Acupressure
Pamela Weiss-Farnan
Touch has been central to the practice of nursing since its inception. This chapter describes a form of touch—and its application in nursing care—known in traditional Chinese medicine (TCM) as acupressure. This method of treatment is common in many cultures. As Dossey, Keegan, and Guzzetta (2000) note, “all cultures have demonstrated that some form of rubbing, pressing, massaging or holding are [sic] natural manifestations of the desire to heal and care for one another” (p. 615). Acupressure is also integral to the practice of shiatsu, tui na, tsubo, and jin si ju jitsyu.
DEFINITIONS
Acupressure is defined by Gach (1990) as “an ancient healing art that uses the fingers to press certain points on the body to stimulate the body’s selfcurative abilities” (p. 3). To assist the reader, the following definitions are also provided:
Acupuncture—“[a] procedure used in or adapted from Chinese medical practice in which specific body areas are pierced with fine needles for therapeutic purposes or to relieve pain or produce regional anesthesia” (FreeDictionary, 2009).
Auricular Acupuncture—“also called ear acupuncture, applies the principles of acupuncture to specific points on the ear” (FirstHealth of Andover, 2009).
Jin Shin Jyutsu—“a nonmassage form of shiatsu—using pressure points to harmonize the flow of energy through the body” (Health Education Alliance for Life and Longevity [HEALL], 2006).
Meridians—“Any of the longitudinal lines or pathways on the body along which the acupuncture points are distributed.” (Answers.com, 2013).
Moxibustion—“[t]he burning of moxa or other substances on the skin, to treat diseases or to produce analgesia” (FreeDictionary, 2009).
Qi (pronounced chee)—“[t]he vital force believed in Taoism and other Chinese thought to be inherent in all things. The unimpeded circulation of Chi (Qi) and a balance of its negative and positive forms in the body are held to be essential to good health in traditional Chinese medicine” (FreeDictionary, 2009).
Shiatsu—“A form of therapeutic massage in which pressure is applied with the thumb and palms to those areas of the body used in acupuncture. Also called acupressure” (FreeDictionary, 2009).
TRADITIONAL CHINESE MEDICINE
TCM is an ancient system of health developed more than 3,000 years ago in Asia. This system is based on the concept that Qi flows throughout the body and that balance of yin and yang forces represents health and well-being. As Kaptchuk (1983) describes it:
This system of care is based on ancient texts and is the result of a continuous process of critical thinking, as well as extensive clinical observation and testing. It represents a thorough formulation and reformulation of material by respected clinicians and theoreticians. It is also, however, rooted in the philosophy, logic and sensibility, and habits of a civilization entirely foreign to our own. It has therefore developed its own perception of the body and health and disease. (p. 2)
The focus of care within this system is to restore balance in the body. To do so, yin and yang must be balanced. Yin aspects are associated with cold, passivity, interiority, and decreases. Yang aspects are associated with warmth, activity, external forces, and increases. Yin and yang are always in relation to each other (Kaptchuk, 1983). According to this conceptualization, they are in continuous flux and there is always yin within yang and yang within yin.
Unschuld (1999) reflects that TCM theory is a mixture of beliefs that pathogenic influences from the outside combine with the lack of balance or harmony within the person and result in illness. TCM is also concerned with the concept of Qi. Qi flows in the body through specific pathways identified as meridians or channels. If the Qi is blocked or diminished, a person experiences pain or illness.
There are 12 bilateral meridians and eight extra meridians. All meridians have an exterior and an interior pathway and are named according to the organ system. Located on the meridians are specific points. In the 12 major meridians, the points are bilateral and in the West are called acupuncture
points. This nomenclature implies that the points are designated for needle insertion and does not fully reflect the TCM concept of the point.
points. This nomenclature implies that the points are designated for needle insertion and does not fully reflect the TCM concept of the point.
Acupuncture points are also used for acupressure. The points do not have a corresponding anatomic structure but are described by their location relative to other anatomical landmarks. This contributes to the skepticism of many Western-trained scientists about their existence. In Chinese, the name of the point usually is descriptive of its function or location. Mistranslation over the years has often limited the substantial amount of the anatomical basis for the nomenclature of points and the apparent knowledge of anatomy of Chinese scholars (Schnorrenberger, 2006).
There are 365 (Kaptchuk, 1983) to 700 (Yang, 2006) major points on the meridians. Dr. Yang, Jwing-Ming stated that 108 points could be stimulated using the fingers. In a traditionally formulated TCM treatment plan, whether the modality is needles or pressure, the points are combined to achieve maximum benefit for the patient. Rarely is only one point used. There are also points that should not be stimulated, especially during pregnancy, which are referred to as “forbidden points.”
