglandJournalofMedicine, 331(16):104450
12

Brady et al (2001) administered Shiatsu massage to a convenience sample of 66 volunteers

complainingoflowerbackpain.Thiswasasinglegrouppretestposttestdesign.Painandanxiety
significantlydecreasedaftertreatment(p<0.001),whichdidnotchangewhendemographicvariables
were controlled for. The absence of a control group and use of a volunteer sample who paid for
treatment limits the validity of these results. 13 patients had previously received Shiatsu, further
limitingthegeneralisabilityoffindings.
Faull (2005) conducted a pilot study to compare the effectiveness of Watsu (water Shiatsu) to Aix
massageforfibromyalgiasyndrome(FMS).17femaleparticipantswererandomlyassignedtoreceive
either Watsu then Aix or vice versa, with a 3 week break between treatment blocks. A significant
improvementwasseenaftertreatmentwithWatsu(p=0.01)forSF36subscalesofphysicalfunction,
bodilypain,vitalityandsocialfunction,butnotforAix.Thiswasonlyapilotstudyandusedavery
smallvolunteersample,only13ofwhomcompletedthestudy.Nocontrolgroupwasused,although
the counterbalanced design should reduce carryover effects of using repeated measures design.
However,ordereffectsmayhaveoccurredduetohighdropoutratefromWatsufirstgroup(4outof8).
Iida et al (2000) investigated the relaxation effects of Shiatsu on anxiety andothersideeffectsin
patients receiving cancer chemotherapy. Nine patients were divided into strong anxiety or weak
anxietygroupsandallweregivenShiatsumassageonthehandsandfeet.Thestronganxietygroup
showedasignificantdecreaseinanxietyafterintervention(p=0.09).Theweakanxietygroupshowed
asignificantincreaseintherelaxationscore(p=0.01).Therewasaslightreliefofphysicalsymptoms
inbothgroupsbutsignificanceisnotstated.Thisisaverysmallstudy,limitingthevalidityofresults,
aggravatedbythefurtherdivisionofthesampleintotwogroups,reasonsforwhicharenotclear.The
useof the ttestonsuchasmallsamplewillonlydetectdifferencesthatarehuge,andmaybethe
reasonwhyfeweffectswereseen.Nocontrolgroupwasused.
Ingram et al (2005) investigated the effects of Shiatsu on postterm pregnancy in 142 women
attendingaconsultantclinicappointmentat40weeksgestation.Twogroupswereused,aShiatsu
group who received thumb pressure on points GB21, Li4 andSp6 andwho weretaughtbreathing
techniques and exercises. The control group received no intervention. The Shiatsu group was
significantly more likelytolabourspontaneouslythanthecontrol(p=0.038)andhadalongerlabour
(p=0.03).Themainflawwasthatgroupswereselectedaccordingtowhichmidwifewasonduty(only
onemidwifewastrainedinShiatsu),althoughgroupswerehomogenousformaternalage,parityand
delivery details. The frequency of use of selfadministered Shiatsu was not monitored. As a
preliminaryauditthisstudygivessomeusefulresults,althoughShiatsuwasnotcomparedtoasham
treatment.
TherewasinsufficientevidencebothinquantityandqualityonShiatsuinordertoprovideconsensus.

6.2 Acupressure
ThestudiesdescribedasgivingacupressureasaninterventionformthesecondpartofAppendix9
andareinalphabeticalorderandsummarisedbelow.
6.2.1 Pain
Pain was the most common issue addressed by acupressure studies. These included studies on
dysmenorrhoea(3studies),labourpain(3studies),lowerbackpain(3studies),onestudyonminor
traumaandoneonneckpain.Sevenofthe11studieswereRCTs,withcontrolgroupsandrandom
assignmenttheremainderdidnothaveacontroland/orrandomassignment.

13

Dysmenorrhoea
Chen and Chen (2004) randomised 69 students with primary dysmenorrhoea into an intervention
groupwhoreceivedacupressureatSp6andacontrolgroupwhorested.Acupressuresignificantly
reducedmenstrualpain(p<0.05).Thesamplesizewaspoweredand72%completedthestudy.The
placeboeffectwasnotcontrolledforasashamtreatmentarmwasnotincluded.Thegeneralisability
ofthefindingsislimitedastheparticipantswerevolunteersandaged1719.
Junetal(2006)carriedoutacontrolledtrialofacupressurecomparedtolighttouchatSp6forprimary
dysmenorrhoea, also on a sample of students. Sample size (58) was powered. The severity of
dysmenorrhoea was significantly reduced in the acupressure group compared to control (p=0.000)
and this effect lasted for up to 2 hours after treatment (p=0.032). Allocation to study groups was
performed sequentially not randomly, although groups were homogenous in their baseline
demographicsandthefactorsaffectingdysmenorrhoea.Studentsanddatacollectorswereblinded.In
boththisandthestudyabove,Hawthornebiasmaybepresentasitispossible(althoughnotstated)
thattheparticipantswerestudentsoftheresearchers.
Pouresmail and Ibrahimzadeh (2002) carried out a threearmed RCT of 216 high school students
(aged1418years),tocomparetheeffectsofacupressure,acupressureatshampointsandIbuprofen
on primary dysmenorrhoea. Results indicated that all three techniques significantly reduced pain
(p<0.01).BothacupressureandIbuprofenwerebetterthanplacebo.Thisisahighqualitystudywith
randomgroupassignmentandalarge samplewithalowattritionrate.However,thevalidityofthe
outcomemeasureswasnotdisclosedanditisnotclearifblindingwasused.
Labourpain
Chungetal(2003)randomlyassigned127parturientwomentoaninterventiongroupwhoreceived
acupressureat Li4 andBL67,placebogroupwhoreceivedlightskinstrokingatthesepointsanda
controlgroup(conversationonly).Allgroupsshowedasignificantdecreaseinlabourpainduringthe
active first phase oflabour(p=0.041)andacupressurewassignificantlymoreeffectivethancontrol
(p=0.017)butnotcomparedtolightstroking.Thisindicatedthateffectsofacupressuremaybedueto
tactile stimulation rather thanmeridian effects.Additionally athird ofwomen receivingacupressure
qualitatively reported that it had reduced their pain. This is a high quality threearmed RCT, with
homogenousgroups,althoughsamplesizeineachgroupwasonly42/43andresponseratewasvery
lowat the transitionalphaseoflabour(31outof127).Boththeoutcomemeasure(VASs)andthe
acupressureprocedurewereshowntobereliableandvalidbytheresearchers.Thethreestepsto
ensure validity and reliability of the acupressure were 1) Protocol was established by experienced
Chinesephysiciansandusing apilotstudy2)Intraraterreliabilitytestwasusedtocontrolpressure
force, measured for each practitioner and three experts evaluated the accuracy of the acupoint
location for each practitioner 3) Practitioners underwent a 2 hour training session and monthly
meetings.
Leeetal(2004)conductedadoubleblindRCTofacupressurecomparedtotouchonSp6acupointfor
labourpain.Avolunteersampleofseventyfivewomeninlabourwerematchedforfivecharacteristics
oflabourandrandomlyassigned. Thereweresignificantdifferencesbetweenthegroupsinsubjective
labourpainscoresimmediatelyaftertheintervention(p=0.012),30minsafter(p=0.021)and60mins
after(p=0.012).Anxietywasalsosignificantlylowerintheacupressuregroupcomparedtothecontrol
(p=0.03).Groupswerehomogenous.Biasmaybeintroducedbyusingavolunteersample.Blinding
wasusedwherepossible(patientsanddatacollectors)andtheuseofaplacebotreatmentcontrolled
fortheemotionalsupportiveeffectsofhumantouch.
Waters and Raisler (2003) used ice massage on acupointLi4duringlabour contractionsin a one
grouppretestpostteststudy. As measured bythe visualanalogue scale(VAS),pain wasreduced
14

aftertheintervention.Thisstudyhadanumberofmethodologicallimitations,themainflawbeingthe
absenceofacontrolgroup.Inaddition,nosamplesizeisgiven,conveniencesamplingwasused,
andonlyearlylabourpainwasinvestigatedduetothelimitationsoftheoutcomemeasure.
Lowerbackpain
Hsiehet al(2004)conducted anRCTofacupressurecomparedtophysicaltherapyforchroniclow
backpain.146participantswererandomlyassignedtoreceivefourweeksofeitheracupressureor
physical therapy(thermotherapy,infrared,electrical stimulation, exercise andtraction). Meanpost
treatmentpainscoresweresignificantlylowerintheacupressuregroup(p=0.0002)andalsoafter6
months (p=0.0004). This is a high quality trial with a powered sample (although convenience),
homogenousgroups,validoutcomemeasuresandusingintentiontotreatanalysistoprotectagainst
attritionbias. Blinding wasused wherepossible practitionersand patientswereblindedtopretest
scores and followup staff were blind to treatment allocation. Although no placebo treatment was
used,itcanbeassumedthatphysicaltherapyisusualcareinTaiwan.Thisstudywaspragmaticas
acupressuretreatmentwasindividualisedratherthanusingastandardisedprotocol.
Hsiehetal(2006)conductedanotherRCTofacupressurecomparedtophysicaltherapyforchronic
lowbackpain,on129orthopaedicoutpatients.ThemethodologywasverysimilartoHsiehetal2004,
comparing acupressure to physical therapy in randomised groups. This study also showed
significantlylowerpainanddisabilityscoresintheacupressuregroupcomparedtophysicaltherapy
(p<0.05). Again, no placebo treatment was used and the treatment was pragmatic rather than
standardised.Asitusedthesamemethodology,thisstudyisofasimilarlyhighqualitytoHsiehetal
(2004).
Yip and Tse (2004) randomly assigned 61 adults with subacute or chronic low back pain into an
intervention or control group (usual care only). The intervention consisted of acupoint stimulation
using an electronic device on acupoints Li10, Li11, Si10, TW15 and BL10 and acupressure with
lavenderoilonUB22,23,25and40.Theinterventiongroupshowedasignificantreductioninpain
intensity compared to the control (p=0.0001) but not for duration of pain. The sample size was
powered,howeverparticipantswerevolunteers,16%droppedoutandthesewereolderwhichmay
causebias.Itisdifficulttoisolatetheeffectofacupressureinthisstudy,duetocointerventionsof
electricalstimulationandlavenderoil,andduetothelackofacontroltreatment.
Neckpain
YipandTse(2006)usedthesameprotocolasabovetotreat28adultswithsubacutenonspecific
neck pain. The acupressure group showed a significantly greater reduction in pain than control
(p=0.001). Although group assignment was random, this trial used a very small sample and no
blindingorplacebo.Again,itisdifficulttoisolatetheacupressureeffect.
Minortrauma
Koberetal(2002)conductedadoubleblindRCTwith60minortraumapatientswhowererandomly
allocatedtoacupressure,shamacupressureorcontrolgroups.Allweretreatedfor3minutesduring
transportationinambulances.Attheendoftransporttheyfoundsignificantlylesspain,anxietyand
heartrateintheacupressuregroupbutnotineithershamorcontrolgroups.Samplingbiasmaybe
presentaseligiblepatientswerepurposivelyselectedbyparamedics.Allgroupswerehomogenous,
the trial was truly double blinded (paramedic giving treatment and patient) and intention to treat
analysiswasused,althoughtherewerenodropouts.

15

Overall, the evidencefortheefficacy ofacupressure for painis fairly strong andcan be gradedas
category 1 evidence (generally consistent findings in a range of evidence from welldesigned
experimental studies) (see p. 3). Although some studies have methodological flaws, a number of
RCTs consistently show that acupressure is more effective than control for reducing pain, namely
dysmenorrhoea(Chen&Chen2004Junetal2006Pouresmail&Ibrahimzadeh2002),lowerback
pain(Hsiehetal2004Hsiehetal2006Yip&Tse2004)andlabourpain(Chungetal2003Leeetal
2004).
6.2.2 Nausea&vomiting
Nauseaandvomitingwasthesecondmostcommonhealthissuetobestudied.Wefound10studies,
whichinvestigatednauseaandvomitinginthreemainsituationspostoperativeincludingcaesarean
(fourstudies),asasideeffectofchemotherapy(threestudies)andduringpregnancy(threestudies).
NearlyallstudiesusedtheP6acupoint.
Postoperative
Chenet al(2005)investigatedtheuseofacupressureatP6onreducingnausea,vomiting,anxiety
andpainin104postcaesareanwomen.Theyfoundthatacupressuresignificantlyreducednausea,
vomiting and retching up to 10 hours postcaesarean compared to a control group who received
standardcare.Anxietyandpainwerealsoreduced.Althoughthisstudyhadafairlylargesampleand
a control group, a convenience sample was used and group assignment was notrandom (first 52
recruitedwereininterventiongroup).Althoughthismayintroduceseasonal/timerelatedbias,thiswas
inordertopreventparticipantsdiscussingthestudyandgroupswereshowntobehomogenousfor
demographicandphysiologicalvariablesandpretestscores.
Tworeviewsforpostoperativenauseaandvomitingwerefound,onesystematicreview(Lee&Done
2004)andonemetaanalysis(Shiao&Dune2006).Lee&Donefound26trialsspecificallyusingP6.
Although studies were heterogeneous, they concluded that acupressure reduced the risk of both
nauseaandvomitingcomparedtoshamtreatment,andreducedtheriskofnauseabutnotvomiting
comparedtoantiemeticmedication.AsaCochranereviewthisisahighqualitysystematicreview,
whichusedcomprehensivesearchtermsandcombineddatafromthetrials.Itwaslimitedtoacupoint
P6. Shiao and Dune pooled the data on 33 trials using some form of acupointstimulation versus
placebo or control, 30 of which used the P6 acupoint. Two further trials compared acupoint
stimulation to medication. Their results showed that all modalities of acupoint stimulation were
effective in reducing postoperative nauseaand vomiting compared tocontrols,and as effective as
medication.Thisisawellconductedmetaanalysisusingcomparablestudiesandagoodselection
process. 18 of the trials were for acupressure, providing a large body of evidence in this area,
althoughmostoftheseusedbandstoapplypressure.Thepooleddatafromthesestudiesshowed
thatacupressurereducednausea(p<0.0001)andtherewasnoevidenceofbias.
Ming et al (2002) conductedarandomisedblock experimentcomparingfingerpressing,wristband
and control (conversation only) in a sample of 150 patients undergoing endoscopic sinus surgery.
They found that postoperative nausea and vomiting were significantly different between the three
groups(p=0.001andp<0.001respectively).Thisstudyhasagoodsamplesizeandverylowattrition
(98.7% follow up) but was not blinded. Patients were matched for motionsickness before being
randomly assigned (it is unclear why this was variable was used) and groups were homogenous.
Although internal validity was high, the study was not blinded which may have introduced
placebo/observerbias.
Chemotherapy
Acupressure for nausea as a sideeffect of chemotherapy was investigated byDibbleet al(2000),
Ezzoetal(2006)andShinetal(2004).
16

Dibbleetal(2000)conductedapilotRCTof17womenundergoingchemotherapyforbreastcancerin
oncology outpatient clinics. Patients were randomised (stratified based on setting and treatment
regimen)toreceiveusualcareorusualcareplusacupressureatP6andST36.Nauseaexperience
andintensityweresignificantlyreducedintheacupressuregroup(p<0.01andp<0.04respectively).
Results of this study areinconclusivedue tothe verysmall samplesize andthe lackof a placebo
treatment(discussedasunethical),althoughgroupswerehomogenous.Also,theHawthorneeffect
mayhavebeenpresentduetotheextraattentiongiventothetreatmentgroup.
Ezzo et al (2006) conducted a Cochrane Systematic review on 11 trials ofacupointstimulation for
chemotherapyinduced nausea and vomiting. Pooled data showed that all methods combined
reduced the incidence of acute vomiting (p=0.04), but not severity ofnausea compared tocontrol.
Acupressure reduced mean acute nausea severity (p=0.04) but not acute vomiting or delayed
symptoms, although studies did not use placebo controls. This is a well conducted review which
reportsallmethodologicaldetails.Datawaspooledusingintentiontotreatanalysisandusingoriginal
datawherepossible.Additionallyduplicatebiasandlanguagebiaswerecontrolledfor.Evidencefor
acupressureishoweverlimitedasthereviewincludedallacupointstimulation(includingacupuncture)
onlythreeofwhichwereacupressuretrialsandwhichincludethosewhichusedbands.
Shin et al (2004) compared the effects of selfacupressure on P6 with antiemesis medication to
medicationalone,inasampleof40postoperativegastriccancerpatientsreceivingthefirstcycleof
chemotherapy. A significant reduction was found between intervention and control groups in the
severityofnauseaandvomiting,durationofnauseaandfrequencyofvomiting(allp<0.01).Although
theseresultsare highlysignificant,anumberofmethodologicalissuesarepresent.Thesampleis
smallandconveniencesamplingwasused,groupallocationwasalsonotrandom(allocationused,
first 20 patients in control group), althoughgroups are homogenousfordemographic,diseaseand
treatment variables. Again, the intervention group had additional attention, which may have
introducedtheHawthorneeffect.
Pregnancy
Three studies investigated nausea and vomiting in pregnancy Habek et al (2004) looked at
hyperemesis gravidarum (HG), which is a more severe and rare form of the nausea and vomiting
investigatedbyMarkoseetal(2004)andBelluominietal(1994).
Habek et al (2004) randomised 36 pregnantwomen withHGto four groupsacupuncture, placebo
acupuncture,acupressureandplaceboacupressure.Resultsshowedthatacupressuresignificantly
reduced the occurrence of HG (p<0.01). Thisstudy wasdoubleblinded which is unusual inthese
studies. Sampling was not given, but group allocation was random. Statistical analysis of group
composition was not performed. The main flaw with this study is the small sample, which is then
dividedintofourgroups,sothepowerineachgroupisverylow.Also,theoutcomemeasureappears
tobesimplythedisappearanceofnauseaandvomitingasassessedbythepatientandgynaecologist,
whichissubjecttobias.Theacupressureprotocolwasnotcontrolledandwasselfadministered.
Markose et al (2004) conductedaone group uncontrolled studyof acupressure on P6 for nausea,
vomitinganddryretchesin35womenpregnantunder12weeks.Aftertreatment(day7)therewasa
significant reduction in the frequency of nausea from day 3 (before treatment) (p=0.008), vomiting
(p=0.000)andretching(p=0.016).Thisstudywasofpoorqualityasitwasuncontrolledanduseda
verysmallsample.Inaddition,only17ofthe35womencompletedthestudy.Samplingprocedureis
notgiven.
Belluominietal(1994)randomised90pregnantwomen(12weeksgestationorless)toreceiveeither
acupressureatPc6orshamacupressureatanonacupoint.Bothgroupsshowedsignificantreduction
17

innauseaandemesisovertime,butthisimprovementwassignificantlygreaterinacupressuregroup
(p=0.0021) than control. There were no differences in severity or frequency of emesis between
groups.Thesamplewasselectedfromreferredpatients,detailsofthisarenotclear.Only60outof
90completedthestudyandintentiontotreatanalysiswasnotused.Dropoutwashoweversimilar
betweenstudygroups.Arandomisedblockdesignwasusedwhichcangivemorepowerfultreatment
effects,but criteria for blocking were not given(may begestational age). Groupshomogenous for
pregnancy characteristics and pretest scores. Maternal age was associated with nausea and
vomiting score. Gestational age was controlled for. This study was single blindand used asham
treatmentarm.Acupressurewasselfadministeredacupressureandreliabilityoftheprocedurewas
notchecked.
In summary, the evidence for acupressure for nausea and vomiting is somewhat inconsistent and
varies with type of nausea investigated. Studies investigating postoperative nausea provide the
strongestevidence,whichcanbeasgradedasCategory1evidence(seeprotocol3b)asthestudies
aregenerallywelldesigned(Chen2005Ming2002),andincludeasystematicreview(Lee&Done
2004)andametaanalysis(Shiao&Dune2006).Thetwotrialsreviewedforchemotherapyinduced
nauseaandvomiting(Dibble2000Shin2004)givelittlereliableevidence,mainlyduetosmallsample
size, and although the Cochrane review (Ezzo 2006) gives quality evidence, little of it is on true
acupressure.Thethreestudiesofacupressurefornauseainpregnancyareofpoorqualitywithsmall
samplesand/oruncontrolledstudydesign(Belluominietal1994Habek2004Markose2004)
6.2.3 RenalSymptoms
Five studies were identified which investigated the use of acupressure for renal symptoms. All of
thesestudieshaveanumberofsimilaritiesasTsaySLwasleadresearcherinfourandcoresearcher
inthefifthstudy.
ChoandTsay(2004)randomlyassigned62haemodialysispatientstoacupressureandcontrolgroups
to test the effect of acupressure on fatigue and depression on EndStage Renal disease (ESRD).
Acupressure group received acupoint massage on zusanli (St36), sanyinjiao (Sp6), taixi (Ki3) and
yungchuan(Ki1)whilethecontrolgroupreceivedroutinecare.Resultsshowedasignificantlygreater
reductionin fatigue (p<0.004) anddepression (p=0.045) intheacupressuregroupthanthecontrol.
Sample size was powered, group assignment random, and treatment groups were homogenous
exceptforage.Differencesinpretestscoresandagewerealsocontrolledfor.Theextraattention
thetreatmentgroupreceivedmayhavehadaneffectasashamtreatmentarmwasnotincluded.
TwoarticlesbyTsay&Chen(2003)andTsayetal(2003)appeartobebasedonthesameRCTof
acupressureforqualityofsleepinESRDpatients,butareincludedasseparatestudiesastheywere
published as individual papers. However, we have only described the methodology/quality once
below, as details are identical. 98 ESRDpatientsfromfour hospitalswererandomlyassignedinto
threegroups,acupressure(onpointsH17andK11),sham(massagenotonacupoints)andcontrol
(standard care). Results indicate that improvement in quality of sleep was significantly greater in
acupressure compared to control (p<0.01). However there were no differences between the
acupressureandtheshamgroup,ortheshamandcontrolgroup,exceptthatsubjectivesleepquality
was improved in the sham group compared to the control (p=0.003). Blinding was used, for
interviewer/data collector, usual care provider and participant, but not acupressure nurse. The
outcomemeasuresandacupressureprocedurewerereliable.Bonferronicorrectioncontrolledfortype
1 error. Group assignment was random, and groups were homogenous for demographics, sleep
affectingbehaviourandESRDrelatedfactors.Attritionwaslow(98from105).
Tsay(2004)conductedanRCTof106ESRDpatients,investigatingacupressureforfatigue.Again,
patients were randomised to three groups, acupressure, sham and control. Acupoints Ki1, St36,
GB34andSp6wereused.Results,adjustedfordifferencesinbaselinefatigue,showedthatpatients
in the acupressure group (p=0.01) and sham group (p=0.003) both had significantly lower fatigue
18

scoresthancontrol.Althoughreductionoffatiguewasgreaterinacupressurethanshamgroups,this
differencewasnotsignificant,indicatingthatnonacupointsmassagealsohadaneffectonreducing
fatigue.Participantswerenotblindedtheresearchersstatedthatparticipantsknewwhichgroupthey
were in. Control andintervention groupsweredemographicallyandclinicallyhomogenousandco
variablesofdepressionandqualityofsleepwerecontrolledforinanalyses.Thereliabilityandvalidity
of the procedure was evaluated by expert validation, and the internal consistency of the outcome
measureswasgood.
Tsayetal(2004)testedtheeffectsofacupunctureortranscutaneouselectricalacupointstimulation
(TEAS)onfatigue,sleepqualityanddepressioninaprospectiveRCT.Theyrandomlyassigned106
haemodialysispatients tothree groups to receive either acupressure orTEASon points Ki1,St36,
GB34 and Sp6 or control who received routine care only. Acupressure and TEAS patients had
significantlylowerfatigue(p=0.05andp=0.016respectively)andlessdepressedmoods(p=0.009and
p=0.008 respectively) than control, adjusted for baseline differences. There were no differences
betweenacupressureandTEASgroups.Thisstudyusedrandomgroupassignmentandthreearms,
withhomogenousgroups.Italsohadapoweredsamplesizeandlowattritionrate(2outof108).The
reliabilityandvalidityoftheprocedurewasevaluatedbyexpertvalidation,andtheinternalconsistency
oftheoutcomemeasureswasgood.However,nodetailsofblindingaregivenandresultsarelimited
tohaemodialysispatients.
These five studies provide category 2 evidence for the use of acupressure for renal symptoms
(evidencebasedonasingleacceptablestudy,oraweakorinconsistentfindinginmultipleacceptable
studies) (see p. 3). This categorisation has beenchosen mainly because they do not represent a
rangeofstudies,asallarefairlysimilarindesignandsettingandmainlyledbyoneresearcher.The
individual studies provide some evidence for the efficacy of acupressure for ESRD/haemodialysis
patients,butthisislimitedingeneralisability.Althoughtheydidcontrolforanumberoffactorsand
biases,moststudieswerenotblindedwhichreducesthequalityoftheevidence.
6.2.4 Chronicobstructivepulmonarydisease/asthma
Three studies on chronic obstructive pulmonary disease (COPD) and one on chronic obstructive
asthmawereidentified(Maaetal1997Maaetal2003Tsayetal2005Wuetal2004).
Maaetal(1997)investigatedtheeffectsofselfadministeredacupressureonreducingdyspnoeaand
otherassociatedsymptomsin31patientswithCOPD.Patientswerethosebeginningapulmonary
rehabilitationprogramattwoprivatehospitalsandacupressurewasusedasanadjuncttostandard
care. The study was a pretestpostest crossover design group 1 had 6 weeks of acupressure
followed by shamacupressureandgroup2viceversa.Realacupressurewasmoreeffectivethan
shamforreducingdyspnoea(p=0.009)andminimallyeffectiveforreducingdecathexis(p=0.044)but
hadnoeffectonanyothersymptoms.Thisstudyhadasmallsample,althoughsensitivityanalysis
wasperformedanddidnotidentifyanyidiosyncraticindividuals.Also,dropoutwashigh(20of51),
and mostly due to medical reasons, which may have biased the results. Also the study was only
singleblind and many patients could identify sham from real acupressure. The crossover design
should reduce effects of retesting, carryover or timerelated effects of patients acting as their own
controls,whichcontrolsforheterogeneity.Outcomeswerevalidandreliable.
Maaetal(2003)conductedapilotrandomisedtrialofacupunctureandacupressureforimprovingthe
qualityoflifeofpatientswithchronicobstructiveasthma.41outpatientswererandomlyassignedto
receiveacupuncture,acupressureorcontrol,allgroupsreceivedstandardcare.Acupressurepatients
hadasignificantlygreaterreductioninhealthrelatedqualityoflife(p=0.05)andinirritability(p=0.06)
but not in any other scores. Again, this study had a smalland purposive sample, although again,
sensitivityanalysiswasperformedanddidnotidentifyanyidiosyncraticindividuals.Therewasalsoa
veryhighattritionrate(41%),whichwasagainmostlyduetomedicalreasonsanddropoutwasalso

19

greater from the acupuncture group. Intention to treat analysis was not used. Thestudy was not
blinded.
Tsayetal(2005)usedatwogroupexperimentalblockingdesigntoinvestigateacupressure(atpoints
Li4,PC6andHT7)fordyspnoea,anxiety,heartrateandrespiratoryrateinpatientswithCOPD.52
patients,allonmechanicalventilationsupport,werematchedforsex,ageandlengthofventilationuse
then randomly assigned to acupressure or control (massage and handholding) groups. Dyspnoea
(p=0.009), anxiety (p=0.011), heart rate (p=0.005) and respiratory rate (p<0.0001) improved
significantly in the acupressure group compared to control. This study had a powered sample
althoughtherewas no informationabout dropout. Thegroupswerehomogenousfordemographic
and clinical factors. Clinical outcome measures were used and the procedure was reliable and
validated by experts. Patients, data collectors and usual care givers were blinded, but not
acupressurenursesorresearchers.
Wuet al(2004)matched44outpatientswithCOPDforage,sex,pulmonaryfunction,smokingand
steroid use then randomly assigned them to receive acupressure (points GV14, CV22 , B13, B23,
L10) or sham acupressure (Sp5, Sp3, Li1). Scores from the Pulmonary Status and Dyspnoea
Questionnaire modified scale showed that the true acupressure group improved significantly more
than the sham group for all three subscales dyspnoea (p<0.05), fatigue (p<0.01) and activity
(p<0.001). Tolerance for activity also significantly improved (p<0.001) as did anxiety (p<0.001).
Although this study used a small sample, the randomised blockdesignshould givemore powerful
treatmenteffects.Theshampointswereondifferentmeridiansandganglionicsections,indicatingthe
efficacyofthespecificacupointschosen.Theacupressureprotocolwashighlyreliableandvalidated
bytheresearchers,usingthreetests:1)independentratingforvaliditytoachieve100%agreement,2)
observationofaccuracyofpointsbyTCMpractitionerand3)trueandshampointscomparedonvideo
forhomogeneityintiming.Theoutcomemeasureswerealsoreliableandvalid.
Overall,theevidenceforacupressureforCOPD/asthmaiscategory2evidence(seep.3)asthereare
only a small number ofstudies andthese have a number ofmethodologicalflaws.Allstudieshad
fairlysmallsamples,andtwooftheidentifiedstudieshadahighdropoutratewhichislikelytohave
biasedtheirresults(Maaetal1997Maaetal2003).
6.2.5 Anxiety/stress/sleepproblems
Three studies were identified which investigated psychosocial aspects of health, specifically pre
operativeanxiety,qualityofsleepandalertness.
Agarwal etal (2005) conducted an RCT with76adultsundergoingelectivesurgery.Patientswere
randomised to receive acupressure at Extra 1 point or sham acupressure at aninappropriate site.
Anxietydecreasedinbothgroups,butbothreturnedtobaselineafter30minutes.Thedecreasein
anxiety was greater in the Extra 1 group (p<0.05). Bispectral indexvalues were alsolower during
treatmentinbothgroups,andwerelowerforExtra1group(p<0.05).Thesamplesizewaspowered,
groupallocationwasrandomandgroupswerehomogenous.Ashamtreatmentarmwasincluded,
althoughtherewasnoothercontrolgroup.Thestudywassingleblinded(patient).
Chenetal(1999)performedathreearmedRCTtestingtheeffectivenessofacupressureinimproving
the sleep quality of institutionalised residents. 246 elderly residents with sleep disturbances were
matched for hypertension, hypnosis, naps and exercise then randomly assigned to acupressure
(pointsbaihui(GV20),fengchi(GB20),anmian(BL18)andshenmen(Ht7)x2),sham(1cm3cunfrom
real points) or control (conversation) groups. Quality of sleep improved in all three groups and
improvementsweresignificantlygreaterinacupressuregroup(scheffesposthoccomparison).This
was a high quality trial, with a large sample size, systematic random sampling and random group
assignment,matchedtogivemorepowerfultreatmenteffects.Thecontrolandinterventiongroups
werehomogenousforahugerangeoffactors(demographicsage,gender,livingconditions,druguse,
20

chronic disease, time at facility, naps, exercise, time in bed, milk tea and coffee consumption,
smoking,sleepindices).Theinternalvalidityoftheprocedurewasextensivelycontrolledbyinterrater
reliabilityandexpertvalidation.However,thestudywasonlysingleblindandtheprincipalinvestigator,
who knew the participants, both administered treatment and collected data, which may introduce
Hawthorneeffectandresearcherbias.Generalisabilityislimitedassettingwasaveryspecifichome
forelderlypeoplewithlowincomeandwithoutason.
Harrisetal(2005)usedacrossoverdesigntotestacupressuretomodifyalertnessintheclassroom.
Theyrandomlyassigned39studentstotwoacupressuretreatmentsequences:stimulationrelaxation
relaxationorrelaxationstimulationstimulation.Comparedtorelaxation,stimulationacupressuregave
a greater alertness score (p=0.019). Day of study and hours of overnight sleep also significantly
affected the score. The study was singleblind (subjects), although the majority of students could
correctly discernthe treatment. This didnotsignificantlyaffect theresults,althoughitcameclose,
raising pto 0.0484. Thereis a chancethat participants werestudentsoftheresearchers,itwhich
case it would appear that Hawthorne effect may be present. Small sample size (39) and low
generalisability as all medical students (well educated, scientific researchers who were highly
motivated tocomply) werealso issues. Group allocationwas random andcontrolandintervention
groupswerehomogenous.Crossoverdesignshouldreduceeffectsofretesting,carryoverortime
relatedeffects,althoughparticipantsactingastheirowncontrolscancausepractiseeffect(especially
withselfreport).Validityoftheoutcomemeasurewasnotgiven.Ninestudentsprovidedmissingdata
retrospectivelywhichmaycauserecallbias.Statisticalanalysiswasverycomprehensive,accounting
foreffectsofsequence,period,treatmentandothercovariates,masking,andcovariates,including
caffeine,sleep,medication,anxietyandcompliance.
Thequalityofstudiesforacupressureforpsychosocialhealthissuesisvariablereliableconclusions
cannot be drawn from the existing evidence base,although evidenceforimprovingsleepqualityin
institutionalisedelderlyisstrong(Chenetal1999).
6.2.6 Anaesthesia/consciousness
Threestudieshaveinvestigatedtheeffectsofacupressureonlevelsofanaesthesiaorconsciousness.
These levels include the acoustic evoked potential (AEP), changes in which reflect the depth of
anaesthesiaandtransitionfromawaketoanaesthetised(Dullenkopfetal2004)bispectralindex(BIS)
and spectral edge frequency (SEF) which are measures of the level of consciousness during
anaesthesia/sedation(Fassoulakietal2003Litscher2004).
Dullenkopf et al (2004) used a repeated measures, counterbalanced design to investigate the
influenceofacupressureatExtra1pointontheAEPofunsedatedadultvolunteers.15volunteers
receivedacupressureatExtra1pointfollowedbyacupressureonacontrolpointthefollowingdayor
viceversa,theorderwaschosenrandomly.Subjectsactedastheirowncontrolsandresultsshowed
thatAEPreducedsignificantlyafter10minutesofpressureonExtra1point(p=0.0044),butthiseffect
onlylastedfor5minutes.Stresslevelswerealsoreduced(p=0.0066).Thisstudyhadaverysmall
sampling and no details of sampling were given. Patients acted as their own controls, which can
causedangerofattrition,andpracticeeffect. Itcanalsocausecarryovereffectsbuttheseshouldbe
addressedbycounterbalancing,astherewerenodifferencesinchangesinAEPbetweenparticipants
whohadExtra1orshamacupressurefirst.
Fassoulakietal(2003)usedasimilarrepeatedmeasuresdesigntogive25volunteersacupressure
onextra1pointoracontrolonalternatedaysinarandomisedmanner,withtheaimofreducingself
reportedstresslevels.BISwassignificantlyreducedduringpressureonextra1point(p<0.001)but
returned to baseline after pressure release. Pressure on the control point also reduced BIS but
reductions from extra 1 were greater (p<0.001). Sample size is small, although it was powered.
Again, sampling/followup details are not given. Participants were excluded if they believed in
Traditional Chinese Medicine theory, which may well bias results. Acupressure was given for 10
21

minutesatExtra1andforonly5minutesinthecontrolgroup,whichisamajorflaw.Again,patients
actingastheirowncontrolscancausedangerofattrition,practiceandcarryovereffects.
Litscher (2004) conducted a crossover trial of acupressure on yintang, acupuncture, laserneedle
acupunctureandshamacupressureontheBISandSEFin25healthyvolunteers.Participantseach
receivedallfourinterventions,theorderofwhichwasrandomisedforeachpatient.Resultsshoweda
significant reduction of BIS and SEF during acupressure (p=0.001). Stress was also reduced by
acupressure(p<0.001)butalsobyshamacupressure(p<0.012).Thiswasavolunteersampleand
quite small, also participants were paid to take part. Subjects and data collectors were blinded.
Again,theuseofsubjectsastheirowncontrolsraisesissuesofbias,especiallyassubjectsonlyhad
20minutesbetweentreatmentssotreatmenteffectsmayoverlap.
Overall,theevidencefortheeffectsofacupressureonconsciousness/anaesthesiaisweak,ratedas
category3(seeprotocol2b)asonlythreestudieshavebeenidentified,allofwhichusearepeated
measures design rather than RCT and small sample size (Dullenkopf et al 2004 Fassoulaki et al
2003Litscher2004).
6.2.7 Otherconditions
The remaining five articles on acupressure investigated distinct health conditions which were not
groupedbutareconsideredseparatelybelow.
Ballegaardetalconductedtwostudiesofacupressureforangina(1999and2004).The1999study
wasmainlyacostbenefitanalysisofusingacupressureaspartofaselfcareprogramforoutpatients
with angina pectoris. 105 patients were given acupressure at CV17, UB14 and UB15, along with
acupunctureandarangeofotherlifestylemodificationsbasedonselfcare.Threegroupswereused
for comparison of risk published data on invasive treatments78, a random sample of the Danish
population and the group used for this study. The intervention group had a 90% reduction in
hospitalisationanda70%reductioninneededsurgery.Medicationintakeanddegreeofdiseasewere
significantly reduced andqualityof life improvedaftertreatment (all p<0.0001).Theriskofcardiac
deathormyocardialinfarctionwaslowerinthetreatmentgroupthangeneralpopulation(significance
not given). As this study was designed as a cost benefit analysis ratherthananefficacy study, a
different study design may have given different results, the main problem being the use of non
equivalentcontrolgroups.Alsothesamplewasvolunteerandconvenience.Itisdifficulttoisolatethe
effectsofacupressurefromcointerventionsofacupunctureandtheselfcareprogram.
Ballegaard et al (2004) investigated the longterm effects of acupressure, as part of integrated
rehabilitation(IR),toreducetheriskofanginapectorissufferersdyingfrommyocardialinfarction(MI).
168 patients (103 candidates for surgery,69inoperable) with angina inaprivate clinic inDenmark
received 12 sessions of IR which included acupressure at CV17, UB14 and UB15. 3 historical
controlswereused1)GeneralDanishpopulation,2)NewYorkclinicaldatabase9 and3)Patientswho
underwent surgery from a study in New York10. The 3 year accumulated risk of death was 2%
(confidencelimits04.7%)forthe103surgerycandidates,comparedto6.4%(confidencelimits4.7
6.1%) for the Danish population and 8.4% (confidence limits 7.7 9.1%) for New York surgery
patients.Riskofdeathwas7.7%(3.911.5%)forthe69inoperablepatients,comparedto16%(10
34%)and25%(1836%)forAmericanpatientstreatedwithlasersurgeryormedicationrespectively.
7

