Hindawi Publishing Corporation

Evidence-Based Complementary and Alternative Medicine

Volume 2014, Article ID 850367, 12 pages
http://dx.doi.org/10.1155/2014/850367

Review Article
Efficacy of Acupuncture in Reducing Preoperative Anxiety:
A Meta-Analysis

Hyojeong Bae,1,2 Hyunsu Bae,3 Byung-Il Min,4 and Seunghun Cho5

1
Department of East-West Medicine, Graduate School, Kyung Hee University, Hoegi-Dong No. 1, Dongdaemun-Gu, Seoul 130-701,
Republic of Korea
2
Soram Korean Medicine Hospital M Tower Building, Samsung-Dong No. 154-11, Gangnam-Gu, Seoul 135-879, Republic of Korea
3
Department of Physiology, College of Korean Medicine, Kyung Hee University, Hoegi-Dong No. 1, Dongdaemun-Gu, Seoul 130-701,
Republic of Korea
4
Department of Physiology, College of Medicine, Kyung Hee University, Hoegi-Dong No. 1, Dongdaemun-Gu, Seoul 130-701,
Republic of Korea
5
Hospital of Korean Medicine, Kyung Hee University Medical Center, Hoegi-Dong No. 1, Dongdaemun-Gu, Seoul 130-701,
Republic of Korea

Correspondence should be addressed to Hyojeong Bae; [email protected]

Received 9 May 2014; Revised 11 July 2014; Accepted 11 July 2014; Published 2 September 2014

Academic Editor: Jian Kong

Copyright © 2014 Hyojeong Bae et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Acupuncture has been shown to reduce preoperative anxiety in several previous randomized controlled trials (RCTs).
In order to assess the preoperative anxiolytic efficacy of acupuncture therapy, this study conducted a meta-analysis of an array of
appropriate studies. Methods. Four electronic databases (MEDLINE, EMBASE, CENTRAL, and CINAHL) were searched up to
February 2014. In the meta-analysis data were included from RCT studies in which groups receiving preoperative acupuncture
treatment were compared with control groups receiving a placebo for anxiety. Results. Fourteen publications (N = 1,034) were
included. Six publications, using the State-Trait Anxiety Inventory-State (STAI-S), reported that acupuncture interventions led to
greater reductions in preoperative anxiety relative to sham acupuncture (mean difference = 5.63, P < .00001, 95% CI [4.14, 7.11]).
Further eight publications, employing visual analogue scales (VAS), also indicated significant differences in preoperative anxiety
amelioration between acupuncture and sham acupuncture (mean difference = 19.23, P < .00001, 95% CI [16.34, 22.12]). Conclusions.
Acupuncture therapy aiming at reducing preoperative anxiety has a statistically significant effect relative to placebo or nontreatment
conditions. Well-designed and rigorous studies that employ large sample sizes are necessary to corroborate this finding.

1. Introduction interventions (e.g., music and preparatory education regard-

ing the operation) are commonly used to reduce preoperative
Anxiety prior to undergoing surgery is experienced by anxiety [5, 6]. However, conventional medical treatments
approximately 60–70% of adult patients [1]. The effects of are only moderately effective and often produce problematic
reducing preoperative anxiety can be observed by estimating side effects, including bradycardia, hypotension, drowsiness,
heart rate (HR), blood pressure (BP), and neuroendocrino- respiratory depression, pruritus, laryngeal rigidity, postop-
logical changes [2]. These effects can also be determined erative nausea and vomiting (PONV), delayed emergence,
during or after surgery through the examination of analgesic and tolerance and dependence, thereby prolonging patient
requirements, behavioral recovery, time taken to awaken, recovery and treatment duration [7, 8]. Therefore, there is a
pain, and whether such outcomes also engender additional clear need for more effective, safer interventions. This has led
financial costs to patients [3, 4]. Pharmacological (e.g., to an increase in the attention received by complementary
opioids and sedatives used as anxiolytics) and psychological and alternative interventions such as acupuncture, which is
2 Evidence-Based Complementary and Alternative Medicine

