2004 Lippincott Williams & Wilkins, Inc.

, Philadelphia

Yeong Hee Shin, PhD, RN

Tae Im Kim, PhD, RN
Mi Sook Shin, MSN, RN
Hee-Soon Juon, PhD

Effect of Acupressure on Nausea and

Vomiting During Chemotherapy Cycle
for Korean Postoperative Stomach
Cancer Patients
K E Y

W O R D S

Despite the development of effective antiemetic drugs, nausea and vomiting

Acupressure

remain the main side effects associated with cancer chemotherapy. The purpose

Emesis control

of this study was to examine the effect of acupressure on emesis control in

Korean

postoperative gastric cancer patients undergoing chemotherapy. Forty

Stomach cancer

postoperative gastric cancer patients receiving the first cycle of chemotherapy

with cisplatin and 5-Fluorouracil were divided into control and intervention
groups (n = 20 each). Both groups received regular antiemesis medication;
however, the intervention group received acupressure training and was
instructed to perform the finger acupressure maneuver for 5 minutes on P6
(Nei-Guan) point located at 3-finger widths up from the first palmar crease,
between palmaris longus and flexor carpi radialis tendons point, at least 3 times
a day before chemotherapy and mealtimes or based on their needs. Both groups
received equally frequent nursing visits and consultations, and reported nausea
and vomiting using Rhodes Index of Nausea, Vomiting and Retching. We found
significant differences between intervention and control groups in the severity of
nausea and vomiting, the duration of nausea, and frequency of vomiting. This
study suggests that acupressure on P6 point appears to be an effective adjunct
maneuver in the course of emesis control.

From the Keimyung University, Dongsan-dong, Jung-gu, Daegu (Dr Shin), the
Daejeon University, Daejeon (Dr Kim), the Daejeon Catholic Hospital, Daejeon
(Ms Shin), Korea; and the Department of Health Policy and Management,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (Dr Juon).

Reprints: Hee-Soon Juon, PhD, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, 712, Baltimore, MD 21205 (e-mail: hjuon@jhsph.edu).
Accepted for publication March 9, 2004.

Acupressure in Korean Postoperative Stomach Cancer Patients

Cancer Nursing, Vol. 27, No. 4, 2004 267

uring the last decade, cancer has been the leading

cause of death in Korea. Stomach cancer was the most
common malignancy with poor prognosis. Of 123.5
per 100,000 cancer deaths, 24% were because of stomach
cancer.1 Surgery and chemotherapy were the treatments of
choice for stomach cancer. Cisplatin and 5-Fluorouracil (5FU) have been used as the postoperative chemotherapeutic
agents or as the major therapeutic agents for inoperable stomach cancers over the last 2 decades.2,3 Although these
chemotherapeutic agents made a considerable contribution to
the treatment of stomach cancer, their side effects (nausea and
vomiting) were frequently reported as serious problems, which
sometimes caused patients to refuse the treatment.4 Pharmacological antiemetics for nausea and vomiting are commonly
prescribed during chemotherapy cycles. However, the overall
effect of antiemetics for chemotherapy-induced nausea and
vomiting seemed less than satisfactory.5
Nausea and vomiting associated with chemotherapy are a
serious problem for cancer patients. Despite recent advancements in pharmaceutical technologies, about 60% of cancer
patients who receive chemotherapy with antiemetic medications
still suffer nausea and vomiting6 and as many as 20% of patients
refuse to continue chemotherapy because of severe nausea and
vomiting.7 Inadequate control of these side effects leads to metabolic imbalance, fatigue, distress, and lowered quality of life.8
More efficient antiemetic drugs will no doubt be developed continuously and this figure will change in the future. However, trials of simple, inexpensive yet effective approaches to managing
chemotherapy-induced nausea and vomiting should continue.
Efforts have been made by investigators to find nonpharmacological techniques as alternatives to antiemetic drugs.9
Acupressure is one of the well-investigated nonpharmacological methods for reducing the incidence of nausea and vomiting.6,1012 After systematic review of reports on postoperative
nausea and vomiting, Lee and Done13 suggested that acupressure and acupuncture were equivalent to pharmacological
treatment in reducing nausea and vomiting.
Acupressure involves pressure with fingers or bands on the
bodys acu-points and is easy to perform, painless, inexpensive,
and an effective approach. The P6 point (Nei-Guan) is located
on the anterior surface of the forearm, 3-finger widths up from
the first wrist crease and between the tendons of flexor carpi
radialis and palmaris longus14 (Fig 1). Practice of acupressure
requires some training and experience, but the technique is
widely accessible to any healthcare professionals, particularly
to clinical nurses. This acupressure technique may be one of
the approaches that should be tried not only by healthcare professionals but also by family members or patient themselves.
Acupressure is based on the ancient Eastern concept that
Chi energy travels through pathways known as meridians.
Along the meridians are acu-points, which are controlling
points for the Chi energy flow. If the energy flow in meridians
is slowed, blocked, or hyperstimulated, it can be rebalanced or
restimulated properly by either applying pressure (acupressure)
or inserting a needle (acupuncture) into 1 or more of these
acu-points. Two points are known for relieving nausea and
vomiting: the Nei-Guan point (P6) and Joksamly (ST36
268 Cancer Nursing, Vol. 27, No. 4, 2004

