2HOURS CE Continuing Education By Judy Wagner, DNP, RN, APRN, CNP, HWNC-BC Incorporating Acupressure into Nursing Practice Rooted in traditional Chinese medicine, this technique may be used to treat nausea and numerous types of pain. ABSTRACT: Rooted in traditional Chinese medicine, the use of acupressure to alleviate symptoms, sup- port the healing process, promote relaxation, and improve overall health has grown considerably in the West. The effects of acupressure—like those of acupuncture, with which it shares a theoretical framework— cannot always be explained in terms of Western anatomical and physiologic concepts, but this noninva- sive practice involves minimal risk, can be easily integrated into nursing practice, and has been shown to be effective in treating nausea as well as low back, neck, labor, and menstrual pain. The author discusses potential clinical indications for the use of acupressure, describes the technique, explains how to evalu- ate patient outcomes, and suggests how future research into this integrative intervention might be im- proved. Keywords: acupoint, acupressure, acupuncture, complementary medicine, integrative health, integrative medicine, integrative nursing, traditional Chinese medicine cupressure is a therapeutic intervention fingertips, palms, elbows, forearms, or various de- rooted in traditional Chinese medicine but vices) to apply pressure at these points.1, 3-7 Acu- A also widely practiced in Korea and Japan. pressure is used to alleviate symptoms, support the Like acupuncture, its theoretical framework can healing process, promote relaxation, and improve be best understood through the lens of a philoso- overall health. phy that sees health as the maintenance of the in- While research into the use of traditional Chi- ternal flow of a vital energy, known as qi, within nese medicine and other integrative therapies has the body.1, 2 According to this theory, when this flow increased substantially over the past two decades, of energy becomes stagnant or is blocked, symptoms the mechanism of action at work in acupressure or disease can develop. Whereas acupuncture seeks and acupuncture remains unexplained in terms of to restore the flow of qi through needle insertion the anatomic and physiologic concepts of Western at specific points on the body, acupressure seeks to medicine.1, 4-6, 8-10 (See Principles of Traditional Chi- do the same through the practitioner’s use of the nese Medicine.1, 4, 6, 8, 9, 11) Nevertheless, it is consid- fingertips (or, in the case of advanced practitioners, ered by its practitioners around the world to be an 40 AJN ▼ December 2015 ▼ Vol. 115, No. 12 ajnonline.com HOLISTIC NURSING Photo courtesy of Judy Wagner. courtesyPhoto of Judy “entirely coherent system, with internal logic and con- practice is common, research on its efficacy for this sistency of thought and practice.”1 specific symptom has produced conflicting evidence. This article discusses clinical indications for the use Further research is warranted. of acupressure; describes the technique, which can be In the clinical setting there are numerous indications easily incorporated into nursing practice; explains how for the use of acupressure, with most research focused to evaluate patient outcomes; and suggests how fu- on nausea and pain. Acupressure has been shown ture research into this integrative therapy might be to be effective in treating chemotherapy-induced and improved. The article also includes figures that illus- postoperative nausea, as well as low back, neck, and trate the acupoints involved in reducing nausea and labor pain, and dysmenorrhea (see Figures 2, 3, and alleviating low back pain, neck tension, and dysmen- 4 for acupressure points and specific indications for orrhea. their use3). Chemotherapy-induced nausea. A systematic re- INDICATIONS FOR USE view of 11 randomized controlled trials analyzed the Acupressure is used in various ways outside the health effects of acupoint stimulation used concurrently with care setting—in community wellness centers, for ex- pharmacologic antiemetic therapy on acute and de- ample. A well-known form of acupressure called shi- layed chemotherapy-induced nausea.12 Stimulation atsu blends the use of direct pressure at specific points was delivered to the acupoints through a variety of of the body with a systematic form of massage to pro- modalities, including acupressure, electroacupuncture, mote healing and wellness.5 One popular application electrostimulation, and manual acupuncture. While of acupressure, used by thousands of people daily, is acupressure reduced both mean and worst acute nau- stimulation of the pericardium 6 (P6) point above the sea severity, it did not reduce acute vomiting, delayed wrist, which many people believe can