Tuesday, 4 December 2018
Chapter 111 - Acupuncture for Nausea and Vomiting
Integrative Medicine (Fourth Edition) 2018, Pages 1044-1046.e1 Author links open overlay panelAaron J.MichelfelderMD Available online 28 April 2017. https://doi.org/10.1016/B978-0-323-35868-2.00111-0 Get rights and content Overview For an overview of acupuncture, its mechanism of action, its safety, and training as well as techniques for performing acupuncture and acupressure, please see Chapter 110. Extensive data are available concerning the use of acupuncture and acupressure for nausea and vomiting, especially with regard to the following causes or types of these conditions: • Postoperative status • Chemotherapy • Pregnancy • Motion sickness Postoperative Nausea and Vomiting In 1997, the National Institutes of Health (NIH) convened a panel of nonadvocate scientists to assess the current evidence concerning acupuncture and its efficacy. At that time, the panel concluded that clear evidence indicated that acupuncture was effective for adult postoperative and chemotherapy-induced nausea and vomiting.1 Since then, six studies have also demonstrated its efficacy in preventing postoperative nausea and vomiting in children.2, 3, 4 A 2004 Cochrane Review of 26 trials involving 3347 children and adults showed that in comparison with controls, acupuncture, with and without electrical stimulation, and acupressure were effective in decreasing the incidence of postoperative nausea and vomiting.5 When compared, acupuncture and acupressure were equivalent to antiemetic drugs in preventing vomiting but were actually better in preventing nausea.5 A Cochrane meta-analysis including 40 trials with a total of 4858 participants looked specifically at stimulation of the wrist acupuncture point pericardium 6 (PC6) for preventing postoperative nausea and vomiting.6 The reviewers found that acupuncture and acupressure at the PC6 acupoint significantly reduced the risk of postoperative nausea and vomiting when compared with sham in both children and adults. The reviewers also found that PC6 stimulation was equivalent to antiemetic drugs.6 Another meta-analysis of 21 studies from 1996 to 2009 showed that acupuncture reduced nausea but not vomiting when compared with antiemetic prophylaxis alone.7 Chemotherapy-Induced Nausea and Vomiting As previously stated, the 1997 NIH Acupuncture Consensus Panel concluded that acupuncture was effective for chemotherapy-induced nausea and vomiting. Dundee and Yang8 found that acupressure was effective for decreasing nausea in hospitalized patients but worked much better when the acupressure bands were stimulated every hour. In an attempt to make this effect stronger, these investigators performed acupuncture with electrical stimulation in 105 patients, all of whom had had nausea and/or vomiting after an earlier chemotherapy treatment. This treatment prevented nausea and/or vomiting in 66% of patients and only 6% did not have any benefit from the acupuncture.8 A meta-analysis of 11 studies including 1247 patients found that self-administered acupressure prevented chemotherapy-induced nausea and vomiting, and electroacupuncture also had a positive effect.9 The reviewers concluded that these studies suggested a biological effect of acupuncture in preventing and treating chemotherapy-induced nausea and vomiting.9 Pregnancy-Related Nausea and Vomiting The data for the use of acupuncture in pregnancy-related nausea and vomiting are equivocal.10 A Cochrane Review of available studies found limited evidence to support the use of wrist and ear acupressure or acustimulation to treat pregnancy-related nausea and vomiting and cited the need for higher-quality, more focused studies in this area.11 Motion Sickness Several devices, including those for acupressure and electrical stimulation, have been approved by the U.S. Food and Drug Administration for the prevention of motion sickness. Hu et al.12 reported that acupressure reduced the symptoms of motion sickness and decreased abnormal gastric myoelectric activity and tachyarrhythmia. However, Miller and Muth,13 who tested two available acupressure and acustimulation bands for the prevention of motion sickness, found that the devices delayed the onset of, but did not prevent, the sickness.10 Acupuncture and acupressure are effective for postoperative and chemotherapy-induced nausea and vomiting, but data are