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Evaluation of Balance Acupuncture for Pain Relief in Cancer Patients
Briony Hudson
School of Psychology, University of Surrey, Guildford, GU2 7XH, [email protected]
Dr Leslie Storey
School of Psychology, Queen’s University, Belfast, BT7 1NN, [email protected]
Charlie Verschoyle
The Fountain Centre, St Luke’s Cancer Centre, Guildford, GU2 7XX, [email protected]
Robin Burby
The Fountain Centre, St Luke’s Cancer Centre, Guildford, GU2 7XX, [email protected]
Abstract
Aims: To explore the impact of balance acupuncture on pain relief for cancer patients in a multi-bed
setting.
Methods: 9 patients completed a 6 week course of balance acupuncture focusing on pain relief. The
measure yourself concerns and wellbeing form (MYCaW) was completed at baseline, trial midpoint (3
weeks) and completion (6 weeks). Outcomes included ratings of pain, general wellbeing and the impact of
another patient identified concern. Current pain, average pain and the intensity of pain were also assessed
over the course of the trial, using a pain thermometer.
Results: After 3 weeks of twice weekly balance acupuncture, significant reductions were observed in the
extent to which pain bothered patients (MYCaW) and the intensity of pain experienced over the previous
week. Upon completion of the 6 week course, significant improvements were observed in the average level
of pain experienced over the past week and the extent to which patients were bothered by a second concern
as listed on the MYCaW form.
Conclusions: Balance acupuncture in a multi-bed setting is an effective method of reducing pain in this
sample. A larger trial is needed to provide more robust, generalisable results.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
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Introduction
The side effects of cancer and its associated treatments are far reaching and well documented (1). Pain is a
common side effect and is linked with depression, anxiety and sleep disturbance (2). A recent Cochrane
review reported that 45% of people with early or intermediate stage cancer, and 90% of those with
advanced stage cancer experience moderate to severe pain. Furthermore, up to 70% of those experiencing
cancer pain do not receive adequate pain relief (3). In light of such statistics it is unsurprising that increasing
numbers of cancer patients are turning to complementary therapies to help manage their pain and improve
their quality of life (1, 4).
Acupuncture, an important component of Traditional Chinese Medicine (TCM) has been used for centuries
in Eastern cultures to treat conditions ranging from pain to digestive disorders. Despite the widespread use
of acupuncture in Eastern society and its growing usage in the West, there is a lack of quality research into
its use. The limited literature contains many discrepancies and inconsistent findings regarding
acupuncture’s efficacy as a treatment for cancer pain. Indeed, a recent systematic review of 15 randomised
clinical trials investigating acupuncture for cancer pain (5), proved inconclusive due to the methodological
flaws of the studies reviewed. This paper is not the first to reach this conclusion (6, 7). There is a real need
for robust, rigorous research into what could potentially be an extremely useful tool for reducing pain and
improving the quality of life for 77% of the UK’s cancer patients.
TCM takes a holistic approach to the treatment of pain and illness and operates on the principle that energy,
known as qi, flows through meridians in the body. The theory states that blockages in these meridians
prevent the flow of qi, resulting in pain or illness. The insertion of very fine needles is thought to remove
these blockages and allow qi to flow freely once more, restoring the body to health and relieving pain.
The Balance Method of acupuncture taught by Dr Richard Teh Fu Tan states that each meridian has several
paired channels in different anatomical sites meaning that needles need never be applied to painful areas.
Patients often report very rapid results and are not required to disrobe as needles are only applied to the
lower arms, legs, hands, feet and head, making balance acupuncture the perfect option for use in a multibed setting. This study aims to provide a pilot for a larger scale multi-bed trial of a 6 week course of
balance acupuncture for cancer patients and their carers.
Materials and Methods
Setting and study population
Data collection took place at The Fountain Centre, a charity providing support and complementary
therapies to cancer patients in the St Luke’s Cancer Centre at the Royal Surrey County Hospital in
Guildford. Data was collected as part of an internal audit and as such ethical review was not required.
Patients were recruited through posters around St Luke’s Cancer Centre and through referrals from within
the hospital. Thirteen patients experiencing pain were originally recruited to the study. Three were
excluded as they attended less than 3 treatment sessions, meaning follow up data was unavailable. One
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patient was unable to attend due to a deterioration in health (unrelated to the trial) while 2 decided not to
continue with the trial after the first session. All outcome measures were collected for 9 cancer patients.
The sample had a mean age of 65.4 years, ranging from 55 to 80 and was composed of 5 females and 4
males.
