Systematic Review and Meta-Analysis on Using Acupressure to Promote the Health of Older Adults

Abstract

Acupressure is noninvasive, safe, and appropriate for use among older adults. However, there remains little evidence of the common elements that contribute to the effectiveness of acupressure in promoting the health of older adults. A systematic review using meta-analysis was designed to examine the effects of acupressure on the health promotion in older adults. Studies published between 2012 and 2017 were searched for in 11 electronic databases. Acupressure was highly effective for improving sleep quality and cognitive functioning (0.85, 95% confidence interval [CI] = [0.49, 1.22]; 1.23, 95% CI = [0.88, 1.59]). A slight to moderate effect was found in alleviating constipation (0.37, 95% CI = [0.03, 0.71]), and a moderate effect was found for alleviating pain and improving quality of life (0.71, 95% CI = [0.09, 1.32]; 0.59 95% CI = [0.36, 0.82]).

Keywords

acupressure aged health promotion meta-analysis older adults systematic review

Introduction

Statistics indicated that 42% of American adults and 46% of British adults have received complementary and alternative medicine (CAM; Institute of Medicine, 2005; Thomas, Nicholl, & Coleman, 2001). Another report showed that 61.3% of Germany older adults have received CAM (Schnabel, Binting, Witt, & Teut, 2014). In addition, traditional Chinese medicine (TCM) is considered as one of the CAM (Institute of Medicine, 2005), which was commonly used in China, Japan, Korea, and elsewhere around the world. The World Health Organization (WHO) has also included TCM in the International Classification of Diseases 11th revision (WHO, 2019). In Taiwan, older adults had used TCM at least once (P. R. Yang, Liang, Chu, Chen, & Lin, 2015). From the perspective of TCM, a person would be healthy if his or her organs functioned normally. Whether an organ functions well is closely related to the circulation of blood and qi in the body. The pathways for transporting blood and qi are called meridians, and acupoints corresponding to different organs and systems are distributed along the meridians from head to toe (Jiang, Chou, Chiao, Yang, & Chan, 2013). According to Harvie, Steel, and Wardle (2019), acupressure is a common method used for self-care in regions other than Asia. Acupressure is a type of safe and noninvasive health care therapy, in which fingers, instead of the fine needles used in acupuncture, are used as the method for applying pressure to specific acupoints. With training, acupressure can be easily applied by the general public, and self-administered acupressure is possible (Maa, 1998). At the beginning of an acupressure treatment, pressure is applied to a specific acupoint by gently, uniformly, and continuously pressing, kneading, and pushing until the person feels sore, numb, or bulgy at the site. Next, additional pressure is applied through more kneading (M. L. Chang et al., 2011). By stimulating acupoints, acupressure can unblock meridians, balance qi, activate blood circulation, and regulate the functions of organs, leading to the alleviation of diseases.

Some studies have highlighted the benefits of acupressure for different health outcomes in older adults. Acupressure can effectively ease physical and mental conditions, such as poor sleep quality (Chan et al., 2017; L. H. Chen, 2013; S. Y. Chen & Lo, 2016; Lei, Chen, Lin, Bao, & Tao, 2015; Lu, Lin, Chen, Tsang, & Su, 2013; Zeng et al., 2016), cognitive dysfunction (Sun, Zeng, & Pan, 2015; Wan, Hu, Sun, & Yang, 2017; Zeng et al., 2016), constipation (M. K. Li, Lee, & Suen, 2014; Mo & Zeng, 2015; Wu, 2012), chronic lower back pain (Yeh et al., 2014), and flatulence (Zhou, 2014). However, sound conclusive evidence of the potential efficacy of acupressure on promoting health in older adults is limited. A systematic review using meta-analysis is needed to have a better understanding of the knowledge base in this area.

