PLOS ONE | DOI:10.1371/journal.pone.

0132989 July 15, 2015 1 / 40 

OPEN ACCESS 
Citation: Tan J-Y, Suen LKP, Wang T, Molassiotis A (2015) Sham Acupressure Controls Used in Randomized Controlled Trials: 
A Systematic Review and Critique. PLoS ONE 10(7): e0132989. doi:10.1371/journal.pone.0132989 
Editor: Nguyen Tien Huy, Institute of Tropical Medicine (NEKKEN), Nagasaki University, JAPAN 
Received: January 22, 2015 
Accepted: June 23, 2015 
Published: July 15, 2015 
Copyright: © 2015 Tan et al. This is an open access article distributed under the terms of the Creative Commons Attribution 
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source 
are credited. 
Data Availability Statement: All relevant data are within the paper and its Supporting Information files. 
Funding: These authors have no support or funding to report. 
Competing Interests: The authors have declared that no competing interests exist. 

RESEARCH ARTICLE Sham Acupressure Controls 

Used in Randomized Controlled Trials: A Systematic 
Review and Critique 
Jing-Yu Tan1,2, Lorna K. P. Suen1, Tao Wang3, Alexander Molassiotis1* 
1 School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong SAR, China, 2 School of 
Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China, 3 The Second Affiliated People’s Hospital, 
Fujian University of Traditional Chinese Medicine, Fuzhou, Fujian, China 
4 [email protected] 

Abstract 
Objectives 
To explore the commonly utilized sham acupressure procedures in existing acupressure tri- als, and to assess whether different 
types of sham interventions yield different therapeutic outcomes, and, as far as possible, to identify directions for the future 
development of an adequate sham acupressure method. 

Methods 
Randomized controlled trials comparing true acupressure with sham interventions were included. Thirteen electronic databases 
were adopted to locate relevant studies from incep- tion to July 3, 2014. Meanwhile, eight Chinese journals on complementary 
and alternative medicine were manually searched to locate eligible articles. In addition, eligible studies listed in the reference lists 
of the included papers and other related systematic reviews on acupressure were also screened to further search any potentially 
eligible trials. Methodolog- ical quality of the included studies was evaluated using the risk of bias assessment tool developed by 
the Cochrane Back Review Group. Descriptive analysis was adopted to sum- marize the therapeutic outcomes. 

Results 
Sixty-six studies with 7265 participants were included. Methodological quality of the included trials was generally satisfactory. 
Six types of sham acupressure approaches were identified and “non-acupoint” stimulation was the most frequently utilized sham 
point while an acupressure device was the most commonly used approach for administering sham treatments. Acupressure 
therapy was a beneficial approach in managing a variety of health problems and the therapeutic effect was found to be more 
effective in the true acupressure groups than that in the sham comparative groups. No clear association could be identified 
between different sham acupressure modalities and the reported treatment outcomes. 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 

Conclusions 
A great diversity of sham acupressure controls have been used in clinical practice and research. A solid conclusion whether 
different sham alternatives are related to different treatment outcomes cannot be derived because of significant clinical 
heterogeneity among the analyzed trials. Non-acupoints are generally recommended but the definite locations should be 
identified with caution. For studies using single sham acupoints on hands or legs, it is suggested to apply identical acupressure 
devices on the same acupoint as in the active intervention without any stimulation. While for studies on pain, stimulation of sham 
acu- points should be avoided. 

Introduction 
Randomized controlled trial (RCT) is one of the commonly used experimental methods for testing the effectiveness 
of an intervention [1]. To distinguish the specific effect of a therapeutic approach from the non-specific effect, a 
placebo control is usually employed [2]. Placebo is defined as “any therapy or component of therapy used for its 
nonspecific, psychological, or psychophysiological effect, or that is used for its presumed specific effect, but is 
without specific activity for the condition being treated” [3] (p. 371). A placebo intervention is commonly used in 
experimental drug studies where the “placebo drug” is identical to the active agent without any specific 
pharmacological activity against the disease. Theoretically, placebo comparisons should be indistinguishable from 
the true intervention, and most importantly, should be inert, which means only create non-specific physiological and 
psychological changes [4]. However, an adequate placebo design becomes difficult to implement when a study is 
adopting complex non-pharmacological interventions such as physiotherapy, acupuncture or acupressure, etc. 
Multiple mechanisms involved in these types of treatments make it complicated to develop an appropriate placebo 
control group. 
Acupressure has been widely applied in dealing with a variety of health issues globally. In addition to the specific 
therapeutic effects, stimulation at the acupoints is also believed to gen- erate some non-specific effects, in both 
physiological and psychological aspects [5]. Placebo controls adopted in acupressure trials are usually referred to as 
“sham interventions”, which indicate faked acupressure approaches. Various types of sham acupressure have been 
reported in the literature which mainly differ in three aspects, the selected acupoints, the acupressure approach, and 
the acupressure intensity. Acupoints adopted in sham procedures commonly include non-acupoints, true acupoints as 
the active acupressure group, and non-therapeutic acupoints. Non-acupoints generally refer to ineffective body 
points which cannot be found on established acupuncture-point charts, while non-therapeutic acupoints means 
irrelevant true acupoints considered to be ineffective for the targeted health problem [2,6]. 
Sham procedures used in acupuncture have received considerable attention in research. A number of RCTs and 
systematic reviews have been conducted to investigate the specific treat- ment effect of acupuncture in a wide range 
of disorders, especially in pain management, and have yielded contradictory results. Some of them supported the 
specific benefit of acupuncture [5,7–9], while others argued that the effects of true acupuncture were similar to that 
in the sham intervention [10–12], and consequently reached the conclusion that the so-called treat- ment effect of 
acupuncture may be only a non-specific physiological effect and/or a placebo effect. However, before developing 
such conclusions, those studies must have a precondition 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 2 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
that the employed sham procedure is inert. Similar situations were also detected in studies of acupressure. Despite 
the significant amounts of research on acupressure during the past decades, it is still uncertain which type of sham 
acupressure is the most adequate design, and to our knowledge, no study has been conducted so far to summarize the 
frequently used sham acupressure modalities and to explore their strengths and drawbacks. Hence, the aims of this 
study are to identify the commonly utilized sham procedures in existing acupressure trials, to assess whether 
different types of sham intervention yield different therapeutic outcomes, and, if possible, to identify directions for 
the future development of an adequate sham acupressure mode. 

Methods 
This study is a systematic review of the literature (S1 File). A review protocol was created by the first author and it 
was approved by two experts with experience in acupressure before the commencement of the study (S2 File). 

Data Sources and Search Strategies 

Both electronic and manual searches were used to locate relevant studies. Thirteen electronic databases were 
accessed including PubMed, EMBase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, 
Allied and Complementary Medicine (AMED), PsycINFO, Thomson Reuters Web of Science, Science Direct, 
Foreign Medical Journal Service (FMJS), China National Knowledge Infrastructure (CNKI), WanFang Data, 
Chinese Scientific Journal Database (CQVIP) and Chinese Biomedical Literature Database (CBM), from inception 
to July 3, 2014. There was no language restriction set for electronic searches. Meanwhile, eight Chinese journals on 
complementary and alternative medicine (issues published within the latest three years) were manually searched to 
possibly identify some latest publications which were still not included in the online databases. In addition, eligible 
studies listed in the reference lists of the included papers and other related systematic reviews on acupressure were 
also screened to fur- ther search any potentially eligible trials. Literature searches were performed independently by 
two reviewers with Chinese medicine background (JYT and TW). Mesh terms, entry terms, key words and free 
words such as “acupressure”, “acupressÔ, “wristbandÔ “shiatsu” and “chih ya” were used in the searching 
strategies. Four selected English and Chinese search strategies are listed in S1 Table. 

Inclusion and Exclusion Criteria 

RCTs comparing true acupressure with a sham intervention were included. Both true and sham acupressure can be 
manipulated through either manual intervention or acupressure devices (e.g., wristbands or attached acupressure 
beads, etc.). To eliminate the effect of electri- cal stimulation on the therapeutic outcomes of acupressure, studies on 
electronic acupressure devices were excluded. At the same time, studies on other modalities of acupuncture-point 
stimulation such as manual/electronic/laser acupuncture and moxibustion, as well as all kinds of auricular therapy 
were excluded. Studies published in languages other than English and Chi- nese were excluded. 

Methodological Quality Evaluation 

Methodological  quality of the included studies was evaluated using the risk of bias assessment tool developed by the 
Cochrane  Back  Review  Group  [13].  The  tool  can  be  viewed  as  an  exten- sion of the original criteria recommended 
by the Cochrane Handbook. It not only includes all 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 3 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
the necessary items described in the latest version of the Cochrane risk of bias tool, but also provides more detailed 
criteria for assessing “incomplete outcome data” and “other sources of potential bias”. The tool consists of 12 items 
including: (1) “Was the method of randomization adequate?”; (2) “Was the treatment allocation concealed?”; (3) 
“Was the patient blinded to the intervention?”; (4) “Was the care provider blinded to the intervention?”; (5) “Was 
the outcome assessor blinded to the intervention?”; (6) “Was the drop-out rate described and acceptable?”; (7) 
“Were all randomized participants analyzed in the group to which they were allocated?”; (8) “Are reports of the 
study free of suggestion of selective outcome reporting?”; (9) “Were the groups similar at baseline regarding the 
most important prognostic indicators?”; (10) “Were co-interventions avoided or similar?”; (11) “Was the 
compliance acceptable in all groups?” and (12) “Was the timing of the outcome assessment similar in all groups?” 
[13]. Each item can be rated as of “yes”, “no” or “unclear” where “yes” indicates a low risk of bias [13]. 
Importantly, different from the original Cochrane risk of bias criteria, the tool used in this study can provide an 
overall methodological quality assessment for a single trial. The overall quality can be assessed as “low risk of bias” 
when at least six items are scored as “yes” and no serious method- ological flaws are identified (e.g. 80% dropout 
rate found in one study arm) [13]. In this review, only RCTs with low risk of bias were eligible for final analysis. 

Data Extraction 
For each of the included studies, the following data was extracted independently by the same two reviewers: (1) 
study general information (first author, year of publication, full name of journal, country of origin, type of study 
design, and study setting); (2) participant characteris- tics (age, gender, sample size, dropout rate, diagnostic criteria, 
inclusion and exclusion criteria, and reason for acupressure); (3) true/sham acupressure protocols (practitioner, 
acupressure equipment, selected acupoints, treatment duration and number of sessions, and acupressure intensity and 
frequency, etc.); (4) main outcome(s) and results of the therapeutic effects; (5) adverse events associated with 
acupressure; and (6) assessment of methodological quality (12 items of the risk of bias tool plus examination of the 
credibility of blinding). For studies com- prising more than two active treatment arms, only data from true and sham 
acupressure arms were extracted for analysis. Meanwhile, for studies including another control group with stan- dard 
methods of care, data from the standard care arm were also extracted accordingly. Dis- agreement between the two 
reviewers was resolved by discussion or by consulting a third reviewer (AM). 

Classification of Sham Acupressure Methods 

After going through all of the sham acupressure protocols of the included studies as well as reviewing the sham 
control classifications for body and auricular acupuncture in previous studies [2,14,15], sham methods in this study 
were classified into six types which are described in Table 1. 

Data Analysis 
A quantitative synthesis of the main outcomes was originally proposed in the study protocol. However, a precise 
meta-analysis was deemed impossible due to the significant clinical hetero- geneity identified in the health 
conditions, patient characteristics, intervention protocols and outcome measures among studies. A subgroup 
meta-analysis for the same health conditions within each sham acupressure type was also considered but finally 
abandoned for the reasons that clinical heterogeneity was still considerable within each sham modality, and the 
number of trials in some sham types was insufficient for data synthesis. To provide an exploratory analysis 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 4 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Table 1. Classification of Sham Acupressure Methods. 
Types of Sham 
Description Methods 
Type 1 Sham Acupressure at Non-acupoints by Manual Pressure Type 2 Sham Acupressure at Non-acupoints by Employing 
Acupressure Devices Type 3 Pseudo-intervention at the Same Acupoints as True Treatment Arm by Manual 
Light-Touch Type 4 Pseudo-intervention at the Same Acupoints as True Treatment Arm by using 
Placebo Devices Type 5 Manual Acupressure at Non-Therapeutic (Irrelevant) Acupoints Type 6 Sham 
Acupressure at Non-Therapeutic (Irrelevant) Acupoints by Adopting 
Acupressure Devices 
doi:10.1371/journal.pone.0132989.t001 
of the study outcomes, responder rate and responder rate ratio (responder rate in true acupres- sure group/responder 
rate in sham group) for each study presenting dichotomous data were calculated, and a risk ratio (RR) with 95% 
confidence interval (CI) was used to present the responder rate ratio. Descriptive analysis was also used to 
summarize the therapeutic outcomes of acupressure, for both the overall effect and the subgroup effect by each sham 
alternative. The overall assessment was to investigate whether true acupressure is superior to sham com- parisons 
while the subgroup analysis was used to assess whether different types of sham meth- ods could induce different 
therapeutic effects. 
Results of the treatment effect for each main outcome in each individual study were extracted by two reviewers 
according to the following vote counts [2]: “++”: true acupressure is significantly better than sham control for the 
main outcome; “+”: trend of the main outcome in favor of true acupressure but without statistical significance; “0”: 
no difference between true and sham acupressure; “−”:trend of the main outcome in favor of sham acupressure but 
with- out statistical significance; and “− −”: sham intervention is significantly better than true acu- pressure for the 
main outcome. For studies reporting multiple main outcomes, all such outcomes were included for analysis. For 
studies not indicating the main outcomes, all vari- ables with between-group comparison were extracted 
accordingly. 
In addition, subgroup descriptive analyses for different types of health problems, interven- tion duration and 
frequency as well as acupressure intensity were also considered when data were available. Based on the analyzed 
trials, length of treatment was categorized into “extremely short-term” (less than one hour), “short-term” (more than 
one hour but less than one day), “mid-term” (more than one day but less than one week), and “long-term” (more 
than one week). For studies on postoperative issue (e.g. nausea, vomiting and pain, etc.) which employed multiple 
assessment time points, postoperative data within the first 24 hours were abstracted for analysis. The chi-square test 
was used to assess the difference in dropout rates between the true and sham acupressure arms. 

Results Characteristics of the Included Studies 

A total of 5225 items were located. Among those 2283 duplicated articles were excluded after screening by the 
reference management software NoteExpress. A total of 2694 records were subsequently removed by checking titles 
and abstracts. For the remaining 248 items, full-texts were accessed for evaluating eligibility, among which, 160 
were further removed because they failed to include a sham control group (n = 92), were conference proceedings (n 
= 32), were auricular acupressure studies (n = 11), and were articles published in Arabic/Farsi (n = 21), 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 5 / 40 
 
Fig 1. Flow Chart of Study Selection. CENTRAL: Cochrane Central Register of Controlled Trials, CINAHL: Cumulative Index 
to Nursing and Allied Health Literature, AMED: Allied and Complementary Medicine, FMJS: Foreign Medical Journal Service, 
CNKI: China National Knowledge Infrastructure, CQVIP: Chinese Scientific Journal Database, CBM: Chinese Biomedical 
Literature Database 
doi:10.1371/journal.pone.0132989.g001 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Korean (n = 3) and French (n = 1). The remaining 88 articles were further adopted for method- ological quality 
evaluation, of which, 22 with high risk of bias were removed (S2 Table) and 66 studies [16–81] were finally 
included for analysis. Fig 1 shows the flow chart of the study selection. 
The included studies comprised 7265 subjects, with an average sample size of 110 patients per study. These 
studies were published between 1991 and 2015 and were conducted in 18 dif- ferent countries or regions. Of which, 
13 studies originated from Iran, 12 from the United States, ten from Taiwan, five from Sweden, four from the United 
Kingdom, three from Austria, three from South Korea, three from Canada, two from Italy, two from Ireland, two 
from India, and one each from Hong Kong, Denmark, Australia, Turkey, Pakistan, Poland and Norway. More than 
half were carried out in hospitals or medical centers. Acupressure was used to deal with a variety of health problems 
including nausea and vomiting, labor pain, primary dysme- norrhea, sleep disturbance, postoperative gastrointestinal 
dysfunction, and anxiety, etc. Char- acteristics of the included studies can be seen in Table 2. 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 6 / 40 
 