the most widely used of such approaches [9]. Patients benefit could not be rejected with certainty, the authors inspected
from the lack of side effects and relatively low cost involved the full text independently and applied an inclusion criterion
in acupuncture [10]. form to definitively assess its eligibility. Where disagreements
Acupuncture is gaining popularity in western medical occurred, the authors discussed the issue until a consensus
culture as a tool for pain relief [11, 12], and evidence is was reached. If an article was excluded, a record was of the
emerging concerning its potential mechanisms of action. reason for exclusion. The final step was to exclude double
For example, electroacupuncture blocks pain by activating publications.
a variety of bioactive chemicals via peripheral, spinal, and
supraspinal mechanisms [13].
2.2. Study Types. The meta-analysis included studies on inpa-
Recently, several studies have evaluated the “extra 1”
tients and outpatients and nonemergency, emergency, and
acupuncture or acupressure point with respect to relieving
transported patients, who were scheduled to undergo both
preoperative and general anxiety [8, 14–18]. However, to
major and minor surgical or endoscopic procedures. Dental
date, there have been no meta-analyses performed regarding
surgery procedures were also included. No restrictions were
this topic; therefore, we sought to summarize and critically
placed on age, sex, or ethnicity, but patients were excluded
assess evidence from randomized controlled trials (RCTs).
if they had a history of psychiatric or neurological problems
The aim of this meta-analysis was to evaluate the efficacy of
or serious medical conditions, such as abuse of or addiction
various types of acupuncture therapy with respect to reducing
to drugs or alcohol, or used analgesics within the week
preoperative anxiety.
preceding the procedure.
Included studies were restricted to RCTs that compared
2. Methods all forms of acupuncture-treated (delivered using classical
sterile single-use needles, plastic balls, or occlusive press
A meta-analysis of the literature was conducted according to needles) and control groups, which included nontreatment
the “Preferred Reporting Items for Systematic Reviews and or placebo treatment (sham acupuncture unrelated to known
Meta-Analyses” (PRISMA) statement pertaining to reporting acupoints for treatment, using a superficial depth of acupunc-
systematic reviews and meta-analyses of studies that evaluate ture, or without electronic stimulation), with the aim of
preoperative care interventions. reducing preoperative anxiety. Quasirandomized trials were
not included. No restrictions were imposed with respect to
publication type or language.
2.1. Literature Search. Electronic searches were performed
We did not include studies in which treatments were
independently by two authors on MEDLINE (1950 to Febru-
administered on days other than the day of surgery. The
ary 2014), Embase (1980 to February 2014), CENTRAL (the
primary outcome was the degree of reduction in preoperative
Cochrane Library 2014, Issue 1), and CINAHL (1982 to
anxiety produced by acupuncture in controlled trials involv-
February 2014). As all of these databases employ their own
ing a group to whom acupuncture was administered and a
subject headings, each was searched independently. We did
control group. Measures of anxiety included the State Anx-
not restrict our search on the basis of language, publication
iety Subscale (STAI-S) of the State-Trait Anxiety Inventory
type, or year. Article bibliographies were checked for current
(STAI), which asks respondents how they feel “right now”
relevant publications and experts in the field contacted. We
on 20 items measuring subjective feelings of apprehension,
also searched for additional relevant journals that may have
tension, nervousness, worry, and activation/arousal of the
been overlooked in the initial electronic search and available
autonomic nervous system. Anxiety scores in the STAI-S
proceedings of conferences for information on additional tri-
range from 1 (not at all) to 4 (very much so) for each item
als. In an effort to identify other published, unpublished, and
[26]. The mean difference (MD) in changes in continuous
ongoing relevant researches, we also searched the reference
scale scores for preoperative anxiety represented a degree of
sections of pertinent studies.
reduction in STAI and visual analogue scale (VAS) scores.
Keywords used to search for the RCTs were (anxiety
VAS simply indicated levels of anxiety according to a 100 mm
OR anxioly∗ OR sedat∗ OR distress OR fear OR panic
scale line, where 0 represents a complete absence of anxiety
OR stress, psychological OR stress, physiological) AND
and 100 the greatest possible level of anxiety. Where scales
(acupressure OR acupoint OR auriculotherapy OR meridians
were scored between 0 and 10, values and standard deviations
OR electroacupuncture OR acupuncture) AND (surgical
were multiplied by a factor of 10 [27]. Secondary outcomes
OR procedure∗ OR preoperative care OR surgery) AND
included physiological variables, heart rate (HR), bispectral
(randomized controlled trial [PT] OR randomized [AB] OR
index (BIS), and blood pressure (BP), patient satisfaction, and
controlled clinical trial [PT] OR placebo [AB] OR clinical
adverse events.
trial as topic [SH] OR randomly [AB] OR trial [TI]) in
MEDLINE. Each database used its own subheadings and was
searched individually. 2.2.1. Quality Assessment. The two authors assessed all
The exclusion and inclusion criteria were applied sepa- included studies for risk of bias and were blinded to each
rately by the two authors, who scanned the titles and abstracts other’s assessments. Continuous data were preferred to
of each record retrieved from the search. If information in binary data because most of the eligible studies reported con-
the abstract clearly indicated that the trial did not meet tinuous outcomes. Further information was requested from
our requirements, it was rejected. When a title or abstract the authors where articles contained inadequate information
Evidence-Based Complementary and Alternative Medicine 3

