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Article history: We reviewed the available evidence for SP6 (Sanyinjiao) acupressure for the relief of primary dysmen-
Received 17 June 2016 orrhea (PD) symptoms, as well as patients' experiences of this intervention. We searched six relevant
Received in revised form databases and gray literature for publications dated up to March 2016. The search yielded 72 potential
31 August 2016
studies. Six of these studies, contributing a total of 461 participants, were included in this review. The
Accepted 8 September 2016
primary outcome was pain intensity. Studies with significant homogeneity were pooled for meta-
analysis. Qualitative data and quantitative data not suitable for meta-analysis were presented as a
Keywords:
narrative synthesis. The Cochrane criteria demonstrated that the included studies were generally of low
Primary dysmenorrhea
SP6 acupressure
quality with a high risk of bias. SP6 acupressure delivered by trained personnel significantly decreased
Sanyinjiao acupressure pain intensity immediately after the intervention (effect size ¼ 0.718; CI ¼ 0.951 to 0.585;
Dysmenorrhea pain p ¼ 0.000), and pain relief remained up to 3 h after the intervention (effect size ¼ 0.979; CI ¼ 1.296 to
0.662; p ¼ 0.000). However, patient-administered intervention required multiple monthly cycles to effect
pain reduction. SP6 acupressure appears to be effective when delivered by trained personnel for some PD
symptoms. Findings suggest that self-administered acupressure shows promise for the alleviation of PD
symptoms. High-quality research is needed before conclusive recommendations are proposed.
© 2016 Elsevier Ltd. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
2.1. Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
2.2. Eligibility criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
2.2.1. Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.2.2. Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.2.3. Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.2.4. Exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.3. Information sources and search strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.4. Study records and data management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.5. Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.6. Data collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
http://dx.doi.org/10.1016/j.ctcp.2016.09.003
1744-3881/© 2016 Elsevier Ltd. All rights reserved.
U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105 93
3.2. Quantitative data analysis of the included studies were RCTs [6,27-31], while one was a pre-
test post-test control trial [28]. Each study had a control group
In conducting the meta-analysis, the statistical approach but the form of control varied between studies, and included par-
compared the standardized mean difference (and the 95% CIs) in ticipants who received acupressure not at acupoints [6,31], par-
the intervention group versus control groups. ticipants who received a light touch at the SP6 acupoint [28,30],
and participants who received rest [27,29]. Personnel trained in
4. Results acupressure technique administered the intervention in all studies.
In addition, two studies [27,29] taught patients to self-administer
The six searched databases yielded a total of 72 potential acupressure for the follow-up treatment after an initial dose
studies. Of these, 26 studies were removed as duplicates, leaving 46 administered by trained personnel.
studies for title and abstract screening. A further 33 studies were The most common duration of intervention was 20e30 min
excluded following the screening of titles and abstracts. A total of 13 three times a day for the duration of dysmenorrhea, and the
studies were considered for full-length reading, after which seven intervention period ranged between one menstrual cycle [28,30] to
studies were further excluded because they: were systematic re- a 3-months follow-up intervention [30]. Regarding endpoints of
views [14,21], included multiple acupoints [22,23], did not specify primary outcome assessment, five of the studies [27,6,28-30]
the acupoint used [24], used a different acupoint [25], and were not assessed outcomes of pain intensity before and immediately after
in English [26]. A total of six studies were included in the data the intervention. Three studies [6,28,30] further assessed pain
extraction (Table 1), and quality appraisal, risk of bias assessment, outcome 3 h after administration by trained personnel, two [27,29]
and level of evidence assessment (Table 2). after 1 month of patient self-intervention (i.e. at one menstrual
cycle), and one [27] had follow up after a further 3 months of self-
4.1. Characteristics of included trial intervention. Visual analogue scale for pain, VASP was used to
assess pain intensity in five of the included studies [6,27-30], two
The six included studied [6,27-31] contributed a total of 461 out of which further utilised the Short-Form McGill Pain Ques-
participants (range: 30 to 86) with an age range of 15e30 years. tionnaire (SF-MPQ) [27,29]. The Short-Form Menstrual Distress
Specific details regarding criteria for the diagnosis of PD were not Questionnaire (SF-MDQ) was also used in two studies [27,29]. In
specified in all the included studies. Regarding research design, five addition to assessing pain intensity, one study [29] included
Table 1
96
Characteristics of Included studies.
