Complementary Therapies in Clinical Practice 25 (2016) 92e105

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Effectiveness of SP6 (Sanyinjiao) acupressure for relief of primary

dysmenorrhea symptoms: A systematic review with meta- and
sensitivity analyses
Ukachukwu Okoroafor Abaraogu a, b, *, Sylvester Emeka Igwe a,
Chidinma Samantha Tabansi-Ochiogu c
a
Department of Medical Rehabilitation Faculty of Health Science and Technology College Medicine University of Nigeria Enugu Campus, Enugu, Nigeria
b
School of Health and Life Sciences Glasgow Caledonian University United Kingdom, UK
c
Physiotherapy Department University of Calabar Teaching Hospital Calabar, Cross-River, Nigeria

a r t i c l e i n f o a b s t r a c t

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

* Corresponding author. Department of Medical Rehabilitation Faculty of Health

Science and Technology College Medicine University of Nigeria Enugu Campus,
Enugu, Nigeria.
E-mail addresses: Ukachukwu.abaraogu@gcu.ac.uk, ukachukwu.abaraogu@unn.
edu.ng (U.O. Abaraogu).

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

2.7. Data items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

2.8. Outcomes and prioritisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
2.9. Risk of bias assessment in individual studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
3. Data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
3.1. Data synthesis including assessment of heterogeneity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
3.2. Quantitative data analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.1. Characteristics of included trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.2. Effect of SP6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.2.1. Effect on pain relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.2.2. Effect on pain relief of interventions delivered by researchers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.2.3. Effect on pain relief of interventions delivered by patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
4.3. Effect on quality of life, anxiety, general health, distress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5.1. Effect on pain relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5.2. Effect on menstrual distress, quality of life, anxiety, and general heath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5.3. Experiences of patients with SP6 acupressure intervention and factors influencing outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
6. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
7. Implications for practice and research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

