Acupuncture Is Underutilized in Hospice and Palliative Medicine

Leanna J. Standish, ND, PhD, LAc, Leila Kozak, PhD, and Sean Congdon, ND
Acupuncture is a complementary and alternative medical modality. A considerable body of acupuncture research has accumulated since 1998. Acupuncture has been integrated into palliative care settings in the United Kingdom but is yet to be widely offered in the United States. The literature was searched to identify clinical trials involving acupuncture, palliative care, hospice, chronic obstructive pulmonary disease, bone marrow, and cancer. Twenty-seven randomized controlled clinical trials of acupuncture were found that reported on conditions common to the hospice and palliative care setting, including dyspnea, nausea and

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vomiting, pain, and xerostomia, and 23 reported statistically significant results favoring acupuncture use for the conditions investigated. Acupuncture is safe and clinically cost-effective for management of common symptoms in palliative care and hospice patients. Acupuncture has potential as adjunctive care in palliative and end-of-life care, and the evidence warrants its inclusion in reimbursed palliative and end-of-life care in the United States.

Keywords:

acupuncture, palliative medicine, hospice

cupuncture is a complementary and alternative medical (CAM) modality widely practiced in the United States that is currently regulated by national and state boards and covered by health insurance carriers.1 Acupuncture is a 3000year-old therapy that is part of traditional Chinese medicine (TCM). Therapeutic effects of acupuncture are based on the guiding premise of TCM that a vital force, or chi (Qi), runs in the body through hypothesized channels called meridians. Traditional Chinese medicine describes symptoms as a manifestation of an obstructed circulation of chi. Treatment of these obstructions involves the insertion of fine needles at predetermined points to stimulate the circulation of chi.2 In TCM, there are different ways of applying the principles of acupuncture. Alternate techniques may be used in different settings or conditions. Some of these techniques have been developed in countries other than China, whereas some others are part of
From Bastyr University, Kenmore, Washington. This research was supported in part by a grant from the National Cancer Institute (R01CA10620). Address correspondence to: Leanna J. Standish, Bastyr University, 14500 Juanita Dr NE, Kenmore, WA 98028; e-mail: ljs@ bastyr.edu.

TCM. For example, typical TCM acupuncture tends to use longer and thicker needles that are inserted at a given depth, whereas Japanese acupuncture uses smaller and thinner needles that are inserted more superficially. Traditional Chinese medicine acupuncture also involves the manual manipulation of the needle once it is in place. Acupressure is a technique in which stimulation of points is produced by means of pressure, using the hands and fingers. Acupressure can be also selfapplied.1 The use of finger pressure on acupuncture points may be as effective as using needles. Electroacupuncture is the application of an electrical current on the acupuncture needles. This technique is widely used in TCM, particularly for anesthesia purposes. Data that compare these modalities are still insufficient, however, and little can be said about the relative effectiveness of all these methods. Acupuncture needle protocols in the clinical setting vary according to the institution, the training of the acupuncturist, and the constitution and condition of the patient. For example, when analgesia is the goal, some acupuncturists may choose electroacupuncture instead of needle acupuncture. Patients who are afraid of needles may be treated using acupressure instead. More recent techniques

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that may be useful for patients who are afraid of needles involve using a laser beam (laser acupuncture) or a vibrating tuning fork (Acutone, Pueblo, Colorado) for stimulation; however, these techniques have yet to be studied in palliative care populations. In addition, data are also needed that compare needle protocols and acupuncture delivery systems such as electroacupuncture versus manual acupuncture.