Table 2. Characteristics of the Included Studies. 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Type 1—Sham Acupressure at Non-Acupoints: Manual Acupressure Tang et al. 2014 [16], Pulmonary Wards of A 
Medical Center, Taiwan 
+1 Not Reported2 
Atrian et al. 2013 [17], Dormitories of Kashan University of Medical Sciences, Iran 
Cancer-related 
Total: 57/ 
TAG 1: Manual 
Fatigue (Tang Fatigue 
12, TAG 1: 
Acupressure at True 
Fatigue Rating Scale) 24/8, TAG 
Acupoints, TAG 2: 2: 17/2, 
Manual Acupressure at SAG: 16/2 
True Acupoints + Essential Oils, SAG: Manual Acupressure at Non-Acupoints 
Pain Intensity (VAS) 0 No AEs Found in 
the Study 
Sehhatie-Shafaie et al. 2013 [18], The Public Hospitals of Ardebil, Iran 
Primary 
Total: 67/ 
TAG: Manual Dysmenorrhea 
8, TAG: 
Acupressure at True 33/6, SAG: 
Acupoints, SAG: 34/2 
Manual Acupressure at Non-Acupoints 
++ Not Reported2 
Chao et al. 2013 [19], An Urban Medical Center in Taipei, Taiwan 
Labor Pain in 
Total: 84/ 
TAG: Manual 
Pain Intensity (Visual Nulliparous 
0, TAG: 
Acupressure at True 
Pain Scale) Women 
42/0, SAG: 
Acupoints, SAG: 42/0 
Manual Acupressure at Non-Acupoints 
Not Reported2 
McFadden et al. 2012 [20], University of Colorado at Boulder, United States 
Postoperative 
Total: 66/ 
TAG: Manual 
Frequency of Bowel 
++(For Bowel Gastrointestinal 
6, TAG: 
Acupressure at True 
Sounds, Time to the 
Sounds, Flatus Function 
30, SAG: 
Acupoints + Routine 
First Flatus Passage 
Passage, and 30 
Care, SAG: Manual 
and Defecation, and 
Liquid Intake), + Acupressure at Non- 
Time to Oral Liquid 
(For Solid Intake Acupoints + Routine 
and Solid Intake 
and Defecation) Care 
0 Not Reported2 
Valiee et al. 2012 [21], Surgery Wards, Hospital of Tehran University of Medical Science, Iran 
Stress Reduction Total: 109/ 
TAG: Manual 
Stress Responses NR, TAG: 
Acupressure at True 
(Heart Rate, Heart 39/NR, 
Acupoints, SAG: 
Rate Variability, Skin SAG: 40/ 
Manual Acupressure at 
Conductance NR, 
Non-Acupoints, CG: An 
 Response, State CG:30/NR 
Audio Relaxation CD 
Anxiety Inventory, and Psychological Stress Measure) 
Not Reported2 
Rad et al. 2012 [22], Rouhani Hospital of Babol University of Medical Science, Iran 
Preoperative 
Total: 70/ 
TAG: Manual 
Preoperative Anxiety 
++ (For Anxiety, Anxiety 
0, TAG: 
Acupressure at True 
(VAS), and Vital 
Respiratory Rate, 35/0, SAG: 
Acupoints, SAG: 
Signs (Blood 
and Systolic Blood 35/0 
Manual Acupressure at 
Pressure, Heart Rate, 
Pressure), + (For Non-Acupoints 
and Respiratory Rate) 
Heart Rate and Diastolic Blood Pressure) ++ No AEs Found in 
the Study 
Chang et al. 2011 [23], A Urogynecology Clinic of Queen Elizabeth Hospital, Hong Kong 
Nausea and 
Total: 85/ 
TAG: Manual 
Intensity of Nausea Vomiting in 
5, TAG: 
Acupressure at True 
(VAS) and Vomiting Pregnancy 
43/3, SAG: 
Acupoints, SAG: 
(Frequency of 42/2 
Manual Acupressure at 
Vomiting) Non-Acupoints Urodynamic Stress 
Total: 81/ 
TAG: Manual 
Pelvic Muscle 
++, TAG was 
Not Reported2 
Incontinence 
4, TAG: 
Acupressure at True 
Strength 
Significantly Better 27/1, SAG: 
Acupoints + Pelvic Floor 
(Perineometry 
than SAG and CG; 27/1, CG: 
Muscle Training, SAG: 
through Measuring 
No Difference was 27/2 
Manual Acupressure at 
Vaginal Squeeze 
Found between Non-Acupoints + Pelvic 
Pressure) 
SAG and CG Floor Muscle Training, CG: Pelvic Floor Muscle Training 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 7 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
McFadden et al. 2011 [24], A Community in Colorado, United States 
++ Not Reported2 
Kashefi et al. 2011 [25], Bojnoord University of Medical Science, Iran 
Traumatic Brain 
Total: 42/ 
TAG: Manual 
Cognitive Impairment Injury 
0, TAG: 
Acupressure at True 
and State of Being 21/0, SAG: 
Acupoints, SAG: 
following Traumatic 21/0 
Manual Acupressure at 
Brain Injury Non-Acupoints 
++ No AEs Found in 
the Study 
Reza et al. 2010 [26], Kahrizak Charity Nursing Home, Iran 
Women’s General 
Total: 86/ 
TAG: Manual 
Women’s General Health 
10, TAG: 
Acupressure at True 
Health (General 43/6, SAG: 
Acupoints, SAG: 
Health Questionnaire) 43/4 
Manual Acupressure at Non-Acupoints 
Not Reported2 
McFadden & Hernández 2010 [27], Denver/Boulder Community in Colorado, United States 
Sleep 
Total: 90/ 
TAG: Manual 
Self-Reported Sleep 
 ++, TAG was Disturbances 
13, TAG: 
Acupressure at True 
Habits (Pittsburgh 
Significantly Better 30/5, SAG: 
Acupoints + Usual 
Sleep Quality Index) 
than SAG and CG; 30/4, CG: 
Care, SAG: Manual 
The Sleep Quality 30/4 
Acupressure at Non- 
in SAG was Better Acupoints + Usual 
than That in CG but Care, CG: Usual Care 
There was no Statistical Significance 
Not Reported2 
Maa et al. 2007 [28], Department of Thoracic Medicine, Chang Gung Memorial Hospital, Taiwan 
Cardiovascular 
Total: 16/ 
TAG: Manual 
Heart Rate and Blood 
++ (For Heart Function in Stroke 
3, TAG: 7/ 
Acupressure at True 
Pressure 
Rate), 0 (For Blood Survivors 
1, SAG: 9/ 
Acupoints, SAG: 
Pressure) 2 
Manual Acupressure at Non-Acupoints 
Not Reported2 
Shin et al. 2007 [29], Two General Hospitals, South Korea 
Symptoms and 
Total: 49/ 
TAG: Manual 
Daily Sputum 
0, TAG was Better Health-Related 
14, TAG: 
Acupressure at True 
Amounts, Efforts to 
than CG Regarding Quality of Life in 
16/5, SAG: 
Acupoints + Standard 
clean Secretions 
to the SGRQ Bronchiectasis 
17/6, CG: 
Care, SAG: Manual 
(Sputum Self- 
Activity Domain, Patients 
16/3 
Acupressure at Non- 
Assessment), Six- 
and SAG was better Acupoints + Standard 
Minute Walking 
than CG in the Care, CG: Standard 
Distance, Breathing 
Improvement of Care 
Difficulty, and Quality 
Sputum Self- of Life (SGRQ) 
Assessment 
Not Reported2 
Bertalanffy et al. 2004 [30], Sites of Accident, Austria 
Nausea, Vomiting, 
Total: 66/ 
TAG: Manual 
Degree of Nausea 
++, The Degree of and Ketonuria 
NR, TAG: 
Acupressure at True 
and Vomiting (The 
Nausea and Levels in Women 
23/NR, 
Acupoints + Routine 
Rhodes Index of 
Vomiting in TAG with Hyperemesis 
SAG: 21/ 
Intravenous Therapy, 
Nausea, Vomiting, 
was Statistically Gravidarum 
NR, CG: 
SAG: Manual 
and Retching), and 
Lower than SAG 22/NR 
Acupressure at Non- 
Degree of Ketonuria 
and CG, and No Acupoints + Routine 
Difference was Intravenous Therapy, 
Found between CG: Routine 
SAG and CG Intravenous Treatment 
++ Not Reported2 
Chen et al. 2003 [31], A Mid-Taiwan Teaching Hospital, Taiwan 
Motion Sickness in 
Total: 100/ 
TAG: Manual 
Nausea Intensity Patients with 
0, TAG: 
Acupressure at True 
(VAS) Trauma 
50/0, SAG: 
Acupoints, SAG: 50/0 
Manual Acupressure at Non-Acupoints Gastrointestinal 
Total: 41/ 
TAG: Manual 
Gastrointestinal 
++ Not Reported2 Motility after 
0, TAG: 
Acupressure at True 
Motility Surgery 
21/0, SAG: 
Acupoints, SAG: 
(Multifunctional 20/0 
Manual Acupressure at 
 Stethoscope) Non-Acupoints 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 8 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Tsay & Chen 2003 [32], Four Dialysis Centers in Major Hospitals in Taipei, Taiwan 
Not Reported2 
Kober et al. 2002 [33], Sites of Accident, Austria 
Sleep Quality Total: 105/ 
TAG: Manual 
Sleep Quality 
0, TAG was 7, TAG: 
Acupressure at True 
(Pittsburgh Sleep 
Significantly Better NR, SAG: 
Acupoints + Usual 
Quality Index) 
than CG; No NR, CG: 
Care, SAG: Manual 
Difference was NR 
Acupressure at Non- 
Found between Acupoints + Usual 
SAG and CG Care, CG: Usual Care 
Not Reported2 
Belluomini et al. 1994 [34], Department of Obstetrics and Gynecology, California Pacific Medical Center, United States 
Pre-Hospital 
Total: 60/ 
TAG: Manual 
Pain (VAS), Anxiety 
Comparisons Analgesia 
0, TAG: 
Acupressure at True 
(VAS), and Heart 
between Groups 19/0, SAG: 
Acupoints, SAG: 
Rate 
were not Performed 20/0, CG: 
Manual Acupressure at 
 (or Not Clearly 21/0 
Non-Acupoints, CG: No 
Reported) Acupressure 
Not Reported2 
Type 2—Sham Acupressure at Non-Acupoints: Acupressure Bands or Other Devices Adib-Hajbaghery & Etri, 2013 [35], 
A General Surgical Ward of A University Hospital, Iran 
Nausea and 
Total: 90/ 
TAG: Manual 
Nausea and Vomiting 
++ (For Nausea), + Vomiting in 
30, TAG: 
Acupressure at True 
(The Index of 
(For Vomiting) Pregnancy 
46/16, 
Acupoints, SAG: 
Nausea, Vomiting, SAG: 44/ 
Manual Acupressure at 
and Retching) 14 
Non-Acupoints 
Not Reported2 
Alessandrini et al. 2012 [36], Otolaryngology Department, University of Rome “Tor Vergata”, Italy 
Postoperative 
Total: 70/ 
TAG: Acupressure at 
Severity of Nausea 
++ (For Pain), 0 Pain, Nausea, and 
0, TAG: 
True Acupoints using 
and Pain (VAS), and 
(For Nausea), NA Vomiting 
35/0, SAG: 
Acupressure Band, 
Severity of Vomiting 
(For Vomiting)3 35/0 
SAG: Acupressure at 
 (Frequency of Non-Acupoints using 
Vomiting) Acupressure Band 
Not Reported2 
Soltani et al. 2011 [37], Farabi Hospital, Iran 
Acute Vertigo Total: 204/ 
TAG: Acupressure at 
Severity of Vertigo 
Comparisons 0, TAG: 
True Acupoints using 
and Neurovegetative 
between Groups 102/0, 
Acupressure Band, 
Symptoms (VAS) 
were not Performed SAG: 102/ 
SAG: Acupressure at 
(or Not Clearly 0 
Non-Acupoints using 
Reported) Acupressure Band Postoperative 
Total: 200/ 
TAG: Using 
Postoperative 
++4 Not Reported2 Nausea and 
0, TAG: 
Acupressure Wrist Band 
Nausea and Vomiting Vomiting 
50/0, SAG 
at True Acupoints, SAG 
during the First Two 1: 50/0, 
1: Using Acupressure 
Hours (0–2 Hours) SAG 2: 50/ 
Wrist Band at Non- 
and the Following 22 0, SAG 3: 
Acupoints, SAG 2: 
Hours (2–24 Hours) 50/0 
Using Acupressure 
after Surgery Wrist Band at Non- Acupoints + Metoclopramide, SAG 3: Using Acupressure Wrist 
Band at Non- Acupoints + Ondansetron 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 9 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Bao et al. 2011 [38], The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, United States 
Pain Intensity (VAS) 0 Mild and Transient Bruising or A Rash at the Acupressure Site (n = 10) 
Majholm & Møller 2011 [39], Copenhagen University Hospital, Denmark 
Pain in Cancer 
Total: 78/ 
TAG: Acupressure at Patients 
1, TAG: 
True Acupoints using undergoing Bone 
38/1, SAG: 
Magnetic Acupressure Marrow Aspiration 
40/0 
Suction Cups and Biopsy 
+ Standard Local (BMAB) 
Analgesics, SAG: Acupressure at Non- Acupoints using Magnetic Acupressure Suction Cups + Standard Local Analgesics 
0 Redness (n = 40), 
Swelling (n = 17), Tenderness (n = 16), and Paresthesias (n = 4) Sinha et al. 2011 [40], A Single Tertiary Maternity Unit, 
Australia 
Postoperative 
Total: 134/ 
TAG: Acupressure at 
Postoperative Nausea and 
22, TAG: 
True Acupoints using 
Nausea and/or Vomiting 
67/8, SAG: 
Acupressure Band, 
Vomiting 67/14 
SAG: Acupressure at Non-Acupoints using Acupressure Band 
0 Discomfort from 
Band (n = 25) 
Wang et al. 2008 [41], A Hospital (Details not Described), United States 
Nausea and 
Total: 340/ 
TAG: Acupressure at 
Incidence of Nausea Vomiting during 
11, TAG: 
True Acupoints using 
and/or Vomiting Labour and 
170/6, 
Acupressure Band, Delivery 
SAG: 170/ 
SAG: Acupressure at 5 
Non-Acupoints using Placebo Acupressure Band 
++ Not Reported2 
Turgut et al. 2007 [42], Department of Anesthesiology, Ankara Oncology Hospital, Turkey 
Pre-Procedural 
Total: 52/ 
TAG: Acupressure at 
Anxiety Level (State Anxiety and Intra- 
0, TAG: 
True Acupoints using 
Anxiety Inventory for Procedural 
26/0, SAG: 
Acupressure Beads, 
Children) Propofol Needs in 
26/0 
SAG: Acupressure at Children 
Non-Acupoints using Undergoing 
Acupressure Beads Anesthesia 
++ Erythema and 
Swelling of the Treated Hand (n = 1) 
Heazell et al. 2006 [43], A Single Secondary Care Center, United Kingdom 
Postoperative 
Total: 102/ 
TAG: Acupressure at 
Severity of Nausea and 
2, TAG: 
True Acupoints using 
Postoperative Vomiting 
51/1, SAG: 
Acupressure Band, 
Nausea and Vomiting 51/1 
SAG: Acupressure at Non-Acupoints using Acupressure Band 
No Discomforts Found in the Study 
Wang et al. 2005 [44], A Hospital (Details not Described), United States 
Nausea and 
Total: 80/ 
TAG: Acupressure at 
No. of Days of 
0 (For No. of Days Vomiting in Early 
0, TAG: 
True Acupoints using 
Hospital Stay, and 
of Hospital Stay), + Pregnancy 
40/0, SAG: 
Acupressure Band, 
No. of Patients Who 
+ (For No. of 40/0 
SAG: Acupressure at 
Required ≧ 4 Days in 
Patients Who Non-Acupoints using 
the Hospital 
Required ≧ 4 Days Acupressure Band 
in the Hospital) Preoperative 
Total: 61/ 
TAG: Acupressure at 
Parental Anxiety 
++ Not Reported2 Parental Anxiety 
NR, TAG: 
True Acupoints using 
(State Anxiety 28/NR, 
Acupressure Beads, 
Inventory) SAG: 33/ 
SAG: Acupressure at NR 
Non-Acupoints using Acupressure Beads 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 10 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Alkaissi et al. 2005 [45], Department of Otolaryngology, University Hospital of Linköping, Sweden 
Feeling Uncomfortable and Tight (n = 2), and Swelling of the Hand (n = 1) 
Samad et al. 2003 [46], Aga Khan University Hospital, Pakistan 
Tolerance to 
Total: 60/ 
TAG: Acupressure at 
Time to the Onset of 
+, Mean Time to Nauseogenic 
0, TAG: 
True Acupoints using 
Moderate Nausea 
Moderate Nausea Motion Stimulation 
20/0, SAG: 
Acupressure Band, 
was Statistically 20/0, CG: 
SAG: Acupressure at 
Longer in TAG than 20/0 
Non-Acupoints using 
That in CG, SCG Acupressure Band, CG: 
was also Longer No Acupressure 
than CG but There was no Statistical Significance 0 Not Reported2 
Alkaissi et al. 2002 [47], University Hospital of Linköping, Sweden 
Postoperative 
Total: 50/ 
TAG: Acupressure at 
Incidence of Nausea Nausea and 
0, TAG: 
True Acupoints using 
and Vomiting Vomiting 
25/0, SAG: 
Wrist-Band with Plastic 25/0 
Bead, SAG: Acupressure at Non- Acupoints using Wrist- Band with Plastic Bead 
Discomforts, Red Indentation or Itching (n = 15), Headache and Dizziness (n = 1), Deep Marks, Blistering or Swelling (n = 45) 
Agarwal et al. 2000 [48], Setting not Described, India 
Postoperative 
Total: 410/ 
TAG: Acupressure at 
Complete Response 
+,Both TAG and Nausea and 
30, TAG: 
True Acupoints using 
of Postoperative 
SAG were Better Vomiting 
135/NR, 
Acupressure Band 
Nausea and Vomiting 
than CG SAG: 139/ 
+ Routine Anesthesia, 
(No Report of NR, CG: 
SAG: Acupressure at 
Nausea, Vomiting or 136/NR 
Non-Acupoints using 
Rescue Medication) Acupressure Band + Routine Anesthesia, CG: Routine Anesthesia 
+ No AEs Found in 
the Study 
Harmon et al. 2000 [49], Rotunda Hospital, Ireland 
Postoperative 
Total: 200/ 
TAG: Acupressure at 
Postoperative Nausea and 
0, TAG: 
True Acupoints using 
Nausea and Vomiting Vomiting 
100/0, 
Acupressure Bands, SAG: 100/ 
SAG: Acupressure at 0 
Non-Acupoints using Acupressure Bands 
++ Not Reported2 
Harmon et al. 1999 [50], Rotunda Hospital, Ireland 
Nausea and 
Total: 94/ 
TAG: Acupressure at 
Nausea and Vomiting Vomiting during 
NR, TAG: 
True Acupoints using 
during and after and after Surgery 
47/NR, 
Acupressure Band, 
Surgery SAG: 47/ 
SAG: Acupressure at NR 
Non-Acupoints using Acupressure Band 
++ No AEs Found in 
the Study 
Alkaissi et al. 1999 [51], University Hospital of Linköping, Sweden 
Postoperative 
Total: 104/ 
TAG: Acupressure at 
Postoperative Nausea and 
0, TAG: 
True Acupoints using 
Nausea and Vomiting Vomiting 
52/0, SAG: 
Acupressure Band, 52/0 
SAG: Acupressure at Non-Acupoints using Acupressure Band Postoperative 
Total: 60/ 
TAG: Acupressure at 
Complete Response 
0, Both TAG and 
Not Reported2 
Nausea and 
10, TAG: 
True Acupoints using 
of Postoperative 
SAG were Better Vomiting 
20/NR, 
Acupressure Band 
Nausea and Vomiting 
 than CG, but There SAG: 20/ 
+ Routine Anesthesia, 
(No Report of 
were No Statistical NR, CG: 
SAG: Acupressure at 
Nausea, Vomiting or 
Significances 20/NR 
Non-Acupoints using 
Rescue Medication) Acupressure Band + Routine Anesthesia, CG: Routine Anesthesia 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 11 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Fan et al. 1997 [52], Maimonides Medical Center, United States 
++ No AEs Found in 
the Study 
O’Brien et al. 1996 [53], Setting Not Described, Canada 
Postoperative 
Total: 200/ 
TAG: Acupressure at 
Postoperative Nausea and 
0, TAG: 
True Acupoints using 
Nausea and Vomiting Vomiting 
108/0, 
Acupressure Band, SAG: 92/0 
SAG: Acupressure at Non-Acupoints using Acupressure Band 
Not Reported2 
Felhendler & Lisander 1996 [54], An Ambulatory Unit in Linköping University Hospital, Sweden 
Nausea and 
Total: 161/ 
TAG: Acupressure at 
Nausea and Vomiting 
0, No Difference Vomiting During 
12, TAG: 
True Acupoints using 
(The Rhodes Index of 
was Detected Pregnancy 
54/NR, 
Acupressure Band, 
Nausea, Vomiting, 
Across Groups SAG: 53/ 
SAG: Acupressure at 
and Retching) NR, CG: 
Non-Acupoints using 54/NR 
Acupressure Band, CG: No Acupressure 
++ Not Reported2 
Bayreuther et al. 1994 [55], Five General Practices in Central Southampton, United Kingdom 
Postoperative Pain Total: 40/ 
TAG: Acupressure at 
Postoperative Pain NR, TAG: 
True Acupoints using A 
(VAS) 20/NR, 
Dentist’s Tool, SAG: SAG: 20/ 
Acupressure at Non- NR 
Acupoints using A Dentist’s Tool 
Nausea (VAS) ++ Not Reported2 
Type 3—Pseudo-Intervention at the Same Acupoints as Intervention Group: Manual Light-Touch without Acupressure 
Hamidzadeh et al. 2012 [56], Fatemiyeh Educational and Research Hospital in Shahroud, Iran 
Early Morning 
Total: 23/ 
TAG: Acupressure at Sickness 
8, TAG: 
True Acupoints using 11/4, SAG: 
Acupressure Band, 12/4 
SAG: Acupressure at Non-Acupoints using Acupressure Band 
++ No AEs Found in 
the Study 
Mirbagher-Ajorpaz et al. 2011 [57], Dormitories of Kashan University of Medical Science, Iran 
Labor Pain Total: 100/ 
TAG: Manual 
Intensity of Labor 0, TAG: 
Acupressure at True 
Pain (VAS) 50/0, SAG: 
Acupoints, SAG: Light 50/0 
Touch on the Same Acupoints 
++ Not Reported2 
Sun et al. 2010 [58], Two Long-Term Care Facilities in Northern Taiwan, Taiwan 
Primary 
Total: 30/ 
TAG: Manual 
Severity of Dysmenorrhea 
0, TAG: 
Acupressure at True 
Dysmenorrhea (VAS) 15/0, SAG: 
Acupoints, SAG: Light 15/0 
Touch on the Same Acupoints 
++ Not Reported2 
Kashanian & Shahali 2010 [59], Akbarabadi Teaching Hospital in Tehran, Iran 
Insomnia Total: 50/ 
TAG: Manual 
Insomnia (The Athens 6, TAG: 
Acupressure at True 
Insomnia Scale- 25/2, SAG: 
Acupoints, SAG: Light 
Taiwan Form) 25/4 
Touch on the Same Acupoints 
++ Not Reported2 
Hjelmstedt et al. 2010 [60], Sree Avittom Thirunal Hospital in Trivandrum, India 
Duration and Pain 
Total: 120/ 
TAG: Manual 
Severity of Labor of the Active 
0, TAG: 
Acupressure at True 
Pain (VAS) and Phase of Labor 
60/0, SAG: 
Acupoints, SAG: Light 
Duration of Active 60/0 
Touch on the Same 
Phase Acupoints Labor Pain Total: 213/ 
TAG: Manual 
Intensity of Labor 
++, TAG was 
Not Reported2 1, TAG: 
Acupressure at True 
Pain (VAS) 
Significantly Better 71/0, SAG: 
Acupoints + Usual 
than CG; SAG was 71/0, 
Care, SAG: Light Touch 
Better than CG but CG:71/1 
on the Same Acupoints 
There was no + Usual Care, CG: 
Statistical Usual Care 
Significance 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 12 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Hsu et al. 2006 [61], Two Long-Term Care Facilities, Taiwan 
++ Not Reported2 
Lee et al. 2004 [62], Delivery Room in A University Hospital, South Korea 
Insomnia Total: 50/ 
TAG: Manual 
Insomnia (Pittsburgh 0, TAG: 
Acupressure at True 
Sleep Quality Index) 25/0, SAG: 
Acupoints, SAG: Light 25/0 
Touch on the Same Acupoints 
++ Not Reported2 
Type 4—Pseudo-Intervention at the Same Acupoints as Intervention Group: Placebo Acupressure Devices Nilsson et al. 
2015 [63], Department of Neurosurgery of Umeå University Hospital, Sweden 
Labor Pain and 
Total: 89/ 
TAG: Manual 
Severity of Labor Length of Delivery 
14, TAG: 
Acupressure at True 
Pain (VAS) and Time 
36, SAG: 
Acupoints, SAG: Light 
Duration of Labor to 39 
Touch on the Same 
Delivery Acupoints 
0 Swelling (n = 12), 
Bruises (n = 2), Paresthesia (n = 1), and Pain (n = 1) 
Molassiotis et al. 2013 [64], Christie NHS Foundation Trust, Clatterbridge Centre for Oncology, Southport General Infirmary, 
and Several Hospitals, United Kingdom 
Postoperative 
Total: 120/ 
TAG: Acupressure at 
Postoperative Nausea and 
25, TAG: 
True Acupoints using 
Nausea (NRS) Vomiting 
52/9, SAG: 
Acupressure Band, 68/16 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
Transient AEs (n = 6): Minor Swelling and Tightness in the Area of Wristbands, and Discomfort when Wearing the Wristbands 
Noroozinia et al. 2013 [65], Imam Khomeini General Hospital of Urmia, Iran 
Chemotherapy- 
Total: 500/ 
TAG: Acupressure at 
Chemotherapy- 
0, Nausea Induced Acute and 
128, TAG: 
True Acupoints using 
Induced Nausea (The 
Experience was Delayed Nausea 
168/36, 
Acupressure Band 
Nausea Experience 
slightly lower in SAG: 166/ 
+ Standard Antiemetics, 
Subscale of The 
Both TAG and SAG 47, CG: 
SAG: Sham 
Rhodes Index of 
than that in CG, but 166/45 
Acupressure at the 
Nausea, Vomiting, 
There was No Same Acupoints using 
and Retching) 
Statistical A Placebo Acupressure 
Significance Band+ Standard Antiemetics, CG: Standard Antiemetics 
++ Not Reported2 
Soltanzadeh et al. 2012 [66], Hospital (Details not Described), Iran 
Postoperative 
Total: 152/ 
TAG: Acupressure at 
 Postoperative Nausea and 
0, TAG: 
True Acupoints using 
Nausea and Vomiting Vomiting 
76/0, SAG: 
Acupressure Band, 
(VAS) 76/0 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band Postoperative 
Total: 120/ 
TAG: Acupressure at 
Incidence of 
++ (For Nausea), + 
No AEs Found in 
Nausea and 
0, TAG: 
True Acupoints using 
Postoperative 
(For Vomiting) 
the Study Vomiting 
40/0, SAG 
Acupressure Band, 
Nausea and Vomiting 1: 40/0, 
SAG 1: Sham SAG 2: 40/ 
Acupressure at the 0 
Same Acupoints using A Dummy Band, SAG 2: Sham Acupressure at the Same Acupoints using A Dummy Band + 
Metoclopramide 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 13 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
White et al. 2012 [67], Cedars Sinai Medical Center in Los Angeles, United States 
++ Constipation 
(n = 2), Headache (n = 3), Fatigue (n = 6), and Drowsiness (n = 3)5 
Ho et al. 2006 [68], Taipei Veterans General Hospital, Taiwan 
Postoperative 
Total: 100/ 
TAG: Acupressure at 
Incidence of Nausea and 
0, TAG: 
True Acupoints using 
Postoperative Vomiting 
50/0, SAG: 
Acupressure Strip, 
Nausea and Vomiting 50/0 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Strip 
+ No AEs Found in 
the Study 
Klein et al. 2004 [69], Toronto General Hospital, Canada 
Nausea and 
Total: 110/ 
TAG: Acupressure at 
Incidence of Nausea Vomiting During 
0, TAG: 
True Acupoints using 
and Vomiting During Surgery 
55/0, SAG: 
Acupressure Band, 
Surgery 55/0 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
+ No AEs Found in 
the Study 
Schultz et al. 2003 [70], A Tertiary Care Hospital in Northern New England, Portland 
Postoperative 
Total: 152/ 
TAG: Acupressure at 
Incidence of Nausea and 
0, TAG: 
True Acupoints using 
Postoperative Vomiting 
75/0, SAG: 
Acupressure Band, 
Nausea and Vomiting 77/0 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
Not Reported2 
Dent et al. 2003 [71], The Coronary Care Unit of A District Hospital, United Kingdom 
Postoperative 
Total: 143/ 
TAG 1: Acupressure 
Incidence of 
—(For Nausea),— Nausea and 
40, TAG 
Band at True Acupoints 
Postoperative 
(For Vomiting) 6 Vomiting 
1:30, TAG 
+ Droperidol, TAG 2: 
Nausea and Vomiting 2:24, SAG 
Acupressure Band at 1:24, SAG 
True Acupoints 2:25 
+ Placebo Drug, SAG 1: Placebo Band at the Same Acupoints + Droperidol, SAG 2: Placebo Band at the Same Acupoints + 
Placebo Drug 
Not Reported2 
Norheim et al. 2001 [72], A University Hospital, Norway 
Acute Myocardial 
Total: 301/ 
TAG: Acupressure at 
Incidence of Nausea 
+,TAG was Better Infarction-Related 
0, TAG: 
True Acupoints using 
and Vomiting 
than SAG and CG, Nausea and 
95/0, SAG: 
Acupressure Band, 
No Difference was Vomiting 
98/0, CG: 
SAG: Sham 
Found between 108/0 
Acupressure at the 
SAG and CG Same Acupoints using A Placebo Acupressure Band, CG: No 
Additional Intervention Morning Sickness 
Total: 97/ 
TAG: Acupressure at 
Incidence and 
+ (For Incidence of 
Pain, Numbness, in 
Pregnancy 
13, TAG: 
True Acupoints using 
Duration of Nausea 
Nausea and 
Soreness, and NR, SAG: 
Acupressure Band, 
and Vomiting 
Vomiting), ++ (For 
Swelling (No. not NR 
SAG: Sham 
Duration of Nausea 
Given); Worse Acupressure at the 
and Vomiting) 
Symptoms (n = 3) Same Acupoints using A Placebo 
Acupressure Band 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 14 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Steele et al. 2001 [73], Seventeen Medical Clinics or Offices in Southern Michigan, United States 
++ Not Reported2 
Woods 1999 [74], Malcolm Grow Air Force Medical Center, United States 
Nausea and 
Total: 138/ 
TAG: Acupressure at 
Severity and Vomiting During 
28, TAG: 
True Acupoints using 
Frequency of Nausea Pregnancy 
85/17, 
Acupressure Band, 
and Vomiting SAG: 53/ 
SAG: Sham 11 
Acupressure at the Same Acupoints using A Placebo Acupressure Band 
- Not Reported2 
Duggal et al. 1998 [75], Hospital (Details not Described), Canada 
Postoperative 
Total: 10/ 
TAG: Acupressure at 
Postoperative Nausea and 
NR, TAG: 
True Acupoints using 
Nausea and Vomiting Vomiting 
5/NR, 
Acupressure Band, 
(VAS) SAG: 5/NR 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
+ Tightness (n = 22), 
Swollen Hands (n = 43), Infusion Problem (n = 4), and Itching Wrists (n = 9) 
Lewis et al. 1991 [76], Hospital (Details not Described), United States 
Postoperative 
Total: 263/ 
TAG: Acupressure at 
Incidence of Nausea Nausea and 
19, TAG: 
True Acupoints using 
and Vomiting Vomiting 
122, SAG: 
Acupressure Band, 122 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
0 Bands were Well 
Tolerated 
Type 5—Acupressure at Non-Therapeutic Acupoints (Irrelevant Acupoints): Manual Acupressure Suh 2012 [77], A 
University Cancer Center in Seoul, South Korea 
Postoperative 
Total: 66/ 
TAG: Acupressure at 
Incidence of Nausea and 
2, TAG: 
True Acupoints using 
Postoperative Vomiting 
33/2, SAG: 
Acupressure Band, 
Nausea and Vomiting 33/0 
SAG: Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band 
Not Reported2 
Lang et al. 2007 [78], A Paramedic- Based Rescue System, Austria 
Chemotherapy- 
Total: 120/ 
TAG 1: Acupressure at 
Chemotherapy- 
++ (For Acute and Induced Nausea 
15, TAG 
Therapeutic Acupoints 
Induced Nausea and 
Delayed Vomiting) 7 and Vomiting 
1:30/5, 
using Acupressure 
Vomiting (The Index TAG 2:30/ 
Band, TAG 2: 
of Nausea, Vomiting, 1, SAG: 
Acupressure at 
and Retching) 30/7, 
Therapeutic Acupoints CG:30/2 
using Acupressure Band + Counseling, SAG: Manual Acupressure at Irrelevant Acupoints, CG: Counseling Only Pre-Hospital 
Total: 32/ 
TAG: Manual 
Intensity of Pain and 
++ (For Pain, 
Not Reported2 
Analgesia 
1, TAG: 
Acupressure at 
Anxiety (VAS), and 
Anxiety and Heart 16/1, SAG: 
Therapeutic Acupoints, 
Blood Pressure and 
Rate), 0 (Blood 16/0 
SAG: Manual 
Heart Rate 
Pressure) Acupressure at Irrelevant Acupoints 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 15 / 40 
 
