acupressure
My ‘ALTERNATIVE MEDICINE HALL OF FAME‘ (the group of people who have managed to publish nothing but positive findings about a dubious therapy) currently consists of 20 members (unless I have forgotten somone, which is possible, of course):
- Jorge Vas (acupuncture, Spain)
- Wane Jonas (homeopathy, US)
- Harald Walach (various SCAMs, Germany)
- Andreas Michalsen ( various SCAMs, Germany)
- Jennifer Jacobs (homeopath, US)
- Jenise Pellow (homeopath, South Africa)
- Adrian White (acupuncturist, UK)
- Michael Frass (homeopath, Austria)
- Jens Behnke (research officer, Germany)
- John Weeks (editor of JCAM, US)
- Deepak Chopra (entrepreneur, US)
- Cheryl Hawk (US chiropractor)
- David Peters (osteopathy, homeopathy, UK)
- Nicola Robinson (TCM, UK)
- Peter Fisher (homeopathy, UK)
- Simon Mills (herbal medicine, UK)
- Gustav Dobos (various SCAMs, Germany)
- Claudia Witt (homeopathy, Germany/Switzerland)
- George Lewith (acupuncture, UK)
- John Licciardone (osteopathy, US)
Today, it is time to add the 21st member. My last post was about a weird study co-authored by someone who struck me as truly remarkable. Terry Oleson is employed by the Department of Traditional Oriental Medicine, Emperor’s College of Traditional Oriental Medicine, Santa Monica, CA, USA. On ‘research gate‘, he describes his expertise as follows:
- Cognitive Psychology
- Clinical Psychology
- Biological Psychology
- Clinical Trials
- Addiction Medicine
- Allied Health Science
Oleson received his BA in Biology from the University of California, Santa Barbara, in 1967, his MA in Psychology from California State University at Long Beach in 1971, and his PhD from UC Irvine in 1973. He went on to conduct a postdoctoral scholarship at UCLA at that time, where he conducted pioneering research in auricular diagnosis and auriculotherapy. Since many years, Oleson has published on auricular acupuncture and acupressure, at least one book and the papers listed below. This is an oddly dubious and biologically implausible so-called alternative medicine (SCAM). Terry Oleson – whom I never knowingly met in person – and his research are all the more remarkable: in his hands auricular therapy seems to work of just about everything:
- Effect of auricular acupressure on postpartum blues: A randomized sham controlled trial. Complement Ther Clin Pract. 2023 Aug;52:101762. doi: 10.1016/j.ctcp.2023.101762. Epub 2023 Apr 10.PMID: 37060791
- Auriculotherapy stimulation for neuro-rehabilitation. NeuroRehabilitation. 2002;17(1):49-62.PMID: 12016347
- Acupuncture: the search for biologic evidence with functional magnetic resonance imaging and positron emission tomography techniques. J Altern Complement Med. 2002 Aug;8(4):399-401. doi: 10.1089/107555302760253577.PMID: 12230898
- Commentary on auricular acupuncture for cocaine abuse. J Altern Complement Med. 2002 Apr;8(2):123-5. doi: 10.1089/107555302317371406.PMID: 12013511
- Clinical Commentary on an Auricular Marker Associated with COVID-19. Med Acupunct. 2020 Aug 1;32(4):176-177. doi: 10.1089/acu.2020.29152.com. Epub 2020 Aug 13.PMID: 32913483
- Comparison of Auricular Therapy with Sham in Children with Attention Deficit/Hyperactivity Disorder: A Randomized Controlled Trial. J Altern Complement Med. 2020 Jun;26(6):515-520. doi: 10.1089/acm.2019.0477. Epub 2020 May 20.PMID: 32434376
- Application of Polyvagal Theory to Auricular Acupuncture.Oleson T.Med Acupunct. 2018 Jun 1;30(3):123-125. doi: 10.1089/acu.2018.29085.tol.PMID: 29937963
- The effect of ear acupressure (auriculotherapy) on sexual function of lactating women: protocol of a randomized sham controlled trial. Trials. 2020 Aug 20;21(1):729. doi: 10.1186/s13063-020-04663-x.PMID: 32819441
- Randomized controlled study of premenstrual symptoms treated with ear, hand, and foot reflexology. Obstet Gynecol. 1993 Dec;82(6):906-11.PMID: 8233263
-
Auricular electrical stimulation and dental pain threshold. Anesth Prog. 1993;40(1):14-9.PMID: 8185085
- Rapid narcotic detoxification in chronic pain patients treated with auricular electroacupuncture and naloxone. Int J Addict. 1985 Sep;20(9):1347-60. doi: 10.3109/10826088509047771.PMID: 2867052
