Acupoint Application Combined with Acupressure as an Adjunctive Therapy for Chemotherapy-Induced Nausea and Vomiting

Summary

Acupoint application combined with acupressure-assisted treatment has a good effect on chemotherapy-induced nausea and vomiting and is more convenient and cost-effective.

Abstract

Chemotherapy-induced nausea and vomiting (CINV) refers to the nausea and vomiting experienced by patients after the application of chemotherapy drugs, significantly affecting their quality of life and physical recovery, as well as increasing the pain of the patients. Basic medicine primarily focuses on acid suppression, gastric protection, and vomiting suppression, but there are still many patients with nausea and vomiting symptoms that cannot be alleviated. Traditional Chinese medicine (TCM) can effectively alleviate nausea and vomiting through acupoint stimulation and pressure, while also offering advantages such as simplicity, affordability, and fewer side effects. The aim of this article is to introduce the method of using acupoint application combined with acupressure as an adjunctive therapy for CINV, using the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT) tablet scale as a questionnaire. The article details aspects such as acupoint selection, production, and the use of acupoint application, massage techniques, and operating procedures, all with the goal of ensuring the safety and efficacy of acupoint application combined with acupressure as an adjuvant therapy, thereby improving patients' clinical symptoms and quality of life.

Introduction

Chemotherapy, as one of the important methods for treating cancer, treats tumors while also imposing various side effects on patients. Chemotherapy-Induced Nausea and Vomiting (CINV) refers to the symptoms of nausea and vomiting that occur after a patient receives chemotherapy drugs. Nausea is a subjective sensation of uneasiness in the epigastrium or throat, often accompanied by an impending sense of vomiting. Vomiting involves the ejection of stomach contents through the mouth. Both nausea and vomiting can happen simultaneously or independently, with nausea being more frequently experienced than vomiting among chemotherapy patients¹. Affecting patients' ability to eat, reducing their quality of life, and making it even more challenging for cancer patients to adhere to treatments, CINV has become one of the most feared side effects among those undergoing chemotherapy. Modern medicine often employs acid-suppressing, gastric protection, and antiemetic medications, such as ranitidine, metoclopramide, and ondansetron, to alleviate discomfort. Despite these drugs, over 30% of cancer patients undergoing chemotherapy still experience CINV, and nausea symptoms are as high as 60%-70%². Hence, the pressing issue at hand is to effectively alleviate CINV and enhance supportive cancer treatments.

Acupoint application combined with acupressure is a traditional Chinese medical operation. In TCM theory, acupoints are locations on the body's surface where qi and blood converge. Stimulating these points influences the flow of qi and blood, thus achieving the purpose of treatment. In traditional Chinese medicine, Cun is the unit of length for measuring human body parts. The measurement methods of cun often include the standard body Cun and Body Cun. In this operation, different acupoints adopt different measurement methods. According to the preferred Body Cun method, the width of the thumb joint of the patient is 1 cun. The total width of the index, middle, ring, and little fingers, stretched side by side, is 3 cun; the middle section of the middle finger is taken as the standard. The standard body cun of an average male is ~2.31 cm. Acupoint application refers to grinding herbs like ginger, clove, sandalwood, persimmon kernel, and mugwort into a paste, which is then applied to specific acupoints such as Shenque (CV8, located in the upper abdomen, at the center of the navel); ZuSanLi (ST36, found on the inner side of the lower leg, 3 cun below DuBi (ST35), along the line connecting DuBi (ST35) and Jiaxi (ST41)); Neiguan (PC6, situated on the anterior aspect of the forearm, 2 cun above the wrist crease, between the tendons of the palmaris longus and the radial flexor of the wrist); Weishu (BL21, on the back, 1.5 cun lateral to the midline, directly below the 12th thoracic vertebra); and Geshu (BL17, on the back, 1.5 cun lateral to the midline, directly below the 7th thoracic vertebra). By being absorbed through the skin on specific areas of the body, acupoint application aims to enhance the circulation of qi and blood, thereby alleviating the symptoms of CINV.

Research indicates that ginger contains bioactive compounds that bind to 5-HT3 receptors, relieving nausea and vomiting³. Regarding anticipatory CINV, the application of acupressure, where consistent rhythmic pressure is applied to specific points on the body, can also alleviate symptoms of nausea and vomiting⁴. According to the expert consensus released by the Chinese Society of Anesthesiology, which integrates traditional Chinese and Western medicine, the primary acupoints for treating postoperative nausea and vomiting are Zusanli and Neiguan⁵. Gently massage the abdomen in a clockwise direction with the palm, synchronizing with the breath, to alleviate the effect of stomach qi upflushing and stop nausea. Research indicates that acupressure also helps divert attention and relieve patients' anxious feelings, demonstrating excellent intervention for nausea⁶. Furthermore, for patients who have undergone multiple chemotherapy sessions, environmental triggers present during previous episodes of CINV, such as visual, auditory, or olfactory cues, can become associated with nausea and vomiting in their minds. Subsequent exposure to the same stimulus environment elicits a conditioned reflex of nausea and vomiting. The operation of acupoint application and acupressure, before chemotherapy, can serve as psychological comfort, reducing or even preventing this conditioned response.

