Explore xxx (xxxx) xxx

Contents lists available at ScienceDirect

EXPLORE
journal homepage: www.elsevier.com/locate/jsch

The effect of acupressure or reiki interventions on the levels of pain and

fatigue of cancer patients receiving palliative care: A randomized
controlled study✰
Hediye Utli a, *, Mahmut Dinç b, Medical Doctor Adil Utli c
a
Department of Elderly Care, Vocational School of Health Services, Mardin Artuklu University, Mardin, Turkey
b
Faculty of Health Sciences, Department of Nursing, Batman University, Batman, Turkey
c
Department of Emergency Medicine, Eskişehir Osmangazi Faculty of Medicine, Eskişehir, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: Taking pain under control is important to calm the individual and reduce complications. This research
Acupressure was conducted with the aim of determining the effect of Acupressure or Reiki interventions on the levels of pain
Analgesic use and fatigue of stage III and IV cancer patients receiving palliative care.
Cancer pain
Method: The research was a single-blind, repeated measures, randomized controlled study. Research data were
Fatigue
Palliative care
collected between February and November 2022. The research sample consisted of Acupressure and Reiki
Reiki intervention groups and a control group with 52 patients in each group for a total of 156 patients. Acupressure or
Reiki was applied to their intervention groups for a total of eight sessions of 20 min each over four weeks, once a
day on two days a week. Data were collected by means of a patient description form, an analgesic follow-up form,
the Numeric Pain Rating Scale, and the Brief Fatigue Inventory.
Results: In comparison with the control group, a significant reduction was seen over time in the levels of pain (p
< 0.001), analgesic use (p < 0.001), and fatigue (p < 0.001) in the Acupressure or Reiki intervention groups.
Conclusion: Acupressure or Reiki interventions were found to effective in reducing levels of pain, analgesic use,
and fatigue. It was seen that in addition to their use in routine nursing care, both treatments can be accepted as
effective nursing interventions that reduce pain and fatigue in stage III and IV cancer patients receiving palliative
care.

Introduction
Fatigue is described by cancer patients as a continuous and subjec­
tive feeling of tiredness, lassitude, and lack of energy that is not relieved
by resting.1,2 A total 55% of patients undergoing cancer treatment and
66% of those with advanced metastasis suffer moderate to severe pain.3
Analgesics regularly used in palliative care, including sublingual fenta­
nyl, benzodiazepines, antidepressants, and anticonvulsants, can cause
fatigue. Moreover, pharmacological interventions have various side ef­
fects such as dependence, hypotension, respiratory depression, and
vomiting.2,4–6 Holistic treatments in which pharmacological and
non-pharmacological regimens are used together are recommended to
treat pain and fatigue in cancer patients.7 Acupressure and Reiki are
non-pharmacological interventions for cancer patients that are easy to
learn and apply, effective, safe, cheap, relaxing, and non-invasive; they
do not require special equipment, can be applied with little effort, and
serve to motivate the patient.4–6,8–12
Acupressure is a massage technique in which pressure is applied to
certain areas of the body with the thumb or index finger, the palm of the
hand, the hands, or a stimulator, thus aiding in the regular functioning of
the energy canals.2,5,6,12,13 When the meridians—the body’s energy
canals—are stimulated, the canals open and the flow of qi (life energy) is
regulated.5,6 Acupressure increases the secretion of endorphin in the
body and relieves pain and fatigue, causing relaxation and greater

✰
The clinical trial registration number is NCT05473845 https://clinicaltrials.gov/ct2/show/NCT05473845.Authors’ contributions: H.U. contributed to the
literature search, study concept, study design, data interpretation, statistical analysis, conducting the trial, data collection, data evaluation and drafting the
manuscript. M.D., and A.U. contributed to literature search, study concept, and drafting of the manuscript. All the authors reviewed and approved the final
manuscript.
* Corresponding author at: Artuklu Campus, Box 47110, Mardin, Turkey.
E-mail address: hediyeutli@artuklu.edu.tr (H. Utli).

https://doi.org/10.1016/j.explore.2022.11.007

1550-8307/© 2022 Elsevier Inc. All rights reserved.

Please cite this article as: Hediye Utli, Explore, https://doi.org/10.1016/j.explore.2022.11.007