Kingetal(1994)Arandomisedcontrolledtrialcomparingcoronaryangioplastywithcoronarybypasssurgery. NEngJ
Med, 331:10441050
8
Yusefetal(1994)Effectofcoronaryarterybypassgraftsurgeryonsurvival:Overviewof10yearresultsfrom
randomisedtrialsbytheCoronaryArteryBypassGraftSurgeryTrialistsCollaboration. Lancet, 344:563570
9
Hannan,RaczM,McCallisterBetal(1999)AComparisonof3yearsurvivalaftercoronaryarterybypassgraftsurgery
andpercutaneoustransluminalcoronaryangioplasty. JourAmCollCardiol,33(1):6372
10
SchofieldPM,SharplesLD,CaineNetal(1999)Transmyocardiallaserrevasculisationinpatientswithrefractory
angina:Arandomisedcontrolledtrial. Lancet,353:519524
22

Theaccumulatedriskofoperation/MI/deathwasreducedingroupswhohadundergonetreatmentfor
longer(p<0.05fortrend).Inaddition,theIRprogramresultedincostsavingsof$36000and$22000
forsurgical/inoperablepatientsrespectively,althoughthesecostswerebasedonanAmericanstudy.
This study had a good sample size although sampling was not random and a very long followup
period.Themainflawsaretheabsenceofanequivalentcontrolgroupandlackofblinding.Also,due
to the pragmatic design, it is difficult to isolate the effects of acupressure from cointerventions of
acupuncture,selfcareprogramincludingChinesehealthphilosophy,stressmanagementandlifestyle
adjustments.ThesamplewasnotsignificantlydifferentinbaselinevariablestoScandinavianheart
patients. The researchers described this study as a quality control review, which is subject to
selection bias, expectation bias and social bias as patients have chosen and are paying for the
treatment.However,evidenceiscitedwhichclaimsthatnobiasisintroducedbypatientschoiceofa
particulartreatmentorpayingfortreatment11.
Chen et al (2003) conducted an RCT using acupressure to improve gastrointestinal(GI) motilityin
women after transabdominal hysterectomy. 41 patients were randomly assigned to intervention
(acupressureonPc6,St36,Sp6)andcontrol(acupressureonshampoints)groups.Theacupressure
grouphadsignificantlyimprovedGImotility(p<0.05),higherselfawarenessofGImotility(p<0.05)and
satisfaction (p<0.001)comparedtocontrol.Thesamplewassmallandnotpoweredandthestudy
wasonlysingleblind.However,groupswerehomogenousforawiderangeoffactors(identifiedfrom
previousresearch)(demographics,bowelmovements,GIhistory,surgeryhistory,durationofsurgery,
bloodloss,analgesics,pain,postsurgicalactivities,leavingthebedandfoodintakepatterns).The
reliabilityoftheprocedurewasverifiedbytraining,expertverificationofpointlocationandGImotility.
Luetal(2000)investigatedtheantigaggingeffectsofacupressurein109dentalpatients.Patients
wererandomlyassignedtothreegroupsacupuncture(P6orshampoint),acupressure(P6orsham)
andpharmacologicalsedationwitheitheracupressureoracupuncture.Acupressurewasadditionally
performedwitheitherthumb,deviceorSeaband.Therewasasignificantreductioningaggingwith
acupuncture(teamevaluationp=0.047,patientp=0.009)andwithdeviceacupressure(teamp=0.002,
patientp=0.001)atP6versusshampoint,butnoothersignificantdifferencesforacupressure(using
thumborSeaband).Thestudywasdescribedasdoubleblindalthoughblindingproceduresarenot
evident.Theuseofsomanycomparisongroupsresultsinverysmallgroupsize(between9and18).
Theoutcomemeasure(subjectiveratingbythedentalteamandpatient)wasnotvalidatedandmay
notbereliable.Groupswerenotcomparedforhomogeneityinbaselinecharacteristics.
Yukseketal(2003)randomised24patientstoreceiveeitheracupressureoroxybutininfornocturnal
enuresis.AcupressurewasappliedtopointsGv4,Gv15,Gv20,B23,B28,B32,H7,H9,St36,Sp4,
Sp6,Sp12,Ren2,Ren3,Ren6,K3andK5.Therewerenosignificantdifferencesinincidenceofbed
wettingbetweengroupsaftertreatment.Nobedwettingwasseenin83.3%ofchildrenwhoreceived
acupressureand58.3%whoreceivedoxybutinin.Themainflawwastheverysmallsamplesize,with
no details of sampling, comparison of groups or randomisation. Additionally selection bias was
introducedfrommoving3patientswhohadpreviouslyunsuccessfulpharmacologicaltreatmentfrom
oxybutinintoacupressuregroup.Acupressurewasnotcomparedtoaplacebo/shamgroup.
Studies retrieved and collated as background information on Shiatsu (Appendix 11), identifiedfour
single case reports ofadverseevents occurringfollowingShiatsu massage (Herskovitzet al1992
Mumm et al 1993 Tsubo 2001 Wada et al 2005). This is an important area for the profession
regardingsafetyissuesandpossiblecausallinksbetweenShiatsuandadverseevents.Note,these
maynothavebeentheonlycasereports.
11

MorrisonDA,SethiG,SacksJetal(2002)TheVAAWESOME(anginawithextremelyseriousoperativemortality
evaluation)MulticenterRegistry. Percutaneouscoronaryinterventionversuscoronarybypassgraftsurgeryforpatientswith
medicallyrefractorymyocardialischemiaandriskfactorsforadverseoutcomeswithbypass:theVAAWESOME
multicenterregistry:comparisonwiththerandomisedclinicaltrial. JAmCollCardiol,39:266273
23

AlimitednumberstudiesassessedqualitativeaspectsofShiatsuasatherapy (Cheesmanetal2001
Long &Mackay2003) but thedata was eithernotpresentedscientificallyor was not carriedoutin
controlledcircumstances.Otherstudiesmentionedacupuncturemassagetechniquesanditisunclear
ifthiswasaboutacupressure(Furlanetal2002).TherewerealsogeneralarticlesmentioningShiatsu
asanintervention(Galantinoetal2003)andsomementionedShiatsuaspartofaserviceprovision
(Peace&Manasse2002Sommersetal2002Yates2005). AsurveywasfundedbytheResearch
Council for Complementary Medicine (Harris & Pooley 1998) to investigate what conditions
practitioners currently treated and to ascertain the direction of future research into the efficacy of
Shiatsu.Thesurveyfoundthatthemostcommonconditionspresentingfortreatmentweremusculo
skeletal and psychological problems and concluded that future efficacy research should focus on
these areas, in particular neck/shoulder, lower back problems, arthritis, depression, stress and
anxiety.TwostudiesreferredtoWatsubutonewasapersonalaccount(Davis2003)andtheothera
seriesofcasereports(Vogtleetal1998).
Backgroundinformationonacupressuremainlyincludedacupressureanditseffectsonnauseaand
vomiting andliterature reviews(Collins &Thomas2004Harris1997).Thearticlesonnauseaand
vomitingincludedsomereviews(Oates&Whitehead2003Oates&Whitehead2004Jewell2003
Aikins1998)buttendedtobeverybroadandincludedeithervarioustypesofinterventionorwerenon
systematicorrelatedtodevicesorcombinationsofinterventions(Anderson&Aikins1998Johnson
2005). Nonpharmacological management was shown to be effective for post operative and
chemotherapyinducednauseaandvomitingbutShiatsuwasnotspecificallymentioned(Lee&Done
1999King1997Panetal2000).
AthesisondeliveringShiatsuingeneralpractice(Pirie2003)lookedattheimpactofShiatsuonGP
consultations and whetherfrequency ofprescriptions for medications werereduced(Appendix15).
Thiswasaqualitativestudyandtheresearcherwasalsothepractitioner.Theresearchconcluded
that complementary medicine could be effectively delivered in general practice and that further
researchinclinicalandcosteffectivenesswaswarranted.
ThesefindingsprovideanimportantadditiontotheexistingknowledgebaseonShiatsubutarevery
limited.

7. Discussion
TheresearchbaseforShiatsuisverymuchinitsinfancyandtheprofessionwillneedtoworkclosely
withpractitionersandresearchersinordertobuildupalargerbodyofevidence.Thisevidencereview
has considered and included research studies which have a conventional RCT design. The
methodological limitations ofthestudies reported inthis systematic literature reviewincludedsmall
sample sizes, non reporting of follow up, insufficient details on sampling, high drop out rates,
uncontrolleddesign,lackofblindingetc.Manystudieswerealsounderpoweredi.e.theirsamplesize
attheoutsetwasinsufficienttodetectasignificantdifference.

Complementarymedicineisunderpressuretoprovidescientificevidenceofefficacyiftheyaretobe
acceptedandintegratedwithintheprevailingframeworkofconventionalmedicine.Therelevanceof
evidence based medicine depends on the quality of the research carried out. While much of the
researchcarriedoutwithShiatsuoracupressureasaninterventionisofinsufficientqualitytoprovide
consensusonitsuse,somehighquality(Category1)clinicalresearch(particularlyaroundpain)does
exist.Thisprovidesamodelforfutureresearch.

24

Contentionisslowlyemergingabouthowcomplementarymedicineshouldbeevaluated12,13,14,15,16,17.
The complexity of interventions and their potential synergistic effect requires innovative evaluative
approaches using whole systems research that include qualitative and quantitative methods.18,19
Analysisoftheliteratureindicatesthatimportantrefinementsarebeinggeneratedincomplementary
medicine research and clinical trial design in response to the challenges posed by the forced
encounteroftheparadigmsofholisticandconventionalmedicalpractice.
ShiatsuisnodifferenttoothercomplementarytherapiesinthatapragmaticRCTapproach(reflecting
normal practice) should be an inherent part of study design. In addition, qualitative data provides
additionalinformationonpatientsand/orpractitionersviewsontheeffectivenessoftreatment.Many
studiesareincludingsuchqualitativedataaspartoftheirdesigntoprovideabroaderpictureofpatient
outcomes.
IfShiatsuistobeevaluatedatleastinpartthroughRCTs,thesemustbeappropriatelydesigned.A
recent paper concluded that RCTs would be more effective in studying acupuncture if participants
were randomised to groups based on acupuncture diagnosis, not solely on conventional western
criteria11.ThismaybetrueforothercomplementarytherapiesincludingShiatsuwhichuseselements
ofTraditionalChineseMedicinediagnosisaswellasHaradiagnosis.Theauthorsfeltthatalthough
treatments must be standardised to ensure replicability of the study, blinding was not absolutely
necessaryforagoodqualityRCT,however,ifused,controlgroupsneedtobestandardised.Theyfelt
that homogeneity of groups based on specific acupuncture diagnostic criteria (which takes into
accountthedifferentphilosophyandChinesemedicinesystem)couldbeusedasevidenceofefficacy
oftheinterventionandsatisfybothacupunctureandconventionalmedicinecritics.
Future clinical research on Shiatsu and acupressure also needs to take into account practitioner
variabilityintermsofpointselection(basedondifferencesintheireducationandtraining).Theissue
of blinding, which involves sham or placebo treatments, is also difficult to resolve. Shiatsu (as
distinctfromacupressure)presentsfuthercomplexitiesastreatmentsarebasedonHaradiagnosis
andrarelyifeverstandardised.
Inthecaseofacupuncturetherehasbeencontroversyabouttheuseofshamacupunctureanditis
nowgenerallyfeltthatitcannotbeusedasaninertcontrolthoughitcouldbeonearmofanRCT12
Thestrengthofanyconclusionsfromresearchwilldependonthequalityoftheevidenceincludedand
even withgoldstandardRCTtherecanstillbebias20.Astheincludedstudieshaveshown,sham

12

WaljiR,BoonH(2006).Redefiningtherandomisedcontrolledtrialinthecontextofacupunctureresearch. Complement
TherClinPract.
13
SheaJ.(2006)ApplyingevidencebasedmedicinetoTraditionalChineseMedicine:Debateandstrategy. JAltern
ComplementMed 12(3):255263.
14
WalkerLG,AndersonJ.(1999)TestingComplementaryandalternativetherapieswithinaresearchprotocol.EuropeanJ
Cancer 35(11)16141617
15
HermanPM,DHuyvetterk.MohlerMJ((2006)ArehealthservicesresearchmethodsamatchforCAM. AlternTher
12(3):7883.
16
BroomA.(2005)UsingqualitativeinterviewsinCAMresearch:Aguidetostudydesign,datacollectionanddata
analysis.ComplementTherMed 13:6573.
17
WalachH,FalkenbergT,FonneboV,LewiothG,JonasWB.(2006)Circularinsteadofhierarchical:methodological
principlesfortheevaluationofcomplexinterventions.6:29.<http://www.biomedcentral.com/14712288/6/29.doi
10.1186/14712288629>.
18
VerhoefMJ,LewithG,RitenbaughC,BoonH,FleishmanS&LeisA.(2005)Complementaryandalternativemedicine
wholesystemsresearch:BeyondidentificationofinadequaciesoftheRCT.ComplementTherMed13(3):206212
19
GiordanoJ,GarciaMK,StricklandG.(2004)IntegratingChineseTraditionalmedicineintoaUSPublicHealthParadigm.
JAlternComplementMed10(4):706710.
20
LeiboviciL.(1999)Alternative(complementary)medicine: acuckoointhenestofempiricistwarblers. BMJ(Clinical
ResearchED.)319:162932.
25

acupressure including light touch at acupoints does have an effect. This means that sham
acupressuremaynotbeanappropriatecontrolunlessastudyisverycarefullydesigned.
Safety is best established with prospective studies and the four reports identified in this review
highlighted the importance of having good evidence on safe practice. The type and frequency of
adverseeventsandanytransientreactionsafterShiatsutherapyneedsexplorationasalthoughthis
wasnotthefocusofthisreview,severalincidencesofadversereactionstoShiatsuwerefound.

26

8. Conclusions
Thesummariesofthebestqualityevidencetodatesuggestthat,duetothesmallnumberofstudies
specificallyrelatingtoShiatsu,welldesignedresearchinanyareawouldbeawelcomeadditiontothe
current evidence base. For acupressure and pain, the evidence is generally consistent and has
demonstratedthatacupressurecancontrolpain.Acupressurestudiesfornauseaandvomitinghave
been somewhat inconsistent and may merit further research. Similarly the studies on COPD and
asthma,psychosocialaspectsofhealth,anaesthesiaandotherhealthconditionsaregenerallyweak
due to study design. From these studies reviewed only pain, nausea and vomiting have provided
someevidenceofbenefitbutaretooheterogeneousandthereforecannotbeamalgamated.

9. Recommendations

SignificantresearchneedstobecarriedoutifShiatsuistodevelopanevidencebase
FurtherresearchisneededtoinvestigatetheeffectivenessofShiatsuasanintervention
Encouragepractitionerstoengageinresearchusingwelldesignedstudies
The relationship between Shiatsu and acupressure needs clarification for marketingand public
awareness
ConsiderthedevelopmentandpilotingofanadverseeventreportingsystemforShiatsu
ExploreclinicalandthecosteffectivenessofShiatsuinanintegratedsetting
Identifyspecifictopicareasforinitialresearchinvestment
DevelopanevaluativeframeworkforintegratedShiatsupractice
Developaresearchresourcefortheprofession
InvestigatetheappropriatenessofvariousresearchmethodologiesforShiatsuresearch

27

Appendix1SearchTermsanddefinitions
Inordertoensurethatthecorrectsearchtermwasused,aMeSHsearchwascarriedoutfortheterm
Shiatsuwith thefollowingresult (copiedfromMeSH)fortheoptionShiatsu[Multi]explodedinto
theMeSHtree:
Acupressure
Atypeofmassageinwhichfingerpressureonspecificbodysitesisusedtopromotehealing,relieve
fatigue,etc.AlthoughtheanatomicallocationsarethesameastheACUPUNCTUREPOINTSusedin
ACUPUNCTURETHERAPY(henceacu),noneedleorotheracupuncturetechniqueisemployedin
acupressure. (FromRandomHouseUnabridgedDictionary, 2ded). Shiatsu is amodern outgrowth
thatfocusesmoreonpreventionthanhealing.
Yearintroduced:1996
EntryTerms:
Shiatsu
Shiatzu
ZhiYa
ChihYa
PreviousIndexing:
AcupuncturePoints(19901995)
Pressure(19831995)
AllMeSHCategories
Analytical,DiagnosticandTherapeuticTechniquesandEquipmentCategory
Therapeutics
ComplementaryTherapies
AcupunctureTherapy
Acupressure
AllMeSHCategories
Analytical,DiagnosticandTherapeuticTechniquesandEquipmentCategory
Therapeutics
ComplementaryTherapies
MusculoskeletalManipulations
Massage
Acupressure
AllMeSHCategories
Analytical,DiagnosticandTherapeuticTechniquesandEquipmentCategory
Therapeutics
MusculoskeletalManipulations
Massage
Acupressure
AllMeSHCategories
Analytical,DiagnosticandTherapeuticTechniquesandEquipmentCategory
Therapeutics
PhysicalTherapyModalities
MusculoskeletalManipulations
Massage
Acupressure

28

Appendix2Databasesearchesandtermsused
Pub/Medsearchterms
Thefollowingsearchtermswereusedfor3initialMEDLINEsearches(09.02.06)withnolimitssetfor
searchcriteria:
1. ShiatsuANDnursing toupdateaprevioussearchthattheShiatsuSocietyUKhad
undertaken.
2. ShiatsuMeSHtermtocaptureanyomissionsfromthefirstsearch.
3. ShiatsuNOTacupressuretorestrictresultstoShiatsu.

OVIDsearches
OVIDisanonlinebiomedicaldataservicewhichcomprisesofanumberofdatabases.Accesscanbe
limited dependant on subscription e.g. EMBASE. This facility allows for a single search to be
performedoveranumberofdatabaseswhichisthenscreenedforduplicatesbetweendatabasesto
produceafinalresult.SomeofthesedatabasesincludepopularhealthpublicationssuchasHeres
Health andarticles published byorganisationsfornewsletters e.g.the ShiatsuSociety News. The
followingdatabaseswereused:
EBM Reviews Cochrane Database of Systematic Reviews, Database of Abstracts of
Reviews,CochraneCentralRegisterofControlledTrials.
AMED(AlliedandComplementaryMedicine)<1985toFebruary2006>(154)
BritishNursingIndex(BNI)<1985toFebruary2006>(12)
CINAHLCumulativeIndextoNursing&AlliedHealthLiterature.
EMBASE
OvidMEDLINE(R)InProcess&OtherNonIndexedCitations
OvidMEDLINE(R)<1966topresent
PsycINFO
Journals@Ovid(thisincludestheformerCoreBiomedical,NursingandMentalHealthfulltext
collections).
OVIDsearchterms
ThemajorityofOVIDdatabasesuseaMeSHsystemforindexingthereforethetermShiatsu
wasusedforthesearch(28.02.06).Itwasonlypossibletoupdatethissearchonce,22.03.06.withno
new results, as EMBASE was no longer accessible for any further searches therefore the same
searchcouldnotberepeated.
Othersources
ThesearchtermsShiatsuandacupressurewereusedforsearchesinjournaldatabases,Indexto
ThesesandZETOC(23.02.06)

29

Appendix3Screeningofsearchresults
Inclusioncriteria
Shiatsuoracupressureadministeredmanually/bodily
Primaryresearch
Secondaryresearch
Systematicreview
Reviewofeffectiveness
Literaturereviewwithdescribedmethodology
Studiesinpreferredstudydesignhierarchy:
Randomisedcontrolledtrial(RCT)
Cohort
Case/Control
Beforeandafter
Costcomparison/effect/benefit/economics
Audit

Furtherdetailsofhierarchyofstudydesignandgradingofevidencecanbefoundat:
http://www.york.ac.uk/inst/crd/pdf/crd4_ph5.pdf pg5of20showshierarchyofstudydesignsfor
studiesofeffectiveness.(CentreforReviewsandDissemination)
http://www.york.ac.uk/inst/crd/pdf/crd4_ph8.pdf pg10of16showsgradingrelevelofevidence
A1D5

Exclusioncriteria
Theexclusioncriteriawerebuiltupinstagesasuntilsearchresultsandabstractswereavailablefor
initialscreening thiscould not be finalised.Forthe purposeofthisreview,qualitativestudies,case
reports,caseseriesandgreyliteraturewerenotincludedforappraisalasthesewerenotconsidered
asscientificevidenceofeffectiveness.
Stage1initialscreeningofresults
PublishedpriortoFebruary1990
Duplicatedinothersearches
Obviousfromtitlethatadevicehasbeenused
Newspaperarticles,bookreviews,popularhealthpublications.
Generalcomments,letters
Stage2fromabstracts
Foreignlanguagepapers
UseofKoreanpoints/meridians
Useofplasters,devices,wristbands
Auricularacupressure
Generalcomments,letters
Stage3fromfulltextarticles.
ThisincludesStage2exclusioncriteriaasitmaynothavebeenobviousfromtheabstracts.
Foreignlanguagepapers
30

UseofKoreanpoints/meridians
Useofplasters,devices,wristbands
Auricularacupressure
Anecdotalevidence
Personalexperience
Shiatsu/acupressure are mentionedastherapiesingeneralcomplementarymedicinepublications
andthereisnosectionwhichrelatesspecificallytoeithertherapy.
Guidelinesfortreatment
Reportsofpossibleadverseevents
Surveys
Casereports
Caseseries
Qualitativestudies
Conferenceabstracts/posters

31

Appendix4SecondMEDLINEMeSHtreeandsubsequentsearches
AcupunctureTherapy
Treatmentofdiseasebyinsertingneedlesalongspecificpathwaysormeridians.
Theplacementvarieswiththediseasebeingtreated.Itissometimesusedinconjunctionwithheat,
moxibustion,acupressure,orelectricstimulation.
Yearintroduced:1990
EntryTerms:
Therapy,Acupuncture
PreviousIndexing:
Acupuncture(19661989)
SeeAlso:
Medicine,ChineseTraditional
Acupuncture
AllMeSHCategories
Analytical,DiagnosticandTherapeuticTechniquesandEquipmentCategory
Therapeutics
ComplementaryTherapies
AcupunctureTherapy
Acupressure
AcupunctureAnalgesia
Acupuncture,Ear
Electroacupuncture
Meridians
AcupuncturePoints
Moxibustion
The term acupuncture therapy was introduced in 1990 and the MeSH tree terms included
acupressureandacupuncturepoints.Acupressure,whereShiatsuisincluded,wasintroducedas
MeSH term in 1996. It was not clear from the information in MEDLINE, whether all citations for
acupressurehadbeenreindexedwhenthetermwasintroduced.
Further searches were thereforecarried out on 24th August2006 toascertain howmany additional
publicationsneededtobereviewed.Thesearchtermsusedandresultswereasfollows:

Code
A
B
C
D
E
F
G

Searchterm
Result
Shiatsu to verify the final 259
Shiatsusearchon1st August
acupressure
360
ShiatsuAND
acupresssure
ShiatsuORacupressure
acupointAND
acupressure
acupuncturepointAND
acupressure
acustimulation

Comment
18notinacupressure
(25918=241=C
119notinShiatsu
(360119=241=C)

241
378
100

(=B+18ShiatsufromA)
Allfoundinacupressure

87

Allfoundinacupressure

24

10notfoundinacupressure

32

The10newresultsintheacustimulationsearchdidnotrefertomanuallyappliedacupressureand
thereforewerenotconsideredforinclusion.
Ofthe119newresultsintheacupressuresearch,15wereduplicatedinothersearchesand25were
before1990.Followingtheexclusioncriteriaprotocol,afurther77publicationswereexcludedandfull
textcopieswererequestedforthetworemainingpublications.
1.Belluomini,J.,Litt,R.C.,Lee,K.A.,andKatz,M.(1994).Acupressurefornauseaandvomitingof
pregnancy:arandomized,blindedstudy.ObstetGynecol84:245248.
Thiswasaddedtotheevidencetablesandappraised.
2. Matsumura,W.M. (1993). Use of acupressure techniques and concepts for nonsurgical
managementofTMJdisorders.JGenOrthod.4:516.
Therewasnoabstractavailableforthispublicationanditwasnotpossibletoobtainafulltextcopy,it
wasthereforeexcluded.

Other
As a result of checking the references of the 146 publications that were left for screening, two
publicationswereconsideredforreview.
Onewasincludedforreviewatthisfinalstage:
Ballegaard,S.,Johannessen,A.,Karpatschof,B.,andNyboe,J.(1999).Additionof
acupunctureandselfcareeducationinthetreatmentofpatientswithsevereangina
pectorismaybecostbeneficial:anopen,prospectivestudy.JAlternComplementMed
5:405413.
Thiswaslistedinthereferencesofanincludedpublicationbythesamefirstauthor,butdidnotappear
inanyoftheMEDLINEsearches,asithadbeenindexedunderacupuncturetherapy:
Ballegaard,S.,Borg,E.,Karpatschof,B.,Nyboe,J.,andJohannessen,A.(2004).Longtermeffects
of integrated rehabilitation in patients with advanced angina pectoris: a nonrandomized
comparativestudy.JAlternComplementMed10:777783.
Onewasexcluded:
Vickers,A.J.(1996). Canacupuncturehave specific effects on health? A systematicreviewof
acupunctureantiemesistrials.JRSocMed89:303311.
Thiswasreferredtoinanexcludedletter:
Hoo,J.J. (1997). Acupressure for hyperemesis gravidarum. Am J Obstet.Gynecol. 176:1395
1397.
Itwasfoundtobeindexedunderacupuncturetherapyanddidnotappearinanysearches,original
orthose carriedouton24th Augustasthekeywordsofthe publicationsincludedacupuncture.34
studieswerereviewed,sevenofwhichreferredtomanualacupressure,threewerebefore1990,three
were excluded from this evidence review and one was subsequently included from the MEDLINE
acupressure search of 24th August. (Belluomini,J., Litt,R.C., Lee,K.A., and Katz,M. (1994).
Acupressure for nausea and vomiting of pregnancy: a randomized, blinded study. Obstet Gynecol
84:245248.)

33

Appendix5Abstractscreeningform
Date:
Author:
Publicationdate:
RefMandatabase:
ID(fromdatabase):
Inclusioncriteria
Primaryresearch
Secondaryresearch
Systematicreview
Reviewofeffectiveness
Literaturereviewwithdescribedmethodology
Shiatsu
Acupressure

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Exclusioncriteria
Foreignlanguagepapers
Qualitative
Caseseries
Casereports
Greyliterature

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Inclusioncriteriapreferredstudydesignhierarchy
Randomisedcontrolledtrial(RCT)
Otheracceptabledesigns
Cohort
Case/Control
Beforeandafter
Costcomparison/effect/benefit/economics
Audit
Exclusioncriteria
UseofKoreanpoints/meridians
Plasters,devices,wristbands
Auricularacupressure

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

Yes/No
Yes/No
Yes/No

Comments
Includestudy

Yes/No

34

Appendix6Initialsearchresults
Pub/Medsearches:
ShiatsuANDnursing
Shiatsu
ShiatsuNOTacupressure

44results,2before1990leaving42forreview
235results,5before1990,41includedinabove,leaving189toreview
9resultsallincludedinaboveorbefore1990,leavingnonetoreview

OVIDsearch
269resultsafterduplicateswithindatabaseswereremoved(viaOVIDsearchengine)insearchresult
order
EBMreviews(inclallCochraneLibrary)
AMEDincludesShiatsuSocietyNews
BNI
CINAHL
EMBASE
MEDLINEinprocess&nonindexed

5
154
12
43
14
2

OVIDMEDLINE
PsycINFO
Total

34
5
269

Exclusions:
Priorto1990
Bookreviews,newspaperclips

19
13

Shiatsu Society News collated into a separate database for 110

Societytoreview
NaturalHealth,HeresHealthetc

includedwithabove

15

Acupuncture

Totallefttocomparewith3Pub/Medsearches

108

DuplicatesbetweenPub/Med&OVIDsearches

36

FinalOVIDsearchresultstobereviewed

72

TotalinitialexclusionsfromOVID

197

Othersearches
Therewere9newresultsfromthejournaldatabasessearchesasdetailedbelow:
ScienceDirect
176ofwhichwerenewresults
BlackwellSynergy
51 (only 4 of these referred to Shiatsu others referred to various
complementarytherapies)1ofwhichwasnew
IngentaSelect
2bothnew
WileyInterscience
0
35

AloancopyofonethesiswasorderedforreviewandtheZETOCsearch(seeAppendix15)couldnot
bedownloadedforreviewandincludedmultipleduplicatesandconferenceabstracts.
Followupsearches
AnumberofadditionalsearcheswerecarriedoutbetweenMarchandAugust2006toensurethatthe
mostrecentpublicationswerecaptured.Searchesincluded4additionalMEDLINEShiatsusearches
andasearchforacupressureinScienceDirectjournaldatabase.
AfterStage1and2exclusionshadbeencompleted,146publicationswereleftforfulltextscreening
andappraisal.
Asummary ofsearches, downloadedto ReferenceManagerdatabasesforreview,andexclusion
stagesisshownbelow:

ReferenceManagerDatabase

Code

ShiatsuandNursingMedlineFeb06
ShiatsuMedlineFeb06
ShiatsuMedline21.03.06newonly
ShiatsuMedline26.04.06newonly
ShiatsuMedline21.06.06newonly
ShiatsuMedline01.08.06newonly
ShiatsuOVID28.02.06/22.03.06newafterfirstexclusions
ShiatsuSocietyNews(OVID)asrequestedbyDB
Lee&Donesearchsystematicreview27.04.06
Shiatsufromjournaldatabases22.03.06newonly
AcupressureScienceDirect04.05.06
AcupressureScienceDirect27.06.06/02.08.06
TOTAL

SNM0206
SM10206
SM20306
SM30406
SM40606
SM50806
SO10306
SSN0806
SLD0406
SJD0306
SDA0506
SDA0606

Search Stage Stage Full text

results 1
2
to
new
screen
only
44
235
7
4
9
4
72
125
1
9
88
4
602

2
46

31
79

30
109
4
2
6
2
57
122
0
4
39
2
377

12
80
3
2
3
2
15
3
1
5
18
2
146

36

Appendix7Retrievedpublicationsforscreening
Ofthe146remainingpublications,106referredtoacupressureand40toShiatsu.Asacupressureand
Shiatsu use the same points, publications on acupressure were included. Further exclusions for
review at this stage included: adverse event reports, Shiatsu as part of multiple interventions,
treatment guidelines, and surveys, case report and series and qualitative studies. A number of
publicationsalthoughnotevidence,wereusedforbackgroundandhistoricalinformation.
Summariesofthescreeningprocessareshownbelow:
Firstscreeningnotallfulltextavailable

Database
SNM0206
SM10206
SM20306
SM30406
SM40606
SM50806
SO10306
SSN0806
SLD0406
SJD0306
SDA0506
SDA0606
Total

Background
To
Include Exclude (Bg)/
waiting for
screen (Inc)
(Exc)
fulltext
12
10
1
1
80
42
26
12
3
1
2
2
1
1
3
3
2
2
15
8
1
6
3
3
1
1
5
4
1
18
13
5
2
2
146
83
30
33

Shiatsu Acupressure
(S)
(A)
2
15

10
65
3
2
3
2

15
3
1
5
18
2
106

40

Secondscreeningallfulltextavailable
Database
SNM0206
SM10206
SM20306
SM30406
SM40606
SM50806
SO10306
SSN0806
SLD0406
SJD0306
SDA0506
SDA0606
Total

To
screen
12
80
3
2
3
2
15
3
1
5
18
2
146

Inc

Bg

Exc

SInc

AInc

10
26
1
1
2

1
18

1
36
2

2
1

8
25
1
1
2

1
1
1
9
3

1
1
1

3
4

44

31

1
5

SBg

ABg

SExc AExc

1
11

1
1
1
9
3

1
29
2

1
5

1
1
13
2
61

3
1

39

1
4

22

19

13

13
2
48

37

Appendix8CriticalAppraisalchecklist
Thefollowingformwasusedtoassessthequalityofeachstudyandwascompiledfrom
checklistsinGreenhalghT&DonaldA,EvidenceBasedHealthCareWorkbook,BMJ
Books2000andCentreforReviewsandDissemination
(http://www.york.ac.uk/inst/crd/report4.htm)
Sample

Samplesizepowered?
adequatesize?
Samplingrandom?
Howwereparticipantsrecruited?
Areresultsgeneralisable?
Group
Wereparticipantsrandomlyassignedtogroups?
assignment
Were groups homogenous for baseline variables and in which
variables?
Blinding
Werethefollowingblindedtowhichgrouptheywerein:
single/double?
Participants?
Caregivers?
Assessors?
Ifnot,wasdoubleblindingtechnicallynotpossible?
Wasaplacebotreatmentused?Weredetailsgiven?
Cointerventions Can the effects of acupressure/Shiatsu be isolated or were co
interventionsused?
Outcomes
Weretheoutcomesappropriate,validandreliable?clinicalarebest
Followup/attrition Wereallparticipantsaccountedfor?
rate
Wasfollowupover80%?
Wasintentiontotreatanalysisused?
Intervention
Interventiondescribed?
Valid&reliable?
Results
Arestatisticsclearandappropriate?
Patients paying Maybiasresults
fortreatment?
Finance/ethics

Howwasstudyfinanced?
Wasethicalapprovalgiven?

38

Appendix9Evidencetablesstudiesincluded
Shiatsu
Author,dateandtitle

Ballegaard,S.,Norrelund,S.,
andSmith,D.F.(1996).
Costbenefitofcombineduse
ofacupuncture,Shiatsuand
lifestyleadjustmentfor
treatmentofpatientswith
severeanginapectoris.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Followupcontrolled
trialwithnonequivalent
controlgroup(seeintervention
below)

Results

Theincidenceofdeathand
myocardialinfarctionwas21%
amongthepatients
undergoingCABG,15%
amongthepatients
Setting:Denmark
undergoingPTCAand7%
amongourpatients.No
Sample:Sixtynine
significantdifferencewas
consecutivepatientswith
foundconcerningpainrelief
severeanginapectoris
betweenthethreegroups.
Fortyninepatientswere
Invasivetreatmentwas
candidatesforcoronaryartery postponedin61%ofour
bypassgrafting(CABG),
patientsduetoclinical
whereasbypassgraftingwas
improvement,andtheannual
rejectedintheremaining20
numberofinhospitaldays
patients.
wasreducedby90%,bringing
aboutanestimatedeconomic
Healthissue:Anginapectoris savingof12,000US$for
eachofourpatients.Despite
Intervention:Patientswere
thefactthatthemeninthe
treatedwithacupuncture,
presentstudy,had
Shiatsuandlifestyle
significantlylesspositive
adjustments,andwere
expectationstowardsthe
followedfor2years.Shiatsu
outcomeofthetreatment,
wasself/spouseadministered whencomparedtothe
atpointCV17.Endpoint
women,therewasno
findings(incidenceofdeath+/ significantdifference
myocardialinfarctionandpain concerningtheeffect.
relief)withthoseofadifferent
study,alargeprospective,
randomizedtrialcomparing
CABGwithpercutaneous
transluminalcoronary
angioplasty(PTCA).

39

StudyConclusions

Commentsonquality

Thestudysuggeststhatthe
combinedtreatmentwith
acupuncture,Shiatsuand
lifestyleadjustmentmaybe
highlycosteffectivefor
patientswithadvancedangina
productsandmayreducethe
riskofdyingand/ormyocardial
infarctionmorethancoronary
bypasssurgeryandPTCA

Conveniencesampling,no
powercalculation
NoShiatsupractitioner
(self/spouseadministered).
Mainflawisuseoffindings
fromapreviousstudyasa
controlgroup,andthereisno
statisticalcomparisonof
differencesbetweenthe
groups.Also,56%of
participantswouldhavebeen
excludedfromoneofthe
controlgroups.Control
groupstudyisfromtheUSA.
Shiatsuisadditional
intervention,cointerventions
ofacupunctureandlifestyle
adjustment.
Goodtwoyearfollowup.
Focusoncostbenefitnot
efficacy.
Noblinding.

Author,dateandtitle

Brady,L.H.,Henry,K.,
Luth,J.F.,andCasper
Bruett,K.K.(2001).

Studymethodology,design,
setting,sample,condition
andintervention
Design:Quasiexperimental,
Pretestposttest,single
groupdesign

TheeffectsofShiatsuon
lowerbackpain.

Setting:Shiatsuclinicand
school(USA)
Sample:Convenience
sample.66
individuals/volunteers
complainingoflowerback
pain
Healthissue:Lowbackpain

Results

StudyConclusions

Commentsonquality

PainusingtheVASdecreased Bothpainandanxiety
after4treatments.P<0.001
decreasedsignificantlyover
AnxietymeasuredbyTrait
time.
AnxietyInventoryshowedno
significantdifferences.State
AnxietyInventoryshoweda
significantreductionP<.0001.

Volunteerpatients.

Demographicvariables
gender,age,genderof
therapist,lengthofhistorywith
lowerbackpain,and
medicationstakenforlower
backpaindidnotalterthe
significantresults.

Patientshadtopayfor
treatmentwhichmaycreate
biasbylimitingaccesstoa
highersocioeconomicgroup.

Intervention:Random
assignmenttoShiatsu
massageprovidedby2
therapists.Eachindividual
measuredonstate/trait
anxietyandpainlevelbefore
andafter4Shiatsutreatments
(5060min)withinan8week
period.Eachsubjectcalled2
daysfollowingeachtreatment
andaskedtoquantifythelevel
ofpain.