A demonstration of acupoint application combined with acupressure for treating nausea and vomiting in a patient receiving chemotherapy is presented in this article. To evaluate the effectiveness and safety of this method, the study used clinical randomized controlled trial data. Efficacy was based on the Multinational Association of Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT) scale⁷ form completed after the patient's treatment..

Protocol

Trial data were collected from a randomized controlled experiment conducted on chemotherapy patients in the Oncology Department of Chengdu First People's Hospital. This trial follows the Helsinki Declaration and was approved by the Oncology Department of Chengdu First People's Hospital, with proper documentation within the department. Patients received relevant trial information and signed informed consent was collected prior to trial commencement.

1. Patient selection

1. Set the inclusion criteria to be confirmed malignant tumor diagnosis, no contraindications to chemotherapy and willingness to undergo it, the absence of nausea and vomiting symptoms 48 h prior to chemotherapy, and an expected survival period of more than 3 months.
2. Set the exclusion criteria to be severe coexisting conditions (such as hypertension, diabetes, or coronary heart disease); nausea and vomiting due to neurological disorders, gastrointestinal diseases, or increased intracranial pressure; significant liver or kidney function issues; and participation in other clinical trials.
3. Terminate the study for a patient if that patient is unwilling to continue with the study, has allergic reactions to the drugs during the trial, and whose condition worsens and prevents further participation.
4. Once selected, assign the patients to a control group (six patients in this study) receiving standard treatment (here, ondansentron and dexamethasone intravenously)⁸ before chemotherapy and the treatment group (six patients here) to be given acupoint application 1 day before the chemotherapy and acupressure performed before and 30 min after chemotherapy.

2. Preparation for the operation

1. Material preparation
   1. Place 100 g of Chinese herbs (20 g of fresh rhizome of ginger, 20 g of cloves [dried flower buds], 20 g of nutmeg [dried ripe fruit], 20 g of Kaki calyx [dried calyx of Diospyros kaki Thunb], and 20 g of Aucklandia lappa Decne[dried roots]) in the grinder machine to grind them in advance and seal the paste in a medical bent plate for later use.
   2. Take 50 g of the Chinese herbal powder and use 50 mL of saline and 50 g of medical Vaseline to make a paste of the Chinese herbal powder.
   3. Take a thumb-sized amount of the Chinese herbal paste from the medical bent plate, make it into a shape similar to a ball (diameter of about 1 cm), and apply it to the breathable adhesive application.
   4. Finally, place the prepared acupoint applications in a medical bowl for later use.
      NOTE: Approximately five patches will suffice.
2. Operator and patient preparation
   1. Confirm that the operating environment is safe and the items are complete.
   2. Instruct the patient to empty the bladder in advance.
      NOTE: Do not operate on an empty or full stomach.
   3. Confirm the patient's information, respect their privacy, and evaluate the local skin of the patient's acupoint to ensure that the skin around the selected points is free of lesions or damage.
   4. Inform the patient or their family about the purpose of the treatment, its contents, and possible adverse reactions.
   5. Assist the patient in lying down comfortably on the treatment bed in a supine position.

3. Operation steps

1. Instruct the patient to sit down and locate the intersection of 3 cun below the concave point of the patient's lateral knee joint and 1 cun from the anterior edge of the tibia; mark this position of the intersection as Zusanli (ZuSanLi ST36, Figure 1).
2. Instruct the patient to lie in a horizontal position, with both legs straight and flat. Mark the patient's center of the navel as Shenque (ShenQue CV8, Figure 2).
3. Instruct the patient to sit, stretch the arm, and hold the fist, slightly bending the wrist. Record 2 cun (~4.6 cm) from the midpoint of the wrist stripes as Neiguan in the forearm area (Neiguan PC6, Figure 3).
   NOTE: Neiguan (PC6) is situated on the anterior aspect of the forearm, 2 cun above the wrist stripes, between the tendons of the palmaris longus and the radial flexor of the wrist.
4. Disinfect both hands, place the thumb thread surface at the patient's Neiguan (PC6), and expand the remaining four fingers in a relative position to balance the force.
5. Bend the wrist joint 40-60°, use the thumb pulp to actively exert force, and press the acupoint by continuously extending and flexing the first finger joint of the thumb.
   NOTE: The frequency is 80-120 times/min, 5-6 min each time until the patient has a sense of soreness.
6. Grasp the fist, using the back of the first knuckle of the index finger as the force point. Press and knead the Zusanli (ST36) acupoint. Press and knead 20x clockwise, and then, press and knead 20x counterclockwise.
   NOTE: The frequency is 50-60 times/min, each lasting 3-5 min until the patient has a sense of acid bloating.
7. Wear the medical rubber glove, soak the cotton swabs in 75% ethyl alcohol, and rub the bilateral Zusanli (ST36) and Shenque (CV8) acupoints with the cotton.
8. Fix the breathable adhesive acupoint applications containing the Chinese herbal paste on the patient's Shenque (ST36) point and bilateral Zusanli (CV8), clean up the excess paste around the acupoint, and assist the patient in dressing. Put the applications on once a day and leave them for 6-8 h. To avoid falling off of the applications, instruct the patient not to do intense exercise. If the patient's skin appears red or the patient experiences blisters or itching, consider drug allergy, remove the acupoint application in time, and clean the skin with normal saline to keep it dry.
9. After the completion of the operation, pick up the remaining items, sort the medical waste, and assist the patient in restoring the position.