equivocal for pregnancy-induced nausea and vomiting as well as for motion sickness. Acupuncture, with or without electrical stimulation, and acupressure appear to be equivalent to antiemetic drugs for the prevention of nausea and vomiting. Acupuncture Points for Nausea and Vomiting Naming of acupuncture points and techniques for performing acupuncture and acupressure is discussed in Chapter 110. Three main points are relevant to this discussion: (1) master of the heart 6, also called PC 6 (MH6, PC6, or P6), (2) stomach 36 (ST36), and (3) liver 3 (LV3). Master of the Heart 6 MH6 is located on the anterior surface of the wrist, approximately three fingerbreadths proximal to the distal wrist crease. It lies between the tendons of the flexor carpi radialis and palmaris longus muscles. Because the median nerve can be very superficial, insert the needle only a few millimeters under the skin, starting proximally, and direct it very superficially toward the hand. Warn the patient that if he or she feels a shooting or shock-like sensation into the hand, it is nothing harmful, and slightly withdraw without removing the needle tip from the skin and then redirect the needle more superficially (Fig. 111.1). Download full-size image FIG. 111.1. The master of the heart (MH6; also called pericardium 6 [PC6 or P6]) acupuncture point. Stomach 36 ST36 is a depression in the anterolateral aspect of the shin, between the tibialis anterior and extensor digitorum longus muscles. You can find this point by placing your thumb on the anterior border of the tibia and sliding superiorly. Where the tibia starts to fan out near the patella (tibial tuberosity), allow your thumb to travel laterally until it encounters a depression approximately six fingerbreadths below the patella and one fingerbreadth lateral to the tibial tuberosity. The needle is inserted perpendicular to the skin, approximately 1–2 cm deep, and is stimulated with clockwise and counterclockwise twisting (Fig. 111.2). Download full-size image FIG. 111.2. The stomach 36 (ST36) acupuncture point. Liver 3 LV3, also a very important point for the treatment of nausea and vomiting, is located on the dorsum of the foot between the first and second metatarsal bones. If you place a finger between the first and second toes and slide it up the foot between the first two metatarsal bones, LV3 is the last place where you can access the underlying muscle between those two bones. The needle is directed toward the tip of the calcaneus and is inserted to a depth of approximately 1 cm (Fig. 111.3). Download full-size image FIG. 111.3. The liver 3 (LV3) acupuncture point. Practical Use of These Points To prevent nausea, stimulate the MH6 point, either with acupressure (using a finger, a commercially available acupressure band, or an acustimulator) or acupuncture. To treat nausea and vomiting, start with MH6 and then add ST36 with stimulation and LV3 in dispersion (see Chapter 110 for the distinction between stimulation and dispersion). During an Acupuncture Treatment For the prevention of nausea, needles should be placed at least 30 minutes before the antiemetic effect is needed and continued for as long as required. For the treatment of nausea and vomiting, needles should stay in for as long as needed. Patients should be relaxing in a comfortable room with the lights low and perhaps some calming music in the background. Distractions should be minimized. Remove acupuncture needles as follows: 1. Place one finger on the skin next to the needle. 2. While holding your finger in place, use the other hand to pull the needle out gently. 3. Sometimes a drop of blood may be released. Applying pressure is not necessary; simply dab the blood away with sterile gauze. Posttreatment Home Program Patients are instructed to moderate their activity for 24 hours after a treatment. They should avoid very hot or very cold foods and liquids, consumption of alcohol, sexual activity, and other physically demanding activities. They should also drink plenty of water and get adequate sleep. Patients can continue to perform acupressure on themselves whenever needed. Acupressure is a great way to empower patients to take control of their own symptoms. What to Look for in an Acupuncturist A physician acupuncturist should have completed training in one of the programs approved by the American Board of Medical Acupuncture. Board certification in