Figure 1 Photograph of P6 acu-point.

located at 4-finger breadths below the knee depression lateral
to the tibia). Because of its easy access and freedom from
restriction, patients tend to prefer the P6 point over the ST36
point. When the points are located correctly and applied
through acupressure or acupuncture, the Chi energy flow is
rebalanced, resulting in relief of nausea and vomiting.1517
Some investigators tried to interpret the mechanism of acupressure in terms of contemporary Western medicine. For
example, Wu and his collaborators18 proposed to explain the
stimulation of acu-points by the release of neurotransmitters
and neurohormones. Similarly, Takeshige and Sato19 and Han20
attributed the effect of the acu-point stimulation by the activation of an endogenous opioid system. These studies found that
acupuncture stimulation applied to specific body sites (acupoints) can facilitate the release of specific neuropeptides (eg,
endorphin) in the central nervous system, eliciting profound
physiological effects such as pain relief and vomiting reflex.
Furthermore, Dale17 and Dold21 proposed that the stimulation
of acu-points in the meridian could be the generation and conduction of electromagnetic signals. No clear mechanism
explains the efficacy of acu-point stimulation in sedating the
nausea in terms of Western medicine at present. However, it is
worthwhile to evaluate this simple and noninvasive approach to
reduce chemotherapy-induced nausea and vomiting.
Although multiple studies have reported that acupressure is
effective in reducing the nausea and vomiting associated with
postoperation2229 and pregnancy,14,3032 only a few studies on
the efficacy of acupressure for controlling chemotherapyinduced nausea and vomiting are available.12,33,34 Moreover,
there are contradictory findings of the effect of acupressure on
reduction of nausea and vomiting among cancer patients. For
example, Stannard35 reported a reduction of chemotherapyinduced nausea and vomiting in all of the patients (n  18)
with the use of Sea-Bands, which is an elastic fabric band, with
a small round plastic button inside, at P6 point. Dundee and
Yang33 also reported the antiemetic effect of acupressure in
87% of patients (N  40) also at P6 using Sea-Bands along
with instruction to the patients to press the Sea-Bands stud for
5 minutes every 2 hours. Dibble et al12 compared differences
in nausea experience and intensity in women undergoing
chemotherapy for breast cancer between those receiving usual
Shin et al

care only and those with usual care plus acupressure training.
They reported significant decrease of frequency and intensity
among all patients (n  17) receiving usual care plus acupressure training. However, Brown et al16 failed to observe any
beneficial effects of acupressure at P6 using the same SeaBands. The sample size of this study was small (n  6) and
they described some difficulty with data collection, and that
their patients were terminally ill. These studies have had mixed
findings based on a small sample. Further studies need to be
conducted in a large sample of cancer patients.
Despite popular use of traditional oriental medicine in
Korea, research concerning the importance of complementary
medicine for chemotherapy-induced nausea and vomiting is
limited among Korean cancer patients. Therefore, the purpose
of this study is to investigate whether acupressure, applied by
a finger to both wrists at P6, together with antiemetic medication reduce the severity, duration, and frequency of nausea and
vomiting during the first chemotherapy cycle of postoperative
stomach cancer patients in Korea. The research addresses the
following specific questions.
1. Are there any differences in the severity of daily nausea
and vomiting between the intervention and the control
group for the 5-day course of chemotherapy?
2. Are there any differences in duration of daily nausea and
vomiting between the intervention and the control group
for the 5-day course of chemotherapy?
3. Are there any differences in the frequency of daily nausea
and vomiting between the intervention and the control
group for the 5-day course of chemotherapy?