Acupuncture Research, 1998-2007

The 1998 National Institutes of Health (NIH) Consensus Development Panel on Acupuncture indicated that . . .promising results have emerged for the use of acupuncture in treating nausea and vomiting related to chemotherapy [and] adult post operative surgery pain. . . The NIH Consensus Report concluded that there was sufficient evidence of acupunctures value to expand its use into conventional medicine and to encourage further studies of its physiology and clinical value.3 Since the publication of the NIH Consensus Development Panel on Acupuncture in 1998, research in acupuncture has greatly increased. Between 1999 and 2007, 1020 uncontrolled and controlled clinical trials were indexed in MEDLINE, 3.14 times higher than the number of acupuncture trials indexed in MEDLINE between 1990 and 1998. The use of acupuncture in palliative and end-oflife care settings has been reported in the literature.4-6 A considerable body of acupuncture research has accumulated since 1998; still, it seems underutilized in palliative and end-of-life care where it is likely to have significant clinical benefit. A 2005 survey of hospices in Washington, for example, showed that 86% of hospices offered massage to their patients, but only 32% offered acupuncture.7 In this article we review the randomized controlled trials (RCTs) of acupuncture in symptoms pertinent to palliative and hospice care and argue that acupuncture should be consistently offered in palliative and hospice care. In an attempt to identify all of the controlled clinical trials on acupuncture in the palliative care setting, we searched the PubMed literature using the following criteria: acupuncture and palliative care or end of life or hospice or cancer or bone marrow or congestive heart failure or COPD (chronic obstructive pulmonary disease) or oncology and (Humans[Mesh]) and (English[lang]) and (Randomized Controlled Trial [ptyp]). This search yielded 33 titles, of which 27

were RCTs involving acupuncture and related therapeutic techniques such as auricular acupuncture, electroacupuncture, and acupressure.8-15 Outcomes for both body and auricular acupuncture are compared with conventional pharmacotherapy,8,10,11 sham acupuncture,16 needling at nonspecific sites,8,12 acupressure,17 and sham transcutaneous electrical nerve stimulation (TENS).18,19 The 27 RCTs reviewed in this article were published between 1986 and 2007, and 23 (85%) reported a statistically significant improvement of symptoms in the treatment group receiving acupuncture. These RCTs suggest that acupuncture may have a role in alleviating nausea and vomiting,8-11,17,20-26 decreasing neuropathic and visceral pain,11,19,27,28 and improving dyspnea16,19,29-33 and xerostomia.34-37 Most of the research pertinent to palliative care has been focused on cancer-related symptoms.8-10,17,21,24,38,39 Relevant data have also been published in palliative care use of acupuncture for COPD, particularly for the management of dyspnea symptoms.18,29,33 Table 1 summarizes the design and results of these trials. In addition, uncontrolled trials of acupuncture have shown that acupuncture may be effective in alleviating symptoms that may be experienced by hospice and palliative care patients, such as headaches,40 and dental pain.41,43 A number of uncontrolled trials on acupuncture are available in the palliative care literature, but uncontrolled trials are more likely to engender bias, leading to false-positive results.44 The acupuncture research field has made significant progress in defining suitable controls for clinical trial research,45,46 making the next generation of acupuncture trials more uniform and comparable.

Acupuncture in Palliative Care

Pain Management
Acupuncture effects on analgesia for cancer pain have been reported for stomach cancer pain,11 metastatic bone pain,47,48 anesthesia during removal of brain neoplasm,49 and cancer-related pain.11,12,27,47,50 One large RCT, involving 286 cancer patients with bone metastasis, showed that acupuncture was associated with decreased pain and consequent reduction in the analgesic and sedative drugs needed among 212 patients.48 In another study, Xu et al50 used acupuncture to treat 92 cancer patients with abdominal pain secondary to metastatic lesions, and 72% experienced symptom relief for up to 1 month after 1 to 2 weeks of daily acupuncture treatment.

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Table 1.
Author Patients

Randomized Controlled Studies of Acupuncture in Palliative Care

Treatment 13 sessions of acupuncture (points selected per pt presentation) over 3 wks Self-administered daily acupressure to LU1, LU2, DU14, LU10, PC8, ST36, LI4 6 sessions, 4-needle protocol (REN 20, REN 21, LI4); each session followed by placement of adhesive studs at acupuncture points used in treatment protocol (studs left in until ejected of their own accord) 20 sessions of acupressure (DU14, REN22, BL13, BL23) over 4 wks Control 13 sessions of sham acupuncture over 3 wks Sham control with crossover after 6 wks 6 sessions of mock TENS at 2 of the acupuncture points used in the protocol. Treatment and control group crossover after 2 week washout Sham acupressure treatment Effects Breathlessnessa Walking distanceb Breathlessnessa Longer Term Effects