H. Utli et al.
comfort.12
Reiki, translated as “universal life energy,” is a biofield energy
therapy involving light touch.1,4,8,10,14 It relieves fatigue by activating
the parasympathetic nervous system, and the results of its painkilling
effects reduce pain and the use of analgesics.15,16 The physiological ef­
fect of Reiki on pain-killing can be explained by “gate control theory.”
According to this theory, skin stimulation suppresses pain signals by
stimulating a-beta thick sensory fibers and suppressing small diameter
fibers that carry pain messages. When the hypothalamus is stimulated,
relief is provided by preventing painful stimuli via naturally secreted
endorphins, enkephalins, and dynorphins (morphine derivatives).15
In a recent literature review, Billot et al.17 highlighted the need for
further studies to determine the benefits of Reiki therapy on pain and
quality of life in palliative care. Many studies have been found that were
conducted with cancer patients in oncology clinics, but little informa­
tion was presented on the effect of Acupressure or Reiki interventions on
the pain and fatigue of cancer patients in palliative care clinics. The aim
of this study was to determine the effect of Acupressure or Reiki in­
terventions on the levels of pain and fatigue of stage III and IV cancer
patients receiving palliative care. The hypotheses of this study were as
follows:
Hypothesis 1. Acupressure or Reiki interventions have an effect on
pain and fatigue levels in stage III and IV cancer patients receiving
palliative care.
Hypothesis 0. Acupressure or Reiki interventions have no effect on
pain and fatigue levels in stage III and IV cancer patients receiving
palliative care.
Methods
Study design
The research was a single blind, repeated measures, randomized
controlled study. The pain levels of stage III and IV cancer patients in
palliative care clinics of the institutions where the research was con­
ducted were measured every 4 h using a visual analogue scale, and their
performance status was measured once a week with the Eastern Coop­
erative Oncology Group Performance Status Scale (ECOG-PS). The pa­
tients were given non-steroid anti-inflammatory drugs (NSAID), non-
opioid analgesics, and opioid analgesics every 4–6 h according to need.
Participants
This research was conducted with stage III and IV cancer patients
admitted to the palliative care clinics of two state hospitals of the
Ministry of Health in a province in eastern Turkey. Research data were
collected between February and November 2022. The research sample
consisted of 156 patients who met the inclusion criteria.
Inclusion criteria
Palliative care patients who met the following conditions were
included in the study: (1) a diagnosis of stage III and IV cancer; (2) 18
years of age or older; (3) had pain for at least one month in connection
with cancer treatment or the symptoms of the disease; (4) uses NSAID or
non-opioid analgesics; (5) a status of 5 or more on the Numeric Pain
Rating Scale (NPRS); (6) a score of 1–3 on the ECOG-PS scale; (7) suit­
able for Acupressure or Reiki according to an oncology specialist; (8) no
burns, scars, cuts or scratches, or deformities in the area where
Acupressure would be applied; (9) have not had Acupressure or Reiki
previously; (10) conscious; (11) no communication problem; (12) no
psychological illness; and (13) agreed to participate in the research.
After the research was started, two patients whose status on the
ECOG-PS scale was 4 and four patients who were using opioid analgesics
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were excluded.
Sample size
No randomized studies were found in the literature on the effect of
Acupressure or Reiki intervention on pain in cancer patients receiving
palliative care, and so the effect size was calculated from the fatigue
findings. The size of the research sample was calculated using the
G*Power 3.1.9.7 program. Effect size was modeled on the findings of
Özdemir and Taşçı.11 In the randomized controlled study by Özdemir
and Taşçı,11 a two-stage experimental group (6.13±1.29) and a control
group (7.09±2.19) indicating fatigue were taken, and the effect size was
found to be 0.53. Using Özdemir and Taşçı11 study to calculate a sample
size, an effect size (f) of 0.53, a type I error (α) of 0.05, a test power (1-β)
of 0.95, analysis of variance (ANOVA) test-fixed effects, an omnibus, and
one-way test, we found that the necessary sample size to determine a
significant difference was a minimum of 60. In the current research, the
sample size was 156 patients: 52 each in the Acupressure, Reiki, and
control groups.
Randomization and blinding
To keep all three groups the same size, the 1:1:1 block randomization
method was used with the online application Research Randomizer.18
Giving information on the interventions to patients in the Acupressure
and Reiki groups can create the Hawthorne effect. The Hawthorne effect
is described as changes in the behavior of patients participating in a
study because of increasing knowledge.19 Therefore, patients included
in the study were not told what was being applied. In this way, partic­
ipants were blinded. However, the researchers (H.U., M.D., and A.U.)
were not blinded.
Procedures
During the study, the routine treatment of the patients in all three
groups was continued. In support of their routine treatment, a total of
eight sessions of Acupressure or Reiki were conducted with the patients
of the intervention (Acupressure or Reiki) groups, with two sessions a
week, once a day, over four weeks. Each session lasted 20 min. All
sessions were held by the same researcher (H.U.). However, no inter­
vention was made to the control group.
The researcher (H.U.) took part in 16 h of Acupressure training, four
hours a day for four days. She has one year of experience as a first-degree
Acupressure practitioner and has a PhD in nursing. Previous studies in