Measures
Measure Yourself Concerns and Wellbeing (MYCaW)
The MYCaW (8) was specifically designed for use with complementary therapy cancer patients to measure
change in two patient identified concerns over time. This measure was developed in recognition of the
specific challenges associated with assessing holistic care. Patients identify, in their own words “one or two
concerns or problems” that they would like to address through the intervention. For all patients in this
sample, concern number 1 was pain (the location of this pain is listed in table 1). These concerns are then
rated on a 7 point scale, from 0 (not bothering me at all) to 6 (bothering me greatly). In addition patients
rated their current general feeling of wellbeing on a 7 point scale from 0 (as good as it could be) to 6 (as
bad as it could be).
The MYCaW follow up form asks patients to repeat the ratings of concern 1 (pain), concern 2 and general
wellbeing. Two additional, optional questions “other things affecting your health” and “what has been most
important to you” are also included on the form. The follow up form was completed at week 3 and week 6
and participants’’ responses are outlined in figure 3.
Pain Thermometer
The pain thermometer is a simple and effective visual tool for assessing pain (9). It contains a faces rating
scale of 0, no pain to 10, extreme pain, mapped onto the picture of a thermometer. Patients indicated which
point, or face, corresponds with their current level of pain, their average pain over the last week and the
worst pain experienced over the last week (pain intensity).
Methods
Consenting patients completed the MYCaW and pain thermometer at the clinic before their first session of
acupuncture. The balance acupuncture was delivered in a multi-bed setting, meaning four patients could be
treated simultaneously, by two qualified acupuncturists. The number of sessions attended by participants
ranged from 3 to 11, with participants attending on average 7.6 sessions. Patients were not required to
disrobe and the specific sites for needles were located by palpating for tender areas along meridians
corresponding to those running through the affected area. The location and frequency of needles applied
was recorded. Once the needles were in place, the acupuncturist sanitised their hands before applying fresh
needles to the next patient. After thirty minutes the needles were removed from the first patient.
Acupuncture was administered on a rolling basis with patients arriving at twenty minute intervals. During
the first 3 weeks of the course, patients attended twice weekly. During week 3 patients completed the
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MYCaW follow up form and repeated the pain thermometer measures. Patients were then advised how
often they should attend for the duration of the course, once or twice weekly. This decision was based upon
the progress made in terms of pain reduction. The MYCaW and pain thermometer were repeated for a final
time at week 6. Three patients were unable to attend the final session and their follow up data was collected
via telephone.
Data analysis
The data was analysed using SPSS version 20. General wellbeing scores were reversed so that higher
scores indicated an improvement. The demographic characteristics and MYCaW concerns are displayed in
table 1. In light of the small sample size (n=9) and in the absence of normality, non-parametric statistical
tests were chosen. Friedman tests assessed whether ratings were statistically different across the three time
points (baseline, week 3 and week 6) for all quantative outcomes. Significant Friedman’s tests were
followed up with Wilcoxon signed rank tests (conducted with a Bonferonni correction resulting in a
significance level of p<.017) to identify the location of significant differences. Qualitative MYCaW data
was analysed in line with a published framework (10) and are reported in figure 3.
Results
Table 1. Demographic and baseline patient characteristics
N
%
Age
Sex
Male
Female
Ethnicity
White
Primary Cancer Type
Colon
Breast
Skin
Oesophageal
Prostate
MYCAW pain rating
Pain location
Back
Localised post-surgical pain
Feet
Legs
Hips
Neck
MYCAW concern 2
Physical concerns
Psychological/emotional concerns
Hospital(treatment) concerns)
Wellbeing concerns
Number of sessions attended
4
4
5
45.5
55.5
9
100
2
3
1
1
2
22.2
33.3
11.1
11,1
22.2
2
2
1
2
1
1
22.2
22.2
11.1
22.2
11.1
11.1
5
2
1
1
55.5
22.2
11.1
11.1
Mean
SD
Range
65.4
8.9
25 (55-80)
7.67
2.5
6 (4-10)
4.3
1.5
4 (2-6)
7.6
2.6
8 (3-11)
Table 2. MYCaW and pain thermometer ratings at baseline, at the midpoint of the trial (week 3) and upon
trial completion (week 6).