Dyspnea Jobst et al,29 24 COPD pts 1986; UK

Maa et al,30 1997; Taiwan Lewith et al,18 2004; UK

31 COPD pts

36 COPD, cystic fibrosis, or pulmonary fibrosis pts, with disabling breathlessness

Breathlessnessb

Wu et al,31 2004; Taiwan Vickers et al,16 2005; US

44 COPD pts

Wu et al,32 2007; Taiwan Maa et al,33 2007; Taiwan Nausea and vomiting Dundee et al,20 1989; UK

47 lung or breast A single 15-min acupuncture A single 15-min sham cancer pts, using specific needle acupuncture session dyspnea complaints protocol (REN 17, ST36, at identical sites auricular, lung, and to intervention; kidney); session followed followed by by placement of placement of acupressure studs acupressure studs 62 COPD pts 5 sessions/wk for 4 wks; 5 sessions/wk for 4 wks Breathlessnessa 5-needle protocol using a 3-needle Oxygen (DU14, REN22, B13, B23) sham protocol saturationa Depressiona 35 bronchiectasis pts 8 wks of daily selfSelf-administered Breathlessnessa administered acupressure acupressure to Sputum by to LU1, LU5, LU10, nonacupoints self-reporta ST36, ST40 Nauseaa

Breathlessnessa Walking distancea Anxietya Both acupuncture and sham breathlessnessa; no significant group differences in breathlessnessb

130 cancer pts receiving chemotherapy; nausea after first infusion McMillan and 16 cancer pts; Dundee,10 receiving multiple 1991; point Ireland 5-day courses of cisplatin; some with multiple drug chemo; all pts receiving antiemetic therapy (ondansetron)

P6 electroacupuncture

Electroacupuncture to nonacupoint

Transcutaneous electrical stimulation at a single point (P6) selfadministered by the patient; stimulation for 5 min every 2 waking hours while receiving chemo and antiemetic therapy

Antiemetic therapy without stimulation

Emesis episodesa

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Table 1. (continued)
Author Pearl et al,9 1999; US Patients 42 gynecologic oncology pts; receiving cisplatin and antiemetic therapy in parallel trial; 18 pts then participated in a follow-up crossover trial 104 breast cancer pts; receiving high-dose chemo and triple therapy antiemetic pharmacotherapy for nausea and vomiting Treatment Single-point (P6) stimulation by miniaturized portable transcutaneous electrical unit (Reliefband),d worn continuously for 7 days Control Disabled miniaturized portable TENs unit (Reliefband), worn at P6 continuously for 7 days Effects Nausea/ emesisa,c Longer Term Effects

Shen et al,8 2000; US

Dibble et al,21 2000; US Roscoe et al,22 2002; US Treish et al,23 2003; US

17 cancer pts receiving chemotherapy 27 cancer pts who experienced nausea after first chemotherapy treatment 49 cancer pts receiving outpatient chemo; intervention concurrent with antiemetic therapy 739 cancer pts receiving their first outpatient chemo treatment; intervention concurrent with antiemetic therapy 80 pts receiving highdose chemo and autologous stem cell transplant; all pts receiving ondansetron antiemetic therapy for nausea and vomiting 96 breast cancer pts who experienced nausea and vomiting after their

(1) Five daily sessions with needle insertion and electrostimulation in points not associated with antiemetic activity; (2) standard pharmacotherapy without needling Acupressure at points P6 and No intervention ST36 once each morning (usual care) and as needed during 21 days of chemo cycle Acustimulation to P6 via No wrist band wrist band

Five once-daily 30-min electroacupuncture sessions at P6 and ST36

Emesis episodesa

Nausea freqa Nausea severitya Nausea severityb Antiemetic drugsa Emesis severitya Nauseaa

Nausea freq Nausea severity

Roscoe et al,24 2003; US

Continuous use of Continuous use of Acustimulation band deactivated (Reliefband) for 5 days; Acustimulation band band worn concurrent worn concurrent with chemo administration with chemo administration Continuous use of No band (usual care) Acupressure band (Sea-Band)e or Acustimulation band (Reliefband) for 5 days

Emesis freqa Nauseaa

Emesis severitya,g Nauseaa,g

Streitberger et al,17 2003; Germany

Single-point acupuncture (P6)

Noninvasive singlepoint stimulation of P6

Emesisb

Roscoe et al,25 2005; US

Acustimulation band (Reliefband); pts instructed to wear as needed for 5 days; band

(1) Sham Acustimulation band; (2) no band (usual care)