to make a decision about eligibility. Quality assessment for The agreement rate, as measured using Cohen’s kappa, was
all studies was undertaken according to the Cochrane Hand- 0.9 [32]. Acupuncture treatments were administered to 439
book for Systematic Reviews of Interventions [28]. Studies patients; the other 595 participants served as controls. One
were assessed by reviewers drawn from six domains. If articles author requested additional data from the authors of four
contained inadequate information to allow for a decision studies; however, the data from one study were not obtained
made about their eligibility, then further information was (Figure 1).
requested from the authors. No studies were excluded from Studies offered acupuncture sessions lasting between 10
the analysis as a result of the quality assessment procedure. and 30 min; sessions were conducted in operating waiting
rooms on the day of surgery. Two studies offered sessions dur-
2.2.2. Data Synthesis and Statistical Analyses. Continuous ing ambulance transfer [15, 22]. Participants were inpatients
data were summarized as mean differences (MD) between in one study and outpatients in two studies; the status of the
pre- and posttreatment STAI-S or VAS scores. The degree of participants in the remaining studies was unclear. Adminis-
reduction in preoperative anxiety, with 95% confidence inter- tration of acupuncture was examined during transportation
vals (CIs), was calculated using Review Manager (RevMan) and emergency cases in two studies and in nonemergency
software (version 5.2 for Windows, The Nordic Cochrane cases in eight studies; the environment in which acupuncture
Centre, Copenhagen, Denmark). If the 95% CI included a was administered was unclear in the remaining studies.
value of 0, then no significant difference existed between Eight studies used acupuncture needles [10, 14, 15, 19–22,
acupuncture-treated and control groups. 24]; the other six used acupressure balls or beads [8, 16–
We subtracted final values from baseline mean values, 18, 23, 25]. Five studies applied auricular acupoints, five others
even if these were not presented explicitly, such that a applied body acupoints, and four applied both. According
positive MD of the changes in scores indicated effective to “Standards for Reporting Interventions in Clinical Trials
reduction of preoperative anxiety. If either of the standard of Acupuncture” (STRICTA), eight of the included studies
deviations (at baseline or final) was unavailable, then one was reported the types of needles used, including the diameter
substituted for the other if it was reasonable to assume that and length as well as the manufacturer and/or the material,
the intervention did not alter the variability of the outcome and the others reported only the types of needles. All of
measure [28]: the studies were based on acupuncture point selection in
traditional acupuncture theory. Various acupoints were used
for decreasing preoperative anxiety in the included RCTs;
SD = √(SD1 2 + SD2 2 − 2𝑅corr SD1 SD2 ) . (1)
the third eye (Yin-Tang), located between the two eyebrows,
was commonly used in six trials, and the relaxation auricular
We considered a 30% greater reduction in STAI and point, located in the superior lateral wall of the triangular
VAS scores following acupuncture treatment, relative control fossa, was also used in six trials. Needle stimulation was
conditions, to be clinically relevant [29, 30]. Our meta- administered manually in four RCTs and electronically (2 Hz
analysis employed a random-effects model, which assumes 25 V) in one RCT. Two studies reported “de qi” sensations,
that effects estimated across different studies are not identical. where reportage of such was recommended. These data are
If there was significant heterogeneity, however, then a fixed- reported in the STRICTA recommendations [33]. Character-
effects model was applied. Concerning statistically significant istics of all included studies are provided in Table 1.
differences in side effects, “number needed to harm” (NNH) The 14 included studies exhibited various degrees of
values were calculated. Forest plots were used to graphically bias susceptibility (Figures 2 and 3). The agreement rate,
represent and evaluate treatment effects. Funnel plots of as measured using Cohen’s kappa, was 0.8 [32]. Only six
effects estimates against standard error were generated if a studies reported concealed allocation; the other six described
sufficient number of studies for each treatment regimen was a method of adequate randomization, although the word
available [31]. “randomization” appeared in all of the articles. Thirteen
A sensitivity analysis was performed in order to identify studies prevented blinding of the participants. Participants
sources of heterogeneity and ensure the stability of results. in these studies had no previous experience of acupuncture.
We excluded studies with two or more unclear biases or a According to STRICTA, two studies enquired after patients’
high risk of bias for any of the risks in key bias domains. An beliefs as a group: there were no significant differences [20,
additional sensitivity analysis was performed where sample 24].
sizes exceeded 100.
Studies were combined in instances where statistical
heterogeneity was not evident. Heterogeneity was examined 3.2. STAI-S. A meta-analysis of six studies using the STAI-S
via the 𝐼2 -test, where 𝐼2 values of 50% or more were indicative to examine state anxiety in 378 participants revealed signifi-
of significant heterogeneity. cantly lower state anxiety levels in participants who received
real versus sham acupuncture interventions (MD = 5.63, 𝑃 <
3. Results .00001, 95% CI [4.14, 7.11], Figure 4(a)). This was expressed
in mean group differences in pre- and postintervention STAI-
3.1. Study Description. An initial search identified 206 poten- S scores. A random-effects model was used in the analysis,
tially relevant articles, of which 14 (𝑁 = 1,034) met our and statistical heterogeneity was not observed across the
inclusion criteria and were thus added to the final analysis. studies (𝐼2 = 0%). Regarding studies distinguishing between
4 Evidence-Based Complementary and Alternative Medicine