40

Absenceofcontrolgroup.
Repeatedmeasures
(regressiontowardsthemean)
cancausecarryovereffects.

13patientshadpreviouslyhad
Shiatsubeforethestudy(itis
unclearwhethertheywere
beingtreatedatthetimethey
wererecruited).

Author,dateandtitle

Faull,K.(2005).
Apilotstudyofthe
comparativeeffectivenessof
twowaterbasedtreatments
forfibromyalgiasyndrome:
WatsuandAixmassage

Studymethodology,design,
setting,sample,condition
andintervention
Design:Twocondition,
repeatedmeasurewith
reverseorder
counterbalancingcomparative
study.
Setting:NewZealand

Results

StudyConclusions

Commentsonquality

Significantchange(p=0.01)in
treatmentandinteraction
effectswerefoundforWatsu
ontheSF36subscalesof
physicalfunction,bodilypain,
vitalityandsocialfunction,but
notforAixtreatment.

Watsuwassupportedasan
effectiveholisticintervention
comparedtoAixmassage.A
studywithalargersampleand
acontrolgroupisrequired
beforeitcanbeinferredthat
thechangeisduetothis
therapy

Pilotstudyforalargerstudyof
Watsu.

Sample:Seventeenrecruited,
thirteencompletedstudy,
femalesdiagnosedwithFMS
Healthissue:Fibromyalgia
syndrome(FMS)
Intervention:The
effectivenessofholistic
therapy(Watsu,WATer
ShiatSU)wascomparedtothe
waterbasedtherapy,Aix
massage.Twotreatment
blockseachoffoursessions
overtwoweeks.Participants
randomlyassignedtoreceive
eitherWatsuthenAixorvice
versa,witha3weekbreak
betweentreatmentblocks.
ShortForm36GeneralHealth
Survey(SF36)datawere
collectedatthestartand
completionoftreatment.Each
SF36subscalewastested
withatwoway,repeated
measureanalysisofvariance.

Volunteersamplingandvery
smallsamplesize(n=13).No
control,although
counterbalancedtoreduce
carryovereffectsofusing
repeatedmeasuresdesign.
However,ordereffectsmay
haveoccurredduetohigh
dropoutratefromWatsufirst
group(4outof8).

VariablesotherthanWatsu
mayhavecausedthe
significantresult.

41

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Iida,M.,Chiba,A.,Yoshida,Y., Design:Onegrouppretest
Thestronganxietygroup
Shimizu,K.,andKanda,K.
posttestquasiexperimental
showedsignificantdeclinein
(2000).
anxietyscoreafterintervention
Setting:GunmaHospital,
(p=0.09),indicatingslight
EffectsofShiatsumassageon Japan
relaxationeffects.Both
reliefofanxietyandsideeffect
groupshadbigexpectationfor
Sample:Ninepatients
symptomsofpatients
psychologicalrelaxation
receivingcancer
scheduledforcancer
effectsofmassage.Therewas
chemotherapy.
chemotherapyweregrouped
aslightreliefofphysical
intotwothestronganxiety
symptomsinbothgroupsbut
groupandtheweakanxiety
significanceisnotstated.In
group.
theweakanxietygroup,
Shiatsumassagesignificantly
Healthissue:Anxietyand
increasedREscore(p=0.01),
sideeffectsymptomsof
showingrelaxationeffects.
cancerchemotherapy.
Therewaslittlechangein
peripheralskintemperature.
Intervention:Therelaxation
effectsofShiatsumassagefor
thesetwogroupsofpatients
werecomparedusingstate
traitanxietyinventory(STAI),
physicalandpsychological
reliefofsideeffectsymptoms
scale,relaxation(RE)scale
andskintemperature.Shiatsu
giventohandsandfeetfor30
minutesmorningandnightfor
4days.Scorescompared
beforeandaftertreatment
usingttest.

42

StudyConclusions

Commentsonquality

ResultsprovedthatShiatsu
massagemayrelieveanxiety.
SuggestedthatShiatsu
massageisusedinadditionto
attentivelisteningtorelieve
anxietyintheclinicalsettings

Verysmallstudy(n=9).In
additionthiswasanalysedin
twogroups,givingn=4and
n=5,givinginconclusive
evidence.Attestona
samplethissmallwillonly
detectdifferencesthatare
hugeandmaybethereason
whyfeweffectswereseen.
Samplewere89%male.
Nocontrolgroup.
Unclearwhygroupwas
dividedintoweakandstrong
anxiety.
Nosamplingprocessgiven.

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Apilotauditwith
Ingram,J.,Domagala,C.,and
Chisquaredandttestswere
Yates,S.(2005).
controlgroup
used.Posttermwomenwho
usedShiatsuwere
TheeffectsofShiatsuonpost Setting:St.Michael's
significantlymorelikelyto
termpregnancy.
Hospital,Bristol
labourspontaneouslythan
Sample:142women,who
thosewhodidnot(p=0.038).
attendedaconsultantclinic
Ofthosewhohadused
hospitalappointmentat40
Shiatsu,17%morewentinto
weeksgestation.66werein
spontaneouslabourcompared
interventiongroup(when
tothosewhowerenottaught
midwifewhohadlearned
Shiatsu
Shiatsuwasonduty)and77
comparisonwomenwere
Shiatsugrouphada
thosewhoattendedsimilar
significantlylongerlabour
clinicswhenthemidwifewas
(p=0.03),althoughanalgesia
notonduty.
usewassimilar.
Healthissue:Postterm
pregnancy
However,ifemergency
caesareansectionsare
Intervention.Womenwere
excluded,spontaneouslabour
taughtthemassage
occursevenmoreinShiatsu
techniquesbyonemidwife,
group(22%p=0.012)and
whohadcompletedthe
labourlengthisnot
Shiatsucourse. Thumb
significantlydifferent(p=0.19).
pressurewasappliedtopoints
GB21,LI4,Sp6.Womenused Maternalage,gestationand
thetechniquesasoftenasfelt babyweightwerenot
comfortable.Somepartners
statisticallysignificantbetween
werealsotaughttechniques.
groups.
Breathingtechniquesand
exercisesonallfourswere
30(45%)womencompleted
alsotaught.
auditquestionnaire87%of
Theauditextractedoutcome
thosetaughtusedShiatsuand
informationfromtheStork
80%foundthetechniques
hospitaldatabaseincluding
useful.
induction,typeofdelivery,
lengthoflabourandanalgesia
usedandaanaudit
questionnairewassentout.

43

StudyConclusions

Commentsonquality

Raisesthehypothesisthat
specificShiatsutechniqueson
posttermwomenbymidwives
candecreasethenumberof
labourswhichneedtobe
inducedpharmacologically.

Groupassignmentnotrandom
(dependsonwhichmidwife
wasonduty),althoughno
significantdifferences
betweengroupsinmaternal
age,parityordeliverydetails.
Relativelysmallsamplesize.
SelfadministeredShiatsu
(taughtbymidwifewhowas
taughtbystudyresearcher).
AlsodirecteffectsofShiatsu
unclearasnocontroloverhow
often/howmuchpressurewas
used.
Preliminaryaudit.
Cointerventionofbreathing
techniquesandexercises.

Acupressure
Author,dateandtitle

Agarwal,A.,Ranjan,R.,
Dhiraaj,S.,Lakra,A.,
Kumar,M.,andSingh,U.
(2005).
Acupressureforpreventionof
preoperativeanxiety:a
prospective,randomised,
placebocontrolledstudy.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Prospective
RandomisedControlledTrial
Setting:Hospital,possibly
India.
Sample:Seventysixadults,
ASAgradeIandII,
undergoingelectivesurgery.
Group1(control)received
acupressureatan
inappropriatesiteandgroup2
(acupressure)received
acupressureatextra1point.
Healthissue:Preoperative
anxiety(characterisedby
increasedanalgesicand
anaestheticrequirement,
postoperativepainand
prolongedhospitalstay)
Intervention:Onmorningof
surgery,followingarrivalin
preoperativearea,patients
relaxedfor15minsthen
acupressurewasappliedfor
10minandpatientswere
observedforanother30min..
Theeffectsofacupressureon
preoperativeanxietyand
bispectralindex(BIS)values
(thisisameasureofthelevel
ofconsciousnessduring
anaesthesia)were
investigated.
Anxietywasrecordedona
visualstressscale(VSS)at
thestartofthestudyand
thereafterat10and40min.
BISwasrecordedat0,2,5,
10,12,15,30and40min.

Results

StudyConclusions

Commentsonquality

Anxiety(measuredbyVSS)
decreasedinbothgroups
followingpressureapplication
for10min:medianVSS
(interquartilerange)were5(1)
vs.8(1)intheacupressure
and7(0)vs.8(1)inthe
controlgroups(p<0.001).
However,after30minsboth
groupsreturnedtobaseline
(p>0.05).Thedecreasein
anxietyafter10minswas
greaterintheextra1point
group(p<0.05).BISvalues
weresignificantlylowerduring
acupressureapplicationthan
baselineorafterreleaseof
treatmentinbothgroups
(p<0.05).Duringacupressure,
BISvalueswerelowerfor
extra1pointthancontrol
group(p<0.05).

Acupressureiseffectivein
decreasingbothpreoperative
anxietyandBIS.Theeffects
arenotsustained30min
followingreleaseof
acupressure.Furtherstudies
areneededtoelucidatethe
durationforwhich
acupressureiseffective.

Randomisedgroupallocation,
althoughnotclearabout
samplingprocedure.
Powercalculationperformed
forsamplesize.
Controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographics).
Placebousedbutdetailsof
inappropriatesiteforsham
acupressurenotgiven.May
havehadeffect.Reductionin
anxietyandBISincontrol
groupmaybedueto
massage/attentioneffects,
althoughextra1groupdid
showagreaterreduction.
Singleblinded(patient).
Usedinsteadofusualcare
(sedativepremedication)not
asadjunct.

44

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Design:Nonrandomised
Ballegaard,S.,Borg,E.,
Karpatschof,B.,Nyboe,J.,and comparativestudy.(reported
Johannessen,A.(2004).
byauthorsasaqualitycontrol
review)
Longtermeffectsofintegrated Setting:Thetreatmentwas
carriedoutasanambulatory
rehabilitationinpatientswith
treatmentinaprivateclinic,
advancedanginapectoris:a
Denmark
nonrandomizedcomparative
Sample:168patientswith
study.
anginapectoris,ofwhom103
werecandidatesforinvasive
treatmentand65forwhom
thishadbeenrejected.
Comparisongroups:1)
GeneralDanishpopulation
matchedforage,gender,and
observationperiod,medical
andinvasivetreatments,2)
NewYorkclinicaldatabase
and3)Americanstudy
Schofieldetal1999.
Healthissue:Anginapectoris
Intervention:12sessions
over34weeksofIntegrated
rehabilitation(IR)
acupuncture,aselfcare
programincluding
acupressure,Chinesehealth
philosophy,stress
managementtechniques,and
lifestyleadjustments.
Acupressureself/spouse
administeredatCV17and
UB14and15.
OUTCOMEMEASURES:
Followupuntildeathor
surgery.Datacollectedfrom
patientdatabaseondeathrate
fromanycause,theneedfor

Results

StudyConclusions

Commentsonquality

The3yearaccumulatedrisk
ofdeathwas2.0%(95%
confidencelimits:0.0%4.7%)
forthe103candidatesfor
invasivetreatment,6.4%for
thegeneralDanishpopulation,
5.4%(4.7%6.1%),and8.4%
(7.7%9.1%)forpatientswho
underwentpercutaneous
transluminalballoon
angioplastyandcoronary
arterybypassgrafting,
respectively,inNewYork.For
the65inoperablepatientsthe
riskofdeathduetoheart
diseasewas7.7%(3.9%
11.5%),comparedto16%
(10%34%)and25%(18%
36%)forAmericanpatients,
whoweretreatedwithlaser
revascularizationor
medication,respectively.
Accumulatedrisk(of
operation,MI,death)improved
significantlyovertime(pfor
trend<0.05)

Integratedrehabilitationwas
foundtobecosteffective,and
addedyearstothelivesof
patientswithsevereangina
pectoris.Theresultsinvite
furthertestinginarandomized
trial

Goodsize(168)but
consecutivenotrandom
sample.

Ofthe103candidatesfor
invasivetreatment,only19
(18%)stillrequiredsurgery.
Costsavingsover3years
wereUS$36,000andUS
$22,000forsurgicaland
nonsurgicalpatients,
respectively.Thesewere
mainlyachievedbythe
reductionintheuseof
invasivetreatmentanda95%

45

Acupressuretreatmentwas
notstandardised,aspartofIR
program,forwhichthemain
philosophybehindthe
treatmentisselfcare.
Thereforeapragmaticdesign.
Resultscannotbeconclusive
ascomparedtonon
equivalentgroups.
Improvementinaccumulated
riskincreasedwithtimesince
onsetoftreatment,indicating
independenttreatmenteffect.
Longfollowupperiod.
CostsbasedonanAmerican
studybutstudyperformedin
Denmark.
Patientsseemtobepayingfor
treatment,althoughtheygive
arefthatthisdoesnotaffect
prognosis.Socialselection
biasnotpresentassampledid
notdifferfromother
Scandinavianheartpatients.
Unclearwhofinancedthe
study(KIDfoundation).
Treatmentnotblinded,but
theysaybiasisavoidedas

invasivetreatment,andhealth reductionininhospitaldays.
careexpenses.

46

patientshadverylittlecontact
withdoctor.

Author,dateandtitle

Ballegaard,S.,
Johannessen,A.,
Karpatschof,B.,andNyboe,J.
(1999).

Studymethodology,design,
setting,sample,condition
andintervention
Design:Anopenprospective
studyandcostbenefit
analysis
Setting:outpatientbasisina
privateresearchclinic,
Denmark?
Sample: 105patientswith
anginapectoris,73candidates
forinvasivetreatment,and32
forwhomthiswasrejected.
Healthissue:Anginapectoris
Intervention:Acupuncture
andselfcareeducation
includingacupressureat
CV17,UB14,UB15was
addedtothepharmaceutical
treatment.OUTCOME
MEASURES:Healthcare
expenses,asatisfactory
medicalstatusdefinedasNew
YorkHeartAssociation
(NYHA)classification0I
and/ornouseofantianginal
medication,andriskmeasured
ascardiacdeathormyocardial
infarction.

Results

StudyConclusions

Commentsonquality

Theestimatedcostsavings
during5yearswere$32,000
(U.S.)perpatient,mainlydue
toa90%reductionin
hospitalizationand70%
reductioninneededsurgery.
Comparedto8%before
treatment,53%ofthepatients
achievedalifewithout
limitations(NYHA0I)1year
aftertreatment,asdid69%
after5years.Noincreased
riskformyocardialinfarctionor
cardiacdeathwasobserved.

Theadditionofacupuncture
andselfcareeducationwas
foundtobecostbeneficialin
patientswithadvancedangina
pectoris.Theresultsinvite
furthertestinginarandomized
controlledtrial

Mainlyacostanalysis,study
designmayhavevariedifthis
wasprimarilyanefficacy
study.
Resultscannotbeconclusive
ascomparedtonon
equivalentgroups.
Volunteer,consecutive
sample.
Pragmaticdesign.Effectsof
acupressurecannotbe
isolatedfromcointerventions
ofacupunctureandlifestyle
modification,allbasedona
theoryofselfcare.
Longfollowupperiod.

47

Author,dateandtitle

Belluomini,J.,Litt,R.C.,
Lee,K.A.,andKatz,M.(1994).
Acupressurefornauseaand
vomitingofpregnancy:a
randomized,blindedstudy

Studymethodology,design,
setting,sample,condition
andintervention
Design:RCT
Setting:Physicianand
midwifepractices,California?
Sample:90pregnantwomen
withnauseawith/without
vomiting,gestationof12
weeksorunder
Healthissue:Nauseaand
vomitingofpregnancy.
Intervention:womenwere
randomizedtooneoftwo
acupressuregroups:one
treatmentgroupusingan
acupressurepoint(PC6)and
onesham(nonacupoint)
controlgroupusingaplacebo
point.Subjectswereblindto
thegroupassignment.Each
eveningfor10consecutive
days,thesubjectscompleted
anassessmentscale(Rhodes
inventoryofN&V)describing
theseverityandfrequencyof
symptomsthatoccurred.Data
fromthefirst3dayswere
usedaspretreatmentscores.
Beginningonthemorningof
thefourthday,eachsubject
usedacupressureather
assignedpointfor10minutes
fourtimesaday.Datafrom
day4werediscardedtoallow
24hoursforthetreatmentto
takeeffect.Datafromdays5
7wereusedtomeasure
treatmenteffect.

Results

StudyConclusions

Commentsonquality

Sixtywomencompletedthe
study.Therewereno
differencesbetweengroupsin
attrition,parity,fetalnumber,
maternalage,gestationalage
atentry,orpretreatment
nauseaandemesisscores.
Analysisofvarianceindicated
thatbothgroupsimproved
significantlyovertime,butthat
nauseaimprovedsignificantly
moreinthetreatmentgroup
thanintheshamcontrolgroup
(F1,58=10.4,P=.0021).
Therewerenodifferencesin
theseverityorfrequencyof
emesisbetweenthegroups.
Therewasasignificant
positivecorrelation(r=0.261,
P=.044)betweenmaternal
ageandseverityofnausea.

Ourresultsindicatethat
acupressureatthePC6
anatomicalsiteiseffectivein
reducingsymptomsofnausea
butnotfrequencyofvomiting
inpregnantwomen

Thesamplewasselected
fromreferredpatients,details
ofthisarenotclear.
Only60outof90completed
thestudyandintentiontotreat
analysiswasnotused.
Dropoutwashoweversimilar
betweenstudygroups.
Randomisedblockdesignbut
criteriaforblockingnotgiven
(couldbegestationalage?).
Groupshomogenousfor
pregnancycharacteristicsand
pretestscores.
Maternalagewasassociated
withN&Vscore.
Controlledforgestationalage
andplaceboeffect.
Singleblind(patient)
Selfadministeredacupressure
andreliabilitynotchecked.
Outcomemeasureisreliable
andvalid.

48

Author,dateandtitle

Chen,H.M.andChen,C.H.
(2004).
Effectsofacupressureatthe
Sanyinjiaopointonprimary
dysmenorrhoea.

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:RCT
AcupressureatSanyinjiao
duringtheinitialsession
Setting:MedicalTechnology reducedthepainandanxiety
College,Taiwan
typicalofdysmenorrhoeabut
notdistress.Nopvalue.In
Sample:69female
theselftreatmentfollowup
adolescentstudents(aged17 session,acupressureat
19).
Sanyinjiaosignificantly
reducedmenstrualpain.Nop
Healthissue:symptomsof
valuebutnotanxietyor
primarydysmenorrhoea
distress.Thirtyone(87%)of
amongadolescentgirls.
the35experimental
Intervention:The
participantsreportedthat
experimentalgroup(n=35)
acupressurewasmorethan
receivedacupressureat
moderatelyhelpful,and33
Sanyinjiao(Sp6)(abovethe
(94%)weresatisfiedwith
ankle)whilethecontrolgroup acupressureintermsofits
(n=34)restedfor20min,
providingpainreliefand
withoutreceivingacupressure. psychologicalsupportduring
Fiftyparticipants(30
dysmenorrhoea.
experimental,20control)
completedthe46week
Interactionsweresignificant
followupsession(self
forinitialpain(p=0.04),initial
administeredacupressure).
anxiety(p<0.001)andself
Fiveinstrumentswereusedto treatmentfollowupain
collectpretestandposttest
(p=0.003).
dataateachsession:(1)
VisualAnalogueScalefor
pain(2)theShortForm
McGillPainQuestionnaire(3)
theMenstrualDistress
Questionnaire(4)theVisual
AnalogueScaleforanxiety
and,fortheexperimental
grouponly,(5)the
AcupressureSelfAssessment
Form.Datawereanalysed
usingrepeatedmeasurestwo
wayANOVA.

49

StudyConclusions

Commentsonquality

Thefindingssuggestthat
acupressureatSanyinjiaocan
beaneffective,costfree
interventionforreducingpain
andanxietyduring
dysmenorrhoea,andwe
recommenditsuseforself
careofprimary
dysmenorrhoea

RCTalthoughnotblindedso
maycreatebias.Alsono
shamtreatmentsoplacebo
effectmaybepresent.
Followuprateof72%.
Volunteersamplewithrandom
groupassignment.
Samplesizecalculatedusing
poweranalysisfrompilot
studyfindings.
Dysmenorrhoeawasself
reportedwhichcouldbe
subjecttobias,includingrecall
bias,althoughtoolswere
testedforreliability.
Theacupressureprocedure
wasvalidated.
Limitedgeneralisability(1719
yearolds)
Abstractsayschisquareandt
testwereperformedbutthese
arenotevidentintext.

Author,dateandtitle

Chen,H.M.,Chang,F.Y.,and
Hsu,C.T.(2005).
Effectofacupressureon
nausea,vomiting,anxietyand
painamongpostcaesarean
sectionwomeninTaiwan.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Quasiexperimental
Setting:Twohospitalsin
Taiwan
Sample:conveniencesample.
104eligiblefemalesawaiting
caesareansectionandhaving
hadspinalanaesthesia
HealthIssue:Nausea,
vomiting,anxietyandpain
Intervention:Participants
assignedtoexperimental
groupreceivedacupressure,
andthoseassignedtothe
controlgroupreceivedonly
postoperativenursing
instruction.Theexperimental
groupreceivedthree
acupressuretreatments.
Pressurewasappliedto
Neigan(P6)fortotalof20mins
oneacharm.Thefirst
treatmentwasperformedthe
nightbeforeCS,thesecond
wasperformed24hoursafter
CS,andthethirdwas
performed810hoursafter
CS.Controlgroupreceived
standardnursingpost
operativeinstruction.The
measuresincludedthe
RhodesIndexofNauseaand
Vomiting,VisualAnalogScale
forAnxiety,StateTraitAnxiety
Inventory,VisualAnalogScale
forPain,andphysiologic
indices.Statisticalmethods
includedpercentages,mean
withstandarddeviation,ttest,
repeatedmeasureANOVA.

Results

StudyConclusions

Commentsonquality

Theuseofacupressure
reducedtheincidenceof
nausea,vomitingorretching
from69.3%to53.9%,
comparedwithcontrolgroup
(95%confidenceinterval=
0.111.65p=0.040)24
hoursafterCS(although
nauseaandvomitingwerenot
independentlysignificant)and
from36.2%to15.4%
comparedwithcontrolgroup
(95%confidenceinterval=
0.590.02p=0.024)810
hoursafterCS(nausea,
vomitingandretchingall
significant).

Theexperimentalgrouphad
significantlyloweranxietyand
painperceptionofcaesarean
experiencesthanthecontrol
group.Significantdifferences
werefoundinallphysiologic
indicesbetweenthetwo
groups.Theutilizationof
acupressuretreatmentto
promotethecomfortofwomen
duringcaesareandeliverywas
stronglyrecommended

Surgerydurationandtypeand
numberofproceduresnot
takenintoconsideration.

Experimentalgroupshowed
anincreasingreduction
comparedwithcontrolsin
anxietyandpainoverall
therapeutictimesforall
outcomemeasures.State
AnxietyInventoryp=0.000.
VASforanxiety(p=0000)VAS
forpain(P=0.001)
Significantdifferencebetween
experimentalandcontrol
groupforRespirationp=0.000,
Pulsep=0.004,systolic
p=0.001,diastolicblood
pressurep=0.006
ANOVAshowedacorrelation
betweentimeandintervention
effects.

50

Conveniencesample.
Sizeok(n=104).
Controlledstudybutgroup
assignmentwasnotrandom
(first52recruitedwerein
controlgroup).However
groupswerehomogeneous
(p>0.05).
Acupressureproceduretightly
controlledtobethesame
eachtime.
Interactioneffectstestedfor.

Author,dateandtitle

Chen,L.L.,Hsu,S.F.,
Wang,M.H.,Chen,C.L.,
Lin,Y.D.,andLai,J.S.(2003).

Studymethodology,design,
setting,sample,condition
andintervention
Design:Randomised
controlledtrial
Setting:MidTaiwanteaching
hospital

Useofacupressuretoimprove
Sample:41patients
gastrointestinalmotilityin
womenaftertransabdominal undergoingTransabdominal
hysterectomy(TAH)without
hysterectomy.
neoplasm

Results

StudyConclusions

Commentsonquality

Acupressureofthesethree
meridianpointssignificantly(p
<0.05)increasedGImotilityin
theexperimentalgroup,but
therewaslittlechangeinthe
controlgroup(p>0.05).
Experimentalgroupalso
showedhigherselfawareness
ofGImotilityafteracupressure
thancontrolgroup(p<0.05).

Ourconclusionsarethatnon
invasiveacupressureofthese
meridianpointscan
significantlyimproveGI
motilityandcanbe
incorporatedintothetechnical
curriculumandclinical
educationprogramofnursing
schools.Patientsandtheir
familymemberscanbetaught
tocontinuethisprocedureat
hometoenhanceGImotilityin
patientswhohaveundergone
TAH

Smallsample,butrandom
groupassignment.Sampling
notgiven,presumably
convenience.

Healthissue:Gastrointestinal
(GI)motilityinwomenafter
Experimentalgrouphad
(TAH).
higherdegreeofsatisfaction
thancontrol(p<0.001).
Intervention:Patientswere
randomlyassignedintotwo
Anecdotally,14patientsfrom
groups.Theexperimental
experimentalgroupreported
group(n=21)received
increaseinGImotilityand
acupressurefor3minutesat
passingofgascomparedto
eachofthreemeridianpoints: noneincontrolgroup.
Neiguan(PC6),Zusanli(ST
36)andSanyinjiao(SP6).
Thecontrolgroup(n=20)
received3minutesof
acupressureonshampoints.
Acupressurewasperformed
twiceaday,foratleastthree
days.Aquestionnairewas
usedtodeterminepatients'
satisfactionpriortoandafter
afternoonacupressure.GI
contractionsweremeasured
withamultifunctional
stethoscopebeforeandafter
acupressure.

51

RCTdesigncontrolsfor
placeboeffect,Hawthorne
effectselectionbiasetc.May
besubjecttoresearcherbias
althoughmeasuresinplaceto
reducethisrisk.
Controlledforalargenumber
ofextraneousvariables,which
wereidentifiedfromprevious
research.Groupswere
homogenousinall:
demographics,bowel
movements,GIhistory,
surgeryhistory,durationof
surgery,bloodloss,
analgesics,pain,postsurgical
activities,leavingthebedand
foodintakepatterns.
Singleblind(usedsham
acupunctureonnonmeridian
points)socanassess
meridianeffects.
3measuresofreliabilityfor
procedure/measurements,
includingverificationfrom
specialists.

Author,dateandtitle

Chen,M.L.,Lin,L.C.,Wu,S.C.,
andLin,J.G.(1999).
Theeffectivenessof
acupressureinimprovingthe
qualityofsleepof
institutionalizedresidents

Studymethodology,design,
setting,sample,condition
andintervention
Design:Arandomizedblock
experimentaldesign
Setting:Publicassistance
facilityforelderlyresidents,
Taiwan.
Sample:246elderlyresidents
withsleepdisturbancesas
screenedforusingthe
PittsburghSleepQualityIndex
(PSQI)questionnaire.84
participantseligibletotake
part.
Healthissue:disturbedsleep
inelderlypeople
Intervention:Bymatchingthe
effectsofhypertension,
hypnosis,naps,andexercise,
subjectswererandomly
assignedtoanacupressure
group,ashamacupressure
group,andacontrolgroup(28
subjectseach).Thesame
massageroutinewasusedin
theacupressuregroupandthe
shamacupressuregroup,
whereasonlyconversation
wasemployedinthecontrol
group.Acupressuregroup
hadpressureappliedat5
points(pointsbaihui

Results

StudyConclusions

Commentsonquality

Thereweresignificant
differencesinPSQIsubscale
scoresofthequality,latency,
duration,efficiencyandglobal
PSQIscores(allp<0.001)
amongsubjectsinthethree
groupsbeforeandafter
interventionsandthe
improvementswereall
significantlygreaterin
acupressuregroupthanother
two(Scheffesposthoc
comparison).Therewasalso
asignificantimprovementin
disturbancesofsleepforall
groups(p<0.05)butthisdid
notdifferbetweengroups.

Thisstudyconfirmedthe
effectivenessofacupressure
inimprovingthequalityof
sleepofelderlypeopleand
offeredanonpharmacological
therapymethodforsleep
disturbedelderlypeople

ThreearmedRCTControl
grouphadconversationto
controlforplaceboeffectand
shampointsenable
identificationofmeridian
effects.Shamgroupshowed
someimprovementwhichmay
beduetoeffectsofmassage,
althoughacupressuregroup
showedgreatest
improvements.

(GV20),fengchi(GB20),
anmian(BL18)and
shenmen(Ht7)Shampoints

ANCOVAshowedthata
greaterfrequencyofnocturnal
awakeninggaveagreater
reduction.

Controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographicsage,gender,
linvingconditions,druguse,
chronicdisease,timeat
facility,naps,exercise,timein
bed,milkteaandcoffee
consumption,smoking,sleep
indices).

Qualitativedatashowed
acupressuregroupweremore
likelytoexperienceincreased
bodycomfortandselfreported
sleepqualitythanshamgroup.

Singleblind.PIadministered
treatmentandcollecteddata
whichmayintroducebias
(subjectswerereluctanttotalk
toastranger),including

were1cm3cunfromreal
points.Acupressure
performedfor15minsaday,
4hoursbeforebedtime,
MondaytoFridayfor3weeks,
bythePrincipalInvestigator.

Dailysleepstatusrecords
showedallgroupsimprovedin
timetofallasleep,hoursof
bedtimeandfrequencyof
nocturnalawakening(p<0.01).
Frequenciesofnocturnal
awakeningandnightwakeful
timeweresignificantly
reducedintheacupressure
groupcomparedtotheother
twogroups.

52

Samplingwassystematic
randomandorderofsubjects
randomlydecided.Groups
randomlyassignedonce
matchedforvariousfactors
(blockdesign).Thisgives
morepowerfultreatment
effectsbutonlyiffactorsare
true,i.e.blocksare
homogenous.Nojustification
forchoiceoffactorsgiven.

DatacollectedusingPSQIin
sleepqualitythanshamgroup.
first(baseline)andfifthweek.
Duringinterventioninformation
onlastnocturnalsleep(LNS)
wasalsocollected.

toastranger),including
Hawthorneeffectand
Researcherbias.
Only65.6%followup.
Internalvalidityofprocedure
extensivelycontrolledbyinter
raterreliabilityandexpert
validation.
Limitedgeneralisabilityas
meanage79years,and
residentshadtohavelow
incomeandhavenoson.
Datasubjecttorecallbias.

53

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:experimentalpretest Theresultsindicatethat
Cho,Y.C.andTsay,S.L.
(2004).
andposttestdesign
subjectsexperienceda
moderateleveloffatigue.
Nearly65%ofhemodialysis
Theeffectofacupressurewith Setting:twohemodialysis
clinicsinmajorhospitalsin
patientshadadepressed
massageonfatigueand
southernTaiwan.
mood.Ttestsshoweda
depressioninpatientswith
significantreductioninfatigue
endstagerenaldisease.
Sample:Sixtytwopatients
(p<0.001)anddepression
withendstagerenaldisease
(p=0.03)inexperimental
(ESRD)receiving
groupbutnotincontrol,
hemodialysistreatment.
confirmedbyANCOVAresults
indicatedthatfatigue
Healthissue:Fatigueand
(F((1.54))=9.05,p=.004)and
depressivemoodexperienced depression(F((1.54))=4.20,p
bypatientswithendstage
=.045)amongpatientsinthe
renaldisease.
acupressuregroupshowed
significantlygreater
Intervention:Patientsinthe
improvementthanpatientsin
acupressuregroupreceived
thecontrolgroup.
acupointmassagefor12
minutesperday,threedays
perweek,forfourweeks.
Subjectsinthecontrolgroup
onlyreceivedroutineunitcare.
Themeasuresincludedthe
RevisedPiperFatigueScale,
andBeck'sDepression
Inventory.Descriptive
statistics,chi2tests,ttestand
analysesofcovariancewere
usedfordataanalysis.

54

StudyConclusions

Commentsonquality

Acupressuretherapycould
effectivelyimproveESRD
patientsperceivedfatigueand
depression,whichmight
provideaninterventional
modelfornursestakingcare
ofESRDpatients

Controlled(comparedto
routinecare)butnosham
treatment.
Samplesizepowercalculation
performed.Convenience
samplebutrandomgroup
assignment.
Cointerventionofmassage,
althoughthiswasonlyfor3
outof15minsoftreatment.
UsedTCMtheorytoselect
pointsandgivereasoningfor
effectiveness.Treatment
clearlydefinedandreliable
Controlandintervention
groupsarealmost
homogenous(nosignificant
differencesindemographics
exceptage).
ANCOVAusedwhichcontrols
fordifferencesinpretest
scoresandage.
Extraattention/interactionwith
experimentalgroupmayhave
affectedmentalstate(placebo
effectnottestedfor)

Author,dateandtitle

Chung,U.L.,Hung,L.C.,
Kuo,S.C.,andHuang,C.L.
(2003).
EffectsofLI4andBL67
acupressureonlabourpain
anduterinecontractionsinthe
firststageoflabour.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Experimentalstudy
withapretestandposttest
controlgroup
Setting:Notclear,maybe
TaipeiNationalCollegeof
NursingHospital

Results

StudyConclusions

Commentsonquality

Findingsindicatedthatthere
wasasignificantdifferencein
decreasedlabourpainduring
theactivephaseofthefirst
stageoflabouramongthe
threegroups(p=0.041),but
notduringlatentand
transitionalphases.

Resultsofthestudyconfirmed
theeffectofLI4andBL67
acupressureinlessening
labourpainduringtheactive
phaseofthefirststageof
labour.Therewerenoverified
effectsonuterinecontractions

Randomisedcontrolled
threearmedtrial.

Sample:127parturient
womenwererandomly
assignedtothreegroups.

Wilcoxonshowedno
significantdifferencesbetween
acupressureandeffleurage
Healthissue:Labourpainand groupsoreffleurageand
uterinecontractionsduringthe controlgroups,butdidshow
firststageoflabour.
differencebetween
acupressureandcontrol
Intervention:Eachgroup
groups(p=0.017)
receivedonlyoneofthe
followingtreatments,LI4and
Therewasnosignificant
BL67acupressure,lightskin
differenceineffectivenessof
stroking,orno
uterinecontractionsduringthe
treatment/conversationonly.
firststageoflaboramongthe
DatacollectedfromtheVAS
threegroups.
andexternalfetalmonitoring
stripswereusedforanalysis.
Durationoflabourwasshorter
inacupressuregroup
comparedtocontrol(p=0.019)
butnotcomparedtoeffleurage
group.
Qualitativedatashowedone
thirdofwomeninacupressure
grouphadpositivefeeling
towardsthetreatmentandfelt
ithadreducedtheirpain.

55

Samplingandgroup
allocationwereboth
random.Controland
interventiongroupsare
homogenous(no
significantdifferencesin
demographics,
obstetricsorattrition).
Samplesizesmallfor
threegroups(n=42/43)
andvlowresponseat
transitionalphase(31
outof127)
Placeboeffectwas
testedforbyuseof3
groups,todetermineif
effectsofacupressure
arefrommeridian
effectsortactile
stimulation.
Outcomemeasure
(VAS)showntobevalid
andreliable.
Threecomprehensive
stepstoensurevalidity
andreliabilityof
acupressureprocedure.
23subjectsexcluded
dueto
medication/caesarean
reducedgeneralisbility

Author,dateandtitle

Dibble,S.L.,Chapman,J.,
Mack,K.A.,andShih,A.S.
(2000).
Acupressurefornausea:
resultsofapilotstudy.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Singlecycle,
randomizedclinicaltrial.
Setting:Outpatientoncology
clinicinamajorteaching
medicalcenterandaprivate
outpatientoncologypractice.
WesternUSA
Sample:Seventeenwomen
participatedinthestudy,
receivingCMFordoxorubicin
andsufferingnausea.

Results

StudyConclusions

Commentsonquality

Significantdifferencesexisted
betweenthetwogroupsin
regardtonauseaexperience(p
<0.01)andnauseaintensity(p
<0.04)duringthefirst10days
ofthechemotherapycycle,
withtheacupressuregroup
reportinglessintensityand
experienceofnausea.The
CPC(retrospectivemeasureof
nausea)reportedno
differences.

Fingeracupressuremay
decreasenauseaamong
womenundergoing
chemotherapyforbreast
cancer

Pilotstudy(mustbereplicated
priortoadvisingpatientsabout
theefficacyofacupressurefor
thetreatmentofnausea)

Healthissue:Nausea
experienceandintensityin
womenundergoing
chemotherapyforbreast
cancer

Smallsample(n=17)
Noplacebo(discussedas
unethical).Hawthorneeffect
maybepresentduetoextra
attentiongiventoacupressure
group(forteaching
acupressure)
Selfadministeredacupressure
Samplingnotdescribed
Stratifiedrandomgroup
assignment(basedonsetting
andtreatmentregimen).
Controlandinterventiongroups
arehomogenous(nosignificant
differencesindemographics,
cancercharacteristicsand
treatment).

Intervention:Finger
acupressurebilaterallyatP6
andST36,acupressurepoints
locatedontheforearmandby
theknee.Baselineandpost
studyquestionnairesplusa
dailylogofnauseaexperience
measuredbytheRhodes
inventoryofNausea,Vomiting,
andRetchingandnausea
intensitywereused.

Twoofthetoolswerenot
validated(twowere)
WomenrarelyusedST36as
theyreportedthatitwas
difficulttoaccess.