Methods

Study Design
This study was a nonequivalent control group design for a single
cycle trial. A cycle of chemotherapy lasted 5 days. Patients undergoing adjuvant chemotherapy after gastric resection for gastric
cancer were selected into control (receiving usual care) and experimental groups (receiving usual care plus an acupressure intervention) in order to investigate the effect of acupressure intervention on the chemotherapy-induced nausea and vomiting.
From the pool of eligible patients, the first 20 patients were
assigned to control group and the next 20 patients were assigned
to the intervention group. Data were collected at St. Mary
Hospital, Daejeon, Korea, June through October 2001. The control in this study was a nonidentical, yet quasi-equivalent group.

Study Sample
The settings of the study were oncology wards in university
medical center located in metropolitan cities in South Korea.
The eligibility criteria included (a) patients without complication entering the first adjuvant chemotherapy, (b) patients
receiving Cisplastin-5FU combination therapy with antiemetic
medications of Metoclopramide and Ondansetron, and (c)
patients signing to participate in this investigation and able to
communicate (both verbal and written).

Measures
The measures included data on family background, diagnosis
and treatment, and assessment of nausea and vomiting. We
adopted measures developed and used previously to assess nausea and vomiting by Rhodes et al.36,37 The English versions of
this instrument were translated into Korean and back-translated into English to ensure equivalency. The instrument was
pilot-tested to ensure cultural appropriateness and acceptance.
The outcome variable was the assessment of nausea experienced by patients using a daily log. The 3-item nausea subscale
of Rhodes Index of Nausea, Vomiting, and Retching (INVR)
was used on a 4-point scale (0never to 4very often). Items
from this scale were summarized. Scores ranged from 0 to 12
with a higher number reflecting a more severe nausea experience. Reliability of original INVR37 was very high (Cronbachs
alpha .98). Reliability of our translated version tested for
consecutive 5 days to our patients were 0.90, 0.71, 0.82,
0.92, and 0.74, respectively. In addition, respondents were
asked questions to evaluate intensity of nausea experience during the past 24 hours. Nausea intensity was rated using a
descriptive numeric rating scale ranging from no nausea (0)
to worst nausea imaginable (10).
Diagnostic information, treatment regimen, and dosages of
chemotherapeutic agents and antiemetics were obtained from
medical and nursing records. This information was to assess the
number and intensity of the side effects experienced by patients
in order to receive any further consultation from oncologists
and clinical nurse specialists in relation to acupressure study. In
addition, demographic information was collected, including
age, marital status, education, and body weight.

Intervention Procedure
We developed the Acupressure Teaching Booklet to teach
patients and family acupressure techniques. Validity of the
content of this booklet has been established by 3 faculties of
East-West Medicine who taught acupressure techniques to our
research members.
At the beginning of a chemotherapy cycle, all participants
completed the baseline questionnaire packet. Participants receiving usual care (control group) were instructed to complete a
daily log of INVR each evening and entered the first cycle of
chemotherapy. For the participants receiving usual care plus acupressure education (intervention group), research team members
visited the ward, distributed the Acupressure Teaching Booklet,
and taught participant and family how to access the P6 acupressure point. Research team members showed the P6 point located
on the anterior surface of the forearm, approximately 3-finger
widths up from the first palmar crease and between the tendons
of flexor carpi radialis and palmaris longus.8 In order to encourage patients to locate and assure the intensity of the finger pressure on the P6 acupressure point correctly, they were urged to
practice the technique on members of the investigation team.
Routine acupressure was carried out by pressing the acupressure
point for 5 minutes before chemotherapy and mealtimes, otherwise anytime sensations of nausea were felt. The acupressure
group completed a daily log of acupressure usage as well as