No difference between 3 groups (continued)

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Table 1. (continued)
Author Patients Treatment Control Effects Longer Term Effects

Molassiotis,26 2007; UK

first chemo; worn concurrent with intervention chemo administration concurrent with antiemetic therapy 54 cancer pts Continuous use of receiving outpatient Acustimulation band first chemo (Reliefband) for 5 days; treatment; band worn concurrent intervention with chemo concurrent with administration antiemetic therapy

No band (usual care)

Nausea severitya Vomiting severityb Nausea freqa Vomiting frqa Nausea distressa Vomiting distressa Paina

Pain Alimi et al,12 90 cancer pts with 2003; posttreatment France neuropathic pain

Xia et al,28 1986; China

76 lung, esophageal, or stomach cancer pts with chest pain

Dang et al,11 48 pts with 1998; intermediate and China late-stage gastric cancer receiving analgesic pharmacotherapy based on WHO protocol

Two sessions of auricular acupuncture; selected sites confirmed by detection of an electrodermal signal via microvoltmeter. Sessions 1 month apart (at each session, needles left in until ejected of their own accord) 38 pts receiving acupuncture at P6 and ST36, and additional points based on symptom presentation; a single course consisted of every other day treatment for 30 days, followed by 7-10 days of rest Treatment arm in 2 groups: 1. Standard acupuncture (ST36, SP6, ST34, P6, LI11, LI4) with pharmacotherapy; standard protocol used for point selection with additional points selected per patient signs and symptoms; therapy administered several times weekly for 2 months 2. Acupuncture point stimulation as above accompanied by injection of human transfer factor twice weekly for 2 months

(1) 2 sessions, 1 month apart of needle insertion at auricular points with no electrodermal signal (placebo); (2) adhesive auricular seeds applied at placebo auricular points at 2 sessions, 1 month apart 38 pts receiving standard care (chemo or radiation)

Painb

1. Patient receiving analgesic; pharmacotherapy monitored for 2 months 2. Also healthy controls without pharmacologic therapy included for comparison of plasma testing only

Painb,h

1.Paina,g Plasma leucineenkephalina,g Leucopeniaa,g Quality of lifea 2.Appetite suppressionb,h Dizzinessb,h Insomniab,h Weaknessb,h

(continued)

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Table 1. (continued)
Author Gadsby et al,19 1997; UK Patients 15 palliative care unit pts Treatment Electrical stimulation at P6 and LI4 and standard pharmacotherapy for symptom control; 5 consecutive daily treatments Control (1) Mock ALTENS with standard pharmacotherapy for symptom control; 5 consecutive daily treatments; (2) standard pharmacotherapy Placebo acupuncture with superficial needling Effects Painb Nauseab Emesisb Fatigueb Longer Term Effects

Xerostomia Blom et al,34 21 severe xerostomia 1992; pts Sweden

Blom et al,35 1996; Sweden

List et al,36 1998; UK

Wong et al,37 2003; Canada

Manual acupuncture 20 min 2/wk 6 wks to ST3, ST4, ST5, ST6, ST7, SI17 and P6, HT7, LI4, LI10, SI3, SI7, DU20, DU17, ST36, K3, K5, SP4, SP6, SP8 plus auricular points 38 pts receiving radiation Two series of acupuncture treatment and for with specific multiple head and neck cancer needle protocol; with xerostomia of 2 sessions/wk for 6 wks varying duration Follow-up observation 12 months 21 Sjgren pts Manual acupuncture with electroacupuncture 30 min/wk 10 wks to ST6,ST7,SJ23, BL2, DU24, DU20, DU26 46 head and neck Electroacupuncture cancer pts 2/wk 6 wks receiving radiotherapy

Salivationa

Same points and frequency as intervention but with superficial needling

No difference between groups

No acupuncture treatment waitlist control

No difference between groups Salivationa in all 3 groups with sustained effects at 3 and 6 mo; Tastea Oral mucusa

Comparison of 3 combination of acupoints

Abbreviations: ALTENS, acupuncture-like transcutaneous electrical nerve stimulation; COPD, chronic obstructive pulmonary disease; pts, patients; TENS, transcutaneous electrical nerve stimulation; WHO, World Health Organization. Test was for a decrease in the outcome. Test was for an increase in the outcome. a Statistically significant effect. b Observed effect not statistically significant. c Significant effect was in comparison with crossover group; parallel group nonspecific positive results were comparable with placebo. d Reliefband, Neurowave Medical Technologies, Chicago, Illinois. e Sea-Band, Sea-Band Ltd, Leicestershire, United Kingdom. f Positive effect noted in treatment group but not significant compared with standard pharmacotherapy. g Significant change compared with standard pharmacotherapy. h Nonsignificant change compared with pharmacotherapy group.