56

Author,dateandtitle

Dullenkopf,A.,Schmitz,A.,
Lamesic,G.,Weiss,M.,and
Lang,A.(2004).
Theinfluenceofacupressure
onthemonitoringofacoustic
evokedpotentialsin
unsedatedadultvolunteers.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Withinsubjects
(repeatedmeasures)design
withcounterbalancing
Setting:Notgiven
Sample:Fifteenunsedated
adultvolunteers
Healthissue:Stresslevelsin
unsedatedvolunteers
InterventionPatients
receivedpressureonthe
acupunctureExtra1point
(EP)andonacontrolpointfor
10minondifferentdays.A
lineAutogressiveIndex(AAI)
wasrecorded5minbefore,
during,and5minafterthe
interventions.Arandom
procedureselectedwhether
participantsreceivedEPor
controlpointpressurefirst.
Beforeandafterthe
procedures,thevolunteers
quantifiedtheirlevelofstress
bymeansofavisualanalog
stressscale(VSS0100).
Correspondingdata
(differencesbeforeandafter
interventionwithinsubjects,
beforetestvaluesandpre
postdifferencesbetween
subjects)werecomparedby
Wilcoxon'ssignedranktest
(Bonferronicorrection,P<
0.05)andsimpleregression
testedforcorrelationbetween
AAIvalueswithinsubjectson
differentdays.

Results

StudyConclusions

Commentsonquality

Dataaremedian(range).AAI
decreasedfrom73(4099)to
53(3394)after10minof
pressureonEP(P=0.0044).
Fiveminutesafterreleaseof
pressuretherewasno
differencecomparedwith
initialvalues.Therewasa
statisticallysignificant
differencebetweenVSS
beforeandafterpressureon
EP(36[767]to15[044]P=
0.0066),butnotoncontrol
point.

1)Therewasawiderangeof
AAIvaluesinawake
volunteers.

Verysmallsample(15).
Samplingprocedurenotgiven,
dontevenknowwherethey
camefrom!

Therewasnodifferencein
changesinAAIorVSS
betweenparticipantswhohad
EPfirstorcontrolfirst.There
wasnocorrelationbetween
AAIandVSSvaluesbefore
intervention.

2)AAIwasinfluencedby
acupressureperformedonthe Nocontrolgroup,patients
EPinunsedatedadult
actedastheirowncontrols.
volunteers.Thisindicatesthat Thiscancause
monitoringoflevelof
1) Dangerofattrition
consciousnessbychangein
2) Carryovereffects
EEGisnotsolelyinfluenced
(addressedby
byanaesthetics.
counterbalancingof
participantshaving
3)Acupressureonthispoint
eitherEPorcontrol
significantlyreducedstress
first)
levels.Acupressuredeserves
3) Practiseeffect
attentionforpotentially beinga
(especiallylikelyin
noninvasive,easytoapply
selfreportsuchas
alternativetoreducestress
VSS)
andanxiety.
Butactingasowncontrols
doescontrolforthe
heterogeneityinAAIwhich
wasobserved.AAI
measurementswere
consistentwithinsubjects.
Bonferronicorrectionwas
usedtocontrolforrepeated
measures,whichisgoodbut
cancausealossinprecision
offindings.

57

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:CochraneSystematic Eleventrials(N=1247)were
Ezzo,J.,Richardson,M.,
Vickers,A.,Allen,C.,Dibble,S., Review
pooled.Overall,acupuncture
Issell,B.,Lao,L.,Pearl,M.,
pointstimulationofall
Setting:
Ramirez,G.,Roscoe,J.,
methodscombinedreduced
Shen,J.,Shivnan,J.,
theincidenceofacute
Streitberger,K.,Treish,I.,and Sample:Randomisedtrialsof vomiting(RR=0.8295%
Zhang,G.(2006).
acupuncturepointstimulation confidenceinterval0.69to
forchemotherapyinduced
0.99P=0.04),butnotacute
ordelayednauseaseverity
Acupuncturepointstimulation nauseaorvomiting.
comparedtocontrol.By
forchemotherapyinduced
Healthissue:Chemotherapy modality,stimulationwith
nauseaorvomiting(review).
inducednauseaandvomiting needlesreducedproportionof
incancerpatients
acutevomiting(RR=0.74
95%confidenceinterval0.58
Intervention:Trialsusing
to0.94P=0.01),butnot
acupuncturepointstimulation acutenauseaseverity.
byanymethod(needles,
Electroacupuncturereduced
electricalstimulation,
theproportionofacute
magnets,oracupressure)was vomiting(RR=0.7695%
usedandchemotherapy
confidenceinterval0.60to
inducednauseaorvomiting,
0.97P=0.02),butmanual
orboth,wasassessed.
acupuncturedidnotdelayed
symptomsforacupuncture
Datawereprovidedby
werenotreported.
investigatorsoftheoriginal
Acupressurereducedmean
trialsandpooledusingafixed acutenauseaseverity(SMD=
effectmodel.Relativerisks
0.1995%confidenceinterval
werecalculatedon
0.37to0.01P=0.04)but
dichotomousdata.
notacutevomitingordelayed
Standardisedmean
symptoms.Noninvasive
differenceswerecalculatedfor electrostimulationshowedno
nauseaseverity.Weighted
benefitforanyoutcome.All
meandifferenceswere
trialsusedconcomitant
calculatedfornumberof
pharmacologicantiemetics,
emeticepisodes.
andall,except
electroacupuncturetrials,used
stateoftheartantiemetics.

58

StudyConclusions

Commentsonquality

Thisreviewcomplementsdata
onpostoperativenauseaand
vomitingsuggestingabiologic
effectofacupuncturepoint
stimulation.
Electroacupuncturehas
demonstratedbenefitfor
chemotherapyinducedacute
vomiting,butstudies
combiningelectroacupuncture
withstateoftheart
antiemeticsandinpatients
withrefractorysymptomsare
neededtodetermineclinical
relevance.Selfadministered
acupressureappearstohave
aprotectiveeffectforacute
nauseaandcanreadilybe
taughttopatientsthough
studiesdidnotinvolveplacebo
control.Noninvasive
electrostimulationappears
unlikelytohaveaclinically
relevantimpactwhenpatients
aregivenstateoftheart
pharmacologicantiemetic
therapy

Cochranereview.Only11
articlesincluded.
Allmethodologicaldetails
givenselectioncriteria,etc.
Datafromstudiespooled
usingIntentiontoTreat
analysisandoriginaldata
wherepossible.
Allacupressuretrialstogether,
includingthoseusingbands
whichwewouldhave
excluded.
Duplicatebiasavoided.
Languagebiasavoided.
Greyliteraturenotsearched.

Author,dateandtitle

Fassoulaki,A.,Paraskeva,A.,
Patris,K.,Pourgiezi,T.,and
Kostopanagiotou,G.(2003).
Pressureappliedontheextra
1acupuncturepointreduces
bispectralindex(BIS)values
andstressinvolunteers.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Crossoverstudy
Setting:Notgiven
Sample:25healthyvolunteers
Healthissue:None,healthy
volunteers.Toreduce
preoperativestress.
InterventionIneach
volunteer,pressurewas
appliedontheExtra1pointfor
10minandonacontrolpoint
for5minondifferentdaysand
inarandomizedmanner.The
BISvalue(thisisameasureof
thelevelofconsciousness
duringanaesthesia)was
recordedbeforeapplying
pressureontheExtra1point
(EP),duringpressure
applicationevery30sfor10
min,andafterpressure
release.Regardingthecontrol
point,BISvalueswere
recordedfor5insteadof10
minduringpressure
applicationbecause
acupressureonthatpointwas
associatedwithanunpleasant
feeling.Eachvolunteerwas
askedtoscorestressbefore
andafterpressureapplication
from0to10.
Friedmantestusedto
compareBISvalues.Wilcoxon
ranktocompareBISvaluesat
differenttimesandfor
EP/controlpointsandVSS
beforeandafter.Mann
WhitneytocompareEPwith
control.

Results

StudyConclusions

Commentsonquality

TheBISvalueswere
significantlyreduced2.5,5,
7.5,and10minduring
pressureapplicationonthe
extra1point(allP<0.001)
andreturnedtothebaseline
valuesafterpressurerelease.
Pressureapplicationonthe
controlpointdecreasedBIS
values(P<0.01andP<0.05
at2.5and5min,respectively).
However,thesevalueswere
maintainedcloseto90%and
weresignificantlyhigherthan
thoseobtainedduring
pressureontheextra1point
(P<0.001andP<0.001for
the2.5and5min
comparisons).Theverbal
sedationscorevalues
obtainedafterpressure
applicationontheextra1point
werealsolowerwhen
comparedwiththevalues
obtainedafterpressure
applicationonthecontrolpoint
(P<0.001).

Acupressureappliedfor10
minontheextra1point
significantlyreducedtheBIS
valuesandtheverbalstress
scorewhencomparedwith
acupressureappliedona
controlpoint

Sampling/followup/response
notgiven

59

Smallsamplebutapparently
poweredfromapilotstudy.
Notclearwhetherparticipants
wereblinded.
Controlpointonlyusedfor5
mins(EPfor10)whichisa
flawinthestudy.Thiswas
donebecausediscomfortwas
experiencedatcontrol.
However,BISdidreducein
EPafter5minsandnotin
control.
Participantsexcludedifthey
believedinTCM,couldbias
sampleandreduces
generalisable.
Nocontrolgroup,patients
actedastheirowncontrols.
Thiscancause
1) Dangerofattrition(testfor
impactofsequenceeffect
showednoeffect.)
2) Carryovereffects
(addressedby
counterbalancingof
participantshavingeither
EPorcontrolfirst)
3) Practiseeffect(especially
likelyinselfreportsuchas
VSS)
Butactingasowncontrols
doescontrolforheterogeneity.

Author,dateandtitle

Habek,D.,Barbir,A.,
Habek,J.C.,Janculiak,D.,and
BobicVukovic,M.(2004).
Successofacupunctureand
acupressureofthePc6
acupointinthetreatmentof
hyperemesisgravidarum.

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Prospective,placebo TheefficiencyoftheHG
controlledtrial
treatmentwithAPofthepoint
Pc6was90%,withAProfthe
Setting:ClinicalHospital
Pc663.6%,withplaceboAP
Osijek,Croatia.
12.5%,andwithplaceboAPr
0%.Theresultsshowedthat
Sample:36pregnantwomen APandAprcansignificantly
withHG.
reducetheoccuranceofHG
(p<0.0001andp<0.01
Healthissue:Pregnant
respectively)
womenwithhyperemesis
gravidarum(HG).
Intervention:Twomethodsof
acupuncturewereused:
bilateralmanualAPofthePc
6(Neiguan)acupoint(group1,
n=10)andbilateralAProfthe
Pc6acupoint(group2,n=
11)furthermore,superficial
intracutaneousplaceboAP
(group3,n=8)andplacebo
APr(group4,n=7)was
carriedout.APrwasself
administeredfor30mins
whenevertheyfeltnausea.
Outcomecriteriawas
disappearanceofnauseaand
vomitingsymptomsandno
needformedicationforHG,
assessedbypatientreport
andindependent
gynaecologistsevaluation.

StudyConclusions

Commentsonquality

Acupuncture(p<0.0001)and
acupressure(p<0.1)are
effective,nonpharmacologic
methodsforthetreatmentof
HG

Doubleblindtoreducebias.
Groupallocationwasrandom,
butthehomogeneityofgroups
wasnotstatisticallyassessed,
eventhoughdatawas
collectedandlookssimilar.
Smallsample(36)anddivided
intofourgroupssopowervery
lowingroups.Alsosampling
processnotgiven,andnot
statedhowwomenwithHG
wereidentified.
Nocontrolofreliabilityof
acupressureprocedure,
especiallyasselfadministered
therecouldbevariationin
procedure.
Outcomemeasuresnotgiven.
Resultsjustgivenas%
effective,measuringthe
disappearanceofsymptoms
assubjectivelyassessedby
patientandgynaecologist.
Also%shouldnotbeusedfor
suchsmallgroups.

60

Author,dateandtitle

Harris,R.E.,Jeter,J.,Chan,P.,
Higgins,P.,Kong,F.M.,
Fazel,R.,Bramson,C.,and
Gillespie,B.(2005).
Usingacupressuretomodify
alertnessintheclassroom:a
singleblinded,randomized,
crossovertrial.

Studymethodology,design,
setting,sample,condition
andintervention
Design:acrossover(two
treatmentsthreeperiods),
singleblinded,randomized
trial.

Results

Baselinecharacteristicsand
protocolcompliancewere
similarbetweenthetwo
sequences.Stimulation
acupressuretreatmentyielded
Setting:TheUniversityof
a0.56pointgreaterdifference
MichiganSchoolofPublic
inscoreontheSSS,
Health
correspondingtolessfatigue,
comparedtotherelaxation
Sample:39Students
acupressuretreatment(p=
attendingacourseinclinical
0.019).Dayofstudy(p=
researchdesignandstatistical 0.004)andhoursofovernight
analysisattheUniversityof
sleep(p=0.042)also
Michigan
significantlyaffectedthe
changeinSSSscores.
Healthissue:alertnessina
Incorporatingparticipants'
fulldayclassroomsetting
beliefsastowhichtreatment
theyreceiveddidnot
Intervention:Blindedsubjects significantlyaltertheobserved
wererandomizedtotwo
treatmenteffect(althoughit
acupressuretreatment
cameclose,raisingpto
sequences:stimulation
0.0484).
relaxationrelaxationor
relaxationstimulation
stimulation.Acupressure
treatmentswere15mins,self
administeredover3
consecutivedays.Preand
posttreatmentalertness
scoreswereassessedeach
dayusingtheStanford
SleepinessScale(SSS).
ChangesintheSSSscore
(afternoonmorning)were
analyzedusingamixed
regressionmodeloffixedand
randomeffects.Important
factorsthatwereexpectedto
affectalertness,suchas

61

StudyConclusions

Commentsonquality

Acupressureatstimulation
andrelaxationpointshas
differentialeffectsonalertness
inaclassroomsetting.Further
researchisnecessaryto
confirmthesefindingsandto
determinewhetherstimulation
andrelaxationacupressure
areequallyeffectivein
influencingalertness

Singleblind(subjects)andall
otherresearchersexcept
thoseteachingacupressure.
Althoughmajorityofstudents
couldcorrectlydiscernthe
treatment,thisdidnot
significantlyaffecttheresults.
Smallsample(39)andlow
generalisabilityasallmedical
students(welleducated,
scientificresearcherswho
werehighlymotivatedto
comply).Samplingnotgiven
maybealleligiblestudents
oncourse.
Randomgroupallocationand
controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographics).
Crossoverdesignshould
reduceeffectsofretesting,
carryoverortimerelated.
However,isonedayenough
toallowtreatmenteffectsto
subside?Alsoparticipants
actingasowncontrolscan
causepractiseeffect
(especiallywithselfreport).
Treatmentwasempirically
designedsonotclearif
acupressuresiteschosen
wereoptimalfortheintended
purpose.

caffeineandpreviousnight's
sleep,werealsoassessed.

ValidityofSSSnotgiven.
Missingdataprovided
retrospectively(n=9)may
causerecallbias.
Verycomprehensivestatistical
analysisaccountingfor:
- Effectsofsequence,
period,treatmentand
othercovariates
- Masking
- Covariatesincluding
caffeine,sleep,
medication,anxietyand
compliance.
Resultswereaffectedbyday
ofstudyandhoursofsleep
whichmaybiasresults.
Ethicalimplicationofsedating
studentsinclass.

62

Author,dateandtitle

Hsieh,L.L.,Kuo,C.H.,
Yen,M.F.,andChen,T.H.
(2004).
Arandomizedcontrolled
clinicaltrialforlowbackpain
treatedbyacupressureand
physicaltherapy.

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Randomized
Therewerenosignificant
controlledclinicaltrial
differencesinbaseline
characteristicsamongpatients
Setting:Orthopedicreferral
randomizedintothetwo
hospitalinTaiwan.
groups.Themeanof
posttreatmentpainscoreafter
Sample:146participantswith a4weektreatment(2.28,SD
chroniclowbackpainwere
=2.62)intheacupressure
randomlyassignedtothe
groupwassignificantlylower
acupressuregroup(69)orthe thanthatinthephysical
physicaltherapygroup(77),
therapygroup(5.05,SD=
betweenDecember20,2000, 5.11)(P=0.0002).Atthe6
andMarch2,2001
monthfollowupassessment,
themeanofpainscoreinthe
Healthissue:withlowback
acupressuregroup(1.08,SD
pain(LBP)
=1.43)wasstillsignificantly
lowerthanthatinthephysical
Intervention:Acupressure
therapygroup(3.15,SD=
fromaseniortherapistwas
3.62)(P=0.0004).The
comparedtoroutinephysical
changeofscorepretopost
therapy.Bothwere6
treatmentwasalso
sessionsover4weeks.
significantlygreaterin
Acupressurewasfor15mins
Acupressure(p<0.0001)
persession.Physicaltherapy
includesthermotherapy,
infrared,electricalstimulation,
exerciseandtraction.Self
appraisedpainscoreswere
obtainedbeforetreatmentas
baselineandaftertreatment
asoutcomesusingthe
ChineseversionofShortForm
PainQuestionnaire(SFPQ).

StudyConclusions

Commentsonquality

Ourresultssuggestthat
acupressureisanother
effectivealternativemedicine
inreducinglowbackpain,
althoughthestandard
operatingproceduresinvolved
withacupressuretreatment
shouldbecarefullyassessed
inthefuture

Goodsamplesize,powered
usingapilotstudy.Sample
wasconvenience,over
specifiedtimeperiod.
Randomassignmentand
controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographics).
ValidityofSFPQassessedfor
thetranslatedversion.
Althoughnotpossibletoblind:
- Practitionersblindtopre
testscores
- Followupstaffblindto
treatment
- Patientsblindtopretest
scores
Nononresponsebias.
Intentiontotreatanalysis
used,whichisdebatablebut
protectsagainstattrition
(dropout)bias.
Onlyassessedpain,not
functionalstatusetc,which
reducescomparabilitywith
otherstudies.
Resultsveryhighlysignificant.
Generalisabilityquitegoodas
awiderangeofageandtypes
ofLBP,andage/genderdid

63

notaffectresults.
Acupressuretreatmentwas
individualisedratherthan
standardisedlikeother
studies.Onlyonetherapist
wasusedthough,which
increasesinternalvaliditybut
decreasesexternal.

64

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Randomised
Hsieh,L.L.,Kuo,C.H.,
ThemeantotalRolandand
Lee,L.H.,Yen,A.M.,
controlledtrial
Morrisdisabilityquestionnaire
Chien,K.L.,andChen,T.H.
scoreaftertreatmentwas
Setting:Orthopaedic
(2006).
significantlylowerinthe
outpatientclinicinKaohsiung, acupressuregroupthaninthe
Treatmentoflowbackpainby Taiwan.
physicaltherapygroup
acupressureandphysical
regardlessofthedifferencein
Sample:129patientswith
therapy:randomised
absolutescore(3.8,95%
controlledtrial.
chroniclowbackpain
confidenceinterval5.7to
1.9)ormeanchangefromthe
Notethisisnotthesameas Healthissue:lowbackpain
baseline(4.64,6.39to
Hsieh,L.L.,Kuo,C.H.,
2.89).Acupressureconferred
Intervention:Acupressureor an89%(95%confidence
Yen,M.F.,andChen,T.H.
(2004).Arandomized
physicaltherapyforone
interval61%to97%)reduction
controlledclinicaltrialforlow month,sixsessions.Physical insignificantdisability
backpaintreatedby
therapywasroutineatthe
comparedwithphysical
acupressureandphysical
clinicandincludedtraction,
therapy.Theimprovementin
therapy.
spinalmanipulation,
disabilityscoreinthe
thermotherapy,infrared,
acupressuregroupcompared
electricalstimulationand
withthephysicalgroup
exercise.
remainedatsixmonthfollow
up.Statisticallysignificant
SelfadministeredChinese
differencesalsooccurred
versionsofstandardoutcome betweenthetwogroupsforall
measuresforlowbackpain
sixdomainsofthecore
(primaryoutcome:Rolandand outcome,painvisualscale,
Morrisdisabilityquestionnaire) andmodifiedOswestry
atbaseline,aftertreatment,
disabilityquestionnaireafter
andatsixmonthfollowup.
treatmentandatsixmonth
Analysiswasttest,chi
followup.
squared,Wilcoxonrankand
logisticregressionandwas
IntentiontoTreat.

65

StudyConclusions

Commentsonquality

Acupressurewaseffectivein
reducinglowbackpainin
termsofdisability,pain
scores,andfunctionalstatus.
Thebenefitwassustainedfor
sixmonths

Randomgroupassignment.
Samplesizepoweredfrom
pilotstudy.15.5%lossto
followup(20of129)but
intentiontotreatanalysis
assumedthoselosthadno
changesfrombaseline.
Controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographics).
Outcomemeasureswerenot
validatedforuseinChinese
language.
Placeboeffectnotassessed.
Blindingnotpossiblebut
therapistsblindtopretest
scoresanddatacollectors
blindtotreatmentasfaras
possible.
Usedonetherapistratherthan
astandardisedprocedure,
whichincreasesinternalbut
decreasesexternalvalidity.

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Design:Anonequivalent
Jun,E.M.,Chang,S.,
Kang,D.H.,andKim,S.(2006). controlgrouppreandposttest
design
Effectsofacupressureon
Setting:Classroomsattwo
dysmenorrheaandskin
universitiesinKorea
temperaturechangesin
collegestudents:Anon
Sample:58Young(1828)
randomizedcontrolledtrial.
femalenursingstudentswith
primarydysmenorrhea.

Results

Therewasasignificant
differenceinseverityof
dysmenorrheabetweenthe
twogroupsimmediatelyafter
(F=18.50,p=0.000)andforup
to2h(F=8.04,p=0.032)post
treatment.Skintemperature
wassignificantlyelevatedat
30minafteracupressureatthe
suprapubicCV2acupointin
theexperimentalgroup
Healthissue:Primary
comparedtothecontrolgroup.
dysmenorrhea
Temperatureelevationwas
alsonotedattheepigastric
Intervention:Participants
CV12acupointposttreatment
wereallottedtoeitheraSP6
butgroupdifferenceswerenot
acupressuregrouporplacebo significant,indicatingthat
groupthatreceivedlighttouch SHP6acupressurerelieves
ontheSP6acupoint.Group
dysmenorrheaprimarilyby
allocationwassequential,so
temperatureelevationinthe
thoserecruitedMayJune
CV2pathway.
wereintreatmentgroupsand
thoserecruitedJulyAugustin
placebogroup.The
experimentalgroupreceived
acupressuretreatmentwithin
thefirst8hofmenstruation,
andseverityofdysmenorrhea
andskintemperaturechanges
intheZhongwan(CV2)and
Qugu(CV12)acupointswere
assessedpriortoand30min,
1,2,and3hfollowing
treatment.

66

StudyConclusions

Commentsonquality

AcupressuretotheSHP6
meridiancanbeaneffective
noninvasivenursing
interventionforalleviationof
primarydysmenorrhea,with
effectslasting2hpost
treatment

Participantsmayhavebeen
studentsoftheresearchers
whichcouldintroduce
Hawthornebias.
Samplesizepoweredusing
pilotstudy.
Groupsnotrandomlyassigned
(assignedsequentially
accordingtotimeperiod),so
resultsmaybeaffectedby
seasonaleffects(whichhave
beensuggestedasaffecting
dysmenorrhea).Groupswere
howeverhomogenousfor
demographicsandfactors
affectingdysmenorrhea
Studentsanddatacollectors
blinded.
Placebocontrolled.
Validityofoutcomemeasure
translatednotestablished.
Noclinicaloutcomes,only
(subjective)VAS.
Limitedgeneralisability(young
andnursingstudents)

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Design:Prospective,
randomised,doubleblinded
trial

Kober,A.,Scheck,T.,
Greher,M.,Lieba,F.,
Fleischhackl,R.,
Fleischhackl,S.,
Randunsky,F.,andHoerauf,K. Setting:Austria
(2002).
Sample:60traumapatients.
Prehospitalanalgesiawith
Healthissue:Untreatedpain
acupressureinvictimsof
minortrauma:aprospective,
duringthetransportationof
randomized,doubleblinded
patientsafterminortrauma
trial.
(simplefractures,small
wounds,contusions).

Intervention:Patientswere
randomlyassignedintothree
groups"truepoints,""sham
points,"and"noacupressure".
Allweretreatedaccordingly
for3minutes.Anindependent
observer,blindedtothe
treatmentassignment,
recordedvitalvariablesand
visualanalogscales(VAS)for
painandanxietybeforeand
aftertreatment.Attheendof
transport,weaskedforratings
ofoverallsatisfaction.For
statisticalevaluation,oneway
analysisofvarianceandthe
ScheffeFtestwereused.P<
0.05wasconsidered
statisticallysignificant.

Results

StudyConclusions

Morphometricand
demographicdataand
potentialconfoundingfactors
suchasage,sex,pain,
anxiety,bloodpressure,and
heartratebeforetreatmentdid
notdifferamongthegroups.

Ourresultsshowthat
acupressureisaneffective
andsimpletolearntreatment
ofpaininemergencytrauma
careandleadstoan
improvementofthequalityof
careinemergencytransport.
Wesuggestthatthis
Attheendoftransportwe
techniqueiseasytolearnand
foundsignificantlylesspain,
riskfreeandmayimprove
anxiety,andheartrateanda
paramedicbasedrescue
greatersatisfactioninthe"true systems.
points"groups(P<0.01),both
shamandnoacupressure
groupsdidnotchange
significantlyinanyvariable..

Commentsonquality

Doubleblind(paramedicA
whowastreatingdidnotknow
whichpointwasshamorreal).
Samplingnotgiven,but
acknowledgmentsection
suggeststhatambulancestaff
choseeligiblepatientstobe
recruited.
Randomisedandallgroups
homogenous.
Treatmentanddatacollection
bydifferentparamedics,who
werenotpresenttogether.
Treatmentanddatacollection
werealsoindependently
audited.
Nodropouts.
Intentiontotreatanalysis
used,whichisdebatablebut
protectsagainstattrition
(dropout)bias.
ReliabilityofVASnotgiven.
Nodiscussionoflimitations.

67

Author,dateandtitle

Lee,A.andDone,M.L.(2004).
Stimulationofthewrist
acupuncturepointP6for
preventingpostoperative
nauseaandvomiting
.

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Systematicreview
Twentysixtrials(n=3347)
wereincluded,noneofwhich
Setting:N/A
reportedadequateallocation
concealment.Therewere
Sample:RCTsoftechniques significantreductionsinthe
thatstimulatetheP6acupoint risksofnausea(RR0.72,95%
comparedwitheithersham
CI0.59to0.89),vomiting(RR
treatment,orantiemeticdrugs 0.71,95%CI0.56to0.91)and
forpreventionofPONV.
theneedforrescue
antiemetics(RR0.76,95%CI
Healthissue:Postoperative
0.58to1.00)intheP6
nauseaandvomiting(PONV) acupointstimulationgroup
followingsurgeryand
comparedwiththesham
anaesthesia.
treatment,althoughmanyof
thetrialswereheterogeneous.
Intervention:Wesearched
Therewasnoevidenceof
CENTRAL(TheCochrane
differenceintheriskofnausea
Library,Issue1,2003),
andvomitingintheP6
MEDLINE(January1966to
acupointstimulationgroup
January2003),EMBASE
versusindividualantiemetic
(January1988toJanuary
groups.However,when
2003)andtheNationalLibrary differentantiemeticswere
ofMedicinepublicationlistof pooled,therewassignificant
acupuncturestudiesuptoand reductionintheriskofnausea
includingJanuary2003.
butnotvomitingintheP6
Referencelistsofretrieved
acupointstimulationgroup
papersandreviewswere
comparedwiththeantiemetic
consultedforadditional
group(RR0.70,95%CI0.50
references
to0.98RR0.92,95%CI0.65
to1.29respectively).Theside
SEARCHSTRATEGY:
effectsassociatedwithP6
SELECTIONCRITERIA:All
acupointstimulationwere
randomizedtrialsof
minor.Therewassome
techniquesthatstimulatedthe evidenceofasymmetryofthe
P6acupointcomparedwith:
funnelplot.
shamtreatmentordrug
therapyforthepreventionof
PONV.Interventionsusedin
thesetrialsincluded

68

StudyConclusions

Commentsonquality

Thissystematicreview
supportstheuseofP6
acupointstimulationin
patientswithoutantiemetic
prophylaxis.Comparedwith
antiemeticprophylaxis,P6
acupointstimulationseemsto
reducetheriskofnauseabut
notvomiting

CochraneReview
Includedchildren
Searchtermsseem
comprehensivealthoughnot
clearhowP6studieswere
identified.
Combineddatausingamodel
forheterogenousstudies.

acupuncture,electro
acupuncture,transcutaneous
nervestimulation,laser
stimulation,acustimulation
deviceandacupressure.
DATACOLLECTIONAND
ANALYSIS:Tworeviewers
independentlyassessed
methodologicalqualityand
extractedthedata.Primary
outcomeswereincidencesof
nauseaandvomiting.
Secondaryoutcomeswerethe
needforrescueantiemetic
therapyandadverseeffects.A
randomeffectsmodelwas
usedandrelativerisk(RR)
withassociated95%
confidenceintervals(95%CI)
arereported.Egger'stestwas
usedtomeasurethe
asymmetryofthefunnelplot.

69

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Randomizedclinical
Lee,M.K.,Chang,S.B.,and
Thereweresignificant
Kang,D.H.(2004).
trial.
differencesbetweenthe
groupsinsubjectivelaborpain
scoresatalltimepoints
EffectsofSP6acupressureon Setting:Deliveryroomina
universityhospital,Korea
followingtheintervention:
laborpainandlengthof
immediatelyafterthe
deliverytimeinwomenduring
Sample:Seventyfive(75)
intervention(p=0.012)30
labor.
womeninlabor,
minutesaftertheintervention
(p=0.021)and60minutes
Healthissue:Laborpain
aftertheintervention(p=
0.012).Thetotallabortime(3
Intervention:30minute
cmdilatationtodelivery)was
acupressure(n=36)ortouch
significantlyshorterintheSP6
(n=39)onSP6acupointwas
acupressureintervention
performed.
groupthaninthecontrolgroup
(p=0.006)althoughlengthof
Laborpainwasmeasuredfour secondstagedidnotdiffer.
timesusingastructured
questionnaire,asubjective
Anxietywassignificantly
laborpainscale(visual
reducedinacupressuregroup
analoguescale[VAS]):before (p=0.03)afterintervention
intervention,immediatelyafter comparedtocontrol.No
theintervention,and30and
significantdifferencein
60minutesafterthe
analgesiause.
intervention.Lengthofdelivery
timewascalculatedintwo
stages:from3cmcervical
dilationtofullcervical
dilatation,andfullcervical
dilatationtothedelivery.

70

StudyConclusions

Commentsonquality

Thesefindingsshowedthat
SP6acupressurewas
effectivefordecreasinglabor
painandshorteningthelength
ofdeliverytime.SP6
acupressurecanbean
effectivenursingmanagement
forwomeninlabor

Doubleblindrandomisedtrial
Participantswereblindedand
datacollectorswereblinded
(nottreatmentgivers)
N=75,quitesmalland
volunteersamplecouldreally
biastheresults.
Groupswererandomly
assignedandmatched
(accordingtoparity,cervical
dilation,laborstage,ruptureof
amnioticmembrane,and
husband'spresenceduring
labor.).Controland
interventiongroupsare
homogenous(nosignificant
differencesindemographics).
Useoftouchgroupascontrol
allowstestingformeridian
effectscomparedtoemotional
supportiveeffects.
Confounderscontrolledfor
anxietyanduseofanalgesics.
Anxietywaslowerposttestin
acupressuregroup.
Verydetailedcontrolof
reliabilityofprocedure.

Author,dateandtitle

Litscher,G.(2004).
Effectsofacupressure,
manualacupunctureand
Laserneedleacupunctureon
EEGbispectralindexand
spectraledgefrequencyin
healthyvolunteers.

Studymethodology,design,
setting,sample,condition
andintervention
Design:randomized,
controlledandpartlyblinded
crossovertrial

Results

Bispectralindexandspectral
edgefrequencyvaluesboth
decreasedsignificantly(P<
0.001)duringacupressureon
Setting:Austria
Yintangtovaluesof62.9
(minimum35)+/13.9
Sample:Twentyfivehealthy bispectralindexandto13.3
volunteers(meanage+/SD: (minimum2.9)+/8.1Hz
25.5+/4.0yr)were
(spectraledgefrequencyright)
investigatedduringtheawake and13.8(minimum2.7)+/
state.
7.3Hz(spectraledge
frequencyleft),respectively.
Healthissue:None,
Bispectralindexwasalso
investigatingeffectsofEEG
significantly(P<0.05)
affectedbyLaserneedle
Intervention:The
acupunctureandacupressure
acupuncturepointYintangand onthecontrolpointbutthe
aplacebocontrolpointwere
changeswerenotclinically
stimulatedfor10mins.Each
relevant,95.4+/4and94.2
personreceivedsensory
+/4.8,respectively.All
(acupressureand
interventionssignificantly
acupuncture)andoptical
(Yintang:P<0.001control
stimulation(Laserneedle
point:P<0.012)reduced
acupuncture)orsham
VSS.HeartrateandBlood
acupressure.Thesequence
pressurewerereducedafter
wasrandomlydecidedfor
acupressure.
eachpatient.Outcomeswere
measuredusing
electroencephalographic
bispectralindex,spectraledge
frequencyandaverbal
sedationscore.

71

StudyConclusions

Commentsonquality

AcupressureatYintanggave
statisticallysignificantand
clinicallyrelevantreductionsin
BISandEFV.Thestudy
highlightsthe
electroencephalographic
similaritiesofacupressure
inducedsedationandgeneral
anaesthesiaasassessedby
bispectralindexandspectral
edgefrequency

Volunteersampleandquite
small(25).Theywerepaidfor
participation.
Subjectsanddatacollectors
blinded.
Withinsubjectrandomisation
oforderoftreatments
(crossoverdesign)toreduce
carryovereffects.Howeverno
analysisoftheseeffects.Also
only20minsbetween
treatmentswhichmaynotbe
enoughtimeforeffecttowear
off,andeffectsnottested
beyond1minafterintervention
Controlledtoreduceplacebo
effect.

Author,dateandtitle

Lu,D.P.,Lu,G.P.,and
Reed,J.F.,(2000).
Acupuncture/acupressureto
treatgaggingdentalpatients:a
clinicalstudyofantigagging
effects

Studymethodology,design,
setting,sample,condition
andintervention
Design:DoubleblindRCT
Setting:Dentaltreatment
centre,USA
Sample:109dentalpatients
aged1776years.
Healthissue:Severegagging
whichpreventeddental
procedure.
Intervention:Patientsdivided
intothreegroups:
1. AcupunctureatP6orsham
point
2. AcupressureatP6orsham,
furtherdividedintothree
subgroupsusingthumb,
deviceorseaband.
3. Conscious
(pharmacological)sedation
witheitheracupressure(3
types)oracupuncture.
Allfor5mins(forimpression
taking)or3mins(allother
procedures.
Dentaltreatmentwasthen
givenandtheoutcome
evaluatedbytreatmentteam
andpatienton4pointranking
scale.

Results

StudyConclusions

Therewasasignificant
differenceinoutcomefor
acupuncture(teamevaluation
p=0.047,patientp=0.009)and
fordeviceacupressure(team
p=0.002,patientp=0.001)atP6
versusshampoint.Noother
significantdifferencesfor
acupressure.Nosignificant
differenceusingacupressure
withconscioussedation.

StimulationofP6with
Doubleblind,althoughblinding
acupunctureneedleor
ofpractitionersnotdescribed.
acupressuredevicehasananti
gaggingeffectfordental
Randomgroupallocation.
procedures.
Smallgroups

Acupuncturehadabettereffect
thanacupressure.For
acupressure,devicewasbetter
thanthumbwhichwasbetter
thanSeaband.

72

Commentsonquality

Outcomemeasuresnotclinical
orvalidated.
Nodetailsofsample,sampling,
comparisonofgroupson
baselinefactors,responsedata,
Noinclusioncriteria.

Author,dateandtitle
Maa,S.H.,Gauthier,D.,and
Turner,M.(1997).
Acupressureasanadjunctto
apulmonaryrehabilitation
program

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:singleblindpretest
Realacupressurewasmore
posttest,crossover
effectivethansham
acupressureforreducing
Setting:twoprivatehospitals dyspnoeaasmeasuredbya
visualanaloguescale(P=
Sample:Thirtyonenew
.009,onetailed),andwas
patientsbeginninga12week minimallyeffectiveforrelieving
PRPattwoprivatehospitals
decathexis(P=.044,one
wererandomlyassignedto
tailed).Otherdyspnoeaand
oneoftwogroups.
othermeasuresshowedno
significantdifference.Sham
Healthissue:dyspnoeaand
acupressureseemedtobe
othersymptomsinpatients
moreeffectivethanreal
withchronicobstructive
acupressureforreducing
pulmonarydisease(COPD).
peripheralsensorysymptoms
(P=.002,twotailed),butthe
Intervention:Patientsin
presenceofthesesymptoms
group1weretaught
mayalsobeanindicationthat
acupressureandpracticedit
theacupressureisaffecting
dailyathomefor6weeks,
thebody.
thenshamacupressureforthe
following6weeks.Ingroup2,
theorderofacupressureand
shamacupressurewas
reversed.Duringweeks1,6,
and12,patientdyspnoea,
othersymptomsassociated
withCOPD,activitytolerance,
lungfunction,andfunctional
exercisecapacitywere
assessed. Analysiswas
extensionofapairedttest,
regressionandsensitivity
analysisforasmallsampleto
testforoutliers.