Authors& Participants' Study design Control and Intervention, Duration of Attrition Outcome(s) assessed; Conclusion/funding sources
country characteristics components components intervention rate outcome(s) measurement
(N ¼ 378) and who delivered and follow-up methods; &results
intervention (where available)
Wong et al. n ¼ 46 (exp ¼ 24, RCT -Rest for20 min at -Acupressure at SP6 Initial testing and 13.04% Dysmenorrhea severity Use of acupressure is simple,
[27], (Hong con ¼ 24) initial intervention for20min by researcher 3months follow-up assessed immediately convenient and non-invasive.
Kong, China) All female students 20min rest upon at initial intervention self-treatment after treatment and It produces both immediate,
Age ˂ 25yrs waking and at bed 20min acupressure (3menstral cycles) after3 months using long term and accumulative
Mean age; time during the self-treatment upon VAS and SF-MPQ (for effects in relieving primary
exp ¼ 22 ± 0.882 first 3 days of the waking and at bed menstrual pain), and dysmenorrhea and can be
con ¼ 21.57 ± 0.746 next 3menstrual time during the first SF-MDQ (for menstrual adopted as a self-care measure
Age of menarche; cycles 3daysof the next3 distress) for adolescent girls.
exp ¼ 12.21 ± 1.224 menstrual cycles 20 a) There were
con ¼ 12.33 ± 1.278 significant differences
97
Criteria; assessed prior to, dysmenorrhea, with
(continued on next page)
Table 1 (continued )
98
Authors& Participants' Study design Control and Intervention, Duration of Attrition Outcome(s) assessed; Conclusion/funding sources
country characteristics components components intervention rate outcome(s) measurement
(N ¼ 378) and who delivered and follow-up methods; &results
intervention (where available)
VAS:visualanaloguescale; SF-MPQ:Short-FormMcGillPainQuestionnaire; SF-MDQ:Short-FormMenstrualDistress Questionnaire; VASA: Visual Analogue Scale for Anxiety; GHQ: General Health Questionnaire.
U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105 99
Table 2
Risk of bias in individual studies.
a b c
Authors Sources of bias Summary of Quality
risk of bias index
Selection bias Allocation Performance bias Detection bias Bias due to Reporting Other bias
concealment attrition bias
Wong et al.,2010 Yes Yes Yes No No No Sample size not High Low
powered
Kashefi et al.,2010 Yes Yes Yes Yes No Yes Sample size not High Low
powered
Chen and Chen, Yes Yes Yes No Yes No High Low
2004
Mirbagher- No Yes Yes Yes Unclear No Sample size not High Low
Ajorpaz powered
et al.,2011
Jun et al.,2006 Yes No No Unclear No No Low High
Kashefi et al.,2011 No No No Unclear No No
a
Yes indicates the presence or potential presence of a source of bias.
b
The Cochrane Collaboration tool for assessing risk of bias was used to determine and summarise risk of bias in included studies (Cochrane 2011).
c
Studies were subsequently rated as low-quality trials (i.e. having high risk of bias) or high-quality’ trials (i.e. having low to moderate risk of bias) if there was 3 or <3
identifiable sources of bias respectively.
anxiety as an outcome, measured with VAS for anxiety (VASA). One 4.2.3. Effect on pain relief of interventions delivered by patients
study [31] assessed the effect of SP6 acupressure on general health Two studies [27,29] reported patient-delivered interventions. At
using the general health questionnaire (GHQ). No study included the first month (one menstrual cycle) of patient intervention, both
outcomes related to quality of life. studies reported no difference in VASP score change between the
treatment and control (Table 3). As expected, the meta-analysis of
these two trials showed no difference in VASP score between the
4.2. Effect of SP6 two groups (see Fig. 6 for details). However, in the study in which
patients continued the intervention up to the third month [27], the
4.2.1. Effect on pain relief SP6 group, compared to the control, reported a lower VASP score
The details of outcomes relating to pain relief in the included (2.67 vs 4.30; p ¼ 0.008); see Table 3.