Nausea and Vomiting Management

A study of chemotherapy-induced emesis published by Shen et al8 showed that electroacupuncture with

needling at the PC6 (inner wrist) and ST36 (lower leg) points decreased emesis episodes. Statistically significant improvements in antiemesis have also been reported by other RCTs.8,9,17,20-23,25,39,51

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Dyspnea Management
Dyspnea is a common distressing symptom in some patients with advanced cancer. Improvement of dyspnea by treatment with acupuncture have been reported.14,52 In terminally ill cancer patients, elevated anxiety is associated with dyspnea even after tumor debulking in the lungs.15 Acupuncture treatments have been shown to reduce dyspnea in terminally ill cancer patients complaining of breathlessness. In a study of 20 metastatic cancer patients, Filshie et al14 investigated the effect of acupuncture by measuring respiratory rate, oxygen saturation, pulse, self-reported breathlessness, pain, anxiety, and relaxation before and after a 10-minute acupuncture treatment. Of these patients, 70% reported significant improvements in breathlessness, anxiety, and relaxation that lasted up to 6 hours after a single treatment. Improvements in respiration were sustained for 90 minutes.14

practitioners conclude that in the hands of competent, well-trained, and skilled practitioners, acupuncture is one of the safer forms of medical intervention.58,59

Xerostomia Management
Xerostomia is a common complaint in hospice patients. Increased salivation has been shown in 2 of 4 trials that tested the effect of acupuncture in patients with xerostomia.34,37

Acupuncture Safety
Acupuncture is considered a low-risk therapy in the hands of well-trained and licensed practitioners. Although serious adverse events such as pneumothorax have been reported sporadically,53 these are isolated case reports.54
In a review of adverse events reported in the case literature in MEDLINE from 1981 to 1994, Norheim55 concluded that serious adverse events were rare and usually the product of poor training. In a 6-year survey of more than 65 000 treatments at an acupuncture teaching clinic in Japan, only 94 adverse events were reported, the most common being failure to remove needles and bruising with or without localized pain.56 No serious or severe adverse events were recorded in this study. Results from a 2001 prospective survey of 78 British physiotherapists and physicians trained in acupuncture were similar. The practitioners provided nearly 32 000 treatments, and 43 significant events were reported, all classified as minor.57 The authors of a 2004 prospective study on 97 733 acupuncture treatments with German

Attending physicians may be reluctant to refer their thrombocytopenic patients or those receiving anticoagulant therapy for acupuncture treatment for fear of bleeding, bruising, and seroma. Experienced acupuncturists, however, report that no episodes of adverse events are seen in clinical practice when acupuncture is used in thrombocytopenic patients or patients receiving anticoagulant therapy. The Bastyr University Clinic has been providing adjunctive acupuncture treatment to cancer patients and patients with human immunodeficiency virus for 5 years, with no recorded bleeding events (S. Given, personal communication, Bastyr University Natural Health Clinic, 2006) and only 1 acupuncture-induced event is indexed in the National Library of Medicine.60 As a rule, patients at the clinic with thrombocyte counts of less than 20 000 L or with visible petechiae are excluded from needling, and patients with coagulopathies or who are receiving anticoagulant therapy are required to be under the care of a physician and have regular coagulation studies (S. Given, personal communication). Hospice and palliative care directors should refer to the 2001 Filshie report61 for contraindications and cautions for acupuncture in palliative care patients.

Is Palliative Acupuncture Care Cost-Effective?