1. Introduction approximately 4 cm above the medial malleolus, at the posterior

border of the medial aspect of the tibia. Chen et al. [14] have
Primary dysmenorrhea (PD) is the most common gynaecological published the most comprehensive review to date on the specific
problem reported by women of reproductive age, with more than effects of the SP6 acupoint in PD, with literature up to 2012
84% of these woman reporting symptoms [1]. Pain caused by reviewed. Although they posited that SP6 acupressure is effective in
dysmenorrhea leads to a reduction in quality of life, and school or relieving dysmenorrhea pain, definitive conclusions could not be
work absenteeism for up to half of those who experience it [2]. It drawn from their findings, as the review was limited by the small
has been suggested that PD is the leading cause of school absen- number of included trials, and their poor quality. In addition, a
teeism among adolescents [3,4]. Despite the availability of medi- major limitation to their review was that it did not include quality
cation to manage this condition, evidence suggests that many of life, and other relevant and important health-related outcomes
women do not get satisfactory relief of symptoms and report in women with PD.
several side effects from common medications [5]. Furthermore, It is important to review the most recent evidence for SP6
given that PD is condition that recurs throughout the reproductive acupressure in PD, particularly which published since Chen et al.’s
lives of women, potentially requiring recurrent management, review, and including important outcomes in addition to pain in-
repeated use of medications carries the risk of cumulative adverse tensity. Similarly, investigation of patient self-administered SP6
effects. acupressure is warranted to determine if these interventions could
Consequently, there is increasing interest in research into be recommended in future clinical practices. This systematic re-
alternative therapies for PD. Acupoint therapy in the form of view aims to answer the following questions: 1) What is the effect
acupressure is frequently recommended as an alternative treat- of SP6 treatment in relieving pain, and in improving quality of life,
ment for symptoms of PD [6,7,8]. Whereas acupressure targets the menstrual distress, anxiety and general health of women with PD e
same energy meridian as acupuncture, the use of surface applica- delivered by trained personnel and self-delivered by patients; and
tion in pressure makes it safer compared to the relatively invasive 2) What are the experiences and perceptions of women with PD
use of needles in acupuncture. PD usually develops in adolescence regarding SP6 treatment aimed at relieving their pain and other
and may persist to 40 years of age [9], requiring recurrent man- important dysmenorrhea outcomes?
agement at each menstrual period. Teaching patients a safe
acupressure technique for self-management will reduce clinic
2. Methods
visits. Therefore, an effective, patient-led acupressure intervention
has potential value for the health system. However, self-
2.1. Design
management has not been a subject of discussion or research
among stakeholders in acupressure therapy.
A systematic mixed-studies review design with a meta-analysis
The major challenge in translating evidence from acupressure
was planned for this review. However, only randomized, controlled
therapies to clinical practice relating to PD is the difficulty in
trials (RCTs) and a pre-test post-test study were seen after searches.
isolating the importance of the individual acupressure points used
The protocol for this review was registered with the International
in the various studies. The few previous attempts to synthesise
Prospective Register of Systematic Reviews (PROSPERO,
evidence through systematic reviews [10,11,12] have mainly
CRD42016034200).
focussed on the effectiveness of acupressure generally in treating
PD. These reviews failed to report the effects of specific acupoints
and the regimens used. 2.2. Eligibility criteria
The efficacy of acupressure depends on the acupoints targeted,
techniques used and frequency of sessions, among other things. The Studies were considered for eligibility according to the following
acupoint of choice in gynaecology is SP6 (Sanyinjiao) [13], located criteria.
94 U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
2.2.1. Studies
Studies in the English language, that were original research
manuscripts in peer reviewed journals and conference proceedings,
were included. Study designs included were restricted to RCTs and
non-RCTs (quasi-RCTs, controlled clinical trials (cross-over trials)).
Studies were included if they evaluated: the effects of SP6
acupressure in women with PD, the factors that influence adher-
ence to these interventions, or the factors that influence the
effectiveness of the interventions. Also, qualitative studies that
evaluated experiences or perceptions of patients receiving SP6 in-
terventions were considered for inclusion.
2.2.2. Participants
Studies involving women with symptomatic PD were included.
2.2.3. Interventions
Studies were included as long as the independent effect of the
SP6 intervention on primary dysmenorrhea could be determined.
2.2.4. Exclusion criteria
Narrative review syntheses, systematic reviews, opinion papers,
letters to the editor, and any study not including primary data or a
clear method of data analysis were also excluded. Research in
languages other than English language was excluded.
2.3. Information sources and search strategy
We implemented a search strategy that was developed and
piloted in accordance with the guidelines of the Cochrane Hand-
book for Systematic Reviews [15], and the recommendations for
Health Care Review by the Centre for Reviews and Dissemination
[16]. First, a literature search of bibliographic databases was con-
ducted utilising the following search terms: “sanyiniao acupres-
sure” OR “SP6 acupressure” AND “menstrual pain” OR “menstrual
cramp” OR “dysmeneorrhea” OR “primary dysmenorrhea” AND
“pain” OR “Quality of life” OR “general health”. The following da-
tabases were searched: CINAHL, Cochrane Library, ProQuest, AMED,
MEDLINE, and PEDRO. Key words and abstracts were searched and
search strategies included explosion as well as Boolean operators
where appropriate. Additionally, searches were performed from the
reference lists of identified studies.
2.4. Study records and data management
Search results were exported into RefWorks™ to check for du-
plicates, and then bibliographic records were exported into
Microsoft excel ™ [17], to facilitate data management and selection
of articles for inclusion. The review team then developed, piloted,
and refined eligibility questions and forms for the studies included
in the review.
2.5. Selection
Initial screening was conducted on the study title and the ab-
stracts by one review author. A second review author then inde-
pendently validated these initial screening results. Two review
authors then independently read through the full lengths of
selected studies for further screening, using the previously deter-
