Managing Pain in Occupational Therapy with Acupressure Guy L. McCormack, PhD, OTR/L,FAOTA Session #43 OTAC Spring Symposium 2018 Learning Objectives: To define the application of acupressure within the scope of the Occupational Therapy Framework. To describe the use of acupressure in cultural context and as a non invasive adjunctive strategy. To provide a systematic review of the evidence and the benefits of selected acupressure points for specific pain syndromes. 1
AOTA Position Paper 2016 The American Occupational Therapy Association has published the official document that supports Complementary Health Approaches and Integrative Health (CHAIH) as a component of practice. Evidence based CHAIH may be used as preparatory methods when supporting active engagement and participation. Domain of Occupational Therapy Occupations ADLs Instrumental ADLs Rest and Sleep Client Factors Values, beliefs, Spirituality Body functions Body structures Performance Skills Motor Skills Performance Patterns Habits Process Skills Routines Social Interaction Skills Rituals Roles 2
What is Acupressure? A Technique of Applying Finger Pressure to Specific Localized Points on the Skin The Degree of Pressure is Varies. Deep Pressure for Acute Pain in young adult (5 7 lbs.) Light Pressure for Frail Elderly (2 4 lbs.) ACUPRESSURE IS: 3
How it works The physiologic mechanism for acupressure is not well understood but appears to involve the release of endorphins, changes in circulating or local bioactive substances such as neurotransmitters, neuromodulators and cytokines. Systematic Reviews Lee EJ, et al.(2011).the efficacy of acupressure for symptom management: A systematic review. J Pain Symptom Manage;42:589 603. Tan, JY, Suen, LK, Wang,T (2015). Sham Acupressure Controls Used in Randomized Controlled Trials: A Systematic Review. PLoS One;10(7):e0132989. Robinson N, et al.(2011).the evidence for Shiatsu; a systematic review of shiatsu and acupressure. BMC Complementary Alternative Medicine;11:88. Selfridge, N. (2012). Acupressure: The evidence presses on. Media/articles/78333http://www.ahcmedia.com/articles/78333 acupressure the evidence presses on. retrieved 12/6/2015 4
The Evidence of a Mechanism Databases of MEDLINE, PubMed, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) was performed using the search terms of "acupressure" and "pain." There is considerable evidence to supports the claim that opioid peptides are released during acupressure. Stimulation by acupressure may also activate neurons in the hypothalamus and the pituitary gland, resulting in systemic effects. Release of neurotransmitters and neurohormones produce changes in blood flow, both centrally and peripherally, and possible mediators for pain relief. There is also evidence of alterations in immune functions produced by acupressure. clear. Manual Therapy Spinal Manipulation Massage Self Applied Mobilization 5
Acupressure is a Form of Manual Therapy Manual therapy (sometimes called bodywork) is a general term for treatment performed mostly with the hands. The goals of manual therapy include promoting relaxation, decreasing pain, and increasing flexibility. Common types of manual therapy include: 1. Massage. Pressure is applied to the soft tissues of the body, such as the muscles. Massage can help relax muscles, increase circulation, and ease pain in the soft tissues. 2. Mobilization. Slow, measured movements are used to twist, pull, or push bones and joints into position. This can help loosen tight tissues around a joint and help with flexibility and alignment. 3. Manipulation. Pressure is applied to a joint. It can be done with the hands or a special device. The careful, controlled force used on the joint can range from gentle to strong and from slow to rapid. www.webmd.com/.../physical therapy types of physical therapy Acupoints on the Head and Face 6
Context Acupressure is a safe and non invasive manual intervention that has its roots in Traditional Chinese Medicine. It is based on the same meridian therapy used in acupuncture, but instead of using needles, acupoints are stimulated by using finger pressure or devices. Acupressure is based on the belief that symptoms result from alterations of the natural flow of energy called Chi which moves in a predictable network of pathways.. Acupoints are used for a variety of pain syndromes Acupoints are Portals 7
Meridians are a network of channels through which energy called Chi is believed to flow throughout the course of the day in a 24 hour cycle throughout the body. Building Evidence Over the last decade better research methodology and systematic reviews have provided evidence of efficacy for the use of acupressure for alleviating certain symptoms in a variety of patient populations. 8
