Running head: ACUPRESSURE TREATMENTS FOR PAIN 1

Abstract

Objectives: The objective of this review was to evaluate evidence for and against using

acupressure as a musculoskeletal pain treatment.

Design: The author examined results from original research articles published between 2008 and

2018 to determine effectiveness of acupressure compared to other treatments, control group care,

and baseline data.

Data Sources: Analyzed articles came from CINAHL Complete, Academic Search Premier,

Health Source: Nursing/Academic Edition, Alt HealthWatch, and PsycINFO databases.

Review/Analysis Methods: All articles met specific criteria and addressed the study objective.

The author evaluated article validity and quality by using a published tool for quantitative

studies. Focus topics included significance of research findings and types of comparison.

Results, Conclusions, and Nursing Practice Implications: Five articles qualified for further

analysis. All articles ranked moderately adequate to totally adequate for quality and used various

acupressure techniques. All studies found significant, positive improvements in participants

receiving acupressure, compared to control groups or baseline data. No studies compared

acupressure to other treatment methods. Although research is limited, the evidence that

acupressure reduces acute and chronic pain is growing. Using acupressure may help providers

reduce pain without using opioids. Future studies should focus on comparing acupressure and

acupressure-medication methods to medication-only treatments.

Key words: acupressure, pain management, chronic pain, acute pain, musculoskeletal pain
ACUPRESSURE TREATMENTS FOR PAIN 2

Acupressure Treatments for Pain: An Analysis of Recent Literature

The United States (U.S.) healthcare system failed to address pain management issues for

many Americans and now faces a new epidemic. According to the Institute of Medicine (IOM;

2011), chronic pain alone affects 100 million Americans and costs the U.S. up to $635 billion

annually. Acute pain expenses are harder to calculate, because not everyone seeks medical care

for acute pain. Mild, acute pain is sometimes managed through over-the-counter medications, but

these methods do not always provide relief (IOM, 2011). Opioids provide stronger pain relief,

but evidence shows opioids can cause side effects, complications, addictions, and deaths (Brush,

2012; Cramer, Wisler, & Gouveia, 2018; Fine & Cheatile, 2015; IOM, 2011; Tormoehlen,

Mowry, Bodle, & Rusyniak, 2011). In spite of providers’ increased attention to pain and

pressures from regulating agencies, opioid use and abuse increased without abolishing pain relief

issues (Atluri, Sudarshan, & Manchikanti, 2014). Atluri et al. (2014) found opioid use and

misuse increased from 1996 to 2011 by 1,448% and 4,680%, respectively. The number of

patients seeking rehabilitation for opioid abuse also increased by 187% from 2007 to 2011

(Atluri et al., 2014). This crisis is the opioid epidemic (Atluri et al., 2014; Bixby, Song, &

Levine, 2017).

Complementary and alternative medicine (CAM; e.g. massage, acupuncture) is gaining

popularity (IOM, 2011) as an alternative to opioids, but not all CAMs are consistently effective

(Talebi, Jalali, Hosseinabadi, Rezaei, & Bodagh, 2016; Yeh et al., 2015). Acupressure is a CAM

shown to be an effective pain management intervention (Talebi et al., 2016; Yeh et al., 2015).

Acupressure is based on Chinese acupuncture and causes patients’ bodies to release neural

mediators that reduce pain when pressure is applied to specific body landmarks (Talebi et al.,

2016; Yeh et al., 2015). If acupressure is effective it may offer better pain relief for patients who
ACUPRESSURE TREATMENTS FOR PAIN 3

are inadequately treated with opioids, without causing opioid-related side effects. The purpose of

this review is to investigate the effectiveness of acupressure and evaluate its practicality as a

complimentary or alternative treatment to opioids in the adult population.

Methods

The following PICO question guided this literature review: In adult patients with chronic

or acute musculoskeletal pain, what effect does acupressure, verses non-acupressure treatments,

have on patients’ pain levels?

The author included all EBSCOhost databases in the literature search, to reduce the

likelihood of accidently missing relevant articles. The key words were pain management and

acupressure. Inclusion criteria consisted of (a) peer-reviewed articles published between 2008

and 2018, (b) published in English, (c) original research study, and (d) acupressure was used as

an intervention for musculoskeletal pain. Exclusion criteria entailed (a) expert opinion articles,

(b) studies of pain conditions specific to one gender (e.g. childbirth, dysmenorrhea), (c)

systematic reviews, and (d) articles with the keyword childbirth. Available database filters based

on the inclusion and exclusion criteria narrowed the results. This resulted in 125 articles from

CINAHL Complete, Academic Search Premier, Health Source: Nursing/Academic Edition, Alt

HealthWatch, and PsycINFO databases. The author analyzed article titles and abstracts for

relevance before evaluating applicable articles for quality and biases using the Iowa Model

Quantitative Research Appraisal Tool from Cullen, Hanrahan, Tucker, Rempel, and Jordan

(2012). Studies that ranked moderately adequate to totally adequate were included in the final

analysis.

