The Assessment and Treatment of Inpatient Cancer-Related Pain with Acupuncture: Development of a Manual

Abstract

Background and Objective:

Pain is a highly prevalent and distressing experience of hospitalized patients with cancer, and undertreatment is a challenging issue. Adding nonpharmacologic treatments such as acupuncture to conventional pain management may help address a patient's total pain experience. A dearth of acupuncture treatment guidelines exists, leaving individual practitioners to develop treatments themselves. The aim of the work described in this report was to develop a standardized clinical reference manual for East Asian Medicine (EAM) assessment, diagnosis, and acupuncture treatment of cancer-related pain in hospitalized patients with cancer.

Design:

The acupuncture manual was developed based on: (1) a narrative review of existing literature on acupuncture and cancer pain; (2) a review of acupuncture charting notes of more than 200 treatments provided in an inpatient setting; and (3) meetings of an expert panel of senior acupuncturists to reach consensus on a manual protocol.

Results:

The resulting manual described diagnosis of patients based on EAM constitution, symptoms and signs, and channel location of the cancer-related pain symptoms. The resulting point selections for acupuncture treatment enables adaptability, reproducibility, and individualized acupuncture treatment of cancer-related pain in hospitalized patients with cancer.

Conclusions:

The manual fills a vital gap in the current literature, and supports community- and hospital-based acupuncturists as a standardized clinical reference. The manual provides guidance for cancer-related pain management, using EAM acupuncture in hospitalized patients.

Introduction

At least half of hospitalized patients with cancer experience pain during their stays.^1–3 Despite improved assessment and pharmacologic management, undertreatment of cancer pain remains a challenging issue.^1–3 Using nonpharmacologic treatments with medications may address patients' pain better by relieving physical and psychologic symptoms and reducing the adverse effects of opioid medications. Evidence from observational research^4,5 and pilot studies^6,7 supports the use of inpatient acupuncture to reduce patients' pain intensity and improve their quality of life (QoL) with fewer functional limitations and an increased sense of well-being.

Although more health systems are adding acupuncture as part of integrative medicine services offered, a lacuna exists across East Asian Medicine (EAM) literature guiding acupuncture treatment of inpatients with cancer-related pain. Acupuncturists have applied EAM theory, principles, and diagnostics to assess and treat inpatients with cancer and have observed positive effects. Large-scale randomized clinical trials are needed to determine the effectiveness of these therapies in real-world hospital settings. Acupuncture as practiced in real-world settings is rarely evaluated in RCTs. In preparation for a pragmatic effectiveness trial, a clinical guide was developed through treatment manualization, a process initially created to evaluate complex, heterogeneous psychotherapy interventions and used in prior clinical trials of acupuncture.^8–10 This article describes the inpatient manual that was developed for assessment, diagnosis, and treatment of hospitalized patients with cancer-related pain.

Manual Development

To develop this treatment manual, methods similar to those recommended by Schnyer and Allen⁹ were used, including: (1) a narrative review of existing literature on acupuncture and cancer pain; (2) review of acupuncture charting notes of more than 200 treatments provided in an inpatient setting; and (3) meetings of an expert panel of senior acupuncturists to reach consensus on a protocol.

The narrative review included contemporary and classic EAM textbooks and published research in English-language journals. Based on this review, the range of EAM patterns and diagnoses that correspond with cancer-related pain were identified, and an inventory was created of acupuncture points and other treatment details for addressing cancer-related pain. The manual was also informed by practice-based data. Reviews were performed of charting notes from more than 200 acupuncture treatments provided during a pilot study conducted at the University of California–San Francisco (UCSF) Mount Zion Hospital in 2014. To inform the manual, data extracted from the electronic medical records were analyzed to identify the most-common EAM diagnoses and frequently used acupuncture points.

To finalize the treatment manual, 5 licensed acupuncturists (LAcs) were consulted at a series of meetings. All of these LAcs had been in practice for more than 10 years and had treated more than 100 patients with cancer. Preliminary drafts of the treatment manual were circulated to the acupuncturists prior to implementation. The acupuncturists discussed details of the treatment protocol and evaluated the manual based on three criteria: (1) likelihood of efficacy; (2) representation of usual practice; and (3) and overall utility with hospitalized patients. Decisions about diagnosis and acupuncture points were made based on the consensus.