- Investigation of the effects of naloxone upon acupuncture analgesia. Pain. 1984 Jun;19(2):201-4. doi: 10.1016/0304-3959(84)90872-8.PMID: 6462730
- Electroacupuncture & auricular electrial stimulation. IEEE Eng Med Biol Mag. 1983;2(4):22-6. doi: 10.1109/MEMB.1983.5005987.PMID: 19493718
- An experimental evaluation of auricular diagnosis: the somatotopic mapping or musculoskeletal pain at ear acupuncture points. Pain. 1980 Apr;8(2):217-229. doi: 10.1016/0304-3959(88)90009-7.PMID: 7402685
14 papers about a dodgy SCAM without the hint of a negative finding! I hope we can all agree that this achievement makes Terry a worthy member of my ‘HALL OF FAME’, a group of people who, like Terry, have been able to publish nothing but positive findings about the most dubious SCAMs.
Welcome Terry!
Women experience more problems in their sexual functioning after childbirth. Due to the high prevalence of sexual problems during the lactation period, the World Health Organization suggests that measures are needed to improve women’s sexual functioning during breastfeeding. This study investigated the effect of auricular acupressure on sexual functioning among lactating women.
A randomized, sham-controlled trial was conducted between October 2019 to March 2020 in urban comprehensive health centers of Qazvin, Iran. Seventy-six women who had been lactating between six months and one year postpartum were randomly assigned to auricular acupressure group (n=38) or sham control group (n=38) using a balanced block randomization method. The intervention group received ear acupressure in 10 sessions (at four-day intervals) and control group received the sham intervention at the same intervals. Sexual functioning was the primary outcome of the study (assessed using the Female Sexual Function Index) before and at three time points post-intervention (immediately after, one month after, and two months after). The secondary outcome was sexual quality of life assessed using Sexual Quality of Life-Female Version.
Auricular acupressure had a large effect on female sexual functioning at all three post-intervention time points:
- immediately after the intervention (adjusted mean difference [95% CI]: 8.37 [6.27; 10.46] with Cohen’s d [95% CI]: 1.81[1.28; 2.34]),
- one month after the intervention (adjusted mean difference [95% CI]: 8.44 [6.41; 10.48] with Cohen’s d [95% CI]: 2.01 [1.46; 2.56]),
- two months after the intervention (adjusted mean difference [95% CI]: 7.43 [5.12; 9.71] with Cohen’s d [95% CI]: 1.57 [1.06; 2.08]).
Acupressure significantly increased participants’ sexual quality of life on the Sexual Quality of Life-Female scale by 13.73 points in the intervention group compared to the control group (p<0.001). The effect size of intervention for female sexual quality was large (adjusted Cohen’s d [95% CI]: 1.09 [0.58; 1.59]). Weekly frequency of sexual intercourse in the intervention group significantly increased compared to sham control group (p<0.001). These changes were clinically significant for sexual functioning and sexual quality of life.
The authors concluded that auricular acupressure was effective in increasing quality of sexual life and sexual functioning among lactating women. Although further research is needed to confirm the efficacy of auricular acupressure, based on the present study’s findings, the use of auricular acupressure by women’s healthcare providers after childbirth is recommended.
One possible explanation for this result is that the study was de-blinded; the sham treatment might not have been distinguished from the verum, or the verbal and/or non-verbal communications between the therapist and the patients contributed to a de-blinding effect. As the sucess of blinding was not reported and probably not even tested, we cannot know. The authors explain that auricular acupressure might improve both endocrine function (increased sex hormones including androgens and estrogens) and its physiological consequences (e.g., vaginal dryness, and vaginal epithelial atrophy), as well as reducing fatigue and insomnia problems (which might increase sexual desire).