206 records identified through

database searching
76 MEDLINE
35 CENTRAL
84 EMBASE
11 CINAHL
172 of records excluded
64 duplications
6 animal studies
13 reviews
34 full-text articles 89 not related to subject
assessed for eligibility

20 full-text articles excluded with reasons

3 duplications
4 no placebo control group
3 participants not scheduled for surgery
2 no acupuncture interventions
1 different type of outcome
2 no relevant data
5 study objectives did not match, no
relevant data
14 studies included in
systematic review

13 studies included in
1 study had insufficient data
meta-analysis

Figure 1: Flow chart for included studies.

adults and children, a significant reduction in scores was (𝐼2 = 86%). Two studies reported significant decreases
observed in five studies that measured STAI-S scores in adults in preoperative anxiety following acupuncture treatment
(MD = 5.93, 𝑃 < .00001, 95% CI [4.31, 7.54]). Similarly, versus nontreatment (MD = 27.34, 𝑃 < .00001, 95%
a significant reduction was found in one study measuring CI [18.07, 36.61]). These data were statistically significant,
STAI-S scores in children (STAI-C, MD = 3.94, 𝑃 = .04, based on the 𝑃 value and the width of the CI, and the
95% CI [0.13, 7.75]). The width of the CI and the 𝑃 value mean difference was closer to clinical significance in the
suggested that these data were statistically sufficient to allow acupuncture-treated group relative to the control group;
for a conclusion; however, the reduction in the mean change however, the sample size was small (𝑛 = 88). A sensitivity
in STAI-S scores did not reach clinical significance [34, 35]. analysis was performed for two of the included studies [23,
When restricting the analysis to studies with 100 or more 25] in order to investigate the source of their heterogeneity.
participants, acupuncture treatment was still associated with Acupuncture’s association with reduced preoperative anxiety,
significantly decreased preoperative anxiety [24] (MD = 5.2, in comparison to sham acupuncture, remained in place (MD
𝑃 = .006, 95% CI [1.51, 8.89]). A sensitivity analysis, which = 34.59, 𝑃 < .00001, 95% CI [26.68, 42.51]) following the
removes studies with lower-quality methodologies, was not exclusion of studies with lower-quality methodologies, where
performed for any of the included studies. this exclusion also improved the homogeneity of results (𝐼2 =
0%). Although the MD was based on more than 30 VAS
change scores, it should not be considered conclusive in light
3.3. VAS. We identified eight studies (𝑛 = 495) that employed of the small sample size (𝑛 = 136).
VAS measurements. The pooled analysis demonstrated that
acupuncture interventions led to greater reductions in VAS
anxiety relative to sham acupuncture (MD = 19.23, 𝑃 < 3.4. Subgroup Analysis. For both types of acupuncture instru-
.00001, 95% CI [16.34, 22.12], Figure 4(b)). A fixed-effects ment (needles and beads), acupoint location (body versus