EAM treatment is multimodal and typically includes a combination of acupuncture, cupping, moxibustion, tui'na (Chinese medical massage), external herb applications, and ingestion of herbal formulas, as well as dietary and lifestyle modifications. Because acupuncture is often used as the sole treatment modality in medical clinics and hospitals, it is the primary treatment method. Thus, this treatment manual using acupuncture in isolation would not be representative of EAM practices that use multiple modalities but would reflect typical treatments offered in biomedical settings.

Based on the clinical experiences of the UCSF Integrative Chinese Medicine team, most cancer-related pain responded to acupuncture within the first 24 hours of treatment. Relief time varied, based on severity and type of pain, as well as type of cancer and underlying causes of the pain.

Treatment Manual

This section presents the framework of EAM pattern diagnosis of cancer-related pain. To lay the groundwork, the first discussions cover terminology and EAM pathophysiology of cancer-related pain. Patients with cancer can be complex to treat, due to frequently having multiple EAM pattern diagnoses and restricted accessibility of points local to the pain. Diagnosis of each patient comprises 2 parts: (1)

Choosing 1 or more EAM pattern diagnoses based on constitution, symptoms, and signs

(2.)

Identifying the channel location of the cancer-related pain symptoms.

Based on the synthesis of findings, a set of EAM pattern diagnoses was created that captured the core information in a format that is easy to apply with high reproducibility. The format also enables choosing EAM pattern diagnoses unique to each patient and determining the acupuncture point selections for the individualized treatment plans.

EAM Terminology

The terminology of this manual is based on the Zang-Fu Organ Theory and Eight Principle patterns of EAM.¹¹ In EAM, symptoms of a patient's cancer-related pain are considered with the rest of a patient's presentation to determine his/her EAM pattern diagnosis. Therefore, cancer-related pain can correlate with a number of different EAM diagnostic patterns. In fact, in EAM, a patient's diagnosis is usually a complex combination of multiple diagnoses¹² that defines the patient's EAM constitution and identifies the disease pathology. This manual uses the term EAM pattern diagnosis (or simply pattern for short) in 1 of 2 ways: (1) a pattern may refer to 1 item on the list of specific patterns described in Section 2C of the manual; or (2) a pattern may refer to a patient's overall combination of multiple patterns that constitute a patient's complete diagnosis.

EAM terminology includes organ systems that are not directly equivalent to anatomical organs despite using similar biomedical syntax. EAM organ physiology may also overlap with biomedical organ physiology. To distinguish between EAM concepts and anatomical or biomedical concepts, the convention of capitalizing the first letter of the word is used (i.e., Blood rather than blood; Stomach rather than stomach). Standard nomenclature recommended by the World Health Organization is used for acupuncture points.¹³ EAM words or phrases that are used in the English language and have entries in Merriam Webster terminology are capitalized but not italicized (e.g., Yin, Yang, and Qi). Uncommon EAM terms not used in the English language are italicized (e.g., Xi cleft/confluent points).

EAM Pathophysiology of Cancer-Related Pain

EAM theory focuses on recreating health and wellness through balancing physiology. EAM pattern diagnosis is based on the Eight Principles and Zang-Fu theory. The most important consideration in choosing an EAM pattern diagnosis is evaluating the patient's signs and symptoms according to the Eight Principles, which refer to 4 pairs of fundamental qualities of a disease: (1) Excess/Deficient, (2) Cold/Heat, (3) Yin/Yang, and (4) Interior/Exterior. The broad differentiation of a patient as Excess or Deficient is commonly the first step in evaluation and, therefore, is the broadest grouping for the differentials used. To formulate treatment, imbalance or pathology must first be identified. The identification of these pathologies becomes the EAM pattern diagnosis. Both the affected organs and channels must be identified to categorize the EAM pathology—the EAM pattern diagnosis, of cancer-related pain—properly. Cancer-related pain can be classified as 1 of 3 patterns of imbalance or pathologies:

Cancer-related pain due to a Deficiency will have the following characteristics: patient generally likes pressure and warmth; pain produces sensations of dull aching, pressure, and heaviness; and can be diffuse. Generally, the pain is less intense.