Role of OT The expanding role of occupational therapy in primary care, acute rehabilitation and long term care will present new opportunities to manage painful symptoms that disrupt participation in occupations of daily living. Systematic Reviews The following references provide further evidence to show that acupressure has an effect on the release of neurotransmitters, such as endorphins, encephalin, dopamine, and serotonin during acupuncture, has analgesic effects that cause sedation and may improve sleep quality: 1. Chen YW, Wang HH (2014). The effectiveness of acupressure on relieving pain: a systematic review. Pain Management Nursing.;15(2):539 50. doi: 10.1016/j.pmn.2012.12.005. Epub 2013 Feb 15. 2. Han, J.S. (2004). Acupuncture and endorphins; Neuroscience Letters, 361 (1 3) (2004), pp. 258 261 3. Cabyoglu, M.T., Ergene,N & Tan, U.(2006).The mechanism of acupuncture and clinical applications. International Journal of Neuroscience, 116 (2) (2006), pp. 115 1254. 4. Lin, L.G. and Chen, W.L. (2008). Acupuncture analgesia: a review of its mechanisms of actions; The American Journal of Chinese Medicine, 36 (4) pp. 635 645 5. Yang, M.H. and Lin, L.C. (2007). Acupressure in the care of the elderly (Chinese);The Journal of Nursing, 54 (4), 10 15 9
Internet Citations Acupuncture 1. PubMed 23,337 2. Clinical Trails 670 3. CINAHL 12,048 Acupressure 1. PubMed 1091 2. Clinical Trails 94 3. CINAHL 1,012 Acupoints andfascia Acupoints are located where neurovascular bundles penetrate the Fascia. Where nerves bifurcate, Acupoints have less electrical resistance Acupoints are found in ligaments and other connective tissue structures. 10
Ashi or Trigger Points? The presence of Ashi points, which are nonspecific pressure points that elicit pain upon palpation and can be used along with the other acupoints to treat local pain. Acupoints have a lower threshold for pain. Wang,ZZ & Zhang, J (2013). Comparison of pain thresholds of acupoints on the leg in healthy volunteers.pmid:23650804 [PubMed indexed for MEDLINE];38(1): 68 72. Stux G, Berman B, Pomeranz B. (2003). Basics of Acupuncture. New York: Springer. The Location of Acupoints Dorsher (2009) found 89% of meridians course through myofascial layer of the body. Dorsher (1990) has made a convincing argument that the meridians may consist of a network of fascia that naturally follows the pattern described as meridians. Dorsher, PT (2009). Myofascial Meridians as Anatomical Evidence of Acupuncture Channels. Medical Acupuncture 21(2)1 7. 11
Comparison to Drugs Painful conditions are often treated with, antiinflammatory drugs or with steroid injections. Opioid drugs are used to treat more severe neuropathic pain. Many prescribed medical interventions have harmful side effects. The evidence supporting drugs for interventions is no better than that for acupuncture or acupressure. 12
Acupressure Acupressure has been shown to be effective for relieving a variety of pains in different populations. Chen YW, Wang HH (2014). The effectiveness of acupressure on relieving pain: a systematic review. Pain Manag Nurs. 2014 Jun;15(2):539 50. doi: 10.1016/j.pmn.2012.12.005. Epub 2013 Feb 15 Most Common Symptoms Treated By Acupressure Pain Low Back Pain Dysmenorrhea Menstrual Pain Labor Pain Fracture pain Dyspnea Nausea and Vomiting Pregnancy Side Effects of Chemotherapy & Radiation Abdominal Surgery Insomnia Fatigue Sleep Disorders 13
Specific Acupoints The following are acupoints that have the most research evidence to support their use in clinical practice. The Large Intestine Meridian 14
Large Intestine 4 (Ho Ku) LI 4 is on the abductor pollicis muscle. Large Intestine 4 (Ho Ku point) has been used for labor pain and pain in the head and neck region Chen, A. Liu,F & Nielsen, L (2006). Mode and site modulation of the human brain. Neuoimage; 29(40 p.1080 1091 15
Pericardium Meridian Pericardium 6 (P6), has been used extensively to relieve nausea, upset stomachs, motion sickness, and Pain associated with carpal tunnel syndrome. 16
Sea Bands P6 One study found that acupressure wrist bands,, reduced radiation-induced nausea. Patients receiving the bands had a significantly greater reduction in average nausea compared to those who did not, equating to a 23.8% decrease in nausea in the combined band groups compared to a 4.8% decrease in the control group. Joseph A. Roscoe, Peter Bushunow, Pascal Jean-Pierre, Charles E. Heckler, Jason Q. Purnell, Luke J. Peppone, Yuhchyau Chen, Marilyn N. Ling, Gary R. Morrow (2010). Acupressure Bands are Effective in Reducing Radiation Therapy-Related Nausea J Pain Symptom Manage.; 38(3): 381 389. doi: 10.1016/j.jpainsymman.2008.09.006 Lung 1, used to relieve discomfort of asthmatic symptoms such as difficulty breathing, chest congestion, chest tightness, and wheezing. Lung Meridian 17