model was used owing to the heterogeneity of the results ear) had no impact on the primary outcome measure of
 Table 1: Characteristics of included studies.
Type of intervention
Subject age Number of participants Outcome measure Adverse events
Author (year, location) Surgery Type of design (duration, side, and type Treated acupoints Type of control group
(years) (Acua /Shamb /Conc 1/Con2) reported (𝑃value) reported (𝑛)
of stimulation)
Elective ambulatory
surgery (orthopedic,
gynecologic, Auricular acupressure Relaxation (1) Traditional Chinese
Wang et al. (2001,
19–66 91 (31/32/27) genitourinary, RCTd needle (30 min, Tranquilizer medicine group STAIe (.01) NRf
USA) [19]
otolaryngologic, nondominant hand side) Mmaster cerebral (2) Sham acupuncture
plastic, general
ophthalmologic)
Auricular acupressure
needle (dominant, (1) Sham auricular
30 min) Relaxation acupressure, no PONVg -acu (4%)
Wang et al. (2007, Elective lithotripsy
18–65 56 (29/27) RCT Bilateral body valium, master electrical stimulation, STAI (.029) con (15%)
USA) [20] procedure
acupuncture with 2 Hz, cerebral, k LI4, l LV3 superficial insertion in 𝑃 = .412
25 V electrical the same locations
stimulation
General anesthesia for
Wang et al. (2008, GI endoscopy (upper Acupressure beads PONV-acu (5) con
8–17 52 (26/26) RCT Yin Tang (1) Sham acupressure STAIC (.012)
USA) [18] endoscopy and (30 min) (8)
Evidence-Based Complementary and Alternative Medicine

colonoscopy)
Paraskeva et al. (2004, Minor or moderate
NR 49 (25/24) RCT Acupuncture (15 min) Yin Tang (1) Sham acupuncture VSSh (NS) NR
Greece) [15] surgery
Body acupuncture
(20 min, dominant) LI4, LV3 m PC6,
Gioia et al. (2006, Cataract surgery under n (1) Nontreatment
71.3 (mean age) 75 (25/25/25) RCT Auricular (manually HT7 o TE5 VASi (.037) NR
Italy) [21] topical anesthesia (2) Sham acupuncture
rotated De Qi) Shenmen
acupuncture
Bilateral body
Elective diagnostic acupuncture and p
Cabrini et al. (2006, LU7, PC6 LI4, HT7 (1) Nontreatment
18+ 48 (16/16/16) fiberoptic RCT auricular (20 min, VAS (.002) None
Italy) [22] Shenmen (2) Sham acupuncture
bronchoscopy manually rotated De Qi)
acupuncture
(1) Placebo auricular
Relaxation acupuncture Nasal burning (7)
Karst et al. (2007, Acupuncture STAI (<.001)
18–65 67 (19/19/19/10) Dental extractions RCT Tranquilizer (2) Intranasal None in the other
German) [10] (nondominant, 25 min) VAS (.012)
Master cerebral midazolam groups
(3) Nontreatment
Transported by Bilateral auricular
Mora et al. (2007,
65–90 100 (50/50) ambulance before RCT acupressure (NR, 1 mm Relaxation (1) Sham acupressure VAS (.001) NR
German) [23]
receiving ESWL plastic ball)
Relaxation
Michalek-Sauberer et Auricular acupuncture (1) Sham acupuncture Acupuncture (14),
18+ 182 (61/60/61) Dental treatment RCT Tranquilizer STAI (.008)
al. (2012, Austria) [24] (20 min, dominant) (2) Nontreatment Sham (12)
Master cerebral
Auricular acupuncture
Acar et al. (2013, General/regional
18–65 52 (26/26) RCT (20 min, ear-press Yin Tang (1) Sham acupressure STAI (<.05) NR
Turkey) [14] anesthesia
needle)
5
 6