Cancer-related pain due to an Excess will have the following characteristics: patient will not like pressure; and sensation may be sharp, stabbing, shooting, and throbbing. Excess pain is described more easily as localized. Generally, the pain is more intense.

Cancer-related pain due to a mixed combination of Deficiency and Excess will have the following characteristics: pain sensation may vary from aching and diffuse to sharp, stabbing, and localized. It is not just the intensity of pain but also the nature of the pain and what relieves the pain. The pain may like touch at one time and not at another time. Pain levels can also vary.

EAM Diagnosis of Patients with Cancer-Related Pain

Patients with cancer can be complex to treat, due to frequently having multiple EAM pattern diagnoses and restricted accessibility of points local to the pain. Diagnosis of each patient will comprise 2 parts:

Choosing 1 or more EAM patterns based on constitution, symptoms, and signs

Identifying the channel location of the cancer-related pain symptoms.

EAM Pattern Diagnoses for Cancer-Related Pain

With cancer-related pain, it is important to remember the EAM characteristics of the specific cancer and of the medications and treatments. It is also important to remain cognizant of the risk of depleting the patient further¹⁴ and of potentially reducing the effectiveness of the cancer treatments by improper treatment. Acupuncturists should consider the effects of the oncology treatments and polypharmacy on EAM physiology as contributors to the differential diagnosis.

The EAM tongue and pulse examinations are essential to achieving an EAM pattern diagnosis. If the tongue and pulse have consistent qualities with each other, then the underlying constitution, the nature of the specific cancer, and the effects of the medications and treatments may all be congruent with an EAM pattern diagnosis. If the tongue and pulse do not match, a general rule is to recognize Deficiency as the patient's underlying constitution and Excess as the result of the medications and treatments.

The foundational elements for the pattern diagnosis are EAM-based subjective and objective data obtained from the Four Questions: (1) questioning; (2) palpation; (3) observation; and (4) listening/smelling. When assessing the EAM pattern diagnosis in cancer-related pain, the inquiries about the pain include: its location and nature; the patient's reactions to pressure, movement, activity, rest, stress, lifestyle, heat, cold, food, drink, and bowel movements. The Zang-Fu organ patterns of imbalance summarized in Table 1 were identified as the most common in patients with cancer-related pain in the clinical experience of the UCSF Integrative Chinese Medicine team and in data from the current authors' pilot study. The diagnoses provided are not mutually exclusive; as noted before, patients with complex conditions, such as cancer-related pain, often have multiple EAM pattern diagnoses.

Table 1.

East Asian Medicine pattern Diagnosis for Cancer-Related Pain

Deficiency patterns	Excess patterns
Yin Deficiency Lung Yin Deficiency with or without Heat/Toxic Heat Heart Yin Deficiency with or without Heat/Toxic Heat Liver Yin Deficiency with or without Heat/Toxic Heat Kidney Yin Deficiency with or without Heat Yang Deficiency Kidney Yang Deficiency Spleen Yang Deficiency Blood Deficiency Heart Blood Deficiency Liver Blood Deficiency Qi Deficiency Spleen Qi Deficiency Kidney Qi Deficiency	Dampness accumulation Temperature –with or without Heat/Toxic Heat –with or without Cold Internal clumping of Toxic Heat Blood Stagnation Qi Stagnation Stomach Qi Counterflow Calm Shen

Channel Location

Channels, also known as vessels or meridians, are lines connecting acupuncture points that traverse the body and correlate with Western anatomy and EAM organs. One can address pain localized to specific anatomical locations or address organ pathology by distal needling away from the affected area, but on the affected channel(s).

