Traditional Chinese Medicine Self-Care and Lifestyle Medicine Outside of Asia: A Systematic Literature Review

Abstract

Background:

Chinese medicine, when applied as a whole system of care, traditionally incorporates self-care techniques and patient understanding as key aspects of patient recovery and health maintenance.

Objectives:

This review aims to explore the literature to date on Traditional Chinese Medicine (TCM) self-care in settings outside of Asia, beyond the sole application of t'ai chi or qigong, to consider simple self-care techniques as health care interventions that may be generalized to a wider population.

Design:

AMED, CINAHL, EMBASE, PubMed, and MEDLINE databases were searched for articles from inception to July 2018. Studies were included, which were undertaken in settings outside of Asia and/or Asian communities, and were excluded if they solely examined t'ai chi or qigong.

Results:

Findings of the included studies (n = 37) were categorized into four key areas in relation to the TCM self-care component evaluated: self-acupressure, self-acupuncture, self-moxibustion, and the adoption of prescribed lifestyle, diet, and exercise advice based on a TCM diagnosis. The studies included randomized clinical trials, case studies, hospital audits, and qualitative evaluations. The studies assessed TCM self-care in relation to a wide range of health conditions, with the majority of studies concluding positive findings.

Conclusion:

This review draws attention to the potential role of TCM self-care techniques, in settings outside of Asia, beyond the sole practices of t'ai chi and qigong, as an adjunct to health maintenance and recovery. Only tentative conclusions can be drawn from the existing research, however, due to variability across studies in reporting transparency and the overall low number of studies retrieved. Further research is warranted.

Background

Traditional medicine practices from China and East Asia, including acupuncture, moxibustion, cupping, and the prescribing of herbal medicine, are increasingly being practiced outside these regions and are increasingly integrated into contemporary health care.^1

–8 These therapies are most commonly practiced in an integrated model referred to as Traditional Chinese Medicine (TCM), which has its foundation in a medical system designed as a whole system of care that prioritizes assessment of the patient in a holistic context.^9,10

Within this system, patient care has historically focused as much on health maintenance and prevention, through encouraging patients to adhere to simple health and lifestyle practices, as it has on the treatment of illness.¹⁰ Thus, self-care practices, which may be considered activities undertaken by an individual to “prevent disease, evaluate symptoms, and restore health,”¹¹ are inherent to TCM.

Lifestyle or health-promoting practices from East Asia have become somewhat known in the West via specific manifestations such as t'ai chi and qigong, exercises that typically combine a set form of movements, breathing techniques, and guided imagery,¹² and are increasingly the topic of scientific investigation.^13

–16

A broader concept of lifestyle practices, however, is referred to in the foundational texts of medicine in China, dating back to the classical era c.300–200 BCE.¹⁰ These texts provide guidance on easily adopted preventative health care measures, including minimizing alcohol intake; engaging in exercise routines that include both aerobic and resting practices; having an awareness of the impact of temperature and environmental conditions; and adopting appropriate dietary adjustments specific to the individual.¹⁰ This perspective on health and lifestyle care has been shown to not only be culturally integrated but also to be retained by members of Asian migrant communities,^17
–19 who report including practices on “self-care, use of herbs, lifestyle, hot/cold balance” in daily life,¹⁹ which align with these traditional perspectives.

TCM self-care thus incorporates health behavior practices that draw on these classical perspectives, and could also include self-moxibustion, self-acupressure, or even self-acupuncture, the latter of which is not common to TCM, but is being used in some contemporary Western health care settings.

Self-moxibustion is the self-applied burning of moxa (the dried herb Artemisia vulgaris), prepared in rice grain-sized threads or larger cigar-shaped poles, and either applied to the skin or held above the skin surface, respectively, to instigate a healing response.²⁰ Self-acupressure involves the patients using their thumb, fingers, or in some cases, a massage tool, to apply therapeutic pressure to selected acupuncture points on their own body. Techniques of acupressure are incorporated into both tuina (TCM massage therapy) and shiatsu (Japanese acupressure therapy). Self-acupuncture involves the patients inserting acupuncture needles to specified therapeutic acupuncture points on their own body.

Noncommunicable chronic and lifestyle illnesses are becoming an increasing part of disease burden globally. In response, the World Health Organization (WHO) has recommended implementation of a number of high-impact measures that are notably similar to TCM lifestyle practices, recommending improvement to individual levels of physical activity; reducing salt/sodium intake, alcohol intake, and tobacco use; as well as providing increased access to medical care and early intervention strategies. The implementation of such measures is perceived to far outweigh the calculated economic and social cost of not applying such interventions.²¹ The WHO has also developed a Traditional Medicine Strategy, recommending the integration of traditional medical systems where evidence suggests there may be evidence of health benefit.

For this reason, examination of the practices of TCM self-care may offer insights—including those beyond currently recommended initiatives—into implementing health behavior change in communities globally. However, to date there has been little formal examination of how traditional systems of medicine have been used to promote self-care in integrative settings. This review aims to remedy this information gap, by assessing and analyzing the primary research into TCM self-care techniques, in communities outside of Asia and/or Asian migrant communities, relative to outcomes of health and well-being.

Methodology

Data sources and searches

Electronic searches were conducted in AMED, CINAHL, EMBASE, PubMed, and MEDLINE for articles from inception to July 2018, using terms related to TCM and self-care. Representative search terms are shown in Table 1. Searches were conducted with no date or language restrictions.

Table 1.

Search Terms Applied in PubMed Database Search

Search terms applied

visit^* OR appointment^* OR clinic^* OR Appointments and Schedules AND group OR shared OR cluster

self-control OR self-manage OR self-care

AND

Traditional Medicine OR Complementary Medicine OR Chinese Traditional Medicine OR Traditional Oriental Medicine OR East Asian Traditional Medicine OR Yoga^* OR Qigong OR Qi Gong OR Chi-Kung OR Chi Gong OR Tai-Chi OR Tai-chi OR Acupressure OR Acupuncture OR Moxa^*

Selection criteria

This review included original research reporting on the therapeutic application of TCM in self-care, inclusive of singular therapeutic interventions that have been drawn from TCM. As TCM practices may be culturally embedded in some Asian communities, studies were excluded if the interventions were delivered in a setting within Asia or Asian communities, to consider self-care techniques as health care interventions that may be generalized to a wider population and to gauge their success in naive populations.

Studies were also excluded if they only reported t'ai chi or qigong interventions as both of these practices have been, comparatively, extensively explored in the literature.^13

–16 Furthermore, t'ai chi and qigong practices often involve a set form, involving a combination of specific physical movements, guided imagery, and breathing exercises,¹² which can be more complex, in learning and application, than other TCM lifestyle recommendations.

Results

Study selection

All identified citations (n = 2109) were downloaded into EndNote referencing and management software program. Of the 2109 downloaded citations, 390 were discarded as duplicates and a further 1237 discarded by title (A.H.). The remaining 482 citations were filtered by abstract with a further 331 identified as not fulfilling the inclusion criteria and being discarded. A random sample of articles were screened by title and abstract by the other authors (A.S. and J.W.).

The 151 retained citations were then screened by full text and a further 22 articles discarded due to not directly incorporating a TCM self-care component or merely comprising a report or discussion of the topic area. A further 90 articles examined a t'ai chi or qigong self-care component only and were therefore discarded, leaving 39 articles, of which 12 were discarded based on being set in an Asian country or Asian community. An additional nine articles were located via manually searching through the reference list of included articles. A random sample of articles were screened by a second author (A.S.). Details of this process are summarized in Figure 1.

FIG. 1.

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data extraction, risk of bias assessment, and synthesis

Data were extracted from selected articles into a summary table, formatted into domains of study design, nature of the TCM self-care intervention, control, outcome measures, practitioner standard of training, duration of intervention, sample population, condition examined, blinding, summary of findings, and data quality. The summary table was prepared by two reviewers (A.H. and A.S.). Data extraction was completed by one reviewer (A.H.) and periodically checked by a second reviewer (A.S.) with discrepancies resolved through discussion until reaching consensus.

Articles were categorized according to study design for risk of bias and quality assessment, however, also categorized according to the nature of TCM self-care intervention for further analysis and discussion. For the purposes of this review, studies on self-applied tuina, shiatsu, and acupressure were categorized together. Risk of bias and quality of evidence were appraised with the Consolidated Standards of Reporting Trials (CONSORT) 2010 Checklist²² for the randomized controlled trials (RCTs); Case Report Statement and Checklist (CARE)²³ for the case series and case studies; Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist²⁴ for the clinical audits, hospital survey, and longitudinal descriptive study; and Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines²⁵ for the qualitative studies.