Baseline
MYCaW
pain
MYCaW
concern 2
MYCaW
General
Wellbeing
Current
pain
Average
pain
Week 3
Base line
to Week 6
(p)
Week 3
to week
6 (p)
-2.38*
-2.37*
-1.67
-1.98
-2.40*
4
(0-4)
-1.00
-1.52
-.70
1.0
(1.1)
3
(0-3)
-1.45
-1.57
-1.0
7
(1-8)
1.6
(1.5)
5
(0-5)
-1.8
-2.31*
-2.0*
9
(1-10)
4.1
(3.2)
9
(1-10)
-2.38*
-1.0
Mean
(SD)
Range
Mean
(SD)
Range
Mean
(SD)
Range
4.7
(1.3)
4.3
(1.5)
3
(3-6)
4
(2-6)
2.1
(1.6)
3.3
(1.5)
5
(1-6)
5
(1-6)
1.6
(1.9)
3.0
(1.9)
6
(0-6)
6
(0-6)
2
3.4
(1.1)
4
(2-6)
3.7
(1.3)
4
(0-4)
3.9
(1.4)
1.45
2
2.6
(3.4)
10
(0-10)
1.2
(1.3)
4
(0-4)
7.4*
2
4.1
(2.8)
8
(0-8)
2.4
(2.3)
2
7.7
(2.5)
6
(4-10)
4.6
(3.7)
(p)
Df
13.86**
2
9.36**
2
1.83
11.6**
Worst pain
Wilcoxon signed rank test
compared to baseline (p value)
Week 6
Base line
to Week 3
(p)
-2.37*
Friedman’s tests: ***p<.001, ** p<.01, * p<.05,
Wilcoxon signed rank tests:***P<.0003, **P<.003, * P<.017 (bonferonni corrections)
10
9
8
7
6
5
4
3
2
1
0
6
5
4
3
2
1
Current Pain
Average Pain
Worst Pain
MYCaW Pain
Week 6
Week 3
Baseline
Week 6
Week 3
Baseline
Week 6
Week 3
Baseline
Week 6
Week 3
Baseline
Week 6
Week 3
Baseline
Week 6
Week 3
Baseline
0
MYCaW Concern 2 MYCaW General
Wellbeing
Figure 1. Bar chart to show the changes in mean
Figure 2. Bar chart to show the changes in mean
scores for MYCaW outcomes at baseline, week 3
current, average and worst pain scores at baseline
and week 6
week 3 and week 6
MYCaW outcomes
Mean pain ratings, as measured on the MYCaW significantly reduced from baseline by week 3, (
(2) =
13.86, p=.001, z=-2.38, p=.016) with a mean difference of 2.6 points on a 7 point scale. At 6 weeks, mean
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-1.13
reduction from baseline had reached 3.1 points (z=-2.37, p=.016). Mean ratings for the extent to which
patients were bothered by concern 2 were also significantly reduced by completion of the acupuncture
course (
(2) = 9.360, p=.009, z=-2.401, p=.016). No significant differences were observed in ratings of
general wellbeing (
(2) =1.826, p=.401).
Pain thermometer outcomes
Mean pain intensity (worst pain) over the last week was significantly reduced by week 3 (
(2) = 11.6,
p=.003, z=-2.37, p=.016) and remained significant at week 6, (z=-2.37, p=.016). Average pain intensity
over the last week was significantly higher at baseline than week 6 (
current pain were not significantly reduced by week 6 (
(2) = 7.40, p=.025). Ratings of
(2) =1.45, p=.483).
Qualitative outcomes
Figure 3 contains the qualitative data collected on MYCaW follow up. Factors identified as the most
important aspects of the acupuncture sessions included, pain relief, relaxation, support and improvements
in wellbeing. Not all patients chose to complete this section.
What has been most important for you?
Week 3
Relaxing for 20-30 minutes
Helping to relax
Week 6
Overall feel that the trial has helped. Glad I did it
and have enjoyed relaxing.
Relief from pain. Improved psychological outlook
from support and attention and care. This is the
missing element -others too busy. Overall sense of
well being.
Feeling of support from a team working towards improving
my condition. This helps psychologically and makes you
work harder yourself. It stops you giving up. Feels like a
positive thing to help improve the condition.
Desperately wanted it to help and it has helped but
not as positively as I had hoped. But if I had not had
positive feelings towards the trial I would not have
come religiously twice a week.
Relief in shoulder and neck pain that he has had for 7 years.
Greater range of movement, is still limited but less painful.
The pain and shoulder stiffness leaving. Enjoyed
the relaxation, it was not painful and it worked!
The complete loss of pain to arm/breast. Total feeling of
wellbeing
Felt very welcome, felt very good when leaving.
Something is being done and is starting to have an effect
The whole experience. Environment, experienced
therapists and explanations. Felt very in control.
Huge benefit, would suggest it.