Cancer-related pain can be diffuse or localized. Selection of the affected channel(s) will focus on the epicenter, or origin, of pain. Multiple channels may also be affected. The treatment of cancer-related pain with the diagnostics of channel diagnosis is delivered by the use of Xi cleft/confluent points listed in Table 2. Xi cleft/confluent points are used to treat pain and are primarily located at the joints. These locations serve well for cancers located in the torso, neck, and head, given that the locations of these cancers are contraindicated for needling. Points are chosen based on location—unilateral; bilateral; or contralateral—enabling utilization of body areas not being tended to by other treatments (e.g., intravenous injections, bandages, surgical sites).

Table 2.

Cancer-Related Pain Channel Diagnosis and Xi cleft/confluent Points

Channel	Xi cleft/confluent point
Lung	LU 6
Large Intestine	LI 7
Stomach	ST 34
Spleen	SP 8
Heart	HT 6
Small Intestine	SI 6
Urinary Bladder	UB 63
Kidney	KI 5
Pericardium	PC 4
San Jiao	TE 7
Gall Bladder	GB 36
Liver	LR 6
Governing	SI 3 (confluent)
Conception	LU 7 (confluent)

Treatment of Cancer-Related Pain

The diagnostic framework includes 2 steps: (1) selecting the EAM pattern diagnosis, including an understanding of the impact of the cancer in EAM terms, and a knowledge of biomedical medications and treatments in EAM terms; and (2) selecting the channel location where the pain is experienced. The acupuncturist should review the patient's chart and most recent laboratory test results to ensure that platelets number >50,000 and absolute neutrophil count is >500 prior to needling, although the minimum levels required at various institutions may differ.

Selection of acupuncture points is individualized for each participant and is modifiable if the participant's EAM pattern diagnosis or affected channel presentation changes while the patient will be enrolled in the study. Aside from selection of points, the remaining aspects of the treatment protocol are consistent for all patients. Acupuncture points are selected to address each of the 2 aspects of the diagnosis:

(1)

Diagnosis is based on question responses, tongue, pulse, and signs and symptoms. This also includes:

(A) The EAM interpretation of the specific cancer impact

(B) The EAM interpretation of the cancer medications and treatment effects.

(2)

Channel location is based on pain location or organ affected by pain. It is common for the areas of pain in patients who have cancer to be inaccessible or contraindicated. Due to these potential factors, the possibility was included to treat cancer-related pain on affected channels using Xi cleft/confluent distal points and avoid inaccessible or contraindicated locations.

Point Selection by Pattern Diagnosis

Point selection is based on the patient's EAM pattern diagnosis and channel(s) affected by pain. Table 3 lists acupuncture points to be used for each pattern diagnosis and its symptoms. The overlap in symptoms among the categories reflects the subtle nuances of EAM pattern diagnosis and the prescribed points for similar categories that also overlap each other. Multiple EAM pattern diagnosis patterns may apply to each patient, and, when used together, describe a more-precise picture of a patient's individual presentation within the EAM milieu. This yields a point prescription that is consistent with EAM theory, uniquely tailored for the patient, and highly reproducible.

Table 3.

Cancer-Related Pain East Asian Medicine Pattern Diagnosis, Symptoms and Treatment Points^*

