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Letter

LETTER

Acupuncture for cancer-induced

bone pain: a pilot study
INTRODUCTION
Metastatic bone pain in cancer is
often severe, unremitting and poorly
controlled,1 and the drugs used to
control the pain can have unpleasant side effects.2 Patients may survive
months or years after diagnosis3 and
therefore it is important for them
to enjoy as high a quality of life as
possible. Acupuncture represents a
potential adjunctive treatment for
cancer-induced bone pain (CIBP) and
yet a recent Cochrane Review4 and an
earlier systematic review5 found no
studies investigating its use in CIBP.
There is also a lack of information
about the suitability of acupuncture
for these patients. The primary aim
of this pilot study was to investigate
tolerability, safety and patient satisfaction with a single acupuncture
treatment on patients with CIBP in
order to inform the design of a larger
feasibility trial.

given an information sheet. After 2 days

they were telephoned to conrm their
participation. Signed, informed consent was obtained at a study appointment and a baseline assessment was
carried out. Present pain intensity (PPI)
at rest and during the performance of
a self-selected painful movement was
measured using NRS.
Patients were assessed for acupuncture and were positioned so that
comfort, support and safety could be
maintained. One treatment of acupuncture was given using a minimum
of four points and lasting approximately 20 min. Decisions on point
selection were made according to the
site of the painful bony metastases, the
segmental distribution of pain and the
presence of myofascial trigger points.
Ten minutes after needle insertion the
NRS for resting pain was repeated and
scores on the Treatment Satisfaction
Questionnaire (TSQ) adapted from
the Pain Treatment Satisfaction Scale8
were collected. After removal of the
needles the pain and TSQ scores
were repeated. After 48 h, telephone
follow-up was made to record pain
scores on rest and movement.

METHODS

RESULTS

A non-randomised design was

used with a convenience sample of
10 patients with CIBP. Ethics approval
was obtained from Leeds Central
Research Ethics Committee (ref: 08/
H1313/65) and NHS permission was
given to recruit cancer outpatients
within Airedale NHS Foundation
Trust.
Patients were identied by consultants as experiencing signicant pain
from bony metastases with global
average pain intensity of 3 on a
Numerical Rating Scale (NRS). This
level corresponds closely with ndings that patients quantify severe pain
as being 35 mm on a Visual Analogue
Scale.6 Patients were screened to
ensure that they met additional eligibility criteria of having a prognosis
of 3 months or more, no prior experience of acupuncture and an Eastern
Cooperative Oncology Group (ECOG)
status of 1 or 2.7
Eligible patients were approached
during routine clinic visits and were

Only 12 patients were screened over

a period of 16 months. Reasons for

the low screening rate included

patients not meeting the eligibility
criteria, being missed in clinic, not
meeting the pain eligibility criteria
or becoming too ill. Of the patients
screened, six did not enter the study
for reasons including medical complications and hospital admission. Of
the six patients entering the study,
one deteriorated and had to withdraw. Five patients, three males and
two females, completed the study.
The age of patients was 5781 years.
The primary cancer sites were breast
(n=2), prostate (n=3) and colon (n=1).
The sites of bony metastases were
widespread but included the spine,
pelvis and ribs.
All ve patients responded that they
were either very satised or satised to all questions on the TSQ both
during and after treatment, which
included questions on comfort, positioning and treatment duration. No
adverse events were reported.
All patients preferred side-lying or
elevated side-lying. Needle placement
and selection of needle thickness and
length was recorded using STRICTA
guidelines.9 The area immediately
over and adjacent to the spine was
avoided where spinal metastases were
present in case of vertebral instability,
but otherwise points were selected

Figure 1 Global average resting pain scores over the previous week recorded at
screening (baseline) and PPI at rest recorded before, during, immediately after treatment
and at 48 h post-treatment.

Paley CA, Johnson MI Acupunct Med (2011).

doi: 10.1136/aim.2010.003087
Copyright
2011 by British

Medical Journal Publishing Group.

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Letter
according to pain patterns and segmental distribution.
Global average resting pain scores
over the previous week were recorded
at screening (baseline) and PPI at rest
recorded before, during, immediately
after and at 48 h as shown in gure 1.
Mean resting pain intensity immediately before treatment was 4.3 and
this reduced to 0.8 during and posttreatment. When resting pain intensity
was recorded 48 h following treatment the mean intensity was 3.2.
Three patients said they experienced movement-related pain. Pain
intensity scores recorded during their
selected painful movement pre and
post-treatment and at 48 h are shown
below (table 1).
At 48 h follow-up one patient
reported an improvement in sleep
quality and another reported pain
relief for approximately 2 h posttreatment. Three patients requested
a course of acupuncture and were
referred to their general practitioner.