Relief from pain and self management through
applying pressure to pressure points. Have reduced
Removal of intermittent severe pain
cocodamol intake, now taking 2 tablets a day
instead of 6-8
Figure 3. Patients’ responses to the question “what has been most important for you, on the MYCaW
follow up forms at week 3 and week 6
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SUMMARY OF RESULTS
Statistically significant reductions
from baseline at week 3
Statistically significant reductions
from baseline at week 6






Outcomes that did not reach
statistical significance


Extent to which patients were bothered by pain
Pain intensity in last week
Extent to which patients were bothered by pain
Extent to which patients were bothered by MYCaW
concern 2
Average pain over the last week
Pain intensity in last week
Current pain
General wellbeing (MYCaW)
Discussion
Within the first 3 weeks of the course of acupuncture, significant reductions were reported in the extent to
which patients were bothered by their pain and also the worst pain intensity they experienced over the past
week. In addition, at 6 weeks, significant improvements were observed in average pain experienced over
the past week and the extent to which patients were bothered by their second MYCaW concern. The size
and speed of the improvements observed are encouraging.
While improvements were evident in all outcome measures studied, improvements in current pain and
general wellbeing did not reach significance. A potential explanation for this could be the characteristics of
the pain under focus. A number of patients presented with pain that was not constant but was initiated or
exacerbated by particular movements or activities. For example, one patient presented with chest pain that
was very intense when walking uphill; but largely absent when stationary or when walking on level ground.
As measures of current pain were taken when the patient was seated, in isolation they would imply that
acupuncture had not been particularly beneficial. However the patient reported dramatic reductions in
average pain and intensity when walking up hill after 2 sessions of acupuncture. Three weeks into the
course of acupuncture, the patient went on a hilly walking holiday, which would previously have been
impossible. The inclusion of measures of average pain and worst pain intensity meant that the inadequacies
of a single pain measure were addressed and a reflection of full pain experience obtained.
While general wellbeing scores improved; this improvement did not reach significance. When taking the
qualitative data into account, this seems surprising. Many patients used words such as “relief”,
“relaxation”, “support” and “benefit” to describe the most important aspects of the acupuncture, all of
which suggest acupuncture was a useful, positive experience. The inconsistencies between the qualitative
and quantitative data emphasise the importance of considering mixed methods when investigating
subjective topics such as pain, particularly in the context of an illness like cancer.
In this evaluation, balance acupuncture was conducted in a multi-bed setting. This increased efficiency but
also provided a safe environment for patients to talk to others experiencing similar illnesses. The majority
of patients reported enjoying this and used the opportunity to talk with other patients in an informal and
relaxed environment, sometimes about their illness and sometimes just shared interests. This set up fostered
a sense of community and a collaborative relationship between patients and acupuncturists with both
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working with and listening to the other. The benefits of this type of relaxed and also empowering approach
were highlighted in the comments given by one patient in the most import aspect section of the MYCaW:
“Feeling of support from a team working towards improving my condition. This helps psychologically and
makes you work harder yourself. It stops you giving up. Feels like a positive thing to help improve the
condition.”
One patient reported a dislike for the multi-bed setting, and felt it was “not hygienic” despite the
acupuncturists’ use of hand sanitizer between each patient and new sterile needles for each. Overall
however the multi-bed set up was very well received and would be a viable option for a larger scale study.
Despite the promising results observed there are obvious limitations to this evaluation, most importantly the
relatively low number of patients involved and lack of control condition. This evaluation aimed to assess
the viability of a larger trial with the same goals, in the same setting. Given the positive results obtained,
this evaluation indicates further, rigorous research is vital, feasible and appropriate for this centre. A robust
randomised controlled trial containing both a control and sham acupuncture group would be ideal. Given
the well documented methodological limitations of previous research in this area, it is imperative that any
further trials meet all guidelines for a robust and scientifically rigorous study, in order to provide gold
standard evidence for the use of acupuncture for pain relief for this patient group.
The lack of control condition makes it difficult to distinguish between the effects of the acupuncture, the
regular contact with the team, dedicated time for relaxation and possible placebo effects. However, the
benefits gained by patients over a short period suggest that further investigation into the effects of
acupuncture in this population is justified.
To conclude, a 6 week course of balance acupuncture led to significant reductions in the intensity and
average rating of pain experienced by patients over the previous week and the degree to which patients
were bothered by their pain and another identified concern. This is an important finding given the current
lack of acceptable alternatives to pharmaceutical approaches for cancer patients. Further research, on a
larger scale, including a health economics assessment, is warranted to fully explore the role that
acupuncture could play in pain management for cancer patients – both those currently receiving treatment
and those who are dealing with ongoing post-surgical pain.
Acknowledgements
Special thanks go to the staff and volunteers of The Fountain Centre
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