the literature11,20,21 were examined, and an Acupressure intervention
protocol was prepared in line with the views of an expert.
The researcher (H.U.) has received Usui Reiki Lineage (Degree 1)
training and has five years of experience as a first-degree Reiki practi­
tioner. Previous studies in the literature8,15,22,23 were examined, and a
Reiki intervention protocol was prepared following the views of an
expert.
Owing to the COVID-19 pandemic, social distancing and the use of
personal protective equipment were observed when collecting research
data. At the first meeting, information was given to the patients
regarding the aim of the research. Participants were given 1 hour to
decide whether to participate in this study. The researchers (H.U., M.D.,
and A.U.) obtained written approval from the patients. Patients who
agreed to participate in the research were assigned to an intervention
group (Acupressure or Reiki) or the control group by the block
randomization method. The patient description form was completed by
the researchers. Information on ECOG-PS and hemoglobin (g/dl) and
hematocrit (%) values were taken from the patients’ files in the first
week.
The pain and fatigue levels of patients who agreed to participate in
the research were measured 4–6 h after the administration of NSAID and
non-opioid analgesic medication after the intervention on the second
H. Utli et al.
day of the starting week (Time 1), after the intervention on the second
day of the second week (Time 2), and after the intervention on the
second day of the fourth week (Time 3). On Time 1, Time 2, and Time 3,
the NPRS, analgesic follow-up form (AFF), and Brief Fatigue Inventory
(BFI) forms were completed for all groups.
Intervention
Acupressure group: To apply Acupressure in a comfortable environ­
ment and not affect the pain and fatigue assessment of the research, the
patients’ relatives were taken out of the room during treatment. Room
temperature was set at 22 ◦ C–26 ◦ C. Before the interventions, the pa­
tient’s room was readied so as to be quiet, dimly lit, and with nothing to
divert the attention. The patient was asked to lie on the bed in a supine
position, dressed, and with feet straight.12
Acupressure for this group was applied to a total of four points on the
extremities that were seen as suitable: stomach meridian 25th point
(Tianshu/ST25) (Right and Left/bilaterally), large intestine meridian
4th point (Hegu/LI4) (Right and Left/bilaterally), stomach meridian
36th point (Susanli/ST36) (Right and Left/bilaterally), and spleen me­
ridian 6th point (San Yin Jiao/SP6) (Right and Left/bilaterally).11,20,21
Acupressure skills include pointing, pressing, kneading, and pushing.
Pointing is the skill of finding the Acupressure point. Pressing is the skill
of applying sufficient pressure to free the flow of qi, which the patient
experiences as tingling and pain. Kneading is the skill of turning the
finger around the Acupressure point to stimulate the improvement ef­
fect. Pushing is the skill of pushing with the thumb from the Acupressure
point toward the extremity to relax the patient’s muscles and increase
blood circulation.21
Before the intervention, the researcher (H.U.) warmed and rubbed
her hands for approximately 20 s. This was to ready the tissues for
intervention to the Acupressure points by reducing tissue sensitivity.
The researcher (H.U.) applied pressure to the determined Acupressure
points in a breathing rhythm by pressing for 10 s and relieving pressure
for 2 s without lifting the fingers. Pressure was applied to the Acupres­
sure points until patients felt tingling or slight pain.5 A total of 16 min of
pressure were applied: 2 min at each of the four selected points and the
symmetrically opposite points on the other extremities. The session for
each patient lasted approximately 20 min, including preparation and the
Acupressure intervention. After the procedure, the patient rested for 10
min. The NPRS, AFF, and BFI forms were completed for the Acupressure
group after the interventions on Time 1, Time 2, and Time 3.
Reiki group: To apply Reiki in a comfortable environment and not
affect the pain and fatigue assessment of the research, the patients’
relatives were taken out of the room during treatment. Reiki does not
involve pressure, massage, rubbing, or the use of any equipment.14
Before and after Reiki sessions, patients are recommended to drink
water.24 In this study, patients were allowed to drink water before the
Reiki session. During the session, the individual had to be dressed and in
a comfortable place and position, such as reclining on a couch or a bed.4
Before the interventions, the patient’s room was readied so as to be
quiet, dimly lit, and with nothing to divert the attention. The Reiki
session was started with the patient in a supine position, clothed, eyes
closed, arms and legs straight, and palms upwards.
Reiki is a calming energy therapy in which the practitioner places
their hands and uses a light touch on or above the patient.4,14,16 There
are seven chakras in the body, and there are many more traditional hand
positions. When applying Reiki, approximately 3 min must be given to
each chakra, and so the researcher (H.U.) placed her hands over the
patient’s body and applied Reiki for 20 min.8,15,22,23
In First Degree Reiki (Reiki I), the “aura attunement” between the
practitioner and the patient allows healing through touch.15 The
researcher (H.U.) held her hands 2–3 cm above the patient and, by
making circular movements from the head toward the feet of the patient,
adjusted their aura. After this process of “aura attunement,” the
researcher (H.U.) placed her hands directly over the patient’s body. She
3
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completed the Reiki treatment by placing her hands on the patient’s
eyes, head, neck, chest, pit of the stomach, groin, and each side of the leg