mined eligibility criteria. Any difference of opinion at this stage
regarding inclusion or exclusion was resolved by discussion and
reflection, in consultation with the third review author if required.
Details of the flow of studies throughout the process of assessment
of eligibility and study selection are represented, along with the
reasons for exclusion, in a PRISMA diagram (Fig. 1).
2.6. Data collection
The Data Extraction Template developed by the Cochrane Con-
sumers and Communication Review Group [18], was adapted to
extract the data.
2.7. Data items
Data were collected from variables including authors details,
year of publication, participant characteristics, study sample size,
study design, components of the intervention, who delivered the
intervention (where available), duration of the intervention and
length of follow-up (where available), attrition rate, outcome(s)
assessed, the outcome(s) tools measurement, results and conclu-
sions. Searches were limited to peer review journal articles and
conference proceeding published in English.
2.8. Outcomes and prioritisation
The primary outcome was pain intensity. Secondary outcomes
were quality of life, menstrual distress, anxiety, and general health.
Also patients' experiences with SP6 acupressure, as well as factors
influencing the effect of SP6 acupressure in primary dysmenorrhea,
were included as secondary outcomes. Endpoints of analysis of
primary outcome included: immediately following the interven-
tion, maximum duration of hours assessed after intervention, and
maximum follow up. Separate analyses were performed for out-
comes of interventions delivered by trained personnel, and patient
self-administered interventions.
2.9. Risk of bias assessment in individual studies
Using the Cochrane Collaboration Tool for Risk of Bias Assess-
ment [15], the risk of bias for each of the studies was evaluated in
six key domains: i) selection bias (random sequence generation,
allocation concealment); ii) performance bias; iii) detection bias;
iv) bias due to attrition; v) reporting bias; and vi) other bias (other
sources of bias not elsewhere addressed). Assessment was made in
each of the included studies and graded as ‘high risk’ or ‘low risk’
following a well-described procedure [15]. Two reviewers made
judgements regarding the risk of bias independent of each other.
Areas of difference were resolved by discussion and reflection, or in
consultation with the third reviewer.
3. Data analysis
3.1. Data synthesis including assessment of heterogeneity
The data on the effectiveness of SP6 acupressure are presented
in the evidence table (Table 3). Cochran's chi squared (c2) test of
homogeneity [19] was performed to generate the inconsistency
index (I2) statistic on mean of relevant and applicable outcomes
from the included studies. Meta-analysis was used if the studies
had acceptable homogeneity (I2 < 85%) of study design, partici-
pants, interventions, controls, and outcome measures. Meta-
analyses were performed using fixed-effect models (I2 < 25%) for
homogeneous studies, and using random-effects methods prior to
fixed-effect models when there was substantial heterogeneity
(25% < I2 < 85%) [15]. Meta-analysis was done using comprehensive
data analysis software [20]. The data from quantitative studies that
could not be analysed statistically were interpreted using narrative
synthesis.
 U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
Figure 1. SP6 acupressure in primary dysmenorrhea PRISMA flow diagram.
3.2. Quantitative data analysis
In conducting the meta-analysis, the statistical approach
compared the standardized mean difference (and the 95% CIs) in
the intervention group versus control groups.
4. Results
The six searched databases yielded a total of 72 potential
studies. Of these, 26 studies were removed as duplicates, leaving 46
studies for title and abstract screening. A further 33 studies were
excluded following the screening of titles and abstracts. A total of 13
studies were considered for full-length reading, after which seven
studies were further excluded because they: were systematic re-
views [14,21], included multiple acupoints [22,23], did not specify
the acupoint used [24], used a different acupoint [25], and were not
in English [26]. A total of six studies were included in the data
extraction (Table 1), and quality appraisal, risk of bias assessment,
and level of evidence assessment (Table 2).
4.1. Characteristics of included trial
The six included studied [6,27-31] contributed a total of 461
participants (range: 30 to 86) with an age range of 15e30 years.
Specific details regarding criteria for the diagnosis of PD were not
specified in all the included studies. Regarding research design, five
95
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
but the form of control varied between studies, and included par-
ticipants who received acupressure not at acupoints [6,31], par-
ticipants who received a light touch at the SP6 acupoint [28,30],
and participants who received rest [27,29]. Personnel trained in
acupressure technique administered the intervention in all studies.
In addition, two studies [27,29] taught patients to self-administer
acupressure for the follow-up treatment after an initial dose
administered by trained personnel.
The most common duration of intervention was 20e30 min
three times a day for the duration of dysmenorrhea, and the
intervention period ranged between one menstrual cycle [28,30] to
a 3-months follow-up intervention [30]. Regarding endpoints of
primary outcome assessment, five of the studies [27,6,28-30]
assessed outcomes of pain intensity before and immediately after
the intervention. Three studies [6,28,30] further assessed pain
outcome 3 h after administration by trained personnel, two [27,29]
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-
intervention. Visual analogue scale for pain, VASP was used to
assess pain intensity in five of the included studies [6,27-30], two
out of which further utilised the Short-Form McGill Pain Ques-
tionnaire (SF-MPQ) [27,29]. The Short-Form Menstrual Distress
Questionnaire (SF-MDQ) was also used in two studies [27,29]. In
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,
[27], (Hong con ¼ 24)
Kong, China) All female students
Age ˂ 25yrs
Mean age;
exp ¼ 22 ± 0.882
con ¼ 21.57 ± 0.746
Age of menarche;
exp ¼ 12.21 ± 1.224
con ¼ 12.33 ± 1.278
RCT -Rest for20 min at -Acupressure at SP6 Initial testing and 13.04% Dysmenorrhea severity Use of acupressure is simple,
initial intervention for20min by researcher 3months follow-up assessed immediately convenient and non-invasive.
20min rest upon at initial intervention self-treatment after treatment and It produces both immediate,
waking and at bed 20min acupressure (3menstral cycles) after3 months using long term and accumulative
time during the self-treatment upon VAS and SF-MPQ (for effects in relieving primary
first 3 days of the waking and at bed menstrual pain), and dysmenorrhea and can be
next 3menstrual time during the first SF-MDQ (for menstrual adopted as a self-care measure
cycles 3daysof the next3 distress) for adolescent girls.
menstrual cycles 20 a) There were
significant differences

