Curt B. Haase, BSN, RN, OCN® - IUPUI

Reeducation of Acupressure for
Chemotherapy-Induced Nausea & Vomiting
Curt B. Haase, BSN, RN, OCN®
Memorial Sloan-Kettering Cancer Center
New York, NY, USA

• Objectives & Research Question
• Chemotherapy-Induced Nausea & Vomiting
• Acupressure
• Initial Education of Nursing Team
• Intervention: Assessment of Acupressure Use
• Next Steps: Reeducation

• Discuss the safe, well-tolerated, low-cost,
effective nature of acupressure for
chemotherapy-induced nausea & vomiting.
• State the importance of reeducation of staff
to ensure appropriate, evidence-based
interventions for patients.

• Among nurses who treat patients receiving
chemotherapy, how often is Acupressure for
Chemotherapy-Induced Nausea and
Vomiting used? What are the barriers to
implementation?

• Nausea and Vomiting are some of the most
upsetting side effects
• Experienced by 70-80% of chemotherapy
patients over the course of treatment
(Chao et al., 2009; Lee, Dibble, Dodd, Abrams, & Burns, 2010; Taspinar & Sirin, 2010)

• Typical management is with pharmacologic
antiemetics
• Not completely effective
• Undesirable side effects
• Main reasons to not follow chemotherapy treatment
schedule
• Financial cost
(Chao et al., 2009; Lee, Dibble, Dodd, Abrams, & Burns, 2010; Taspinar & Sirin, 2010)

(Figueroa-Moseley et al., 2007)

Acupressure
•Based on
Acupuncture &
Meridians
•Traditional Chinese
Medicine
•More than 5,000
years old
Image Used with Permission.

Acupressure
•Stimulation of an
acupoint with a finger
•Acupoints can help
release tension,
promote blood
circulation, and relieve
side effects
Image Used with Permission.

• Mechanism of Action
• Unclear
• Thought to release beta-endorphins to the cerebrospinal
fluid and change serotonin transmission
• Preventing the activation of the 5-HT 3 chemoreceptors
in the GI tract and in the medullary vomiting center
(Nunley, Wakim, & Guinn, 2008)

• Safe
• Low-cost
• Convenient
• Easy-to-learn
• Effectively prevents CINV across populations, ages,
and cancer diagnoses
• Minimal to no side effects!!
(Figuertoa-Moseley et al., 2007; Gardani et al., 2007; Jones et al., 2008; Roscoe et al., 2009; Roscoe et al., 2010; Taspinar & Sirin, 2010)

• Acute nausea
• Delayed nausea
• Anticipatory nausea
(Ezzo et al., 2006; Gardani et al., 2007; Taspinar & Sirin, 2010)

• Acute nausea: nausea within 24 hours of treatment
• Reduction of nausea severity and mean nausea scores
• Lowest efficacy seen when used during anthracyclinecontaining
regimen
• Increased efficacy with other chemotherapies
(Ezzo et al., 2006; Gardani et al., 2007; Taspinar & Sirin, 2010)

• Delayed nausea: nausea after the first 24 hours of
treatment
• Difficult to manage, especially day 3 post-treatment
• Even with acupressure, there is a peak level of nausea
at day 3
• Can delay addition of neurokinin-1 receptor
antagonists (aprepitant)
(Gardani et al., 2007; Lee et al., 2008; Lee et al., 2010; Taspinar & Sirin, 2010)

• Anticipatory nausea: the expectation of a unpleasant
experience
• Difficult to treat because patient anxiety is increased
• Best to prevent nausea from the beginning
• Acupressure with standard treatment yields
significantly less anticipatory nausea, but only for the
first 2 cycles
• Expectation plays an important role
(Figueroa-Moseley et al., 2007; Roscoe et al., 2010)

Pericardium 6 (P6, PC6)
Stomach 36 (ST36)

Pericardium 6 (P6, PC6)
Nèi guān
“Inner Gate”
內 關
• Easily accessible!

Locating
P6
3 finger-widths
below the
hand crease,
between the
flexor tendons.

Locating
P6
Apply firm
pressure in a
circular
motion.
Should not be
discomforting.

P6 Patient
Education
3 finger-widths
below the
hand crease,
between the
flexor tendons.

P6 Return
Demonstration
Apply firm
pressure in a
circular
motion.
Should not be
discomforting.

P6 Return
Demonstration

• Before meals and at bedtime for 2-3 minutes, and as
needed
• Every 2 hours for 3-5 days after treatment
• Continuous for 3-5 days, with
wristbands
(Gardani et al., 2007; Lee et al., 2008; Lee et al., 2010; Taspinar & Sirin, 2010)

• December 2009
• Gastrointestinal Chemotherapy Suite
• 16 Chemotherapy Nurses
• In-service by Integrative Medicine Staff
• Patient Information Fact Card Development and Use

• One Year Later… “How Are We Doing?”
• Intervention: Survey to Gastrointestinal
Chemotherapy Suite Nurses in December 2010

• Acupressure education.
• Number of patients in the month prior that they spoke
with about acupressure.
• Reasons that prevented the nurse from offering.
• Perceived barriers from patients.
• Other interventions offered.
• Suggestions to help to promote acupressure to patients.