area.8,15 The Reiki intervention was started from between the patient’s
eyes. Universal life energy flows naturally to the areas where it is most
needed in the recipient’s body.17 In the areas where the researcher (H.
U.) placed her hands, the researcher felt heat and tingling to differing
degrees in her palms. Each position lasted for 1–3minutes. The number
of hand positions used depended on the need of each patient. The
researcher (H.U.) kept her hands over the patient’s body until she felt
that the “energy” had stopped. She carried out Reiki for a total of 20 min.
After the procedure, the patient rested for 10 min. Patients were allowed
to drink water after the Reiki session. The NPRS, AFF, and BFI forms
were completed for the Reiki group after the interventions on Time 1,
Time 2, and Time 3.
The control group was merely allowed to rest for 20 min. There was
someone present during their rest period. The treatment protocol of the
control group was the same as that of the Acupressure or Reiki groups.
The only difference was the absence of Acupressure or Reiki therapy in
the control group’s protocol. The NPRS, AFF, and BFI forms were
completed for the control group after the interventions on Time 1, Time
2, and Time 3.
Data collection tools
A patient description form, the NPRS, the BFI, and the AFF were used
for data collection.
Patient description form
This form was prepared in line with the literature.11,22 It consists of
eight questions on the patient’s demographics, including age (years),
number of children, gender, marital status, education level, employment
status, place of residence, and monthly income, and ten questions
relating to cancer, such as the stage, diagnosis, time since diagnosis
(years), comorbidities, current comorbid diseases, chemotherapy,
chemotherapy protocol, ECOG-PS, and hemoglobin (g/dl) and hemat­
ocrit (%) values, for a total of 18 questions.
Numeric pain rating scale
The scale starts from an absence of pain and extends to an unbearable
level of pain. A score of 0 indicates no pain, 1–3 slight pain, 4–6 moderate
pain, and 7–10 severe pain.25,26 Patients are asked to report their pain
intensity in the previous 24 h. The NPRS can easily be used as an oral
and written scoring system and is therefore a valid and reliable scale for
measuring pain intensity.26,27
The Cronbach’s alpha value of the scale is reported to be 0.90.28 In
the present study, Cronbach’s alpha value was found to be 0.93.
Brief fatigue inventory
This scale evaluates the fatigue levels of cancer patients in the pre­
ceding 24 h. It is scored between 0 and 10. A score of 0 indicates not
affected, 1–3 a low level of fatigue, 4–6 a moderate level of fatigue, 7–9 a
high level of fatigue, and 10 affected at the highest level.29
The Cronbach’s alpha coefficient of the scale is between 0.82 and
0.97.29 In the current study, the Cronbach’s alpha value of the scale was
found to be 0.95.
Analgesic follow-up form
This form, which was created by the researchers, records the total
weekly dose (mg) of NSAID and non-opioid analgesics used as well as the
times of measurement.
H. Utli et al.
Data analysis
Data were analyzed using the Statistical Package for Social Sciences
25.0 (SPSS, IBM Corp., Armonk, NY, USA). In the analysis of data,
descriptive statistical methods were used, with numerical values, per­
centages, mean, standard deviation, medians, maxima, and minima. The
compatibility of the data to normal distribution was analyzed through
the Shapiro-Wilk test and Q-Q graphical reviews. Parametric tests were
chosen because the NPRS and BFI score values were in accordance with
the normal distribution. One-way ANOVA test was utilized to compare
mean NPRS and BFI scores among the three groups, while one-way
ANOVA Post-hoc Bonferroni test was used in intergroup dual compari­
sons. Repeated measures ANOVA test followed by pairwise comparisons
was used on dependent groups during intragroup comparisons. Non-
parametric tests were chosen because the AFF score values did not
conform to the normal distribution. The Kruskal-Wallis test was utilized
to compare median AFF scores among the three groups. This was fol­
lowed by a Post-hoc one-way ANOVA test for intergroup dual compar­
isons. The Friedman test followed by the Post-hoc Dunn test was used on
dependent groups during intragroup comparisons. Statistical signifi­
cance was taken as p < 0.05.
Ethical considerations
The research was approved by the Non-Interventional Clinical
Research Ethics Committee of Mardin Artuklu University (No. E-
76,272,411–900–44,647, dated 11 February 2022). Patients were given
information on the aim of the study, and their written approval was
Fig. 1. CONSORT flow diagram.
4
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obtained. The research conformed with the principles outlined in the
Declaration of Helsinki. It was registered with ClinicalTrials.gov
(XXXXX), and the trial design followed CONSORT guidelines.30
Results
Participant flow
The flow of the participants throughout this study is illustrated in
Fig. 1.
Demographic characteristics
No significant difference was found between the groups with regard
to descriptive characteristics. Thus, the groups were homogeneous (p >
0.05) (Table 1).
Numeric pain rating scale
A statistically significant decline was found in the mean NRPS scores
of the Acupressure or Reiki groups of the stage III and IV cancer patients
receiving palliative care in measurements after the interventions on
Time 1, Time 2, and Time 3 (F = 85.377, p < 0.001; F = 57.806, p <
0.001), while no significant difference was found in the control group (F
= 3.180, p > 0.05). To find the time creating the difference in intra-
group measurements, the repeated measures ANOVA test followed by
the pairwise comparison test was used. It was seen that in the
Acupressure group, the intra-group measurement after the intervention
H. Utli et al. EXPLORE xxx (xxxx) xxx