73

StudyConclusions

Commentsonquality

Acupressureseemstobe
usefultopatientswithCOPD
asanadjuncttoaPRPin
reducingdyspnoea.Some
personswhoarenotinitially
familiarwithtraditional
Chinesemedicinecanlearn
andwillacceptself
administeredacupressureas
partoftheirselfcare

Singleblind(andstatedthat
manypatientscouldidentify
shamvsreal)withplacebo
treatments.
Crossoverpatientsactas
owncontrols.
Givessampledetails,reasons
fordropoutetc,butdropout
washigh(20of51),mostly
duetomedicalreasons.
Smallsample,although
sensitivitytestdidnotidentify
anyidiosyncraticindividuals.
Outcomemeasuresvalidated
forthisgroupandreliability
tested.
Placebocontrolled.
Genderwasdeterminedtobe
acovariable(results
significantlydifferentfor
male/female)

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Maa,S.H.,Sun,M.F.,Hsu,K.H., Design:prospective,
Hung,T.J.,Chen,H.C.,
randomizedstudy
Setting:Outpatients
Yu,C.T.,Wang,C.H.,and
Lin,H.C.(2003).
departmentofThoracic
medicine,ChangGung
Effectofacupunctureor
MemorialHospital(TaoYuan,
acupressureonqualityoflife
Taiwan)betweenMarch1997
ofpatientswithchronic
andSeptember1998.
Sample:Fortyone(n=41)
obstructiveasthma:apilot
study
patientswithchronic
obstructiveasthma
Healthissue:chronic
obstructiveasthma
Intervention:Patientswere
randomlyassignedtoreceive
acupunctureinadditionto
standardcare(n=11),
acupressureandstandard
care(n=17),orstandardcare
alone(n=13).Twenty(20)
acupuncturetreatmentswere
administered,andself
administeredacupressurewas
performeddailyfor8weeks.
Sixminutewalking,the
DyspneaVisualAnalogue
Scale,themodifiedBorg
scale,St.George's
RespiratoryQuestionnaire
(SGRQ),andtheBronchitis
EmphysemaSymptom
Checklist(BESC)wereused
atthebeginningandendof
the8weeksoftreatment.
AnalysiswasANOVA,
KruskalWallis,chisquared,
oddsratioandmultiplelogistic
regression.

Results

StudyConclusions

Commentsonquality

ThetotalSGRQscoreof
acupuncturesubjectsshowed
anaverage18.5fold
improvement(95%confidence
interval[CI]1.54211.48,p=
0.02)theimprovementforthe
acupressuresubjectswas
6.57fold(95%C.I.0.98
44.00,p=0.05).Additionally,
forpatientswhoreceived
acupressure,theirritability
domainscoredeterminedby
theBESCexhibitedan11.8
foldimprovement(95%C.I.
0.88158.64,p=0.06)after
adjustmentforcovariables.
Theothervariablesdidnot
differfromthoseofthe
controls

Patientswithclinicallystable,
chronicobstructiveasthma
experiencedclinically
significantimprovementsin
qualityoflifewhentheir
standardcarewas
supplementedwith
acupunctureoracupressure

Pilotstudy.
Smallsample,although
sensitivitytestdidnotidentify
anyidiosyncraticindividuals
Nonprobability,purposive
sampling.
Highattritionrate(29outof
70),mostlyduetonon
medicalreasons,plusgreater
fromacupuncturegroup&not
intentiontotreatanalysis>
finalsamplemayhavehad
differentviews/beliefsof
treatment.
Notblindedascontrolgroup
receivednointervention.
Controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographics).
Outcomemeasureswere
valid.

74

Author,dateandtitle

Markose,M.T.,
Ramanathan,K.,and
Vijayakumar,J.(2004).
Reductionofnausea,
vomiting,anddryretcheswith
P6acupressureduring
pregnancy

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Uncontrolled,one
Aftertreatment(day7)there
grouppreposttestdesign.
wasasignificantreduction
fromday3offrequencyof
Setting:India?
nausea(p=0.008),vomiting
(p=0.000),retching(p=0.004
Sample:35womenpregnant anddistressduetonausea
lessthan12weekswith
(p=0.002),vomiting(p=0.008)
nauseawith/withoutvomiting
andretching(p=0.016).There
wasnofurtherdecreasefrom
Healthissue:nausea
day8to10.
with/withoutvomitingduring
earlypregnancy
Intervention:Acupressureon
P6fromthe4th dayofstudy,
10minsoneachhandfour
timesadayforfourdays.
RhodesInventoryofNausea,
VomitingandRetchingusedto
recordsymptoms.McNemar
nonparametricteststo
comparescoresbeforeand
aftertreatment.

StudyConclusions

Commentsonquality

ThisstudyfoundP6
acupressureusefulforthe
reductionofnausea,vomiting
andretching.

Articleisabrief
communicationsocomments
arelimited.
Verysmallsample.
Poorresponserateof17out
of35.
NotRCTnotrandomisedor
controlled.
Samplewashomogenousfor
baselinesymptoms.
Samplingnotgiven.

75

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Randomizedblock
Ming,J.L.,Kuo,B.I.,Lin,J.G.,
Significantdifferencesinthe
andLin,L.C.(2002).
experimental
incidenceofthepostoperative
nausea(p=0.001)and
vomiting(p<0.001)werefound
Theefficacyofacupressureto Setting:Medicalcentre,
betweentheacupressure,
preventnauseaandvomiting Taipei
Sample:150subjects
wristband,andcontrol
inpostoperativepatients
scheduledforfunctional
groups,withareductioninthe
endoscopicsinussurgery
incidencerateofnauseafrom
(FESS)undergeneral
73.0%to43.2%andvomiting
anaesthesia.Eachgroup
incidenceratefrom90.5%to
consistedof50subjects.
42.9%intheformer.Retching
Healthissue:Postoperative didnotdiffer.Nauseaand
nauseaandvomiting
vomitingweresignificantly
differentbetweengroups
Intervention:Patientswere
(p<0.05).Theamountof
matchedformotionsickness
vomitusandthedegreeof
thenrandomlyassignedtoa
discomfortwere,respectively,
fingerpressinggroup,awrist lessandlowerintheformer
bandgroup,andacontrol
group(p<0.01andp<0.001
group.Theacupoints(P6and respectively).
H7)andtreatmenttimeswere
similarinthefingerpressing
Anxietydecreasedinthewrist
groupandwristbandpressing band(p<0.05)andcontrol
group,whereasonly
(p<0.01)groupsbutnotfor
conversationwasemployedin acupressureoroverall.
thecontrolgroup.Treatment
wasfor20minsonthree
occasions1hourbefore,
directlybeforeand10hours
afteroperation.
TheRhodesIndexofNausea,
VomitingandRetching(INVR)
questionnairewasusedasa
tooltomeasureincidenceand
theStateAnxietyInventory
wasused..Datawascollected
thedaybeforeandatrandom
pointsduring24hours
postoperation.

76

StudyConclusions

Commentsonquality

Inviewofthetotalabsenceof
sideeffectsinacupressure,its
applicationisworthyofuse.
Thisstudyconfirmedthe
effectivenessofacupressure
inpreventingpostoperative
nauseaandvomiting

Goodsamplesize(150)and
lowattritionrate(98.7%).
Blockdesignmatchedfor
motionsicknessnotsure
why.
Notblinded.
Internalvaliditycontrolledby
interraterreliabilityand
independentverificationof
acupressurepoints.
Limitedgeneralisability(only
forFESSpatients).
Controlandintervention
groupsarehomogenous(no
significantdifferencesina
widerangeofvariables).

Author,dateandtitle

Pouresmail,Z.and
Ibrahimzadeh,R.(2002).
Effectsofacupressureand
ibuprofenontheseverityof
primarydysmenorrhea

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:3armedRCT
Theresultsindicatedthatthe
threetherapeutictechniques
Setting:3HighSchools,Iran. weresignificantlyeffectivein
reducingthepain,witha
Sample:216femalehigh
beforeandafterreduction
schoolstudents,aged
(p<0.01)forallthree.The
between14to18years,were scoreonthedysmenorrhea
randomlyselectedanddivided scalewas0for0%before,
intothreegroups
increasingto50%after
acupressure,36%inIbuprofen
Healthissue:Primary
and18%inplacebo.However
dysmenorrhea(PD)
thetherapeuticefficaciesof
acupressureandIbuprofen
Intervention:Eachgroup
weresimilarwithnosignificant
underwentdifferenttreatment difference,andwere
techniques:acupressure,
significantlybetterthanthe
Ibuprofenandsham
placebo.
acupressureasaplacebo.
AcupressurewasonLi4,
SP15,ST36,Sp6andLR3for
2minseach,shamwasfour
shampoints,notacupoints,
andIbuprofenwas9tablets
(400ml),allfor3daysstarting
24hoursbeforeonsetof
period.Acupressureand
shamalsohadarelaxation
session.2checklistswere
usedtoassesstheseverityof
dysmenorrheabeforeand
aftertreatment.

77

StudyConclusions

Commentsonquality

Acupressure,withno
complications,is
recommendedasan
alternativeandalsoabetter
choiceinthedecreaseofthe
severityofPD

Randomsample.
3armedRCT
Selectedfromarangeof
socioeconomicbackgrounds.
Followedupfor3monthsprior
tostudytodetermine
menstruationpattern.
Outcomemeasurenotclinical.
Lowattritionrate.
Notclearifproviderorpatient
blinded(inshamvs
acupressure).
Verystrictinclusioncriteria
mayreducegeneralisability.

Author,dateandtitle

Shiao,S.Y.andDune,L.S.
(2006).
Metaanalysesof
acustimulations:effectson
nauseaandvomitingin
postoperativeadultpatients

Thirtythreequality
randomizedcontrolledtrials
(RCT)publishedoverthepast
threedecadeswereidentified
byevaluatingthequalityof
randomizationandtreatment
methods,andresultswere
pooledusingafixedeffects
model.

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Metaanalysis
Twentyfourtrialswerepooled
fornausea,29trialsfor
Setting:N/A
vomiting,and19trialsfor
rescueantiemetics,withAS
Sample:RCTsonany
comparedwithplaceboor
acupointstimulationfor
controls.Twoadditionaltrials
nauseaandvomiting
didnothavecontrolgroups
symptoms(NVS)in
butcomparedASto
postoperativeadult
medicationgroups.Compared
populations.
withthecontrols,AS(all
modalities)reducednausea
Healthissue:nauseaand
(relativerisk[RR]=0.60,95%
vomitingsymptoms(NVS)in
confidenceinterval[CI]:0.54
postoperativeadult
0.67,P<.0001),vomiting(RR
populations.
=0.51,95%CI:0.450.57,P<
.0001),anduseofrescue
Intervention:Metaanalysesof antiemetics(RR=0.63,95%
effectsofvariousacupoints
CI:0.540.74,P<0001).All
stimulations(AS)(including
ASmodalitieswereeffectivein
acupuncture,acupressure,
reducingNVS.Koreanhand
andelectricalstimulation)on
acupressurestimulations(two
NVSinpostoperativeadult
trials)hadthebestimpacton
populationswereperformed.
reducingvomiting.Therewere
Tworeviewersindependently nosignificantdifferenceson
reviewedandevaluatedall
pooledRRsfornausea(five
relevantinformationanddata trials)andvomiting(eight
waspooled.
trials)betweenmedicationand
ASgroups,butmedication
groupshadincreaseduseof
rescueantiemetics(twotrials,
RR=2.27,95%CI:1.483.49,
P=.0002).Therewasa
placeboeffectwhencompared
withcontrolsinreducing
nausea(fourtrials,RR=0.67,
95%CI:0.500.90,P=.0069)
andvomiting(threetrials,RR
=0.39,95%CI:0.190.80,P=
.0106).

78

StudyConclusions

Commentsonquality

Thismetaanalysis
demonstratedthatASisjust
aseffectiveasmedicationsin
reducingNVSandthat
acupressureisjustas
effectiveasacupunctureor
electricalstimulationin
reducingNVSfor
postoperativeadult
populations

Somegreyliteratureincluded.
OnlyRCTs
Goodselectionprocess.
Studiesusedhadquitesimilar
proceduresandoutcomes
allowingcombinability.
18acupressuretrials
identified.

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Shin,Y.H.,Kim,T.I.,Shin,M.S., Design:Nonequivalent,
andJuon,H.S.(2004).
controlgrouptrial.
Setting:Oncologywardsat
UniversityMedicalCentres,
Effectofacupressureon
SouthKorea.
nauseaandvomitingduring
Sample:Fortypostoperative
chemotherapycyclefor
Koreanpostoperativestomach gastriccancerpatients
receivingthefirstcycleof
cancerpatients.
chemotherapywithcisplatin
and5Fluorouracil
Healthissue:Nauseaand
vomitingassociatedwith
cancerchemotherapy
Intervention:Bothgroups
receivedregularantiemesis
medicationhowever,the
interventiongroup(n=20)
receivedacupressuretraining
andwasinstructedtoperform
thefingeracupressure
manoeuvrefor5minuteson
P6(NeiGuan)pointlocatedat
3fingerwidthsupfromthe
firstpalmarcrease,between
palmarislongusandflexor
carpiradialistendonspoint,at
least3timesadaybefore
chemotherapyandmealtimes
orbasedontheirneeds.Both
groupsreceivedequally
frequentnursingvisitsand
consultations.Nauseaand
vomitingmeasuredby
Rhode'sIndexofNausea,
VomitingandRetching,side
effectsassessedbydatafrom
medicalrecords.Groups
comparedforseverity,
durationandfrequencyof
nauseaandvomitingusingt
testsandtwowayANOVA

Results

StudyConclusions

Commentsonquality

Significantdifferencesfound
betweeninterventionand
controlgroupsintheseverity
ofnauseaandvomiting,the
durationofnausea,and
frequencyofvomiting(all
p<0.01).

Thisstudysuggeststhat
acupressureonP6point
appearstobeaneffective
adjunctmanoeuvreinthe
courseofemesiscontrol

Smallsampleandnot
randomised(convenience
samplingandallocationfirst
20patientsincontrolgroup,
next20ininterventiongroup).
Althoughcontroland
interventiongroupsare
homogenous(nosignificant
differencesindemographics,
diseaseortreatment
variables)

RepeatedmeasuresANOVA
showedsignificanttimeeffects
forallthreeaspects(p<0.01)
andinteractioneffect(with
time)wassignificantfor
duration(p<0.01)and
frequency(p<0.05).

Notclearifallpatientswere
fromthesamehospital.
Limitedtopatientswith
stomachcancerandon
specificdrugregimen.
Acupressureself/family
administered.
Testsacupressureasan
adjuncttostandardcare(anti
emeticdrugsusedinboth
groups).
Interventiongrouphad
additionalattentionfrom
researchstaff.
Highlysignificantresults
Testedforinteractioneffects.
SelfreportedN&Vmaybe
subjecttorecallbias,although
measurehashighreliability.

79

Author,dateandtitle

Tsay,S.L.andChen,M.L.
(2003).
Acupressureandqualityof
sleepinpatientswithend
stagerenaldiseasea
randomizedcontrolledtrial

Notethisisbasedonthe
samestudyasref90
(Tsay,S.L.,Rong,J.R.,and
Lin,P.F.(2003).Acupoints
massageinimprovingthe
qualityofsleepandqualityof
lifeinpatientswithendstage
renaldisease)

Studymethodology,design,
setting,sample,condition
andintervention
Design:randomized
controlledtrial
Setting:Dialysiscentersof
fourmajorhospitals
Sample:98participantswere
randomlyassignedintoan
acupressuregroup,asham
acupressuregroup,anda
controlgroup.
Healthissue:sleepqualityof
endstagerenaldisease
patients
Intervention:Patientswere
randomlyassignedintoan
acupressuregroup,asham
acupressuregroup,anda
controlgroup.Acupressure
andshamacupressuregroup
patientsreceivedacupoints
(H17&Ki1)ornoacupoints
massage(5minsrelaxing
massage,9minsacupoint
massage)threetimesaweek
duringhaemodialysis
treatmentforatotalof4
weeks.Controlgroupreceived
noadditionalintervention
(standardcare).Themain
outcomesmeasuredwerethe
Pittsburghsleepqualityindex
(PSQI)andthedailysleeplog.
Datawerecollectedatpre
treatment(before
randomisation)andfollowing
treatment.Primarystatistical
analysiswasbymeansof
AnalysisofCovariance,the
KruskalWallisTestand
repeatedmeasureANOVA.

Results

StudyConclusions

Commentsonquality

Theresultsindicatedthat
PSQIscoresofthe
acupressuregrouphavea
significantlygreater
improvement(p<0.01)than
thecontrolgroup.However,
therewerenodifferences
betweentheacupressure
groupandtheshamgroupor
theshamgroupandthe
controlgroup(p>0.05).
SubscalesofPSQIwere
furtheranalyzed.Results
demonstratedsignificant
differencesbetweenthe
acupressuregroupandthe
controlgroupinsubjective
sleepquality(p=0.009),
sleepduration(p=0.004),
habitualsleepefficiency(p=
0.001),andsleepsufficiency
(p=0.004).Significant
differencesinthesubscaleof
subjectivesleepquality(p=
0.003)betweenthesham
acupressuregroupandthe
controlgroupwerealso
observed.Sleeplogdata
showedthattheacupressure
groupsignificantlydecreased
awaketimeandimproved
qualityofsleepovertimemore
thanthecontrolgroup(p<
0.01).Theimprovementcould
beseenassoonasthe
acupointsmassagewas
implemented,anditwas
maintainedthroughthepost
intervention

Thisstudysupportsthe
effectivenessofacupoints
massageinimprovingthe
qualityofsleepandlifequality
ofendstagerenaldisease
patients,andoffersa
noninvasivetherapyforsleep
disturbedpatients

Blinded(interviewer/data
collector,usualcareprovider,
participant)butnotresearcher
oracupressurenurse.
Threearmed.

80

Outcomemeasuresare
reliable.
Attritionwaslow(98from105)
Reliabilityandvalidityof
acupressureprocedure
established.
Groupshomogenousfor
demographics,sleepaffecting
behaviourandESRDrelated
factors.
Bonferronicorrectionusedto
controlfortype1error.
Limitedgeneralisability(renal
endstageandnorthern
Taiwan)

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Randomizedcontrol
Tsay,S.L.,Rong,J.R.,and
Theresultsindicated
Lin,P.F.(2003).
trial
significantdifferences
betweentheacupressure
Setting:Fouroutpatient
Acupointsmassagein
groupandthecontrolgroupin
improvingthequalityofsleep dialysiscentresinhospitalsin PittsburghSleepQualityIndex
andqualityoflifeinpatients
Taipei.
subscalescoresofsubjective
withendstagerenaldisease
sleepquality(p=0.009),sleep
Sample:98endstagerenal
duration(p=0.004),habitual
Notethisisbasedonthe
diseasepatientswithsleep
sleepefficiency(p=0.001),
samestudyasref93
disturbances
sleepsufficiency(p=0.004),
(Tsay,S.L.andChen,M.L.
andglobalPittsburghSleep
Healthissue:Sleep
(2003).Acupressureand
QualityIndexscores
qualityofsleepinpatientswith disturbanceanddiminished
(p=0.003).Nosignificant
endstagerenaldiseasea
qualityoflifeinpatientswith
differencebetween
randomizedcontrolledtrial)
endstagerenaldisease
acupressureandsham.Sleep
logdatarevealedthatthe
Intervention:Patientswere
acupressuregroup
randomlyassignedintoan
significantlydecreasedwake
acupressuregroup,asham
timeandexperiencedan
acupressuregroup,anda
improvedqualityofsleepat
controlgroup.Acupressure
nightoverthecontrolgroup.
andshamacupressuregroup MedicalOutcomeStudy
patientsreceivedacupointsor ShortForm36dataalso
noacupointsmassage(5mins documentedthatacupressure
relaxingmassage,9mins
grouppatientsexperienced
acupointmassage)three
significantlyimprovedquality
timesaweekduring
oflifeonanumberof
haemodialysistreatmentfora subscales:physicalrole
totalof4weeks.Controlgroup (p=0.01),bodypain(p=0.001),
receivednoadditional
vitality(p=0.001),social
intervention(standardcare).
function(p=0.05),total
Datacollectedatbaselineand physical(p=0.05)andtotal
oneweekaftercourse,using
mental(p=0.05).Thesewere
PittsburghSleepQuality
greaterforacupressuregroup.
Index,andtheMedical
OutcomeStudyShortForm
36.PlusdailySleepLog.

81

StudyConclusions

Commentsonquality

Thisstudysupportsthe
effectivenessofacupoints
massageinimprovingthe
qualityofsleepandlifequality
ofendstagerenaldisease
patients,andoffersa
noninvasivetherapyforsleep
disturbedpatients

Blinded(interviewer,usual
careprovider,participant)but
notresearcheroracupressure
nurse.
Threearmed.
Outcomemeasuresare
reliable.
Attritionwaslow(98from105)
Reliabilityandvalidityof
acupressureprocedure
established.
Groupshomogenousfor
demographics,sleepaffecting
behaviourandESRDrelated
factors.
Limitedgeneralisability(renal
endstage)

Author,dateandtitle

Studymethodology,design,
setting,sample,condition
andintervention
Design:arandomizedcontrol
Tsay,S.L.(2004).
trial
Setting:notclear
Acupressureandfatiguein
Sample:106participants
patientswithendstagerenal
Healthissue:fatiguein
diseasearandomized
controlledtrial
patientswithendstagerenal
disease(ESRD).
*Notethisisverysimilarto InterventionParticipants
randomlyassignedinto
90and93(Tsay,S.L.,
Rong,J.R.,andLin,P.F.(2003) acupressuregroup,sham
andTsay,S.L.andChen,M.L. grouporcontrolgroup.All
(2003)),butthesamplesize receivedstandardcare.
Acupressurewas3minsof
isdifferent(sameas
relaxingmassagethen3mins
Tsay,S.L.,Cho,Y.C.,and
peracupointonK1,St36,
Chen,M.L.(2004).)sonot
GB34andSp6.Shamgroup
sureifthisisanoriginal
wasacupressureonsham
study.
points.Acupressurewasthree
timesaweekforatotalof4
weeksPatientsinthecontrol
grouponlyreceivedroutine
unitcare.Allinstructednotto
massageanyacupoints.
Themeasuresincludedthe
revisedPiperFatigueScale
(PFS),VASofFatigue,the
PittsburghSleepQualityIndex
andtheBeckDepression
Inventory.Dataoffatigue
measureswerecollectedat
pretreatmentandaweek
followingtreatment.Sleep
qualityanddepressionwere
collectedduringposttestonly.
Thestatisticalmethods
includedthedescriptive
statistics,onewayANOVA,
ANCOVA,andrepeated
measuresANOVA.:

Results

StudyConclusions

Commentsonquality

ANCOVAthatadjustedfor
differencesinbaselinefatigue
scores(PFS),posttestof
depressionandsleepquality,
resultwassignificant,
F(2,100)=3.99,p=0.02.Post
hoctestsrevealedthat
patientsintheacupressure
groupweresignificantly
havinglowerscoresoffatigue
thanpatientsinthecontrol
group.ANCOVAresultsalso
significantforVASofFatigue
amonggroups,F(2,100)=5.63,
p=0.003.Comparisons
indicatedthattherewere
significantdifferences
betweentheacupressure
groupandthecontrolgroup
(p=0.01)andbetweenthe
shamgroupandcontrolgroup
(p=0.003).Predialysisfatigue
wasassessedroutinelyby
usingaratingof010.
RepeatedmeasuresANOVA
resultsdemonstratethegroup
maineffectwassignificantin
theperceivedfatigue
(F(2,88)=19.46,p<0.001).
Followuptestsindicatedthere
weresignificantdifferences
betweentheacupressure
groupandthecontrolgroup
(p<0.001)andbetweenthe
shamgroupandcontrolgroup
(p<0.001).

Thestudyprovidedan
alternativemethodforhealth
careproviderstomanaging
ESRDpatientswithfatigue

Randomgroupassignment.

82

Threearmed(treatment,
placeboandcontrol)BUT
NOTblinded(inconclusion
obviouslypatientsareaware
thattheyarereceiving
acupointsornonacupoints
treatments)
Controlandintervention
groupsarehomogenous(no
significantdifferencesin
demographicandclinical
factors)andbaselinefactors
werecontrolledfor.
Reliabilityandvalidityof
procedureevaluated(expert
validation).Internal
consistencyofoutcome
measuresgood.

Author,dateandtitle

Tsay,S.L.,Cho,Y.C.,and
Chen,M.L.(2004).
Acupressureand
TranscutaneousElectrical
AcupointStimulationin
improvingfatigue,sleep
qualityanddepressionin
hemodialysispatients

Studymethodology,design,
setting,sample,condition
andintervention
Design:Prospective,
randomizedcontrolledtrial
Setting:4dialysiscentresin
majorhospitalsinNorthern
Taiwan.
Sample:106patients
randomlyassignedto
acupressure,Transcutaneous
ElectricalAcupointStimulation
(TEAS)orcontrolgroups.
Healthissue:Fatigue,sleep
qualityanddepressionin
patientswhowerereceiving
routinehemodialysistreatment

Results

Theresultsindicatedthat
patientsintheacupressure
(p=0.006)andTEASgroups
(p=0.02)hadsignificantly
lowerlevelsoffatigue,abetter
sleepquality(p=0.05and
p=0.016respectively)andless
depressedmoods(p=0.009
andp=0.008respectively)
comparedwithpatientsinthe
controlgroupbaseduponthe
adjustedbaselinedifferences
(groupmaineffectwas
significantp<0.001).However,
therewerenodifferences
Intervention:Patientsinthe
betweenacupressureand
acupressureandTEAS
TEASgroupsinoutcome
groupsreceived15minutesof measures(p>0.05).
treatment3timesaweekfor1
month,instructednotto
massageanyacupoints.
Acupressurewas3minsof
relaxingmassagethen3mins
peracupointonK1,St36,
GB34andSp6.Acupressure
wasthreetimesaweekfora
totalof4weeksPatientsin
thecontrolgrouponly
receivedroutineunitcare.
Methodsofmeasurement
includedtherevisedPiper
FatigueScale(PFS),the
PittsburghSleepQualityIndex
andtheBeckDepression
Inventory.Datawerecollected
atbaseline,duringthe
interventionandpost
treatment.

83

StudyConclusions

Commentsonquality

Thisstudyprovidesan
alternativemethodforhealth
careprovidersinmanaging
dialysispatientswith
symptomsoffatigue,poor
sleepordepression

Randomgroupassignment.
Threearmed.
Samplesizewaspowered.
Reliabilityandvalidityof
procedureevaluated(expert
validation).Internal
consistencyofoutcome
measuresgood.
Verylowattritionrate(2outof
108).
Groupshomogenous.
ANCOVAtotestforbaseline
differencestoestablishgroup
effectasmaineffect.
Nodetailsofblinding.
Lowgeneralisability
(haemodialysispatientsin
northernTaiwan).

Author,dateandtitle

Tsay,S.L.,Wang,J.C.,Lin,K.C.,
andChung,U.L.(2005).
Effectsofacupressuretherapy
forpatientshavingprolonged
mechanicalventilationsupport

Studymethodology,design,
setting,sample,conditionand
intervention
Design:Twogroupexperimental
blockingdesign.
Setting:Twointermediate
respiratoryintensivecareunits.
Thestudywascarriedoutin
2003.
Sample:52patientswith
chronicobstructivepulmonary
diseaseinnorthernTaiwan.
Healthissue:dyspnoea,anxiety
andphysiologicalindicatorsof
heartrateandrespiratoryratein
patientswithchronicobstructive
pulmonarydiseasehaving
mechanicalventilationsupport.

Results

StudyConclusions

Commentsonquality

Patientswithchronicobstructive
pulmonarydiseasewhowere
usingprolongedmechanical
ventilatorysupportexperienced
highlevelsofdyspnoeaand
anxiety.Dyspnoea(P=0.009),
anxiety(P=0.011)Heartrate
(p=0.005)andrespiratoryrate(P
<0.0001)intheacupressure
groupimprovedstatistically
significantlyovertimewhen
comparedwiththoseofthe
comparisongroup.

Thisresultssupportthe
suggestionthatacupressure
therapycoulddecrease
sympatheticstimulationand
improveperceivedsymptomsof
dyspnoeaandanxietyinpatients
withchronicobstructive
pulmonarydiseasewhoare
usingprolongedmechanical
ventilation

Samplesizepowered.
Procedurereliableandvalid
(expertvalidation).
Clinicaloutcomemeasures
(HRandRR)aswellasself
reported(VAS)
Singleblinded(patients,data
collectorsandcaregivers)but
notresearchers,nurses
givingacupressure.
Groupshomogenousfor
baselinedemographicsand
clinicalfactors.

Intervention:Aftermatchingfor
sex,ageandlengthofventilation
use,patientswererandomly
assignedtoanacupressure
groupandacomparisongroup.
Intheexperimentalgroup
receiveddailyacupressure
therapyandmassagetreatment
for10days,onL14,PC6,HT7
for4minseachand3mins
relaxingmassage.Patientsinthe
comparisongroupreceived
massagetreatmentand
handholding.Theprimary
outcomemeasureswerethe
visualanaloguescalesfor
dyspnoeaandanxiety,and
physiologicalindicatorsofheart
rateandrespiratoryrate.Data
werecollectedeverydayfrom
baseline(day1),duringthe
treatment(days210)andfollow
up(days1117).Datawere
analysedusinggeneralized
estimationequations.

UsedGEEtocontrolfor
confoundingvariables.
Noinformationon
dropout/compliancerates.

84

Author,dateandtitle

Waters,B.L.andRaisler,J.
(2003).
Icemassageforthereduction
oflaborpain

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:Aonegroup,pretest, Participantsnotedapain
posttestdesign
reductionmeanontheVASof
28.22mmonthelefthandand
Setting:HospitalinNew
11.93mmontherighthand.
Mexico
ThepostdeliveryrankedMPQ
droppedfromnumber3
Sample:Hispanicandwhite
(distressing)tonumber2
Medicaidrecipientswho
(discomforting).
receivedprenatalcareata
women'sclinicstaffedby
certifiednursemidwivesand
obstetricians

StudyConclusions

Commentsonquality

Thestudyresultssuggestthat
icemassageisasafe,
noninvasive,
nonpharmacologicalmethod
ofreducinglaborpain

Nocontrolorrandomisationor
blinding.
Conveniencesample,no
samplesizecalculated.
Lowdropoutrate(4from53).
Onlyearlylabourstages
investigatedduetodifficulties
completingVASlateron.
Limitedgeneralisability.

Healthissue:laborpain
duringcontractions

Nomonitoringofextrauseof
ice(byfamilymember)which
wasanoption.

Intervention:Icebagwas
appliedtoLi4during
contractionsfor20minseach
hand.Afamilymemberwas
thentaughttheprocedureso
couldcontinue.Thestudy
used100mmVisualAnalog
Scales(VAS)andtheMcGill
PainQuestionnaire(MPQ)
rankednumericallyand
verballytomeasurepain
levelsthepretestservedas
thecontrol.Analysiswas
standardanalysisofvariance.

Statisticalanalysiswas
limited.

85

Author,dateandtitle

Wu,H.S.,Wu,S.C.,Lin,J.G.,
andLin,L.C.(2004).
Effectivenessofacupressure
inimprovingdyspnoeain
chronicobstructivepulmonary
disease.

Studymethodology,design,
setting,sample,condition
andintervention
Design:Arandomizedblock
experimentaldesign.
Setting:Outpatients
departmentatamedical
centreandthreeregional
hospitalsinTaipei.
Sample:44patients
diagnosedwithCOPDand
livingathome.
Healthissue:Dyspnoeain
patientswithchronic
obstructivepulmonarydisease
(COPD)
Intervention:Usingage,sex,
pulmonaryfunction,smoking,
andsteroiduseasmatching
factors,wererandomly
assignedeithertoatrue
acupointacupressureora
shamgroup.Thetrueacupoint
acupressuregroupreceiveda
programmetodecrease
dyspnoea.Thoseinthesham
groupreceivedacupressure
usingshampressurepoints.
Bothacupressure
programmesconsistedoffive
sessionsperweeklasting16
minutespersession,
extendingover4weeksfora
totalof20sessions.Before
andafteroutcomemeasures:
PulmonaryStatusand
DyspnoeaQuestionnaire
modifiedscale(PFSDQM)
SpielbergerStateAnxiety
scale6minutewalking
distancetest.Physiological
indicatorsofoxygensaturation

Results

StudyConclusions

Commentsonquality

ScoresfromthePFSDQM
improvedsignificantlymorein
trueacupointgroupthansham
groupforallthreesubscales
dyspnoea(p<0.05),fatigue
(p<0.01)andactivity
(p<0.001).Tolerancefor
activity(walkingdistance
measurement)wasimproved
significantlyintrueacupoint
group(p<0.001).Pulmonary
function(respiratoryrateand
oxygensaturation)andstate
anxietyscoresalsoimproved
significantlymoreintrue
acupointgroupthansham
group(bothp<0.001)

Thefindingssuggestthat
acupressurecanbeusedasa
nursinginterventionto
improvedyspnoeainpatients
withCOPD

Smallsample(n=44)
Samplingmethodnotgivenin
detail.
Randomisedblockdesign,this
willgivemorepowerful
treatmenteffects,butonlyif
theblocksaremore
homogenousthanthewhole
sample,andnodiscussionof
howblockfactorswere
decided/justifiedisgivenhere.
Controlleddesignwithsham
treatmentshouldisolate
meridianeffects.Shampoints
especiallygoodasondifferent
meridiansandganglionic
sections.Howevereffects
maybeduetolocationof
points(ontheback)promoting
relaxation.
Acupressureprotocolhighly
reliableandvalidassubjectto
manytests:
independentlyrated
forvalidityand
amendedtogive
100%score
accuracyofpoints
observedbyTCM
practitioner
Trueandsham
treatmentscompared
onvideofor
homogeneityintiming

86

andrespiratoryratewere
measuredbeforeandafter
everysession.
Resultsanalysedusing
descriptivestatistics,chi
squaredandMannWhitneyU
tests.

Outcomemeasuresare
reliableandvalid.
Resultshighlysignificant
(mostp<0.001)forall
variables.
Generalisabilitylimitedas
majorityofsamplemaleand
averageage=73

87

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Yip,Y.B.andTse,S.H.(2004). Design:Randomised
ThebaselineVASscoresfor
controlledtrial
theinterventionandcontrol
groupswere6.38(S.E.M.=
Theeffectivenessofrelaxation
Setting:Thecommunity
0.22)and5.70(S.E.M.=0.37)
acupointstimulationand
centre,OldAgedHomeand
outof10,respectively(
acupressurewitharomatic
lavenderessentialoilfornon WomenWorkersAssociation, P=0.24).Oneweekafterthe
endoftreatment,the
specificlowbackpaininHong HongKong.
interventiongrouphad39%
Kong:arandomisedcontrolled
Sample:adultswithsub
greaterreductioninVASpain
trial
acuteorchronicnonspecific
intensitythanthecontrol
lowbackpain.
group(P=0.0001),improved
walkingtime(P=0.05)and
greaterlateralspineflexion
Healthissue:subacuteor
chronicnonspecificlowback range(P=0.01).
pain.
Groupsweresimilarforpain
duration(p=0.08).
Intervention:8session(35
40minseachrelaxation
Interferenceindailyactivities
acupointstimulationfollowed
byacupressurewithlavender wasunaffected.
oilovera3weekperiod.
Acupointstimulationwaswith 78%weresatisfiedand15%
stronglysatisfiedwith
digitalElectronicMuscle
SimulatoronLi10,Li11,Si10, treatment.
TW15andBL10,acupressure
onUB22,23,25,40.The
controlgroupreceivedusual
careonly.

StudyConclusions

Commentsonquality

Ourresultsshowthat8
sessionsofacupoint
stimulationfollowedby
acupressurewitharomatic
lavenderoilwereaneffective
methodforshorttermLBP
relief.Noadverseeffectswere
reported.Tocomplement
mainstreammedicaltreatment
forsubacuteLBP,the
combinedtherapyofacupoint
stimulationfollowedby
acupressurewitharomatic
lavenderoilmaybeoneofthe
choicesasanaddontherapy
forshorttermreductionof
LBP

Cointerventionsofelectrodes
andlavenderoil,also
performedondifferent
acupointstoacupressure.
Hardtoisolatethe
acupressureeffect.
Randomgroupassignment.
Acupointsvalidatedbyexpert.
Samplesizepowered
althoughvolunteersample,
mayintroducebias.
84%followupanddropoutnot
formedicalreasons.However,
dropoutgroupwereolderand
hadgreaterinterferenceon
dailyactivitieswhichmay
causebias.
Outcomemeasurescontent
validated
Groupshomogenousfor
sociodemographicand
clinicalvariables
Notblindedandnoplacebo
placeboeffectmaybepresent

Changesfrombaselinetothe
endoftreatmentwere
assessedinpainintensity(by
VisualAnalogueScale)and
durationlateralfingertipto
grounddistancein
centimetreswalkingtimeand
interferenceondailyactivities.

Interventiongrouphadmuch
morefrequentmeasurements
maycausebias.

88

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Yip,Y.B.andTse,S.H.(2006). Design:Experimentalstudy
ThebaselineVASscorefor
design
theinterventionandcontrol
groupswere5.12and4.91out
Anexperimentalstudyonthe
Setting:TheTelehealthclinic of10,respectively(P=0.72).
effectivenessofacupressure
andthecommunitycentre,
Onemonthaftertheendof
witharomaticlavender
HongKong.
treatment,comparedtothe
essentialoilforsubacute,
controlgroup,themanual
nonspecificneckpaininHong
Sample:adultswithsub
acupressuregrouphad23%
Kong
acutenonspecificneckpain. reducedpainintensity(P=
0.02),23%reducedneck
Healthissue:subacutenon stiffness(P=0.001),39%
specificneckpain
reducedstresslevel(P=
0.0001),improvedneckflexion
Intervention:Acourseof8
(P=0.02),necklateralflexion
sessionmanualacupressure
(P=0.02),andneckextension
withlavenderoilovera3
(P=0.01).However,
weekperiod.30minneckpain improvementsinfunctional
acupuncturemassageon20
disabilitylevelwerefoundin
pointsfor2minseach.
boththemanualacupressure
group(P=0.001)andcontrol
Changesfrombaselinetothe group(P=0.02).
endoftreatmentwere
assessedonneckpain
Interferencewithdailylife
intensity[byVisualAnalogue
improvedinbothgroupsat1
Scale(VAS)]stiffnesslevel
monthfollowup(p=0.001
stresslevelnecklateral
treatmentandp=0.02control).
flexion,forwardflexionand
extensionincm,and
76%weresatisfiedand16%
interferencewithdaily
stronglysatisfiedwith
activities.
treatment.