studies are presented in Table 3. One study [31] did not include a
pain-related outcome, and therefore was not part of the subsequent 4.3. Effect on quality of life, anxiety, general health, distress
meta-analysis on the effect of SP6 acupressure on dysmenorrhea
pain. No included study reported on quality of life outcomes. One
study which reported outcomes on anxiety [29] indicated that
initial treatment by the researcher produced an immediate
4.2.2. Effect on pain relief of interventions delivered by researchers decrease in VAS anxiety (VASA) scores in the acupressure group
Five studies [6,27-30] reported that researchers administered compared to control (3.13 vs 3.74; p < 0.05). However, after self-
the interventions and that VASP scores were assessed immediately treatment by patients, there was no significant group difference
after the intervention, with significant reduction in the SP6 in VASA scores (3.26 ± 2.23 vs 2.76 ± 2.16; p > 0.05). Also, only one
acupressure group compared to control for four of these studies study [31] contributed outcomes on general health. The study
[27-30]. The VASP scores for the five studies were judged to be showed that SP6 acupressure significantly improved the total mean
homogenous (Q ¼ 5.770; I2 ¼ 30.679%; Tau2 ¼ 0.00) after a c2 general health questionnaire (GHQ) score, as well as all the sub-
analysis, hence the random-effects model was implemented for the domains of somatic, depression, anxiety and social dysfunction
meta-analysis. There was a significant difference between the SP6 compared to control in both the first and second months of inter-
acupressure groups and control in terms of the pooled standardized vention (p < 0.001) (details in Table 3).
differences in mean VASP scores after intervention (pooled stan- Two studies reported on menstrual distress [27,29]. Each of
dardized mean difference (effect size) ¼ 0.718; CI ¼ 0.951 these studies reported no between-group differences in menstrual
to 0.585; p ¼ 0.000); see Fig. 2. A subsequent sensitivity plot, distress questionnaire (MDQ) scores immediately after in-
whereby one study in turn was removed from the meta-analysis, terventions by researchers. Also, there were no significant mean
did not change the direction of the prior meta-analysis. Details MDQ differences in the SP6 acupressure group compared to control
are shown in Fig. 3. after 1 month of self-treatment by patients (see Table 3). The post
Three studies [6,28,30] reported VASP scores at 3 h after inter- mean values of MDQ score from the studies relating to effect
vention and indicated that the SP6 acupressure group, compared to immediately after researcher intervention (Q ¼ 1.155; Tau2 ¼ 0.000;
the control, had a greater mean reduction in VASP scores. The c2 I2 ¼ 13.403), as well as following one month of self-treatment by
homogeneity test for this outcome indicated that the post- patients (Q ¼ 1.072; Tau2 ¼ 0.000; I2 ¼ 6.707) were all homogenous.
intervention mean pain VASP scores from the three studies were The fixed-effects model of meta-analysis for analysis showed no
homogenous (Q ¼ 2.608; I2 ¼ 23.302; Tau2 ¼ 0.000). A fixed-effects significant difference between the SP6 and control groups for both
meta-analysis showed significance in the pooled standardized interventions. The pooled standardized differences in mean MDQ
differences in mean VASP scores after intervention (effect score reduction were between 0.522 and 0.194, with an overall
size ¼ 0.979; CI ¼ 1.296 to 0.662; p ¼ 0.000) (Fig. 4). This was mean difference of 0.164 for researcher-administered interven-
unchanged after sensitivity analysis (Fig. 5). tion (shown in Fig. 7); and between 0.344 and 0.371, with an
Table 3
100
Data extraction from included studies.