Table 2. (Continued) 
Study & Setting(s) Condition(s) Sample 
Size & Dropout (N/n) 
Acupressure- related AEs 
Wu et al. 2007 [79], Wu et al. 2004 [80], A Medical Center and Three Regional Hospitals in Taipei, Taiwan 
++ Not Reported2 
Type 6—Acupressure at Non-Therapeutic Acupoints (Irrelevant Acupoints): Acupressure Bands or Other Devices Nordio 
& Romanelli 2008 [81], Setting not Described, Italy 
Chronic Dyspnea 
Total: 62/ 
TAG: Manual 
Depression (The in Chronic 
18, TAG: 
Acupressure at 
Geriatric Depression Obstructive 
22, SAG: 
Therapeutic Acupoints, 
Scale), Anxiety (The Pulmonary 
22 
SAG: Manual 
State Anxiety Disease 
Acupressure at 
Inventory), Chronic Irrelevant Acupoints 
Dyspnea (Pulmonary Function Status and Dyspnea Questionnaire Modified and VAS), and Six-Minute Walking Tests 
Insomnia Total: 40/ 
TAG: Acupressure at 
Level of Global Life 
NR (For Life 
No AEs Found in 7, TAG: 
Therapeutic Acupoints 
Quality (General 
Quality, 
the Study 20/2, SAG: 
using Wrist 
Health 
Comparison 20/5 
Acupressure Device, 
Questionnaire), Sleep 
between Groups SAG: Acupressure at 
Quality (Pittsburgh 
was not Shown), ++ Irrelevant Acupoints 
Sleep Quality Index), 
(For Sleep Quality), using Wrist 
and Anxiety (State 
+ (For Anxiety), ++ Acupressure Device 
Trait Anxiety 
(For Urinary Inventory); and 
Melatonin Urinary Melatonin 
Metabolite) Metabolite 
AE: Adverse event, TAG: True acupressure group, SAG: Sham acupressure group, VAS: Visual Analogue Scale, NA: Not 
applicable, CG: Control group, SGRQ: The Saint George Respiratory Questionnaire, NRS: Numerical Rating Scale 1: For true 
acupressure group 1 and sham acupressure group 2: The study did not assess acupressure-related adverse events 3: Statistical 
analysis was not conducted for vomiting 4: For true acupressure group and sham acupressure group 1 5: Incidence of 
postoperative adverse events, not sure whether these events were associated with acupressure 6: For true acupressure group 1 and 
sham acupressure group 1 7: For true acupressure group 1 and sham acupressure group. 4Vote counts of results of therapeutic 
effects: “++”: True acupressure group is significantly better than sham acupressure group for the main outcome; “+”: Trend of 
the main outcome in favor of true acupressure group but without statistical significance; “0”: No difference was found between 
true and sham acupressure groups; “−”:Trend of the main outcome in favor of sham acupressure group but without statistical 
significance; “− −”: sham acupressure group is significantly better than true acupressure group for the main outcome. 
doi:10.1371/journal.pone.0132989.t002 
Sham Acupressure Controls Used in Randomized Controlled Trials 
Intervention & Control 
Main Outcome(s) Therapeutic Groups 
Effects of Acupressure* 

Methodological Quality and Risk of Bias of the Included Studies 

Results of the risk of bias assessment for all the included trials can be seen in S3 Table. Method- ological quality of 
the included trials was generally satisfactory, as already all studies of high risk of bias were excluded. Forty-nine 
trials adequately described the method of randomization. Twenty-six studies appropriately described the allocation 
concealment. Blinding of partici- pants was adopted in 45 trials. Outcome assessor was blinded to the intervention in 
the major- ity of studies (51 studies), but there were only 17 studies which reported blinding for the care provider. 
Eighteen studies employed a single-blind design for either participant, or care pro- vider, or outcome assessor. 
Double-blinding for both participant and outcome assessor was uti- lized in 26 trials, and blinding for both the care 
provider and the outcome assessor was used in 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 16 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
four studies. There were 11 trials that incorporated a triple-blind design. No trial tested the credibility of blinding 
during the study period. 
Dropout of study subjects was mentioned and acceptable in 89.4% of the included studies. Thirty-two trials 
reported that all randomized participants were included for analysis. Selective outcome reporting was detected in 
only one study, and baseline data were similar between groups in most of the studies. Co-intervention (e.g. 
intra-operative anesthesia or standard care, etc.) was similar or avoidable in more than half of the articles (42 
studies). Participants’ compli- ance to treatment was mentioned and satisfactorily achieved in seven studies. The 
timing of outcome assessment was found similar among groups in 96.97% of the included trials. 