Located on the radial side of the wrist crease. Lung 9 This acupoint is called the Valium Point due to it s tranquilizing effects. Heart Meridian HT7 is located on the ulnar side of the wrist crease. HT7 has been studied for insomnia. 18
Acupoint Heart 7 HT7 point may be an effective complementary therapy for residents with insomnia in long term care facilities. Acupressure offers a safe, and nonpharmacologic method to relieve insomnia severity. Sarris, J. & Byrne, GJ(2011). A systematic review of insomnia and complementary medicine. Sleep Medical Reviews;15: 99 106. Urinary Bladder Meridian UB26 Located lateral to spinous process Level with iliac crest Used as a Homeostatic acupoint Relieves Low Back Pain Relieves Urinary Incontinence 19
Bladder 26 Low Back Pain UB 26 Level with iliac crests Located on the Posterior Cutaneous Nerve Labor and Delivery Pain Thumb pressure about ½" to either side of the spine, in the low back. Press firmly, making small, slow, circular motions. Slowly move up the back to the neck. 20
Spleen Meridian S6 Spleen 6 Location about four fingers above the medial malleolus. Huang ST, Chen GY, Lo HM, Lin JG, Lee YS, Kuo CD (2005). Increase in the vagal modulation by acupuncture at Neiguan point in the healthy subjects. Am J Chin Med.;33:157 164. doi: 10.1142/S0192415X0500276X. [PubMed] [Cross Ref] 21
Bi Lateral Pressure SP 6 Used for dysmenorrhea, labor pain and to shorten the duration of labor (Do not use during Pregnancy) Neck Pain Studies show that there is evidence that acupressure for chronic neck pain is more effective than placebo. Trinh K, Graham N, Gross A, et al (2006 ). Acupuncture for neck disorders.; Cochrane Database Systematic Review. Jul 19;3:CD004870. 22
Gall Bladder Acupoints are commonly used for for Neck and Shoulder Pain (GB 20 & GB 21) Gall Bladder 20 & 21 23
Gallbladder 20 Yip, Y.B & Hing Min Tse, S. (2006). An experimental study on the effectiveness of acupressure with aromatic lavender essential oil for sub acute, non specific neck pain in Hong Kong. School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China;12(1)18 26 Gall Bladder 21 Shoulder Well or Motor Point 24
Gallbladder 21 (GB21) is used to neck stiffness, shoulder tension, and headaches. Neck Pain Below C7 Vertebrae 25
Shoulder Neck Release Reduces emotional stress Reduces muscle tension Promotes relaxation Breathe deeply Neck and Shoulder Release 26
ACUPRESSURE PRECAUTIONS for Pregnancy Summary 1. Systematic reviews of the literature shows that acupressure is more effective than control for reducing pain in the neck and low back area (GB 20, B 26). 2. Acupressure was found to effective in managing pain associated with dysmenorrhea (LI 4 & SP6). 3. Acupressure applied to an area near the ankles (SP6) was effective on labor pain and the duration of labor. 4. The use of Sea Bands on the wrist (P6) has been found to be effective for motion sickness, post operative nausea and vomiting even when compared to antiemetic's. 5. Acupressure has been implicated in reducing anxiety, stress & fatigue (SP6, ST 36,LI4). 27
Outcome studies Acupressure improved sleep quality in an institutionalized elderly population. Acupressure was found to be effective for pain related to trauma (radial fracture) Acupressure reduced heart rate significantly in people experiencing strokes. Conclusion At the present time, evidence on acupressure are improving but many are small samples studies and have methodological flaws. Some studies appear to have bias. Acupressure appears to be a safe noninvasive procedure that can control many symptoms. 28
References Akbarzade, M, Ghaemmaghami, M,Yazdanpanahi, Z et al.(2016). Comparison of the Effect of Dry Cupping Therapy and Acupressure at BL23 Point on Intensity of Postpartum Pain Based on the Short Form of the McGill Pain Questionnaire. Journal of Reproductive Infertility; 17(1): 39 46. Mollart L, Skinner V, Foureur M. (2016). A Feasibility Randomized Controlled Trial of Acupressure to Assist Spontaneous Labor for Prim Gravid Women Experiencing a Post date Pregnancy. Midwifery. 2016 May; 36:21 7. doi: 10.1016/j.midw.2016.02.020. Epub 2016 Mar 4. Beikmoradi, A., Najafi,F., Roshanari, G. et. at.(2015). Acupressure and Anxiety in Cancer Patients. Iranian Red Crescent Medical Journal; 17(3):e25919 doi: 10:5812/ircmi.25919. Kafaei Atrian, M, Mirbagher Ajorpaz,N, Sarvieh,M et al.(2016). The Effect of Acupressure at Third Liver Point on Anxiety Level in Patients with Primary Dysmenorrhea. Iran Journal of Nursing Midwifery Research. Mar Apr;21(2):142 6. Doi:10.4103/1735 9066.178233. Liu, CT, Lai, JN, Ko,Yl (2016). Effects of Auricular Acupressure on Improving the Sleep Quality of Puerperae. 63(2):39 48. Doi:10.6224/JN.63.2.39 PMID: 27026556 [Pubmed]. Lee, EJ and Frazier, S (2011). The Efficacy of Acupressure for Symptom Management: A Systematic Review. Journal of Pain Symptom Management, 42(4):589 603. 29