U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105

Criteria; in VAS scores &SF-MPQ
➢ PVAS score of >5 between the acupressure&
at least 2months in control groups immediately
past half year after initial intervention
➢ Nil history of (VAS:4.11versus5.81,
gynaecological P ¼ 0.003; SF-MPQ:
diseases/surgery/secondary 5.26versus7.38, P ¼ 0.02)
dysmenorrhea b) There were significant
➢ Nil pain medication differences in VAS, SF-MPQ
taken 6 hr before and and SF-MDQ scores between
during intervention the acupressure and control
groups after 3months of
self-care(VAS:2.79versus4.30,
P ¼ 0.008; SF-MPQ:
3.53versus5.81, P ¼ 0.012;
SF-MDQ:23.96versus 26.61,
P< 0.024)
Kashefi et al. n ¼ 86(exp ¼ 43, con ¼ 43) RCT Acupressure at a Acupressure at SP6 2 months 5.81% 1oDysmenorrhea Acupressure at SP6
[6], (Iran) Age; 18-26yrs non acupoint for 30min applied by (2menstrual severityassessedby acupointmaybe an effective
Mean age; 20.84 ± 1.64yrs applied for 30min researcher during the cycles) VASbeforeand immediately, way to alleviate primary
Weight; 39e72 kg by the researcher first 24 hr of menstrual 30min, and1,2, and3hafter dysmenorrhea among young
(mean 55.59 ± 5.7 kg) during the first cycle for 2cycles intervention for 2menstrual college women and can be
Age of menarche; 24 hr of menstrual cycles integrated into clinical

12e17yrs (mean cycle for 2cycles 2 a) For the first cycle, practice as an inexpensive
13.3 ± 1.44) there were significant and easy to learn midwifery
Criteria; differences in VAS scores intervention.
➢ PVAS score of >4 between the acupressure Funded by Deputy for
➢ Nil history of and control groups 30min,1,2, Research of Shiraz University
gynaecological and 3 h after intervention of Medical Sciences
diseases/surgery/secondary (4.90versus6.06, 4.38
dysmenorrhea versus6.23,4.55versus6.34,
➢ With regular and 5.34versus6.81 resp.,
menstrual cycles all P< 0.001).
➢ Nil pain medication No D immediately after
before and 3 hr after Intervention (6.86 vs 6.67)
intervention b) For the second cycle,
there were significant
differences in VAS scores
between the acupressure
and control groups
immediately,30min,
1,2, and3hrs after
intervention (5
versus6.16, 4.86

Chen and Chen n ¼ 69 (exp ¼ 40, con ¼ 41)
[29] Age <20yrs (range 15-20yrs)
(Taiwan) Mean age;
exp ¼ 18.06 ± 1.28
con ¼ 17.50 ± 1.54
Age of menarche;
range 10-16yrs
Mean, exp ¼ 12.37 ± 1.35,
con ¼ 12.50 ± 1.38
Criteria;
➢ VAS score of >5
➢ Nil history of
gynaecological
diseases/surgery/secondary
dysmenorrhea
➢ Nil pain medication
4 hr before intervention
Mirbagher- n ¼ 30(exp ¼ 15, con ¼ 15)
Ajorpaz et al., Age; range 18-30yrs
[30] (Iran) mean age; exp ¼ 22 ± 1.6
con ¼ 22 ± 2.64
Age of menarche;
exp ¼ 13 ± 1.5,
con ¼ 11 ± 2.35
Criteria;
➢ VAS score 3
➢ Must not be pregnant
➢ Nil diagnosis of
secondary dysmenorrhea
➢ Must agree to refrain
from oral contraceptives
or intra uterine devices
at least 3 h before and
after treatment
Jun et al. [28] n ¼ 61(exp ¼ 30, con ¼ 31)
(Korea) Age 18-28yrs
Mean age 22 ± 2.65yrs
Weight 50 ± 4.57 kg
Age of menarche; 13 ± 1.47yrs
Criteria;
versus6.04, 4.72
versus6.44,4.60
versus6.58,and5.67
versus7.06,
resply., all P< 0.001)
RCT Restfor20minat AcupressureatSP6 Initial testing plus 1 14.82% 1oDysmenorrhea Acupressure is an effective,
initialintervention for20minapplied monthself- severityassessed cost-free, easy to learn and
and 20minrestduring byresearcherat treatment usingVASP, SF-MPQ, safe form of therapy and
next menstrual cycle initialintervention, follow-up (during and MDQforpain, can be integrated into clinical
then 20minacupressure next menstrual VASA foranxiety practice and health education
self-treatment cycles) and the Acupressure in order to enhance the
duringnext Self-Assessment Form quality of life of adolescents
menstrualcycle (for the experimental with primary dysmenorrhea.
group only) Funded partially by National
2oa)Initial intervention; Science Council, Taiwan.
Thereweredifferencesin
U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
VASpain andanxietyscores
betweenthe acupressure
andcontrol (pain:3.88vs4.79;
anxiety:3.13vs 3.74. But no
significant group difference
in menstrual distress on
the MDQ.
b) After self-treatment;
Thereweredifferencesin
VASpain scoresbetween
theacupressureand control
groups(2.92versus3.04)
but no significant group
difference in anxiety and
menstrual distress
c) There were positive
results from the Acupressure
Self-Assessment evaluation
with 89% reporting “more
than moderately helpful”
and 94% reporting “more
than moderately satisfied”.
RCT LighttouchatSP6 AcupressureatSP6 1 menstrual cycle ———— 1oDysmenorrhea severity Acupressure on the SP6
for20minapplied for20minapplied measured usingVASbeforeand meridian can be an effective
byresearcher byresearcher immediately, 30min, 1,2, non-invasive nursing
and3hafter treatment intervention for alleviating
2oThereweresignificantdifferencesin primary dysmenorrhea and its
VASscoresbetweentheacupressure effects lasts for 3 h
andcontrolgroupsimmediately,1, post-treatment.
2,and3hafterintervention(3.50
versus5.06,3.30versus4.86,2.40
versus5.00,and1.66versus4.80,
resp., all P< 0.05)
Pretest- LighttouchatSP6 AcupressureatSP6 1 menstrual cycle 4.92% 1oDysmenorrhea Acupressure on the SP6
posttest without pressure for20minapplied severitymeasured meridian can be an
controlled (placebo) byresearcher usingVAS and skin effective non-invasive
trial for20minapplied temperature changes nursing intervention for
byresearcher in CV2 and CV12acupoints alleviating primary
97
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 score 4 immediately, 30min, effects lasts for 2 h