Personally, I find this VERY hard to believe. Auricular acupressure or auriculotherapy, as it is also called, was invented by Paul Nogier in the 1950s. Its assumptions are not in line with our knowledge of anatomy and physiology. The different maps used by proponents of auriculotherapy show embarrassing disagreements. The therapy is being promoted as a treatment for many conditions. However, the clinical evidence that it might be effective is weak, not least because many of the clinical trials are of low quality and thus unreliable. One of the first rigorous tests of auriculotherapy was published in 1984 by one of the most prominent researchers of pain, R. Melzack. Here is the abstract[2]:
Enthusiastic reports of the effectiveness of electrical stimulation of the outer ear for the relief of pain (“auriculotherapy”) have led to increasing use of the procedure. In the present study, auriculotherapy was evaluated in 36 patients suffering from chronic pain, using a controlled crossover design. The first experiment compared the effects of stimulation of designated auriculotherapy points, and of control points unrelated to the painful area. A second experiment compared stimulation of designated points with a no-stimulation placebo control. Pain-relief scores obtained with the McGill Pain Questionnaire failed to show any differences in either experiment. It is concluded that auriculotherapy is not an effective therapeutic procedure for chronic pain.
Today we have an abundance of clinical trials of this therapy. Their results are by no means uniform. It is therefore best not to rely on single studies but on systematic reviews that include the evidence from all reliable trials. Our review concluded that “because of the paucity and of the poor quality of the data, the evidence for the effectiveness of auricular therapy for the symptomatic treatment of insomnia is limited. Further, rigorously designed trials are warranted to confirm these results.”[3] Other, less rigorous reviews arrive at more positive conclusions; due to the often poor quality of the primary studies, they should, however, be interpreted with great caution.[4]
The most frequently reported adverse events of auriculotherapy include local skin irritation and discomfort, mild tenderness or pain, and dizziness. Most of these events were transient, mild, and tolerable, and no serious adverse events were identified.[5]
In view of all this, I think that we need much more and much better evidence for auricular acupressure to be recommended for ANY condition.
[1] Wirz-Ridolfi A. The History of Ear Acupuncture and Ear Cartography: Why Precise Mapping of Auricular Points Is Important. Med Acupunct. 2019 Jun 1;31(3):145-156. doi: 10.1089/acu.2019.1349.
[2] Melzack, R., & Katz, J. (1984). Auriculotherapy fails to relieve chronic pain. A controlled crossover study. JAMA, 251(8), 1041–1043.
[3] Lee MS, Shin BC, Suen LK, Park TY, Ernst E (2008) Auricular acupuncture for insomnia: a systematic review. Int J Clin Pract 62(11):1744–1752.
[4] Usichenko, T. I., Hua, K., Cummings, M., Nowak, A., Hahnenkamp, K., Brinkhaus, B., & Dietzel, J. (2022). Auricular stimulation for preoperative anxiety – A systematic review and meta-analysis of randomized controlled clinical trials. Journal of clinical anesthesia, 76, 110581.
[5] Tan JY, Molassiotis A, Wang T, Suen LK (2014) Adverse events of auricular therapy: a systematic review. Evid Based Complement Alternat Med 2014:506758
This study investigated the potential benefits of auricular point acupressure on cerebrovascular function and stroke prevention among adults with a high risk of stroke.
A randomized controlled study was performed with 105 adults at high risk for stroke between March and July 2021. Participants were randomly allocated to receive either
- auricular point acupressure with basic lifestyle interventions (n = 53) or
- basic lifestyle interventions alone (n = 52) for 2 weeks.
The primary outcome was the kinematic and dynamic indices of cerebrovascular function, as well as the CVHP score at week 2, measured by the Doppler ultrasonography and pressure transducer on carotids.
Of the 105 patients, 86 finished the study. At week 2, the auricular point acupressure therapy with lifestyle intervention group had higher kinematic indices, cerebrovascular hemodynamic parameters score, and lower dynamic indices than the lifestyle intervention group.
The authors concluded that ccerebrovascular function and cerebrovascular hemodynamic parameters score were greater improved among the participants undergoing auricular point acupressure combined with lifestyle interventions than lifestyle interventions alone. Hence, the auricular point acupressure can assist the stroke prevention.
Acupuncture is a doubtful therapy.
Acupressure is even more questionable.
Ear acupressure is outright implausible.