Differential diagnosis	Signs and symptoms	Treatment points
	Deficiency patterns
Yin Deficiency (Heart, Kidney, Liver, Lung) with or without Heat	Dull, lingering pain alleviated with pressure With Heat, patient does not like pressure & pain may be burning Neuropathy; anxiety; palpitations; restlessness; dry mouth, throat, & eyes; tongue lesions; night sweating; insomnia; feelings of heat in afternoon or evening; malar flush; thirst; dizziness; vertigo; poor memory; tinnitus; hearing loss; constipation; dark scanty urine; thin body; bone aches; easily startled T: thin, red, cracked C: dry or nonexistent P: superficial, Deficient, thin, thready; rapid if Heat signs	CV17, HT6,^* HT7,^* LR8, ST44, KI3, LU7, KI6,^* LI11, LR2, KI2 Ear: Shen Men^*
Yang Deficiency (Kidney, Spleen)	Low-back pain; knee pain; lingering, dull, aching pain with sensation of pressure Patient likes pressure Dyspnea; fatigue; weakness; lassitude; depression; spontaneous sweating; poor appetite; loose stools; feelings of cold; cold limbs; bright pale face; absence of thirst; desire for hot drinks; frequent pale urination; exhaustion; decreased libido; edema in lower part of body; long-term chronic illness T: pale; possibly enlarged, scalloped C: wet; possibly white, greasy P: Deficient; deep; weak	GV20,^* ST36, SP6,^* SP9, KI3, KI7
Blood Deficiency (Liver, Heart)	Numbness; tingling; achy pain Patients likes pressure Neuropathy; muscle cramps; dull, white, sallow complexion; dizziness; poor memory; eye floaters; blurred vision; dry eyes; diminished night vision; insomnia; pale lips; brittle nails; dry hair & skin; depression; anxiety; palpitations; bruises easily; tremors T: Pale; puffy C: dry or none P: choppy; thin; or superficial & empty	CV17, LI4, SI3, HT3^, HT7^, TE5, PC6, SP6^, LR3, LR8, ST36, ST37, GB39, GB31 Ear- Shen Men^
Qi Deficiency (Spleen, Kidney)	Dull, aching, lingering pain Patient likes pressure Fatigue; dyspnea; poor appetite; “foggy” headed, dull thinking; dull countenance; spontaneous sweating; loose stools; abdominal distention; possible edema; pale face T: pale; enlarged, scalloped C: white P: weak; soft; thin; slippery	ST36, SP6^, LI4, GV20^, LU9, CV12, KI3, KI7, GB39

	Excess patterns
Damp With or without Heat/Cold	Swelling; edema; feelings of heaviness/sinking; burning pain; poor appetite; nausea; vomiting; urinary difficulty &/or cloudy urine; absence of thirst; difficulty thinking clearly; dull headache; increased secretions; loose stools, leucorrhea; mucus in lungs, nose, throat, or stool With Heat, feelings of Heat scanty dark urine; low-grade fever; jaundice; oily sweat; bitter taste; yellow mucus; pruritus & skin lesions; strong odor T: enlarged ± red. C: wet; sticky/greasy white or yellow P: slippery; soft ± rapid ± full	CV12, LU9, LI11, SP9, ST40, LR2, GB34, BL60, LR5
Internal clumping of Toxic Heat	Fixed & stabbing pain that may feel hot; writhing pain; neuropathy; dry withered appearance; irascible; tumor; exhaustion; weakness; thirsty & hot; constipation; restlessness; fever; red face & eyes; dry mouth; reflux T: dusky; red; scorched; dry ± distended sublingual veins C: may have dry, greasy, yellow coating or no coating P: full; rapid; choppy	LU6, LR2, LI11, ST40, ST44, HT3, SP10, CV12
Blood Stasis	Fixed, severe, stabbing pain, worse with pressure; reduced range of motion; swelling T: purple/dusky; distended sublingual veins P: choppy; tight	SP10, PC6, SP4^, LR3, LR2, LR6, BL60, SP21 Ba Feng*
Qi Stagnation	Distention & pain in the body that is achy, throbbing, diffuse Patient does not like pressure Depression; irritability; easily angered; moodiness; belching; difficulty swallowing; poor appetite T: dusky; red; stiff P: bowstring; full	ST34, PC6, BL60, GB34, LR2, HT3^, SP21, CV12, CV17, LI4, LR3, SI3, BL62, TE5, GB41, Ba Feng*
Stomach Qi Counterflow	Nausea; vomiting; belching/burping; gastric reflux; hiccups; cough; palpitations; dizziness T: tender; red ± thick coat P: rapid; full; bowstring; slippery; Deficient	CV12, ST36, ST44, PC6, LR3
Calm Shen	—	Yintang, GV24, HT4, HT5 Ear: Shen Men, Amygdala, Sympathetic, Point Zero

Point is also indicated for calming the Shen.

T, tongue; P, pulse; C, coating.

The following acupuncture points can be included for relaxation and for calming the Shen: yin tang; GV 24; HT 4; HT 5; and ear points Shen Men, Amygdala, Sympathetic, or Point Zero. These points are used to calm the Mind,¹⁵ and are clinically appropriate for hospitalized patients with cancer-related pain.