➢ Must not be pregnant 1,2, and3hafter treatment post-treatment.
➢ Must be in good 2oa) There was significant
general health difference in severity of
➢ With regular dysmenorrhea between
menstrual cycle the two groups immediately
➢ Nil diagnosis of after treatment and for up to
secondary dysmenorrhea 2 h post-treatment
➢ Must agree to (2.73versus4.21; p ¼ 0.000
refrain from use of oral and 2.33versus3.57;
contraceptives or intra p ¼ 0.032)

U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105

uterine devices a week b) Skin temperature
before onset of was significantly
menstrual period. elevated at 30min
after acupressure at
CV2acupoint in
experimental compared
to control group
(35.01versus34.71).
There was also notable
temperature increase
at CV12acupoint, post
treatment, but group
differences were not
significant.

Kashefi et al., n ¼ 86(exp ¼ 43, con ¼ 43) Randomized Acupressure Acupressure at 2months 11.63% 1 General health Both acupressure and sham
[31] (Iran) Age (range); 18e28yrs single-blind at sham point SP6 for 30min measured using pressure were effective in
(mean); 20.84 ± 1.64yrs placebo- for 30 min by applied by GHQ(having four promoting women's general
Criteria; controlled researcher researcher. domains; somatic, health; nevertheless, the
➢ Having regular menstrual trial anxiety, social efficacy of acupressure was
cycles (3e8 days of dysfunction and more than that of sham
menstruation with depression) before pressure.
intervals of 22e35 days) intervention, and
➢ Not taking any after both first and
medication such as second months of
hormonal contraceptives, intervention.
antipsychotics, 2oBoth acupressure
antidepressants, and sham pressure
vitamins had positive effects
➢ GHQ scores of <23 on general health and
➢ Not suffering from any its improvement after
psychiatric disorder, 1st month of intervention
such as major depressive but with statistically
disorder, panic significant differences
disorder, or epilepsy between the two groups
(11.65versus15.69).
There were also
significant differences
between the two
groups after 2 nd
month of
intervention
(3.99versus7.57)