Results
ACUPRESSURE TREATMENTS FOR PAIN 4

The search produced one-hundred and twenty-five articles that matched the key words.

Most articles did not meet the inclusion and exclusion criteria. Only five articles qualified to

remain in the study, as outlined in Figure 1. All five studies used acupressure in the experimental

groups. Study criteria placed no limitations on comparison groups.

Study Quality

According to Cullen, Hanrahan, Tucker, Rempel, and Jordan’s (2012) research appraisal

tool, the studies by Dabariya and Shobha (2017) and Yeh et al. (2015) ranked moderately

adequate to totally adequate for internal and external validity. Talebi, Jalali, Hosseinabadi,

Rezaei, and Bodagh’s (2016) study ranked moderately adequate to totally adequate for external

validity and moderately adequate for internal validity. The studies by Movahedi, Ghafari Nazari,

and Valiani (2017) and Lin et al. (2015) scored moderately adequate for internal and external

validity. Dabariya and Shobha (2017) and Talebi et al. (2016) do not discuss their study biases

and limitations. However, some limitations and potential biases are discernable from the study

descriptions. The other three studies list biases and limitations, although Movahedi et al. (2017)

barely mentions them.

Study Characteristics and Results

Lin et al. (2015), Movahedi et al. (2017), Talebi et al. (2016), and Yeh et al. (2015) used

randomized controlled or randomized clinical trial designs. Dabariya and Shobha (2017) used a

quantitative pre-test, post-test design. All five studies used quantitative methods to evaluate the

effects of acupressure on participants’ pain levels.

Dabariya and Shobha (2017) conducted their study in India using a 30-participant sample

of adults, ages 65 and over, who lived in what the authors called an old age home. The

participants suffered from chronic hip, knee, or hip and knee pain. The authors failed to specify
ACUPRESSURE TREATMENTS FOR PAIN 5

the type of acupressure utilized. This study compared pre and post-intervention pain levels. The

results showed post-intervention pain levels significantly decreased compared to the pre-

intervention levels. The authors also found functional scores significantly increased after

treatment (Dabariya & Shobha, 2017).

Lin et al. (2015) examined the effects of auricular point acupressure on chronic low back

pain. Their sample consisted of 61 adults between 20 and 82 years-old who attended a clinic in

the United States for treatments. The comparison group received sham treatments. The authors

found statistically significant improvements in pain severity for the intervention group, but not

for the control group. The authors also found significant improvements in some post-treatment

biomarker levels, but not all biomarker levels improved (Lin et al., 2015).

Movahedi et al. (2017) sampled 50 female nurses in Iran with chronic low back pain. The

participant’s ages were between 25 and 55 years-old. The study examined the pain outcomes

between real acupressure applied to multiple sites and sham acupressure. Results showed pain

levels significantly reduced in the experimental group, compared to the control group,

immediately after the treatment and at the two and four-week reassessment marks (Movahedi et

al., 2017).

Talebi et al. (2016) conducted their study in an Iranian emergency department. Their

sample included 160 adults, between 18 and 50 years-old, who were brought in for acute, minor

trauma. The study criteria excluded patients with chronic pain. The intervention group received

acupressure at the LI4 and SP6 acupressure points, while the control group received false point

pressure treatments. The intervention group’s post-treatment pain levels were significantly lower

than the control group’s levels (Talebi et al., 2016). The writing quality in this article is lower

than normal for a professional article. The country of origin and types of minor grammar
ACUPRESSURE TREATMENTS FOR PAIN 6

mistakes suggest the authors speak English as a second language. These issues make some

information slightly harder to understand, but do not reduce the article quality or validity.

Yeh et al. (2015) conducted their United States-based study in a clinic. They sampled 61

adults over 18 years-old with chronic low back pain. The intervention group received auricular

point acupressure treatments, while the control group received sham treatments. Participants

receiving the real treatment reported statistically significant decreases in pain severity compared

to the sham group. The authors also discuss the average decrease in pain levels that occurred

after each treatment. Additionally the intervention group used fewer analgesics compared to the

control group, but this was not statistically significant (Yeh et al., 2015).