Table 1
Comparison of descriptive characteristics of groups (N = 156).
Acupressure Reiki Control
group group group
(n = 52) (n = 52) (n = 52)
Variables n(%) n(%) n(%) x2 p

Age (years) 0.205 0.903

18–64 27(51.9) 29(55.8) 27(51.9)
≥ 65 25(48.1) 23(44.2) 25(48.1)
Number of children Mean±SD 1.365 0.505
2.88±1.80 3.21±2.14 3.23±1.88
Gender 1.730 0.421
Female 16 (30.8) 22 (42.3) 17 (32.7)
Male 36 (69.2) 30 (57.7) 35 (67.3)
Marital status 1.482 0.477
Single/ divorced 9 (17.3) 6 (11.5) 5 (9.6)
Married 43 (82.7) 46 (88.5) 47 (90.4)
Education level 2.079 0.354
Literate 9 (17.3) 6 (11.5) 5 (9.6)
Primary school 20 (38.5) 23 (44.5) 23 (44.2)
High school 17 (32.7) 16 (30.8) 14 (26.9)
University 6 (11.5) 7 (13.5) 10 (19.2)
Employment status 0.456 0.796
Working 8 (15.4) 6 (11.5) 6 (11.5)
Not working 44 (84.6) 46 (88.5) 46 (88.5)
Place of residence 3.808 0.149
City 18 (34.6) 17 (32.7) 23 (44.2)
Town 11 (21.2) 16 (30.8) 17 (32.7)
Village 23 (44.2) 19 (36.5) 12 (23.1)
Monthly income 0.688 0.709
Income less than expenses 22 (42.3) 25 (48.1) 28 (53.8)
Income equal to expenses 22 (42.3) 18 (34.6) 15 (28.8)
Income greater than expenses 8 (15.4) 9 (17.3) 9 (17.3)
Stage 4.615 0.100
III. 31 (59.6) 29 (55.8) 39 (75.0)
IV. 21 (40.4) 23 (44.2) 13 (25.0)
Diagnosis 0.377 0.828
Breast CA 9 (17.3) 8 (15.4) 10 (19.2)
Colorectal CA 9 (17.3) 7 (13.5) 10 (19.2)
Lung CA 9 (17.3) 9 (17.3) 8 (15.4)
Lymphoma 9 (17.3) 9 (17.3) 6 (11.2)
Ovarian CA – 6 (11.5) 5 (9.6)
Stomach-esophagus-pancreas CA 8 (15.4) 7 (13.5) 6 (11.5)
Bladder-prostate CA 8 (15.4) 6 (11.5) 7 (13.5)
Time since diagnosis (years) 5.664 0.059
0–1 9 (32.7) 9 (17.3) 6 (11.5)
2–5 35 (67.3) 21 (40.4) 20 (38.5)
≥6 13 (25.0) 22 (42.3) 26 (50.0)
Comorbidities 1.691 0.429
Yes 35 (67.3) 34 (65.4) 29 (55.8)
No 17 (32.7) 18 (34.6) 23 (44.2)
Current comorbid diseases 4.839 0.089
Hypertension 11 (21.2) 18 (34.6) 12 (23.1)
Diabetes 9 (17.3) 16 (30.8) 11 (21.2)
Hypertension+Diabetes 8 (15.4) – –
Asthma+Bronchitis – – 6 (11.5)
Kidney failure 7 (13.5) – –
Chemotherapy 0.122 0.941
Gemcitabine 8 (15.4) 8 (15.4) 9 (17.3)
Gemcitabine + Cisplatin 8 (15.4) 10 (19.2) 9 (17.3)
Gemcitabine + Cisplatin + Navelbine 12 (23.1) 11 (21.2) 11 (21.2)
Carboplatin+ Paclitaxel 12 (23.1) 11 (21.2) 12 (23.1)
Carboplatin+ Paclitaxel+ Bevacizumab 12 (23.1) 12 (23.1) 11 (21.2)
Chemotherapy protocol 2.067 0.356
2–4 cure 10 (19.2) 8 (15.4) 8 (15.4)
5–7 cure 27 (51.9) 27 (51.9) 36 (69.2)
8–10 cure 15 (28.8) 17 (32.7) 8 (15.4)
ECOG-PS 0.398 0.820
Grade-0 – – –
Grade-1 5 (9.6) 4 (7.7) 4 (7.7)
Grade-2 21 (40.4) 19 (36.5) 20 (38.5)
Grade-3 26 (50) 29 (55.8) 28 (53.8)
Grade-4 – – –
Grade-5 – – –
′
Hemoglobin (g/dl) X (Min-Max) 0.062 0.969
11.46(8.93–15.90) 11.28(7.73–15.20) 12.24(7.93–15.00)
′
Hematocrit (%) X (Min-Max) 0.471 0.790
34.73(21.20–43.20) 34.94(21.70–43.40) 34.79(21.33–43.20)

5
H. Utli et al. EXPLORE xxx (xxxx) xxx

Note: p< 0.05, x2 : Ki-kare değeri.