Description of Acupressure Protocols 

True acupressure protocols used in the included trials are presented in Table 3. Among the analyzed trials, 30 
adopted manual acupressure while another 36 chose acupressure equipment to provide constant pressure on the 
targeted acupoints. The majority (52 studies) described the person conducting acupressure, being an acupuncturist, 
acupressure practitioner, anesthetist, nurse, paramedic and study investigator, etc. For studies where acupressure was 
administered by non-acupuncture/acupressure professionals, 60% (27/45) specified that the intervention operator 
had received training in acupressure or application of the acupressure device. Length of acupressure therapy varied 
significantly among studies due to the nature of the treated con- ditions. The shortest intervention (three minutes) 
emerged in one study focusing on pre-hospi- tal analgesia [33] while the longest treatment was five months for 
cancer-related fatigue [16]. Fifty studies reported the intensity for acupressure, 24 claimed equal intensity between 
groups, while sham groups received only light acupressure or no stimulation in the other 26 studies. 
For the types of acupressure, 61 articles employed Chinese acupuncture theory to guide the acupressure protocol, 
and three adopted the Japanese Jin Shin acupressure [20, 24, 27], while the other two used Korean hand acupressure 
[30,66]. Bilateral acupoints were stimulated in both groups in 38 studies, and eight trials only employed unilateral 
stimulation, while in the other 20 studies, both bilateral and unilateral acupoints were used or such information were 
not reported. The number of selected acupoints ranged from one to 15 in the true treatment groups, and the majority 
(50 studies) only applied one acupoint (bilateral or unilateral) for acu- pressure. In one study on postoperative pain 
[54], 15 acupoints were chosen for stimulation. Selection of the acupoints was based on the targeted health issue, 
and neiguan (P6) was fre- quently used for controlling nausea and/or vomiting, sanyinjiao (SP6) and hegu (LI4) 
were used for treating various types of pain such as peri-operative pain, primary dysmenorrheal and labor pain, 
shenmen (HT7) was mainly used for sleep disorders, and yintang (EX-NH3) was used for anxiety relief. 

Description of Sham Acupressure Procedures 

Sham acupressure protocols are also summarized in Table 3. Six types of sham acupressure were identified. 
Non-acupoint was used in 40 studies, of which, 19 manually stimulated the non-acupoint (type 1). For studies with 
type 1 sham mode, 12 described the definite location of the selected non-acupoints and most of them were near the 
real acupoints used in the true intervention groups. More specifically, three studies [25, 26, 32] indicated that the 
non-acu- points should be away from the nearby meridians, with 0.5 cun (a traditional Chinese term that translates to 
"anatomical inch") in one study [26], and one cm in another [32]. In addition, there was one study [31] stating that 
the non-acupoints should be three to four cm away from the targeted active acupoints. Total duration of treatment as 
well as duration of each session were similar between groups. In terms of the acupressure intensity, three studies 
[19, 22, 25] 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 17 / 40 
 
applied equal pressure between groups, and one [23] only exerted light pressure on non-acu- points, while this 
information was not reported in the other 15 articles. 
Twenty-one  studies  used  acupressure  devices  at  the  non-acupoints  (type  2).  Both  true  and  sham  study  arms 
utilized  the  same  equipment. Wrist bands such as sea-bands or vital-bands, etc. were adopted in 16 studies and these 
tools usually possess a plastic/metal button located at 
Table 3. True and Sham Acupressure Protocols of the Included Studies. 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Type 1—Sham Acupressure at Non-Acupoints: Manual Acupressure (19 Studies) Tang et al. 2014 [16] 
Nurse Students with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Hegu (LI4), Zusanli (ST36), and Sanyinjiao 
(SP6) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoints at Inner Ankle, Patella, and 
the First Metacarpal Head 
Total Duration: Daily Treatment for Consecutive 5 Months, Each Treatment: 6 Min with 1 Min for Each Acupoint 
Not Reported 
Atrian et al. 2013 [17] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Taichong (LR3) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoints located 2 cm above the 
Distance between the Third and Fourth Toes 
Total Duration: NR (3 Treatments in Total), Each Treatment: 16 Mins (Each Acupoint on Each Leg for 2 Min Pressure and 2 
Min Resting, Repeated Twice) 
Not Reported 
Sehhatie- Shafaie et al. 2013 [18] 
Research Assistant with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Sanyinjiao (SP6), and Hegu (LI4) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoints on the Legs and Hands 
(Details not Described) 
Total Duration: Four Treatments in Total, Each Treatment: 20 Min 
Not Reported 
Chao et al. 2013 [19] 
Research Nurse with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Zusanli (ST36) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoint located at the Tibia 
Total Duration: 3 Treatments Per Day for 5 Days, Each Treatment: 5 Continuous 1-second Press followed by a 2-Second Rest, 
Repeated for 3 Min 
Equal for Both TA and SA 
McFadden et al. 2012 [20] 
Acupressure Practitioner 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): True Acupoints (Details not Described) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints which cannot be Found on Established 
Acupressure Point Charts (Details not Described) 
Total Duration: 40 Min (Only One Treatment) 
Not Reported 
Valiee et al. 2012 [21] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Yintang (or Extra-1, EX-NH3), and Shenmen (Ear) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints located at the External Corner of the 
Left Eyebrow, and the Entrance of the Cavity of the Ear 
Total Duration: 10 Min (Only One Treatment) 
Not Reported 
Rad et al. 2012 [22] 
Researcher with the Certificate of Conducting Acupressure 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Youmen (KI21) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Unilateral) No-Acupoint (Details Not Described) 
Total Duration: Daily Treatment for 4 Consecutive Days, Each Treatment: 2 Min Acupressure followed by 2 more Min Massage 
at the Acupoints, Repeated for 20 Min 
Equal for Both TA and SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 18 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Chang et al. 2011 [23] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Zhongji (CV3), Guanyuan (CV4), Qihai (CV6), 
Shenshu (BL23), Pangguangshu (BL28), Ciliao (BL32), Sanyinjiao (SP6), and Zusanli (ST36) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints (Details Not Described) 
Total Duration: 3 Treatments Per Week for 10 Weeks, Each Treatment: 30 Min 
Unequal (Less in SA, Only Light Pressure) 
McFadden et al. 2011 [24] 
Acupressure Practitioner 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): True Acupoints (Details not Described) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints which cannot be Found on Established 
Acupressure Point Charts (Details not Described) 
Total Duration: 2 Treatments Per week for 4 Weeks, Each Treatment: 40 Min 
Not Reported 
Kashefi et al. 2011 [25] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Sanyinjiao (SP6) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoint located at the Dorsal Side of 
the Leg, Away from Meridians and is not Stimulated upon the Achilles Tendon 
Total Duration: NR (One Treatment for Each Menstrual Cycle, 2 Treatments in Total), Each Treatment: 6-Second Pressure 
followed by 2-Second Rest, Repeated for 30 Min 
Equal for Both TA and SA 
Reza et al. 2010 [26] 
Investigator with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Neiguan (P6), Shenmen (Hand, HT7), 
Shenmen (Ear), Yungchuan (KI1), Sanyinjiao (SP6), and Anmian (EX-HN22) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints Located 0.5 cun Away from Meridian 
Total Duration: 3 Treatments Per Week for 4 Weeks 
Not Reported 
McFadden & Hernández 2010 [27] 
Acupressure Practitioner 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): True Acupoints (Details not Described) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints which cannot be Found on Established 
Acupressure Point Charts (Details not Described) 
Total Duration: One Treatment Per Week for 8 Weeks, Each Treatment: 40 Min 
Not Reported 
Maa et al. 2007 [28] 
Investigator Skilled in Acupressure 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Zhongfu(LU1), Chize (LU5), Yuji (LU10), 
Fenglong (ST40), and Zusanli (ST36) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoints located near Real Acupoints 
(where no Acupoints are Known to Exist) 
Total Duration: Daily Treatment (at Least) for 8 Weeks, Each Treatment: 30 Seconds to 2 Min Acupressure for Each Acupoint 
(Total Duration for Each Treatment not Mentioned) 
Not Reported 
Shin et al. 2007 [29] 
Nurse with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Neiguan (P6) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoint located at a Bony Part around the 
Radial Pulse at the Wrist 
Total Duration: 3 Treatments Per Day, From the Second Day of Hospitalization to the Day before Discharge, Each Treatment: 10 
Min (7 Seconds Acupressure Followed by 2 Seconds Rest, Repeated for 10 Min) 
Not Reported 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 19 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Bertalanffy et al. 2004 [30] 
Paramedic Method(s): Manual 
Acupressure at True Acupoints using A Hard Plastic Ball, Selected Acupoint(s): (Bilateral) Korean Hand Acupressure Point 
located at the Middle Phalanx of the Fourth Finger (K-K9) 
Method(s): Manual Acupressure at Non-Acupoints using A Hard Plastic Ball, Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Middle Phalanx of the Second Finger 
Total Duration: From the Time of Randomization to Arrival at the Hospital 
Not Reported 
Chen et al. 2003 [31] 
Research Assistant with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Neiguan (P6), Zusanli (ST36), and Sanyinjiao (SP6) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints located at the Tibia or Radial Bone 
Surface Approximately 3–4 cm from the Selected True Acupoints 
Total Duration: 4 Days in Hospital and Self- Acupressure at Home in the Following Days (Details Not Described), Each 
Treatment: 9 Min (3 Min for Each Acupoint) 
Not Reported 
Tsay & Chen 2003 [32] 
Investigator and Research Assistant with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Shenmen (Hand, HT7), Shenmen (Ear), 
Yungchuan (KI1) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoints located 1 cm away from 
Meridian 
Total Duration: 3 Treatments Per Week for 4 Weeks, Each Treatment: 14 Min 
Not Reported 
Kober et al. 2002 [33] 
Paramedic with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Zhongchong (PC9), Neiguan (P6), Kunlun (BL60), 
Hegu (LI4), and Baihui (GV20) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoints located at the Middle of Dorsal Wrist, 
Middle of Clavicle, Middle of Patella, Lateral Metacarpophalangeal Junction of the Second Finger, and Middle of Lateral 
Malleolus 
Total Duration: 3 Min Not Reported 
Belluomini et al. 1994 [34] 
Not Reported Method(s): Manual 
Acupressure at True Acupoints, Selected Acupoint(s): Neiguan (P6) 
Method(s): Manual Acupressure at Non-Acupoints, Selected Acupoint(s): Non- Acupoint located at the Palmar Surface of the 
Hand, Proximal to the Head of the Fifth Metacarpal Joint 
Total Duration: 4 Times Per Day for Consecutive 7 Days, Each Treatment: 10 Min 
Not Reported 
Type 2—Sham Acupressure at Non-Acupoints: Acupressure Bands or Other Devices (21 Studies) Adib- Hajbaghery & 
Etri, 2013 [35] 
Researcher with Acupressure Training 
Method(s): Acupressure at True Acupoints using Acupressure Band (PsiBand), Selected Acupoint(s): (Unilateral) Lanwei 
(EX-LE7) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (PsiBand), Selected Acupoint(s): (Unilateral) Non-Acupoint 
located at the Opposite Site of the Lanwei (EX-LE7) Point 
Total Duration: 7 Hours (Loosened for 10 Min every 2 Hours and then Tightened) 
Unequal (Less in SA) 
Alessandrini et al. 2012 [36] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Part of the Carpus 
Total Duration: 30 Min Equal for Both TA 
and SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 20 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Soltani et al. 2011 [37] 
Not Reported Method(s): Using 
Acupressure Wrist Band at True Acupoints, Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Using Acupressure Wrist Band at Non-Acupoints, Selected Acupoint(s): (Bilateral) Non-Acupoint located at the 
Posterior Surface of Both Forearms 
Total Duration: Applied 30 Min before Induction of Anesthesia and Removed 6 Hours Later 
Equal for Both TA and SA 
Bao et al. 2011 [38] 
Acupressure Operator 
Method(s): Acupressure at True Acupoints using Magnetic Acupressure Suction Cups + Standard Local Analgesics, Selected 
Acupoint(s): (Bilateral) Hegu (LI4) 
Method(s): Acupressure at Non-Acupoints using Magnetic Acupressure Suction Cups, Selected Acupoint(s): (Bilateral) 
Non-Acupoint located at the Proximal Dorsum of the Fourth Interosseus Space of the Hand 
Total Duration: The Entire BMAB Procedure 
Equal for Both TA and SA 
Majholm & Møller 2011 [39] 
Nursing Assistant Method(s): Acupressure 
at True Acupoints using Acupressure Band (Vital- Band), Selected Acupoint(s): (Unilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Vital-Band), Selected Acupoint(s): (Unilateral) 
Non-Acupoint located at the Dorsum of the Forearm 
Total Duration: Applied just before Induction of Anesthesia and Kept for 24 Hours after Surgery 
Equal for Both TA and SA 
Sinha et al. 2011 [40] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Pressure RightTM), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Placebo Acupressure Band, Selected Acupoint(s): (Bilateral) Non- Acupoint 
located at A Distance of 3 of the Parturient’s Finger- Breadths from the Proximal Palmar Crease 
Total Duration: From the Time of Randomization to 2 Hours after Vaginal Delivery or the Time of A Decision of Caesarean 
Delivery 
Unequal (No Pressure was Applied for SA) 
Wang et al. 2008 [41] 
Acupuncturist Method(s): Acupressure 
at True Acupoints using Acupressure Beads, Selected Acupoint(s): Yintang (or Extra-1, EX-NH3) 
Method(s): Acupressure at Non-Acupoints using Acupressure Beads, Selected Acupoint(s): Non-Acupoint (Above the Lateral 
Boarder of the Left Eyebrow) 
Total Duration: Entire Anesthesia Period (Applied before Enter the Operation Room and Removed at the Completion of the 
Procedure) 
Equal for Both TA and SA 
Turgut et al. 2007 [42] 
Anesthesiologist Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Surface of the Forearm 
Total Duration: Applied 30 Min before Anesthesia and Kept for 24 Hours after Surgery 
Equal for Both TA and SA 
Heazell et al. 2006 [43] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Aspect of the Forearm 
Total Duration: Not Reported (8 Hours Per Day) 
Equal for Both TA and SA 
Wang et al. 2005 [44] 
Acupuncturist Method(s): Acupressure 
at True Acupoints using Acupressure Beads, Selected Acupoint(s): Yintang (or Extra-1, EX-NH3) 
Method(s): Acupressure at Non-Acupoints using Acupressure Beads, Selected Acupoint(s): Non-Acupoint (Above the Lateral 
Boarder of the Left Eyebrow) 
Total Duration: More than 20 Min 
Equal for Both TA and SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 21 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Alkaissi et al. 2005 [45] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Side of both Forearms, 4 Fingers Breadth Proximal to the Proximal Flexor Palmar Crease 
Total Duration: Not Reported 
Equal for Both TA and SA 
Samad et al. 2003 [46] 
Investigator Method(s): Acupressure 
at True Acupoints using Wrist-Band with Plastic Bead, Selected Acupoint (s): (Unilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Wrist- Band with Plastic Bead, Selected Acupoint(s): (Unilateral) 
Non-Acupoint located at the Dorsum of the Right Forearm away from P6 Acupoint 
Total Duration: Applied 30 Min before Induction of Anesthesia, and Kept for 6 Hours after Surgery 
Equal for Both TA and SA 
Alkaissi et al. 2002 [47] 
Nurse Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Site of the Forearm, 4 Fingers Breadth Proximal to the Flexor Palmar Crease 
Total Duration: 24 Hours Equal for Both TA 
and SA 
Agarwal et al. 2000 [48] 
Individual who was Trained in the Application of Acupressure Band 
Method(s): Acupressure at True Acupoints using Acupressure Bands, Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Bands, Selected Acupoint(s): (Bilateral) Non- Acupoint located at 
the Posterior Surface of the Wrist 
Total Duration: Applied 30 Min before Induction of Anesthesia, and Removed 6 Hours after Surgery 
Equal for Both TA and SA 
Harmon et al. 2000 [49] 
Anesthetist Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Unilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Unilateral) 
Non-Acupoint located at the Dorsal Site of the Right Forearm 
Total Duration: Applied 5 Min before Induction of Anesthesia, and Removed 6 Hours after Discharge to the Ward 
Equal for Both TA and SA 
Harmon et al. 1999 [50] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Unilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Unilateral) 
Non-Acupoint (Details Not Described) 
Total Duration: Applied immediately before Induction of Anesthesia, and Removed 20 Min after Induction of Anesthesia 
Equal for Both TA and SA 
Alkaissi et al. 1999 [51] 
Researcher Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsal Site of Both Forearms, 4 Fingers Breadth Proximal to the Proximal Flexor Palmar Crease 
Total Duration: Applied just before Surgery, and Removed after Discharge to Home (Details not Described) 
Equal for Both Groups 
Fan et al. 1997 [52] 
Individual who was Trained in the Application of Acupressure Band 
Method(s): Acupressure at True Acupoints using Acupressure Band (AcuBand), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (AcuBand), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Dorsum of Both Wrists 
Total Duration: Applied before Induction of Anesthesia, and Removed 6 Hours after Surgery 
Unequal (AcuBands were Tied Loosely in SA) 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 22 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
O’Brien et al. 1996 [53] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) Non-Acupoint 
located at the Radius of Both Forearms 
Total Duration: 3 Days (From the Morning of Study Day 3 to The Morning of Study Day 6) 
Equal for Both TA and SA 
Felhendler & Lisander 1996 [54] 
Researcher Method(s): Acupressure 
at True Acupoints using A Dentist’s Tool (A 15-cm Handle with A Ball at the End), Selected Acupoint (s): (Unilateral) Chengqi 
(ST1), Lidui (ST45), Yinbai (SP1), Dabao (SP21), Gongsun (SP4), Jingming (BL1), Zhiyin (BL67), Yungchuan (KI1), Youmen 
(KI27), Dazhong (KI4), Ligou (LR5), Tongziliao (GB1), Zuqiaoyin (GB44), Dadun (LR1), and Qimen (LR14) 
Method(s): Acupressure at Non-Acupoints using A Dentist’s Tool (A 15-cm Handle with A Ball at the End), Selected 
Acupoint(s): (Unilateral) Non- Acupoints Situated 2 cm from the Nearest True Acupoints 
Total Duration: 30 Min after Patients Awoke from Anesthesia 
Unequal (Only Light Pressure for SA) 
Bayreuther et al. 1994 [55] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): Neiguan (P6) 
Method(s): Acupressure at Non-Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): Non- Acupoint located 
Above or Below the Elbow 
Total Duration: 7 Days Equal for Both TA 
and SA 
Type 3—Pseudo-Intervention at the Same Acupoints as Intervention Group: Manual Light-Touch without Acupressure 
(7 Studies) Hamidzadeh et al. 2012 [56] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Hegu (LI4) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): (Bilateral) Hegu (LI4) 
Total Duration: 20 Min (5 Pressure Per Min) 
No Pressure was Applied for SA 
Mirbagher- Ajorpaz et al. 2011 [57] 
Researcher with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): Sanyinjiao (SP6) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): Sanyinjiao (SP6) 
Total Duration: 20 Min (10 Second-Cycle repeated 120 Times) 
No Pressure was Applied for SA 
Sun et al. 2010 [58] 
Research Assistant with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Shenmen (HT7) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): (Bilateral) Shenmen (HT7) 
Total Duration: Daily Treatment for Consecutive 5 Weeks, Each Treatment: 5-Second Pressure Followed by 1-Second Rest, 
Repeated for 5 Min 
No Pressure was Applied for SA 
Kashanian & Shahali 2010 [59] 
Investigator Method(s): Manual 
Acupressure at True Acupoints, Selected Acupoint(s): Sanyinjiao (SP6) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): Sanyinjiao (SP6) 
Total Duration: 30 Min No Pressure was 
Applied for SA 
Hjelmstedt et al. 2010 [60] 
A Person with Acupressure Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Sanyinjiao (SP6) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): (Bilateral) Sanyinjiao (SP6) 
Total Duration: 30 Min No Pressure was 
Applied for SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 23 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Hsu et al. 2006 [61] 
Researcher with TCM Training 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Shenmen (HT7) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): (Bilateral) Shenmen (HT7) 
Total Duration: Daily Treatment (5 Min) for Consecutive 5 Weeks 
No Pressure was Applied for SA 
Lee et al. 2004 [62] 
Research Intervener 
Method(s): Manual Acupressure at True Acupoints, Selected Acupoint(s): (Bilateral) Sanyinjiao (SP6) 
Method(s): Light Touch (without Acupressure) on the Same Acupoints, Selected Acupoint (s): (Bilateral) Sanyinjiao (SP6) 
Total Duration: 30 Min During Each Uterine Contraction 
No Pressure was Applied for SA 
Type 4—Pseudo-Intervention at the Same Acupoints as Intervention Group: Placebo Acupressure Devices (14 Studies) 
Nilsson et al. 2015 [63] 
Nurse Anesthetist Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Unilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Unilateral) Neiguan (P6) 
Total Duration: 2 Days No Pressure was 
Applied for SA 
Molassiotis et al. 2013 [64] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band with the Plastic Button located at the 
Exterior of the Wrist Band, Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: 7 Days No Pressure was 
Applied for SA 
Noroozinia et al. 2013 [65] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band, Selected Acupoint(s): Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Pressure Button, Selected 
Acupoint(s): Neiguan (P6) 
Total Duration: 30 Min Prior to Spinal Anesthesia 
No Pressure was Applied for SA 
Soltanzadeh et al. 2012 [66] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band, Selected Acupoint(s): (Bilateral) Korean Hand Acupressure Point (K-K9) located at 
the Middle Phalanx of the Fourth Finger on Both Hands 
Method(s): Sham Acupressure at the Same Acupoints using A Dummy Band (Details not Described), Selected Acupoint (s): 
(Bilateral) Korean Hand Acupressure Point (K-K9) located at the Middle Phalanx of the Fourth Finger on Both Hands 
Total Duration: Applied 15 Min Prior to Induction of Anesthesia and Kept for 24 Hours 
Not Reported 
White et al. 2012 [67] 
Investigator Method(s): Acupressure 
at True Acupoints using Acupressure Strip, Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Strip without the Pressure Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: Applied 30 to 60 Min before Induction of Anesthesia and Kept for 72 Hours after Surgery 
No Pressure was Applied for SA 
Ho et al. 2006 [68] 
Acupuncturist Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band with A Blunted Plastic Button, 
Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: Applied More than 30 Min before Induction of Anesthesia and Removed after Arrival in the Post-Anesthesia 
Care Unit 
No Pressure was Applied for SA 
Klein et al. 2004 [69] 
Not Reported Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: Applied before Induction of Anesthesia and Removed 24 Hours after Extubation 
No Pressure was Applied for SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 24 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Schultz et al. 2003 [70] 
Preoperative Nurse Method(s): Acupressure 
Band (Sea-Band) at True Acupoints + Droperidol, Selected Acupoint(s): Neiguan (P6) 
Method(s): Placebo Band (with A Flat Button) at the Same Acupoints, Selected Acupoint (s): Neiguan (P6) 
Total Duration: Not Reported 
No Pressure was Applied for SA 
Dent et al. 2003 [71] 
Nurse who was Trained in Accurate Location of Targeted Acupoints 
Method(s): Acupressure at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: 24 Hours No Pressure was 
Applied for SA 
Norheim et al. 2001 [72] 
Study Assistant Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: 4 Days No Pressure was 
Applied for SA 
Steele et al. 2001 [73] 
Nurse who was Trained in the Application of Acupressure Band 
Method(s): Acupressure at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: 4 Days No Pressure was 
Applied for SA 
Woods 1999 [74] 
Anesthesia Provider Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: Applied at Least 15 Min before Induction of Anesthesia and Kept for 24 Hours after Surgery 
No Pressure was Applied for SA 
Duggal et al. 1998 [75] 
Nurse Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Plastic Button, Selected 
Acupoint(s): (Bilateral) Neiguan (P6) 
Total Duration: At Least 10 Hours 
No Pressure was Applied for SA 
Lewis et al. 1991 [76] 
Investigator Method(s): Acupressure 
at True Acupoints using Acupressure Band (Sea- Band), Selected Acupoint(s): (Bilateral) Neiguan (P6) 
Method(s): Sham Acupressure at the Same Acupoints using A Placebo Acupressure Band without the Stud, Selected Acupoint(s): 
(Bilateral) Neiguan (P6) 
Total Duration: Applied 1 Hour before Operation and Kept until Discharge from Hospital on the same Day 
No Pressure was Applied for SA 
Type 5—Acupressure at Non-Therapeutic Acupoints (Irrelevant Acupoints): Manual Acupressure (4 Studies) Suh 2012 
[77] Researcher and 
Research Assistant 
Method(s): Acupressure at Therapeutic Acupoints using Acupressure Band (Sea-Band), Selected Acupoint(s): (Bilateral) 
Neiguan (P6) 
Method(s): Manual Acupressure at Non- Therapeutic (Irrelevant) Acupoints, Selected Acupoint (s): (Bilateral) Houxi (SI3) 
Total Duration: 5 Days Unequal 
(Continuously Automatic Pressure for TA and Manual Acupressure for SA) Lang et al. 2007 [78] 
Paramedic with Acupressure Training 
Method(s): Manual Acupressure at Therapeutic Acupoints, Selected Acupoint(s): Baihui (GV20) and Hegu (LI4, Unilateral) 
Method(s): Manual Acupressure at Non- Therapeutic (Irrelevant) Acupoints, Selected Acupoint (s): Geshu (BL17) and Jianliao 
(TE14, Unilateral) 
Total Duration: Not Reported (3 Min Acupressure for Each Acupoint) 
Equal for Both TA and SA 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 25 / 40 
 