Acupressure in Korean Postoperative Stomach Cancer Patients

Cancer Nursing, Vol. 27, No. 4, 2004 269

Table 1 Characteristics of Patients

Characteristics
Sex
Male
Female
Age (Mean SD)
Education
06 y
711 y
12+ y
Marital status
Married
Other
Body weight prior
to treatment
(Mean SD)
Stage of cancer
II
III
IV
Type of surgery
Subtotal gastrectomy
Total gastrectomy
Other surgery

Intervention
(n = 20)

Control
(n = 20)

16(80%)
4(20%)
52.75  10.91

12(60%)
8(40%)
47.25  6.80

5(25%)
5(25%)
10(50%)

3(15%)
5(25%)
12(60%)

18(90%)
2(10%)
53.8  8.3

18(90%)
2(10%)
52.8  7.1

1 (5%)
15(75%)
4(20%)
14(70%)
4(20%)
2(10%)

nausea measures. A research assistant made regular visits for both

groups in the evening before meal time to collect daily logs and
confirmed compliance of acupressure practice for the intervention group. Participants, both control (n  20) and intervention
(n  20) groups, were receiving the first cycle of Cisplatin-5-Fu
chemotherapy after surgery for gastric cancer. All patients
received the same antiemetics as prescribed by their physicians,
including Metoclopramide and Ondansetron.


Results

Sample
Participants of our study included 28 males and 12 females, with
an average age of 50 years and all but 4 married. More than half

2 or t

1.905

.168

1.914

.111

3.771

.287

1.333

.513

1.818

.708

5(25%)
9(45%)
6(30%)

0.495

.910

12(60%)
4(20%)
4(20%)

0.839

.169

of our study subjects had more than a high school education. No

significant differences existed between the 2 groups with regard
to demographics, disease, or treatment variables (Table 1).

Evaluation of Effect of Acupressure

Maneuver
First, the severity of daily nausea and vomiting experienced by
the control group and the intervention group was compared
for the 5-day course of chemotherapy (Table 2). Average score
of severity was 4.35 for the intervention group whereas the
control group scored 7.95, showing statistically significant differences (t  3.54, P  .01). The time course of the severity of
nausea and vomiting experienced by the 2 groups of patients is
presented in Figure 2. Severity appeared to increase gradually

Table 2 Severity of Nausea and Vomiting During First 5 days of Chemotherapy*

Days
1st
2nd
3rd
4th
5th
Average

Groups

Mean  SD

Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control

1.55  3.42
3.85  6.38
5.95  1.95
7.45  3.59
5.15  2.53
9.40  6.19
3.05  2.91
9.50  8.95
6.05  2.85
9.55  5.47
4.35  2.75
7.95  5.91

1.42

.099

1.64

.024

Between group

12.70

.000

2.84

.005

Within group

9.34

.000

3.06

.000

Group  time

2.11

.082

2.54

.006

3.54

.001

*Intervention group (n = 20); control group (n = 20).

270 Cancer Nursing, Vol. 27, No. 4, 2004

Shin et al

Figure 2 Severity of nausea and vomiting during first 5 days of chemotherapy.

in the control group, whereas it seemed to stabilize from the

third day in the intervention group. Furthermore, when
repeated measure ANOVA was used to see the trend, the group
effect was significant (F  12.70, P  .01) as was the effect of
time (F  9.34, P  .01). The group  time interaction was
not significant.
Second, duration of daily nausea and vomiting was compared between control and intervention groups (Table 3).
Average duration time for the intervention group was 0.89
hour, whereas that for the control group was 2.23 hours and
the difference was statistically significant (t  2.92, P  .01).
Time course of the duration of nausea and vomiting is presented in Figure 3. Duration of daily nausea and vomiting in
the control group rises steeply, whereas that of the intervention
group becomes stabilized for 4 days and rises gradually. In
order to evaluate these tendencies, the 2 groups were compared

according to the repeated measure ANOVA technique. The

group effect was significant (F  10.54, P  .01) as was the
time effect (F  11.40, P  .01). The group  time interaction was also significant (F  4.19, P  .01). Duration of
nausea and vomiting was apparently stabilized in the intervention group.
Finally, the frequency of daily nausea and vomiting experienced by control and intervention groups is compared in
Table 4. Average frequency of the control group was 0.63 times
and that of the intervention group was 0.20 times per day, and
the difference was statistically significant (t  3.65, P  .01).
Daily average frequency of the nausea and vomiting was plotted against the time course of the chemotherapy for the 2
groups to show their apparent differences (Fig 4). The
differences were further analyzed by repeated measure
ANOVA technique. The group effect was significant (F  4.26,