• 19 Nurses completed survey.
• 58% of those were not acupressure educated.
• Only 38% of acupressure-educated nurses
surveyed offer acupressure to patients.

Forgot
No Time/
Busy Day
Did Not
Understand It
My Patients
Aren’t
Interested
Not
Comfortable
Explaining
“I Don’t
Think It
Works”

Did Not
Understand
Did Not
Know
About It
No Perceived
Need/Benefit
No Time
Not
Interested
Unpleasant
Past
Experience

• Identified by Chemotherapy Nurses
• “It helps when patients are open to it.”
• Time was needed to explain and perform
procedure well.
• Fact Cards need to be displayed on the unit.

• Reinforce the original in-services.
• Some nurses missed the in-services.
• New nurses have joined the team.
• 88% of nurses not previously educated are
interested in learning.

• Give nurses better understanding and increased
comfort level
• Reeducation of all chemotherapy nurses is
needed to overcome barriers

• Can reduce pharmacologic antiemetic use
• Delay addition of 5-HT3 antagonist (ondansetron)
and/or NK-1 receptor antagonist (aprepitant)
• Reduce cost and side effects
• More convenient
(Chao et al., 2009)

• Stress the safety, efficacy, and simplicity
• Relieves anxiety
• Every patient, every chemo visit
• At treatment and at home
(Chao et al., 2009)

Chao, L.-F., Zhang, A. L., Liu, H.-E., Cheng, M.-H., Lam, H.-B., & Lo, S. K.
(2009). The efficacy of acupoint stimulation for the management of therapyrelated
adverse events in patients with breast cancer: A systematic review.
Breast Cancer Res Treat, 118, 255-267. doi:10.1007/s10549-009-0533-8
Ezzo, J., Richardson, M. A., Vickers, A., Allen, C., Dibble, S., Issell, B. F., …
Zhang, G. Acupuncture-point stimulation for chemotherapy-induced nausea
or vomiting. Cochrane Database of Systematic Reviews 2006, Issue 2. Art No.
:CD002285. doi:10.1002/14651858.CD002285.pub2.
Figueroa-Moseley, C., Jean-Pierre, P., Roscoe, J. A., Ryan, J. L., Kohli, S., Palesh,
O. G., et al. (2007). Behavioral interventions in treating anticipatory nausea
and vomiting. J Nat Compr Cancer Network , 5(1), 44-50.
Gardani, G., Cerrone, R., Biella, C., Galbiati, G., Proserpio, E., Casiraghi, M., et
al. (2007). A progress study of 100 cancer patients treated by acupressure for
chemotherapy-induced vomiting after failure with the pharmacological
approach. Minerva Medica , 98(6), 665-8.

Jones, E., Isom, S., Kemper, K. J., & McLean, T. W. (2008). Acupressure for
chemotherapy-associated nausea and vomiting in children. J Soc Integr
Oncol, 6(4), 141-145. doi:10.2310/7200.2008.0023
Lee, J., Dibble, S., Dodd, M., Abrams, D., & Burns, B. (2010). The relationship of
chemotherapy-induced nausea to the frequency of pericardium 6 digital
acupressure. Oncol Nur Forum, 37(6), E419-E425. doi:10.1188/10.ONF.E419-
E425
Lee, J., Dodd, M., Dibble, S., & Abrams, D. (2008). Review of acupressure studies
for chemotherapy-induced nausea and vomiting control. J Pain Symptom
Manage , 36(5), 529-544. doi:10.1016/j.jpainsymman.2007.10.019
Nunley, C., Wakim, J., & Guinn, C. (2008). The effects of stimulation of
acupressure point P6 on postoperative nausea and vomiting: A review of
literature. J Peri Anesth Nurs , 23(4), 247-261. doi:10.1016/j.jopan.2008.05.001

Roscoe, J. A., Bushunow, P., Jean-Pierre, P., Heckler, C. E., Purnell, J. Q.,
Peppone, L. J., … Morrow, G. R. (2009). 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
Roscoe, J. A., O'Neill, M., Jean-Pierre, P., Heckler, C. E., Kaptchuk, T. J.,
Bushunow, P., … Smith, B. (2010). An exploratory study on the effects of an
expectancy manipulation on chemotherapy-related nausea. J Pain Symptom
Manage , 40(3), 379-390. doi:10.1016/j.jpainsymman.2009.12.024
Taspinar, A. & Sirin, A. (2010). Effect of acupressure on chemotherapy-induced
nausea and vomiting on gynecological cancer patients in Turkey. Eur J Oncol
Nurs , 14, 49-54. doi:10.1016/j.ejon.2009.07.006

Cathy Cruz
Lourdes Diaz
Donna Fade
Jeanine Gordon
Purnima Persaud
Suzanne Stamile
Rori Salvaggio
GI Chemotherapy Suite Staff
Denise Stone
Yi Chan
Bendheim Integrative Medicine Center Staff
Jon Themann

Reeducation of Acupressure for
Chemotherapy-Induced Nausea & Vomiting
Curt B. Haase, BSN, RN, OCN®
haasec @ mskcc.org