Systematic reviews can effectively integrate currently available information. This integrated data can be used in rational decision-making to improve the reliability of conclusions, explain inconsistent or conflicting data, and improve the reliability of evidence (Higgins & Green, 2011; Mulrow, 1994). To date, many systematic reviews contain a meta-analysis. A meta-analysis uses statistical methods to summarize findings from individual studies (Glass, 1976). The results from two or more independent studies can be consolidated using quantitative statistical methods for analysis and evaluation, from which a research conclusion can be drawn (S. S. Chang, 2016; Higgins & Green, 2011). Compared with an evaluation of a single study, a meta-analysis has more satisfactory statistical, explanatory, and inferential power because all relevant studies are aggregated (Juang, 2011). Meta-analyses can offset certain limitations that occur in a small-scale research design (S. S. Chang, 2016; Higgins & Green, 2011). Thus, we incorporated studies on the application of acupressure in older adults by means of systematic review and meta-analysis. The specific purposes of this article were to (a) identify the effectiveness of acupressure in alleviating physical and mental conditions experienced by older adults and (b) appraise acupressure studies on their research design, acupoint stimulation, acupressure frequency and duration, assessment methods, and research quality.

Method

Search Strategy and Study Selection

Numerous articles related to acupressure have been published. To present the most current situation of using acupressure, studies published between 2012 and 2017 were searched for in the electronic databases of Medline, PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycINFO, ProQuest Health & Medical Complete, Cochrane Library, Embase, Web of Science, Allied and Complementary Medicine Database (AMED), Chinese Electronic Periodical Services (CEPS), and WANFANG DATA. The search keywords were acupressure (or acupress*, shiatsu, Zhi Ya, acupuncture points, acupoints, acupoint, acupoint*) and aged (or aging, elder, elderly, geriatric, or older adults, senior, elders, geriatr*, older person*, older patient*, older patient*, older women, old women, older men, old men, old adult*, older adult*, older individual, older individuals, old people, oldest old, Nonagenarians, Nonagenarian, Octogenarians, Octogenarian, Centenarians, Centenarian, septuagenarian, septuagenarians, older population, aging population, geront*, old-aged, old-age). The prespecified inclusion criteria were (a) studies that adopted acupressure as the primary intervention, (b) studies whose participants were older adults, and (c) studies that were randomized clinical trials. The exclusion criteria were (a) studies that were case reports, (b) studies written in a language other than Chinese or English, and (c) studies in which other treatment methods were used as the intervention in addition to acupressure, and the sole effect of the acupressure could not be identified.

Quality Appraisal

Two reviewers trained in empirical research and TCM independently evaluated the full text of potentially eligible studies. Inclusion of studies in this systematic review was determined by the agreement of both reviewers. Disagreements were resolved through discussion and consensus in the presence of a third reviewer. Prior to the meta-analysis, the Modified Jadad Scale was used to assess the quality of the potentially eligible studies identified by the two reviewers. The Modified Jadad Scale assessed eight domains of the studies: (a) randomization, (b) appropriateness of the randomization method, (c) blinding, (d) appropriateness of the blinding method, (e) the number of and reasons for withdrawals, (f) inclusion and exclusion criteria, (g) adverse effects, and (h) statistical analysis methods (Table 1). Each domain is given a value of 1 point, and the total score ranges from 0 to 8; a higher score represents a higher research quality (Oremus et al., 2001). Scores of 0 to 3 are considered having poor research quality and 4 to 8 suggest a high research quality (Zhao, Jiang, Yuan, Wang, & Yu, 2016). Therefore, studies that were scored 4 or higher were included in the present analysis.

Table 1.

Article Appraisal Based on the Modified Jadad Scale.

