Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

Original Research

Effects of Acupuncture/Moxibustion and/or Massage Program on
Levels of Health-related Quality of Life and Symptom Distress in
Frail Elderly
HIRAKAWA Yoshihisa
Department of Geriatrics, Nagoya University Graduate School of Medicine
Abstract[AIM] Recently, the demand for acupuncture/moxibustion and massage as adjunct therapies to medical treatment
has been on the rise. A number of papers have highlighted the positive effect of these therapies. However, to ourknowledge, few studies have reported on the effect of acupuncture/moxibustion and massage on the frail elderly.
Therefore, we conducted a pilot study to evaluate the effect of acupuncture/moxibustion and/or massage on thequality of life (QOL) and the level of severity of 20 symptoms prevalent among the frail elderly.
[DESIGN] Observational study[SETTINGS] Twenty-four clinics belonging to the Society of Practitioners of Acupuncture, Moxibution and Massage, the Acupuncture and Moxibustion Association, and the Association of Licensed Massage Professionals.
[PATIENTS] Elderly users 65 years and above, willing to respond to study questions, able to stand up, attending
hospital as outpatient, and not having received acupuncture/moxibustion or massage within 3 months of enrollment.
[INTERVENTION] Thirty-minute sessions of customized therapy consisting of acupuncture/moxibution and/orJapanese-style massage, administered at differing frequencies depending on the patient's needs.
[MAIN OUTCOME MEASURE] Health-related QOL (Short Form-36) and symptom severity were evaluated atbaseline and at 3 months.
[RESULTS] For the 8 SF-36 sub-scales, namely Role Physical, Role Emotional, Physical Functioning, SocialFunctioning, Mental Health, Vitality, Body Pain, and General Health, the figures indicate clinically significant
change over time for these patients. In anorexia, nausea, loss of sleep, depression, anxiety, shoulder or neck stiffness, back pain, lower back pain, and arthralgia, there were significant improvements over time (p=0.04, 0.05,<0.01, 0.01, 0.01, 0.01, 0.02, <0.01 and 0.03, respectively).
[CONCLUSIONS] Our study suggested that acupuncture/moxibustion and/or massage have a positive effect on
physical and mental health among the frail elderly. Larger studies are nevertheless needed to confirm these results.
Key words: Acupuncture/Moxibustion, Massage, Health-related Quality of Life, Symptom Distress, ElderlyCorresponding author Yoshihisa Hirakawa
Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Aichi, Japan 4668550
E-mail y.hirakawa@k 8.dion.ne.jp

14Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

Ⅰ．Introduction
One of the byproducts of the aging of the population isa rise in the number of frail elderly patients attending
hospitals as outpatient. The aged are vulnerable to various chronic medical problems that are difficult to alleviate by relying solely on Western medicine; attention has
thus recently increasingly focused on ways to enhance
the quality of life of the elderly through alternativemethods. The steadily increasing elderly population
intensifies the need for integrating complementary andalternative treatment with Western medicine1).
In Japan, acupuncture/moxibustion and massage havebeen used since ancient times; these therapies are offeredby trained professionals and are partially covered bypublic medical insurance as an alternative medical service1). Recently, the demand for acupuncture/moxibustion and massage as adjunct therapies tomedical treatment has been on the rise1). There is now aneed for "evidence-based alternative medicine" in addition to evidence-based medicine1,2). As for acupuncture/
moxibustion and massage, a number of papers havehighlighted their positive effect3-9). However, to ourknowledge, few studies have reported on the effect ofacupuncture/ moxibustion and massage on the frail elderly.