Study characteristics

A total of 37 articles were identified for inclusion in the review. Articles were dated between 2003 and 2018, with the majority of studies (n = 22) being conducted in the past 5 years. Twenty-six of the articles retrieved were randomized clinical trials,^{26

–51} of which 11 were undertaken in the United States,^{26,32
–34,37

–40,49
–51} 3 in Iran,^27,29,47 and 5 in the United Kingdom,^{35,41
–43,46} with single RCTs being drawn from Australia,⁴⁴ Denmark,³⁰ Italy,²⁸ Portugal,⁴⁵ Uganda,³⁶ and Germany³¹ and 1 study being conducted in both Australia and China.⁴⁸

Studies reviewed that were not RCTs include two case studies^52,53 and a case series⁵⁴ undertaken in the United Kingdom, United States, and Canada, respectively; three clinical audits^55
–57 and one hospital survey⁵⁸ undertaken in the United Kingdom; and a longitudinal descriptive study undertaken in Germany.⁵⁹ The article data are summarized in Table 2.

Table 2.

Traditional Chinese Medicine Self-Care Studies' Summary Table

Author and year	Country	Setting	Study design	Blinding	Duration	Participants	Practitioner Training	Conditions examined	Intervention: self-care component (standardized/individualized) ^a	Control	Outcome measures	Summary of findings	Data quality ^b (instrument/rating)
Abbott et al. (2014)²⁶	United States	Unspecified and participants' home/private setting	RCT	None	4 Weeks	Adults with functional constipation (n = 100)	Unspecified	Constipation	Standardized: perineal self-acupressure (3–5-min oral instruction)+standard care	Usual care	Primary: QOL (PAC-QOL); secondary: bowel function (BFI); health and well-being (SF-12v2)	Improved: QOL (TED 0.59, p < 0.01), BFI (TED 13.8, p < 0.01), SF-12v2 Physical (TED 3.05, p < 0.01) and SF-12v2 Mental (TED 2.82, p < 0.07)	CONSORT: high
Abedian et al. (2015)²⁷	Iran	Unspecified and participants' home/private setting	RCT	Single-blinded	4 Weeks	Menopausal women between ages 41 and 65 years (n = 128)	Unspecified	Sleep	Standardized: self-acupressure of four points (SP6, HT 7, GB20, YT) for 10 min; 6 nights week; 1–2 h before sleeping	Control 1: Sham acupressure [1–3 CUN away from true acupoints]. Control 2: Usual care	Primary: Sleep quality (PSQI)	Improved: Acupressure Group: PSQI (p ≤ 0.001); Sham-Acupressure group: PSQI (p ≤ 0.001).	CONSORT: medium
Baccetti et al. (2014)²⁸	Italy	Centre of TCM, public outpatient clinic of Florentine health care system and participants' home/private setting	RCT	None	6 Weeks; follow-up at 4 months	Menopausal women (n = 100)	Medical doctors with minimum 400-h postgraduate training	Hot flushes	Standardized: Group A: Acupuncture, × 2 weeks, for 6 weeks+TCM individualized self-care	Group B: Wait-list Acupuncture (delayed 6 weeks): plus Individualized TCM diet+TCM self-massage for 6 weeks during wait period.	Primary: menopausal symptoms, via interview questionnaire; Time points: Group A: baseline; 6 weeks; Group B: baseline, 6 weeks, 12 weeks; A and B: 4 months post-treatment completion	Improved: Acupuncture+TCM self-care significantly greater than in Group B: hot flushes, 1.3 points, sudden sweating 1.2 points, sleep disorders 1.1 points, headache, chest pain, vaginal dryness, 1.0 point, irritability, bone pain, memory reduction, urination disorders 0.9 points, depression 0.7 points, genital itching 0.5 points (only s/s not sustained at 4-month follow-up); no reported difference: TCM self-care alone	CONSORT: high
Bardy et al. (2015)⁶⁰	United Kingdom	Unspecified and participants' home/private setting	Qualitative study (Bardy et al.⁶²), nested within, RCT (Molassiotis et al.⁴³)	None (pragmatic randomized trial)	4 Weeks (following initial 6-week RCT)	Participants in multisite self-acupuncture RCT (n = 23): practitioners (n = 15); patients (n = 8)	“Experienced therapists” no further details given	Cancer-related fatigue	Standardized: acupuncture self-needling (SP6, ST36), × 1 week, 4 weeks, following multisite RCT of 6-week practitioner-delivered course of acupuncture; OR, teaching self-needling (SP6, ST36) to patients following same multisite RCT; Standardized No. 2: Continuation of acupuncture as administered by acupuncturist, × 1 week, 4 weeks (Molassiotis et al.⁴³)	Usual care	Primary: self-needling experience (patients); self-needling training experience (practitioners); Time points: postintervention (shortly after trial had ended)	Self-needling was found to be acceptable to, and manageable by. patients, and enthusiastically adopted by most practitioners	COREQ: medium
Behbahani et al. (2016)²⁹	Iran	Shiraz University and participants' dorm room/private setting	Multiarm RCT	None	2 Months	Women, ages 18–25 years, with primary dysmenorrhea (n = 120)	“Specialist in physical medicine and rehabilitation”; further details undisclosed	Dysmenorrhea	Standardized No. 1: Acupressure (CV4, CV2) 20 min on days 1 and 2, for two cycles; Standardized No. 2: Four, 1–1.5 h (non-TCM) educational self-care sessions, including nutrition and exercises	Ibuprofen 400 mg	Primary: pain intensity (McGill Pain Questionnaire); Time points: Baseline; postintervention	Improved: statistically significant improvement in pain compared with control in both groups (p < 0.001). Postintervention: mean intensity of pain 14.40 ± 6.87 acupressure group; 10.65 ± 5.71 training group; 19 ± 5.41 control group	CONSORT: high
Bergman et al. (2014)³⁰	Denmark	Unspecified and participants' home/private setting	RCT	Single blinded (observer blinded)	3 Months	Patients with IHD (n = 213)	“Professional instructor” (who had undergone a 4-week course+practical examination relevant to the techniques applied)	Stress; depression and QOL, in relation to IHD	Standardized (with self-analysis component): self-measurement of PPS, × 2 days, and if high, self-acupressure (CV17, BL14, BL15) for 1 min each, and reflection; daily online tracking	Usual care	Primary: PPS via a PPS algometer; Secondary: Depressive symptoms; QOL via online questionnaires (MDI, WHO-5 (well-being), SF-36 (mental and physical QOL); Time points: Baseline; 3 months	Improved: at 3 months, PPS decreased 28% in intervention group and only 11% in control, (p < 0.001); MDI decreased 22%, vs. 12% in control (p = 0.040); WHO-5 increased to 71 vs. 64.8 control, (p = 0.015); SF-36 mental score sum increased to 55.3 vs. 53.5 control (p = 0.08)	CONSORT: high
Blodt et al. (2018)³¹	Germany	App-based (patients' everyday environment)	Two-arm RCT	None	6 Months (six mens. Cycles)	Women, 18–34 years, with self-reported dysmenorrhea (n = 221)	Acupressure points for App rec. by group of experts; details of training undisclosed	Primary dysmenorrhea, women 18–34 years	Standardized: App-based self-acupressure (LI4, LR3, SP6) for 1 min daily, (or up to five times daily), for 5 days pre-menses	Usual care	Primary: mean pain intensity, on days with pain, during third cycle	Improved: mean pain intensity after three cycles (acupressure: 4.4; 95% CI, 4.0–4.7; usual care 5.0; 95% CI, 4.6–5.3; mean difference −0.6); after six cycles, (mean difference, −1.4, 95% CI) reaching clinical relevance	CONSORT: high
Brown et al. (2014)⁵⁴	Canada	University of Alberta, Faculty of Rehabilitation Medicine affiliated clinics and participants' home/private setting	Case series (pilot)	None	8 Weeks	Participants with diagnosed musculoskeletal conditions and self-reported sleep problems (n = 14)	Certified shiatsu therapist with >10 years clinical and trainer experience, for protocol development	Sleep, in persons with chronic pain	Standardized: hand self-shiatsu	1 Week of baseline data	Primary: objective sleep latency, via ActiSleep monitor; secondary: self-reported sleep patterns, Sleep latency; Pain; (VAS), (PSQI); Time points: Baseline; 2 weeks postintervention; 8 weeks postintervention	Improved: trend emerged toward improved sleep latency and sleep duration, however, sample insufficient to draw statistical conclusions	CARE: high