Enrolled study	Items of Modified Jadad Scale^a								Jadad score
Enrolled study	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	Jadad score
Chan et al. (2017)	1	1	0	0	0	1	1	1	5
L. H. Chen (2013)	1	0	0	0	0	1	1	1	4
S. Y. Chen and Lo (2016)	1	1	0	0	0	1	0	1	4
Kwan, Leung, and Lai (2017)	1	1	1	1	1	1	1	1	8
Lai et al. (2017)	1	0	0.5	1	0	1	0	1	4.5
Lei, Chen, Lin, Bao, and Tao (2015)	1	0	0	0	0	1	1	1	4
J. Li, Zhang, and Sun (2014)	1	0	0	0	0	1	1	1	4
M. K. Li, Lee, and Suen (2014)	1	1	1	1	1	1	0	1	7
Liu and Liu (2017)	1	0	0	0	0	1	1	1	4
Lu, Lin, Chen, Tsang, and Su (2013)	1	0	0	0	1	1	0	1	4
Mo and Zeng (2015)	1	0	0	0	0	1	1	1	4
Rodríguez-Mansilla et al. (2015)	1	1	1	1	1	1	0	1	7
Sun, Zeng, and Pan (2015)	1	1	0	0	1	1	0	1	5
Wan, Hu, Sun, and Yang (2017)	1	1	0	0	0	1	0	1	4
Wu (2012)	1	1	0	0	0	1	0	1	4
Yeh et al. (2014)	1	1	1	1	1	1	1	1	8
Zeng et al. (2016)	1	1	0.5	0	1	1	1	1	6.5
Zhou (2014)	1	0	0	0	0	1	1	1	4

Eight questions in the Jadad score are as follows: (a) Was the study described as randomized? (b) Was the method of randomization appropriate? (c) Was the study described as blinded (double-blind RCT 1 point; single-blind RCT 0.5 point)? (d) Was the method of blinding appropriate? (e) Was there a description of withdrawals and dropouts? (f) Was there a clear description of the inclusion/exclusion criteria? (g) Was the method used to assess adverse effects described? (h) Was the method of statistical analysis described? RCT = randomized control trial.

Data Synthesis and Statistical Analysis

Comprehensive Meta-analysis 2.0 software was used to analyze the effectiveness of acupressure (Borenstein, Rothstein, & Cohen, 2009). Heterogeneity was measured by I² statistics, I² = 100% × (Q − df)/Q. An I² of 25% represents low heterogeneity, 50% represents moderate heterogeneity, and 75% represents high heterogeneity (Higgins, Thompson, Deeks, & Altman, 2003). When there was homogeneity between studies, a fixed effects model was used for analyses; when there was heterogeneity between studies, a random effects model was used for analyses to incorporate intergroup and intragroup sampling errors. A sensitivity analysis was further performed when there was heterogeneity between studies to exclude inappropriate studies for reanalysis (Juang, 2011). The combined effect size was estimated by odds ratio, mean, and standard deviation. When different assessment methods were used, standardized mean difference was used to estimate the combined effect size (Joanna Briggs Institute, 2014). Summary effect size and 95% confidence interval (CI) served as indicators of intervention effect and were illustrated by forest plots. Effect sizes of 0.2, 0.5, and 0.8 represent a small, medium, and large effect, respectively (Cohen, 1988). The publication bias was examined using Egger’s regression test, with p < .1 representing asymmetrical statistical significance (Egger, Davey, Schneider, & Minder, 1997) and indicating publication bias.