We therefore conducted a pilot observational study toevaluate the effect of acupuncture/moxibustion and/ormassage on the quality of life (QOL) and the level ofseverity of twenty symptoms prevalent among the frailelderly.
Ⅱ．Materials and Methods
1) Study population (Figure 1)
We contacted the following associations in Aichi prefecture to explain our study procedure: the Society ofPractitioners of Acupuncture, Moxibution and Massage,
the Acupuncture and Moxibustion Association, and theAssociation of Licensed Massage Professionals. These
three societies are non-profit organizations comprised oflicensed practitioners of acupuncture/moxibution and/ormassage. Twenty-four practitioners agreed to join ourstudy. Patients were recruited for a period of eightmonths, from December 2004 through July 2005. The
study practitioners were in charge of recruitment. The
inclusion criteria were as follows: 65 years and above,
able to respond to study questions, able to stand up,
attending hospital as outpatient, and not having received
acupuncture/ moxibustion or massage within 3 monthsof enrollment. All eligible participants were required tosign informed consent forms. Also, this study was de-15Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

signed to allow patients to respond anonymously toquestions. Because there is no definite agreement on themeaning of the term "frail" in the world10), we definedthe "frail elderly" as elderly who can stand up but whoattend a hospital as outpatient, as mentioned in our study
inclusion criteria.

In Japan, acupuncture/moxibustion and massage arewidely used as joint therapy1). Therefore, we opted toconsider them as a single therapy unit rather than as
distinct therapies based on the advice of the abovementioned associations. We therefore analyzed and assessed the effectiveness of these therapies as a whole.

2) Treatment
At each clinic, patients received 30-minute sessions ofcustomized therapy consisting of acupunc ture/
moxibution and/or Japanese-style massage. Some applicants also received hot pack therapy, photothermal therapy, kinesitherapy, and other alternative treatments.
Japanese-style massage is a two-faceted medical therapy
comprised of: therapeutic massage and nursing massage1). Both approaches consist predominantly of rubbing and finger-pressure techniques. Therapeutic massage aims at the direct treatment of illnesses in internal
medicine, orthopedics, neurology and other fields.
Meanwhile, nursing massage aims at the indirect treatment of illnesses, acting to prevent or improve the patient's weakness or fatigue. Kinesitherapy includes sitting balance exercises, sitting up exercises, standing-up
exercises, gait exercises, and range of motion (ROM)exercises.

3) Baseline and Follow-up Assessment
Using a standard questionnaire, assessments were performed at baseline and at 3 months. To avoid the influence of any interaction with the practitioner on the patient's replies, both assessments were conducted prior tothe visit of the practitioner. The questionnaire broached
two main issues: health-related QOL and symptom severity. The health-related QOL of participants was assessed based on The Medical Outcomes Study ShortForm 36-Item Health Survey (SF-36), which is a widelyused, standardized questionnaire consisting of 36 questions11,12). We calculated the usual eight-dimension
scores. Symptom severity was assessed based on ouroriginal questionnaire which focused on the followingtwenty symptoms: anorexia, nausea, constipation, shortness of breath/ palpitation, cough/ sputum, weakness,indigestion, dizziness, loss of sleep, exhaustion,
chilling/rush, ringing, irritation, depression, anxiety,16
Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

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Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