Point Selection Based on Symptom Channel Location

It is common for the areas of pain in patients with cancer to be inaccessible or to be contraindicated. Due to these potential factors, distal treatment on affected channels was included to avoid the aforementioned difficulties. Xi cleft/confluent points are chosen due to their traditional use for pain treatment along the organs and channels, as points where the Qi and Blood of a meridian accumulate. Table 3 lists the Xi cleft/confluent points to be used for Channels affected by cancer-related pain. The Governing and Conception channels are treated with confluent points because no Xi cleft/confluent point exists for these 2 channels. Confluent points help open the channel and therefore address pain.

Additional Rationale for Point Selection for Treating Cancer-Related Pain

The treatment manual described here aims to standardize an effective, practical, and reproducible process in the style of EAM's Eight Principles, Zang-Fu Theory, which is a school of EAM thought taught broadly and practiced in the United States and China. In addition, the points included in the protocol are appropriate for an inpatient setting. As previously discussed, the points chosen enable treatment when the area(s) of pain are contraindicated for needling due to either the prevalence of cancer in the area, the placement of medical equipment, or the area having a wound. This enables use of constitutional points (see Table 2) to address pain as well as using distal Xi cleft/confluent points (Table 3). These specific Xi cleft/confluent points are selected from either: (1) the same channel as the location of pain symptoms; (2) on the same channel with the affected Zang-Fu organ system affected by cancer-related pain; or (3) the treatment of cancer-related pain according to the EAM pattern diagnosis.

One advantage of using both EAM pattern diagnosis and channel-location points is that a patient will not have to remove bandages and/or medical equipment, or be moved from the hospital bed. The patient can be seated comfortably or remain lying in the hospital bed during treatment. Distal points such as Xi cleft/confluent points are recognized in the acupuncture world as being highly effective and are frequently used points for pain in acupuncture practice.¹²

Number of Needles and Needling Techniques

The least number of needles that can address all local symptoms—branch (symptoms) and root (source of symptoms)—is preferable because use of fewer needles enables the treatment to be more focused.¹³ In addition, administering too many needles potentially drains a patient's Qi, which is contraindicated for patients with underlying Deficiencies, as is often the case with patients with cancer. For the study that will use this manual, the guideline is 4–12 needles.

Needling techniques are classified as tonifying, reducing, or even, and involve various dimensions of needle insertion, manipulation, retention, removal, and practitioner intention. While a tonifying and reducing technique may increase effectiveness for certain conditions, implementing such techniques is challenging with patients who have cancer-related pain. In addition, needling techniques vary greatly across individual practitioners. Based on consensus among the UCSF Integrative Chinese Medicine acupuncturists participating in the study, procedures will use the even technique to: (1) standardize the approach for research purposes; (2) provide a consistent quality of treatments; and (3) facilitate implementation of inpatient acupuncture procedures.

De Qi is a sensation of tingling, heaviness, mild pressure, or achiness.^17,18 To avoid depleting the patient, a neutral, even technique will be used, wherein the acupuncturist engages the Qi (De Qi) gently and actively avoids robust sedation or tonification needling techniques, muscle fasciculation, or twitching. All needling will be manual. Practitioner intention will be set prior to needling (Table 4).

Table 4.