89

StudyConclusions

Commentsonquality

Ourresultsshowthateight
sessionsofacupressurewith
aromaticlavenderoilwerean
effectivemethodforshortterm
neckpainrelief

Smallsample(28completed)
Followupgood88%
Cointerventionoflavenderoil,
Hardtoisolatethe
acupressureeffect.
Randomgroupassignment.
Pointsvalidatedbyexpert.
Outcomemeasurescontent
validated
Groupshomogenousfor
sociodemographicand
clinicalvariables
Notblindedandnoplacebo
placeboeffectmaybepresent
Improvementinbothgroupsat
1monthindicatesmaybeneed
totestfortimeeffect
Interventiongrouphadmuch
morefrequentmeasurements
maycausebias.

Author,dateandtitle

Studymethodology,design, Results
setting,sample,condition
andintervention
Design:RCT
Yuksek,M.S.,Erdem,A.F.,
NOsignificantdifference
Atalay,C.,andDemirel,A.
betweengroups.Complete
Setting:Unclear,maybe
(2003).
(nobedwetting)andpartial
Turkey
responses(reductioninbed
wetting)after6monthsof
Acupressureversusoxybutinin
Sample:24patients
treatmentwereseenin83.3%
inthetreatmentofenuresis
and16.7%,respectively,of
Healthissue:nocturnal
patientstreatedwith
enuresis
acupressure,andin58.3%
and33.3%,respectively,of
InterventionAcupressure
childrenwhoreceived
wasadministeredto12
oxybutinin
patientsbytheirparents,who
hadbeentaughtthe
technique.Pressurewas
appliedbytheparentfor5sec
perpointperdayat
acupuncturepointsGv4,
Gv15,Gv20,B23,B28,B32,
H7,H9,St36,Sp4,Sp6,Sp12,
Ren2,Ren3,Ren6,K3and
K5.Twelvecontrolpatients
received0.4mg/kgoxybutinin.
Parentswereaskedtorecord
incidencesofbedwettingand
patientsand/orparents
completedaquestionnaire15
daysand1,3and6months
afterthestartoftreatment.
Analysiswasindependent
samplesttest,chi
squared/Fishersexacttest.

90

StudyConclusions

Commentsonquality

Inconclusion,nocturnal
enuresiscanbepartially
treatedbyoxybutininbut
acupressurecouldbean
alternativenondrugtherapy.
Acupressurehasthe
advantagesofbeingnon
invasive,painlessandcost
effective

Verysmallsample(12in
eachgroup).3patientswho
hadpreviouslyunsuccessful
pharmacologicaltreatment
movedtogroupA
(acupressure)>selection
bias.
Significancevaluesnotgiven.
6monthfollowupperiod
EthicalapprovalwasNOT
sought.
Verybriefreport,nodetailsof
sampling,randomisation,
comparisonofgroupsat
baseline
Introstatesstudyinvestigated
acupressureespeciallyfor
thosenotwantingdrugor
acupuncture
Acupressurecomparedto
drugnotplacebo/sham.

Appendix10Excludedfromreview
FulltextpublicationsexcludedatStage3screening
Exclusioncriteria:
Foreignlanguagepapers
UseofKoreanpoints/meridians
Useofplasters,devices,wristbands
Auricularacupressure
Anecdotalevidence
Personalexperience
Shiatsu/acupressurearementionedastreatmentsingeneralcomplementarymedicinepublicationsbut
arenotthemainsubjectareaofthepublication.
Guidelinesfortreatment
Reportsofpossibleadverseevents
Surveys
Conferenceabstracts/posters
Of the 146 publications that remained for screening and review, 44 were reviewed as evidence and
assessedforquality.41publicationswereconsideredusefulasbackgroundinformationbutnotevidence
onShiatsu/acupressure.Theremaining61publicationswereexcludedatthisstage,13Shiatsuand48
acupressure.
Excludedpublicationsandreasonsforexclusion

10.1Shiatsu
1.Atchison,J.W., Taub,N.S., Cotter,A.C., and Tellis,A. (1999). Complementary and alternative
medicine treatments for low back pain. Physical Medicine and Rehabilitation: State of the Art
Reviews 13:561586.
Thisisareviewofinformationandefficacyoftreatmentsforlowbackpainwhichincludemanipulation,
massagetherapy,mindbodytherapyandacupuncture
Reasonforexclusion: ShiatsuandacupressurearedescribedastherapiesintheMassagesectionand
brieflymentionedinaparagraphdiscussingefficacystudies
2.Booth,B.(1993).Shiatsu.NursTimes89:3840.
Thisisapartofaseriesoncomplementarymedicine
Reasonforexclusion: Thisisaverygeneralarticleisnotastudyanddoesnotaddtotheknowledgebase
forShiatsu.
3.CentreforReviewsandDissemination(2006).Ismassageusefulinthemanagementofdiabetes:
asystematicreview(Structuredabstract)
DatabaseofAbstractsofReviewsofEffectiveness.
Thisisasummaryofasystematicreview.
Reasonforexclusion:Shiatsuandacupressurewereincludedinthesearchtermsbutnotinanyofthe
studiesreviewed.
4.Daniels,J.M., Ishmael,T., and Wesley,R.M. (2003). Managing Myofascial Pain Syndrome: sorting
throughthediagnosisandhoningtreatment
PhysicianandSportsMedicine31:3945.
Thispaperdiscussestreatmentoptionsandguidelines
Reasonforexclusion: ThereisoneparagraphdescribingShiatsuasatechniquewithonereferencedating
backto1975

91

5.Elliott,M.A. and Taylor,L.P. (2002). "Shiatsu sympathectomy": ICA dissection associated with a
Shiatsumassager.Neurology58:13021304.
Thesearetwocasereportsofinternalcarotidartery(ICA)dissectionthatoccurredafteruseofaShiatsu
massagemachine.
Reasonforexclusion: ThisisnotrelatedtothepracticeofShiatsu.
6.Fields,N.(1995).Teachingthegentlewaytolabour...midwifery,yoga,Shiatsu.
NursingTimes1995Feb81491:4445.
ThisshortarticleexplainsthebenefitsofpractisingyogaandShiatsuduringpregnancy.
Reasonforexclusion:Thisisapersonalviewpointanddiscussescoursesavailableatacentrewherethe
authorteachesyoga.
7.Inagaki,J., Yoneda,J., Ito,M., and Nogaki,H. (2002). Psychophysiological effect of massage and
Shiatsuwhileinthepronepositionwithfacedown.NursHealthSci4:A5A6.
ThisstudyexaminedtheeffectofShiatsuandmassageon24healthywomen.
Reasonforexclusion:Thisisanabstractforasymposiumonhealthycarefortheelderly.Thereareno
referencesandthestudyhasnotbeenpublished.
8.Omura,Y. and Beckman,S.L. (1995). Application of intensified (+) Qi Gong energy, () electrical
field,(S)magneticfield,electricalpulses(12pulses/sec),strongShiatsumassageoracupuncture
ontheaccurateorganrepresentationareasofthehandstoimprovecirculationandenhancedrug
uptake in pathological organs: clinical applications with special emphasis on the "Chlamydia
(Lyme)uric acid syndrome" and "Chlamydia(cytomegalovirus)uric acid syndrome".
Acupunct.Electrother.Res20:2172.
This study included 15 patients presenting with a variety of symptoms. It investigated a number of
interventionsusedtoimprovecirculationbystimulationoforganpointsonthehands.
Reasonforexclusion: Koreanpointswereusedanddeepmassageand/orShiatsuwasappliedforabout
aminuteonorganrepresentationareas.
9.Omura,Y.,Shimotsura,Y.,Ooki,M.,andNoguchi,T.(1998).Estimationoftheamountoftelomere
molecules in different human age groups and the telomere increasing effect of acupuncture and
Shiatsu on St.36, using synthesized basic units of the human telomere molecules as reference
controlsubstancesforthebidigitalOringtestresonancephenomenon.Acupunct.Electrother.Res
23:185206.
Thisstudyincludedapproximately30subjectswithagesrangingfrominfancyto76yearsofage.There
wasnoindicationonhowthesesubjectsweregroupedtoreceivetheinterventions.
Reasonforexclusion:Thiswasapreliminaryreporttoassesstheeffectofacupunctureand/orShiatsu
ontelomerelevels.Thereweresomeresultsreportedforthosewhohadreceivedacupuncturebutnone
given for Shiatsu, other than a comment that Shiatsu had less of an effect than acupuncture. It was
unclearifsubjectshadreceivedbothacupunctureandShiatsu.
10. Saito,H. (2000). Preventing and resolving postlaparotomy intestinal obstruction: an effective
Shiatsumethod.AmJChinMed28:141145.
ThisdescribestheeffectofShiatsufrompersonalexperienceandfromonecasereport.
Reasonforexclusion: Thisisapersonalviewpointwithreferencestotheauthorspublicationsfollowinghis
experiencewithcancer.
11. Toth,M., Kahn,J., Walton,T., Hrbek,A., Eisenberg,D.M., and Phillips,R.S. (2003). Therapeutic
Massage Intervention for Hospitalized Patients with Cancer: A Pilot Study. Alternative &
ComplementaryTherapies9:117124.
Thispilotstudyinvestigatedtheeffectofpermittedmassagetechniquesonsevenconsentingpatients,four
ofwhomdiedduringhospitalisation
Reasonforexclusion:Shiatsuandacupressurewerebothmentionedaspermittedtechniques,butthereis
noindicationthateitherwasused.

92

12.ViggoHansen,N.,Jorgensen,T.,andrtenblad,L.(2004).MassageandTouch
fordementia[Protocol].CochraneDatabaseofSystematicReviews.
Comment: This is the protocol for the systematic review which was subsequently published on 18th
October2006:
Viggo Hansen N, Jrgensen T, rtenblad L. Massage and touch for dementia. Cochrane Database of
SystematicReviews2006,Issue4.Art.No.:CD004989.DOI:10.1002/14651858.CD004989.pub2.
Reasonforexclusion:Shiatsuwasincludedinthesearchtermfortrials.However,noShiatsutrialswere
includedandonlytwotrialswerefoundtomeettheminimalmethodologicalcriteria.
13.Zullino,D.F.,Krenz,S.,Fresard,E.,Cancela,E.,andKhazaal,Y.(2005).Localbackmassagewith
anautomatedmassagechair:generalmuscleandpsychophysiologicrelaxingproperties.JAltern
ComplementMed11:11031106.
ThisstudiestheeffectofthreedifferentShiatsumassageprogrammesontenhealthyvolunteers.
Reasonforexclusion:Useofamassagechair.

10.2Acupressure
A. Devicesused
Inthe14studieslistedinthissection,acupressurewasnotappliedmanuallybutbyusingdevicessuchas
wristbands,particularlyinstudiesinvestigatingtheeffectsofacupressureonnauseaandvomiting.Those
mostcommonlyusedwereSeaBandwhichresemblesweatbandswhichhaveaplasticbuttonattached.
Thesebandswereinitiallyproducedtorelievetravelsicknessbuttheirusehasbeenextendedtoinclude
treatmentofnauseaandvomitingassociatedwithpregnancy,chemotherapyandpostoperativeeffectsof
anaesthesia.(Bayreuther,Pickering,Lewith,1994)
1. Alkaissi,A.,Stalnert,M.,andKalman,S.(1999).Effectandplaceboeffectofacupressure(P6)on
nauseaandvomitingafteroutpatientgynaecologicalsurgery. ActaAnaesthesiol.Scand. 43:270274.
Reasonforexclusion: Wristbands(SeaBand)used
2.Alkaissi,A.,Ledin,T.,Odkvist,L.M.,andKalman,S.(2005).P6acupressureincreasestoleranceto
nauseogenicmotionstimulationinwomenathighriskforPONV.Can.JAnaesth.52:703709.
Reasonforexclusion:Wristbands(SeaBand)used
3.Bayreuther,J.,Pickering,R.,andLewith,G.T.(1994).Adoubleblindcrossoverstudytoevaluate
theeffectivenessofacupressureatpericardium6(P6)inthetreatmentofearlymorningsickness
(EMS).ComplementaryTherapiesinMedicine2:7076.
Reasonforexclusion:Wristbands(SeaBand)used
4.Felhendler,D.andLisander,B.(1996).Pressureonacupointsdecreasespostoperativepain. ClinJ
Pain12:326329.
Reasonforexclusion: Dentiststoolused
5. Felhendler,D. and Lisander,B. (1999). Effects of noninvasive stimulation of acupoints on the
cardiovascularsystem.ComplementTherMed7:231234.
Reasonforexclusion: Dentiststoolused
6. Harmon,D., Gardiner,J., Harrison,R., and Kelly,A. (1999). Acupressure and the prevention of
nauseaandvomitingafterlaparoscopy.BrJAnaesth.82:387390.
Reasonforexclusion:Wristbands(SeaBand)used

93

7.Harmon,D.,Ryan,M.,Kelly,A.,andBowen,M.(2000).Acupressureandpreventionofnauseaand
vomitingduringandafterspinalanaesthesiaforcaesareansection.BrJAnaesth.84:463467.
Reasonforexclusion: Wristbands(SeaBand)used
8. Heazell,A., Thorneycroft,J., Walton,V., and Etherington,I. (2006). Acupressure for the inpatient
treatment of nausea and vomiting in early pregnancy: a randomized control trial Am J
Obstet.Gynecol.194:815820.
Reasonforexclusion:Wristbands(SeaBand)used
9. Melchart,D., IhbeHeffinger,A., Leps,B., von,S.C., and Linde,K. (2006). Acupuncture and
acupressure for the prevention of chemotherapyinduced nauseaa randomised crossover pilot
study.Support.CareCancer14(8):878882.
Reasonforexclusion:Acupressurewristbandsused,brandnotspecified.
10.Neri,I.,Allais,G.,Schiapparelli,P.,Blasi,I.,Benedetto,C.,andFacchinetti,F.(2005).Acupuncture
versuspharmacologicalapproachtoreduceHyperemesisgravidarumdiscomfort.MinervaGinecol.
57:471475.
Reasonforexclusion:Wristbands(SeaBand)used.
11. Tokumaru,O. and Chen,J.D.(2005).Effectsofacupressureongastricmyoelectricalactivityin
healthyhumans.Scand.JGastroenterol40:319325.
Reasonforexclusion:Pressureappliedusinga3pounddumbbell.
12. Wang,S.M., Gaal,D., Maranets,I., CaldwellAndrews,A., and Kain,Z.N. (2005). Acupressure and
preoperativeparentalanxiety:apilotstudy.Anesth.Analg.101:6669.
Reasonforexclusion: Acupressurebeadmanufacturedwithanocclusivetapecovering.
13. Werntoft,E. and Dykes,A.K. (2001). Effect of acupressure on nausea and vomiting during
pregnancy.Arandomized,placebocontrolled,pilotstudy.JReprod.Med46:835839.
Reasonforexclusion:Acupressurewristbandsused,brandnotspecified.
14. Wollaston,D.E., Xu,X., Tokumaru,O., Chen,J.D., and McNearney,T.A. (2005). Patients with
systemic sclerosis have unique and persistent alterations in gastric myoelectrical activity with
acupressuretoNeiguanpointPC6.JRheumatol.32:494501.
Reasonforexclusion:Pressureappliedusinga3pounddumbbell.
B. Applicationtootherpointsand/ortreatmentguidelines
AcupressurewasincludedintheMeSHtermsoftheMEDLINEcitationsofthefollowingpapers,butthis
wasnotthemaintherapeuticinterventionorsubjectareainthemajorityofthem.Itshouldalsobenoted
that the references in papers from the Journal of Traditional Chinese Medicine are in Chinese and
thereforecannotbecheckedorverified.
1. Bei,Y., Fang,X., and Yao,Z. (2004). Sixtytwo cases of simple obesity treated by acupuncture
combinedwithmassage.JTradit.ChinMed24:3639.
Thisstudycompared32casestreatedwithauricularseedembeddingandmassagewith30casestreated
withauricularseedembeddingandacupuncture
Reasonforexclusion: Treatmentdidnotincludeacupressureoracupoints.Massageincludedspinal
pinchingandmanipulation.
2.Chen,R.(1997).Treatmentofapoplectichemiplegiabydigitalacupointpressureareportof42
cases.JTradit.ChinMed17:198202.

94

Thispaperdescribes3methodsofdigitalacupointpressure(DAP)one,threeandfivedigitswhichthe
authorhasusedtotreat42caseswithdifferingdiagnoses.
Reasonforexclusion:Thispaperfocusesonhowtoapplyatherapeuticprocedureandbrieflysummarises
theauthorsanalysisofthetherapeuticeffecton42unrelatedcases.
3.Cui,M.(1996).Advancedinstudiesonacupunctureabstinence.JTradit.ChinMed16:6569.
This paper reviews methods for treating addiction (smoking and alcohol). These include auricular
acupuncture,electroacupuncture,auricularplasterswithseedsembeddedandlaserradiation.
Reasonforexclusion: Acupressurewasnotaconsideredmethod
4. Cummings,M. (2001). Hand acupressure reduces postoperative vomiting after strabismus
surgery(n=50).Acupunct.Med 19:5354.
Thisisareviewofastudywhichisincludedinasectionofresearchreviews.Thestudyinvestigatedthe
effectsofplacinganacupressuredevice(smalldisc)onaKoreanhandacupuncturepoint.
Reasonforexclusion: AKoreanpointandadevicewereused.
5.Dai,G.(1997).Advancesintheacupuncturetreatmentofacne.JTradit.ChinMed17:6572.
Thispaperreviews38studiesonthetreatmentofacne.Theinterventionsincludebodyacupuncturein
combination with either moxibustion, electric stimulation, herbs, cupping, pricking ordrawingbloodand
auricularacupuncture.Thereisonestudywhichreferstodigitalfacialacupointpressure.
Reasonforexclusion: AcupressureisonlymentionedbrieflyandthereferencetothestudyisinChinese.
6.Li,Y.andPeng,C.(2000).Treatmentof86casesoffacialspasmbyacupunctureandpressureon
otopoints.JTradit.ChinMed20:3335.
Thisstudycompared86casestreatedwithacombinationofacupunctureonfacialacupointsandpressure
with Vaccariasegetalisseedsonselectedotopointswith38casestreatedwithfacialacupunctureonlyand
40casestreatedwithpressureonotopointsonly.
Reasonforexclusion: Treatmentdidnotincludeacupressureonacupoints.
7.Ma,J.(1995).Periomarthritistreatedwithpainpointpressureincombinationwithlocalexercises.
JTradit.ChinMed15:289.
Thispaperdescribestheapplicationofpressuretopainpointsandquotesonecasestudy.
Reasonforexclusion:Treatmentdidnotinvolveacupoints
8.Shen,P.(2004).Twohundredcasesofinsomniatreatedbyotopointpressureplusacupuncture.J
Tradit.ChinMed24:168169.
ThispaperdescribesatreatmentprotocolusingselfappliedpressurewithVaccariasegetalisseedson
selectedotopointscombinedwithacupunctureatselectedpointsfordifferentlevelsandtypesofinsomnia.
Reasonforexclusion:Treatmentdidnotincludeacupressureonacupoints.
9. Vachiramon,A. and Wang,W.C. (2002). Acupressure technique to control gag reflex during
maxillaryimpressionprocedures.JProsthet.Dent.88:236.
Thisisaletterwhichdescribestheauthorsuseofacupressuretomanagethegagreflex.Theauthors
refertoastudythathasbeenincludedforreview:
Lu,D.P.,Lu,G.P.,andReed,J.F.,III(2000).Acupuncture/acupressuretotreatgaggingdentalpatients:a
clinicalstudyofantigaggingeffects.GenDent.48:446452.
Reasonforexclusion: Thisisbasedontheauthorspersonalexperience.
10. Vachiramon,A. and Wang,W.C. (2005). Acupuncture andacupressuretechniquesforreducing
orthodonticpostadjustmentpain.JContemp.Dent.Pract6:163167.
Thispaperintroducestechniquesthatthemayreducedentalpain.Asin9above,theauthorsrefertoa
studythathasbeenincludedforreview:
Lu,D.P.,Lu,G.P.,andReed,J.F.,III(2000).Acupuncture/acupressuretotreatgaggingdentalpatients:a
clinicalstudyofantigaggingeffects.GenDent.48:446452.

95

Reason for exclusion: This introduced a technique to fellow dentists and their patients. It cannot be
consideredasevidence.
C.Commentsreferringtopapersincludedforreview
1.Bledsoe,B.E.andMyers,J.(2003).Futuretrendsinprehospitalpainmanagement.JEMS.28:68
71.
This focuses on various drug options and briefly mentions one study that is included in the evidence
review:
Kober,A., Scheck,T., Greher,M., Lieba,F., Fleischhackl,R., Fleischhackl,S., Randunsky,F., and
Hoerauf,K. (2002). Prehospital analgesia with acupressure in victims of minor trauma: a
prospective,randomized,doubleblindedtrial.Anesth.Analg.95:723
2. Golembiewski,J.A. and O'Brien,D. (2002). A systematic approach to the management of
postoperativenauseaandvomiting.JournalofPeriAnesthesiaNursing17:364376.
Althoughthisisanextensivereview,onlythreeoutof59referencesrefertoacupointstimulationandonly
oneoftheseisincludedinthisevidencereview:
Ming,J.L.,Kuo,B.I.,Lin,J.G.,andLin,L.C.(2002).Theefficacyofacupressuretopreventnauseaand
vomitinginpostoperativepatients.JAdvNurs39:343351
D. Systematic and other reviewswhereacupressureisincludedintheMeSHtermsofMEDLINE
citations
1.Allaire,A.D.(2001).Complementaryandalternativemedicineinthelaboranddeliverysuite.Clin
Obstet.Gynecol.44:681691.
Thisisaliteraturereviewwithalimitedmethodology.Acupressureisincludedwithacupunctureandrelated
modalities.
Reasonforexclusion: Acupressureisdescribedasaformofacupuncture,therearenoreferencestoany
acupressurestudies.
2.Dune,L.S.andShiao,S.Y.(2006).Metaanalysisofacustimulationeffectsonpostoperativenausea
andvomitinginchildrenExplore(NY)2:314320.
Thismetaanlysisinvestigatedtheeffectsofanumberofacupunctureandacupressuretechniques.These
includedtheuseofelectrodes,lasers,bandsandplasters.12RCTswerereviewed,fiveofthesereferred
toacupressureoracupressureinconjunctionwithacupuncture.
Reason for exclusion: None of the five studies used manual acupressure. The interventions were
acuplasters,bands,pressureonKoreanpoints,electrodeacupressure.
3. Ernst,E. (1997). Acupuncture/acupressure for weight reduction? A systematic review.
Wien.Klin.Wochenschr.109:6062.
Fourclinicaltrialsfulfilledtheinclusioncriteriaforthisreview.Oneofthesestudiesusedacupressureas
theintervention.
Reasonforexclusion:Acupressuredevices,oneintheearandoneonthewrist,wereused
4. FughBerman,A., Kronenberg,F. (2003). Complementary and alternative medicine (CAM) in
reproductiveage women: a review of randomized controlled trials. Reproductive Toxicology
17:137152.
Thissystematicreviewinvestigatedcomplementaryandalternativemedicinetrialsrelevanttoobstetrics
and gynaecology. Ten trials where acupressure was used for nausea and vomiting associated with
pregnancywereincluded.
Reasonforexclusion: Nineofthesetrialsusedacupressurewristbands.Onetrialwhereacupressurewas
selfapplied,datedfrom1988andthereforenotconsideredforinclusion.

96

5.Keller,V.E.(1995).Managementofnauseaandvomitinginchildren.JournalofPediatricNursing
10:280286.
Thisreviewedavailablepharmacologicalandnonpharmacologicalinterventionsincludingacupunctureand
acupressure.
Reasonforexclusion:Theuseofacupressurebandswasmentionedasapossibleintervention.
6. Thompson,H.J. (1999). The management of postoperative nausea and vomiting. J Adv Nurs
29:11301136.
Thisreviewedpharmacological,dietaryandbehaviouralinterventions.Acupressurewasconsideredasa
behaviouralintervention.
Reasonforexclusion:Theuseofacupressurebandswasmentionedasapossibleintervention.
7.White,A.,Rampes,H.,andCampbell,J.(2006).Acupunctureandrelatedinterventionsforsmoking
cessation.CochraneDatabaseSystRev(1):CD000009.
Acupressurewasconsideredasarelatedinterventionandinvestigatedforitseffectivenessforsmoking
cessation.24studieswereincludedinthereview,threeofthesereferredtotheuseofacupressureeither
aloneorinconjunctionwithacupunctureorelectroacupuncture.
Reasonforexclusion: Auricularacupressurewithseedswastheinterventionusedinallthreestudies.
E.Applicationofsubstancestoacupressurepoints
Allfourpapersdiscussthepossibletherapeuticeffectsofapplyingfloweressencesandessentialoilsto
acupressurepoints.Thesepapersmaybeofgeneralinterestbuttheydonotaddtotheevidencebase.
1.Balinski,A.A.(1998).UseofWesternAustralianfloweressencesinthemanagementofpainand
stressinthehospitalsetting.ComplementaryTherapiesinNursingandMidwifery4:111117.
Abstract: This article explores the use of the unique flora from Western Australia. These wildflower
essencesarecollectedfromacrossthestateandaremadeintofloweressences.Theseessencesare
madeinaformsimilartohomoeopathy.Theessencescanbegiveninternally,orappliedtotheexternal
body and acupressure points. Angela and Craig Balinski have used the Western Australian flower
essences in their complementary therapy practice where patients are treated for stress and pain
management. This programme is currently being utilized at nine of Perth's hospitals. The Western
Australian flower essences and their specific application techniques are compatible within the hospital
environmentbecausetheyaresafe,produceconsistentresults,andtakelittletimetoapplytothepatient.
Oneoftheotheroutstandingfeaturesoftheseessencesisthattheycanbeusedwithoutanyinterference
to medical procedures. The Western Australian flower essences and the techniques for their use are
unique and have, over the last two years, been presented at all of the major nursing conferences in
Australia. At present, across Australia there are over 16 hospitals which are currently offering these
treatmentstotheirpatients
2.Mojay,G.(1998).Aromaticacupressure:Thetherapeuticapplicationofspecificessentialoilsfor
the organ meridians and acupressure points of oriental medicine. International Journal of
Aromatherapy9:105114.
Noabstractavailable
3. Mojay,G. (2002). Healing the jade poolthe phytoaromatic and acupressure treatment of
dysmenorrhoea and menopausal syndrome: an EastWest approach. International Journal of
Aromatherapy12:131141.
Abstract: Contrary to orthodox scientific medicine, gynaecological therapeutics in traditional Chinese
medicine(TCM)isinseparablefromthetreatmentofthewomanasawholeprimarilybecause,fromthe
perspective of TCM, the precise nature of her symptomatology, carefully analyzed and assessed,
implicatesimbalancesthathavetheirrootinherenergeticconstitutionalphysiology.Thus,inthelanguage
of TCM, it is only by addressing the problem in the root (Ben) that one is able to begin healing the
manifestationorbranch(Biao).

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While pharmacological drugs, through their refined or synthesized single compound structure, are
necessarily designed to address only the branch of a disease, essential oils have a dynamic,complex
structureandthusasynergisticactivitywhichisfundamentallyinkeepingwiththebodysownfunctional
biochemicalhomeostaticintricacy.However,thefullpotentialofthewholesystempropertiesofessential
oils can only be achieved through a therapeutic system that can describe and match these, through
thoroughdiagnosisandaccurateapplication,tothetrueclinicalneedsoftheclientpatient.
Through affording such a system, Oriental medicine allows the clinical aromatherapist to approach the
treatmentofcommongynaecologicalconditionssuchasdysmenorrhoeaandmenopausalsyndromewith
the diagnostic differentiation that a truly individualized natural therapy demands. In such a context, the
practitionersscientific,evidencebasedknowledgeofessentialoiltherapeuticsneednotbedisregarded
andindeedisoftenprovidedwithabroadenedsignificanceandamorepreciseapplication.
In this paper, Gabriel Mojay draws from his 15 years experience of treating dysmenorrhoea and
menopausalsyndromewiththeaidofessentialoilsandaromaticacupressureaccordingtothediagnostic
wisdomofOrientalmedicine.
4.Mojay,G.(2004).Thearomaticandacupressuretreatmentofcommonmusculoskeletaldisorders:
anOrientalmedicineapproachInternationalJournalofAromatherapy14:8188.
Abstract:Althoughresearchevidencedoesexistformanyofthemostcommonessentialoilsusedinthe
relief of joint pain, stiffness and inflammation, the purpose of this paper is to outline a terrainbased
approachtothearomatictreatmentofrheumaticconditionsanapproachthatisdefinedbytheprinciples
ofOrientalmedicine.Thepurposebehindthisisnottoofferanalternativetherapeuticmethodology,but
onethatiscomplementarytothatofscience
F.Conferenceabstractsandposters
Thesepublicationshavebeenexcludedastheyareverybriefreportsofstudies,therearenoreferences
andnosubsequentpublicationshavebeenfound.
1. Hoffman,T.S., Hu,S., Stritzel,R., and Chandler,A. (1995). P6 acupressure reduces nausea and
gastrictachyarrhythmiaprovokedbyoptokineticrotation.Gastroenterology108:A615.
Thisstudy,with64subjects,investigatedtheeffectivenessofP6acupressureonreducingnauseainduced
byviewinganoptokineticrotatingdrum.Theabstractdidnotstatehowacupressurewasapplied,butas
thesubjectssatinthedrum,itisprobablethatwristbandswereused.Fromtheresults,itwasconcluded
thatP6acupressurereducednausea.
2. Lu,B., Ren,S., Hu,X., and Lichstein,E. (2000). A randomized controlled trial of acupuncture and
acupressuretreatmentforessentialhypertension
AmericanJournalofHypertension13:S185.
Thisstudy,with12patients,investigatedtheeffectofacupunctureandselfadministeredacupressureon
high blood pressure. Although not clearly stated, it would appear that auricular acupressure was self
administered.TheresultssuggestedthattheinterventionsmaybeefficaciousindecreasingarterialBPin
hypertensivepatients.
3. Park,Y., Cho,J., Kwon,J., Ahn,E.,Lim,J.,andChang,S.(2003).TheeffectofSanYinJiao(SP6)
acupressureonlaborprogression.AmericanJournalofObstetricsandGynecology189:S209.
Thisstudy,with62pregnantwomen,evaluatedtheeffectofacupressureonpainrelief,labourtimeand
frequencyandintensityofuterinecontractions.Itwasnotstatedhowtheacupressurewasapplied.From
the results it was concluded that pain was reduced and effective and adequate uterine contractions
inducedinthegroupreceivingacupressure.
G.Miscellaneous
1.Hoo,J.J.(1997).Acupressureforhyperemesisgravidarum.AmJObstet.Gynecol.176:13951397.
Reasonforexclusion: Thisletterdiscussesthelocationofthecorrectacupointandreferstoareviewof 33
controlledtrials VickersA.J(1996)Canacupuncturehavespecificeffectsonhealth?Asystematicreview

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ofacupunctureantiemesistrials.JRSocMed89:303311.Thisreviewwasnotincludedintheresultsof
anyoftheShiatsusearches.
2.Simkin,P.andBolding,A.(2004).Updateonnonpharmacologicapproachestorelievelaborpain
andpreventsufferingJournalofMidwifery&WomensHealth49:489504.
Reasonforexclusion: Thisisanupdatetopreviousreviewswhichfoundnoacupressuretrialsforlabour
painandthereforehasnorelevancetothisreview.
3.Youngs,P.J.(2000).Acupressureandpreventionofnauseaandvomiting.BrJAnaesth.85:807
808.
Reason for exclusion: This is a comment on the drugs used in a study that investigated the use of
wristbands.
H.DuplicatepublicationsfromScienceDirectsearches
1.Markose,M.T.,Ramanathan,K.,andVijayakumar,J.(2004).Reductionofnausea,vomiting,anddry
retches with P6 acupressure during pregnancy International Journal of Gynecology & Obstetrics
85:168169.
Reason for exclusion: This is a duplicate reference from a Science Direct search. The result from the
MEDLINEsearchhasbeenincludedforreview.
2. McDougall G J,J. (2005). Research review: The effect of acupressure with massage on fatigue
anddepressioninpatientswithendstagerenaldiseaseGeriatricNursing26:164165.
Reason for exclusion: This is a duplicate reference from a Science Direct search. The result from the
MEDLINEsearchhasbeenincludedinthebackgroundinformationsection..
3. Murphy,P.A. (1998). Alternative therapies for nausea and vomiting of pregnancy Obstetrics &
Gynecology91:149155.
Reasonforexclusion: ThisisaduplicatereferencefromaScienceDirectsearch.Theresultfromthe
MEDLINEsearch,wheretheauthordetailsapprearedasAikinsM.Phasbeenincludedinthebackground
informationsection.
I.PublicationsinGerman
Foreignlanguagepaperswerepartoftheexclusioncriteria.Itwashopedthatthefollowingtwopapers
couldbetranslatedandthereforeincludedhowever,thiswasnotpossible.
1.Litscher,G.(2004).Effectsofacupressure,manualacupunctureandLaserneedleacupunctureon
EEGbispectralindexandspectraledgefrequencyinhealthyvolunteers.EurJAnaesthesiol.21:13
19.
Abstract:BACKGROUNDANDOBJECTIVE:Themainpurposeofthisstudywastoinvestigatetheeffects
of sensory (acupressure and acupuncture) and optical stimulation (Laserneedle acupuncture) on
electroencephalographic bispectral index, spectral edge frequency and a verbal sedation score.
METHODS:Twentyfivehealthyvolunteers(meanage+/SD:25.5+/4.0yr)wereinvestigatedduringthe
awakestate.TheacupuncturepointYintangandaplacebocontrolpointwerestimulated.Thestudywas
performedasarandomized,controlledandpartlyblindedcrossovertrial.RESULTS:Bispectralindexand
spectraledgefrequencyvaluesbothdecreasedsignificantly(P<0.001)duringacupressureonYintangto
valuesof62.9(minimum35)+/13.9bispectralindexandto13.3(minimum2.9)+/8.1Hz(spectraledge
frequencyright)and13.8(minimum2.7)+/7.3Hz(spectraledgefrequencyleft),respectively.Bispectral
index was also significantly (P < 0.05) affected by Laserneedle acupuncture and acupressure on the
control point but the changes were not clinically relevant, 95.4 +/ 4 and 94.2 +/ 4.8, respectively. All
interventions significantly (Yintang: P < 0.001 control point: P < 0.012) reducedverbalsedationscore.

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CONCLUSIONS: The study highlights the electroencephalographic similarities of acupressure induced

sedationandgeneralanaesthesiaasassessedbybispectralindexandspectraledgefrequency
2.Schlager,A.(1998).[Acupunctureinpreventionofpostoperativenauseaandvomiting].Wien.Med
Wochenschr.148:454456.
Abstract: In this review the effectiveness of the acupuncture point Pericard 6 (P 6) on postoperative
nausea and vomiting (PONV) is described. Use of the acupuncture, acupressure as well as the laser
stimulationofP6provedasefficientprophylaxisofPONVinnumerousstudies.Thesemethodsarefreeof
sideeffectsandrepresentthereforeagoodalternativetothepharmacologicalprophylaxisandtreatmentof
PONV.
J.PublicationsfromsecondMeSHtermseach
(seeAppendix4forsearchdetails)
1. Matsumura,W.M. (1993). Use of acupressure techniques and concepts for nonsurgical
managementofTMJdisorders.JGenOrthod.4:516.
Therewasnoabstractavailableforthispublicationanditwasnotpossibletoobtainafulltextcopy,itwas
thereforeexcluded.
2. Vickers,A.J. (1996). Can acupuncture have specific effects on health? A systematic review of
acupunctureantiemesistrials.JRSocMed89:303311.
Thiswasreferredtoinanexcludedletter:
Hoo,J.J.(1997).Acupressureforhyperemesisgravidarum.AmJObstet.Gynecol.176:13951397.
Itwasfoundtobeindexedunderacupuncturetherapyanddidnotappearinanysearches,originalor
thosecarriedouton24th Augustasthekeywordsincludedacupuncture.34studieswerereviewed,seven
ofwhichreferredtomanualacupressure,threewerebefore1990,threewereexcludedfromthisevidence
review and one was subsequently included from the MEDLINE acupressure search of 24th August.
(Belluomini,J.,Litt,R.C.,Lee,K.A.,andKatz,M.(1994). Acupressurefornauseaandvomitingofpregnancy:
arandomized,blindedstudy.ObstetGynecol84:245248.)

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Appendix11Backgroundreview
BackgroundinformationonShiatsuandacupressure
Of the 146 publications that remained for screening and review, 44 were reviewed as evidence and
assessedforqualityand61wereexcludedfromanyfurtherassessment.41publicationswereconsidered
usefulasbackgroundinformationbutdidnotprovidespecificevidenceoneffectivenessofeitherShiatsuor
acupressure. 22 of these publications referred to Shiatsu and 19 to acupressure. Abstracts, where
availableareshownbelow,togetherwithanyapplicablecommentsonthepublications.