Most of what we do know about the cost-effectiveness of acupuncture therapy is contained in a review by Herman et al.62 In an analysis of 56 economic evaluations of CAM therapy, the authors found acupuncture to be more cost-effective than conventional therapy for migraine headaches and comparable with the cost of conventional care in treating dyspepsia.62 Little is known about the economic impact of acupuncture for other symptoms and conditions, however, particularly in the palliative and end-of-life care setting. Although the inclusion of acupuncture and other CAM modalities into palliative and hospice care in the United States (US) may be of value to patients and their families, health care administrators must make hard decisions about how to allocate the current available reimbursement for hospice patients. As of

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October 1, 2005, the daily reimbursement rate for Medicare was $647.09 for inpatient care, $150.48 for respite care, and $145.46 for routine care.63 Although acupuncture is widely reimbursed by health insurance companies across many states, Medicare and Medicaid have thus far not covered any CAM services for any condition. In a 2005 survey of hospices in Washington State, only 5% of CAM services were declared to be covered by some type of health insurance, including Medicare and Medicaid.7 If acupuncture is to be truly integrated into our oncology, palliative, and hospice health care systems, then the evidence must be strong and the costs of providing these services must fit within the reimbursement schedules.

to qualify for state licensure. All licensed acupuncturists in the United States are trained to provide acupuncture therapy to pediatric, geriatric, and seriously ill patients.

Ethical Argument
Although it is prudent to extend research into the application of acupuncture in palliative and end-of-life care in larger and better designed RCTs, there is also a need to assess realistically how reasonable it is to continue waiting for data from RCTs in end-oflife care to make these therapies available to patients who are suffering. Acupuncture appears effective in a number of RCTs (Table 1) and has a low risk of serious complications. In the hands of well-trained and knowledgeable practitioners, acupuncture seems a safe and effective treatment and may provide another useful tool for the multidisciplinary palliative/end-oflife care team. The biomedical community is currently discussing the issue of how much data from RCTs is necessary for an intervention to be accepted as standard of care, particularly in cases in which enough data are available to indicate safety and efficacy of a certain intervention. Moreover, some authors consider it unethical to wait for the results of more RCTs of public health interventions when an intervention has been shown to be low risk and beneficial.65 Other authors66 suggest CAM therapies such as acupuncture are useful and necessary components of palliative care and need to be integrated into palliative and end-of-life settings.

Possible Obstacles to the Inclusion of Acupuncture in Reimbursed Palliative Care

Conceptual barriers to the inclusion of acupuncture in palliative medicine include
1. the concern that patients may be needle-phobic and will not find acupuncture acceptable, 2. confusion about how to credential acupuncture providers in the inpatient or outpatient hospice or palliative care setting, and 3. lack of third-party payment for acupuncture services.

Probably the single largest obstacle for the inclusion of acupuncture in reimbursed palliative care is the lack of reimbursement by Medicare, the largest payer covering patients within the age or disability range who would benefit from this modality. Other obstacles include the resistance of admitting providers to refer patients to receive acupuncture and the lack of credentialing committees in some states. In the United Kingdom (UK), acupuncture is regularly offered as part of palliative and hospice care, particularly through palliative day care services and hospice.64 The wide acceptability of acupuncture in UK palliative services seems to indicate that patients may find acupuncture more acceptable than their US providers believe. Nonphysician acupuncture is a licensed modality in 43 states in the United States. Medical insurance companies provide reimbursement for acupuncture services depending on each states laws. Currently, acupuncturists must pass national board examinations

Conclusions
A review of current RCTs of acupuncture in palliative and hospice care suggest that acupuncture may have a role in palliative care, particularly in alleviating nausea and vomiting,8-10,17,20-26 decreasing neuropathic and visceral pain,11,19,27,28 and improving dyspnea16,18,29-33 and xerostomia.34-37 Although we still have much to learn about acupuncture, the evidence from 27 RCTs is sufficient to argue that acupuncture should be included in hospice and palliative care management of nausea and vomiting, dyspnea, and pain. More well-designed clinical trials of acupuncture are needed to clarify which needle protocols may be most effective for each symptom and to be able to compare different acupuncture

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techniques, such as body acupuncture, ear (auricular) acupuncture, electroacupuncture, and acupressure. Because of its acceptable safety record, clinical efficacy, and low cost, acupuncture should be more widely used in hospice and palliative care settings.

Acknowledgments
We gratefully acknowledge the editorial revision by Arushi Sinha, PhD, and Steven Given, DOAM, LAc, Associate Dean for Clinical Education, Bastyr University School of Acupuncture & Oriental Medicine.

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