DISCUSSION
All CIBP patients tolerated a single acupuncture treatment with no
adverse effects and indicated that they
were satised with the treatment.
This study was not designed to investigate intervention effect, although it
was observed that patients reported
a reduction in resting and movementrelated pain during and immediately
after acupuncture. The pain results are
consistent with anecdotal evidence
that acupuncture analgesia is shortlived in this patient group and regular
treatments are necessary to maintain
effective pain relief.10 As the sample
was small and patients were willing
volunteers we cannot discount the
possibility of a placebo effect.
Individualised
point
selection
was used because it reects normal
Table 1 Movement-related pain
N=3

PPI pre-acup PPI post-acup

PPI at 48 h
post-acup

Patient 1
Patient 2
Patient 4
Mean

7
9
7
7.7

5
7
7
6.3

2
2
4
2.7

Acup, acupuncture; PPI, present pain intensity.

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clinical practice. Acupuncture dose

was guided by minimum criteria
for intervention adequacy developed by White et al as needling for
at least 20 min using at least four
points.11 Needles were rotated multidirectionally every 5 min during treatment to maintain stimulation. Some
patients verbally reported needle
sensations (de qi), but these were not
formally recorded. So-called strong
points, such as LI4, were not used
because these patients had not experienced acupuncture before and it
was not known whether they would
be strong reactors. Normally, patients
would receive a course of treatment
and evidence indicates that regular
top-ups are more effective in achieving sustained analgesia via low-frequency stimulation of A bres.12 13
Animal studies suggest that CIBP
is a unique pain state, resulting from
hyper-excitable dorsal horn cells
and involving both inammatory
and neuropathic mechanisms.1418
Acupuncture may produce rapid
short-term analgesia via inhibition of
central nociceptive transmission and
reduction in central sensitisation,18 19
or sustained analgesia via upregulation of opioid receptors and release
of inhibitory neuromodulators in the
dorsal horn, which reduces activity
in wide-dynamic range and nociceptive-specic neurons.13 20 Analgesia
may also be maintained by a positive
feedback loop in the meso-limbic system21 22 and a via a placebo response
resulting from treatment expectancy
and patient-therapist interactions.2325
The slow recruitment rate and
resultant small sample size limits generalisation of the ndings. Similar difculties were experienced in a study
investigating the use of transcutaneous electrical nerve stimulation for
CIBP.26 Patients must be well enough
to undergo acupuncture treatment
and psychologically able to cope with
another intervention on top of extensive regimes of oral drug therapy, chemotherapy and radiotherapy. The use
of additional recruitment sites, such as
specialist palliative care services and
improving patient screening, might
increase recruitment rates in future
studies.

CONCLUSIONS
This study indicates that acupuncture
is well tolerated and safe in a small
group of patients suffering from CIBP.
Patients reported decreases in their
pain both at rest and on movement
during and immediately after treatment, although the sample size was
too small to draw any conclusions
from the results and a placebo effect
cannot be discounted.
In future studies, consideration
should be given to improving recruitment rate by increasing the number of
research sites and improving identication of eligible patients.
Carole A Paley,1,2 Mark I Johnson2
1
Research Office, Airedale NHS Foundation Trust, Keighley,
UK
2
Leeds Metropolitan University, Leeds, UK
Correspondence to Ms Carole A Paley, Research
Office, Airedale NHS Foundation Trust, Skipton Road,
Steeton, Keighley BD20 6TD, UK;
biodynamics.physiotherapy@tesco.net

Acknowledgements The authors would like to

acknowledge the contribution of Dr S M Crawford,
Consultant Medical Oncologist, and the Research Team
at Airedale NHS Foundation Trust.
Competing interests None.
Ethics approval This study was conducted with the
approval of the Leeds (Central) REC. Ref: 08/H1313/65.
Provenance and peer review Not commissioned;
externally peer reviewed.
Accepted 12 January 2011

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Acupuncture for cancer-induced bone pain: a

pilot study
Carole A Paley and Mark I Johnson
Acupunct Med published online February 6, 2011

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