11.1Shiatsu
FourpapersweresinglecasereportsofadverseeventsthatoccurredfollowingShiatsumassage.
1.Herskovitz,S.,Strauch,B.,andGordon,M.J.(1992).Shiatsumassageinducedinjuryofthemedian
recurrentmotorbranch.MuscleNerve15:1215.
Comment: This letter expressed the concern that the popularity of massage techniques, particularly
vigourousones,mayresultinthistypeofinjury.Thecaseforconcernwasthatofa61yearoldphysician
whounderwentaprofessionalShiatsumassagewhichincludedtheapplicationofstrongdigitalpressure
in the region of the base of the palm and thenar muscles.ThedayafterShiatsu,therecipientnoticed
'painlessweaknessoftheleftthumb,withoutsensorysymptoms'.Medicalexaminationsuggested'isolated
dysfunctionoftherecurrentthenarmotorbranchofthemediannerve,apparentlytheresultoffocaltrauma
fromthemassage.'Thesymptomsimprovedafterthreeweeksandnormalisedoverthenextfewmonths.
While it could be considered that that there is no direct evidence that the massage caused the injury,
practitionersshouldbeawareofthispossibleadverseeventoccurring.
2.Mumm,A.H.,Morens,D.M.,Elm,J.L.,andDiwan,A.R.(1993).ZosterafterShiatsumassage.Lancet
341:447.
Comment:Thisletterreferredtoacaseofvaricellazostervirusdiagnosedina64yearoldwomanseven
daysafterreceivinganoverlyvigorousShiatsumassage.Theauthorsspeculatethatinthiscasezoster
resulted from either direct trauma to the nerve or nerve root during the massage, or to subsequent
inflammationcausingswellingorimmunologicalinjurytothenerve.Theyalsostatethatvaricellazoster
virusisrarelydiagnosedtoday,thispatienthavingsufferedapreviousepisodeattheageof11,andthat
muchoftheevidencefortheexistenceofthisconditionisanecdotal. Althoughacausallinkcannotbe
scientificallyproven,thiscaseraisesawarenessofpossibleadverseevents.
3. Tsuboi,K. (2001). Retinal and cerebral artery embolism after "Shiatsu" on the neck. Stroke
32:2441.
Comment:This letter referred to thecaseofan80yearoldmanwhohadbeenhospitalisedforseven
days following a transient ischemic attack. On the evening he was discharged, he received a Shiatsu
massageonhisneckfor10minutesandimmediatelyafterrising, hewasawarethatthenasalhalfofhis
rightvisualfieldwasimpaired.Hewashospitalisedforafurthersevendaysandexaminationsrevealed
diffuse retinal edema with multiple emboli in many branchesof the central retinal artery. Although the
author could not find any medical reports of cerebral or retinal arteryembolisms directly caused by
Shiatsu, he stressed that complications can be avoided ifpatients at high risk are properly informed
beforehandofthe potentialassociationbetweenembolicstrokeandmanipulation ontheneck.
Thisletterhighlightsapotentialriskofembolicaccidentsandseriousneurological symptomsinpatients
withatheroscleroticextracranialcarotid arterydisorders.
4. Wada,Y., Yanagihara,C., and Nishimura,Y. (2005). Internal jugular vein thrombosis associated
withShiatsumassageoftheneck.JNeurolNeurosurgPsychiatry76:142143.
Comment: This letter suggested, that although possibly coincidental, a causal link between Shiatsu
massageandIJVthrombosissupportedbypatientsclaimofamassageinduced swellingandpaininhis
neck,andbythetemporalrelation betweenthemassageandtheonsetofsymptomsthatprogressed toIJV

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andcerebralvenoussinusthrombosis.Althoughtheexactmechanismofthethrombosisinthiscasecould
notbedetermined,theauthorsstatetwopossibilities.Onepossibilityisthatdirecttrauma orpressuremay
haveinducedbothvenousstasisandvascular injuryduringtheShiatsumassage.Theotherpossibilityis
thatextrinsiccompressionoftheIJVby tissueswellingsubsequent totraumaduringtheShiatsumassage
mayhaveinducedvenous stasis,resultinginthrombosisatthisunusualsite.
Theauthorsrefertothepreviouscase(Tsuboi,K.2001)asafurtherincidenceofvascularcomplications
following Shiatsu massage and would therefore like to draw attentionto the possibility that Shiatsu
massageoftheneckmaycause seriousneurologicalcomplications.
Generalinformation,surveys,usesofShiatsu
1. Adams,G. (2002). Shiatsu in Britain and Japan: personhood, holism and embodied aesthetics.
Anthropology&Medicine 9:245265.
Abstract:Inthispaper,globalisationprocessesareexaminedthroughtheprismofShiatsu,anoriginally
Japanese,touchbasedtherapy,nowpractisedinEurope,Japan,NorthAmerica,andmanyotherplaces.
Examiningthisemergentplaneoftherapeuticpracticeprovidesanopportunitytoreflectoncategoriesof
personhood,notablythatoftheindividual,anditsplacewithinprocessesofglobalisation.Thearticleis
dividedintotwoparts.InthefirstparttheholismsinherenttoEastAsianmedicalpracticeandunderlying
notionsofpersonhoodinJapanandBritainarecriticallyexamined.Theseeminglyreductionisticpracticeof
'bodily holism' in Japan is shown to reflect sociocentred notions of the person. The concept of holism
animatingShiatsuinaBritishschoolinLondon,farfrombeingJapanese,'ancient',or'timeless',isshown
toreflectindividualismcharacteristicoftheNewAgemovement.Inthesecondpartofthepaper,usingan
autophenomenologicalapproach,adescriptionofpractitionerandclient'slivedexperienceofShiatsuis
givenincasestudyform.Thisillustrateshow'holism'isfeltwithinthecontextofaShiatsutreatment.The
aestheticformoftheShiatsutouchdescribedisshowntobeimplicitlyindividualising.Thishas,itisargued,
profoundimplicationsforunderstandingtheembodieddimensionsofpractitionerpatientencounters,the
potentialefficacyoftreatment,andmoregenerallythepracticeofglobalisedEastAsian'holistic'therapies
inBritainandothersettings.
2. Cheesman,S., Christian,R., and Cresswell,J. (2001). Exploring the value of Shiatsu in palliative
caredayservices.IntJPalliat.Nurs7:234239.
Abstract: This qualitative study sought to evaluate the effects of Shiatsu therapy on clients attending
hospicedayservices.Elevenclientswithadvancedprogressivediseasereceivedfivetherapysessions
eachatweeklyintervals.Dataabouttheeffectswascollectedthroughfiveunstructuredinterviewswith
eachclient.Fourofthesewereconductedbefore,during,andshortlyafterthetherapyregime,andthefifth
wasundertakenfourweeksaftertreatmentended.Alltheinterviewsweretaperecorded,transcribedand
subjecttocontentanalysis.Theresultsoftheanalysisrevealedsignificantimprovementsinenergylevels,
relaxation,confidence,symptomcontrol,clarityofthoughtandmobility.Thesebenefitswereofvariable
duration in some instances lasting a few hours but in others extending beyond the 5week treatment
regime.Actiontoensureresearchtrustworthinessincludedkeepingresearchjournalstoprovideanaudit
trail,conductingmemberchecksandusingpeerdebriefing.Thestudyinvolvedthreeoverlappingcohorts
ofparticipantsinadatacollectionperiodthattookapproximately6months.
Comment: Thisisapurelyqualitativestudywithnoquantifiableorstatisticalanalysisandthereforecannot
beassessedasevidence.Itdoeshowever,offeraninsightintothepossiblebenefitsoftheuseofShiatsu
forpalliativecarepatients.
3. Ferguson,P. (1995). Empowerment through selfhealing. Shiatsu for nurses. Revolution: The
JournalofNurseEmpowerment1995Winter5:4446.
Comment: ThisintroducesthepracticeofShiatsutonursesforpatientsandforthemselves.
4. Fujisaki,N. and Fujisaki,M. (2004). The three principles of Shiatsu therapy and their effects.
ShiatsuSocietyNews91:1011.
Comment: This article has been included as requested by the Shiatsu Society UK to provide some
backgroundinformation.

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5.Furlan,A.D.,Brosseau,L.,Imamura,M.,andIrvin,E.(2002).Massageforlowbackpain[Systematic
Review].CochraneDatabaseofSystematicReviews.
Abstract:Background:,Lowbackpainisoneofthemostcommonandcostlymusculoskeletalproblemsin
modernsociety.Proponentsofmassagetherapyclaimitcanminimizepainanddisability,andspeedreturn
tonormalfunction.,Objectives:,Toassesstheeffectsofmassagetherapyfornonspecificlowback pain.,
Search strategy:, We searched Medline, Embase, Cochrane Controlled Trials Register, HealthSTAR,
CINAHL and Dissertation abstracts from their beginning to May 2001 with no language restrictions.
Referencesintheincludedstudiesandinreviewsoftheliteraturewerescreened.Contactwithcontent
expertsandmassageassociationswasalsomade.,Selectioncriteria:,Thestudieshadtoberandomized
orquasirandomizedtrialsinvestigatingtheuseofanytypeofmassage(usingthehandsoramechanical
device)asatreatmentfornonspecificlowbackpain.,Datacollectionandanalysis:,Twoauthorsblinded
to authors, journal and institutions selected the studies, assessed the methodological quality using the
criteriarecommendedbytheCochraneBackReviewGroup,andextractedthedatausingstandardised
forms. The studies were analysed in a qualitative way due to heterogeneity of population, massage
technique, comparison groups, timing and type of outcomemeasured.,Mainresults:,Ninepublications
reportingoneightrandomizedtrialswereincluded.Threehadlowandfivehadhighmethodologicalquality
scores.OnestudywaspublishedinGermanandtherestinEnglish.Massagewascomparedtoaninert
treatment (sham laser) in one study that showed that massage was superior, especially if given in
combinationwithexercisesandeducation.Intheothersevenstudies,massagewascomparedtodifferent
activetreatments.TheyshowedthatmassagewasinferiortomanipulationandTENSmassagewasequal
to corsets and exercises and massage was superior to relaxation therapy, acupuncture and selfcare
education.Thebeneficialeffectsofmassageinpatientswithchroniclowbackpainlastedatleastoneyear
after the end ofthetreatment.Onestudycomparingtwodifferenttechniquesofmassageconcludedin
favour of acupuncture massage over classic (Swedish) massage., Conclusions:, Massage might be
beneficialforpatientswithsubacuteandchronicnonspecificlowbackpain,especiallywhencombined
withexercisesandeducation.Theevidencesuggeststhatacupuncturemassageismoreeffectivethan
classicmassage,butthisneedconfirmation.Morestudiesareneededtoconfirmtheseconclusionsandto
assesstheimpactofmassageonreturntowork,andtomeasurelongertermeffectstodeterminecost
effectivenessofmassageasaninterventionforlowbackpain
Comment:Thisreviewreferredtoaconferenceabstractforanongoingtrialfrom1998investigatingthe
EffectivenessofbackschoolorShiatsumassagereflextherapyonchroniclowbackpain:aprospective
randomisedcontrolledblindtrialMandala2001Nofurtherpublicationsforthistrialhavebeenfound.
6. Galantino,M.L., Boothroyd,C., and Lucci,S. (2003). Complementary and alternative medicine
interventions for the orthopedic patient: A review of the literature. Seminars in Integrative
Medicine.Vol.1(2):6579.
Abstract:Newbranchesofestablisheddisciplinesarecontinuallybeingdevelopedtohelppatientswith
chronicorthopedicailments.Whatisthoughttobeconventionaltreatmentvariesbetweencountriesand
changesovertime.Thereforetheboundarybetweencomplementaryandconventionalmedicineremains
blurred and constantly shifting. This article reviews the most frequently used CAM interventionsforthe
orthopedic population and will include the use of massage, acupuncture, herbal medication, nutrition,
chiropractic,osteopathy,Shiatsu,prayer/spirituality,visualization,hypnosis,relaxation,biofeedback,and
variousformsofexercise(e.g.,Feldenkraismethod,taichi,andyoga).
Comment: ThisreviewincludesatwopagesectiononShiatsuandspinalmanipulationastherapiesfor
lowbackpainandreferstooneofthestudiesthathavebeenreviewedasevidence:
Brady,L.H.,Henry,K.,Luth,J.F.,andCasperBruett,K.K.(2001).TheeffectsofShiatsuonlowerback
pain.JHolistNurs19:5770.
7. Harris,P.E. and Pooley,N. (1998). What do Shiatsu practitioners treat? A nationwide survey.
ComplementaryTherapiesinMedicine.6(1):3035.
Abstract:Objective: The study aimed to survey theillnessconditionspresentingforShiatsutreatment.
Design:AnationwidequestionnairesurveywasconductedofallqualifiedShiatsupractitionersregistered
with the Shiatsu Society UK. Methods: Client and practitioner questionnaires were piloted during a

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preliminarystage.Inthemainsurvey,allregisteredShiatsupractitionersintheUK(n=397)wereaskedto
completestructuredquestionnairesaboutthemselvesandthreeoftheirclients.Results:in thenationwide
survey 288 practitioners (73%) completed at least one client questionnaire, giving a total of 792 client
questionnaires for analysis. It was evident from both the preliminary stage and the main survey that
musculoskeletal and psychological problems were the most common conditions presenting for Shiatsu
treatment.Conclusion:ItwasconcludedthatefficacyresearchinShiatsushouldfocusonmusculoskeletal
and psychological problems particularly neck/shoulder and lower back problems, arthritis, depression,
stressandanxiety
Comment:ThissurveywasfundedbytheResearchCouncilforComplementaryMedicine(RCCM)and
supported by the Shiatsu Society UK to ascertain the direction of future research into the efficacy of
Shiatsu.
8.Pooley,N.(1998).ThepinningdownofShiatsu,orwhatIlearnedfrommyresearchexperience.
ComplementaryTherapiesinMedicine6:4546.
Comment: Thisprovidesabackground,byoneoftheauthorsofthepaperonthesurveyconductedon
whatShiatsupractitionerstreat(HarrisandPooley1998).
9. Long,A.F. and Mackay,H.C. (2003). The effects of Shiatsu: findings from a twocountry
exploratorystudy.JAlternComplementMed9:539547.
Abstract: OBJECTIVES: To provide insight into client and practitioner perceptions of the effects of
Shiatsu, in the short and longer term, and positive and negative in nature. DESIGN: A twocountry,
exploratory study was undertaken in the United Kingdom and Germany. Indepth interviews were
undertakenwithapurposivesampleof14Shiatsupractitionersand15clients.Clientinterviewsfocusedon
theexperienceofShiatsuandperceptionsofitseffects,bothpositiveandnegative.Practitionerswerealso
askedaboutfactorsthatenhancedorinhibitedsuccessfultreatment.Thetapedand transcribeddatawere
analyzed using grounded theory, assisted by NVivo (QSR, Markham, Ontario, Canada) software. To
enhancegeneralizability,thefindingsfromthealternativecountrydatasetwerepresentedtoafurtherset
of practitioners in each country and as a whole to an international meeting of practitioners from seven
Europeancountries.RESULTS:Therewassimilarityintheperspectivesoftheclientsandpractitionersand
participantsfromtheUnitedKingdomandGermany.Bothdescribedawiderangeofcommon,immediate
and longer term effects. These included effects on initial symptoms, relaxation, sleeping, posture, and
experiences of the body. A category of transitional effect arose, describing an effect that was not
particularly positive and did not last long. Practitioners characterized this as being part of the healing
response. Only a few negative effects were described by clients. One mentioned a negative physical
reactionandtwoindicateddifficultiescopingwithemotionalreactions.Whilemostpractitionersconceived
negative effects to be possible, these were more likely to be described as negative reactions.
CONCLUSION:ThisexploratorystudyhasshedgreaterlightontheeffectsofShiatsu.Thesamplefindings
provideauserandpractitionergroundedbaseforthedesignofappropriatequestionsforexplorationina
largerandmoregeneralizablestudyoftheeffectsofShiatsu.
Comment:Thefullreport,whichwascommissionedbytheEuropeanShiatsuFederation,providesmore
detailsofthestudyanditsresults:
Mackay H, Long AF. (2003) The Experience and Effects of Shiatsu: A Two Country Exploratory
Study.Salford:HealthCarePracticeR&DUnit,UniversityofSalford,ReportNo.9,2003.
10. Long,A.F. (2005). The effects and experiences of Shiatsu: a crossEuropean study. Shiatsu
SocietyNews95:1415.
Comment:Thisprovidesanoverviewoftheabovementionedstudy.
11.Palanjian,K.(2004).Shiatsu.SeminarsinIntegrativeMedicine.2(3):107115.
Comment: This provides the history, principles and philosophy, diagnosis, practices, techniques and
treatments of Shiatsu. There is also a short section on RCTs that have been recently published, the
majorityofwhichrefertoacupressure,includingtheuseofacupressurebands.
12.Peace,G.andManasse,A.(2002).TheCavendishCentreforintegratedcancercare:assessment
ofpatients'needsandresponses.ComplementTherMed10:3341.

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Abstract: Theuseofcomplementarytherapiesincombinationwithconventionalmedicineisincreasing.In
cancercare,asattheCavendishCentreforCancerCareinSheffield,therangeoftherapiesofferedcan
include aromatherapy, massage, reflexology, Shiatsu, acupuncture, homeopathy, counselling,
visualization, hypnotherapy, relaxation, healing and art therapy. Before offering any therapy careful
assessmentofpatients'needsisimportantaspatientsseekingcomplementarytherapiesmaypresentwith
unrealistichopesandexpectationsofbenefit.Therearewidevariationsinprovisionofservicesoffering
complementarycancercarethroughouttheUnitedKingdombutfewofferacomprehensiveassessment
whichisusedasabaselineforbothplanningtreatmentandevaluatingitsoutcomeandwhichisconducted
by a trained and objectivepractitionerwhohasnoinvestmentinanyspecifictherapy.Wedescribethe
modelofcaredevelopedattheCavendishCentrewithparticularemphasisontheassessmentprocess.
Ourmodelofassessmentprovidesanopportunityforpatientstotelltheirstory,makesenseoftheillness
experience, construct meaning from it and set realistic expectations for thechosenintervention.Italso
offerspatientsinvolvementandchoiceindecisionsabouttheircare.Inadditionwepresentevaluativedata
fromacaseseriesof157patients,138ofwhom(88%)reportedimprovementintheirmainconcernon
MYMOP(MeasureYourMedicalOutcomeProfile)
Comment: There is nospecificreferencetotheuseofShiatsuinthisparticularcentre,butthispaper
providesanexampleofamodelofcareforcancerpatients.
13. Sommers,E., Porter,K., and DeGurski,S. (2002). Providers of complementary and alternative
healthservicesinBostonrespondtoSeptember11.AmericanJournalofPublicHealth92:1598.
Abstract:Examinedtheuseofcomplementaryandalternativemedical(CAM)treatmentsbythosewho
responded to the September 11, 2001, attacks on the World Trade Center. 47 firefighters, police,
emergency medical technicians, and other rescue personnel (aged 660 yrs) who responded to the
September 11 attack attended clinics and received services from acupuncturists, reiki practitioners,
massage therapists, Shiatsu providers, and polarity therapists. Results show that 81 treatments were
providedduringtheclinicsessions.Ofthese,51%wereacupuncturetreatments,15%werereikisessions,
12%wereShiatsu,and9%weremassage.51%ofsubjects(Ss)receivedasingletreatment,34%received
2treatments,and15%received36treatments.Atleast8Ssindicatedthattheirtreatmentwastheir1st
useofCAMtherapy.12Sswhoreceived1+treatmentreportedimprovedrelaxationandsleep,reduced
painandstress,andincreasedenergy.
Comment: Thisdescribestheevaluationofstressreductionclinicsthatweresetup.TwentyfiveCAM
practitioners,includingoneShiatsupractitioner,providedthetreatments.
14.Weintraub,M.I.(1996)Shiatsumassagetherapy:aremarkablehealingtechniqueinspinepain.
JournalofBackandMusculoskeletalRehabilitation7(3):195197.
Comment: Thisistheauthorsdiscussionand analysisofastudywhichheconductedin1992.Thisstudy
was an open and uncontrolled trial of a medically supervised programme created by the author. This
programmeconsistedofShiatsu,Swedishmusclemassageandtriggerpointsuppression(SSMMTPS) as
ahandsonattempttointerruptthepaincycle.Thepublicationofthestudydidnotappearinanyofthe
search results and a copy could not be obtained from the British Library and therefore could not be
reviewed:
WeintraubM.I.(1992)Shiatsu,SwedishMuscleMassage,andTriggerPoint
SuppressioninSpinalPainSyndromeAmericanJournalofPain
Management(AJPM)2(2),7478.
15.White,A.(2002).Thecaseforuncontrolledclinicaltrials.ShiatsuSocietyNews62:1013.
Comment: Thisprovidesatrialprotocolforundertakinguncontrolledtrialstoestablishwhetherthereisa
clinicaleffectworthinvestigating.
16.Yates,S. (2005). Shiatsu and acupressure in practice. MIDIRS Midwifery Digest.
Abstract: An Insight into the Use of Complementary Therapies in Maternity Care supplement. Use of
Shiatsu in midwifery practice, including a summary of its benefits for the mother, baby, midwives and
maternity units. A case study on setting up a Shiatsu service in the Borders Hospital, Scotland and
commentsfrommidwiveswhohaveattendedShiatsucoursesareincluded.

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Comment:Inadditiontodetailingtheprocessofsettingupaservice,theauthorlistsanumberofbenefits
oftheuseofShiatsufromanecdotalevidence.
WaterShiatsu(Watsu)
TwopublicationsreferredtotheaquaticuseofShiatsu.
1.Davies,L.(2003).WaterandShiatsu:watertherapyandwombs.(BenefitsofWatsu,waterbased
massage,forpregnantwomenandfetuses.MIDIRSMidwiferyDigest.
Comment: This personal account provides an introduction into water Shiatsu (Watsu) which was
developedintheearly1980s.
2. Vogtle,L.K., Morris,D.M., and Denton,B.G. (1998). An aquatic program for adults with cerebral
palsylivingingrouphomes.PhysTherCaseRep1:250259.
Comment: Thisincludedindividualcasereportsthereforewasnotincludedinthereviewofevidence.
Abstract: Six adults with cerebral palsy participated in aquatic therapy 2 days a week for 7 weeks.
Activities included approximately 35 minutes of water Shiatsu (WATSU) using a modified head cradle
sequence and approximately 15 minutes of Halliwick method activities focused on head, trunk, and
extremitymovementcontrol.Activitieswereconductedbyentryleveloccupationalandphysicaltherapy
studentswhoweretrainedinthespecifictechniquesused.Outcomemeasuresincludedpassiverangeof
motion(PROM)oftheshoulder,elbow,hip,andkneejoints,restingheartrate,bloodpressure,painrating,
caretakerreports,andsocialskillmeasures.Caretakerreportsofeaseofcaresubstitutedforfunctional
measures owing to clients' limitedfunctionalabilityandpotentialforfunctionalimprovement.Outcomes
suggest that the program was effective for improving PROM, decreasing pain, and providing a
pleasureable social experience. Benefits were also realised by the students participating in the swim
program,includingskilldevelopmentandappreciationofpatientswithdisabilitywithindividuals

11.2Acupressure
These publications provide further information on acupressure and may inform the direction of future
research.Severalofthemarereviewsthatrefertotheeffectsofacupressureonnauseaandvomiting.
Thereferenceslistsofthereviewswerecheckedtoensurethatallacupressurestudieshadbeenincluded
inthesearchresultsforscreening.Themajorityoftheseacupressurereferenceswereforstudiesthat
werepublishedpriorto1990orincludedtheuseofdevicessuchaswristbands.
Reviewsofresearchonacupressure
1. Collins,K.B. and Thomas,D.J. (2004). Acupuncture and acupressure for the management of
chemotherapyinducednauseaandvomiting.JAmAcadNursePract16:7680.
Abstract: PURPOSE: To review existing research, the National Institutes of Health (NIH) consensus
statement,andfederalregulationsregardingtheuseofacupunctureandacupressureinthemanagement
ofchemotherapyinducednauseaandvomitinginordertogivenursepractitioners(NPs)theinformation
they need to provide the best care for patients undergoing chemotherapy treatment for cancer. DATA
SOURCES: Selected scientific literature and Internet sources. CONCLUSIONS: Research supports the
effectiveness of acupuncture and acupressure for the treatment of chemotherapyinduced nausea and
vomiting. Used in conjunction with current antiemetic drugs, acupuncture and acupressure have been
shown to be safe and effective for relief of the nausea and vomiting resulting from chemotherapy.
IMPLICATIONSFORPRACTICE:Evenwiththebestantiemeticpharmacologicalagents,60%ofcancer
patientscontinueto experiencenauseaandvomitingwhenundergoingchemotherapytreatments.Because
theNIHsupportstheuseofacupuncturefornauseaandvomiting,theNPisobligatedtobeknowledgeable
abouttheuseoftheseandothereffectivecomplementarytreatmentsinordertoprovidethebestcare

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2.Harris,P.E.(1997).Acupressure:areviewoftheliteratureComplementaryTherapiesinMedicine
5:156161.
Abstract:Acupressureisameansofmanipulatingthesameacupointsthatareusedinacupuncture,but
without the needles. A literature review was conducted in two parts. The first part examines Western
research regarding the prophylactic use of singlepoint acupressure. The second reviews a sample of
mainly Chinese clinical research concerning the restorative use of multipoint acupressure. The primary
literature search was conducted using the Research Council for Complementary Medicine database
(CISCOM). The most convincing finding supporting the effectiveness of acupressure comes from
methodologicallyrigorousstudiesoftheuseofPC6asanantiemetic.Anumberofstudieshaveshownthat
PC6ismoreeffectivethanplaceboinreducingfeelingsofnauseaduringpregnancy,aftersurgeryandin
cancerchemotherapy.Thescientificqualityofmostofthepublishedstudies examiningtheeffectivenessof
multipointacupressure,predominantlyauriculotherapy,hasbeenpoor,withoutadequatecontrolgroups,
randomization,placebos,blindingandstatisticalanalyses.Thereseemstobeaculturaldividebetween
theory and methodological rigour. The scientifically rigorous studies have tended to be atheoretical in
selectingtheacupointfortreatmentandinexplaininghowthepointmaywork
3. Hickman,A.G., Bell,D.M., and Preston,J.C. (2005). Acupressure and postoperative nausea and
vomiting.AANA.J73:379385.
Abstract: Despite great strides during the preceding 3 decades, the ability to consistently eliminate
postoperativenauseaandvomiting(PONV)continuestoeludeanesthesiapractitioners.Theoccurrenceof
PONV related to anesthesia and surgery prolongs hospital stays and increases healthcare costs.
Protracted recoverytimesplaceconstraintsonpatients,healthcaresystems,andhealthcarefinanciers.
ManypharmacologicalantiemeticshavebeendevelopedandareinuseintheattempttoalleviatePONV.
Sideeffectsandcostprofilesofmanyoftheseinterventions,however,reinforcethebroadlyheldbeliefthat
there remains opportunity for improvement. Because the Western culture almost exclusively favors
evidencebasedscientificpracticeandinterventions,thesearchcontinuesforanideal,costeffective,safe,
andefficaciouspharmacologicalagenttopreventPONV.Easternculture,ontheotherhand,reliesheavily
onnaturopathicremedieswhosesuccessfulusehasspannedthousandsofyears.Increasingattentionhas
been given to the potential benefits of nonpharmacological intervention for the prevention of PONV in
association with anesthesia care. Therefore, the purpose of this AANA Journal course will be to focus
attentiononwhatisknownandwhatisunknownintheliteratureregardinguseofthenonallopathicremedy
ofacupressureasanonpharmacologicalalternativetocommonlyutilizedantiemeticprophylaxis
ClinicalEvidencereviews
ThisBMJresourceisadatabaseofevidencefortheeffectsoftreatmentfornumerousconditions.Clinical
Evidencesummarisesthecurrentstateofknowledgeanduncertaintyaboutthepreventionandtreatment
ofclinicalconditions,basedonthoroughsearchesandappraisaloftheliterature.Itisneitheratextbookof
medicinenorasetofguidelines.Itdescribesthebestavailableevidencefromsystematicreviews,RCTs
andobservationalstudieswhereappropriate,andifthereisnogoodevidenceitsaysso.
(http://www.clinicalevidence.com/ceweb/about/index.jsp)
ThreereviewsincludedtheeffectofP6acupressure,amongstothertreatments,fornauseaandvomiting.
Themostuptodatereview(2004)statedthatitislikelytohaveabeneficialeffect:
1.OatesWhitehead,R.(2004).Nauseaandvomitinginearlypregnancy.ClinEvid.18401852.
2.OatesWhitehead,R.(2003).Nauseaandvomitinginearlypregnancy.ClinEvid.16711682.
3.Jewell,D.(2003).Nauseaandvomitinginearlypregnancy.ClinEvid.15611570.
Reviews of non pharmacological interventions, including complementary and alternative
treatments,fornauseaandvomiting
Fivereviews,whereacupressurewasincludedasanintervention,assessedtheavailableevidenceforthe
treatmentofnauseaandvomiting.

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1.Aikins,M.P.(1998).Alternativetherapiesfornauseaandvomitingofpregnancy.Obstet.Gynecol.
91:149155.
Abstract:OBJECTIVE:Toreviewavailableevidenceabouttheeffectivenessofalternativetherapiesfor
nauseaandvomitingofpregnancy.DATASOURCES:MEDLINEand13additionalUSandinternational
data bases were searched in 19961997 for papers that described use of alternative medicine in the
treatmentofpregnancyandpregnancycomplications,specificallythoseaddressingnausea,vomiting,and
hyperemesis.Bibliographiesofretrievedpaperswerereviewedtoidentifyadditionalsources.METHODS
OF STUDY SELECTION: All relevant English language clinical research papers were reviewed.
Randomized clinical trials addressing specifically the use of nonpharmaceutical and nondietary
interventions were chosen for detailed review. TABULATION, INTEGRATION, AND RESULTS: Ten
randomizedtrialsstudyingtheeffectsofacupressure,ginger,andpyridoxineonnauseaandvomitingof
pregnancywerereviewed.Evidenceofbeneficialeffectswasfoundforthesethreeinterventions,although
thedataonacupressureareequivocal.Insufficientevidencewasfoundforthebenefitsofhypnosis.Other
interventionshavenotbeenstudied.CONCLUSION:Thereisadearthofresearchtosupportortorefute
theefficacyofanumberofcommonremediesfornauseaandvomitingofpregnancy.Thebeststudied
alternativeremedyisacupressure,whichmayaffordrelieftomanywomen gingerandvitaminB6alsomay
bebeneficial
2.Anderson,F.W.J.andJohnson,C.T.(2005).Complementaryandalternativemedicineinobstetrics
InternationalJournalofGynecology&Obstetrics91:116124.
Abstract: Objective: To identify, survey and review randomized controlled studies of the use of
complementaryandalternativemedicine(CAM)forobstetrictreatmentorhealthpromotion.Methods:The
MEDLINEdatabasewassearchedtoidentifyrandomizedcontrolledtrialsofCAMtreatmentandtherapies
inobstetrics.Studiesexaminingmodalitiesfortreatmentorimprovementofhealthstatuswerereviewed.
Results: Fiftyfour articles assessing a variety of health modalities met the criteria for inclusion.
Acupressureandgingerforprenatalnauseaandvomiting,moxibustionforversionofbreechpresentation,
sterilewaterinjectionsforbackpainreliefinlabor,andperinealmassagetopreventperinealtraumahave
three or more studies demonstrating beneficial effect. Other interventions have been studied less, and
evidenceforthemislimited.Conclusions:SomeCAMinterventionshaveevidenceofeffectivenessforuse
in obstetric patients, while others require further investigation before they can be consideredforusein
practice
3. King,C.R. (1997). Nonpharmacologic management of chemotherapyinduced nausea and
vomiting.OncolNursForum24:4148.
Abstract: PURPOSE/OBJECTIVES:Toreviewthenonpharmacologicinterventionsindicatedtopreventor
control chemotherapyinduced nausea and vomiting. DATA SOURCES: Journal articles. DATA
SYNTHESIS:Despiteimprovementsinantiemeticdrugtherapy,asmanyas60%ofpatientswithcancer
who are treated with antineoplastic agents experience nausea and vomiting. Anticipatory nausea and
vomiting are thought to be caused by the behavioral process of classical conditioning. Most
nonpharmacologicinterventionsthatareusedtopreventorcontrolnauseaandvomitinginpatientswith
cancer are classified as behavioral interventions. Behavioral interventions involve the acquisition of
adaptive behavioral skills to interrupt the conditioning cycle. CONCLUSIONS: Nonpharmacologic
interventions appear to be effective in reducing anticipatory and posttreatment nausea and vomiting.
IMPLICATIONSFORNURSINGPRACTICE:Thesebehavioralinterventionscanbeeffectiveinreducing
anticipatory and posttreatment nausea and vomiting. Oncology nurses must learn these
nonpharmacologictechniquesandteachtheirpatientstousethemincombinationwiththeirprescribed
antiemetictherapy
4.Lee,A.andDone,M.L.(1999).Theuseofnonpharmacologictechniquestopreventpostoperative
nauseaandvomiting:ametaanalysis.Anesth.Analg.88:13621369.
Abstract: Weassessedtheefficacyofnonpharmacologictechniquestopreventpostoperativenausea and
vomiting (PONV) by systematic review. These studies included acupuncture, electroacupuncture,
transcutaneouselectricalnervestimulation,acupointstimulation,andacupressure.Ofthe24randomized
trialsretrievedbyasearchofarticlesindexedontheMEDLINEandEMBASEdatabases(19801997),19

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wereeligibleformetaanalysis.Theprimaryoutcomesweretheincidenceofnausea,vomiting,orboth06
h(earlyefficacy)or048h(lateefficacy)aftersurgery.Thepooledrelativerisk(RR)andnumbersneeded
totreat(NNT)werecalculated.Inchildren,nobenefitwasfound.Someresultsinadultsweresignificant.
Nonpharmacologictechniquesweresimilartoantiemeticsinpreventingearlyvomiting(RR=0.89[95%
confidenceinterval0.471.67]NNT=63[10infinity])andlatevomiting(RR=0.80[0.351.81]NNT=25
[5infinity])inadults.Nonpharmacologictechniqueswerebetterthanplaceboatpreventingearlynausea
(RR=0.34[0.200.58]NNT=4[36])andearlyvomitinginadults(RR=0.47[0.340.64]NNT=5[48]).
Nonpharmacologic techniques were similar to placebo in preventing late vomiting in adults (RR = 0.81
[0.461.42]NNT=14[6infinity]).Usingnonpharmacologictechniques,20%25%ofadultswillnothave
early PONV compared with placebo. It may be an alternative to receiving no treatment or firstline
antiemetics. IMPLICATIONS: This systematic review showed that nonpharmacologic techniques were
equivalent to commonly used antiemetic drugs in preventing vomiting after surgery. Nonpharmacologic
techniquesweremoreeffectivethanplaceboinpreventingnauseaandvomitingwithin6hofsurgeryin
adults,buttherewasnobenefitinchildren
5.Pan,C.X.,Morrison,R.S.,Ness,J.,FughBerman,A.,andLeipzig,R.M.(2000).Complementaryand
AlternativeMedicineintheManagementofPain,Dyspnea,andNauseaandVomitingNeartheEnd
of Life: A Systematic Review Journal of Pain and Symptom Management 20:374387.
Abstract: Toreviewtheevidenceforefficacyofcomplementaryandalternativemedicine(CAM)modalities
intreatingpain,dyspnea,andnauseaandvomitinginpatientsneartheendoflife,originalarticleswere
evaluated following a search through MEDLINE, CancerLIT, AIDSLINE, PsycLIT, CINAHL, and Social
WorkAbstractsdatabases.Searchtermsincludedalternativemedicine,palliativecare,pain,dyspnea,and
nausea.Twoindependentreviewersextracteddata,includingstudydesign,subjects,samplesize,age,
responserate,CAMmodality,andoutcomes.TheefficacyofaCAMmodalitywasevaluatedin21studies
of symptomatic adult patients with incurable conditions. Of these, only 12 were directly accessed via
literaturesearching.Elevenwererandomizedcontrolledtrials,twowerenonrandomizedcontrolledtrials,
andeightwerecaseseries.Acupuncture,transcutaneouselectricalnervestimulation,supportivegroup
therapy,selfhypnosis,andmassagetherapymayprovidepainreliefincancerpainorindyingpatients.
Relaxation/imagerycanimproveoralmucositispain.Patientswithseverechronicobstructivepulmonary
disease may benefit from the use of acupuncture, acupressure, and muscle relaxation with breathing
retrainingtorelievedyspnea.Becauseofpublicationbias,trialsonCAMmodalitiesmaynotbefoundon
routine literature searches. Despite the paucity of controlled trials, there are data to support theuseof
someCAMmodalitiesinterminallyillpatients.Thisreviewgeneratedevidencebasedrecommendations
andidentifiedareasforfutureresearch.
Commentsorlettersreferringtoreviewedstudies
1.Anon(2006)."Needling"awayyour(aching)backpain.Acupunctureandacupressurebothcan
providelonglastingreliefforlowbackpain,newstudies,sayHealthNews12:1112.
2.Frost,H.andStewartBrown,S.(2006).Acupressureforlowbackpain.BMJ332:680681.
Comment: Bothoftheaboverefertothefollowingstudy:
Hsieh,L.L., Kuo,C.H., Lee,L.H., Yen,A.M., Chien,K.L., and Chen,T.H. (2006). Treatment of lowback
painbyacupressureandphysicaltherapy:randomisedcontrolledtrial.BMJ.
Abstract:OBJECTIVE:Toevaluatetheeffectivenessofacupressureintermsofdisability,painscores,and
functional status. DESIGN: Randomised controlled trial. SETTING: Orthopaedic clinic in Kaohsiung,
Taiwan. PARTICIPANTS: 129 patients with chronic low back pain. INTERVENTION: Acupressure or
physical therapy for one month. MAIN OUTCOME MEASURES: Self administered Chinese versions of
standard outcome measures for low back pain (primary outcome: Roland and Morris disability
questionnaire)atbaseline,aftertreatment,andatsixmonthfollowup.RESULTS:ThemeantotalRoland
andMorrisdisabilityquestionnairescoreaftertreatmentwassignificantlylowerintheacupressuregroup
than in thephysicaltherapygroupregardlessofthedifferenceinabsolutescore(3.8,95%confidence
interval5.7to1.9)ormeanchangefromthebaseline(4.64,6.39to2.89).Acupressureconferredan