Chen et al. (2013)³²	United States	Baltimore, outpatient addiction treatment facility and participants' home/private setting	RCT	None	12 Weeks	Cocaine-dependent patients (n = 56)	“Trained staff”	Cocaine addiction	Standardized: IMEA via herbal seeds (Shenmen, Subcortex, HT, LR, LU) to be pressed 20 × , 4–5 × daily, for first 2–3 weeks	Usual care	Primary: Treatment retention rate; abstinence; Secondary: Addiction-related symptoms: anxiety, craving, depression, withdrawal symptoms via a number of validated tools; Time points: weeks 8 and 12	Improved: 80.8% in IMEA completed the 12-week study compared with 58.3% in control (p = 0.08); significantly fewer (88.5% vs. 62.5%; p = 0.03) IMEA participants dropped out of treatment by week 8 compared with control; IMEA had a higher abstinence rate as measured by 6 or more consecutive weeks of negative urine tests for cocaine (65% vs. 33%; p = 0.06)	CONSORT: high
Dibble et al. (2007)³³	United States	Community clinical oncology programs assoc. w/University Texas and nine independent sites and participants' home/private setting	RCT	Double blinded	21 Days (one cycle of chemotherapy)	Women beginning their second or third cycle of chemotherapy for breast cancer with moderate nausea intensity scores on previous cycles (n = 160)	Nurses and research assistants who received 2-h training in study protocol+access to teaching video on protocol	CINV (acute and delayed)	Standardized: self-acupressure with wristband to P6	Control No. 1 (Sham): self-acupressure to SI3; Control No. 2: usual care	Acute and delayed nausea and vomiting	Improved: delayed CINV in treatment group (No. 1); no significant difference: acute CINV	CONSORT: high
Enblom et al. (2017)⁵⁹	Sweden	Two university hospitals	Longitudinal descriptive via daily questionnaire	None	5-Week data per patient, gathered over 3 years	Radiotherapy (abdominal or pelvic) patients, with or without chemo (n = 200)	N/A	Nausea during radiotherapy; Type of CAM strategy (if any) adopted	Non-standardized: any CAM self-care strategy (incl. acupressure)	Type of CAM adopted	Primary: adoption of CAM self-care practice; Secondary: reduction in nausea; Time points: daily, through radiotherapy treatment (M-F; 5 weeks)	CAM self-care practicing patients without nausea practiced self-care more frequently than nauseous patients. 25% patients practiced CAM self-care (n = 50); acupressure (n = 2); modifications of eating/drinking (n = 45); physical exercise (n = 3); resting (n = 9); self-induced vomiting (n = 1)	STROBE: high
Fagan and Staten (2003)⁵⁵	United Kingdom	Participants' own home	Clinical audit	None	Unspecified	Patients chosen according to condition; ages 35–73 years (n = 16)	GPs having undergone BMAS foundation training course, comprising 24 training hours ⁶¹	Varied	Standardized: Self-acupuncture audit of GP private practice patients; time varied (not specified)	None	Primary: Effectiveness in assisting condition; Secondary: acceptability; frequency of treatment; needle retention times; Time point(s): post intervention (undefined)	Ten out of 16 patients reported their results to be good or excellent; no adverse affects reported	STROBE: low
Filshie et al. (2005)⁵⁶	United Kingdom	Royal Marsden Hospital, London and Surrey and participants' home/private setting	Clinical audit	None	Up to 6 years, average 9 months, (over 13-year period)	Patients who had been treated with acu or self-acupuncture, via Royal Marsden Hospital, for hot flushes, majority of whom had breast cancer (n = 194)	Consultants in anesthesia and pain management, acupuncture training undisclosed	Hot flushes and pain	Standardized: Acupuncture (SP6, LR3, LI4, TE5 + 2 sternal points; n = 194) and (followed by) self-acupuncture (press-studs; SP6; n = 144) or self-needling (SP6; n = 14), or both at different times (n = 9)	None	Primary: estimated frequency of hot flushes; Time points: before and after program (1 month to 6 years)	114 Patients (79%) using self-acupuncture studs had ≥50% reduction in hot flushes	STROBE: medium
Harris et al. (2005)³⁴	United States	University of Michigan School of Public Health	Crosover RCT	Single blinded (participant blinded)	3 Days	Students attending course in research design and statistics (n = 39)	Instructor trained in acupressure (3 and 5 years); protocol refined by TCM acupuncturists (5 years experience)	Alertness	Standardized No. 1: Self-administered acupressure: stimulation (LI4, ST36, KI1, UB10)-relaxation (YT, Anmian, HT7, LV3, SP6)-relaxation; Standardized No. 2: self-administered acupressure: relaxation/stimulation	None	Primary: alertness via SSS; Secondary: assessment of influencing factors such as caffeine, previous night's sleep; Time points: pre and postintervention daily; × 3 days	Improved: stimulation acupressure treatment yielded 0.56 greater difference in score on the SSS, corresponding to less fatigue, compared with relaxation arm (p = 0.019)	CONSORT: high
Hughes (2015)³⁵	United Kingdom	Christie NHS Foundation Trust	RCT (feasibility study)	None	5 Weeks	Cancer patients (breast, prostate, colorectal) with chronic insomnia (n = 7)	Nurses with training from either BMAS or British Academy of Western Medical Acupuncture with at least 3-year experience treating cancer patients	Sleep	Semistandardized No. 1: practitioner administered ear-acupressure ear seeds+patient acupressure (1 min each night) stimulation (Auricular: Shenmen; +any two according to symptoms: insomnia 1, 2; heart; liver; kidney; subcortex); semistandardized No. 2: Self-acupressure (HT7; + any two from: PC6; GB20; Ex8 [Anmian]; KI6; BL62)	Usual care (n = 2)	Primary: Sleep quality via PSQI; Secondary: impact of treatment on concerns and wellbeing (MYCaW); Time points: pre and postintervention (baseline and 5 weeks)	Improved: auricular therapy: PSQI reduced from 12.5 at baseline to 8 at completion of treatment; self-acupressure PSQI reduced from 15 to 11; No treatment: PSQI 14.5 at baseline and follow-up	CONSORT: high
Ibanda (2018)³⁶	Uganda	Kiswa Health Centre (public primary health care facility)	RCT	Single	6 Months	TB patients, newly diagnosed (n = 180)	Undisclosed (study nurse)	TB	Standardized: self-administered moxa, bilaterally, on leg point (ST36), 3–7 moxa cones daily	Usual care	Primary: TB sputum negative; Secondary: full blood counts; radiologic analysis; renal and hepatic function; well-being; Time points: baseline; 1–6 months	Improved: higher rates of TB sputum negative in first month in moxa group (p = 0.32); greater hemoglobin improvement in moxa group (p = 0.03); adherence to drug therapy higher in moxa group (p = 0.001)	CONSORT: high
Lee et al. (2010)³⁷	United States	Community clinical oncology programs associated with University Texas MD Anderson Cancer Center and six independent sites	RCT secondary data analysis	Double blinded	11 Days	Patients with breast cancer, receiving chemotherapy, randomly assigned to active arm of PC6 intervention (n = 53)	Research assistants or nurses with at least 2 h training+access to video	Relationship between intensity of CINV (acute and delayed) and frequency of PC6 self-acupressure	Standardized: self-acupressure (PC6); 3 min daily+when nausea occurred	Usual care	Primary: nausea intensity, via daily log INVR; Secondary: Acupressure frequency; Time points: daily	Participants who used acupressure more frequently after peak of nausea (on day 4) were predicted to have a 0.97 point higher nausea intensity in acute phase (incidence rate ratio = 1.52, p < 0.01)	CONSORT: medium
Lee et al. (2012)³⁸	United States	Undisclosed and participants' home/private setting	RCT (pilot)	None	4 Weeks	Adult patients with AD recruited from a single academic center (n = 15)	Medical doctor, further acupuncture and/or TCM training undisclosed	Eczema/AD	Standardized: self-acupressure (LI11) using 1.2 mm acupellet, 3 min, 3 × week, for 4 weeks	Usual care	Primary: severity of itch and AD, measured on VAS, IGA, EASI; Secondary: eczema care regimen: use of creams, medication, acupressure; Time points: Baseline; 4 weeks (±3 days)	Improved: Trial group showed greater decrease in VAS (p = 0.04), decrease in IGA (p = 0.03), decrease in EASI lichenification score (p = 0.03)	CONSORT: high
Li et al. (2016)³⁹	United States	Research centre and community residence	RCT (feasibility study)	Double blinded	8 Weeks	Community-living older adults (n = 150)	Research assistants trained by acupuncturist/coinvestigator certified by NCCAOM (minimum 4 academic years of training)⁶²	Knee OA	Standardized: self-acupressure protocol (YT, Anmian, HT7, SP6, KI3) daily, 5 × week, for 8 weeks+weekly phone call from research assistant	Control No. 1 (Sham): as intervention, applied on non-acupoints+weekly phone call; Control No. 2: usual care+weekly phone call	Primary: ease of sample recruitment and retention; Secondary: Treatment fidelity and adherence; Tertiary: Tolerability and adverse events; Time points: Baseline; 4 weeks; 8 weeks	Feasibility of study: 83% participants attended all 3 requested visits; 80% reported performing self-acupressure as instructed most of the time; 10% reported discomfort; 30 adverse events reported, most related to pre-existing health conditions	CONSORT: high