Table 3. (Continued) 
Study Practitioner True Acupressure (TA) Sham Acupressure (SA) Intervention Duration Acupressure 
Intensity 
Wu et al. 2007 [79]Wu et al. 2004 [80] 
Investigator with Acupressure Training 
Method(s): Manual Acupressure at Therapeutic Acupoints, Selected Acupoint(s): Dazhui (GV14), Tiantu (CV22), Feishu (B13, 
Bilateral), Shenshu (B23, Bilateral), and Yuji (L10, Unilateral) 
Method(s): Manual Acupressure at Non- Therapeutic (Irrelevant) Acupoints, Selected Acupoint (s): Shangqiu (SP5), Taibai 
(SP3), and Dadun (LR1) 
Total Duration: 5 Treatments Per Week for Consecutive 4 Weeks, Each Treatment: 16 Min 
Equal for Both TA and SA 
Type 6—Acupressure at Non-Therapeutic Acupoints (Irrelevant Acupoints): Acupressure Bands or Other Devices (1 
Study) Nordio & Romanelli 2008 [81] 
Not Reported Method(s): Acupressure at Therapeutic Acupoints using Wrist Acupressure Device, Selected Acupoint(s): 
(Bilateral): Shenmen (HT7) 
Method(s): Acupressure at Non-Therapeutic (Irrelevant) Acupoints using Wrist Acupressure Device, Selected Acupoint(s): 
(Bilateral): Acupoint Known as not to Interfere with Insomnia and/or Anxiety (Details not Described) 
Total Duration: 20 Days Equal for Both TA 
and SA 
doi:10.1371/journal.pone.0132989.t003 
Sham Acupressure Controls Used in Randomized Controlled Trials 
the interior surface which can exert constant pressure at the targeted acupoint. However, in one study [40], the 
button was replaced by a backing square in the sham group. In two trials where the non-acupoints located at the 
forehead, adhesive beads were applied [41, 44]. Special band was also adopted on the non-acupoint located below 
the knee in one study [35], and mag- netic suction cup was utilized in another trial to stimulate the non-acupoints on 
both hands [38]. Particularly, a dentist’s tool was employed for acupressure in one trial which selected more than ten 
non-acupoints [54]. Twenty studies described the definite locations of the non- acupoints. Most of the studies with 
type 2 design adopted equal acupressure intensity between groups, while it was unequal in four trials [35, 40, 52, 54] 
with sham groups receiving lower- intensity pressure or no stimulation at all. 
In 21 articles, the sham study arms employed the same acupoints as in the true acupressure arms. Manual light 
touch was applied in seven trials without any pressure (type 3) whereas the other 14 used a placebo device but also 
no pressure was exerted (type 4). The intervention pro- tocols were all similar between groups except for the 
acupressure intensity. For studies utilizing type 4 sham procedures, pseudo devices used in the control groups were 
identical from those applied in true acupressure with the only exception that the pressure button was missing, or was 
replaced by a blunted/flat one, or was located at the exterior of the equipment. One study stated that a dummy band 
was applied but no detailed information was given [66]. 
Non-therapeutic acupoints were chosen as sham intervention in five trials. Of which, four utilized manual 
acupressure (type 5) [77–80] and one employed a wrist acupressure device (type 6) [81]. In studies with type 5 sham 
method, the intervention protocol was similar between groups in 3 studies [78–80], but in another trial [77], the 
acupressure intensity was unequal between groups with the true intervention group applying a wrist band to create 
con- stant pressure while the sham comparison received manual acupressure with discontinuous stimulation. The 
only one article with type 6 sham procedure focused on insomnia [81]. Unfor- tunately, this study failed to specify 
the selected sham acupoints but only stated that the irrele- vant acupoints were “known as not to interfere with” the 
treated condition [81]. 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 26 / 40 
 
Table 4. Summary of the Therapeutic Outcomes based on Different Sham Acupressure Types. 
Results of Therapeutic Effects 
Types of Sham Control 
No. of 
SAG is Superior to 
Studies 
TAG4 
Type 1 18# 13 (72.2%) 1 (5.6%) 4 (22.2%) 0 (0%) Type 2 20## 11 (55.0%) 3 (15.0%) 6 (30.0%) 0 (0%) Type 3 7 7 (100.0%) 0 
(0%) 0 (0%) 0 (0%) Type 4 14 5 (35.7%) 4 (28.6%) 3 (21.4%) 2 (14.3%) Type 5 4 4 (100.0%) 0 (0%) 0 (0%) 0 (0%) Type 6 1 1 
(100.0%) 0 (0%) 0 (0%) 0 (0%) Total 64 41 (64.1%) 8 (12.5%) 13 (20.3%) 2 (3.1%) 
Type 1: Sham acupressure at non-acupoints by manual pressure; Type 2: Sham acupressure at non-acupoints by employing 
acupressure devices; Type 3: Pseudo-intervention at the same acupoints as true treatment arm by manual light-touch; Type 4: 
Pseudo-intervention at the same acupoints as true treatment arm by using placebo devices; Type 5: Manual acupressure at 
non-therapeutic (irrelevant) acupoints; Type 6: Sham acupressure at non- therapeutic (irrelevant) acupoints by adopting 
acupressure devices 1: For studies reporting multiple main outcomes, at least one “++” were identified 2: For studies reporting 
multiple main outcomes, no “++” but at least one “+” were identified 3: “0” for all main outcome(s) 4: “−” or “− −”for all main 
outcome(s) #: Sham acupressure control type 1 was applied in 19 studies, but comparison between groups was not performed (or 
not clearly reported) in one study ##: Sham acupressure control type 2 was applied in 21 studies, but comparison between groups 
was not performed (or not clearly reported) in one study 
doi:10.1371/journal.pone.0132989.t004 
TAG is Significantly Superior 
TAG is Superior to 
No Difference between TAG to SAG1 
SAG2 
and SAG3 
Sham Acupressure Controls Used in Randomized Controlled Trials 

Therapeutic Effects of Acupressure 

Therapeutic outcomes of acupressure are summarized in Tables 4 and 5. Meanwhile, results of the responder rate 
ratio calculation are presented in Table 6. 
Overall Assessment. Sixty-four studies reported treatment outcomes between the true and sham acupressure 
groups. For the main outcomes, 64.1% (41/64) reported that true acupres- sure was significantly superior to sham 
intervention, and 12.5% favored the true procedure but the difference did not reach statistical significance, while 
there were 13 studies (20.3%) which found no difference between groups. In addition, the sham acupressure was 
found to be more effective than true intervention in two trials (3.1%) [70, 74] with one even reaching statistical 
significance [70]. Among all the included studies, 12 compared the effects of acupressure (true/sham) with the study 
arms using standard methods of care. In four trials [23, 29, 32, 71], true acupressure was shown to be more effective 
than sham treatment and/or standard care, while no difference was found between sham acupressure and standard 
care. In another seven studies [26, 28, 45, 47, 51, 60, 64], both true and sham procedures were found to be superior 
to conventional care with or without statistical significance, while one trial [53] found no differ- ence among groups. 
Thirty-four articles which provided dichotomous data were included for calculating responder rate ratio, and the 
majority (27 studies) supported the superiority of true acupressure compared with sham intervention, with the 
responder rate ratio (as measured by RR) greater than 1.0. 
Subgroup Analysis. Subgroup analysis was performed based on different sham alterna- tives (Table 4). Fourteen 
out of 18 studies (77.8%) employing type 1 sham procedure favored true acupressure. For type 2 studies, 70% 
(14/20) supported the superiority of the true interven- tion. Of the 14 studies using pseudo-acupressure devices (type 
4), nine (64.3%) reported that true acupressure was more effective than sham control, three (21.4%) found no 
difference between groups, and two (14.3%) favored sham acupressure. Number of studies for sham type 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 27 / 40 
 
Table 5. Summary of the Therapeutic Outcomes based on Different Health Problems and Treatment Durations. 
Results of Therapeutic Effects 
Subgroups No. of 
Studies 
SAG is Superior to TAG4 
Health Problem Peri-operative Nausea and Vomiting # 
TAG is Significantly 
TAG is Superior 
No Difference between Superior to SAG1 
to SAG2 
TAG and SAG3 
21 8 5 6 2 
Nausea and Vomiting in Pregnancy 
9 7 0 2 0 
Labor Pain 5 5 0 0 0 Sleep Disturbances 5 4 0 1 0 Perioperative/Prehospital Pain 4## 3 0 1 0 Anxiety 3 3 0 0 0 Symptoms in 
Patients with Respiratory Disorders 
3 2 0 1 0 
Motion Sickness 2### 1 1 0 0 Primary Dysmenorrhea 2 1 0 1 0 Chemotherapy-induced Nausea and Vomiting 
2 1 0 1 0 
Postoperative Gastrointestinal Function 
2 2 0 0 0 
Cancer-related Fatigue 1 0 1 0 0 Stress Reduction 1 0 0 1 0 Urodynamic Stress Incontinence 1 1 0 0 0 Traumatic Brain Injury 1 1 
0 0 0 Women’s General Health 1 1 0 0 0 Cardiovascular Function in Stroke Survivors 
1 1 0 0 0 
Post MI-related Nausea and Vomiting 
1 0 1 0 0 
Treatment Duration Less than 1 Hour 12#### 10 0 2 0 More than 1 Hour but Less than 1 Day 
13 7 3 3 0 
More than 1 Day but Less than 1 Week 
16 8 3 4 1 
More than 1 Week 16 12 1 3 0 
1: For studies reporting multiple main outcomes, at least one “++” were identified 2: For studies reporting multiple main 
outcomes, no “++” but at least one “+” were identified 3: “0” for all main outcome(s) 4: “−” or “− −”for all main outcome(s); MI: 
Myocardial infarction # Twenty studies for postoperative nausea and vomiting and one study for intra-operative nausea and 
vomiting ## Perioperative/prehospital pain was observed in 5 studies, but comparison between groups was not performed (or not 
clearly reported) in 1 study ### Motion sickness was observed in 3 studies, but comparison between groups was not performed 
(or not clearly reported) in 2 studies #### Acupressure durations were less than 1 hour in 14 studies, but comparison between 
groups was not performed (or not clearly reported) in 2 studies 
doi:10.1371/journal.pone.0132989.t005 
Sham Acupressure Controls Used in Randomized Controlled Trials 
3, 5 and 6 were limited, but all supported the superiority of true intervention. Responder rate ratios were also 
separately analyzed for different sham acupressure types and the true interven- tion groups were found to be more 
effective than the sham comparisons in the majority of the analyzed trials within each sham acupressure control 
(Table 6). 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 28 / 40 
 