Results

Figure 1 shows the study identification and selection, and the reasons for excluding a study. The search retrieved 2,721,220 studies from 11 Chinese and English databases, and two additional records were manually examined from the reference lists of the retrieved studies. After eliminating 278,100 duplicates, 2,443,122 studies, comprising 205 papers written in Chinese and 2,442,917 in English, remained for further assessment. Irrelevant studies were further excluded. Abstracts of the remaining studies were scrutinized against the agreed inclusion and exclusion criteria. Sixty-two potential reports were retrieved for full-text evaluation. The reviewers assessed the quality and eligibility of the studies according to predefined inclusion and exclusion criteria. A total of 36 studies, including 25 papers written in Chinese and 11 in English, were identified for quality evaluation using the Modified Jadad Scale. Finally, 18 studies that were scored 4 or higher contributed to this meta-analysis. The distribution of the topics in the 18 studies were sleep quality (three studies); sleep quality and cognitive functioning (three studies); sleep quality and quality of life (one study); sleep quality, pain, and quality of life (one study); cognitive functioning (one study); cognitive functioning and quality of life (one study); constipation (three studies); constipation and quality of life (one study); pain (one study); pain, anxiety, and depression (one study); agitation (one study); and flatulence (one study). Regarding meta-analysis, studies with two or more topics were counted as an individual study in their respective topics. Thus, the analysis included eight studies on sleep quality, five studies on cognitive functioning, four studies on constipation, three studies on pain, four studies on quality of life, and one study each on depression, anxiety, agitation, and flatulence. Supplemental Appendix A shows a summary of all the included studies. Because the study topics of depression, anxiety, agitation, and flatulence have only one study for each, meta-analysis could not be performed on these topics. In all, this meta-analysis examined the effects of acupressure on sleep quality, cognitive functioning, constipation, pain, and quality of life in older adults.

Figure 1.

PRISMA flow diagram.

Study Characteristics

Among the 18 papers, nine were published in Chinese and nine in English. Eleven studies (60%) were conducted in China, two (11%) in Taiwan, three (17%) in Hong Kong, one (6%) in Spain, and one (6%) in the United States. The sample size was between 37 and 160 participants. All studies (100%) were randomized clinical trials. Four studies (22%) used a double-blind methodology and two studies (11%) used a single-blind methodology. Regarding the type of intervention, 15 (83%) studies employed acupressure and three (17%) studies employed auricular acupressure. On the Modified Jadad Scale, 10 studies received a score of 4, one of 4.5, two of 5, one of 6.5, two of 7, and two of 8 (Table 1).

Summary of Evidence

Eight studies investigated the effects of acupressure on sleep quality. These studies recruited frail older adults, patients with hypertension, institutionalized residents, or psychiatric patients. In three of the eight studies, acupressure was self-administered by the participants. The acupoints stimulated in the acupressure treatment included anmian (EX-HN22), baihui (GV20), fengchi (GB20), yongquan (KI1), taiyang (EX-HN5), shenmen (HT7), neiguan (PC6), and sanyinjiao (SP6). The duration of each acupressure session ranged from 20 to 30 min, or each targeted acupoint was stimulated 50 times per session. The treatment period ranged from 1 to 2 months, with frequencies of three to 14 sessions per week, in which 14 sessions per week was the most common frequency. Seven of eight studies used the Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) to assess sleep quality. The meta-analysis revealed that these studies were statistically heterogeneous (Q = 102.02, p < .001, I² = 93.14). Therefore, a random effects model and a sensitivity analysis were performed. Heterogeneity remained high (Q = 39.51, p < .001, I² = 84.81) after excluding one study (Lu et al., 2013). Another study was further excluded (Lai et al., 2017); doing so resulted in a moderate heterogeneity (Q = 15.99, p = .007, I² = 68.73). Results of Egger’s regression test (p = .597) did not show publication bias. As shown on the forest plot, the summary effect size was 0.85 (95% CI = [0.49, 1.22]; Table 2), indicating that acupressure was highly effective for improving sleep quality in older adults.

Table 2.

Meta-Analysis on Sleep Quality, Cognitive Function, Constipation, Pain, and Quality of Life.