4. Assessment of efficacy utilizing the MAT tool

NOTE: The assessment of efficacy utilized the Brief Assessment Scale for Chemotherapy-Induced Nausea and Vomiting (CINV) developed by the Multinational Association for Supportive Care in Cancer (MASCC). This scale (Supplemental File 1) consists of eight items, with the first four items addressing acute nausea and vomiting and the last four items focusing on delayed nausea and vomiting. Items 4 and 8 use a quantitative form of 0 to 10 to assess the subjective symptoms of nausea.

1. Fill the upper part of the MAT scale (items 1-4) within 24 h after chemotherapy and the lower part after 24 h after chemotherapy, and grade the degree of nausea and vomiting according to the scores and WTO evaluation indicators.
   1. Define grade 0 as no nausea (a score of 0-1) or vomiting; grade I as mild nausea (a score of 2-4) without vomiting; grade II as mild nausea and vomiting (<2x over 24 h); grade III as moderate nausea (a score of 5-7) and vomiting (<3-5x over 24 h); grade IV as severe nausea (a score of 8-10) and vomiting (>5x over 24 h).
2. Collect data from the MAT scale scores of the treatment and control groups. Consider grades 0-I as complete remission (markedly effective treatment), grade II as partial remission (effective), and grades III-IV as no remission (ineffective). Use analysis software of choice and chi-square test for treatment effectiveness and independent sample t-test for the nausea scores.

Results

A clinical trial was conducted involving 12 patients receiving chemotherapy at the First People's Hospital of Chengdu for oncology treatments between January and February 2024. A total of 12 patients receiving chemotherapy were included in this study, of which 8 were male, accounting for 66.6%, and 4 were female, accounting for 33.3%. Of the 12 patients receiving chemotherapy, six were in the control group and six in the treatment group. The statistical analysis of weight and height between the treatment group and th...

Discussion

Numerous cancer patients, such as those with breast cancer, lung cancer, prostate cancer, or hematological malignancies, commonly endure nausea and vomiting during chemotherapy. This unpleasant experience can lead to decreased appetite, inadequate nutrition intake, and poor physical condition, negatively impacting the overall treatment outcome. It also reduces patient adherence to therapy and fosters fear towards chemotherapy⁹. In over three decades of research, it has been found that the 5-HT3 re...

Materials

Name	Company	Catalog Number	Comments
Acupoint application for external use breathable adhesive application	Holy Royal Hall	Lu 's standard 20152090318	Encapsulate traditional Chinese medicine paste and fix it on specific human skin.
Chinese herbal medicine superfine grinding machine	Yongkang Sufeng Industry & Trade Co., Ltd.	YB-2500A	Grinding Chinese medicine into powder
disinfection alcohol	Zhejiang Prokonyu Pharmaceutical Co., Ltd.	CYHB2101229GB	Povidone iodine aqueous solution has no disadvantages of iodine tincture, light coloring, easy elution, small stimulation to mucosa, no need for ethanol deiodination, no corrosion effect, and low toxicity.
Medical Vaseline	Dezhou Yile Disinfection Technology Co., Ltd.	Lu Weixiao Certificate ( 2020 ) No. 1363	This product is suitable for the preparation of ointment matrix, used as lubricant, waterproof agent, can also be used for precision instrument maintenance
medical rubber glove	Jiangsu Huicheng Medical Technology Co., Ltd.	National Machinery No.20160956	Disposable latex gloves
medical absorbent cotton	Hebei Kangji Pharmaceutical Co., Ltd.	Ji mechanical injection20192140019	medical absorbent cotton
medical bowl	Chaozhou Caitang Town Yuekang Hardware Medical Treatment	201/304	Store acupoint application
Medical bending plate	Shenzhen Defu Medical Device Co., Ltd.	DF-238	Put cotton swabs, stickers, gloves and other items.
rinse-free hand sanitizer	Anhui Qicheng Biotechnology Co., Ltd.	Wanwei Xiaozhengzi 2019 No. A0009	For operator hand disinfection
SPSS statistics	IBM	IBM spss statistics 25	IBM SPSS Statistics supports a top-down, hypothesis testing approach to your data
Saline 100 mL	Shandong Qidu Pharmaceutical Co., Ltd.	Luzi Pharmaceutical Supervision Machinery Production Preparation No.20230003	0.9 % physiological saline-sterile for the preparation of traditional Chinese medicine powder
traditional chinese medicinal herbs 20 g of ginger 20 g of clove 20 g of nutmeg 20 g of Kaki calyx 20 g of Aucklandia lappa	Hongya County Wawushan Pharmaceutical Co., Ltd.	23020	Acupoint application of traditional Chinese medicine powder