medical acupuncture identifies individuals who have completed at least 200 hours of training, passed a board examination, practiced for at least 2 years, and performed at least 500 acupuncture treatments. A nonphysician acupuncturist should be licensed. The letters “L.Ac.” should follow a licensed acupuncturist’s name. In addition, the National Certification Commission for Acupuncture and Oriental Medicine has a database of certified acupuncturists (see the Key Web Resources). Conclusion • Acupuncture has been shown to be effective for the prevention and treatment of postoperative and chemotherapy-induced nausea and vomiting. Acupuncture may be helpful for the prevention of pregnancy-induced nausea and vomiting as well as motion sickness. • For the prevention of nausea, stimulate the MH6 point with acupuncture, acupressure, or electrical stimulation. • To treat nausea and vomiting, use MH6, but also add ST36 with stimulation (clockwise and counterclockwise twisting action) and LV3 in dispersion (needle left alone). • For more information about learning acupuncture, visit the American Academy of Medical Acupuncture Web site (see the Key Web Resources). Key Web Resources American Academy of Medical Acupuncture: The main certifying group of physician acupuncturists http://www.medicalacupuncture.org/ American Board of Medical Acupuncture: The certifying board for physicians. Includes requirements to sit for the board exam. http://www.dabma.org/requirements.asp Acumedico: A list of acupuncture sites with illustrations http://www.acumedico.com/acupoints.htm National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM): Certifying group maintaining a database of certified acupuncturists http://www.nccaom.org Acupuncture Today: Acupuncture news source with information on clinicians and acupuncture research http://www.acupuncturetoday.com/mpacms/at/home.php Sea-Band: A commercial product that stimulates PC6 for nausea and vomiting http://www.sea-band.com/ Mayo Clinic: YouTube video on acupuncture for nausea http://www.youtube.com/watch?v=XWdDMrS8WlA References 1 Acupuncture: NIH Consensus Statement, 15 (1997), pp. 1-34 Google Scholar 2 A. Lee, M.L. Done The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting: a meta-analysis Anesth Analg, 88 (1999), pp. 1362-1369 CrossRefView Record in ScopusGoogle Scholar 3 L.M. Rusy, G.M. Hoffman, S.J. Weisman Electroacupuncture prophylaxis of postoperative nausea and vomiting following pediatric tonsillectomy with or without adenoidectomy Anesthesiology, 96 (2002), pp. 300-305 CrossRefView Record in ScopusGoogle Scholar 4 Z. Shenkman, R.S. Holzman, C. Kim Acupressure-acupuncture antiemetic prophylaxis in children undergoing tonsillectomy Anesthesiology, 90 (1999), pp. 1311-1316 CrossRefView Record in ScopusGoogle Scholar 5 A. Lee, M.L. Done Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting Cochrane Database Syst Rev, 3 (2004) CD003281 Google Scholar 6 A. Lee, L.T. Fan Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting Cochrane Database Syst Rev, 1 (2009) CD003281 Google Scholar 7 P. Holmer Pettersson, Y. Wengstrom Acupuncture prior to surgery to minimise postoperative nausea and vomiting: a systematic review J Clin Nurs, 21 (13-14) (2012), pp. 1799-1805 CrossRefView Record in ScopusGoogle Scholar 8 J.W. Dundee, J. Yang Prolongation of the anti-emetic action of P6 acupuncture by acupressure in patients having cancer chemotherapy J R Soc Med, 83 (1990), pp. 360-362 View Record in ScopusGoogle Scholar 9 J.M. Ezzo, A.M. Richardson, A. Vickers, et al. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting Cochrane Database Syst Rev (2) (2006) CD002285 Google Scholar 10 D. Jewell, G. Young Interventions for nausea and vomiting in early pregnancy Cochrane Database Syst Rev (4) (2003) CD000145 Google Scholar 11 A. Matthews, T. Dowswell, D.M. Haas, et al. Interventions for nausea and vomiting in early pregnancy Cochrane Database Syst Rev (8) (2010) CD007575 Google Scholar 12 S. Hu, R. Stritzel, A. Chandler P6 acupressure reduces symptoms of vector-induced motion sickness Aviat Space Environ Med, 66 (1995), pp. 631-634 View Record in ScopusGoogle Scholar 13 K.E. Miller, E.R. Muth Efficacy of acupressure and acustimulation bands for the prevention of motion sickness Aviat Space Environ Med, 75 (2004), pp. 227-234 View Record in ScopusGoogle Scholar Copyright © 2018 Elsevier Inc. All rights reserved.