Study name	Statistics for each study
Study name	Standard difference in Ms	Lower limit	Upper limit	Standard difference in means and 95% CI
Sleep quality	0.36	−0.04	0.75
Chan et al. (2017)	0.68	0.28	1.09
S. Y. Chen and Lo (2016)	0.65	−0.26	1.55
L. H. Chen (2013)	1.16	0.64	1.67
Lei, Chen, Lin, Bao, and Tao (2015)	0.74	0.25	1.24	Favors control	Favors acupressure
J. Li, Zhang, and Sun (2014)	1.55	1.05	2.04
Zeng et al. (2016)	0.85	0.49	1.22
Cognitive functioning
Lei et al. (2015)	0.92	0.42	1.42
Sun, Zeng, and Pan (2015)	1.69	1.17	2.21
Wan, Hu, Sun, and Yang (2017)	0.95	0.49	1.42
Zeng et al. (2016)	1.41	0.92	1.89	Favors control	Favors acupressure
	1.23	0.88	1.59
Constipation
M. K. Li, Lee, and Suen (2014)	0.26	−0.26	0.77
Mo and Zeng (2015)	0.46	0.00	0.91
	0.37	0.03	0.71	Favors control	Favors acupressure
Pain
Chan et al. (2017)	0.45	0.06	0.85
Yeh et al. (2014)	1.09	0.40	1.78
	0.71	0.09	1.32	Favors control	Favors acupressure
Quality of life
Chan et al. (2017)	0.37	−0.02	0.76
Lai et al. (2017)	0.77	0.25	1.29
M. K. Li et al. (2014)	0.55	0.03	1.07
Wan et al. (2017)	0.78	0.32	1.23	Favors control	Favors acupressure
	0.59	0.36	0.82

CI = confidence interval.

Five studies examined the effects of acupressure on cognitive functioning. Participants were patients with hypertension, patients with mild cognitive dysfunctions, patients with dementia, or patients with impaired sleep quality. In all of the five studies, acupressure was self-administered by the participants. The acupoints stimulated were anmian (EX-HN22), baihui (GV20), fengchi (GB20), taiyang (EX-HN5), shenmen (HT7), neiguan (PC6), sanyinjiao (SP6), sishencong (EX-HN1), and shenting (DU24). The duration of each acupressure session ranged from 15 to 30 min, or each targeted acupoint was stimulated 50 times per session. The treatment period ranged from 1 month to 1 year, with frequencies of 14 to 28 sessions per week in which 14 sessions per week was the most common frequency. All the five studies used the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) to assess cognitive functioning. The meta-analysis revealed that these studies were statistically heterogeneous (Q = 29.04, p < .001, I² = 86.22). Therefore, a random effects model and a sensitivity analysis were performed. Heterogeneity was moderate (Q = 6.29, p = .099, I² =52.27) after excluding one study (J. Li, Zhang, & Sun, 2014). Results of Egger’s regression test (p = .355) did not indicate publication bias. As shown on the forest plot, the summary effect size was 1.23 (95% CI = [0.88, 1.59]; Table 2), indicating that acupressure was highly effective for improving cognitive functioning in older adults.

Four studies investigated the effects of acupressure on constipation; one of them employed auricular acupressure. Participants were institutionalized residents, patients with constipation, or patients with musculoskeletal conditions or orthopedic trauma. In one of the four studies, acupressure was administered by a registered nurse; the other three studies did not specify who administered acupressure. In addition to the auricular acupoints that corresponded to large intestines, rectum, san jiao, spleen, lung, sympathesis, and subcortex, other acupoints stimulated for constipation included tianshu (ST25), shangjuxu (ST37), zusanli (ST36), qihai (CV6), zhongwan (CV12), and guanyuan (CV4). Each acupoint was stimulated 30 times per session. The treatment period ranged from 3 days to 1 month, with frequencies of five to 21 sessions per week. Effectiveness was assessed by successful bowel movements. The meta-analysis revealed that these studies were statistically heterogeneous (Q = 38.16, p < .001, I² = 92.14). Therefore, a random effects model and a sensitivity analysis were performed. The studies were still not homogeneous (Q = 3.73, p = .155, I² = 46.34) after excluding one study (Liu & Liu, 2017). The results of Egger’s regression test (p = .089) also showed publication bias. As a result, an additional study was excluded (Wu, 2012). A homogeneous sample (Q = 0.32, p = .574, I² < .001) was produced, so a fixed effects model was performed. Because there remained only two studies, publication bias could not be tested. As shown on the forest plot, the summary effect size was 0.37 (95% CI = [0.03, 0.71]; Table 2), indicating that acupressure had a small to moderate effect on alleviating constipation in older adults.