Discussion

This sample size of five articles is similar to the sample size Crawford, Lee, and May

(2014) used in their systematic review. Crawford et al. (2014) found three similar, high-quality,

acupressure studies conducted by the same author. Crawford et al. (2014) reported the studies

showed acupressure or acupressure and vitamin supplements were more effective than physical

therapy or muscle relaxants, however, no strength of recommendation existed due to the small

number of publications.

The diversity in the included studies spanned three different countries (i.e. India, Iran,

United States) and three different settings (i.e. clinics, emergency department, old age home).

Wellington (2014) previously performed a comprehensive literature search and concluded

Europe and the United States had not published research on acupressure effectiveness in treating

chronic back pain, while Hong Cong and Taiwan had published a few studies. This current

review shows countries that previously never studied acupressure are now investigating it.
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However, the setting diversity reduces the evidence strength, since only five articles qualified for

this review.

Four studies (Dabariya & Shobha, 2017; Movahedi et al., 2017; Lin et al., 2015; Yeh et

al., 2015) focused on chronic pain, with the most common type being low back pain. Only one

study (Talebi et al., 2016) focused on acute trauma pain. There are many medical applications for

acupressure in pain relief. Pak, Micalos, Maria, and Lord (2015) reviewed acupressure

effectiveness in studies involving childbirth, dysmenorrhea, various gastrointestinal disorders,

trauma, nausea, vasoconstriction, and hip fractures. The search process for this literature review

revealed multiple articles that address health issues Pak et al. (2015) mentioned. Those articles

failed the inclusion criteria for this review.

The acupressure treatment points also varied between the five studies. This decreases the

evidence strength for any one type of acupressure. However, all the studies ranked moderate to

high on quality and all studies showed significant improvements in the intervention groups’ pain

levels. This shows there is growing evidence acupressure can improve the pain in some patients.

Pak et al. (2015) also found evidence for the effectiveness of different types of acupressure and

mention there are more than 360 acupressure points on the body. Pak et al. (2015) state the

effectiveness of auricular acupressure may be beneficial in situations where the painful site

cannot be directly treated due to local trauma.

Importance of Results and Implications

This review provides evidence that acupressure is a successful alternative treatment for

specific acute and chronic pain conditions in adults. Although the diversity between the studies

decreased the strength of evidence for treating pain in specific settings, this review shows

evidence acupressure effectiveness is not limited by culture, pain acuity, or location of

ACUPRESSURE TREATMENTS FOR PAIN 8

musculoskeletal pain. Providers should consider incorporating acupressure into the care plan for

patients with musculoskeletal pain and encourage researchers to investigate acupressure

effectiveness. Since one study showed some reduction in analgesic use, this may indicate

patients receiving acupressure could reduce their analgesic use when receiving acupressure

treatments. This is an important consideration in light of the United States opioid epidemic crisis.

Limitations and Recommendations for Further Research

A limitation of this review is the small number of analyzed articles. This review was not

designed to evaluate the effectiveness of one type of acupressure over another and the results do

not provide enough information to identify whether one type is superior. Another limitation is

these studies only compared acupressure to baseline pain levels and sham treatments. A

recommendation for future study is to conduct studies that compare acupressure to common

medication treatments, such as opioids and acetaminophen. Another recommendation is more

studies should focus on more types of musculoskeletal pain, such as shoulder and neck pain.

Conclusion

This literature review investigated the effectiveness of acupressure compared to other

methods in the treatment of acute and chronic musculoskeletal pain. Although few articles met

the criteria, the results show acupressure is often effective in reducing musculoskeletal pain. This

is consistent with results from previous systematic reviews. Although no articles researched

acupressure in combination with or compared to specific opioid treatments, acupressure may be

effective in decreasing opioid use. The limited use of acupressure in current healthcare practices

may be due to lack of research, western healthcare traditions, and lack of provider awareness.

Conducting further research and increasing provider awareness is essential to increasing the

acceptance and use of acupressure in the current healthcare system.

ACUPRESSURE TREATMENTS FOR PAIN 9

Figure 1

Search using
key words:
125 articles

Criteria applied 118 articles disqualified

(e.g. systematic
reviews, cancer patient
sample, acupressure
used with invasive
7 articles procedures,
remaining acupuncture rather than
acupressure)

Relevance to 2 articles disqualified

PICO (i.e. pain severity not
measured)

5 articles
retained
ACUPRESSURE TREATMENTS FOR PAIN 10

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