Acupuncture Details Based on STRICTA Guidelines¹⁶

STRICTA item	Acupuncture description
Needling details
Number of needle insertions per subject per session (mean & range when relevant)	The minimum number of needles is 4 with a maximum of 12. The least number of needles should be inserted when considering the patient's physical status. There will be 1 set of needles inserted per session. There will not be a reinsertion of needles.
Names (or locations if no standard names) of points used (uni/bilateral)	Names of points to be used for the study are listed in Tables 2 & 3.Points may be needled bilaterally or unilaterally but no more than 12 needles may be used per session. It is the practitioner's choice when deciding the best way to treat and balance each patient. Decisions regarding laterality will also depend on avoiding areas of cancer, surgical site, IV lines, PICC lines, and any other medical equipment used for monitoring the patient or distributing medication.
Depth of insertion, based on a specified unit of measurement or on a particular tissue level	Point needling depth, direction, & location are based on standard recommendations provided in EAM texts.^a
Response sought	Neutral insertion will be used as an approach to the unique constitution of each patient & a gentle, mild “response” will be sought during needling. The utilization of neutral technique:(1) standardizes the approach for research purposes; (2) provides a consistent quality of treatments; (3) facilitates implementation of inpatient acupuncture procedures; & (4) addresses the depleted constitution of patients with cancer. Overstimulation of needling could compromise the patients' Qi & ability to manage pain.
Needle stimulation	Needle stimulation will be manual. No other stimulation technique will be used.
Needle-retention time	Needles will be retained for 20–30 min. This minimum time was chosen because it takes 20 minutes for Qi to circulate completely through all 12 channels of the body.^b A treatment <20 min would theoretically be ineffective. Thirty min is the maximum amount of time needles should be retained so the patient is not compromised and depleted of Qi.
Needle types	Body points: Seirin^® J-Type, 0.16 mm × 30 mm will be usedEar points: Seirin D-Type 0.16 mm × 15 mm will be used.
Treatment regimens
Number of treatment sessions	The # of treatment sessions will be a minimum of 1 and a maximum of 4 depending on each patient's LOS in the hospital.
Frequency & duration of treatment sessions	Frequency: While patients are in the hospital, they will receive treatment once per day for up to 4 days.Duration: Each treatment will last 20–30 min.
Other components of treatment
Details of other interventions administered to the acupuncture patient group	Inpatient treatment often does not include use of moxibustion, cupping, herbs, exercises, & lifestyle advice. All inpatients will receive their usual pain medications.
Setting & context of treatment	Acupuncture treatments will take place in the oncology wards at 2 hospitals: UCSF Mission Bay and ZSFG.
Participating acupuncturists	Acupuncturists will have a minimum of 5 years of experience since licensure; should be privileged to practice at UCSF or ZSFG; & have experience in providing treatments in hospital settings & patients with cancer.

Deadman P, Al-Khafaji M, Baker K. A Manual of Acupuncture. East Sussex, England: Journal of Chinese Medicine Publications; 1998.

Unschuld PU. Nan Jing: The Classic of Difficult Issues, 2nd ed. Oakland, CA: University of California Press; 2016.

STRICTA, STandards for Reporting Interventions in Clinical Trials of Acupuncture; IV, intravenous; PICC, peripherally inserted central catheter; EAM, East Asian Medicine; min, minutes; LOS, length of stay; USCF, University of California–San Francisco; ZSFG, Zuckerberg San Francisco General Hospital.

Electroacupuncture (EA) and transcutaneous electrical acupoint stimulation (TEAS) were not included in this evaluation because the majority of the selected patients had postoperative intravenous ports or lines, PICC [peripherally inserted central catheter] lines, and/or metal components on or in their bodies, and would not have been good candidates for these modalities. Further evaluation will be needed to determine the applicability of this manual to other forms of acupuncture such as EA and TEAS.

Conclusions

To fill an important gap within the current literature and support community- and hospital-based acupuncturists with a clinical reference, a treatment manual was developed for addressing inpatient cancer-related pain with manual acupuncture, based on a narrative literature review, an internal-chart audit, and consensus among the acupuncturists who will be involved in the study. The approach incorporates Zang-Fu diagnosis and channel theory and specific needling techniques with the intention to improve pain management and QoL in hospitalized patients with cancer-related pain. This manual enables adaptability and individualized treatment to address a patient's total pain experience and also remains reproducible due to standardization.

Footnotes

Acknowledgments

The authors thank Denise Bowden, LAc, Vadan Ritter, LAc, and Candice Turchin, LAc, for their valuable input and feedback on the manual. The views in this article are solely the responsibility of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its board of governors, or methodology committee, or any of the funders.

Author Disclosure Statement

No financial conflicts of interest exist.

Funding Information

Support for the development of this manual was partially funded through a PCORI Award (CER-1609-36220) and the Helen Diller Family Foundation.

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