SCIENTIFIC BASIS
Western medicine is the dominant system of health care in the United States. It is characterized by hospitals; clinics; pharmaceutical resources; and a workforce of physicians, nurses, specialized therapists, and various support service personnel. There are many differences between Western medicine and TCM that become more evident as nurses seek to add TCM modalities to their practice. Western medicine emphasizes disease, causal agents, and treatments that are designed to control or destroy the cause of disease (Kaptchuk, 1983). Once a causal agent or mechanism is identified, treatment plans are developed that focus on the agent or mechanism as a consistent factor in all human manifestations of the disease. In Western journals, almost all studies using the modality of acupuncture and acupressure emphasize the specific effects of needling one point known to address a specific symptom. Medical researchers are eager to find the mechanism by which acupuncture alleviates the symptoms. Some of the mechanisms have been suggested in Western medical research (National Center for Complementary and Alternative Medicines [NCCAM], 2000; National Institutes of Health [NIH], 1997). The therapeutic effect that seems to be produced by stimulation of the points with needles or with pressure may be due to the following:
Conduction of electromagnetic signals that may start the flow of painkilling biochemicals, such as endorphins, and of immune system cells to specific sites in the body that are injured or vulnerable to disease (Dale, 1997; Takeshige, 1989; Wu, Zhou, & Zhou, 1994).
Activation of opioid systems, which also reduces pain (Han, 1997).
More sophisticated tools have been used recently to further explore the mechanism of acupressure/acupuncture. Recent meta-analyses indicate that changes in brain chemistry and brain imaging occur during stimulation of the points (Huang et al., 2012; Liang, Chen, & Cooper, 2012).
The scientific research into an underlying mechanism demonstrates one of the differences between Western medicine and the TCM system. The focus in TCM is the imbalance in the patient, and the causality is always multifactorial. The function of the points is described in terms of TCM diagnosis. For example, Western medicine research has focused on pericardium 6, or nei guan, for the treatment of nausea. In English its name means “inner border gate.” Lade (1986) describes the point:
The name refers to the point’s role as the gateway or connecting point of the triple burner channel and the yin-linking vessel. Inner refers to the palmar aspect of the forearm and to the point’s location on the yin channel. The actions of this point are: to regulate and tonify the heart, transform heart phlegm, facilitate qi flow, regulate the yin-linking vessel and clear heart fire, redirect rebellious qi downward, expand and relax the chest and benefit the diaphragm. The indications for use of the point are: asthma, bronchitis, pertussis, hiccups, vomiting, diaphragmatic spasms, intercostal neuralgia, chest fullness, and pain and dyspnea. (pp. 196, 197)
Whereas Western medicine focuses on the treatment of nausea for this point, the TCM paradigm suggests multiple uses. In TCM theory, nausea is considered rebellious Qi (Qi that flows in the wrong direction). Nausea and vomiting are examples of this. Nei guan (pericardium 6) is used as one of the points in the treatment of a patient who presents with nausea. In TCM theory, nausea is considered one of the external manifestations of the imbalance; however, in an authentic TCM treatment, a practitioner would evaluate the imbalances that set up the manifestation and treat the underlying condition. Therefore, a combination of points to treat nausea would be used, possibly including other primary points for antiemesis (Hoo, 1997): Stomach 36 on the stomach meridian located on the knee, Ren 12 on the ren/conception meridian located on the upper abdomen, or the Spleen 4 on the spleen meridian located on the foot. Application of multiple acupoints may be more effective for the treatment of nausea; however, in Western medicine, the focus on finding the single active point or the mechanism creates an almost insurmountable challenge to the fullest application of the therapy.
In 1997, the National Institutes of Health held the first consensus conference on acupuncture. The conference concluded that:
Acupuncture is effective in the treatment of adult nausea and vomiting in chemotherapy and probably pregnancy and in postoperative dental pain. The conference members stated there is an indication that acupuncture may be helpful in the treatment of addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. (NIH, 1997)
Research evidence underlying the use of the point called nei guan (pericardium 6) for nausea is reviewed in the text that follows. This NIH statement was the springboard for increasing the number of studies completed for the treatment of nausea and vomiting that include the use of devices to apply pressure or stimulation to pericardium 6. These devices included an elastic bracelet with a pressure button called Sea-Bands® or an electrical stimulation device called a ReliefBand®.
In recent years, the research focusing on the effectiveness of pericardium 6 for the treatment of nausea and vomiting have increased. Exhibit 26.1 demonstrates that current studies continue to find conflicting results about the effectiveness of using pericardium 6 for the treatment of nausea and vomiting from any condition. Meta-analyses published by the Cochrane Collaborative conclude that inclusion of acupressure for multiple symptoms may be useful but more rigorous trials are required. (Griffiths et al., 2012; Lee & Frazier, 2011; Robinson, Lorenc, & Liao, 2011).
Exhibit 26.1. Sample of Studies Using P6 for Nausea
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