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

Random sequence Participant and Blinding of Incomplete Selective

generation personnel blinding outcome outcome data reporting
assessment

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
study [31] assessed the effect of SP6 acupressure on general health
using the general health questionnaire (GHQ). No study included
outcomes related to quality of life.
4.2. Effect of SP6
4.2.1. Effect on pain relief
The details of outcomes relating to pain relief in the included
studies are presented in Table 3. One study [31] did not include a
pain-related outcome, and therefore was not part of the subsequent
meta-analysis on the effect of SP6 acupressure on dysmenorrhea
pain.
4.2.2. Effect on pain relief of interventions delivered by researchers
Five studies [6,27-30] reported that researchers administered
the interventions and that VASP scores were assessed immediately
after the intervention, with significant reduction in the SP6
acupressure group compared to control for four of these studies
[27-30]. The VASP scores for the five studies were judged to be
homogenous (Q ¼ 5.770; I2 ¼ 30.679%; Tau2 ¼ 0.00) after a c2
analysis, hence the random-effects model was implemented for the
meta-analysis. There was a significant difference between the SP6
acupressure groups and control in terms of the pooled standardized
differences in mean VASP scores after intervention (pooled stan-
dardized mean difference (effect size) ¼ 0.718; CI ¼ 0.951
to 0.585; p ¼ 0.000); see Fig. 2. A subsequent sensitivity plot,
whereby one study in turn was removed from the meta-analysis,
did not change the direction of the prior meta-analysis. Details
are shown in Fig. 3.
Three studies [6,28,30] reported VASP scores at 3 h after inter-
vention and indicated that the SP6 acupressure group, compared to
the control, had a greater mean reduction in VASP scores. The c2
homogeneity test for this outcome indicated that the post-
intervention mean pain VASP scores from the three studies were
homogenous (Q ¼ 2.608; I2 ¼ 23.302; Tau2 ¼ 0.000). A fixed-effects
meta-analysis showed significance in the pooled standardized
differences in mean VASP scores after intervention (effect
size ¼ 0.979; CI ¼ 1.296 to 0.662; p ¼ 0.000) (Fig. 4). This was
unchanged after sensitivity analysis (Fig. 5).
4.2.3. Effect on pain relief of interventions delivered by patients
Two studies [27,29] reported patient-delivered interventions. At
the first month (one menstrual cycle) of patient intervention, both
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
two groups (see Fig. 6 for details). However, in the study in which
patients continued the intervention up to the third month [27], the
SP6 group, compared to the control, reported a lower VASP score
(2.67 vs 4.30; p ¼ 0.008); see Table 3.
4.3. Effect on quality of life, anxiety, general health, distress
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
decrease in VAS anxiety (VASA) scores in the acupressure group
compared to control (3.13 vs 3.74; p < 0.05). However, after self-
treatment by patients, there was no significant group difference
in VASA scores (3.26 ± 2.23 vs 2.76 ± 2.16; p > 0.05). Also, only one
study [31] contributed outcomes on general health. The study
showed that SP6 acupressure significantly improved the total mean
general health questionnaire (GHQ) score, as well as all the sub-
domains of somatic, depression, anxiety and social dysfunction
compared to control in both the first and second months of inter-
vention (p < 0.001) (details in Table 3).
Two studies reported on menstrual distress [27,29]. Each of
these studies reported no between-group differences in menstrual
distress questionnaire (MDQ) scores immediately after in-
terventions by researchers. Also, there were no significant mean
MDQ differences in the SP6 acupressure group compared to control
after 1 month of self-treatment by patients (see Table 3). The post
mean values of MDQ score from the studies relating to effect
immediately after researcher intervention (Q ¼ 1.155; Tau2 ¼ 0.000;
I2 ¼ 13.403), as well as following one month of self-treatment by
patients (Q ¼ 1.072; Tau2 ¼ 0.000; I2 ¼ 6.707) were all homogenous.
The fixed-effects model of meta-analysis for analysis showed no
significant difference between the SP6 and control groups for both
interventions. The pooled standardized differences in mean MDQ
score reduction were between 0.522 and 0.194, with an overall
mean difference of 0.164 for researcher-administered interven-
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)

U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105

Kashefi et al. [6], a)Nil significant difference in VAS scores between
groups immediately after intervention (p˃0.05)
b) Forthefirstcycle, therewere significant differences in
VAS scores between the acupressure and control groups
30min,1,2, and3h after intervention 30mins; 4.90 ± 1.30
vs 6.06 ± 1.35, 1 h; 4.38 ± 1.21 vs 6.23 ± 1.52,2 h;
4.55 ± 1.60 vs6.34 ± 1.57, and3h; 5.34 ± 1.47
vs6.81 ± 1.56,(all p˂0.05).
c)) For these condcycle, there were significant
differences in VAS scores between the acupressure
and control groups immediately,30min, 1,2, and3h
after intervention
Immediately; 5 ± 1.21 vs6.16 ± 1.47,
30min; 4.86 ± 1.30 vs 6.04 ± 1.21, 1 h; 4.72 ± 1.36
vs 6.44 ± 1.46, 2 h; 4.60 ± 2.02 vs6.58 ± 1.60, 3 h;
5.67 ± 1.64 vs7.06 ± 1.58, (all P < 0.05)
Chen and Chen [29] a) Initial intervention; ThereweredifferencesinVASpain There was decrease in MDQ a) Initial intervention;
scoresbetweenthe acupressureandcontrol scores within groups after Thereweredifferencesin
(3.88 ± 1.83 vs 4.79 ± 1.84) initial and self-treatment VASanxietyscoresbetweenthe
b) After self-treatment; ThereweredifferencesinVASpain follow-up test but no acupressureandcontrol
scoresbetweentheacupressureand controlgroups significant difference (3.13 ± 2.19 vs 3.74 ± 1.94)
(2.92 ± 1.68 vs3.04 ± 2.54 between groups. b) After self-treatment;
Therewere no significant
group difference in VAS
anxiety scores.
Mirbugher-Ajorpaz Thereweresignificantdifferencesin VASscores between
et al. [30], theacupressure andcontrolgroupsimmediately,1, 2,
and3hrs afterintervention
Immediately; 3.50 ± 1.42 vs 5.06 ± 1.43(p ¼ 0.004),
1 h; 3.30 ± 1.60 vs4.86 ± 1.24(p ¼ 0.007),
2 h; 2.40 ± 2.16 vs5.00 ± 1.25(p ¼ 0.005),and
3 h; 1.66 ± 1.98 vs4.80 ± 1.37(p ¼ 0.000)
Jun et al. [28], There was significant difference in severity of a)At the suprapubic
dysmenorrhea between the two groups immediately CV2acupoint, the skin
after treatment and for up to 2 h post-treatment temperature was
Immediately; 2.73 ± 1.53 vs 4.21 ± 1.47(F ¼ 18.50, elevated with
p ¼ 0.000) significant difference
30min; 2.23 ± 1.50 vs 3.60 ± 1.64 (F ¼ 12.29, p ¼ 0.004) between groups
1 h; 2.26 ± 1.68 vs 3.75 ± 1.66 (F ¼ 12.37, p ¼ 0.004) 30mins after treatment
2 h; 2.33 ± 1.88 vs 3.57 ± 1.52 (F ¼ 8.04, p ¼ 0.032) (35.01 ± 0.67 vs
34.71 ± 0.64, F ¼ 4.87,
p ¼ 0.03)
b)At epigastric
 CV12acupoint,
temperature elevation
was noted post
treatment but group
differences were not
significant (F ¼ 1.46,
p ¼ 0.23)
Kashefi et al., [31] Both acupressure
and sham pressure
improved the general
health of participants
with significant
differences in GHQ
scores between groups
in both 1st and
2ndmonths