on Time 2 showed a significant decline compared with the intra-group

measurement on Time 1 (p < 0.001). The intra-group measurement
after the intervention on Time 3 showed a significant decline compared
with the intra-group measurement on Time 2 (p = 0.037). The intra-
group measurement after the intervention on Time 3 was found to
have a significant decline compared with the intra-group measurement
on Time 1 (p < 0.001). In the Reiki group, the intra-group measurement
made after the intervention on the second week showed a significant
decline compared with the intra-group measurement on Time 1 (p <
0.001). It was found that the intra-group measurement made after the
intervention on Time 3 showed a significant decline compared with the
intra-group measurement on Time 1 (p < 0.001). It was determined that
the intra-group measurement made after the intervention on Time 3 was
significantly lower than the intra-group measurement on Time 2 (p <
0.001).
A statistically significant difference was found between the groups
with regard to NPRS mean scores in the measurements on Time 2 and
Time 3 (F = 62.409, p < 0.001; F = 188.591, p < 0.001). It was found
that NPRS score averages between the groups were statistically signifi­
cant (FGroup = 68.243, p < 0.001; FTime = 117.766, p < 0.001;
FGroup*Time = 47.870, p < 0.001) (Table 2). The comparison of NPRS
Fig. 2. Comparison of the NPRS scores of groups.
scores of groups is illustrated in Fig. 2. To find the group causing the
difference, the one-way ANOVA Post-hoc Bonferroni test was used. In
two-way comparisons of the groups, a significant difference was found to show a significant decline compared with the intra-group measure­
between the Reiki and control groups and the Acupressure and control ment on Time 2 (p < 0.001). In the Reiki group, it was determined that
groups in the measurements made after the interventions on Time 2 and the intra-group measurement made after the intervention on Time 2
Time 3 (p< 0.001) (Table 2). showed a significant decline compared with the intra-group measure­
ment made on Time 1 (p < 0.001). It was found that the intra-group
measurement made after the interventions on Time 3 showed a signifi­
Brief fatigue inventory cant decline compared with the intra-group measurement on Time 1 (p
< 0.001). The intra-group measurement made after the interventions on
In the Acupressure or Reiki groups, significant reductions were seen Time 3 was found to show a significant decline compared with the intra-
in BFI mean scores in the stage III and IV cancer patients receiving group measurement made on Time 2 (p < 0.001).
palliative care in measurements taken after the intervention on Time 1, A significant difference was found between the groups in terms of
Time 2, and Time 3 (F = 16.710, p < 0.001; F = 14.333, p < 0.001). mean BFI scores in measurements made on Time 2 and Time 3 (F =
However, in the control group, no significant difference was detected (F 37.590, p < 0.001; F = 33.642, p < 0.001). It was found that BFI score
= 2.146, p > 0.05). To find the time creating the difference in intra- averages between the groups were statistically significant (FGroup =
group measurements, the repeated measures ANOVA test followed by 27.422, p < 0.001; FTime = 38.694, p < 0.001; FGroup*Time = 14.612, p <
pairwise comparison test was used. In the Acupressure group, the intra- 0.001). To find the group causing the difference, the one-way ANOVA
group measurement made after the interventions on Time 2 was found to Post-hoc Bonferroni test was used. The two-way comparison of the
have a significant decline compared with the intra-group measurement groups revealed a significant difference between the Reiki and control
made on Time 1 (p < 0.001). The intra-group measurement made after groups and the Acupressure and control groups in measurements made
the interventions on Time 3 also showed a significant decline compared after the interventions on Time 2 and Time 3 (p < 0.001) (Table 3).
with the intra-group measurement on Time 1 (p < 0.001). The intra-
group measurement made after the intervention on Time 3 was found

Table 2
Comparison of NPRS scores of groups after Acupressure or Reiki intervention.
Acupressure group Reiki Control
(n ¼ 52) Group Group
(n ¼ 52) (n ¼ 52)
NPRS Mean±SD Mean±SD Mean±SD F p Bonferroni group F p

Time 1 6.82±1.47 6.75±1.51 6.71±1.22 0.090 0.914* FGroup=68.243 p< 0.001***

FTime=117.766 p< 0.001***
FGroup*Time= 47.870 p< 0.001***
Time 2 4.71±1.36 5.17±0.64 7.05±1.25 62.409 p<0.001* A-R: 0.119
R-C: p<0.001**
A-C: p<0.001**
Time 3 3.94±0.87 4.19±0.79 7.13±1.10 188.591 p<0.001* A-R: p = 0.520
R-C:p< 0.001**
A-C:p< 0.001**

F 85.377 57.806 3.180

p p< 0.001*** p<0.001*** p = 0.060***

Note: *F= One way ANOVA test statistics, **One way ANOVA test followed by bonferroni, ***F= Repeated Measure ANOVA test followed by pairwise comparisons,
p< 0.05 Significance level, SD: Standard Deviation, A: Acupressure, R: Reiki, C: Control, NPRS: Numeric Pain Rating Scale.

6
H. Utli et al. EXPLORE xxx (xxxx) xxx

Table 3
Comparison of BFI scores of groups after Acupressure or Reiki intervention.
Acupressure group Reiki Control
(n = 52) Group Group
(n = 52) (n = 52)
BFI Mean±SD Mean±SD Mean±SD F p Bonferroni group F p

Time 1 6.15±1.19 6.26±1.05 6.26±0.88 0.209 0.812* FGroup=27.422 p< 0.001***

FTime=38.694 p< 0.001***
FGroup*Time= 14.612 p< 0.001***
Time 2 5.09±0.56 5.44±0.66 6.30±0.91 37.590 p<0.001* A-R: 0.052
R-C: p<0.001**
A-C: p<0.001**
Time 3 4.94±1.46 4.96±0.86 6.46±0.80 33.642 p<0.001* A-R: p = 0.990
R-C:p< 0.001**
A-C:p< 0.001**

F 16.710 14.333 2.146

p p< 0.001*** p<0.001*** p = 0.133***

Note: *F= One way ANOVA test statistics, **One way ANOVA test followed by bonferroni, ***F= Repeated Measure ANOVA test followed by pairwise comparisons,
p< 0.05 Significance level, SD: Standard Deviation, A: Acupressure, R: Reiki, C: Control, BFI: Brief Fatigue Inventory.