Table 1: Continued.
Type of intervention
Subject age Number of participants Outcome measure Adverse events
Author (year, location) Surgery Type of design (duration, side, and type Treated acupoints Type of control group
(years) (Acua /Shamb /Conc 1/Con2) reported (𝑃value) reported (𝑛)
of stimulation)
Transported by
Kober et al. (2003, Bilateral auricular
23–89 36 (17/19) ambulance for RCT Relaxation (1) Sham acupressure VAS (.002) NR
Austria) [25] acupressure (NR)
gastrointestinal illness
Acupressure (10 min,
Agarwal et al. (2005, Elective surgical
18–50 76 (36/36) RCT 20–25 cyc/min manually Yin Tang (1) Sham acupressure VSS (<.001) NR
India) [8] procedure
rotated)
Borimnejad et al. Acupressure (30 min,
9–12 80 (40/40) Elective surgery RCT Yin Tang (1) Sham acupressure STAIC (NSj ) NR
(2012, China) [16] 1.3 psi acupressure bead)
Abdominal surgery Acupressure (10 min,
(cholecystectomy, nondominant,
Valiee et al. (2012, 44.04 ± 11.25 Shenmen
70 (35/35) hysterectomy, RCT 20–25 cyc/min, (1) Sham acupressure VAS (<.001) NR
Iran) [17] (mean age) Yin Tang
herniorrhaphy, acupressure bead)
laparoscopy) Auricular acupressure
a
Acu: acupuncture; b Sham: sham acupuncture; c Con: control group; d RCT: randomized controlled trials; e STAI: the State-Trait Anxiety Inventory; f NR: not reported; g PONV: postoperative nausea and vomiting;
h
VSS: verbal-scale score; i VAS: visual analogue scale; j NS: not significant; k LI: large intestine; l LV: liver; m PC: pericardium; n HT: heart; o TE: triple energizer; p LU: lung.
Evidence-Based Complementary and Alternative Medicine
Evidence-Based Complementary and Alternative Medicine 7

Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Other biases

0 25 50 75 100
(%)
Low risk of bias
Unclear risk of bias
High risk of bias

Figure 2: Risk of bias. Each risk of bias item presented as percentages across all included studies.
Blinding of participants and personnel (performance bias)

preoperative anxiety. Publication bias was reported via Begg’s

funnel plot (Figure 5), where asymmetry of the plots may
have arisen through publication bias and the relationship
Blinding of outcome assessment (detection bias)

between trial size and effect size.

Random sequence generation (selection bias)

Incomplete outcome data (attrition bias)

3.5. Secondary Outcomes. For exploratory purposes, addi-

Allocation concealment (selection bias)

tional analyses of secondary outcomes were performed for

Selective reporting (reporting bias)

physiological variables (HR, BIS, and BP). Six studies mea-

sured heart rate before and after intervention; none of these
reported a significant difference between the acupuncture
and sham groups [10, 21–23, 25, 36]. Two studies also reported
no significant difference in blood pressure [17, 23]. No signif-
icant changes in BIS scores were observed between groups in
Other biases