U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105

of intervention.
Mean total GHQ scores;
1 st month; 11.65 ±
3.63 vs 15.69 ± 3.14
(F ¼ 38.87,
p˂0.001)
2 nd month; 3.99 ± 2.69
vs 7.57 ± 2.67(F ¼ 124.58,
p˂0.001)
Mean scores for GHQ
domains;
Somatic; 1st month;
4.81 ± 0.09 vs 6.09 ± 0.73
(F ¼ 15.12, p˂0.0001)
2 nd month; 2.07 ± 0.99 vs
4.52 ± 1.45 (F ¼ 59.99, p˂0.0001)
Anxiety; 1st month; 3.83 ± 1.31
vs 5.3 ± 2.47 (F ¼ 7.76,p ¼ 0.02)
2 nd month; 1.13 ± 0.24 vs 3.21
± 1.76 (F ¼ 47.87, p˂0.0001)
Social dysfunction;
1st month; 5.63 ± 1.04 vs
8.7 ± 1.98 (F ¼ 8.39,p ¼ 0.04)
2 nd month; 2.41 ± 0.85 vs
5.07 ± 2.95 (F ¼ 44.38, p˂0.0001)
Depression;
1st month; 3.12 ± 1.41 vs
5.58 ± 2.67 (F ¼ 4.21,p ¼ 0.02)
2 nd month; 1.71 ± 1.06 vs
4.11 ± 2.01 (F ¼ 61.12, p˂0.0001)