Analgesic follow-up form
In the Acupressure or Reiki groups, significant reductions were seen
in AFF mean scores in the stage III and IV cancer patients receiving
palliative care in measurements taken after the interventions on Time 1,
Time 2, and Time 3 (Fr = 90.194, p < 0.001; Fr = 95.696, p < 0.001).
However, in the control group, no significant difference was detected
(Fr = 0.286, p > 0.05). In intra-group measurements, the Friedman test
and post-hoc Dunn test were used to find the time that made the dif­
ference in the measurements. In the Acupressure group, it was found
that the intra-group measurement made after the intervention on Time 2
showed a significant decline compared with the intra-group measure­
ment made on Time 1 (p < 0.001). The intra-group measurement made
after the intervention on Time 3 likewise showed a significant decline
compared with the intra-group measurement on Time 1 (p < 0.001).
The intra-group measurement made after the intervention on Time 3
was found to show a significant decline compared with the intra-group
measurement on Time 2 (p < 0.001). In the Reiki group, it was deter­
mined that the intra-group measurement made after the intervention on
Time 2 showed a significant decline compared with the intra-group
measurement made on Time 1 (p < 0.001). The intra-group measure­
ment made after the intervention on Time 3 showed a significant decline
compared with the intra-group measurement on Time 1 (p < 0.001).
The intra-group measurement made after the interventions on Time 3
showed a significant decline compared with the intra-group measure­
ment made on Time 2 (p < 0.001).
A significant difference was found between the groups in terms of
mean AFF scores in measurements made on Time 2 and Time 3 (X2 =
47.436, p < 0.001; X2 = 94.339, p < 0.001). To find the group creating
the difference, the Kruskal-Wallis test followed by a Post-hoc one-way
ANOVA test was used. The two-way comparison of the groups indicated
a significant difference between the Reiki and control groups and the
Acupressure and control groups in measurements made after the in­
terventions on Time 2 and Time 3 (p < 0.001) (Table 4).
Discussion
In this study, it was established that the Acupressure or Reiki in­
terventions were effective care interventions in relieving symptoms of
pain and fatigue in stage III and IV cancer patients receiving palliative
care.
Pain and fatigue
Bringing pain under control is important to make people comfortable
and reduce complications. In this study, pain and fatigue levels fell in the
Acupressure or Reiki groups, but there was no change in the control
group. Thus, it can be said that the Acupressure or Reiki intervention
reduced the levels of pain and fatigue in stage III and IV cancer patients
receiving palliative care. In a systematic review by Behzadmehr et al.,31
Acupressure or Reiki interventions were found to be effective in pain
management in women with breast cancer. In a meta-analysis and sys­
tematic review study conducted by He et al.,32 it was found that the
intervention of Acupressure was effective in relieving cancer-related
pain. Similar to our study, it was found in Sharif Nia et al.5 with leu­
kemia patients and in Sharifi Rizi et al.6 with cancer patients undergoing

Table 4
Comparison of AFF values of groups after Acupressure or Reiki intervention.
Acupressure Reiki Control
group Group Group
(n ¼ 52) (n ¼ 52) (n ¼ 52)
AFF (Milligrams) ′
X (Min±Max)
′
X (Min±Max)
′
X (Min±Max) X2 & p-value Pair-wise Comparison of the Groups

Time 1 350.00(250.00–525.00) 350.00(250.00–525.00) 350.00(250.00–525.00) 0.885

0.642**
Time 2 250.00(150.00–420.00) 250.00(200.00–350.00) 350.00(250.00–525.00) 47.436 A-R: p = 0.683
p<0.001** R-C: p< 0.001**
A-C: p< 0.001**
Time 3 200.00(145.00–350.00) 200.00(130.00–300.00) 350.00(215.00–450.00) 94.339 A-R: p = 0.164
p<0.001** R-C: p< 0.001**
A-C: p< 0.001**
Fr & p-value Fr=90.194 Fr=95.696 Fr=0.286
p< 0.001* p< 0.001* 0.867*

Note: *Fr: Friedman test followed by Post-hoc Dunn test, ** KW: Kruskal Wallis test followed by Post-hoc one-way ANOVA test, p< 0.05 Significance level, A:
Acupressure, R: Reiki, C: Control, AFF: Analgesic Follow-up Form.