Authors Outcomes
Pain intensity Menstrual distress Quality of life Anxiety General health Skin temperature
Wong et al. [27], a) There was statistically significant decrease in pain a) No significant difference
scores between groups for PVAS & SF-MPQ was noted in SF-MDQ scores
immediately after intervention. PVAS; 4.11 ± 1.94 between groups immediately
vs 5.81 ± 1.33 (p ¼ 0.003). SF-MPQ; 5.26 ± 3.05 vs after intervention (p ¼ 0.146)
7.38 ± 3.05(p ¼ 0.02) b) There were significant
b) There were also significant differences in PVAS differences in SF-MDQ scores
&SF-MPQ after 3months of self-care treatment. PVAS; between groups after 3months
2.79 ± 1.58 vs 4.30 ± 1.74 (p ¼ 0.008). SF-MPQ; of self-care intervention.
3.53 ± 4.03 vs 5.81 ± 3.92 (p ¼ 0.012) Experimental vs control group;
23.96 ± 4.79 vs 26.61 ± 5.10
(p ¼ 0.024)
101
102 U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
overall mean difference of 0.013 at one month (one cycle) for intervention, or outcomes from patient-administered acupressure.
patient-administered intervention (see Fig. 8). However, Wong In addition to extending the reported effectiveness of pain relief up
et al. [27] followed up patient-administered intervention for 3 to 3 h after intervention, the present systematic review is the first
months and reported that patients in the SP6 acupressure group evaluation of self-administered, alongside trained personnel-
had significantly more improvement in MDQ compared to the delivered, acupressure for pain relief in PD. It not clear whether
control (23.96 ± 4.79 vs 26.61 ± 5.10; p ¼ 0.024). differences in outcome between self-administered intervention
and intervention delivered by trained personnel is due to between-
5. Discussion trial differences, heterogeneous components in the trials, or solely
due to skill differences between patients and the trained personnel.
This systematic review identified several studies of treatment of This particular finding underscore the need for a future research
PD with SP6 acupressure, investigating outcomes of pain severity investigating intervention fidelity and factors influencing the effi-
and other menstrual outcomes. Although few published studies cacy of self administered acupressure for symptomatic relief in PD
met the criteria for inclusion in the review and meta-analysis, the and potentially other conditions.
present review includes the largest number of studies to date
among available reviews on SP6 acupressure treatments for PD. In 5.2. Effect on menstrual distress, quality of life, anxiety, and general
addition, this review is novel in a number of ways. This is the first heath
systematic review on a specific acupoint used for treatment of PD
that includes questions on health outcomes other than pain Findings suggest that SP6 acupressure was not effective in
severity. Secondly, this review presents a meta-analysis of out- reducing menstrual distress whether delivered by a trained
comes of patients' self-management, in addition to attempting to personnel or patient self-delivered; and there is a lack of evidence
address patients' experiences of SP6 acupressure, and factors regarding the effect of SP6 acupressure on quality of life. As for pain
influencing effect of interventions. relief, initial intervention by trained personnel led to a decrease in
anxiety, but no benefit was derived when patients treated them-
5.1. Effect on pain relief selves. This is the first systematic review to include quality of life,
menstrual distress, anxiety and general health, which are impor-
Findings demonstrate that SP6 acupressure delivered by re- tant health-related outcomes affected in women with PD. Although
searchers is effective in immediate pain relief among women with this is one strength of this review, making conclusions regarding
PD, and that pain relief could continue for up to 3 h following the these outcomes from the included studies is difficult because the
intervention. However, with the possible exception of interventions evidence for each of anxiety [29] and general health [31] were from
continued for 3 months, pain reduction is not achieved through a single poor-quality RCT, or a meta-analysis from two trials of low
patient self-management. This may indicate that a specialised quality. Similarly, only two trials [26,27] used in our meta-analysis
technique is necessary to administer SP6 acupressure, and perhaps provided evidence on menstrual distress. Considering their
also that patients need a longer period to master the skill. This importance in patients with PD, outcomes of anxiety, general
argument holds strong given that significant pain reduction was health and menstrual distress should be included in more high-
achieved in the third month of patient-administered intervention. quality research before a robust conclusion regarding effect of
Achieving pain reduction with self-administration of acupressure SP6 on these outcomes is proposed.