stiffness in shoulders and neck, back pain, lower backpain, arthralgia, and numbness. Symptom severity wasassessed on a 5-item scale (4=always, 3=often,
2=occasionally, 1=seldom, 0=never) based on answers
to the following symptom experience: "To what extent
do you experience the following symptom in daily life?"
For the follow-up assessment, we used a questionnaireor the telephone to inquire about the content and frequency of the therapies that the patients had received.
4) Statistical analysis
Values are reported as mean ± standard deviation. We
analyzed the significance of differences in measurements
before and after the program, using the Wilcoxon
signed-ranks test. P values < 0.05 were considered significant. Statistical analyses were performed withStatview J-5.0.
Ⅲ．Results
A total of 101 patients were recruited for the presentstudy. Fifty-one patients completed the 3-month therapy
and pre- and post-evaluations. The remaining 50 patients
withdrew for personal reasons and could not be followed-up. The baseline characteristics of the 51 study
participants followed-up at 3 months are shown in Table
1. A greater number of subjects were female. Hypertension was the most frequent complication, followed byarthritis. The frequency of therapy the subjects received
is shown in Table 2. Forty of the 51 subjects received
acupuncture/moxibustion, and twenty-one received massage therapy. As for additional treatment, 19 subjects
received hot-pack therapy. Twice a week was the mostcommon treatment frequency for acupuncture,moxibustion and massage.
The effect of acupuncture/moxibustion and/or massage
on the SF-36 is shown in Table 3. In the score of 8 SF36 sub-scales, namely Role Physical, Role Emotional,Physical Functioning, Social Functioning, Mental Health,Vitality, Body Pain, and General Health, the figuresindicate clinically significant change over time for the 51
study participants.
The effect of acupuncture/moxibustion and/or massage
on levels of symptoms is shown in Table 4. In anorexia,
nausea, loss of sleep, depression, anxiety, shoulder orneck stiffness, back pain, lower back pain, and arthralgia,
there were significant improvements over time (p=0.04,0.05, <0.01, 0.01, 0.01, 0.01, 0.02, <0.01 and 0.03, respectively).
IV．Discussion
This pilot study examined the influence of acupuncture/ moxibustion and/or massage therapy programs on
the QOL of frail elderly patients with chronic diseases.
These therapies are considered to be important featuresof complementary alternative medicine (CAM.) Despite
the increasing popularity of CAM therapy use by patients with chronic diseases or pre-symptomatic disease(Mibyo), very few studies concerning the benefits ofCAM therapy a have so far been conducted, especially inJapan. We believe that the present study, despite certain
limitations such as its restricted size, is valuable in planning additional trials to assess the benefits of CAM therapy for elderly patients.
We experienced difficulties in recruiting frail elderly
patients willing to take part in this pilot study. The condition of some of the patients may have been severe due
to cancer and cardiovascular disease. Eligibility shouldhave been restricted to patients with minor illnesses.
Also, nearly half of the recruited patients who were notsatisfied with the therapy or who recovered completely
were inclined not to seek further treatment. It is possiblethat the initial eligibility criteria for this prospective
study were not adequate.
Study participants reported decreased levels of distresssymptoms such as anorexia, nausea, loss of sleep, depression, anxiety, shoulder or neck stiffness, back pain,
lower back pain, and arthralgia, as shown by the 20-item
subjective distress scores at the 3-month follow-up. Various studies have documented the physical and/or mental
benefits of acupuncture/moxibustion7-9) or massage3-6),13).
The present study corroborated the value of these therapies and revealed a range of benefits for frail elderly
patients. A number of studies have reported that endogenous opioid peptides are important substrates for mediation of acupuncture analgesia9). Others have revealed
that massage decreases the stress response and promotes
relaxation. Because distress symptoms have a negative
effect on the QOL of the frail elderly, our results offer
valuable tools toward the improvement of the QOL offrail elderly, which is one of the aims of geriatric medicine.
Also, our study suggested that acupuncture/
moxibustion and/or massage have a positive effect on

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Hirakawa Yoshihisa, Japanese Acupuncture and Moxibustion, 2008; Vol.4(1): 13-18

physical and mental health, as shown by the SF-36 results. Although it is difficult to make an accurate evaluation on QOL1), SF-36 is one of the most widely used andreliable scales of QOL9). We can therefore assume that
our results are consistent enough to confirm the value ofthe therapy in improving the QOL of the frail elderly.
However, our results should nevertheless be interpreted with caution due to certain limitations with our study.
First, because participants might receive other treatmentsin the hospital during the study period, we should haveinvestigated the medical treatments the patients hadreceived from other sources in order to accurately examine the effects of acupuncture/moxibustion and/or massage programs. Second, the administration procedures ofacupuncture/ moxibustion therapy differed from practitioner to practitioner. We did not precisely investigate
the methods used to administer acupuncture/
moxibustion such as needling procedure, length and sizeof the needles, acupuncture points, depth of needle insertion, and number of moxa cones. Also, because intervention frequency is often tailored to the individual needs ofpatients, we were unable to properly assess the dosedependent effect of acupuncture/ moxibustion or massage therapy. Third, the scale of this pilot study was too
limited to allow us to confirm the effect of acupuncture/
moxibustion and/or massage according to disease orsymptom. Finally, our results were biased because thepractitioners knew the aim of the study and also because
a number of patients dissatisfied with therapy ceased it.
A full RCT trial is required to examine whether thechanges over time are the result of the program or are
the result of the placebo effect.
Ⅴ. Conclusion
Our study suggested that acupuncture, moxibustion
and massage have a positive effect on the physical andmental health of the frail elderly.
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