prevent motion nausea, or delayed vomiting. Electroacupuncture and sickness (see Figure 13). Stimulation may be achieved manual acupuncture were more effective than acu- by finger pressure or by specialized elastic wristbands pressure in reducing acute vomiting but did not re- that apply direct pressure to the P6 point. While this duce acute nausea. [email protected] AJN ▼ December 2015 ▼ Vol. 115, No. 12 41 A quasiexperimental controlled study compared Figure 1. Acupoint for Nausea and Motion Sickness the effects of standard antiemetic drugs alone or in conjunction with wristband-delivered acupressure on nausea, vomiting, and anxiety in 64 patients receiving chemotherapy for stage I to stage III breast cancer.13 P 6 Results showed that nausea and anxiety were signifi- cantly reduced in the experimental group compared with the control group, suggesting that acupressure applied to the P6 pressure point is effective in reduc- ing chemotherapy-induced nausea and anxiety in pa- Anterior View tients with breast cancer. Vomiting and retching were also reduced in the experimental group, though these reductions were not significant. A randomized controlled trial comparing the ef- fects of standard antiemetic therapy alone or together Acupressure.com with either P6-stimulating acupressure wristbands or sham wristbands on 500 patients receiving emetogenic P6, the pressure point stimulated to relieve nausea and chemotherapy found no statistically significant differ- motion sickness, is located approximately three finger ences between the three groups in terms of vomiting, widths above the transverse crease of the inner wrist be- anxiety, or quality of life.14 When considered together, tween the two tendons. To accurately locate the P6 acu- however, both wristband groups reported a nearly sig- point, use the patient’s own fingers: place the three middle nificant (P = 0.07) reduction in nausea compared with fingers of the patient’s other hand across and above the the group receiving antiemetic therapy alone. wrist, and then lift all but the index (pointer) finger—this Postoperative nausea. White and colleagues inves- finger will rest at the P6 point. Reprinted with permission tigated the effects of acupressure on postoperative nau- from Gach MR. Acupressure’s potent points: a guide to self- sea and vomiting in a double-blind, sham-controlled care for common ailments. New York: Bantam Books; 1990.3 study of 100 patients undergoing laparoscopic surgery Principles of Traditional Chinese Medicine with general anesthesia.15 In addition to giving patients standard antiemetic therapy, the investigators random- In traditional Chinese medicine, health is maintained when a vital en- ized half the patients to receive P6 stimulation using a ergy known as qi (often spelled “chi” and pronounced “chee” in English disposable acupressure wrist strip and half to receive a usage) flows unobstructed throughout the body, within a closed, in- sham wrist strip. Strips were applied to patients’ wrists terconnected system (conceptually parallel to the nervous, lymph, or 30 to 60 minutes before anesthesia was induced, and vascular systems) that comprises seven symmetrical pairs of “energy patients were instructed to leave the strips in place for channels,” often called meridians.6 According to this theoretical con- 72 hours following surgery. The acupressure group struct, when qi circulation within the meridians is impeded, the pri- had significantly less postoperative vomiting than mary universal forces exerted on matter and energy—yin (associated the sham group at both 24 hours (10% versus 26%; with passivity) and yang (associated with activity)—are thrown out of P = 0.04) and 72 hours (12% versus 30%; P = 0.03) balance, thereby producing symptoms or disease. Within this para- following surgery. digm, balance, and thus health, may be restored when specific points In a randomized controlled trial investigating nau- along the meridians, called acupoints, are manipulated, either through sea and vomiting in 102 women undergoing elec- pressure applied using the pads on the practitioner’s fingertips (or, tive cesarean section, participants were randomly with advanced training and substantial experience, the palms, elbows, assigned to receive one of three therapies: metoclo- forearms, or various devices), as in acupressure, or through needle in- pramide 10 mg iv immediately before anesthesia in- sertion, as in acupuncture.1, 4, 6 Applying pressure or inserting a nee- duction, acupressure bands applied at the P6 point dle at these points is thought to help disperse stagnant qi, encourage on both wrists 15 minutes before anesthesia induc- its natural flow, and stimulate the body’s healing mechanisms.11 Ap- tion, or no prophylaxis for nausea and vomiting