Table 6. Results of Response Rates for Studies Presenting Dichotomous Data. 
Study Outcome# Definition of Response TAG (n/ 
N) 
Relative Risk 95% CI 
Type 1 Sham Acupressure at Non-Acupoints: Manual Acupressure Bertalanffy et al. 2004 Sympathetic Activity Peripheral 
Vasodilation 46/50 2/50 23.00 [5.90, 89.64] Kober et al. 2002 Pre-Hospital Anxiety Anxiety Reduction 13/19 10/20 1.37 [0.80, 
2.33] Type 2 Sham Acupressure at Non-Acupoints: Acupressure Bands or Other Devices Adib-Hajbaghery & Etri 2013 
Postoperative Nausea Absence of Nausea 17/35 18/35 0.94 [0.59, 1.51] 
Adib-Hajbaghery & Etri 2013 
Postoperative Vomiting Absence of Vomiting 19/35 20/35 0.95 [0.63, 1.44] 
Alessandrini et al. 2012 Neurovegetative Symptom Symptom Improvement 87/102 11/102 7.91 [4.50, 13.90] Soltani et al. 2011 
Postoperative Nausea Absence of Nausea 44/50 31/50 1.42 [1.12, 1.80] Soltani et al. 2011 Postoperative Vomiting Absence of 
Vomiting 40/50 27/50 1.48 [1.11, 1.98] Bao et al. 2011 Pain Intensity Less Severity Pain 36/37 32/40 1.22 [1.03, 1.43] Majholm 
& Møller 2011 Postoperative Nausea Absence of Nausea 37/57 29/51 1.14 [0.84, 1.55] Majholm & Møller 2011 Postoperative 
Vomiting Absence of Vomiting 43/58 38/52 1.01 [0.81, 1.27] Sinha et al. 2011 Nausea and Vomiting in 
Delivery 
Absence of Nausea and/or Vomiting 82/170 87/170 0.94 [0.76, 1.17] 
Wang et al. 2008 Postoperative Nausea and 
Vomiting 
Absence of Nausea and Vomiting 21/26 18/26 1.17 [0.85, 1.60] 
Turgut  et  al.  2007  Postoperative  Nausea  Absence  of  Nausea  34/50  18/50  1.89  [1.25,  2.86]  Turgut  et  al.  2007  Postoperative 
Vomiting  Absence  of  Vomiting  37/50  21/50  1.76  [1.22,  2.54]  Heazell  et  al. 2006 Length of Hospitalization Less than 4 Days in 
the Hospital 29/40 22/40 1.32 [0.94, 1.85] Samad et al. 2003 Postoperative Nausea and 
Vomiting 
Absence of Nausea and Vomiting 25/25 25/25 1.00 [0.93, 1.08] 
Alkaissi et al. 2002 Postoperative Nausea and 
Vomiting 
90/135 86/139 1.08 [0.90, 1.29] 
Agarwal  et  al.  2000  Postoperative  Nausea Absence of Nausea 82/100 80/100 1.02 [0.90, 1.17] Agarwal et al. 2000 Postoperative 
Vomiting Absence of Vomiting 93/100 91/100 1.02 [0.94, 1.11] Harmon et al. 2000 Postoperative Nausea and 
Vomiting 
Absence of Nausea, Vomiting or Rescue Medicine 
Absence of Nausea and Vomiting 30/47 16/47 1.88 [1.19, 2.95] 
Harmon et al. 1999 Postoperative Nausea and 
Vomiting 
Absence of Nausea and/or Vomiting 42/52 30/52 1.40 [1.07, 1.83] 
Alkaissi et al. 1999 Postoperative Nausea and 
Vomiting 
11/20 11/20 1.00 [0.57, 1.75] 
Fan et al. 1997 Postoperative Nausea and 
Vomiting 
Absence of Nausea, Vomiting or Rescue Medicine Absence of Nausea and Vomiting 83/108 54/92 1.31 [1.07, 1.60] 
Bayreuther et al. 1994 Morning Sickness Symptom Reduction 10/15 5/15 2.00 [0.90, 4.45] Type 3 Pseudo-Intervention at the 
Same Acupoints as Intervention Group: Manual Light-Touch without Acupressure Kashanian & Shahali 2010 
Cesarean Delivery No Need for Cesarean Delivery 54/60 35/60 1.54 [1.23, 1.94] 
Hjelmstedt et al. 2010 Use of Analgesics No Need for Analgesics 36/71 37/71 0.97 [0.71, 1.34] Lee et al. 2004 Use of Analgesics 
No Need for Analgesics 31/36 29/39 1.16 [0.92, 1.45] Type 4 Pseudo-Intervention at the Same Acupoints as Intervention Group: 
Placebo Acupressure Devices Nilsson et al. 2015 Postoperative Nausea and 
Vomiting 
Absence of Nausea and Vomiting 24/43 31/52 0.94 [0.66, 1.33] 
Molassiotis et al. 2013 Chemotherapy-induced Nausea No Nausea Experience 41/126 36/118 1.07 [0.74, 1.55] Molassiotis et al. 
2013 Chemotherapy-induced 
Vomiting 
No Vomiting Experience 85/126 80/118 1.00 [0.84, 1.18] 
Noroozinia et al. 2013 Postoperative Nausea and 
Vomiting 
Absence of Nausea and Vomiting 76/76 72/76 1.06 [1.00, 1.12] 
(Continued) 
Sham Acupressure Controls Used in Randomized Controlled Trials 
SAG (n/ N) 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 29 / 40 
 
Table 6. (Continued) 
Study Outcome# Definition of Response TAG (n/ 
N) 
Relative Risk 95% CI 
Soltanzadeh  et  al.  2012  Postoperative  Nausea  Absence  of  Nausea  29/40  22/40  1.32  [0.94,  1.85]  Soltanzadeh  et  al.  2012 
Postoperative  Vomiting  Absence  of  Vomiting  32/40  25/40  1.28  [0.96,  1.70]  White et al. 2012 Postoperative Nausea Absence of 
Nausea  30/50  26/50  1.15  [0.81,  1.64]  White  et  al.  2012  Postoperative  Vomiting  Absence  of  Vomiting  45/50  37/50  1.22  [1.01, 
1.47]  Ho  et  al.  2006  Intraoperative  Nausea  Absence  of  Nausea  20/55  16/55  1.25  [0.73,  2.15]  Ho  et  al.  2006  Intraoperative 
Vomiting  Absence  of  Vomiting  43/55  40/55  1.07  [0.87,  1.33]  Klein  et  al.  2004 Postoperative Nausea Absence of Nausea 50/75 
50/77  1.03  [0.82,  1.29]  Klein  et  al.  2004  Postoperative  Vomiting  Absence  of  Vomiting 63/75 62/77 1.04 [0.90, 1.21] Schultz et 
al.  2003  Postoperative  Nausea  Mild  Nausea  14/25  14/21  0.84  [0.53,  1.33]  Dent  et  al.  2003  Post-MI  Nausea  and  Vomiting 
Absence  of  Nausea  and  Vomiting  55/95  48/98  1.18  [0.91,  1.54]  Duggal  et  al.  1998  Postoperative  Nausea  Absence  of  Nausea 
53/122 42/122 1.26 [0.92, 1.73] Duggal et al. 1998 Postoperative Vomiting/ 
Retching 
Absence of Vomiting/Retching 72/122 66/122 1.09 [0.88, 1.36] 
Lewis et al. 1991 Postoperative Vomiting Absence of Vomiting 9/31 9/33 1.06 [0.49, 2.33] Type 6 Sham Acupressure at 
Non-Therapeutic Acupoints (Irrelevant): Acupressure Bands or Other Devices Nordio & Romanelli 2008 Melatonin Metabolite 
Normal Melatonin Rhythm 13/18 5/15 2.17 [1.00, 4.68] 
TAG: True acupressure group; SAG: Sham acupressure group; MI: Myocardial infarction #: Outcome used for response rate 
estimation 
doi:10.1371/journal.pone.0132989.t006 
Table 7. Summary of Dropout Rate Reported in the Included Studies. 
Number of Dropout/Sample Size (Dropout Rate, %) 
Types of Sham Control No. of Studies# TAG SAG Total Chi-Squared Test 
Type  1  15  51/457  (11.2%)  37/450  (8.2%)  88/907  (9.7%) χ2 = 2.233, df = 1, P = 0.135 Type 2 15 20/895 (2.2%) 24/882 (2.7%) 
44/1777  (2.5%)  χ2  =  0.435,  df  =  1,  P = 0.509 Type 3 6 2/246 (0.8%) 4/246 (1.6%) 6/492 (1.2%) χ2 = 0.169, df = 1, P = 0.681 
Type  4  10  64/729  (8.8%)  74/716  (10.3%)  138/1445  (9.55%) χ2 = 1.013, df = 1, P = 0.314 Type 5 2 6/46 (13.0%) 7/46 (15.2%) 
13/92  (14.1%)  χ2  =  0.090,  df  =  1,  P  =  0.765  Type  6  1  2/20 (10.0%) 5/20 (25.0%) 7/40 (17.5%) χ2 = 0.693, df = 1, P = 0.405 
All Types 49 145/2393 (6.1%) 151/2360 (6.4%) 296/4753 (6.2%) χ2 = 0.234, df = 1, P = 0.629 
Type 1: Sham acupressure at non-acupoints by manual pressure; Type 2: Sham acupressure at non-acupoints by employing 
acupressure devices; Type 3: Pseudo-intervention at the same acupoints as true treatment arm by manual light-touch; Type 4: 
Pseudo-intervention at the same acupoints as true treatment arm by using placebo devices; Type 5: Manual acupressure at 
non-therapeutic (irrelevant) acupoints; Type 6: Sham acupressure at non- therapeutic (irrelevant) acupoints by adopting 
acupressure devices # Number of studies which were available for dropout rate calculation 
doi:10.1371/journal.pone.0132989.t007 
Sham Acupressure Controls Used in Randomized Controlled Trials 
SAG (n/ N) 
Subgroup analyses were also applied for different types of health conditions and treatment duration (Table 5). 
Descriptive analysis showed that true acupressure can be an effective approach in managing postoperative and 
pregnancy-related nausea and/or vomiting, perioper- ative/prehospital pain, labor pain, sleep disturbances, 
respiratory disorders, anxiety, postopera- tive gastrointestinal dysfunctions and motion sickness. Studies on primary 
dysmenorrhea and chemotherapy-induced nausea and vomiting reported contradictory findings, where two stud- ies 
[57, 77] supported the superiority of true acupressure, while another two [17, 64] stated no difference between 
groups. Results from a single study indicated that the true intervention was 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 30 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
better than sham control in treating urodynamic stress incontinence [23], traumatic brain injury [24], cancer-related 
fatigue [16] and myocardial infarction-related nausea and vomiting [71], and in maintaining women’s general health 
[25] and stroke survivors’ cardiovascular functions [27]. The only study on stress reduction failed to prove the 
superiority of true acu- pressure [20]. For each subgroup under “treatment duration”, more than half (68.75% to 
83.3%) supported that true acupressure was more effective than sham intervention (Table 5). Further investigation 
on acupressure frequency and intensity was not feasible due to insuffi- cient information and absence of available 
data. 

Dropout Rates and Adverse Events associated with Acupressure 

In 26 studies, all the randomized subjects completed the study. Thirty-four studies reported participants’ dropout, 
however, 11 of them only provided the total dropout number but failed to specify the number in each study arm [19, 
32, 47, 51, 53, 62, 70, 72, 75, 79, 80]. Reasons for dropout were diverse and included changing treatment protocol, 
refusing to continue with the study, suffering from adverse events, or death, etc. The total dropout rate was 6.2%, 
with the true intervention groups 6.1% and the sham groups 6.4%. Dropout rates also varied signifi- cantly among 
different sham alternatives. The lowest was found in type 3 trials, with the total dropout rate being 1.22% (true 
acupressure 0.8% and sham comparison 1.6%). Chi-square tests showed that there was no difference of the dropout 
rates between groups (Table 7). 
There were 24 studies that observed potential adverse events associated with acupressure, among which, 13 
reported no adverse events, and the other 11 reported acupressure device- related harm data including local swelling 
and redness, discomfort and tenderness at the wrist, and paresthesia, etc. No serious adverse events were noted. 
There was one study [67] that detected adverse events such as constipation, headache, fatigue and drowsiness, but 
informa- tion was insufficient to judge whether these were caused by acupressure. No study assessed the causality 
between the acupressure and the reported adverse events. 

Discussion 
This study analyzed 66 trials with six sham acupressure types. The findings indicated that “non-acupoint” was the 
most frequently selected sham acupoint and an acupressure device was the commonly adopted approach for sham 
intervention. Meanwhile, our findings supported that acupressure was a beneficial method in managing a variety of 
health problems, and the effect was found to be more effective in true acupressure than that in sham procedure. 
Because of the significant clinical heterogeneity among the included studies, the relationship between sham 
acupressure methods and the treatment outcomes is not fully conclusive at this stage. 
Our findings showed that true acupressure was more effective than sham acupressure, and the effect of sham 
intervention was somewhat better than that in the standard care arms. These results support the specific benefits of 
true acupoint stimulation, but also indicate that sham acupressure more or less produces some specific or 
non-specific treatment effects. Sham acu- pressure may be associated with larger effects than control groups 
adopting standard methods of care. Placebo effects of sham acupoint stimulation may be related to patients’ 
expectation of treatment, and ventral striatum and prefrontal cortex are commonly believed to be involved in the 
activation of the reward system which contributes to a feeling of symptom improvement during intervention [82]. 
Previous studies indicated that “physical placebos”, including sham acupoint stimulation (e.g. acupuncture), could 
result in larger effects over non-treatment arms than drug placebos [83, 84]. Reasons for the relatively larger effects 
in sham acupoint stimula- tion are complicated, and from a psychological perspective, any forms of acupoint 
stimulation could be viewed as an emotional focused therapy which more or less produces some treatment 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 31 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
effects [82]. However, whether the effects produced by sham acupoint stimulation are only non-specific placebo 
effects or are mixed with any specific therapeutic benefits, we still cannot reach a definite conclusion at present. 
Similar to the results from the descriptive analysis, the exploratory analysis of the responder rate ratios also 
showed that true acupressure was more effective than sham comparisons regardless of the sham acupressure types. 
However, these findings should be interpreted pru- dently because the responder rate ratio only provides a rough 
summary of the study results, and the dichotomous data we used were not the main measures in some of the 
analyzed trials. Meanwhile, even within the subgroup of each sham acupressure method, clinical heterogene- ities 
(e.g. differences in the health conditions, patient characteristics, intervention duration and outcome measures, etc.) 
were still considerable in the analyzed trials. In addition, the number of studies included within each subgroup was 
quite imbalanced among the sham types, with type 2 and 4 respectively gathering more than 10 studies, whereas 
other sham modalities only including no more than three studies. 
In the analyzed studies, non-acupoint was the most frequently adopted sham acupoint approach used. 
Non-acupoint is a popular sham modality because generally it would not create any therapeutic effects. However, 
we are not sure whether all the so-called “non-acupoints” in our analyzed trials are real non-acupoints because only 
few of them pointed out that the selected non-acupoints were situated away from the meridians, while in the 
remaining studies, the relation between the non-acupoints and their nearest active acupoints and/or meridians was 
not provided. Meanwhile, researchers should prudently select the non-acupoints because currently there are more 
than 2000 established extra-points which are not linked with meridi- ans, and this cannot exclude the possibility that 
the so called “non-acupoints” in some trials may be unintentionally therapeutic points in nature [85]. 
In addition to the non-acupoints, true acupoints were also commonly used as sham acu- pressure. The acupoints 
were the same as the active intervention groups but were only provided with light tough or totally received no 
stimulation. It is believed that light stimulation on the true acupoints would not activate the deqi sensation, and thus, 
avoid the generation of specific treatment effects [6, 85]. But recent studies on pain concluded that light stimulation 
on the skin could evoke the activity of the cutaneous afferent nerves and/or the insular region of the brain, and may 
result in some augmented therapeutic benefits [4, 86]. Also, patients with pain conditions could experience similar 
treatment effects when the selected true and sham acu- points located at the same or nearby myotome [4, 87]. Light 
touch may not be a proper sham approach for studies on pain management. Also, light stimulation was deemed 
inadequate to maintain blinding of the participants, especially for those with previous acupressure experi- ence. 
Light touch does not exert additional pressure and avoids evoking the deqi sensation. When the intervention is 
observed by participants, it may be easy for them to judge that they are not receiving the “true” acupressure. 
Non-therapeutic acupoints were used as the sham intervention in five of the included stud- ies. Regarding to the 
location of the non-therapeutic acupoint, it is recommended to be situated near the selected active acupoint to 
achieve proper blinding, but is also required to avoid being on the same meridian as in the true intervention. In one 
trial which focused on pre-hospital analgesia for patients with distal radius fracture, jianliao (TE14) was employed 
as one of the sham acupoints, and acupressure intensity was equal in both groups [78]. However, this kind of sham 
design might not be adequate enough because acupressure at any of the body acu- points could contribute to some 
pain relieving effects. In the meantime, jianliao is mainly used for treating shoulder and back pain, although not 
specific for distal radius fracture, stimulation of jianliao might somewhat produce some positive impact on the pain 
management of the whole body. According to the “holism concept” of acupuncture theory, every single stimulation 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 32 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
of the acupoint could result in comprehensive responses of the human body and subsequently generate specific 
and/or non-specific effects [85]. That is to say, pressing irrelevant acupoints may also create some treatment effects 
for the targeted condition, especially when the sham intervention receives the same acupressure intensity as in the 
active intervention arm. 
Acupressure devices can be an adequate method for retaining blinding. In our analyzed studies, acupressure 
bands with or without the pressure button were commonly incorporated as sham interventions. The same or identical 
equipment used in both groups makes the blind- ing of participants and outcome assessors possible, and blinding of 
care providers can also be achieved if they are not involved in the application of the acupressure devices. In type 2 
sham designs, most of the trials employed acupressure equipment on non-acupoints and used the same acupressure 
intensity as in the true intervention arms. However, as mentioned above, acupressure at non-acupoints might induce 
some unexpected treatment effects, and thus makes the type 2 design more effective than its own placebo effects. 
Type 4 designs with pseudo-devices could be viewed as a good sham mode because those do not apply additional 
pressure to the selected acupoints which could minimize the potential therapeutic effects at a greater extend. Also, 
the appearance looks indistinguishable from the true acupressure tools which could keep the blinding at a 
satisfactory level, particularly for acupressure-naive partici- pants. Unfortunately, tools such as acupressure bands 
currently are only applicable for acu- points located on the arms or legs, and when a study adopts too many 
acupoints, using acupressure equipment nearly becomes impossible. 
Participants’ dropout rates were similar between groups. Although reasons for dropout var- ied among trials, no 
participants were reported dropping out because of being allocated to sham group. Meanwhile, this review found 
that the type 3 control had the lowest dropout rate. However, the low rate seemed not to be caused by the sham 
intervention itself but by the nature of the included health problems. Among the six studies with the type 3 sham 
approach, more than half were studying pregnant women preparing for delivery and the acupressure only lasted 
several minutes. 
For studies that observed potential adverse events associated with acupressure, no such events were found in 
more than half of the studies. Adverse events related to acupressure iden- tified in the remaining trials were 
generally mild and transient. Reported adverse events were associated with acupressure devices, which were mostly 
attributed to wearing of the equipment for a longer time. Loosening the bands temporarily during the intervention 
could help to reduce the side effects to some extent. Acupressure seems to be a relatively safe approach for 
acupoints-stimulation. However, it is noted that none of the included trials assessed the causal- ity between the 
acupressure and the reported adverse events, and standard causality assessment tools (e.g. The WHO-Uppsala 
Monitoring Centre System for Standardized Case Causality Assessment) were failed to be applied in the analyzed 
studies, which make it difficult to judge whether these adverse events are really caused by the acupressure 
intervention or not. 
Some limitations were identified in the analyzed studies which could affect the reliability of our results. Firstly, 
true and sham acupressure protocols were described unclearly in some studies. Relationship and distance between 
the non-acupoint and the nearest meridian were seldom reported. Information on intervention frequency and 
intensity were also provided insufficiently in some trials, which made the subgroup analyses on the acupressure 
frequency and intensity impossible. Secondly, subjective outcomes were utilized in more than half of the articles, 
which produced a possibility for exaggerating the treatment effects of the intervention, especially for studies with 
inadequate blinding and/or allocation concealment [88]. Thirdly, methodological flaws still existed among studies. 
Assessment of the credibility of blinding is essential in clinical trials for evaluating the successfulness of blinding 
design, especially for tri- als with a placebo/sham control arm, as inadequate blinding could contribute to 
performance 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 33 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
and/or detection biases, which could exaggerate the potential specific/non-specific treatment effects of the 
placebo/sham intervention. However, credibility of blinding was not tested in all the trials, and for some studies to 
which the blinding of care providers could have been achieved (e.g. studies using identical acupressure bands), such 
a design also failed to be incor- porated. Moreover, Chinese syndrome differentiation was not employed to guide 
subject recruitment, acupoint identification, and acupressure-technique selection in studies using Chi- nese 
acupressure, which may downgrade the feasibility and reliability of the intervention proto- cols to some degree. 
The study objective which focused on whether different types of sham procedure yield dif- ferent therapeutic 
outcomes was difficult to achieve in this review as limited homogeneous data could be accessed for conducting 
subgroup analysis on the same health condition within each sham acupressure modality. Descriptive analysis only 
provided a preliminary summary of the therapeutic effects of acupressure. The exploratory analysis of the responder 
rate ratio was unable to always be consistent with the finding drawn from the study main outcomes with con- 
tinuous variables as responder rate ratio was only a rough estimation and dichotomous data were not the main 
outcomes for some studies. Meanwhile, even within single sham alternative, trials still showed heterogeneity in a 
number of aspects, such as the differences in patient char- acteristics, treatment duration and the outcome measures, 
etc., all of which made the interpre- tation of results a difficult task. In addition, our findings at the current stage 
could not evaluate whether there were any sham designs that had produced additional treatment effects over and 
above their own placebo effects. Finally, although we have made efforts to locate as much eligi- ble studies as 
possible, the final included studies were only in English and Chinese. Several arti- cles written in languages other 
than English or Chinese were excluded, inevitably leading to some language bias. 