has potential value in reducing pressure on the health system, by
reducing recurrent visits to clinics. 5.3. Experiences of patients with SP6 acupressure intervention and
There have been previous systematic reviews and meta- factors influencing outcomes
analyses of acupressure interventions for PD that assessed pain
reduction [10-12]; however, direct comparison cannot be drawn Surprisingly, no studies were identified that reported on patient
with the present review due to the heterogeneity of different experiences of SP6 acupressure for PD. Similarly, apart from po-
acupressure techniques included in the previous reviews. However, tential inferences from the differential outcomes in interventions
one study [14] that conducted a specific review of SP6 acupressure delivered by researchers compared to those from patient self-
reported similar findings relating to immediate pain relief, but treatment, no study reported data on factors influencing the
failed to analyse outcomes for an extended period after effectiveness of outcomes in SP6 acupressure interventions for PD.
Figure 2. Forest plot showing immediate differences in mean using the pain visual analogue scale score for studies' outcome data in which researcher administered acupressure at
the SP6 versus control. Data are presented as the difference in means with the 95% confidence interval (CI). P < 0.05 indicates a statistically significant difference.
U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105 103
Figure 3. Sensitivity analysis for the influence of individual studies on the pooled estimate (as determined using the leave-one-out approach) of the immediate pain visual analogue
scale score for studies' outcome data in which researcher administered acupressure at the SP6 versus control. Data are presented as the difference in means with the 95% confidence
interval (CI). P < 0.05 indicates a statistically significant difference.
Figure 4. Forest plot showing differences in of the pain visual analogue scale score 3 h post intervention for studies' outcome data in which researcher administered acupressure at
the SP6 versus control. Data are presented as the difference in means with the 95% confidence interval (CI). P < 0.05 indicates a statistically significant difference.
Figure 5. Sensitivity analysis for the influence of individual studies on the pooled estimate (as determined using the leave-one-out approach) of the pain visual analogue scale score
3 h after intervention for studies' outcome data in which researcher administered acupressure at the SP6 versus control. Data are presented as the difference in means with the 95%
confidence interval (CI). P < 0.05 indicates a statistically significant difference.
This is disappointing because patients' experiences are valid in- perspectives prior to developing intervention, as well as the
dicators of intervention acceptability, and perhaps efficacy, from acceptability and practicality of acupressure interventions after
the patient perspective. These may influence adherence to long- implementing the intervention. This is particularly relevant given
term interventions, particularly those involving self-treatment. that it has the potential of enhancing patients ownership of the
Our finding has both practice and research implication and high- intervention, hence increasing patient adherence and perhaps the
lights important gap in previous acupressure interventions. success rate of the intervention. Stakeholders in acupoint therapy
Importantly, given that PD may require recurrent management at practice and research should make this an important consideration
monthly menstrual cycles, interventions need to consider patients in future interventions.
104 U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
Figure 6. Forest plot showing immediate differences in mean using the pain visual analogue scale score for studies' outcome data in which patient self-administered acupressure at
the SP6 for one menstrual cycle versus control. Data are presented as the difference in means with the 95% confidence interval (CI). P < 0.05 indicates a statistically significant
difference.
Figure 7. Forest plot showing immediate differences in mean using the MDQ score for studies' outcome data in which researcher administered acupressure at the SP6 for one
menstrual cycle versus control. Data are presented as the difference in means with the 95% confidence interval (CI). P < 0.05 indicates a statistically significant difference.
Figure 8. Forest plot showing immediate differences in mean using the MDQ scale score for studies' outcome data in which patient self-administered acupressure at the SP6 for one
menstrual cycle versus control. Data are presented as the difference in means with the 95% confidence interval (CI). P < 0.05 indicates a statistically significant difference.
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