Li et al. (2017)⁴⁰	United States	Community residence	RCT	Double blinded	8 Weeks	Community-living older adults (≥65 years) with symptomatic knee OA (n = 150)	Research assistants (no further details given)	Knee OA	Standardized: self-acupressure protocol (YT, Anmian, HT7, SP6, KI3) once daily, 5 × week, for 8 weeks + weekly phone call from research assistant	Control No. 1 (Sham): as intervention, applied on nonacupoints (ST channel, LU channel, BL channel)+weekly phone call; Control No. 2: usual care+weekly phone call	Primary: WOMAC pain subscale; Secondary: NRS for pain; physical function; Time points: Baseline; 4 weeks; 8 weeks	Improved: Both verum and sham acupressure in WOMAC pain (mean difference −1.27 units, [95% CI, −1.95 to −0.58] and −1.24 units [95% CI, −1.92 to −0.55], respectively); NRS pain (−0.74 units [95% CI, −1.24 to −0.24] and −0.51 units [95% CI, −1.01 to −0.01] and WOMAC function (−4.83 units [95% CI, −6.99 to −2.67] and −4.21 units [95% CI, −6.37 to −2.04], respectively)	CONSORT: high
Macpherson et al. (2017)⁴¹	United Kingdom	Private practice settings	Secondary qualitative analysis (within pragmatic three arm RCT)	None	5 Months (with follow-up at 6, 12 months)	Participants randomized to acupuncture treatment group (n = 160), within larger RCT⁴²	Acupuncturists registered with British Acupuncture Council [3600 h degree level training⁶³] with minimum 3 years postqualification experience	Chronic neck pain	Individualized No. 1: TCM lifestyle advice+TCM acupuncture+usual care; Individualized No. 2: Alexander technique+usual care	Usual care	Primary: self-care, self-efficacy and lifestyle advice acted upon	Improved: acupuncture-related lifestyle advice helped patients improve the way they live and care for themselves and enhanced self-efficacy	CONSORT: medium
Macpherson et al. (2015)⁴²	United Kingdom	Private practice settings	RCT (pragmatic three arm)	None	5 Months (with follow-up at 6, 12 months)	Primary care patients who consulted their GP for chronic neck pain (n = 517)	Acupuncturists registered with British Acupuncture Council (3600 h degree level training⁶³) with minimum 3 years postqualification experience; Alexander teachers members of Society of Teachers of A. Technique	Chronic neck pain	Individualized No. 1: TCM acupuncture (including TCM lifestyle advice), × 12 sessions, +usual care; Individualized No. 2: Alexander technique, × 20, one-to-one sessions, +usual care	Usual care	Primary: pain and disability, via NPQ; Secondary: self-efficacy, QOL, adverse events; Time points: Baseline, 3, 6 and 12 months	Improved: between-group reductions in NPQ score at 12 months: 3.92% for acupuncture (95% CI, 0.97–6.87% points; p = 0.009); 3.79% points for Alex. (CI, 0.91–6.66% points; p = 0.010); at 12 months reductions in NPQ from baseline: 32% acupuncture; 31% Alex. self-efficacy improved for both groups	CONSORT: high
Macpherson and Thomas (2008)⁶⁴	United Kingdom	Private acupuncture clinics (n = 3)	Qualitative study (nested within pragmatic RCT⁴⁶	None	3 Months (with 12 month follow-up)	Acupuncturists who had participated in an RCT⁴⁶ assessing low back pain (n = 6)	Acupuncturists registered with British Acupuncture Council (completion of 3600-h degree level training⁶³) with minimum 3 years postqualification experience	Low back pain	Individualized: self-care TCM advice within context of acupuncture treatment (course of 10 individualized acupuncture treatments)	Usual care	Primary: descriptions of self-care advice provided; Secondary: Rationale for self-care advice; strategies used to improve uptake of such advice; expected impact upon health; Time points: postintervention (details unspecified) (2008)	Self-care advice seen by both participants and practitioners as an integral and interactive component of acupuncture treatment;⁶⁴ Improved: weak evidence found of effect of TCM acupuncture on LBP at 12 months; stronger evidence of small benefit at 24 months⁴⁶	COREQ: medium
Molassiotis et al. (2013)⁴³	United Kingdom	Unspecified and participants' home/private setting	RCT	None (pragmatic randomized trial)	4 Weeks (following initial 6 week RCT)	Breast cancer patients from previous acupuncture RCT (n = 197)	“Trained acupuncturists”; no further details given	Cancer-related fatigue	Standardized: acupuncture self-needling (SP6, ST36), × 1 week, 4 weeks, following 6 weeks of practitioner delivered course of acupuncture, within multisite RCT; Standardized No. 2: Continuation of acupuncture (SP6, ST36), as administered by acupuncturist, × 1 week, 4 weeks	Usual care/no maintenance treatment	Primary: general fatigue; Secondary: Mood, QOL, safety; Time points: Postintervention (shortly after trial had ended)	No further improvement: with self-acupuncture beyond initial clinic-based course; No statistical difference between trial arms (p = 0.18)	CONSORT: high
Mollart et al. (2016)⁴⁴	Australia	Two outer metropolitan public hospitals in NSW and participants' home/private setting	RCT (feasibility study)	None	±10 Days	Healthy primigravid women at 40 weeks ±2 days gestation (n = 67)	Trained midwife, attended 1-day workshop on acupressure; advice to protocol sought from trained acupuncturist, who is considered an expert in the field	Postdate pregnancy	Standardized: self-acupressure (SP6, LI4) every 2 h (GB21) × 2 day, until spontaneous or induced labor begins	Usual care	Primary: willingness of women to participate; Secondary: Compliance with study protocol; sample size estimation for future study; Time points: postintervention	Interest found in use of acupressure for initiation of labor with high protocol compliance in study group	CONSORT: high
Orpen et al. (2004)⁵⁸	United Kingdom	42 Hospitals and participants' home/private setting	Survey (via postal questionnaire)	N/A	Undisclosed	Hospital staff respondents (n = 30)	Various levels (E Pain grade nurses → nurse consultant, medical staff, physiotherapists, pharmacist): further acupuncture training undisclosed		Undisclosed Details No. 1: acupuncture administered at hospital; Undisclosed Details No. 2: self-acupuncture administered at home	None (N/A)	Primary: assessment of self-acupuncture as taught to patients through U.K. hospitals; Secondary: assessment of use of acupuncture in pain clinics in U.K. hospitals	Acupuncture found to be popular with patients who attend chronic pain clinics with existing hospital services unable to meet demand.	STROBE: medium
Sousa et al. (2015)⁴⁵	Portugal	Undisclosed and participants' home/private setting	RCT	Single blinded	3 Weeks	Professional orchestra musicians with PRMD as diagnosed by a physiotherapist (n = 69)	Practitioner with >30 years experience (formal training undisclosed)	PRMD in professional musicians	Individualized: self-applied tuina techniques according to a TCM diagnosis	Self-applied tuina techniques away from the commonly used acupuncture points	Primary: pain intensity via NVS; Secondary: frequency of practice; Time points: Baseline, and 1,3,5,10,15, 20 days	Improved: pain intensity significantly reduced: intervention group presented average of 5.03 (SD = 1.87); control average 3.8 (SD = 1.8); values at baseline not statistically different (p = 0.51)	CONSORT: medium
Sprague and Chang (2011)⁵²	United States	Undisclosed and participant's home/private setting	Single case study	N/A	6 Months	Single 34 year old patient diagnosed with CRPS	Unclear, however authors have DO (Doctor Osteopathy) and MACOM, Lac (Licensed Acupuncturist)	Chronic CRPS	Standardized: self-treatment via laser acupuncture pen device (large point prescription up to 20 points: 3 min per point, daily)+disposable press needles+acupuncture: 3 × week, 6 months; also dietary modifications, pain medications, cardio workouts on elliptical machine, avoiding strenuous physical activity	None, N/A	Primary: Mental state (BDI), Pain (McGill Pain Questionnaire), Disability (SDS); Time points: Baseline and postintervention	Improved: at 6 months: SDS decreased to 4; BDI to 0; MPQ to 10; Overall program led to 70% reduction in pain	CARE: high