The authors discuss that the physiological mechanism underlying the effect of APA therapy on cerebrovascular hemodynamic function is not fully understood at present. There may be two possible explanations.
- First, a previous study has demonstrated that auricular acupuncture can directly increase mean blood flow velocity in the middle cerebral artery.
- Second, cerebrovascular hemodynamic function is indirectly influenced by the effect of APA therapy on blood pressure.
I think there is a much simpler explanation: the observed effects are directly or indirectly due to placebo. As regular listeners of this blog know only too well by now, the A+B versus B study design cannot account for placebo effects. Sadly, the authors of this study hardly discuss this explanation – that’s why they had to publish their findings in just about the worst SCAM journal of them all: EBCAM.
Acupuncture is questionable.
Acupressure is highly questionable.
Auricular acupressure is extremely questionable.
This study investigated the effect of auricular acupressure on the severity of postpartum blues. A randomized sham-controlled trial was conducted from February to November 2021, with 74 participants who were randomly allocated into two groups of either routine care + auricular acupressure (n = 37), or routine care + sham control (n = 37). Vacaria seeds with special non-latex adhesives were used to perform auricular acupressure on seven ear acupoints. There were two intervention sessions with an interval of five days. In the sham group, special non-latex adhesives without vacaria seeds were attached in the same acupoints as the intervention group. The severity of postpartum blues, fatigue, maternal-infant attachment, and postpartum depression was assessed. 
Auricular acupressure was associated with a significant effect in the reduction of postpartum blues on the 10th and 15th days after childbirth (SMD = −2.77 and −2.15 respectively), postpartum depression on the 21st day after childbirth (SMD = −0.74), and maternal fatigue on 10th, 15th and 21st days after childbirth (SMD = −2.07, −1.30 and −1.32, respectively). Also, the maternal-infant attachment was increased significantly on the 21st day after childbirth (SMD = 1.95).
The authors concluded that auricular acupressure was effective in reducing postpartum blues and depression, reducing maternal fatigue, and increasing maternal-infant attachment in the short-term after childbirth.
Let me put my doubts about these conclusions in the form of a few questions:
- If you had sticky tape on your ear, would you sometimes touch it?
- If you touched it, would you feel whether a vacaria seed was contained in it or not?
- Would you, therefore, say that such a trial could be properly blinded (not to forget the therapists who were, of course, in the know)?
- If the trial was thus de-blinded, would you claim that patient expectation did not influence the outcomes?
If you answered all of these questions with NO, you are – like I – of the opinion that the results of this trial could have easily been brought about, not by the alleged effects of acupressure, but by placebo and other non-specific effects.
Given the high prevalence of burdensome symptoms in palliative care (PC) and the increasing use of so-called alternative medicine (SCAM) therapies, research is needed to determine how often and what types of SCAM therapies providers recommend to manage symptoms in PC.
This survey documented recommendation rates of SCAM for target symptoms and assessed if, SCAM use varies by provider characteristics. The investigators conducted US nationwide surveys of MDs, DOs, physician assistants, and nurse practitioners working in PC.
Participants (N = 404) were mostly female (71.3%), MDs/DOs (74.9%), and cared for adults (90.4%). Providers recommended SCAM an average of 6.8 times per month (95% CI: 6.0-7.6) and used an average of 5.1 (95% CI: 4.9-5.3) out of 10 listed SCAM modalities. Respondents recommended mostly:
- mind-body medicines (e.g., meditation, biofeedback),
- massage,
- acupuncture/acupressure.
The most targeted symptoms included:
- pain,
- anxiety,
- mood disturbances,
- distress.
Recommendation frequencies for specific modality-for-symptom combinations ranged from little use (e.g. aromatherapy for constipation) to occasional use (e.g. mind-body interventions for psychiatric symptoms). Finally, recommendation rates increased as a function of pediatric practice, noninpatient practice setting, provider age, and proportion of effort spent delivering palliative care.
The authors concluded that to the best of our knowledge, this is the first national survey to characterize PC providers’ SCAM recommendation behaviors and assess specific therapies and common target symptoms. Providers recommended a broad range of SCAM but do so less frequently than patients report using SCAM. These findings should be of interest to any provider caring for patients with serious illness.