Three studies examined the effects of acupressure on pain; two of them employed auricular acupressure. Participants were frail older adults, patients with dementia living in care facilities, or patients with lower back pain. In two of the three studies, acupressure was administered by a professional; in the remaining study, acupressure was self-administered by the participants. In acupressure, the source of pain determines which acupoints should be stimulated. Therefore, only one common acupoint, the auricular shenmen, was involved in two of the three studies. The duration of each acupressure session ranged from 3 to 15 min. The treatment period ranged from 1 to 3 months, with frequencies of 4 to 21 times per week. Levels of pain were assessed by the visual analogue scale (VAS), the Doloplus-2 Scale, or the worst pain item on the Brief Pain Inventory–Short Form (BPI-sf). The meta-analysis revealed that these studies were statistically heterogeneous (Q = 23.65, p < .001, I² = 91.54). Therefore, a random effects model and a sensitivity analysis were performed. Homogeneity was still not reached (Q = 2.48, p = .116, I² = 59.61) after excluding one study (Rodríguez-Mansilla et al., 2015). Because there remained only two studies, publication bias could not be tested. As shown on the forest plot, the summary effect size was 0.71 (95% CI = [0.09, 1.32]; Table 2), indicating that acupressure had a moderate effect on relieving pain in older adults.

Four studies investigated the effects of acupressure on quality of life; one of them employed auricular acupressure. Participants were frail older adults, institutionalized residents, or community older adults with dementia. In two of the four studies, acupressure was administered by a professional; in one study, acupressure was self-administered by the participants; and the remaining study did not specify who administered acupressure. All quality of life studies also investigated a second topic, such as sleep quality, cognitive functioning, or constipation. The meta-analysis revealed that these studies were statistically homogeneous (Q = 2.35, p = .502, I² < .001), so a fixed effects model was performed. Results of Egger’s regression test (p = .345) did not indicate publication bias. As shown on the forest plot, the summary effect size was 0.59 (95% CI = [0.36, 0.82]; Table 2), indicating that acupressure had a moderate effect on improving quality of life in older adults.

Discussion

To our knowledge, this is the first systematic review and meta-analysis investigating the effectiveness of acupressure in improving the health of older adults. A total of 18 studies were reviewed. Six studies (33%) used experts to perform the acupressure, and seven studies (39%) taught patients to perform the acupressure for themselves. Positive outcomes of acupressure were found in both experts and patients as the interveners. With appropriate training, acupressure can be easily self-administered and applied by the general public (Maa, 1998). No special educational background is required. However, it is strongly recommended that the patients are instructed and confirmed by the experts with proper way of performing acupressure themselves.

In the studies regarding sleep quality, shenmen (HT7), neiguan (PC6), and sanyinjiao (SP6) were the most commonly stimulated acupoints. These points were targeted in five of the studies (63%). From TCM point of view, “the spirit resides in the heart” so that the heart controls mental and emotional activities. The primary cause of poor sleep quality is a deficiency of the heart. Shenmen, located on inner wrist crease toward the ulnar side (Hsu, Shih, Teng, & Tu, 2010), is the source point of the heart meridian. As an adage stated, “all diseases of the organs can be treated by the source points,” shenmen is the key acupoint to treat poor sleep quality (Hong, 2007). In TCM, sleep dysfunctions are also closely related to the spleen, liver, and kidney meridians, which are all foot yin meridians. Sanyinjiao, located four finger-widths above the tip of the medial malleolus on the posterior border of the tibia (Hsu et al., 2010), represents the intersection of the three yin meridians and is often chosen as a complementary acupoint for effectively soothing the spirit (Hong, 2007). The neiguan acupoint is also effective for calming the heart and soothing the spirit. It lies on the front of the forearm between the ulna and radius bones, three finger-widths above the inner wrist crease (Hsu et al., 2010; D. W. Yang, 2009). In all, shenmen, neiguan, and sanyinjiao are targeted acupoints that are suitable for improving sleep quality. Because most of the studies used the PSQI (Buysse et al., 1989), the results of the assessment of acupressure effectiveness were relatively consistent. Acupressure can dredge the meridians, balance qi, activate circulation, and regulate organ functions through acupoint stimulation (Maa, 1998). Acupressure reduces levels of anxiety in older adults and makes them feel relaxed, which, in turn, is likely to lead to an improved sleep quality (M. H. Yang & Lin, 2007).