Teig et al. (2006)⁵⁷	United Kingdom	General hospital and participants' home/private setting	Clinical audit (retrospective)	N/A	4 Weeks to respond to questionnaire+a reminder call+text audit	Chronic pain patients who were taught self-acupuncture in the previous 3 years (n = 52)	Nurse pain specialists; acupuncture training undisclosed	Chronic pain	Undisclosed details: self-acupuncture as taught by one of three nurse pain specialists, performed “no more than once every 2 days”	None, N/A	Primary: Pain relief (VAS), QOL; Secondary: Reasons for stopping self-acupuncture, Adverse events; Time points: postintervention (up to 3 years)	Improved: QOL reported by 73.7% patients; 86.8% continued use of self-acupuncture; pain relief gained 5.7 (SD 2.6) on VAS; adverse events reported included: bleeding from site:1; bruising:1; tiredness/fatigue:5; headache:1; increased pain:1; drowsiness:2	STROBE: high
Thomas et al. (2006)⁴⁶	United Kingdom	Private acupuncture clinics (n = 3)	RCT	None	3 Months (with 12 and 24 month follow-up)	Adults with LBP (n = 241), referred from 18 GP clinics	Acupuncturists registered with British Acupuncture Council (completion of 3600 h degree level training⁶³) with minimum 3 years postqualification experience	Low back pain	Individualized: self-care TCM advice within context of acupuncture treatment (course of 10 individualized acupuncture treatments)	Usual care	Primary: SF-36 bodily pain at 12, 24 months; Secondary: Use of analgesics, pain disability, patient satisfaction; Time points: Baseline, 3, 12, 24 months	Improved: weak evidence found of effect of acupuncture on LBP at 12 months; stronger evidence of small benefit at 24 months	CONSORT: high
Torkzahrani et al. (2015)⁴⁷	Iran	Deziani hospital	RCT	None	Term to childbirth (sampling over 6 months)	Primigravida women with term pregnancy (n = 150)	15 Years experience as nurses/midwives; further TCM training undisclosed	Cervical ripening pre-labor	Standardized: Nurse delivered acupressure (SP6) for 2 min alternated with no acupressure, for 20 min, for 1–5 days; Standardized No. 2: Self-acupressure “as above”	Usual care	Primary: cervical ripening (Bishop score); Secondary: record of application daily; Time points: every 48 h, from term to labor	Improved: mean Bishop score enhanced after 48 h (p ≤ 0.021) in researcher-performed acupressure group and in self-performed acupressure group (p ≤ 0.007) compared to control	CONSORT: high
Walter and Curtis (2013)⁵³	United Kingdom	GP clinic and participant's home/private setting	Single case report	N/A	2½ Years	Woman with SOD type III, 46 years, (n = 1)	General practitioner practicing western medical acupuncture, further training undisclosed	SOD type III; severe pain episodes	Standardized: self-electroacupuncture intervention, applied weekly and with episodes of severe pain	N/A	Primary: pain episodes (via pain diary); Secondary: frequency of intervention application; need for pain medication; Time points: Baseline, and via diary records	Improved: episodes of severe nighttime pain attacks and need for oxycodone and dihydrocodeine eliminated after 2 months of self-acupuncture and sustained for 12 months with ongoing monthly self-EA	CARE: high
Wenham et al. (2018)⁶⁵	United Kingdom	Private practice settings	Qualitative study (nested within pragmatic RCT⁴²	None	12 Months	6 Months (n = 30); 12 months, (n = 26)	Acupuncturists registered with British Acu. Council (3600 h degree level training⁶³) with minimum 3 years postqualification experience; Alexander teachers members of Society of Teachers of A. Techn.	Chronic neck pain (perspectives of participant in relation to self-efficacy and treatment)	Individualized: TCM acupuncture (including TCM lifestyle advice), × 12 sessions, +usual care; active 2: Alexander technique, × 20, one-to-one sessions, +usual care	Usual care	Primary: participants' perceptions and experiences of interventions; Secondary: factors participants associated with impact of interventions; Time points: 6 and 12 months	Five key themes: (1) comparison with pretrial experience of biomedical treatment and associated disempowerment; (2) pain reduction, movement freedom; (3) self-care, self-efficacy, self-empowerment and positive relationship with practitioner; (4) developing sense of embodiment; (5) all factors contributing to sustaining benefits in long-term	COREQ: medium
Zhang et al. (2014)⁴⁸	Australia and China	RMIT Clinical Trial Clinic and Guangdong Provincial Hospital of Chinese Medicine	RCT	Single blinded	8 Weeks (+12 weeks follow-up)	Adults with PAR (n = 245)	Acupuncturists with 5-year degree level training and over 10-years experience	PAR	Standardized: EAP via stainless steel pellets, applied by practitioner, weekly, on 5 points (Shenmen, Internal nose, Wind Stream, Adrenal) and pressed by patient three times a day for ∼10 sec	Standardized Sham Treatment: EAP via stainless steel pellets, applied by practitioner, weekly, on 5 points not typically used to treat PAR and pressed by patient three times a day for ∼10 sec	Primary: reduction of nasal and non-nasal symptom scores; Secondary: QOL, change of relief medication usage, credibility of blinding; Time points: Baseline, 1–8 weeks, 12 weeks	Improved (in real EAP group compared to sham): sneezing score (−0.39 [0.77 to −0.01]; runny nose score (−0.51 [−0.92 to −0.01]); total nasal symptom score (0.49 [−0.87 to −0.10]); eye symptom score (−0.36 [0.67 to 0.05]); QOL (0.50 [0.17 to 0.83])	CONSORT: high
Zhang et al. (2012)⁴⁹	United States	Clinic and community settings in West Texas metropolitan area and participant's home/private setting	RCT (feasibility study)	None	12 Weeks	Postmenopausal women with knee OA (n = 36)	Training material, including DVD, developed by licensed acupuncturist	Knee OA	Standardized: self-acupressure routine (10 min; 8 local acupoints)+warm up, rubbing kneecap, gentle movement (9 min), 5 × week, for 12 weeks	Usual care	Primary: feasibility of training self-acupressure to women with knee OA; Secondary: pain, stiffness, function (WOMAC); QOL (SF-36); Time points: Baseline, 6, 12 weeks	Self-acupressure for postmenopausal women with knee OA is easy to learn and safe to perform at home; no statistically significant results observed for clinical outcomes	CONSORT: high
Zick et al. (2011)⁶⁶	United States	Participant's home/private setting and study clinic	RCT (pilot study)	Single blinded	12 Weeks	Adult cancer patients with persistent moderate to severe fatigue (n = 43)	Acupressure practitioner with at least 2 years actively seeing patients, various degrees (ND, TCM, LAc, Dipl Ac)	Cancer-related fatigue, persistent (PCRF)	Standardized No. 1: self-acupressure: relaxing (YT, Anmian, HT7, SP6, LR3), 27 min total; × 2 day, for 12 weeks; Standardized No. 2: self-acupressure: HIS (ST36, SP6, KI3, LI4, CV6, GV20), 30 min total; × 2 day, for 12 weeks; Standardized No. 3: self-acupressure: LIS (ST36, SP6, KI3, LI4, CV6, GV20), 30 min total; 3 × week, for 12 weeks	None	Primary: fatigue (BFI); Secondary: assessment of blinding, treatment compliance; Time points: BFI: baseline and weeks 1–12; treatment compliance: daily; beliefs and expectations: baseline, week 12	Improved: reduction in fatigue in all groups: RA 4.0 ± 1.5, HIS 2.2 ± 1.6, LIS 2.7 ± 2.2; self-administered RA caused greater reductions in fatigue compared with either HIS or LIS	CONSORT: high
Zick et al. (2016)⁵¹	United States	Participant's home/private setting	RCT	Single blinded	10 Weeks	Breast cancer survivors (n = 288)	Acupressure educator, trained by acupuncturist with NCCAOM certification (minimum 4 academic years of training)⁶²	Cancer-related fatigue	Standardized No. 1: self-acupressure: relaxing (YT, Anmian, HT7, SP6, LR3), 3 min per point; × 1 day, for 6 weeks; Standardized No. 2: self-acupressure: stimulating (GV20, CV6, LI4, ST36, SP6, KI3), 3 min per point; × 1 day, for 6 weeks	Usual care	Primary: fatigue (BFI); Secondary: sleep quality (PSQI); QOL (LTQL); Time points: QOL: baseline, 6 weeks (end of treatment); 10 weeks; BFI: baseline and weeks 1–10	Improved: Sleep Quality (significantly lower PSQI) with relaxing acupressure at week 6; QOL significantly improved to usual care with relaxing acupressure at weeks 6 and 10	CONSORT: high