Initially, one might feel encouraged by these data. Mind-body therapies are indeed supported by reasonably sound evidence for the symptoms listed. The evidence is, however, not convincing for many other forms of SCAM, in particular massage or acupuncture/acupressure. So encouragement is quickly followed by disappointment.
Some people might say that in PC one must not insist on good evidence: if the patient wants it, why not? But the point is that there are several forms of SCAMs that are backed by good evidence for use in PC. So, why not follow the evidence and use those? It seems to me that it is not in the patients’ best interest to disregard the evidence in medicine – and this, of course, includes PC.
No 10-year follow-up study of so-called alternative medicine (SCAM) for lumbar intervertebral disc herniation (LDH) has so far been published. Therefore, the authors of this paper performed a prospective 10-year follow-up study on the integrated treatment of LDH in Korea.
One hundred and fifty patients from the baseline study, who initially met the LDH diagnostic criteria with a chief complaint of radiating pain and received integrated treatment, were recruited for this follow-up study. The 10-year follow-up was conducted from February 2018 to March 2018 on pain, disability, satisfaction, quality of life, and changes in a herniated disc, muscles, and fat through magnetic resonance imaging.
Sixty-five patients were included in this follow-up study. Visual analogue scale score for lower back pain and radiating leg pain were maintained at a significantly lower level than the baseline level. Significant improvements in Oswestry disability index and quality of life were consistently present. MRI confirmed that disc herniation size was reduced over the 10-year follow-up. In total, 95.38% of the patients were either “satisfied” or “extremely satisfied” with the treatment outcomes and 89.23% of the patients claimed their condition “improved” or “highly improved” at the 10-year follow-up.
The authors concluded that the reduced pain and improved disability was maintained over 10 years in patients with LDH who were treated with nonsurgical Korean medical treatment 10 years ago. Nonsurgical traditional Korean medical treatment for LDH produced beneficial long-term effects, but future large-scale randomized controlled trials for LDH are needed.
This study and its conclusion beg several questions:
WHAT DID THE SCAM CONSIST OF?
The answer is not provided in the paper; instead, the authors refer to 3 previous articles where they claim to have published the treatment schedule:
The treatment package included herbal medicine, acupuncture, bee venom pharmacopuncture and Chuna therapy (Korean spinal manipulation). Treatment was conducted once a week for 24 weeks, except herbal medication which was taken twice daily for 24 weeks; (1) Acupuncture: frequently used acupoints (BL23, BL24, BL25, BL31, BL32, BL33, BL34, BL40, BL60, GB30, GV3 and GV4)10 ,11 and the site of pain were selected and the needles were left in situ for 20 min. Sterilised disposable needles (stainless steel, 0.30×40 mm, Dong Bang Acupuncture Co., Korea) were used; (2) Chuna therapy12 ,13: Chuna is a Korean spinal manipulation that includes high-velocity, low-amplitude thrusts to spinal joints slightly beyond the passive range of motion for spinal mobilisation, and manual force to joints within the passive range; (3) Bee venom pharmacopuncture14: 0.5–1 cc of diluted bee venom solution (saline: bee venom ratio, 1000:1) was injected into 4–5 acupoints around the lumbar spine area to a total amount of 1 cc using disposable injection needles (CPL, 1 cc, 26G×1.5 syringe, Shinchang medical Co., Korea); (4) Herbal medicine was taken twice a day in dry powder (2 g) and water extracted decoction form (120 mL) (Ostericum koreanum, Eucommia ulmoides, Acanthopanax sessiliflorus, Achyranthes bidentata, Psoralea corylifolia, Peucedanum japonicum, Cibotium barometz, Lycium chinense, Boschniakia rossica, Cuscuta chinensis and Atractylodes japonica). These herbs were selected from herbs frequently prescribed for LBP (or nerve root pain) treatment in Korean medicine and traditional Chinese medicine,15 and the prescription was further developed through clinical practice at Jaseng Hospital of Korean Medicine.9 In addition, recent investigations report that compounds of C. barometz inhibit osteoclast formation in vitro16 and A. japonica extracts protect osteoblast cells from oxidative stress.17 E. ulmoides has been reported to have osteoclast inhibitive,18 osteoblast-like cell proliferative and bone mineral density enhancing effects.19 Patients were given instructions by their physician at treatment sessions to remain active and continue with daily activities while not aggravating pre-existing symptoms. Also, ample information about the favourable prognosis and encouragement for non-surgical treatment was given.