Table 3 Duration of Nausea and Vomiting During First 5 days of Chemotherapy*

Days
1st
2nd
3rd
4th
5th
Average

Groups

Mean SD

Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control

0.45  1.36
0.65  1.46
0.85  1.57
0.90  1.37
0.70  0.92
2.75  2.57
0.75  0.85
2.60  2.89
1.70  2.49
4.25  3.27
0.89  1.43
2.23  2.31

0.45

.598

0.11

.719

Between group

10.54

.002

3.35

.000

Within group

11.40

.000

2.75

.000

Group  time

4.19

.003

2.77

.010

2.92

.006

*Intervention group (n = 20); control group (n = 20).

Acupressure in Korean Postoperative Stomach Cancer Patients

Cancer Nursing, Vol. 27, No. 4, 2004 271

Figure 3 Duration of nausea and vomiting during first 5 days of chemotherapy.

P  .05) as was the time effect (F  4.18, P  .01). The
group  time interaction was also significant (F  2.70,
P  .05). The acupressure maneuver was apparently effective
in reducing the frequency of chemotherapy-induced nausea
and vomiting.

Discussion

In this study, acupressure was shown to reduce the frequency,

duration, and severity of chemotherapy-induced nausea and
vomiting. Although several Western investigators reported on
the effective control of nausea and vomiting by acupressure on
the P6 point for patients receiving cancer chemotherapy,5,16,33,34
surprisingly, this is the first study to explore finger acupressure as
a nausea modulating maneuver in Korea. We found that the

acupressure group experienced less nausea and vomiting in frequency, severity, and duration.
We also found that frequencies of nausea and vomiting
showed gradual increase in both the control and the intervention groups from the second day on. If this tendency persists
in the second and next cycles of chemotherapy, the anticipatory psychological stress could aggravate the nausea and vomiting. Pharmacodynamics of chemotherapy and antiemetics
are relatively well investigated. However, the mechanism of
action of acupressure and acupuncture on nausea and vomiting has not been established. Further studies should be
expanded to address research questions, such as whether the
anticipatory psychological stress could be controlled by acupressure techniques.
Our study has several limitations regarding measurement
and sampling. First, the measure of nausea and vomiting has

Table 4 Frequency of Nausea and Vomiting During First 5 Days of Chemotherapy*

Days
1st
2nd
3rd
4th
5th
Average

Groups

Mean  SD

Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control
Intervention
Control

0.10  0.45
0.10  0.45
0.20  0.62
0.25  0.79
0.20  0.62
0.85  1.27
0.20  0.62
1.05  1.61
0.30  0.73
0.90  1.33
0.20  0.06
0.63  1.09

0.00

1.000

0.22

.620

Between group

4.26

.046

2.06

.000

Within group

4.18

.003

2.21

.000

Group  time

2.70

.033

1.76

.000

3.65

.001

*Intervention group (n = 20); control group (n = 20).

272 Cancer Nursing, Vol. 27, No. 4, 2004

Shin et al

Figure 4 Frequency of nausea and vomiting during the first 5 days of chemotherapy.
been debated during the last decade as nausea and vomiting
has been identified as a major quality factor from the patients
point of view.36 Thus, self-reported nausea experience may
have some degree of measurement error, such as errors related
to memory lapse of nausea and vomiting. Second, the finding
has limited generalizability because this study was regional and
small samples were involved.
This study suggests a need for further research to complement these limitations. Further study of acupressure as a
complementary therapy for chemotherapy-induced nausea
should be carried out in a large number of cases with a randomized control design. We also need to clearly understand
the multifactor etiology of postoperative chemotherapyinduced nausea and vomiting that may be considered as
other confounding factors. Finally, nurse educators and clinical nurses should recognize information on nonpharmacologic management of nausea and vomiting, such as acupressure techniques and need to develop educational tools
(eg, pamphlets, audiovisual tapes) for training nursing
students, patients, and families on the use of acupressure
techniques.

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