Standardized/Individualized—Standardized treatment applied according to basic biomedically defined condition/Individualized—Individualization of treatment according to a TCM or similar differential diagnosis.

Data quality: CONSORT: RCTs; CARE: case reports; COREQ: qualitative studies; STROBE: clinical audit, hospital survey, longitudinal descriptive study.

95% CI, 95% confidence interval; AD, atopic dermatitis; BDI, Beck Depression Inventory; BFI, Bowel Function Index; BMAS, British Medical Acupuncture Society; CAM, Complementary and Alternative Medicine; CARE, Case Report Statement and Checklist; CINV, Chemotherapy induced nausea and vomiting; CONSORT, Consolidated Standards of Reporting Trials; COREQ, Consolidated Criteria for Reporting Qualitative Research; CRPS, complex regional pain syndrome; EAP, ear acupressure; EASI, Eczema Area and Severity Index; GP, General Practitioner; HIS, Stimulating/High Dose; IGA, Investigators Global Assessment; IHD, ischemic heart disease; IMEA, Integrative Meditation and Ear Acupressure; INVR, Index of Nausea, Vomiting and Retching; LBP, low back pain; LIS, Stimulating/Low Dose; LTQL, Long-Term Quality of Life Instrument; MDI, major depression inventory; MPQ, McGill Pain Questionnaire; MYCaW, measure yourself concerns and well-being; NPQ, Northwick Pain Questionnaire; NRS, Numeric Rating Scale; NVS, Numeric Verbal Scale; OA, osteoarthritis; PAC-QOL, Patient Assessment of Constipation-Quality of Life Questionnaire; PAR, perennial allergic rhinitis; PPS, pressure pain sensitivity; PRMD, playing-related musculoskeletal disorders; PSOT, practitioner standard of training; PSQI, Pittsburgh Sleep Quality Index; QOL, quality of life; RA, relaxation acupressure; RCT, randomized controlled trial; SD, standard deviation; SDS, Sheehan Disability Scale; SF-12v2, Short Form Health Survey version 2; SF-36, 36-item Short-Form Health Survey; SOD, Sphincter of Oddi dysfunction; SSS, Stanford Sleepiness Scale; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology; TB, tuberculosis; TCM, Traditional Chinese Medicine; TED, treatment-effect difference; VAS, Visual Analog Scale; WHO-5, 5-item World Health Organization Well-Being Index; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

Risk of bias assessment

Assessed against CONSORT,²² the majority of the self-care RCTs adhered closely to the guidelines, with transparent reporting of study methodology (Supplementary Table S1). There was a notable lack of blinding in 12 of the RCTs, however, this was largely reflective of the design of these trials as either pragmatic studies assessing a routine clinical practice^41
–43,46 or as studies directly assessing self-care techniques.^{26,28,29,31,32,35,38,47}

Other items that scored weakly against the CONSORT include 7 trials failing to detail how sample size was determined,^{32
–34,37,38,41,45} a number of studies failing to detail the method used to generate^33,37,41 and type^{28,33,37,38,45,47,49} of randomized allocation sequence applied, and 11 of the RCTs failing to define dates of recruitment and follow-up.^{27,29,30,32
–34,37
–39,43,45} There was a notable lack of reporting on harms, with nine of the RCTs failing to mention whether there had been any adverse events.^{27

–30,32,33,37,41,45} Seven of these were acupressure studies, one comprised both acupressure and acupuncture,²⁸ and one was a secondary analysis.⁴¹ Clinical trial registration also rated poorly, with 13 RCTs being unregistered, bringing into question positive reporting bias.^{28,32

–35,37
–39,41,45,47,49,50}

The case studies^52,53 and case series⁵⁴ rated well against CARE²³ (Supplementary Table S2), however, all failed to clearly identify study methodology in their report title, as well as failed to comment on adverse events. The clinical audits and hospital survey varied in reporting integrity, when assessed against STROBE²⁴ (Supplementary Table S3), which was chosen as being the most relevant reporting guidelines published for such studies, however, it may be that STROBE is not adequately reflective of the nuances of clinical audits. The longitudinal descriptive study rated well against STROBE.

There were also three qualitative studies; the first investigating the experience of practitioners and patients⁶⁰ in one of the included self-acupuncture RCTs,⁴³ and the other two studies exploring TCM self-care advice as a component of traditional acupuncture care, from both the practitioner⁶⁴ and patient⁶⁵ perspective, within a pragmatic RCT. These studies failed to comply with certain items in the COREQ guidelines,²⁵ with key information missing in all studies, in relation to the research team and any potential pre-existing relationships (Supplementary Table S4).

Categorization of findings

Four key areas emerged in relation to the TCM self-care components evaluated within the included studies: self-acupressure; self-acupuncture; self-moxibustion; and adoption of prescribed lifestyle, diet, and exercise advice based on a TCM diagnosis. One study incorporated both self-care advice and self-acupressure, thus falling into two of the categories.²⁸

Self-acupressure

The self-care component of TCM most commonly investigated was self-applied acupressure (n = 23), assessed in relation to a biomedically diagnosed condition;^{26

–35,37

–40,44,45,47

–51,54,59} this included one study on self-shiatsu (a Japanese variation of TCM acupressure techniques)⁵⁴ and one examining self-applied tuina (TCM therapeutic massage).⁴⁵ All but two of the acupressure studies^54,59 were RCTs.

Conditions investigated in the acupressure studies varied widely (Table 3). Five studies examined women's health issues,^{28,29,31,44,47} four studies assessed acupressure in relation to mental state and/or quality of life (QOL),^30,34,50,51 three studies examined quality of sleep for sample groups with chronic pain,⁵⁴ a diagnosis of cancer,³⁵ and for women going through menopause,²⁷ with other studies assessing gastrointestinal complaints,^26,33,37,59 skin conditions,³⁸ allergic rhinitis,⁴⁸ and addiction withdrawal.³² Only four of the 20 acupressure studies evaluated musculoskeletal conditions,^39,40,45,49 with 2 of these being feasibility studies primarily examining recruitment and retention rates.^39,49

Table 3.

Conditions Investigated in Self-Acupressure Studies

Health area	Specific condition studied
Addiction withdrawal	Cocaine addiction³²
Gastrointestinal complaints	Constipation²⁶
Gastrointestinal complaints	Nausea/vomiting (chemo induced)^33,37,59
Mental state	Stress, depression³⁰
Mental state	Alertness³⁴
MSK	Knee osteoarthritis^39,40,49
MSK	Musician-related MSK disorders⁴⁵
QOL	QOL (ischemic heart disease)³⁰
QOL	Cancer-related fatigue^51,66
Respiratory	Allergic rhinitis⁴⁸
Skin	Atopic dermatitis³⁸
Sleep	Sleep quality during menopause²⁷
	Sleep quality with chronic pain⁵⁴
	Sleep quality in cancer patients³⁵
Women's health	Hot flushes²⁸
	Dysmenorrhea^29,31
	Postdate pregnancy⁴⁴
	Cervical ripening prelabor⁴⁷

MSK, musculoskeletal; QOL, quality of life.