Fengchi (GB20) and taiyang (EX-HN5) were acupoints most commonly stimulated for improving cognitive functioning. Fengchi can be stimulated to improve blood circulation in the brain (Wen et al., 2016), increase blood flow, repair brain tissue, and eliminate stagnant blood (Hong, 2007). Fengchi lies in the depression between the upper portion of the sternocleidomastoid muscle and the trapezius (Hsu et al., 2010). Taiyang (EX-HN5), located in a depression about one finger-width posterior to the midpoint between the lateral end of the eyebrow and the outer canthus of the eye (Hsu et al., 2010), is an extraordinary acupoint. A large amount of nerve tissue is located in the forehead and near taiyang, forming part of the neocortex of the brain, and is responsible for functions of rational analysis, judgment, and learning (Cho, 2006). Although taiyang is not located on the meridians, stimulating it is effective for alleviating headaches and improving blood circulation in the head (Hong, 2007; Zheng, Chen, Wu, Li, & Liang, 2010), leading to improved cognitive functioning. Compared with acupressure for improving sleep quality, the acupressure for improving cognitive functioning requires a longer length of treatment to achieve efficacy. As a result, the required length of acupressure treatment may range from 1 month to 1 year. Because all the studies used the MMSE (Folstein et al., 1975), the results of acupressure effectiveness evaluation were relatively consistent. Acupressure was highly effective for improving cognitive functioning.

Tianshu (ST25) and Zhongwan (CV12) were acupoints most commonly stimulated for treating constipation. These points were targeted in three studies (75%). The main function of Tianshu (ST25), located three finger-widths from the navel laterally (D. W. Yang, 2009), is to promote spleen and stomach functioning. Zhongwan (CV12), located one hand-width above the navel (Hsu et al., 2010), is also used to promote spleen and stomach functioning. It is a crucial acupoint for treating digestive illnesses. Stimulating Zhongwan can alleviate abdominal bloating (Hong, 2007), which unblocks the gastrointestinal tract, and thus alleviates constipation. In addition to subjective measurement, the assessment method used for investigating the effects of acupressure on constipation should be more objective. Therefore, the effects of acupressure on constipation were assessed by successful bowel movements. The cause of constipation among older adults varies and can include, for example, dietary and lifestyle choices, multiple drug use, physical activity, metabolic disorders (e.g., diabetes or uremia), neurological or psychiatric disorders (e.g., dementia or depression), cognitive dysfunction, and emotional states (Huang, Su, Hung, Chiu, & Tseng, 2009). As a result, the effectiveness of acupressure in alleviating constipation was lower compared with the effectiveness of acupressure on treating impaired sleep quality, cognitive functioning, pain, and quality of life.

As for the study topic of pain, auricular shenmen was the only common acupoint targeted in two of the studies (67%). Pain increases heart rate and causes emotional fluctuations. Severe pain can cause physical and mental exhaustion. Stimulating the auricular shenmen decreases heart rate, anxiety, and fatigue (Kuo, Tsai, Chen, & Tzeng, 2016). Therefore, pain can be alleviated by stimulating the auricular shenmen in conjunction with other corresponding acupoints. Levels of pain were assessed by the VAS, the Doloplus-2 Scale, or the worst pain item on the BPI-sf. Because the methods of assessment differed and the targeted acupoints varied depending on the source of pain, heterogeneity was found between the studies. Compared with studies regarding sleep quality and cognitive functioning improvement, which involved similar assessment methods and shared acupoints, the effectiveness of acupressure in alleviating pain was found to be lower. Acupressure was only moderately effective for alleviating pain.