The traditional Korean spinal manipulations used (‘Chuna therapy’ – the references provided for it do NOT refer to this specific way of manipulation) seemed interesting, I thought. Here is an explanation from an unrelated paper:
Chuna, which is a traditional manual therapy practiced by Korean medicine doctors, has been applied to various diseases in Korea. Chuna manual therapy (CMT) is a technique that uses the hand, other parts of the doctor’s body or other supplementary devices such as a table to restore the normal function and structure of pathological somatic tissues by mobilization and manipulation. CMT includes various techniques such as thrust, mobilization, distraction of the spine and joints, and soft tissue release. These techniques were developed by combining aspects of Chinese Tuina, chiropratic, and osteopathic medicine.[13] It has been actively growing in Korea, academically and clinically, since the establishment of the Chuna Society (the Korean Society of Chuna Manual Medicine for Spine and Nerves, KSCMM) in 1991.[14] Recently, Chuna has had its effects nationally recognized and was included in the Korean national health insurance in March 2019.[15]
This almost answers the other questions I had. Almost, but not quite. Here are two more:
- The authors conclude that the SCAM produced beneficial long-term effects. But isn’t it much more likely that the outcomes their uncontrolled observations describe are purely or at least mostly a reflection of the natural history of lumbar disc herniation?
- If I remember correctly, I learned a long time ago in medical school that spinal manipulation is contraindicated in lumbar disc herniation. If that is so, the results might have been better, if the patients of this study had not received any SCAM at all. In other words, are the results perhaps due to firstly the natural history of the condition and secondly to the detrimental effects of the SCAM the investigators applied?
If I am correct, this would then be the 4th article reporting the findings of a SCAM intervention that aggravated lumbar disc herniation.
PS
I know that this is a mere hypothesis but it is at least as plausible as the conclusion drawn by the authors.
This systematic review examined the efficacy of acupressure on depression. Literature searches were performed on PubMed, PsycINFO, Scopus, Embase, MEDLINE, and China National Knowledge (CNKI). Randomized clinical trials (RCTs) or single-group trials in which acupressure was compared with various control methods or baseline (i.e. no treatment) in people with depression were included. Data were synthesized using a random-effects or a fixed-effects model to analyze the impacts of acupressure treatment on depression and anxiety in people with depression. The primary outcome measures were depression symptoms quantified by various means. Subgroups were created, and meta-regression analyses were performed to explore which factors are relevant to the greater or lesser effects of treating symptoms. 
A total of 14 RCTs (1439 participants) were identified. Analysis of the between-group showed that acupressure was effective in reducing depression [Standardized mean differences (SMDs) = -0.58, 95%CI: -0.85 to -0.32, P < 0.0001] and anxiety (SMD = -0.67, 95%CI: -0.99 to -0.36, P < 0.0001) in participants with mild-to-moderate primary and secondary depression. Subgroup analyses suggested that acupressure significantly reduced depressive symptoms compared with different controlled conditions and in participants with different ages, clinical conditions, and duration of intervention. Adverse events, including hypotension, dizziness, palpitation, and headache, were reported in only one study.
The authors concluded that the evidence of acupressure for mild-to-moderate depressive symptoms was significant. Importantly, the findings should be interpreted with caution due to study limitations. Future research with a well-designed mixed method is required to consolidate the conclusion and provide an in-depth understanding of potential mechanisms underlying the effects.
I think that more than caution is warranted when interpreting these data. In fact, it would have been surprising if the meta-analyses had NOT generated an overall positive result. This is because in several studies there was no attempt to control for the extra attention or the placebo effect of administering acupressure. In most of the trials where this had been taken care of (i.e. patient-blinded, sham-controlled studies), there were no checks for the success of blinding. Thus it is possible, even likely that many patients correctly guessed what treatment they received. In turn, this means that the outcomes of these trials were also largely due to placebo effects.
Overall, this paper is therefore a prime example of a biased review of biased primary studies. The phenomenon can be aptly described by the slogan:
RUBBISH IN, RUBBISH OUT!
Acupressure is the stimulation of specific points, called acupoints, on the body surface by pressure for therapeutic purposes. The required pressure can be applied manually of by a range of devices. Acupressure is based on the same tradition and assumptions as acupuncture. Like acupuncture, it is often promoted as a panacea, a ‘cure-all’.