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
patient-administered intervention (see Fig. 8). However, Wong
et al. [27] followed up patient-administered intervention for 3
months and reported that patients in the SP6 acupressure group
had significantly more improvement in MDQ compared to the
control (23.96 ± 4.79 vs 26.61 ± 5.10; p ¼ 0.024).
5. Discussion
This systematic review identified several studies of treatment of
PD with SP6 acupressure, investigating outcomes of pain severity
and other menstrual outcomes. Although few published studies
met the criteria for inclusion in the review and meta-analysis, the
present review includes the largest number of studies to date
among available reviews on SP6 acupressure treatments for PD. In
addition, this review is novel in a number of ways. This is the first
systematic review on a specific acupoint used for treatment of PD
that includes questions on health outcomes other than pain
severity. Secondly, this review presents a meta-analysis of out-
comes of patients' self-management, in addition to attempting to
address patients' experiences of SP6 acupressure, and factors
influencing effect of interventions.
5.1. Effect on pain relief
Findings demonstrate that SP6 acupressure delivered by re-
searchers is effective in immediate pain relief among women with
PD, and that pain relief could continue for up to 3 h following the
intervention. However, with the possible exception of interventions
continued for 3 months, pain reduction is not achieved through
patient self-management. This may indicate that a specialised
technique is necessary to administer SP6 acupressure, and perhaps
also that patients need a longer period to master the skill. This
argument holds strong given that significant pain reduction was
achieved in the third month of patient-administered intervention.
Achieving pain reduction with self-administration of acupressure
has potential value in reducing pressure on the health system, by
reducing recurrent visits to clinics.
There have been previous systematic reviews and meta-
analyses of acupressure interventions for PD that assessed pain
reduction [10-12]; however, direct comparison cannot be drawn
with the present review due to the heterogeneity of different
acupressure techniques included in the previous reviews. However,
one study [14] that conducted a specific review of SP6 acupressure
reported similar findings relating to immediate pain relief, but
failed to analyse outcomes for an extended period after
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.
intervention, or outcomes from patient-administered acupressure.
In addition to extending the reported effectiveness of pain relief up
to 3 h after intervention, the present systematic review is the first
evaluation of self-administered, alongside trained personnel-
delivered, acupressure for pain relief in PD. It not clear whether
differences in outcome between self-administered intervention
and intervention delivered by trained personnel is due to between-
trial differences, heterogeneous components in the trials, or solely
due to skill differences between patients and the trained personnel.
This particular finding underscore the need for a future research
investigating intervention fidelity and factors influencing the effi-
cacy of self administered acupressure for symptomatic relief in PD
and potentially other conditions.
5.2. Effect on menstrual distress, quality of life, anxiety, and general
heath
Findings suggest that SP6 acupressure was not effective in
reducing menstrual distress whether delivered by a trained
personnel or patient self-delivered; and there is a lack of evidence
regarding the effect of SP6 acupressure on quality of life. As for pain
relief, initial intervention by trained personnel led to a decrease in
anxiety, but no benefit was derived when patients treated them-
selves. This is the first systematic review to include quality of life,
menstrual distress, anxiety and general health, which are impor-
tant health-related outcomes affected in women with PD. Although
this is one strength of this review, making conclusions regarding
these outcomes from the included studies is difficult because the
evidence for each of anxiety [29] and general health [31] were from
a single poor-quality RCT, or a meta-analysis from two trials of low
quality. Similarly, only two trials [26,27] used in our meta-analysis
provided evidence on menstrual distress. Considering their
importance in patients with PD, outcomes of anxiety, general
health and menstrual distress should be included in more high-
quality research before a robust conclusion regarding effect of
SP6 on these outcomes is proposed.
5.3. Experiences of patients with SP6 acupressure intervention and
factors influencing outcomes
Surprisingly, no studies were identified that reported on patient
experiences of SP6 acupressure for PD. Similarly, apart from po-
tential inferences from the differential outcomes in interventions
delivered by researchers compared to those from patient self-
treatment, no study reported data on factors influencing the
effectiveness of outcomes in SP6 acupressure interventions for PD.
 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-
dicators of intervention acceptability, and perhaps efficacy, from
the patient perspective. These may influence adherence to long-
term interventions, particularly those involving self-treatment.
Our finding has both practice and research implication and high-
lights important gap in previous acupressure interventions.
Importantly, given that PD may require recurrent management at
monthly menstrual cycles, interventions need to consider patients
perspectives prior to developing intervention, as well as the
acceptability and practicality of acupressure interventions after
implementing the intervention. This is particularly relevant given
that it has the potential of enhancing patients ownership of the
intervention, hence increasing patient adherence and perhaps the
success rate of the intervention. Stakeholders in acupoint therapy
practice and research should make this an important consideration
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.

6. Limitations deliberately excluded. In addition, there were wide variations in the

There are so many limitations in the present review. Despite
including the largest studies compared to previous reviews in SP6
acupressure for PD, the evidence is yet limited to a small number of
mostly low quality trials. We did not include any study other than
those in English language excluding potentially relevant studies
that were published in other languages. Included studies did not
specified criteria for diagnosing people PD with the implication
that participants with secondary dysmenorrhea were not
forms of control groups meaning that homogeneity test did not
consider the control arm. Lastly, no study included outcomes
related to quality of life.
7. Implications for practice and research
Available evidence supports the continued use of SP6 acupres-
sure by trained personnnnels for pain women with PD. Weak evi-
dence suggest that patient-administered intervention could be
 U.O. Abaraogu et al. / Complementary Therapies in Clinical Practice 25 (2016) 92e105
beneficial perhaps when applied for extended monthly circles, but
high quality trials are needed before recommendation are made in
this direction. Our findings suggest underscores the need for future
trials in this population to specify criteria for the diagnosis of pri-
mary dysmenorrhea in future trials. Quality of life should be
considered as this outcome is known to be impacted by PD. In
addition, there is need for research into patients constructs relating
to the perceptions or experiences of patients regarding SP6
acupressure interventions for symptoms relief in primary
dysmenorrhea as no study has reported on this.
8. Conclusion
Despites the limitations inherent in the present review, the
following conclusion are made. When delivered by trained
personnel, SP6 appears to be effective for immediate pain relief,
reduction of anxiety, and may improve general health. Pain
reduction from self-management is achieved only after interven-
tion for multiple menstrual cycles. Notwithstanding, findings sug-
gest that self-administered acupressure shows promise for
alleviating the symptoms of PD. Given the low quality and small
number of included studies supporting the efficacy of SP6
acupressure, and that acupressure is safe, cheap, and perhaps easily
learnt by patients, clinicians should continue to utilise SP6
acupressure treatment to relief pain from PD, but more robust and
high-quality trials are needed to build the evidence base for SP6
acupressure in PD. Furthermore, important health-related out-
comes like quality of life, menstrual distress and anxiety should be
included in future trials. In addition, an SP6 trial looking at pro-
tocols for patient self-treatment, or comparing self-treatment with
interventions administered by trained personnel, is desirable to
improve the quality of evidence regarding the feasibility and utility
of self-treatment by SP6 acupressure.
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