Of the self-acupressure RCTs, three were double blinded^33,39,40 and seven single blinded.^{27,30,34,45,48,50,51} Sample size ranged from 7³⁵ to 288 participants⁵¹ with average sample size being 110 participants and over half the studies comprising 100 participants or more.^{26

–31,33,39,40,47,48,51} Duration of intervention ranged from 3 days³⁴ to ∼3 months,^30,32,49,50 with the average intervention time being 6 weeks.

Four of the self-acupressure RCTs prescribed an intervention based on an individualized diagnosis.^28,30,35,45 Individualized tuina protocols, based on a differential TCM diagnosis ascertained by an experienced practitioner, were prescribed in a study examining playing related musculoskeletal disorders in musicians, in Portugal.⁴⁵ Dietary recommendations were also made based on an individualized TCM diagnosis in an Italian study.²⁸

In evaluation of self-acupressure on stress, depression, and QOL in ischemic heart disease patients, one study incorporated daily self-assessment via testing pressure pain sensitivity (PPS) at certain acupuncture points.³⁰ After gauging PPS, a standardized self-acupressure treatment was then only applied if indicated, and in an ear-acupressure study conducted in the United Kingdom, auricular points were added to standardized points, from a small subsample, according to weekly symptoms.³⁵ Remaining studies prescribed standardized acupressure point protocols according only to the predefined biomedical symptom or condition.

All excepting one²⁸ of the acupressure RCTs, which examined a specific condition (n = 17), concluded positive findings^{26,27,29

-35,38,40,45,47,48,50,51} or a trend toward improved health outcomes.⁵⁴ In some cases, however, conclusions were tentative due to study limitations that included small sample sizes^{32,34,35,38,45} and a lack of blinding (n = 10).^{26

–29,31,32,35,37,47,49} Although some studies compared two active acupressure protocols,^{34,40,45,47,50,51} over a third (n = 8) compared the primary intervention with usual care only^{30

–33,35,38,44,49} or with baseline data.⁵⁴

Five studies included a sham acupressure intervention as a secondary^27,39,40,45 or primary control arm,⁴⁸ incorporating the use of acupressure points away from the recommended study protocol. The study that reported no benefit in self-acupressure compared individualized TCM diet and self-acupressure for those on a wait list, for the same protocol with the addition of acupuncture.²⁸

Self-acupuncture

The majority of studies examining self-acupuncture protocols were U.K. based, with four studies evaluating outcomes of existing self-acupuncture protocols, being prescribed by General Practitioners (GPs),⁵⁵ nurse pain specialists,⁵⁷ or other hospital staff,^56,58 in a GP practice and general hospital settings, respectively, via post-treatment audits. One study documented a single-case study of GP-prescribed self-administered acupuncture, with the addition of electrostimulation for a severe pain presentation,⁵³ and a qualitative evaluation,⁶⁰ nested within a multisite RCT,⁴³ examined the practitioner and patient experience of teaching and adopting self-acupuncture as an intervention protocol. A U.S. study documented a single case of daily self-administered laser stimulation on acupuncture points with the addition of disposable press needles.⁵²

All of the self-acupuncture studies assessing pain outcomes^53,55
–57 reported positive findings, with the qualitative study concluding self-acupuncture to be an acceptable and manageable intervention for patients.⁶⁰

Self-moxibustion

One RCT undertaken in Uganda examined the health outcomes of newly diagnosed tuberculosis (TB) patients, who self-administered rice grain-sized moxibustion daily, for 6 months, to the moxibustion point ST36, in combination with standard TB drug therapy.³⁶ Patients were trained in moxa application at their first visit by a designated TB nurse.³⁶ Improved outcomes in becoming sputum negative were seen in the moxa group in the first month, and a significantly larger improvement in hemoglobin levels was noted in the moxa group at 6 months.³⁶

Adoption of prescribed lifestyle, diet, and exercise advice based on a TCM diagnosis

Three studies, with results published in six articles, examined interventions that incorporated a TCM whole-system approach to care.^41,64,65

All based in the United Kingdom, the first examined, in addition to pain and disability outcomes, self-care efficacy and TCM lifestyle advice acted upon by patients,⁴¹ following 12 sessions of treatment within a pragmatic 3-arm RCT for chronic neck pain, via practitioner reporting.⁴² The second examined, qualitatively, the perspectives of participants,⁶⁵ in relation to self-efficacy and the TCM treatment provided, within the same RCT,⁴² and the third study examined, from the practitioner perspective, descriptions of TCM self-care advice provided, as well as the TCM rationale, adopted strategies to improve uptake and expected impact upon patient health,⁶⁴ within an RCT investigating traditional TCM-delivered acupuncture for back pain.⁴⁶

In both of these trials, self-care advice was individualized, integrated with TCM diagnostics, and delivered as an inherent part of each treatment session, with practitioners reporting that advice was most commonly related to exercise, relaxation, diet, rest, and work.⁴¹ One of the self-acupressure studies, conducted in Italy, also incorporated aspects of a whole-system approach, with the two arms of the intervention comparing self-acupressure combined with differentiated TCM dietary modifications, with the same intervention alongside standardized acupuncture.²⁸

Discussion

This review provides an overview of the known published research examining TCM self-care practices in cultural contexts outside of Asia, other than qigong and t'ai chi. A number of important findings are highlighted in this review, which warrant further consideration.

The limited number of TCM self-care studies in context of the broader TCM field

First, a relatively low number of studies on TCM self-care practices have been published. This is surprising given the high rates of TCM use globally,^67,68 reflected not only in the number of consumers but also in the national registration of TCM as a health profession in numerous countries outside China, including national registration in Australia,⁶⁹ state registration of acupuncture in over 46 states in the United States,^70,71 and provincial regulation of TCM and/or acupuncture in 5 Canadian provinces, as well as significant recognition in other countries. Furthermore, there appears to be relatively little attention to holistic approaches to treatment in these studies. All but four of the studies^28,41,64,65 based their self-care intervention on acupuncture points or channels, rather than implementing and/or assessing a broader interpretation of TCM self-care.

It may be that the promising body of evidence emerging from the research into acupuncture⁷² has placed “acupuncture” (and its meridian architecture), in application as well as in language, in a highlighted position in relation to the perception of what it is that comprises holistic TCM health care. This focus has potentially placed in the background an interest in utilizing and assessing the value of broader self-care aspects of TCM and foundational Chinese medicine philosophy and practice, despite their traditional place being considered highly important for patient recovery, prevention of illness, and long-term health.¹⁰

Further to t'ai chi and qigong, which falls outside the scope of this review, these broader aspects can include maintaining daily rhythms in line with 24-h and seasonal cycles, supporting metabolism and immunity through dress and hygiene practices, and adjusting diet according to individualized differentiation and seasonal change.^73,74 A focus on single therapies and treatments, outside of a TCM context, may not be congruent to the stated focus of TCM on holistic and patient-focused care. Its increasing use in research contexts may be related to the fact that single therapies are easier to integrate into other existing programs and into the design context of a randomized controlled trial, even if they may not be representative of TCM care in clinical practice.⁷⁵

Evaluation of TCM self-care practices within a whole system of care approach

Individualization of treatment in TCM is also overlooked by most studies, even though it remains a core element of TCM practice. Of 37 articles retrieved, only 3 evaluated an individualized intervention delivered within TCM as a whole system of care,^41,64,65 and only a further 3 applied an intervention based upon an individualized TCM diagnosis.^28,30,45 In countries where professional registration is in place for TCM, registration standards require practitioners to undertake years of training, not only in acupuncture as a symptomatic treatment approach but also in TCM as a complete system of diagnosis and care, based in the constructs and paradigm of the medicine.^69
–71,76

Moreover, this ignores contemporary developments in practice of TCM such as individualized TCM diagnosis being codified for inclusion in the newest update of the International Classification of Diseases⁷⁷ and the fact that this individualized approach has been repeatedly identified as one of the primary reasons that patients are attracted to complementary medicine approaches such as TCM.⁷⁸ This comprehensive and individualized approach is, however, only sparsely reflected in research methodology in studies examining TCM.

Future research could more accurately assess the impact of TCM interventions as they occur in “real-world” practice settings, if designed in line with flexible individualized diagnoses, adapted according to the patient's real-time presentation, as is the recommended practice for those who are professionally accredited in the field. With this in mind, researchers may benefit from employing the pragmatic clinical trial methodology⁷⁹ to interrogate TCM interventions.