Several systematic reviews of the clinical trials of acupressure have been published. An overview published in 2010 included 9 such papers and concluded that the effectiveness of this treatment has not been conclusively demonstrated for any condition.
But since 2010, more trials have become available.
Do they change the overall picture?
The objective of this study was to test the efficacy of acupressure on patient-reported postoperative recovery. The researchers conducted a single centre, three-group, blind, randomised controlled, pragmatic trial assessing acupressure therapy on the PC6, LI4 and HT7 acupoints. Postoperative patients expected to stay in hospital at least 2 days after surgery were included and randomised to three groups:
- In the acupressure group, pressure was applied for 6 min (2 min per acupoint), three times a day after surgery for a maximum of 2 postoperative days during the hospital stay.
- In the sham group, extremely light touch was applied to the acupoints.
- The third group did not receive any such intervention.
All patients also received the normal postoperative treatments.
The primary outcome was the change in the quality of recovery (QoR), using the QoR-15 questionnaire, between postoperative days 1 and 3. Key secondary outcomes included patients’ satisfaction, postoperative nausea and vomiting, pain score and opioid (morphine equivalent) consumption. Assessors for the primary and secondary endpoints were blind to the group allocation.
A total of 163 patients were randomised (acupressure n=55, sham n=53, no intervention n=55). The mean (SD) postoperative change in QoR-15 did not differ statistically (P = 0.27) between the acupressure, sham and no intervention groups: 15.2 (17.8), 14.2 (21.9), 9.2 (21.7), respectively. Patient satisfaction (on a 0 to 10 scale) was statistically different (P = 0.01) among these three groups: 9.1 (1.5), 8.4 (1.6) and 8.2 (2.2), respectively. Changes in pain score and morphine equivalent consumption were not significantly different between the groups.
The authors concluded that two days of postoperative acupressure therapy (up to six treatments) did not significantly improve patient QoR, postoperative nausea and vomiting, pain score or opioid consumption. Acupressure, however, was associated with improved patient satisfaction.
This study is a good example to show why it is so difficult (or even impossible) to use a clinical trial for demonstrating the ineffectiveness of a therapy for any given condition. The above trial fails to show that acupressure had a positive effect on the primary outcome measure. Acupressure fans will, however, claim that:
- there was a positive effect on patient satisfaction,
- the treatment was too intense/long,
- the treatment was not intense/long enough,
- the wrong points were used,
- the sample size was too small,
- the patients were too ill,
- the patients were not ill enough,
- etc., etc.
In the end, such discussions often turn out to be little more than a game of pigeon chess. Perhaps it is best to ask before planning such a trial:
IS THE ASSUMPTION THAT THE TREATMENT WORKS FOR THIS CONDITION PLAUSIBLE?
If the answer is no, why do the study in the first place?
Acupressure is the stimulation of acu-points by using pressure instead of needles, as in acupuncture. The evidence for or against acupressure mirrors that of acupuncture, except there is far less of it. This is why this new trial might be important.
The aim of this RCT was to determine the effect of self-acupressure on fasting blood sugar (FBS) and insulin level in type 2 diabetes patients. A total of 60 diabetic patients were selected from diabetes clinic in Rafsanjan in Iran, and assigned to 2 groups, 30 in the acupressure and 30 in the control-group. The intervention group received acupressure at ST-36, LIV-3, KD-3 and SP-6 points bilaterally for 5 minutes at each point in 10 seconds pressure and 2 seconds rest periods. Subjects in the control group received no intervention. The FBS and insulin levels were measured before and after the intervention for both groups.
There were no significant differences between the acupressure and control group regarding age, sex and level of education. The insulin level significantly increased after treatment in the acupressure group (p=0.001). There were no significant differences between the levels of insulin in study or control groups. Serum FBS level decreased significantly after intervention in the acupressure group compared to the control group (p=0.02).
The authors concluded that self-acupressure as a complementary alternative medicine can be a helpful complementary method in reducing FBS and increasing insulin levels in type 2 diabetic patients.