Finally, all quality of life studies examined a second topic, including sleep quality, cognitive functioning, or constipation. As aforementioned, positive effects of acupressure on those aspects have been evidenced; acupressure undeniably helped to improve quality of life in older adults, which was found to be moderately effective.

The results of this study revealed that acupressure has moderate effects on improving sleep quality, cognitive function, pain relieving, and quality of life. Accordingly, it is possible to integrate corresponding acupoints, treatment duration, and frequency to improve health conditions in older adults and to serve as a reference for further acupressure studies or treatment guidelines in older adults. However, the discrepancies among the studies only allowed us to obtain preliminary conclusions from the current research.

Limitations

Interpretation of the results of this study should take into account its limitations. Due to language constraints, studies that were published in Korean and Japanese were excluded. Nevertheless, some studies regarding traditional medicine related to acupressure have been conducted in Korea and Japan. Expanding search strategy to include Korean and Japanese databases could provide additional evidence-based knowledge. In addition, the evidence was limited by publication bias and heterogeneity. Future prospective studies with careful designs remain necessary to validate the present findings.

Conclusion

Systematic review and meta-analysis methods were used in this study to extensively and systematically gather empirical results for further compilation and analysis. These methods produced aggregate results that had higher statistical power and accuracy. The meta-analysis demonstrated that acupressure is an effective intervention for improving sleep quality, cognitive functioning, pain, and quality of life in older adults. However, some topics were limited by the number of empirical studies, such as constipation; thus, another meta-analysis should be performed in the future after the accumulation of an abundant number of empirical studies. The physical condition of older adults differs from that of young or middle-aged adults; however, through comprehensive and systematic analysis, this review provides more objective empirical results of positive acupressure appropriateness and effectiveness in promoting the health of older adults. This study encompasses outcomes of sleep quality, cognitive functioning, constipation, pain, and quality of life. Previous studies have found that in addition to these five outcomes, neurological and psychological disorders are also among the most common health problems faced by older adults, particularly the conditions of depression and dementia (WHO, 2017). However, few studies have been conducted to investigate the effectiveness of acupressure in treating these disorders. Future acupressure studies could examine the effects of acupressure on depression and dementia to benefit a greater number of older adults.

Supplemental Material

Acupressure_SRplusMA_JAG_R2_appendix – Supplemental material for Systematic Review and Meta-Analysis on Using Acupressure to Promote the Health of Older Adults

Supplemental material, Acupressure_SRplusMA_JAG_R2_appendix for Systematic Review and Meta-Analysis on Using Acupressure to Promote the Health of Older Adults by Meng-Chin Chen, Li-Yen Yang, Kuei-Min Chen and Hui-Fen Hsu in Journal of Applied Gerontology

Footnotes

Acknowledgements

Sincere appreciation is directed by our group to Professor Frank Belcastro for his superlative manuscript editing.

Author Contributions

All authors meet the criteria for authorship, have approved the final article, and all those entitled to authorship are listed as authors. Meng-Chin Chen, Li-Yen Yang, and Kuei-Min Chen contributed to study concept and design and data analysis and interpretation; Meng-Chin Chen and Li-Yen Yang to acquisition of data; Meng-Chin Chen, Kuei-Min Chen, and Hui-Fen Hsu to drafting of the article and Hsu to critical revision of the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Yuh-ing Junior College of Health Care and Management (Grant 107S-03).

ORCID iD

Kuei-Min Chen

Supplemental Material

Supplemental material for this article is available online.

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