Positive findings and the relationship between health, self-efficacy, and self-care

Despite these limitations, there appears to be a promising emergent body of evidence for TCM self-care approaches. Of the TCM self-care studies that assessed health-related outcomes, the majority concluded positive findings (n = 24).^{26,27,29

–32,34
–36,38,40,41,45,47,48,50

–55,57,59,80} However, there may be some issues with generalizability; only three studies^41,45,65 prescribed an intervention based upon an individualized differential TCM diagnosis suggesting that, in similarity to acupuncture studies,⁷² effect size may be misrepresentative due to the limitations inherent in applying standardized intervention protocols.

Such limitations include the simplification of more complex diagnoses⁴¹ to align with the current practice and language of biomedicine, as well as the simplification of the TCM intervention itself, to allow replication and ease of assessment within the context of clinical trials. Nevertheless, the promising results of studies in this review suggest that further investigation of TCM self-care approaches in broader health care settings is warranted.

Incorporation of individual TCM therapies within a whole-system context appears to improve results of those treatments. In an analysis of patients receiving acupuncture treatment in the context of a whole system of care approach, patients were found to have increased their self-efficacy, and for there to be an association between increased self-efficacy and significant reductions in pain and disability in relation to the condition assessed at 6 months postintervention.⁴²

In secondary analyses of the same study, self-care advice provided by practitioners was most commonly related to exercise, relaxation, diet, rest, and work,⁴¹ with patients identifying a positive practitioner relationship, as well as a developing sense of embodiment and self-empowerment, as factors that contributed to sustaining long-term benefits.⁶⁵ In addition to self-efficacy, a German study, outside of the citations included in this review, assessing an integrative medicine inpatient program (n = 2486), concluded that patients' stage of change and their health locus of control (HLOC), that is, their beliefs in relation to control of health outcomes, were all predictors for health behavior change.⁸¹

This relationship between beliefs, understanding of one's health, and improvement in self-efficacy is of interest relative to TCM self-care, which aims to engage the patients in an element of understanding as to why a certain practice may be affecting their health positively or adversely. This aspect of sharing knowledge and imparting understanding, within the TCM consult, may therefore encourage the patients to increase their internal HLOC to affect behavior change.

In a pragmatic U.K. study of self-care communication in TCM acupuncture consults, self-care advice was seen by practitioners as being integral to the patient's treatment and was found to be delivered in the context of a therapeutic relationship based on continuity, mutuality, and trust,⁸² thus providing ongoing support in the potential encouragement of self-efficacy. These findings of improved self-efficacy are similar to the results of a New Zealand study that examined the impact of self-care advice on patients receiving acupuncture for primary dysmenorrhea.⁸³ Study participants reported that they felt the self-care advice received during appointment visits had been related to both an increase in self-efficacy and positive outcomes in relation to symptom control.

These findings suggest that health promotion activity is intrinsically built into contemporary TCM practice—just as it was in historical TCM practice—even when TCM care is not specifically targeting self-care. These positive results suggest that this aspect of TCM care should be encouraged and supported through education and regulation initiatives, which can sometimes favor competency in individual treatments over holistic medical paradigms.⁸⁴

Also of interest is the finding in the acupressure self-care study, included in this review, which examined the effect of acupressure on cervical ripening at the initiation of labor, in which Bishop scores were found to be significantly higher in the group where the acupressure was self-administered compared with when it was nurse-delivered.⁴⁷ Such a finding suggests that an increased internal HLOC may have improved patient outcomes in the self-acupressure group beyond the effects of the intervention itself and thus provides a case for further investigation into the comparison of practitioner-applied or patient-applied interventions. Future research involving TCM self-care (and self-care more generally) should thus consider HLOC as a mediating factor upon study outcome and could consider including comparative interventions with HLOC as a control.

TCM self-care studies and the issue of safety

The majority of studies in the review assessed a standardized treatment protocol in relation to a predefined biomedical condition.^{34

–40,43,44,47

–53,56

–59,85} Such an approach allows for the design of a rigorous study methodology that can be more readily replicated and assessed in an RCT, however, brings with it the limitation of lacking the prescription of individualized diagnoses and treatments, which are the traditional and existent design of delivery for those practicing TCM, including in countries with legislated TCM registration in place.^69
–71

It must therefore be carefully considered whether such trials designed with symptomatic prescriptions, be they in acupuncture, herbal medicine, or self-care techniques, are truly assessing a holistic TCM approach, or rather, simply assessing a singular TCM technique within a compromised context that may not accurately reflect real-world practice.

Further to this issue is the concern of patient safety beyond the baseline observations of soreness, bleeding, bruising, or skin irritation at an acupressure or acupuncture site. With varying research-based evidence to indicate that acupuncture affects numerous internal systems, including the hormonal, circulatory, respiratory, and musculoskeletal systems,^{72,86

–91} the ethical stance of applying standardized treatment, without assessing the patient's entire presentation, must be considered. In the context of this review, TCM treatment—whether practitioner-applied or self-applied—which is not carefully aligned with a comprehensive TCM diagnosis, may place the subject at risk of adverse treatment effects, when viewed from the perspective of TCM. Although some studies indicate that individualized TCM treatment protocols are not superior to standardized interventions in relation to the primary condition examined,^92,93 it must be noted that treatment outcome measures in these studies rarely extend to include other concomitant changes in baseline health status. Furthermore, slow and gradual changes would not warrant being noted as adverse events, and positive changes in another aspect of the patient's health are not, in most RCTs, recorded unless predetermined by the research team.

Individualized diagnoses versus simple TCM self-care approaches

The majority of studies reviewed applied a version of TCM self-care, similar to that of a prescribed standardized intervention, such as in the case of acupressure being applied to three set acupuncture points for patients with dysmenorrhea.³¹ Broader lifestyle approaches, which draw on a TCM perspective, however, aim to impart understanding, along with a lifestyle change, which has the potential to improve self-awareness and self-efficacy.⁴²

For example, a TCM practitioner may recommend eating warm foods before and during a woman's menses, in line with the concept of encouraging improved blood flow and circulation, thus potentially leading to less menstrual pain;⁸³ advice that can be tailored further based upon the patient's presentation. Thus, it is the case that both individualized advice and prescriptions can be recommended from a TCM perspective, as would occur in a real-world clinical setting, and that general TCM concepts can be employed as self-care.

Review limitations and future areas of research

The findings of this review need to be considered within the context of certain limitations. First, the retrieved articles for this review have been selected with a specific focus on self-reported TCM care practices engaged with by the patient, outside of qigong and t'ai chi, as well as outside of Asia and Asian communities, employing search terms based upon categories used in the literature.

However, despite attempts to be as exhaustive as possible within the scope of the research question, the authors acknowledge that this focus may have inadvertently resulted in some articles being missed, such as those that did not specifically identify as TCM or East Asian Medicine, as well as articles with broader scope, which may have incorporated a whole systems approach and individualized treatment. Thus, the focus has landed primarily on physical activities undertaken by the patient, potentially resulting in the clustering of articles on self-acupressure and self-acupuncture.

Second, the relative simplicity and degree of cultural integration of many TCM and foundational Chinese medicine self-care practices, even in settings outside of Asia, suggest that analyzing these components in individual parts may provide a limited perspective on the topic. Future research could consider an approach that compares individual self-care components with existing cultural practices in context and the potential role such practices play in the overall health of an individual or community.

Conclusion

The positive findings indicated by results of studies into TCM self-care, in settings outside of Asia, beyond the sole practices of t'ai chi and qigong, suggest a potential benefit from such practices and that this field warrants further investigation. The limited amount of research retrieved does not allow for definitive conclusions on the effectiveness of TCM self-care interventions. However, the trend toward positive results in the trials uncovered suggests the potential benefit of TCM self-care practices, which, if assessed with greater validity in a real-world context, could potentially provide benefit to health outcomes in community and population health programs, or be incorporated into health promotion initiatives.

TCM self-care practices may also increase long-term health outcomes by increasing the patient's level of self-awareness, and internal HLOC, thus leading to long-term health-related behavior change.

Footnotes

Acknowledgment

This research is supported by an Australian Government Research Training Program (RTP) scholarship.

Author Disclosure Statement

No competing financial interests exist with respect to the research, authorship, and/or publication of this article.

Supplementary Material

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

Supplementary Table S4

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