I do not want to go into the methodological details of this study; suffice to say that it was less than rigorous and that its findings are therefore not trustworthy (never mind the fact that the results are biologically implausible). Even if that had not been the case, a single study would certainly not be sufficient reason to reach the conclusion that acupressure is helpful to control diabetes. For that, I am sure, we would need at least half a dozen independent replications.
Like most people, I have several non-medical friends who suffer from diabetes. They would love nothing better than having a simple, safe and effective method applying pressure to their skin in order to manage their disease. If they read this paper, some of them might conclude that acupressure is the answer to their problems and use it to control their condition. One does not need all that much imagination to see that this could seriously harm them, or even cost several lives.
Acupressure might be virtually free of risks, but with a bit of ill advice, even seemingly harmless treatments can kill.
Often referred to as “Psychological acupressure”, the emotional freedom technique (EFT) works by releasing blockages within the energy system which are the source of emotional intensity and discomfort. These blockages in our energy system, in addition to challenging us emotionally, often lead to limiting beliefs and behaviours and an inability to live life harmoniously. Resulting symptoms are either emotional and/ or physical and include lack of confidence and self esteem, feeling stuck anxious or depressed, or the emergence of compulsive and addictive behaviours. It is also now finally widely accepted that emotional disharmony is a key factor in physical symptoms and dis-ease and for this reason these techniques are being extensively used on physical issues, including chronic illness with often astounding results. As such these techniques are being accepted more and more in medical and psychiatric circles as well as in the range of psychotherapies and healing disciplines.
An EFT treatment involves the use of fingertips rather than needles to tap on the end points of energy meridians that are situated just beneath the surface of the skin. The treatment is non-invasive and works on the ethos of making change as simple and as pain free as possible.
EFT is a common sense approach that draws its power from Eastern discoveries that have been around for over 5,000 years. In fact Albert Einstein also told us back in the 1920’s that everything (including our bodies) is composed of energy. These ideas have been largely ignored by Western Healing Practices and as they are unveiled in our current times, human process is reopening itself to the forgotten truth that everything is Energy and the potential that this offers us.
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If you ask me, this sounds as though EFT combines pseudo-psychological with acupuncture-BS.
But I may be wrong.
What does the evidence tell us?
A systematic review included 14 RCTs of EFT with a total of 658 patients. The pre-post effect size for the EFT treatment group was 1.23 (95% confidence interval, 0.82-1.64; p < 0.001), whereas the effect size for combined controls was 0.41 (95% confidence interval, 0.17-0.67; p = 0.001). Emotional freedom technique treatment demonstrated a significant decrease in anxiety scores, even when accounting for the effect size of control treatment. However, there were too few data available comparing EFT to standard-of-care treatments such as cognitive behavioural therapy, and further research is needed to establish the relative efficacy of EFT to established protocols. Meta-analyses indicate large effect sizes for posttraumatic stress disorder, depression, and anxiety; however, treatment effects may be due to components EFT shares with other therapies.
Another, more recent analysis reviewed whether EFTs acupressure component was an active ingredient. Six studies of adults with diagnosed or self-identified psychological or physical symptoms were compared (n = 403), and three (n = 102) were identified. Pretest vs. posttest EFT treatment showed a large effect size, Cohen’s d = 1.28 (95% confidence interval [CI], 0.56 to 2.00) and Hedges’ g = 1.25 (95% CI, 0.54 to 1.96). Acupressure groups demonstrated moderately stronger outcomes than controls, with weighted posttreatment effect sizes of d = -0.47 (95% CI, -0.94 to 0.0) and g = -0.45 (95% CI, -0.91 to 0.0). Meta-analysis indicated that the acupressure component was an active ingredient and outcomes were not due solely to placebo, nonspecific effects of any therapy, or non-acupressure components.
From these and other reviews, one could easily get the impression that my above-mentioned suspicion is erroneous and EFT is an effective therapy. But I still do have my doubts.
Why?
These reviews conveniently forget to mention that the primary studies tend to be of poor or even very poor quality. The most common flaws include tiny sample sizes, wrong statistical approach, lack of blinding, lack of control of placebo and other nonspecific effects. Reviews of such studies thus turn out to be a confirmation of the ‘rubbish in, rubbish out’ principle: any summary of flawed studies are likely to produce a flawed result.
Until I have good quality trials to convince me otherwise, EFT is in my view:
- implausible and
- not of proven effectiveness for any condition.