Implications for Future Research and Practice 

Verbal and non-verbal interactions between practitioners/researchers and participants should be pre-standardized to 
avoid increasing participants’ expectations to the treatment which may exaggerate the non-specific psychological 
effects of the treatment [89, 90]. In studies utilizing an acupressure device, it is suggested that researchers and care 
providers are not involved in the application of acupressure equipment in order to retain satisfactory blinding. 
Furthermore, it would be better for future studies to recruit participants without any previous experience in 
acupressure. Acupressure-naive subjects do not have any experience of deqi sensation, which may increase the 
chance of reaching successful blinding of participants [6]. To equalize the treatment expectations among 
participants, if possible, participants’ characteristics such as educational background, religion, and lifestyle, etc. 
should be kept similar at the baseline, as these elements are considered to be potential social-psychological factors 
that could affect par- ticipants’ expectations to treatment [85]. 
Selection of the sham methods should be in accordance with the study objectives and the actual requirements of 
the intervention and participants, as well as the nature of the disease being treated. For example, if a study intends to 
test the specificity of some particular acu- points, the true and sham acupressure protocols should be the same with 
the only difference in the selected acupoints. To minimize potential therapeutic effects of sham interventions and to 
maintain a satisfactory blinding design, non-acupoints located near the targeted true acupoints are generally 
recommended but the definite locations should be identified with caution, and an acupoint detector (a commonly 
utilized device for accurately locating effective body/auricular acupoints) could be considered to distinguish 
ineffective non-acupoints from active true acu- points. For acupressure intensity, future studies are suggested to 
exert only light or no 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 34 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
stimulation to the sham acupoints to prevent the generation of the deqi sensation. Particularly, acupoint stimulation 
should be avoided in pain studies adopting sham acupressure. While for studies using single sham acupoints on 
hands or legs, it is suggested to apply identical acupres- sure devices on the same acupoints as in the true 
intervention groups without any stimulation. 
To facilitate the blinding of participants and/or care providers, some methods could be con- sidered to prevent 
them from observing the treatment procedure, for instance, letting partici- pants wear eye patches when 
administering the intervention [91], or using bandages to cover the wrist bands during surgical acupressure trials. 
Moreover, some studies also pointed out that the effects of acupoint stimulation can be reflected on the neural 
activities in the limbic system and subcortical structures which provides a possible direction for future research to 
use the functional magnetic resonance imaging (fMRI) to adequately evaluate sham procedures based on the neural 
activities of the brain [92,93]. 
As subjective outcomes (e.g. questionnaire and visual analogue scale, etc.) could be affected by the participants’ 
expectations to treatment, which subsequently exaggerates therapeutic effects, future studies could consider 
including some objective measures. Some scholars point out that instead of using the word of “sham” or “placebo”, 
informing participants that the aim of study is to compare two different treatment procedures would be more 
credible to reach a successful blinding of study subjects [2, 94]. This kind of incomplete informed consent may be in 
debate for ethical reasons [2]. However, according to the results of a nested qualitative study within a RCT using 
acupressure (both true and sham) for controlling chemotherapy-induced nausea, it was acceptable for the study 
participants to receive this kind of consent process [94]. Meanwhile, from the findings of this review as well as other 
studies on sham acupoint stimula- tion [92, 95], sham interventions can also contribute to symptom improvement, 
and thus, it seems plausible to view the sham acupressure as a non-specific treatment approach in nature. Finally, the 
methodological quality of future trial needs to be improved. More detailed informa- tion on the theoretical 
background of the selection and identification of true and sham acu- points should be provided. Treatment duration, 
number of sessions, and acupressure intensity should be described in detail in the acupressure protocols. Even if it is 
difficult to incorporate blinding of the practitioner in manual acupressure trials, a double-blind design for both 
partici- pants and outcome assessors is still possible. Credibility of blinding should also be tested to investigate the 
successfulness of blinding design and subsequent to identify the potential risk of performance and/or detection 
biases. Related guidelines such as the CONSORT [96] and STRICTA [97] guidelines should be followed in the 
development and reporting of acupressure trials. 

Conclusions 
A great diversity of sham acupressure controls have been used in the literature. A solid conclu- sion whether 
different sham alternatives are related to different treatment outcomes cannot be derived because of the significant 
clinical heterogeneity among the analyzed trials. Based on the findings of this systematic review, non-acupoints are 
generally recommended but the defi- nite locations should be identified with caution. For studies using single sham 
acupoints on hands or legs, it is suggested to apply identical acupressure devices on the same acupoint as in the 
active intervention without any stimulation. While for studies on pain, stimulation of sham acupoints should be 
avoided. 

Supporting Information 
S1 File. PRISMA Checklist. (PDF) 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 35 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
S2 File. Systematic Review Protocol. (PDF) 
S1 Table. Selected Searching Strategies. (PDF) 
S2 Table. Excluded Acupressure Trials due to High Risk of Bias. (PDF) 
S3 Table. Risk of Bias Assessment of the Included Trials. (PDF) 

Author Contributions 
Conceived and designed the experiments: JYT LKPS AM. Performed the experiments: JYT TW. Analyzed the data: 
JYT AM. Contributed reagents/materials/analysis tools: TW. Wrote the paper: JYT. Revised the manuscript: JYT 
AM LKPS WT. 