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89% (95% confidence interval 61% to 97%) reduction in significant disability compared with physical
therapy.Theimprovementindisabilityscoreintheacupressuregroupcomparedwiththephysicalgroup
remainedatsixmonthfollowup.Statisticallysignificantdifferencesalsooccurredbetweenthetwogroups
forallsixdomainsofthecoreoutcome,painvisualscale,andmodifiedOswestrydisabilityquestionnaire
after treatment andatsixmonthfollowup.CONCLUSIONS:Acupressurewaseffectiveinreducinglow
backpainintermsofdisability,painscores,andfunctionalstatus.Thebenefitwassustainedforsixmonths
3. Brill,J.R. (1995). Acupressure for nausea and vomiting of pregnancy: A randomized, blinded
studyObstetrics&Gynecology85:159160.
ThiscommentsonastudythatdidnotappearintheinitialsearchesastheMeSHtermsforthepublication
includedacupuncturepointsandacupuncturetherapy/methodsnotacupressure.Acopywasobtained
andthestudywassubsequentlyreviewed:
Belluomini, J., Litt, R,C,, Lee, K.A., Katz, M. (1994) Acupressure for nausea and vomiting of
pregnancy:arandomized,blindedstudy.ObstetGynecol:84(2):2458.
OBJECTIVE:Toevaluatetheeffectivenessofacupressureinreducingnauseaandvomitingofpregnancy.
METHODS: Symptomatic pregnant women were randomized to one of two acupressure groups: one
treatmentgroupusinganacupressurepoint(PC6)andoneshamcontrolgroupusingaplacebopoint.
Subjects were blind to the group assignment. Each evening for 10 consecutive days, the subjects
completedanassessmentscaledescribingtheseverityandfrequencyofsymptomsthatoccurred.Data
fromthefirst3dayswereusedaspretreatmentscores.Beginningonthemorningofthefourthday,each
subjectusedacupressureatherassignedpointfor10minutesfourtimesaday.Datafromday4were
discardedtoallow24hoursforthetreatmenttotakeeffect.Datafromdays57wereusedtomeasure
treatmenteffect.RESULTS:Sixtywomencompletedthestudy.Therewerenodifferencesbetweengroups
in attrition, parity, fetal number, maternal age, gestational age at entry, or pretreatment nausea and
emesisscores.Analysisofvarianceindicatedthatbothgroupsimprovedsignificantlyovertime,butthat
nauseaimprovedsignificantlymoreinthetreatmentgroupthanintheshamcontrolgroup(F1,58=10.4,P
=.0021).Therewerenodifferencesintheseverityorfrequencyofemesisbetweenthegroups.Therewas
a significant positive correlation (r = 0.261, P = .044) between maternal age and severity of nausea.
CONCLUSIONS:OurresultsindicatethatacupressureatthePC6anatomicalsiteiseffectiveinreducing
symptomsofnauseabutnotfrequencyofvomitinginpregnantwomen.
4. Chernyak,G. (2003). Tender active acupoint is not an ideal control for acupressure study.
Anesth.Analg.97:925926.
5.Usichenko,T.I.andPavlovic,D.(2003).Suggestingtheoptimalcontrolprocedureforacupressure
studies.Anesth.Analg.97:11961197.
Comment: Bothoftheaboverefertothefollowingstudy:
Fassoulaki,A., Paraskeva,A., Patris,K., Pourgiezi,T., and Kostopanagiotou,G. (2003). Pressure
appliedontheextra1acupuncturepointreducesbispectralindexvaluesandstressinvolunteers.
Anesth.Analg.96:88590.
Abstract:Weinvestigatedtheeffectofpressureapplicationontheacupuncturepoint"extra1"andona
control point on the bispectral index (BIS) values and on stress in 25 volunteers. In each volunteer,
pressurewasappliedontheextra1pointfor10minandonacontrolpointfor5minondifferentdaysand
inarandomizedmanner.TheBISvaluewasrecordedbeforeapplyingpressureontheextra1point,during
pressureapplicationevery30sfor10min,andafterpressurerelease.Regardingthecontrolpoint,BIS
valueswererecordedfor5insteadof10minduringpressureapplicationbecauseacupressureonthat
pointwasassociatedwithanunpleasantfeeling.Eachvolunteerwasaskedtoscorestressbeforeand
afterpressureapplicationfrom0to10.TheBISvaluesweresignificantlyreduced2.5,5,7.5,and10min
duringpressureapplicationontheextra1point(P< 0.001foreachcomparison,respectively)andreturned
to the baseline values after pressure release. Pressure application on the control point decreased BIS
values(P<0.01andP<0.05at2.5and5min,respectively).However,thesevaluesweremaintained
closeto90%andweresignificantlyhigherthanthoseobtainedduringpressureontheextra1point(P<
0.001andP<0.001forthe2.5and5mincomparisons).Theverbalsedationscorevaluesobtainedafter

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pressureapplicationontheextra1pointwerealsolowerwhencomparedwiththevaluesobtainedafter
pressureapplicationonthecontrolpoint(P<0.001).IMPLICATIONS:Thiscrossoverstudyinvestigated
theeffectofpressureapplicationontheacupuncture"extra1"pointinhealthyvolunteers.Acupressure
appliedfor10minontheextra1pointsignificantlyreducedtheBISvaluesandtheverbalstressscore
whencomparedwithacupressureappliedonacontrolpoint
6.McDougall,G.J.(2005).Researchreview:theeffectofacupressurewithmassageonfatigueand
depressioninpatientswithendstagerenaldisease.Geriatr.Nurs26:164165.
Thisreferstothefollowingstudy:
Cho,Y.C.andTsay,S.L.(2004).Theeffectofacupressurewithmassageonfatigueanddepression
inpatientswithendstagerenaldisease.JNursRes12:5159.
Abstract:Fatigueanddepressivemoodarethemostsignificantsymptomsexperiencedbypatientswith
endstagerenaldisease.Thepurposeofthisstudywastoexaminetheeffectivenessofacupressurewith
massageinfatigueanddepressioninpatientswithendstagerenaldisease(ESRD)receivinghemodialysis
treatment.Thestudyappliedanexperimentalpretestandposttestdesign.Sixtytwohemodialysispatients
participatedinthestudy.Datawerecollectedfromtwohemodialysisclinicsinmajorhospitalsinsouthern
Taiwan.Followingconsenttothestudy,subjectswererandomlyassignedtoanacupressuregroupora
controlgroup.Patientsintheacupressuregroupreceivedacupointmassagefor12minutesperday,three
daysperweek,forfourweeks.Subjectsinthecontrolgrouponlyreceivedroutineunitcare.Themeasures
includedtheRevisedPiperFatigueScale,andBeck'sDepressionInventory.Descriptivestatistics,chi2
tests, ttest and analyses of covariance were used for data analysis. The results indicatethatsubjects
experienced a moderate leveloffatigue.Nearly65%ofhemodialysispatientshadadepressedmood.
ANCOVA results indicated that fatigue (F((1.54)) = 9.05, p =.004) and depression (F((1.54)) = 4.20, p
=.045)amongpatientsintheacupressuregroupshowedsignificantlygreaterimprovementthanpatientsin
thecontrolgroup.ThefindingsofthisstudyprovideaninterventionalmodelfornursestakingcareofESRD
patients
Miscellaneous
1. Ostberg,O., Horie,Y., and Feng,Y. (1992). On the merits of ancient Chinese eye acupressure
practices.ApplErgon. 23:343348.
Abstract:Chineseschoolchildrenandadultswithstrenuousvisualtasksroutinelyperformmassageand
pressureexercisesonselectedacupressurepointsaroundtheeyes.Thispractice,taughtbytheJingLuo
school of acupuncture for more than 4000 years, is claimed to prevent and cure myopia and other
afflictionsthoughttoresultfromvisualclosework.Afourweekpilotexperimentwascarriedoutwiththe
aim of designing a proper study on the possible shortterm benefits of eye acupressure programmes.
Questionnairedatarevealedthatthesubjectsdidexperiencevariouseye/visionsymptomsasaresultof
the90minexperimentaltask.Thiscouldnotbeverifiedbythemeasurementsofaccommodationprecision
and critical flicker fusion, nor could any beneficial effects of acupressure be seen over the four
experimentalweeks
Comment: Theaimofthisvisionexerciseprogrammewastoenablethe designofastudyonthepossible
shorttermbenefitsofeyeacupuncture.
2.Wu,X.,Bai,G.,Wen,J.,andYang,J.(2005).Evaluationonthetherapeuticeffectsofdigitalacupoint
pressureforobstetricspasticcerebralpalsy.JTradit.ChinMed25:247251.
Abstract:ToprobetheevaluationmethodsforeffectsofTCMtreatmentofcerebralpalsythroughclinical
observationonthedigitalacupointpressureintreatingobstetricspasticcerebralpalsy.From19982003,
40 cases of spastic cerebral palsy were treated with digital acupoint pressure therapy. Ten indexes
including intelligence, language, salivation, handgrasping, thumbadduction, turnover, sitting, standing,
walking,andscissorsgaitweredividedintothe4gradesofnormal,mildabnormal,moderateabnormal,
andsevereabnormal(dysfunction),respectivelymarkedas6,4,2,and0point,with2pointsincreasedfor
improving each grade of each item after the treatment. Meanwhile, the ranges were recorded and
evaluatedbeforeandafterthetreatmentonshoulderabduction,elbowextension,wristextension,forearm
backwardrotation,hipabduction,straightleglifting,kneeextension,andankledorsiflexion.Thosewiththe
improvement of 10 degrees, 15 degrees, 20 degrees, 25 degrees, and 30 degrees in the range of

111

movement of their contractured joints would obtain respectively 1, 2, 3, 4, and 5 points. There were
significant differences before and after the treatment in the 18 items under observation except for
intelligence,withobviousimprovementshownafterthetreatment(P<0.01),theeffectiveratebeing92.5%.
Thetherapeuticcriteriasetinthisresearcharewellestablishedinreflectingthefunctionalimprovementsof
thepatient
Comment: This was an observational study to probe the evaluation criteria for the TCM therapeutic
effectsoncerebralpalsy.

112

Appendix12Evidencetablesreferences
12.1 Shiatsu
Ballegaard,S.,Norrelund,S.,andSmith,D.F.(1996).Costbenefitofcombineduseofacupuncture,Shiatsu
andlifestyleadjustmentfortreatmentofpatientswithsevereanginapectoris.Acupunct.Electrother.Res
21:187197.
Brady,L.H.,Henry,K.,Luth,J.F.,andCasperBruett,K.K.(2001).TheeffectsofShiatsuonlowerbackpain.
JHolistNurs19:5770.
Faull,K.(2005).Apilotstudyofthecomparativeeffectivenessoftwowaterbasedtreatmentsfor
fibromyalgiasyndrome:WatsuandAixmassage.JournalofBodyworkandMovementTherapies9:202
210.
Iida,M.,Chiba,A.,Yoshida,Y.,Shimizu,K.,andKanda,K.(2000).EffectsofShiatsumassageonreliefof
anxietyandsideeffectsymptomsofpatientsreceivingcancerchemotherapy.KitakantoMedical
Journal.Vol.50(3):227232.
Ingram,J.,Domagala,C.,andYates,S.(2005).TheeffectsofShiatsuonposttermpregnancy. Complement
TherMed13:1115.

12.2 Acupressure
Agarwal,A.,Ranjan,R.,Dhiraaj,S.,Lakra,A.,Kumar,M.,andSingh,U.(2005).Acupressureforpreventionof
preoperativeanxiety:aprospective,randomised,placebocontrolledstudy.Anaesthesia60:978981.
Ballegaard,S.,Johannessen,A.,Karpatschof,B.,andNyboe,J.(1999).Additionofacupunctureandself
careeducationinthetreatmentofpatientswithsevereanginapectorismaybecostbeneficial:anopen,
prospectivestudy.JAlternComplementMed5:405413.
Ballegaard,S.,Borg,E.,Karpatschof,B.,Nyboe,J.,andJohannessen,A.(2004).Longtermeffectsof
integratedrehabilitationinpatientswithadvancedanginapectoris:anonrandomizedcomparativestudy.J
AlternComplementMed10:777783.
Belluomini,J.,Litt,R.C.,Lee,K.A.,andKatz,M.(1994).Acupressurefornauseaandvomitingofpregnancy:
arandomized,blindedstudy.ObstetGynecol84:245248.
Chen,H.M.andChen,C.H.(2004).EffectsofacupressureattheSanyinjiaopointonprimary
dysmenorrhoea.JAdvNurs48:380387.
Chen,H.M.,Chang,F.Y.,andHsu,C.T.(2005).Effectofacupressureonnausea,vomiting,anxietyandpain
amongpostcesareansectionwomeninTaiwan.Kaohsiung.JMedSci21:341350.
Chen,L.L.,Hsu,S.F.,Wang,M.H.,Chen,C.L.,Lin,Y.D.,andLai,J.S.(2003).Useofacupressuretoimprove
gastrointestinalmotilityinwomenaftertransabdominalhysterectomy.AmJChinMed31:781790.
Chen,M.L.,Lin,L.C.,Wu,S.C.,andLin,J.G.(1999).Theeffectivenessofacupressureinimprovingthe
qualityofsleepofinstitutionalizedresidents.JGerontol.ABiolSciMedSci54:M389M394.
Cho,Y.C.andTsay,S.L.(2004).Theeffectofacupressurewithmassageonfatigueanddepressionin
patientswithendstagerenaldisease.JNursRes12:5159.
Chung,U.L.,Hung,L.C.,Kuo,S.C.,andHuang,C.L.(2003).EffectsofLI4andBL67acupressureonlabor
painanduterinecontractionsinthefirststageoflabor.JNursRes11:251260.

113

Dibble,S.L.,Chapman,J.,Mack,K.A.,andShih,A.S.(2000).Acupressurefornausea:resultsofapilot
study.OncolNursForum27:4147.
Dullenkopf,A.,Schmitz,A.,Lamesic,G.,Weiss,M.,andLang,A.(2004). Theinfluenceofacupressureonthe
monitoringofacousticevokedpotentialsinunsedatedadultvolunteers.Anesth.Analg.99:114751,table.
Ezzo,J.,Richardson,M.,Vickers,A.,Allen,C.,Dibble,S.,Issell,B.,Lao,L.,Pearl,M.,Ramirez,G.,Roscoe,J.,
Shen,J.,Shivnan,J.,Streitberger,K.,Treish,I.,andZhang,G.(2006).Acupuncturepointstimulationfor
chemotherapyinducednauseaorvomiting.CochraneDatabaseSystRevCD002285.
Fassoulaki,A.,Paraskeva,A.,Patris,K.,Pourgiezi,T.,andKostopanagiotou,G.(2003).Pressureappliedon
theextra1acupuncturepointreducesbispectralindexvaluesandstressinvolunteers.Anesth.Analg.
96:885890.
Habek,D.,Barbir,A.,Habek,J.C.,Janculiak,D.,andBobicVukovic,M.(2004).Successofacupunctureand
acupressureofthePc6acupointinthetreatmentofhyperemesisgravidarum.ForschKomplementarmed
Klass.Naturheilkd.11:2023.
Harris,R.E.,Jeter,J.,Chan,P.,Higgins,P.,Kong,F.M.,Fazel,R.,Bramson,C.,andGillespie,B.(2005). Using
acupressuretomodifyalertnessintheclassroom:asingleblinded,randomized,crossovertrial.JAltern
ComplementMed11:673679.
Hsieh,L.L.,Kuo,C.H.,Yen,M.F.,andChen,T.H.(2004).Arandomizedcontrolledclinicaltrialforlowback
paintreatedbyacupressureandphysicaltherapy.PrevMed39:168176.
Hsieh,L.L.,Kuo,C.H.,Lee,L.H.,Yen,A.M.,Chien,K.L.,andChen,T.H.(2006).Treatmentoflowbackpain
byacupressureandphysicaltherapy:randomisedcontrolledtrial.BMJ332:696700.
Jun,E.M.,Chang,S.,Kang,D.H.,andKim,S.(2006).Effectsofacupressureondysmenorrheaandskin
temperaturechangesincollegestudents:AnonrandomizedcontrolledtrialIntJNursStud.InPress
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(2002).Prehospitalanalgesiawithacupressureinvictimsofminortrauma:aprospective,randomized,
doubleblindedtrial.Anesth.Analg.95:723727.
Lee,A.andDone,M.L.(2004).StimulationofthewristacupuncturepointP6forpreventingpostoperative
nauseaandvomiting CochraneDatabaseSystRevCD003281.
Lee,M.K.,Chang,S.B.,andKang,D.H.(2004).EffectsofSP6acupressureonlaborpainandlengthof
deliverytimeinwomenduringlabor.JAlternComplementMed10:959965.
Litscher,G.(2004).Effectsofacupressure,manualacupunctureandLaserneedleacupunctureonEEG
bispectralindexandspectraledgefrequencyinhealthyvolunteers.EurJAnaesthesiol.21:1319.
Lu,D.P.,Lu,G.P.,andReed,J.F.,III(2000).Acupuncture/acupressuretotreatgaggingdentalpatients:a
clinicalstudyofantigaggingeffects GenDent.48:446452.
Maa,S.H.,Gauthier,D.,andTurner,M.(1997).Acupressureasanadjuncttoapulmonaryrehabilitation
programJCardiopulm.Rehabil.17:268276.
Maa,S.H.,Sun,M.F.,Hsu,K.H.,Hung,T.J.,Chen,H.C.,Yu,C.T.,Wang,C.H.,andLin,H.C.(2003).Effectof
acupunctureoracupressureonqualityoflifeofpatientswithchronicobstructiveasthma:apilotstudy J
AlternComplementMed9:659670.

114

Markose,M.T.,Ramanathan,K.,andVijayakumar,J.(2004).Reductionofnausea,vomiting,anddryretches
withP6acupressureduringpregnancy IntJGynaecol.Obstet.85:168169.
Ming,J.L.,Kuo,B.I.,Lin,J.G.,andLin,L.C.(2002).Theefficacyofacupressuretopreventnauseaand
vomitinginpostoperativepatients JAdvNurs39:343351.
Pouresmail,Z.andIbrahimzadeh,R.(2002).Effectsofacupressureandibuprofenontheseverityofprimary
dysmenorrhea JTradit.ChinMed22:205210.
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postoperativeadultpatient.Explore.(NY)2:202215.
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chemotherapycycleforKoreanpostoperativestomachcancerpatients.CancerNurs27:267274.
Tsay,S.L.andChen,M.L.(2003).Acupressureandqualityofsleepinpatientswithendstagerenal
diseasearandomizedcontrolledtrial IntJNursStud.40:17.
Tsay,S.L.,Rong,J.R.,andLin,P.F.(2003).Acupointsmassageinimprovingthequalityofsleepandquality
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Tsay,S.L.(2004).Acupressureandfatigueinpatientswithendstagerenaldiseasearandomized
controlledtrialIntJNursStud.41:99106.
Tsay,S.L.,Cho,Y.C.,andChen,M.L.(2004).AcupressureandTranscutaneousElectricalAcupoint
Stimulationinimprovingfatigue,sleepqualityanddepressioninhemodialysispatients AmJChinMed
32:407416.
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prolongedmechanicalventilationsupportJAdvNurs52:142150.
Waters,B.L.andRaisler,J.(2003).IcemassageforthereductionoflaborpainJournalofMidwifery&
Women&rsquosHealth48:317321.
Wu,H.S.,Wu,S.C.,Lin,J.G.,andLin,L.C.(2004).Effectivenessofacupressureinimprovingdyspnoeain
chronicobstructivepulmonarydisease.JAdvNurs45:252259.
Yip,Y.B.andTse,S.H.(2004).Theeffectivenessofrelaxationacupointstimulationandacupressurewith
aromaticlavenderessentialoilfornonspecificlowbackpaininHongKong:arandomisedcontrolledtrial
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Yip,Y.B.andTse,S.H.(2006).Anexperimentalstudyontheeffectivenessofacupressurewitharomatic
lavenderessentialoilforsubacute,nonspecificneckpaininHongKong ComplementTherClinPract
12:1826.
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treatmentofenuresis JIntMedRes31:552556.

115

Appendix13Excludedfromreviewreferences
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systematicreview(Structuredabstract)DatabaseofAbstractsofReviewsofEffectiveness.
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13.2Acupressure
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116

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Cummings,M.(2001).Handacupressurereducespostoperativevomitingafterstrabismussurgery(n=50).
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Wien.Klin.Wochenschr.109:6062

for

weight

reduction?

systematic

review.

Felhendler,D.andLisander,B.(1996).Pressureonacupointsdecreasespostoperativepain.ClinJPain
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nauseaandvomiting.JournalofPeriAnesthesiaNursing17:364376.
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117

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118

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119

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withcerebralpalsylivingingrouphomes.PhysTherCaseRep1:250259.
Wada,Y.,Yanagihara,C.,andNishimura,Y.(2005).InternaljugularveinthrombosisassociatedwithShiatsu
massageoftheneck.JNeurolNeurosurgPsychiatry76:142143.
Weintraub,M.I.(1996)Shiatsumassagetherapy:aremarkablehealingtechniqueinspinepain. Journalof
BackandMusculoskeletalRehabilitation7(3),195197.
White,A.(2002).Thecaseforuncontrolledclinicaltrials.ShiatsuSocietyNews62:1013.
Yates,S.(2005).Shiatsuandacupressureinpractice.MIDIRSMidwiferyDigest.

14.2Acupressure
Aikins,M.P.(1998).Alternativetherapiesfornauseaandvomitingofpregnancy.Obstet.Gynecol.91:149
155.
Anderson,F.W.J. and Johnson,C.T. (2005). Complementary and alternative medicine in obstetrics
InternationalJournalofGynecology&Obstetrics91:116124.
Anon(2006)."Needling"awayyour(aching)backpain.Acupunctureandacupressurebothcanprovide
longlastingreliefforlowbackpain,newstudiessay.HealthNews12:1112.
Brill,J.R. (1995). Acupressure for nausea and vomiting of pregnancy: A randomized, blinded study
Obstetrics&Gynecology85:159160.
Chernyak,G.(2003).Tenderactiveacupointisnotanidealcontrolforacupressurestudy.Anesth.Analg.
97:925926.
Collins,K.B.andThomas,D.J.(2004).Acupunctureandacupressureforthemanagementofchemotherapy
inducednauseaandvomiting.JAmAcadNursePract16:7680.
Frost,H.andStewartBrown,S.(2006).Acupressureforlowbackpain.BMJ332:680681.
Harris,P.E.(1997).Acupressure:areviewoftheliteratureComplementaryTherapiesinMedicine5:156
161.
Hickman,A.G.,Bell,D.M.,andPreston,J.C.(2005).Acupressureandpostoperativenauseaandvomiting.
AANA.J73:379385.
Jewell,D.(2003).Nauseaandvomitinginearlypregnancy.ClinEvid.15611570.
King,C.R.(1997).Nonpharmacologicmanagementofchemotherapyinducednauseaandvomiting.Oncol
NursForum24:4148.
Lee,A.andDone,M.L.(1999).Theuseofnonpharmacologictechniquestopreventpostoperativenausea
andvomiting:ametaanalysis.Anesth.Analg.88:13621369.
McDougall,G.J. (2005). Research review: the effect of acupressure with massage on fatigue and
depressioninpatientswithendstagerenaldisease.Geriatr.Nurs26:164165.
OatesWhitehead,R.(2003).Nauseaandvomitinginearlypregnancy.ClinEvid.16711682.
OatesWhitehead,R.(2004).Nauseaandvomitinginearlypregnancy.ClinEvid.18401852.

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Ostberg,O.,Horie,Y.,andFeng,Y.(1992).OnthemeritsofancientChineseeyeacupressurepractices.
ApplErgon. 23:343348.
Pan,C.X., Morrison,R.S., Ness,J., FughBerman,A., and Leipzig,R.M. (2000). Complementary and
AlternativeMedicineintheManagementofPain,Dyspnea,andNauseaandVomitingNeartheEndofLife:
ASystematicReviewJournalofPainandSymptomManagement20:374387.
Usichenko,T.I.andPavlovic,D.(2003).Suggestingtheoptimalcontrolprocedureforacupressurestudies.
Anesth.Analg.97:11961197.
Wu,X., Bai,G., Wen,J., and Yang,J. (2005). Evaluation on the therapeutic effects of digital acupoint
pressureforobstetricspasticcerebralpalsy.JTradit.ChinMed25:247251.

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Appendix15ResultsfromIndextoThesesandZETOCsearches.
Noneoftheresultsfromeitherofthesesearcheswereincludedforreviewastheydidnotmeetthe
inclusioncriteria.
IndextoTheses
http://www.theses.com/
Thiswebsiteprovidesacomprehensivelistingoftheseswithabstractsacceptedforhigherdegreesby
universitiesinGreatBritainandIrelandsince1716.
TwosearcheswerecarriedoutinFebruary2006,oneforShiatsuandoneforacupressure.
Thereweretworesultsfrombothsearchesandoneloancopywasorderedasonethesisreferred
specificallytoShiatsu.Theabstractsastheyappearonthewebsiteareshownbelowtogetherwiththe
reasonsforexclusion.

15.1Shiatsusearchresults
1.Pirie,Z.TheimpactofdeliveringShiatsuingeneralpractice.
2003,G5f
Ph.D.,Sheffield,5313808
ThisthesispresentsaPhDresearchstudyontheintegrationofacomplementarymedicineclinicina
generalpractice.ItdescribestheimpactofdeliveringShiatsuonaninnercitygeneralpractice,itsGPs,
patientsandtheShiatsupractitioner.Practitionerresearchwasconductedutilisingapostpositivist,
constructivistepistemologyandpredominantlyqualitativemethods.Thesemethodswereintegratedusing
Cunninghams(1998)InteractiveHolisticResearch(IHR)whichincludesactionresearch.Thequalitative
findingswereevaluatedwithInterpretivePhenomenologicalAnalysis(Smith,1995)andthequantitative
datawasassessedwithastatisticspackageforthesocialservices(SPSS).
ThemainimpactoftheShiatsucliniconthegeneralpracticewasthatGPconsultationswithreferred
patientssignificantlyreducedintermsofdurationandfrequencyandinvolvedfewerprescriptionsfor
medication.GPsclaimedthattheclinicsavedpracticeresources,offeredgreateroptionsforcare,
increasedtheirconfidenceinreferralstoShiatsu,enhancedthereputationofthepracticeandencouraged
amoreholisticapproachtohealth.
Thereferredpatientspresentedacomplex mixofchronicphysicalandpsychological/emotionalsymptoms.
AfterhavingShiatsu,theyclaimedtheyexperiencedlesspain,digestivedisorders,stress,depression,
angerandanxietyandmoreenergy,immunity,relaxationandsupport.Acycleofimprovementemerged
thatsuggestedhowthiswaspartlyduetopatientsreassessingtheirhealthandadoptingnewbehaviours
topreventandtreatsymptoms.
Inthisstudy,theresearcherwasboththeresearcherandthecomplementarypractitioner.Themain
impactoftheShiatsucliniconwasontheroleaspractitionerandthechallengeofworkingwithanew
patientgroupinanewsettingandreceivingdetailedevaluationfromthepatientsandGPs.
Reasonforexclusion:
AloancopyofthisthesiswasobtainedformtheUniversityofSheffieldforreview.Thiswasa
predominantlyqualitativeresearchprojectwithasampleof10patientswhopresentedwithavarietyof
healthproblems.Apartfromapublishedabstractfromapresentationatthe7thAnnualSymposiumon
ComplementaryHealthCare7th9thDecember2000,Exeter,UK,whichisshownbelow,nofurther
publicationswerefoundforthisauthor:
FocusAlternComplementTher20016:89
DeliveringShiatsuingeneralpractice

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PirieZ
InstituteofGeneralPracticeandPrimaryCare,ScHARR,TheUniversityofSheffield,NorthernGeneral
Hospital,Sheffield,S57AU,UK
Objective
ToassesstheimpactofdeliveringaShiatsuclinicinaninnercitygeneralpractice.
Materialsandmethods
TheimpactofaShiatsuclinicwasmeasuredby:analysingrecruitmentofpatients(n =10)viareferralfrom
fourGPscomparingGPandpatientperceptionsofpatientshealthmeasuringchangesinpatientshealth
length/contentofconsultationswiththeirGPsandtheexperiencesandsatisfactionofallinvolved.
Qualitativedatacamefrom30semistructuredinterviewswithpatients,sixinterviewswiththeGPsandthe
CPsreflectivejournal.Quantitativedatawasgatheredfromtwovalidatedhealthquestionnaires,the
MYMOPandSF12.
Results
Tenfemalepatientsagedbetween27and63yearsattendedtheShiatsuclinic,receivingatotalof56
treatments.Themostcommonsymptomwasclinicaldepression,reportedbyfive(50%)ofthe10patients.
Muscularpainanddigestivesymptomswerealsocommon,andsymptomsweremainlychronic,persisting
over10years.However,duringthestudy,patientsandGPsreportedmanychangesinthesepotentially
veryresistantsymptomsandanimprovementinhealthandwellbeing,includingadramaticreductionin
medicationandconsultations.
Conclusion
Complementarymedicinecanbedeliveredeffectivelyingeneralpractice,increasingitsequityofaccessto
arangeofpatientsinprimarycare.SeveralpositivebenefitscanbeassociatedwithreceivingShiatsuand
furtherresearchonclinicalandcosteffectivenessiswarranted.
2.Burrows,R.HolisticapproachestohealthandwellbeinginNorthernIreland.
1993,B4
Ph.D.,Queen'sUniversityBelfast,453572
ThethesisisananthropologicalstudyofholisticapproachestohealthandwellbeinginNorthernIreland,
whichplacesthese'alternative'therapieswithinawidernewagemovement.Definitionsofholistic
approachestohealthcareareexaminedandacritiqueofconventionalmedicineisofferedfromaholistic
perspective.Theoriesofsocialmovementsareanalyzedandthenewagemovementisrepresentedasan
innovativeformoftheproductionofknowledge,withspecificattentiongiventoholisticpractitionersand
newageleaderswhooperateas'movementintellectuals'.Centralmetaphorswithinthemovementare
identifiedanddiscussed,principally,'nature','emotion',and'thebody'.
Theresearcherusedparticipantobservationtoprovideanindepthanalysisofspecifictherapies,including
Shiatsu,aromatherapy,taichi,andgestaltpsychotherapy.Aswellasidentifyingthecommonalitiesand
divergenceswithinmovementdiscourses,thethesisseekstocontextualizewhatcanbeseenasa
transculturalmovementwithinalocal,NorthernIrishframework.Newagecommunitiesandspiritualityare
understoodasanaspectofabroadholisticmovementwhichattemptstotransformtheworldby
transformingtheself.
Reasonforexclusion:Shiatsuwasnotthemainsubjectarea

15.2Acupressuresearchresults
1.Dent,H.E.Developmentofaresearchbaseandmanagementpositionprotocolfortheuseof
nursescaringforpatientswithnauseaandvomitingfollowingacutemyocardialinfarction
1999,G5f
Ph.D.,Exeter,496544
Todevelopaknowledgebaseandmanagementprotocolfortheuseofnursescaringforpatients
experiencingnauseaand/orvomitingoccurringafteracutemyocardialinfarction.
Study1,anobservationalstudywithdatacollectedonadmissionandattwohourlyintervalsfor24hours,
todetermine:1)Incidenceofpostmyocardialinfarctionnauseaand/orvomitingoccurringafter
commencementofmedicaltreatment(PMINV),2)SeverityofPMINVmeasuredbythenumberofepisodes

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andaseverityscore,3)AssociationofPMINVwithsite,sizeandthicknessofinfarction,previousinfarction,
leftventricularfailure,opiateadministration,thrombolysis/reperfusion,cardiacpain,autonomic
disturbances,ageandgender,4)Effectivenessofantiemetictreatment,andwhethersomePMINVis
severe,persistentandintractabletotreatment,5)Whethertheresultsofpreviousstudiesintotheincidence
of,andfactorsassociatedwith,nauseaand/orvomitingatonsetofinfarctionpriortocommencementof
medicaltreatmentcouldbeconfirmed.
Theincidenceofnauseaand/orvomitingatonsetofinfarctionwasnotassociatedwithsite,sizeor
thicknessofinfarction,previousmyocardialinfarction,gender,age,orautonomicdisturbance.These
resultsdisputetheresultsofpreviousstudieswhichhavesuggestedvariouslythatnauseaandvomiting
wereassociatedwithinferior,transmuralandlargeinfarctions,andvagaloverexcitation.Theresultsof
studieswhichindicatedthesymptomswerenotassociatedwithsiteofinfarctionwereconfirmed.
Study2wasapartiallyrandomised,placebocontrolledclinicaltrial,carriedoutconcomitantlywiththe
observationalstudy,todeterminewhetherP6acupressure,appliedcontinuouslybywristbandtoboth
wrists,waseffectiveasanadjuncttostandardantiemetictherapyduringthe24hoursafteradmissionto
thecoronarycareunit.
P6acupressurereducedtheincidence(p<0.05)butnotseverityofPMINVcomparedwithplaceboduring
thelatter20hoursoftreatment,butnobenefitwasdemonstratedduringthefirstfourhours.
Reasonforexclusion: Acupressurebandswereusedinthisresearchproject.
2.Yang,J.Cancerchemotherapyandantiemetics
1989,G5c
M.Med.Sci.,Queen'sUniversityBelfast,404058
Inrecentyearssignificantadvanceshavebeenmadeinthetreatmentofmalignantdiseasewithcytotoxic
drugs,butnauseaandvomitingremainsaseveresideeffectofmanyregimens.Ina204patientsurvey,
lookingatwhichfactorspredisposedtochemotherapysickness,womenweremorepronethanmen.
Womenwhohavepostoperativesicknesswereparticularlypronewithmoderatelyemeticdrugs.Menwho
sufferfromtravelsicknessaremorepronetochemotherapysicknessthanthosewhodonot.Fearofthe
effectsofchemotherapypredisposestosickness,asdoesexpectationofsickness.Thisresearchexplored
theclinicaluseofantiemeticdrugsandacupuntureatp6pointorothermeansofstimulatingp6.Usingup
todatamethodologyitinvolvedthefollowing:(1)Assessingtheefficacyofinvasiveandnoninvasive
methods.(2)Prolongingtheeffectofp6acupuncturebyacupressure.(3)Comparingtheefficacyofsmall
andlargeelectrodes.P6acupunctureisaneffectiveadjuvanttoconventionalantiemetictherapyfor
patientshavingcytotoxicdrugs.Itsefficacyislimitedtoabout8hours,butthebenefitcanbeprolongedby
useofaSeaBand,pressedfor5minuteseverytwohours.Bestresultsareobtainedwithinvasive
acupuncture.Surfaceelectrodesarenotgoodasneedingbutarestillveryeffective.Thelargersizeis
slightlybetterthanthesmallerone.AcupressurebySeaBandsisnotveryeffectiveasaprimarytreatment
inthesepatients.P6acupuncturehasnosideeffects.
Reasonforexclusion: Thisresearchwasconductedpriorto1990andacupressurebandswereused.

15.3ZETOC(BritishLibraryElectronicTableofContents)search
ZetocprovidesaccesstotheBritishLibrary'sElectronicTableofContentsofaround20,000current
journalsandaround16,000conferenceproceedingspublishedperyear.Thedatabasecovers1993to
date,andisupdatedonadailybasis.Itincludesanemailalertingservice,toenableyoutokeepuptodate
withrelevantnewarticlesandpapers.
ZetocisfreetouseformembersofJISCsponsoredUKhigherandfurthereducationinstitutions.Itisalso
availabletoNHSScotlandandNorthernIreland.
Itisnotclearwhatthelevelofaccessisforthegeneralpublicornonacademicinstitutions.Thedatabase
canbeaccessedat:
http://zetoc.mimas.ac.uk/

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Twosearches,oneforShiatsuandoneforacupressure,werecarriedoutinApril2006,bothsearches
includedconferenceproceedings.ItwasnotpossibletodownloadreferencestoReferenceManager,
copiesofresultswereavailableviaemailfromthesite.
Therewere57resultsforShiatsuand220foracupressure.Therewereanumberofduplicateswithinthe
searcheswherethesameresultappearedtwicewithdifferentidentificationnumbers.Intheacupressure
searchtherewere45resultsfromTownsendLetterforDoctorsandPatients,anonlineforumfor
complementaryandalternativemedicine,whichreferredtoGJoacupressure awesternizedversionofthe
socalled"ahshi"or"tenderpoint"styleofacupuncturewithoutneedles(acupressure). http://www.g
jo.com/faq.html
Therewerenoabstractsavailableforapreliminaryscreening.Alloftheacupressureresultswereexcluded
accordingtotheexclusioncriteria.CopiesoftwopublicationsfromtheShiatsuresultswereobtainedfor
furtherscreening.ThesewerecollectionsofpostersfromaconferenceheldinJapanin2002andtherefore
werenotincludedforreview.
AkiraFukuoka,ErikoUeda,HiroshiFukuoka&YukoKoyama(2002)
ComparisonoftheeffectivenessthatShiatsumassageofcervicobrachialareahasonpsychosomatic
relaxationwhereQiisappliedandwhereitisnot.
JournalofinternationalSocietyofLifeinformationScience:20(2)S400405.
ErikoUeda,HiroshiFukuoka,YukoKoyama&AkiraFukuoka(2002)
UsefulnessofShiatsumassageoncervicobrachialareaandTranscutaneousElectricalAcupunkturepoint
Stimulation(TEAS)indentaltreatment.
JournalofInternationalSocietyofLifeInformationScience:20(2)S.412416

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