7
H. Utli et al.
bone marrow biopsy and aspiration that the intervention of Acupressure
reduced pain.
Olson et al.33 and Birocco et al.14 found that the intervention of Reiki
reduced pain in cancer patients. In a qualitative study by Kirshbaum
et al.34 investigating the experiences of women with cancer regarding
the Reiki intervention, pain-relieving touch was shown. In a systematic
review by Lopes-Júnior et al. ,9 Reiki was as found to be effective in pain
management in children and adolescents receiving palliative care.
Indeed, many studies in the literature have been performed on cancer
patients. However, there is limited information on the intervention of
Reiki for stage III and IV cancer patients receiving palliative care.
Acupressure or Reiki interventions give hope to cancer patients
receiving palliative care with regard to treatment for pain and fatigue.
Non-invasive Acupressure or Reiki can be applied to stage III and IV
cancer patients receiving palliative care as a nursing intervention,
thereby supporting pharmacological interventions.
Similar to this research, the capability of Acupressure to reduce fa­
tigue was found, including Özdemir and Taşçı11 working with elderly
cancer patients, Zick et al.13 with patients recovering from breast cancer,
Khanghah et al.2 with cancer patients undergoing chemotherapy, Serçe
et al.12 with cancer patients with bone metastasis, Zick et al.35 with
women with stage 0–III breast cancer, Bastani et al.36 with children with
acute lymphoblastic leukemia, Molassiotis et al.37 with breast cancer
patients, Tang et al.21 with lung cancer patients undergoing chemo­
therapy, and Zick et al.20 with patients recovering from cancer and with
persistent fatigue. In a study by Hsieh et al.38 using meta-analysis and a
systematic review of 14 randomized controlled studies, it was concluded
that the intervention of Acupressure was effective in relieving
cancer-related fatigue. While many studies in the literature were per­
formed with cancer patients, there was limited information on the
effectiveness of Acupressure for stage III and IV cancer patients receiving
palliative care. Therefore, this research will make a contribution to the
literature.
Similar to this research, Karaman and Tan23 and Orsak et al.39 found
that the intervention of Reiki reduced fatigue in women with breast
cancer receiving chemotherapy. It was found in several studies in the
literature that the intervention of Reiki reduced pain and fatigue, such as
Fleisher et al.40 working with patients being treated for cancer; Thrane
et al.4 with children with cancer aged 7–16 receiving palliative care;
Zucchetti et al.10 with pediatric patients having hematopoietic stem cell
transplants; and Demir et al. ,1 Buyukbayram and Citlik Saritas,8 and
Tsang et al.41 with cancer patients in oncology clinics.
These results supported Hypothesis 1: Acupressure or Reiki in­
terventions have an effect on pain and fatigue levels in stage III and IV
cancer patients receiving palliative care.
Analgesic use
In this study, there was a significant reduction in analgesic use in the
Acupressure or Reiki groups but no change in the control group.
Therefore, it can be said that the Acupressure or Reiki interventions
reduced the level of analgesic use. In the literature, it was found in a
meta-analysis and systematic review of 17 randomized controlled
studies by He et al.32 that the intervention of Acupressure reduced
analgesic use in connection with types of cancer pain. The same study
also recommended that further research should be conducted on the use
of Acupressure so as to integrate opioid use into clinical care.
A similar result to this research was the finding of Birocco et al. ,14
who applied Reiki to 22 cancer patients in four 30-minute sessions. They
reported that 47% of the patients did not use medication in spite of
cancer pain. Different from these research results, Olson et al.33 found
that opioid use was not reduced when Reiki was applied to cancer pa­
tients in 90-minute sessions over seven days. In that study, the opioid use
of the cancer patients was monitored for seven days. When pain becomes
chronic in stage III and IV cancer patients, pain management must be
monitored in the long term. In the present study, the NSAID and
8
EXPLORE xxx (xxxx) xxx
non-opioid analgesic use of stage III and IV cancer patients were
monitored for four weeks.
Limitations
The first limitation of this study is that participants were not double-
blinded on inclusion. The researcher (H.U.) was the same individual
performing the Reiki and Acupressure interventions. The second limi­
tation of the study is that only four points were used in the Acupressure
intervention.
The third limitation is that Acupressure or Reiki interventions were
performed 4–6 h after NSAID and non-opioid analgesic medications had
been taken. Therefore, it is inevitable that these medications had an
effect in relieving pain. The amount of analgesics routinely used by stage
III and IV cancer patients receiving palliative care is determined by a
doctor. For reasons of ethical procedures, the researchers (H.U., M.D.,
and A.U.) could not intervene in the amounts of routine analgesics used
between the Acupressure, Reiki, and control groups. The fourth limita­
tion is that the data of this research were collected from only two hos­
pitals. More studies are needed in order to generalize the results. The
fifth limitation is that cultural, social, and psychological factors, which
we could not control in this study, may potentially affect the patients’
sense of pain. These factors should be taken into account in future
studies.
This research was a medium-strength randomized controlled study in
which the Acupressure or Reiki interventions relieved pain and fatigue
in stage III and IV cancer patients receiving palliative care. The findings
may offer constructive ideas to other researchers working with
Acupressure or Reiki interventions, this population, and/or
intervention.
Conclusion
Acupressure or Reiki interventions were found to be effective in
reducing pain, analgesic use, and fatigue levels. In hospitals, non-
invasive Acupressure or Reiki can be applied to stage III and IV cancer
patients receiving palliative care as a nursing intervention, thereby
supporting pharmacological interventions. Nurses working in palliative
care clinics should encourage the use of Acupressure or Reiki in­
terventions to improve the pain and fatigue symptoms of stage III and IV
cancer patients. As a result of the experiences obtained from this
research, we recommend that nurses receive training on Acupressure or
Reiki techniques. In addition, Acupressure or Reiki techniques should be
included in the undergraduate nursing curriculum. When these tech­
niques are included in the undergraduate curriculum, the nurses can
become early stage practitioners. Nurses should make training in
Acupressure or Reiki interventions a basic duty for themselves and make
such training not just a one-time thing but rather use it continuously.
For future research, we recommend that qualitative studies should be
performed to show the experiences of stage III and IV cancer patients
receiving palliative care with regard to the Acupressure or Reiki
interventions.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors are grateful to the stage III and IV cancer patients for
participating in the study.
Supplementary materials
Supplementary material associated with this article can be found, in
H. Utli et al.
the online version, at doi:10.1016/j.explore.2022.11.007.
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