References 
1. McGovern DPB. Randomized controlled trials. In: McGovern DPB, Valori RM, Summerskill WSM, eds. 
Key topics in evidence based medicine. Oxford: BIOS Scientific Publishers, 2001:pp. 26–29. 2. Dincer F, Linde K. Sham 
interventions in randomized clinical trials of acupuncture-a review. Comple- 
ment Ther Med, 2003, 11(4), 235–242. PMID: 15022656 3. Shapiro AK, Morris LA. The placebo effect in medical and 
psychological therapies. In: Garfield SL, Ber- 
gin AE, editors. Handbook of psychotherapy and behavior change. New York: Wiley; 1978: p. 371. 4. Lund I, Näslund J, 
Lundeberg T. Minimal acupuncture is not a valid placebo control in randomised con- 
trolled trials of acupuncture: a physiologist’s perspective. Chin Med, 2009, 4(1), 1. 
5. Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE et al. Acupuncture for 
chronic pain: individual patient data meta-analysis. Arch Intern Med, 2012, 172(19), 1444–1453. doi: 
10.1001/archinternmed.2012.3654 PMID: 22965186 6. Zhang HW, Tang JL. Development and selection of sham approaches in 
clinical trials of acupuncture. 
Zhongguo Zhong Xi Yi Jie He Za Zhi, 2003, 23(4), 247–250. PMID: 12764902 7. Itoh K, Katsumi Y, Hirota S, Kitakoji H. 
Effects of trigger point acupuncture on chronic low back pain in 
elderly patients—a sham-controlled randomised trial. Acupunct Med, 2006, 24(1), 5–12. PMID: 16618043 8. Sun Y, Gan TJ. 
Acupuncture for the management of chronic headache: a systematic review. Anesth 
Analg, 2008, 107(6), 2038–2047. doi: 10.1213/ane.0b013e318187c76a PMID: 19020156 9. Molsberger AF, Schneider T, 
Gotthardt H, Drabik A. German Randomized Acupuncture Trial for chronic shoulder pain (GRASP)—a pragmatic, controlled, 
patient-blinded, multi-centre trial in an outpatient care environment. Pain, 2010, 151(1), 146–154. doi: 
10.1016/j.pain.2010.06.036 PMID: 20655660 10. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, et al. 
Acupuncture for patients with 
migraine: a randomized controlled trial. JAMA, 2005, 293(17), 2118–2125. PMID: 15870415 11. Ernst E. Acupuncture as a 
symptomatic treatment of osteoarthritis. Scand J Rheumatol, 1997, 26(6), 
444–447. PMID: 9433405 
12. Scharf HP, Mansmann U, Streitberger K, Witte S, Krämer J, Maier C, et al. Acupuncture and Knee 
Osteoarthritis: A Three-Armed Randomized Trial. Ann Intern Med, 2006, 145(1), 12–20. PMID: 16818924 13. Furlan AD, 
Pennick V, Bombardier C, van Tulder M. 2009 updated method guidelines for systematic 
reviews in the Cochrane Back Review Group. Spine, 2009, 34(18), 1929–1941. doi: 10.1097/BRS. 0b013e3181b1c99f PMID: 
19680101 14. Zhang CS, Yang AW, Zhang AL, May BH, Xue CC. Sham control methods used in ear-acupuncture/ 
ear-acupressure randomized controlled trials: a systematic review. J Altern Complement Med, 2014, 20(3), 147–161. doi: 
10.1089/acm.2013.0238 PMID: 24138333 15. Zhang H, Bian Z, Lin Z. Are acupoints specific for diseases? A systematic review 
of the randomized 
controlled trials with sham acupuncture controls. Chin Med, 2010, 5(1). doi: 10.1186/1749-8546-5-1 PMID: 20145733 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 36 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
16. Tang WR, Chen WJ, Yu CT, Chang YC, Chen CM, Wang CH, et al. Effects of acupressure on fatigue of 
lung cancer patients undergoing chemotherapy: An experimental pilot study. Complement Ther Med, 2014, 22(4), 581–591. doi: 
10.1016/j.ctim.2014.05.006 PMID: 25146059 17. Atrian MK, Abbaszadeh F, Sarvieh M, Sarafraz N, Jafarabadi MA. 
Investigating the effect of pressure on third liver point on primary dysmenorrhea: a randomized controlled clinical trial. Iran Red 
Crescent Med J, 2013, 15(9), 848–853. doi: 10.5812/ircmj.12719 PMID: 24616798 18. Sehhatie-Shafaie F, Amani F, Heshmat R. 
The effect of acupressure on Sanyinjiao and Hugo points on 
labor pain in nulliparous women: a randomized clinical trial. J Caring Sci, 2013, 2(2), 123–129. doi: 10. 5681/jcs.2013.015 
PMID: 25276718 19. Chao HL, Miao SJ, Liu PF, Lee HHC, Chen YM, Yao CT, et al. The beneficial effect of ST-36 (Zusanli) 
acupressure on postoperative gastrointestinal function in patients with colorectal cancer. Oncol Nurs Forum, 2013, 40(2), 
E61–E68. doi: 10.1188/13.ONF.E61-E68 PMID: 23448746 20. McFadden KL, Healy KM, Hoversten KP, Ito TA, Hernández 
TD. Efficacy of acupressure for non-phar- 
macological stress reduction in college students. Complement Ther Med, 2012, 20(4), 175–182. doi: 10.1016/j.ctim.2011.12.003 
PMID: 22579428 21. Valiee S, Bassampour SS, Nasrabadi AN, Pouresmaeil Z, Mehran A. Effect of acupressure on preoper- 
ative anxiety: a clinical trial. J Perianesth Nurs, 2012, 27(4), 259–266. doi: 10.1016/j.jopan.2012.05. 003 PMID: 22828022 
22. Rad MN, Lamyian M, Heshmat R, Jaafarabadi MA, Yazdani S. A randomized clinical trial of the efficacy of KID21 point 
(Youmen) acupressure on nausea and vomiting of pregnancy. Iran Red Crescent Med J, 2012, 14(11), 697–701. doi: 
10.5812/ircmj.2153 PMID: 23397064 23. Chang KKP, Wong TKS, Wong THK, Chung JWY. Leung AWN. Effect of 
acupressure in treating urody- 
namic stress incontinence: A randomized controlled trial. Am J Chin Med, 2011, 39(6), 1139–1159. PMID: 22083987 24. 
McFadden KL, Healy KM, Dettmann ML, Kaye JT, Ito TA, Hernández TD. Acupressure as a non-phar- 
macological intervention for traumatic brain injury (TBI). J Neurotrauma, 2011, 28(1), 21–34. doi: 10. 1089/neu.2010.1515 
PMID: 20979460 25. Kashefi F, Khajehei M, Ashraf AR, Jafari P. The efficacy of acupressure at the Sanyinjiao point in the 
improvement of women's general health. J Altern Complement Med, 2011, 17(12), 1141–1147. doi: 10. 1089/acm.2010.0589 
PMID: 22082432 26. Reza H, Kian N, Pouresmail Z, Masood K, Sadat Seyed Bagher M, Cheraghi MA. The effect of acupres- 
sure on quality of sleep in Iranian elderly nursing home residents. Complement Ther Clin Pract, 2010, 16(2), 81–85. doi: 
10.1016/j.ctcp.2009.07.003 PMID: 20347838 27. McFadden KL, Hernández TD. Cardiovascular benefits of acupressure (Jin 
Shin) following stroke. 
Complement Ther Med, 2010, 18(1), 42–48. doi: 10.1016/j.ctim.2010.01.001 PMID: 20178877 28. Maa SH, Tsou TS, Wang 
KY, Wang CH, Lin HC, Huang YH. Self-administered acupressure reduces 
the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. J Clin Nurs, 2007, 16(4), 794–804. PMID: 
17402962 29. Shin HS, Song YA, Seo S. Effect of Nei-Guan point (P6) acupressure on ketonuria levels, nausea and 
vomiting in women with hyperemesis gravidarum. J Adv Nurs, 2007, 59(5), 510–519. PMID: 17645494 30. Bertalanffy P, 
Hoerauf K, Fleischhackl R, Strasser H, Wicke F, Greher M. Korean hand acupressure for 
motion sickness in prehospital trauma care: a prospective, randomized, double-blinded trial in a geriat- ric population. Anesth 
Analg, 2004, 98(1), 220–223. PMID: 14693623 
31. Chen LL, Hsu SF, Wang MH, Chen CL, Lin YD, Lai JS. Use of acupressure to improve gastrointestinal 
motility in women after trans-abdominal hysterectomy. Am J Chin Med, 2003, 31(5), 781–790. PMID: 14696681 32. Tsay SL, 
Chen ML. Acupressure and quality of sleep in patients with end-stage renal disease—a ran- 
domized controlled trial. Int J Nurs Stud, 2003, 40(1), 1–7. PMID: 12550145 33. Kober A, Scheck T, Greher M, Lieba F, 
Fleischhackl R, Fleischhackl S, et al. Prehospital analgesia with 
acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anesth Analg, 2002, 95(3), 723–727. 
PMID: 12198060 34. Belluomini J, Litt RC, Lee KA, Katz M. Acupressure for nausea and vomiting of pregnancy: a random- 
 ized, blinded study. Obstet Gynecol, 1994, 84(2), 245–248. PMID: 8041539 35. Adib-Hajbaghery M, Etri M. Effect of 
acupressure of Ex-Le7 point on pain, nausea and vomiting after 
appendectomy: A randomized trial. J Res Med Sci, 2013, 18(6), 482–486. PMID: 24250696 36. Alessandrini M, Napolitano B, 
Micarelli A, De Padova A, Bruno E. P6 acupressure effectiveness on 
acute vertiginous patients: a double blind randomized study. J Altern Complement Med, 2012, 18(12), 1121–1126. doi: 
10.1089/acm.2011.0384 PMID: 22950829 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 37 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
37. Soltani ARE, Mohammadinasab H, Goudarzi M, Arbabi S, Mohammadinasab A, Mohammadinasab F, 
et al. Comparing the efficacy of prophylactic p6 acupressure, ondansetron, metoclopramide and pla- cebo in the prevention of 
vomiting and nausea after strabismus surgery. Acta Med Iran, 2011, 49(4), 208–212. PMID: 21713729 38. Bao T, Ye X, Skinner 
J, Cao B, Fisher J, Nesbit S, et al. The analgesic effect of magnetic acupressure 
in cancer patients undergoing bone marrow aspiration and biopsy: a randomized, blinded, controlled trial. J Pain Symptom 
Manage, 41(6), 995–1002. doi: 10.1016/j.jpainsymman.2010.08.012 PMID: 21306863 
39. Majholm B, Møller AM. Acupressure at acupoint P6 for prevention of postoperative nausea and vomit- 
ing: a randomised clinical trial. Eur J Anaesthesiol, 2011, 28(6), 412–419. doi: 10.1097/EJA. 0b013e32833f6f42 PMID: 
21544020 40. Sinha A, Paech MJ, Thew ME, Rhodes M, Luscombe K, Nathan E. A randomised, double-blinded, pla- 
cebo-controlled study of acupressure wristbands for the prevention of nausea and vomiting during labour and delivery. Int J 
Obstet Anesth, 2011, 20(2), 110–117. doi: 10.1016/j.ijoa.2010.10.005 PMID: 21194921 41. Wang SM, Escalera S, Lin EC, 
Maranets I, Kain ZN. Extra-1 acupressure for children undergoing anes- 
thesia. Anesth Analg, 2008, 107(3), 811–816. doi: 10.1213/ane.0b013e3181804441 PMID: 18713889 42. Turgut S, Ozalp 
G, Dikmen S, Savli S, Tuncel G, Kadiogullari N. Acupressure for postoperative nausea 
and vomiting in gynaecological patients receiving patient-controlled analgesia. Eur J Anaesthesiol, 2007, 24(1), 87–91. PMID: 
16895618 43. Heazell A, Thorneycroft J, Walton V, Etherington I. Acupressure for the in-patient treatment of nausea and 
vomiting in early pregnancy: a randomized control trial. Am J Obstet Gynecol, 2006, 194(3), 815– 820. PMID: 16522418 44. 
Wang SM, Gaal D, Maranets I, Caldwell-Andrews A, Kain ZN. Acupressure and preoperative parental 
anxiety: a pilot study. Anesth Analg, 2005, 101(3), 666–669. PMID: 16115972 45. Alkaissi A, Ledin T, Odkvist LM, 
Kalman S. P6 acupressure increases tolerance to nauseogenic motion 
stimulation in women at high risk for PONV. Can J Anaesth, 2005, 52(7), 703–709. PMID: 16103382 46. Samad K, Afshan 
G, Kamal R. Effect of acupressure on postoperative nausea and vomiting in laparo- 
scopic cholecystectomy. J Pak Med Assoc, 2003, 53(2), 68–71. PMID: 12705488 47. Alkaissi A, Evertsson K, Johnsson 
VA, Ofenbartl L, Kalman S. P6 acupressure may relieve nausea and 
vomiting after gynecological surgery: an effectiveness study in 410 women. Can J Anaesth, 2002, 49 (10), 1034–1039. PMID: 
12477673 48. Agarwal A, Pathak A, Gaur A. Acupressure wristbands do not prevent postoperative nausea and vomit- ing after 
urological endoscopic surgery. Can J Anaesth, 2000, 47(4), 319–324. PMID: 10764175 49. Harmon D, Ryan M, Kelly A, Bowen 
M. Acupressure and prevention of nausea and vomiting during and 
after spinal anaesthesia for caesarean section. Br J Anaesth, 2000, 84(4), 463–467. PMID: 10823097 50. Harmon D, 
Gardiner J, Harrison R, Kelly A. Acupressure and the prevention of nausea and vomiting 
after laparoscopy. Br J Anaesth, 1999, 82(3), 387–390. PMID: 10434821 51. Alkaissi A, Stålnert M, Kalman S. Effect and 
placebo effect of acupressure (P6) on nausea and vomiting after outpatient gynaecological surgery. Acta Anaesthesiol Scand, 
1999, 43(3), 270–274. PMID: 10081532 52. Fan CF, Tanhui E, Joshi S, Trivedi S, Hong Y, Shevde K. Acupressure treatment for 
prevention of post- 
operative nausea and vomiting. Anesth Analg, 1997, 84(4), 821–825. PMID: 9085965 53. O'Brien B, Relyea MJ, Taerum T. 
Efficacy of P6 acupressure in the treatment of nausea and vomiting 
during pregnancy. Am J Obstet Gynecol, 1996, 174(2), 708–715. PMID: 8623811 54. Felhendler D, Lisander B. Pressure 
on acupoints decreases postoperative pain. Clin J Pain, 1996, 12 
(4), 326–329. PMID: 8969878 55. Bayreuther J, Pickering R, Lewith GT. A double-blind cross-over study to evaluate the 
effectiveness of 
acupressure at pericardium 6 (P6) in the treatment of early morning sickness (EMS). Complement Ther Med, 1994, 2(2), 70–76. 
56. Hamidzadeh A, Shahpourian F, Orak RJ, Montazeri AS, Khosravi A. Effects of LI4 acupressure on 
labor pain in the first stage of labor. J Midwifery Womens Health, 2012, 57(2), 133–138. doi: 10.1111/j. 
1542-2011.2011.00138.x PMID: 22432484 57. Mirbagher-Ajorpaz N, Adib-Hajbaghery M, Mosaebi F. The effects of 
acupressure on primary dysme- 
norrhea: a randomized controlled trial. Complement Ther Clin Pract, 2011, 17(1), 33–36. doi: 10.1016/ j.ctcp.2010.06.005 PMID: 
21168112 
58. Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long- 
term care facilities with insomnia: a randomized controlled trial. Int J Nurs Stud, 2010, 47(7), 798–805. doi: 
10.1016/j.ijnurstu.2009.12.003 PMID: 20056221 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 38 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
59. Kashanian M, Shahali S. Effects of acupressure at the Sanyinjiao point (SP6) on the process of active 
phase of labor in nulliparas women. J Matern Fetal Neonatal Med, 2010, 23(7), 638–641. 60. Hjelmstedt A, Shenoy ST, 
Stener-Victorin E, Lekander M, Bhat M, Balakumaran L, et al. Acupressure to reduce labor pain: a randomized controlled trial. 
Acta Obstet Gynecol Scand, 2010, 89(11), 1453– 1459. doi: 10.3109/00016349.2010.514323 PMID: 20822474 61. Hsu W, Hsu 
HY, Sun JL. Effects of shenmen acupressure on improving the condition of institutional res- 
idents with insomnia. J Evid Based Nurs, 2006, 2(4), 331–338. 62. Lee MK, Chang SB, Kang DH. Effects of SP6 
acupressure on labor pain and length of delivery time in 
women during labor. J Altern Complement Med, 2004, 10(6), 959–965. PMID: 15673989 63. Nilsson I, Karlsson A, 
Lindgren L, Bergenheim T, Koskinen LO, Nilsson U. The efficacy of P6 acupres- sure with sea-band in reducing postoperative 
nausea and vomiting in patients undergoing craniotomy: a randomized, double-blinded, placebo-controlled Study. J Neurosurg 
Anesthesiol, 2015, 27(1), 42– 50. doi: 10.1097/ANA.0000000000000089 PMID: 24978062 64. Molassiotis A, Russell W, 
Hughes J, Breckons M, Lloyd Williams M, Richardson J, et al. The effective- ness and cost-effectiveness of acupressure for the 
control and management of chemotherapy-related acute and delayed nausea: assessment of Nausea in Chemotherapy Research 
(ANCHoR), a rando- mised controlled trial. Health Technol Assess, 2013, 17, 26. 65. Noroozinia H, Mahoori A, Hasani E, 
Gerami-Fahim M, Sepehrvand N. The effect of acupressure on 
nausea and vomiting after cesarean section under spinal anesthesia. Acta Med Iran, 2013, 51(3), 163– 167. PMID: 23605600 
66. Soltanzadeh M, Behaeen K, Pourmehdi Z, Safarimohsenabadi A. Effects of acupressure on nausea 
and vomiting after gynecological laparoscopy surgery for infertility investigations. Life Sci J, 2012, 9(3), 871–875. 67. White PF, 
Zhao M, Tang J, Wender RH, Yumul R, Sloninsky AV, et al. Use of a disposable acupressure 
device as part of a multimodal antiemetic strategy for reducing postoperative nausea and vomiting. Anesth Analg, 2012, 115(1), 
31–37. doi: 10.1213/ANE.0b013e3182536f27 PMID: 22504214 68. Ho CM, Tsai HJ, Chan KH, Tsai SK. P6 acupressure does 
not prevent emesis during spinal anesthesia 
for cesarean delivery. Anesth Analg, 2006, 102(3), 900–903. PMID: 16492848 69. Klein AA, Djaiani G, Karski J, Carroll 
J, Karkouti K, McCluskey S, et al. Acupressure wristbands for the prevention of postoperative nausea and vomiting in adults 
undergoing cardiac surgery. J Cardiothorac Vasc Anesth, 2004, 18(1), 68–71. PMID: 14973803 70. Schultz AA, Andrews AL, 
Goran SF, Mathew T, Sturdevant N. Comparison of acupressure bands and 
droperidol for reducing post-operative nausea and vomiting in gynecologic surgery patients. Appl Nurs Res, 2003, 16(4), 
256–265. PMID: 14608559 71. Dent HE, Dewhurst NG, Mills SY, Willoughby M. Continuous PC6 wristband acupressure for 
relief of 
nausea and vomiting associated with acute myocardial infarction: a partially randomised, placebo-con- trolled trial. Complement 
Ther Med, 2003, 11(2), 72–77. PMID: 12801491 72. Norheim AJ, Pedersen EJ, Fønnebø V, Berge L. Acupressure treatment of 
morning sickness in preg- 
nancy. A randomised, double-blind, placebo-controlled study. Scand J Prim Health Care, 2001, 19(1), 43–47. PMID: 11303547 
73. Steele NM, French J, Gatherer-Boyles J, Newman S, Leclaire S. Effect of acupressure by sea-bands 
on nausea and vomiting of pregnancy. J Obstet Gynecol Neonatal Nurs, 2001, 30(1), 61–70. PMID: 11277163 
74. Woods RM. Pericardium-6 acupressure for the prevention of postoperative nausea and vomiting. Uni- 
formed Services University of the Health Sciences, 1999. 75. Duggal KN, Douglas MJ, Peteru EA, Merrick PM. 
Acupressure for intrathecal narcotic-induced nausea 
and vomiting after caesarean section. Int J Obstet Anesth, 1998, 7(4), 231–236. PMID: 15321185 76. Lewis IH, Pryn SJ, 
Reynolds PI, Pandit UA, Wilton NCT. Effect of P6 acupressure on postoperative 
vomiting in children undergoing outpatient strabismus correction. Br J Anaesth, 1991, 67(1), 73–78. PMID: 1859764 77. Suh EE. 
The effects of P6 acupressure and nurse-provided counseling on chemotherapy-induced nau- 
sea and vomiting in patients with breast cancer. Oncol Nurs Forum, 39(1), E1–E9. doi: 10.1188/12. ONF.E1-E9 PMID: 
22201663 78. Lang T, Hager H, Funovits V, Barker R, Steinlechner B, Hoerauf K, et al. Prehospital analgesia with 
acupressure at the Baihui and Hegu points in patients with radial fractures: a prospective, randomized, double-blind trial. Am J 
Emerg Med, 2007, 25(8), 887–893. PMID: 17920972 79. Wu HS, Lin LC, Wu SC, Lin JG. The psychologic consequences of 
chronic dyspnea in chronic pulmo- nary obstruction disease: the effects of acupressure on depression. J Altern Complement Med, 
2007, 13(2), 253–261. PMID: 17388769 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 39 / 40 
 
Sham Acupressure Controls Used in Randomized Controlled Trials 
80. Wu HS, Wu SC, Lin JG, Lin LC. Effectiveness of acupressure in improving dyspnoea in chronic obstruc- 
tive pulmonary disease. J Adv Nurs, 2004, 45(3), 252–259. PMID: 14720242 81. Nordio M, Romanelli F. Efficacy of 
wrists overnight compression (HT 7 point) on insomniacs: possible 
role of melatonin? Minerva Medica, 2008, 99(6), 539–547. PMID: 19034253 82. Lundeberg T, Lund I, Sing A, Näslund J. 
Is placebo acupuncture what it is intended to be?. Evid Based 
Complement Alternat Med, 2011. Article ID 932407. doi: 10.1093/ecam/nep049 83. Linde K, Niemann K, Meissner K. Are 
sham acupuncture interventions more effective than (other) pla- 
cebos? A re-analysis of data from the Cochrane review on placebo effects. Forsch Komplementarmed, 2010, 17(5), 259–264. 84. 
Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database 
Syst Rev, 2010, CD003974. doi: 10.1002/14651858.CD003974.pub3 85. Pan LJ, Chen B, Zhao X, Guo Y. Thinking on 
designation of sham acupuncture in clinical research. 
Zhongguo Zhen Jiu, 2014, 34(1), 83–86. PMID: 24673069 
86. Olausson H, Lamarre Y, Backlund H, Morin C, Wallin BG, Starck G, et al. Unmyelinated tactile afferents 
signal touch and project to insular cortex. Nat Neurosci, 2002, 5(9), 900–904. 
87. Lundeberg T, Lund I. Are reviews based on sham acupuncture procedures in fibromyalgia syndrome 
(FMS) valid? Acupunct Med, 2007, 25(3), 100–106. PMID: 17906605 88. Wood L, Egger M, Gluud LL, Schulz KF, Jüni 
P, Altman DG, et al. Empirical evidence of bias in treat- 
ment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiologi- cal study. BMJ, 2008, 
336(7644), 601–605. doi: 10.1136/bmj.39465.451748.AD PMID: 18316340 89. Azad A, John T. Do randomized acupuncture 
studies in patients with cancer need a sham acupuncture 
control arm? J Clin Oncol, 2013, 31(16), 2057–2058. doi: 10.1200/JCO.2012.47.8750 PMID: 23610109 90. Kelley JM, Lembo 
AJ, Ablon JS, Villanueva JJ, Conboy LA, Levy R, et al. Patient and practitioner influ- 
ences on the placebo effect in irritable bowel syndrome. Psychosom Med, 2009, 71(7), 789–797. doi: 
10.1097/PSY.0b013e3181acee12 PMID: 19661195 91. Kondziolka D, Lemley T, Kestle JR, Lunsford LD, Fromm GH, Jannetta 
PJ. The effect of single-applica- 
tion topical ophthalmic anesthesia in patients with trigeminal neuralgia: a randomized double-blind pla- cebo-controlled trial. J 
Neurosurg, 1994, 80(6), 993–997. PMID: 8189280 
92. Lundeberg T, Lund I, Näslund J, Thomas M. The Emperors sham-wrong assumption that sham nee- 
dling is sham. Acupunct Med, 2008, 26(4), 239–242. PMID: 19098696 93. Hui KK, Liu J, Makris N, Gollub RL, Chen AJ, 
I Moore C, et al. Acupuncture modulates the limbic system 
and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp, 2000, 9(1), 
13–25. PMID: 10643726 
94. Hughes JG, Russell W, Breckons M., Richardson J, Lloyd-Williams M, Molassiotis A. (2014). “I 
assumed that one was a placebo”: Exploring the consent process in a sham controlled acupressure trial. Complement Ther Med, 
22(5), 903–908. doi: 10.1016/j.ctim.2014.07.005 PMID: 25440382 95. Hughes JG, Russell W, Breckons M, Richardson J, 
Lloyd-Williams M, Molassiotis A. “Until the trial is complete you can’t really say whether it helped you or not, can you?”: 
exploring cancer patients’ per- ceptions of taking part in a trial of acupressure wristbands. BMC Complement Altern Med, 2013, 
13(1), 1–10. 96. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the 
quality of reports of parallel group randomized trials. BMC Med Res Methodol, 2001, 1(1), 2. 97. MacPherson H, Altman DG, 
Hammerschlag R, Youping L, Taixiang W, et al. Revised STandards for 
Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): Extending the CONSORT State- ment. PLoS Med, 2010, 
7(6): e1000261. doi: 10.1371/journal.pmed.1000261 PMID: 20543992 
PLOS ONE | DOI:10.1371/journal.pone.0132989 July 15, 2015 40 / 40 
 
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