four studies [8, 14, 15, 18]; one of these also reported that BIS
values did not differ between the groups before, during, or
after acupuncture, but, during acupuncture, BIS scores were
significantly lower in the group receiving acupuncture but
Agarwal et al. (2005, India) + + + + − + −
not in the placebo group [15]. In contrast to the significant
Acar et al. (2013, Turkey) + ? + + ? + −
reductions seen for the primary outcome measure of anxiety,
Cabrini et al. (2006, Italy) ? ? − − ? − + no significant difference in physiological measurements was
Gioia et al. (2006, Italy) ? ? − − ? + + identified.
Karst et al. (2007, Germany) + ? − − ? + −
Kober et al. (2003, Austria) ? + + + + + + 3.6. Side Effects. Among studies reporting adverse events,
Borimnejad et al. (2012, China) ? ? + + ? − + two found no adverse events in either the acupuncture or
Michalek-Sauberer et al. (2012, Austria) + + − − + + − sham acupuncture groups, relative to the control group, for
Mora et al. (2007, Germany) ? + + + + + + which a burning sensation in response to intranasal medi-
Paraskeva et al. (2004, Greece) ? + ? ? ? + + cation was reported in 32.6% of the participants (NNH = 7)
Valiee et al. (2012, China) + ? + + ? + − [10, 22]. Two RCTs reported PONV in both the intervention
Wang et al. (2001, USA) ? ? + + ? + + and control groups, but with no significant differences in rate
Wang et al. (2007, USA) ? + + + + + − of occurrence (OR = 0.42, 𝑃 = 0.13, 95% CI [0.14, 1.29])
Wang et al. (2008, USA) + ? + + ? + + [18, 20]. Ear warmth and peculiar sensations and dizziness
were reported in only one study, but there was no significant
+: low risk of bias difference in occurrence rates between groups (Figure 4(c))
−: high risk of bias [24].
?: unclear risk of bias

Figure 3: Methodological quality summary. Methodological quality 3.7. Patient Satisfaction. Two of the included studies inves-
indices for all included studies. “+” = low risk of bias, “−” = high risk tigated patient satisfaction via VAS scales (0–10 points) [20]
of bias, and “?” = unclear risk of bias. and discontinuous numeric scales (from 1 to 5) [10]; no
8 Evidence-Based Complementary and Alternative Medicine

Real acupuncture Sham acupuncture Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
3.1.1 STAI
Acar et al. (2013, Turkey) 3.49 9.588217 26 0.88 9.219431 26 8.5% 2.61 [−2.50, 7.72]
Karst et al. (2007, Germany) 6.94 9.463472 19 4.11 12.37298 19 4.5% 2.83 [−4.17, 9.83]
Michalek-Sauberer et al. 8.7 10.60566 61 3.5 10.10149 60 16.2% 5.20 [1.51, 8.89]
(2012, Austria)
Wang et al. (2001, USA) 11 10.58301 32 5 13.52775 27 5.6% 6.00 [−0.28, 12.28]
Wang et al. (2007, USA) 5 3.605551 29 −2 4.358899 27 49.9% 7.00 [4.90, 9.10]
Subtotal (95% CI) 167 159 84.7% 5.93 [4.31, 7.54]
Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 3.52; df = 4 (P = 0.48); I2 = 0%
Test for overall effect: Z = 7.20 (P < 0.00001)

3.1.2 STAIC
Borimnejad et al. 0 8.54 40 2.32 8.797744 40 Not estimable
(2012, China)
Wang et al. (2008, USA) 3.24 7 26 −0.7 7 26 15.3% 3.94 [0.13, 7.75]
Subtotal (95% CI) 26 26 15.3% 3.94 [0.13, 7.75]
Heterogeneity: not applicable
Test for overall effect: Z = 2.03 (P = 0.04)

Total (95% CI) 193 185 100.0% 5.63 [4.14, 7.11]

Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 4.41; df = 5 (P = 0.49); I2 = 0%
Test for overall effect: Z = 7.42 (P < 0.00001) −20 −10 0 10 20
Test for subgroup differences: 𝜒2 = 0.89; df = 1 (P = 0.35); I2 = 0% Favors [control] Favors [acupuncture]

(a)

Real acupuncture Control Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, fixed, 95% CI IV, fixed, 95% CI
3.2.1 acupuncture versus sham acupuncture
Agarwal et al. (2005, India) 30 10 38 10 10 38 37.6% 20.00 [15.50, 24.50]
Cabrini et al. (2006, Italy) 26.7 21.96657 16 −0.4 24.89518 16 2.9% 27.00 [10.83, 43.37]
Gioia et al. (2006, Italy) 30 18.68154 25 3 17.34935 25 7.6% 27.00 [17.01, 36.99]
Karst et al.
12.2 26.94958 19 11.5 28.78819 19 2.4% 0.70 [−17.03,18.43]
(2007, Germany)
Kober et al. (2003, Austria) 25.2 18.01444 17 −4.2 28.11423 19 3.3% 29.40 [14.13, 44.67]
Mora et al.
42.2 18.91137 50 5.7 27.5229 50 8.9% 36.50 [27.24, 45.76]
(2007, Germany)
Paraskeva et al.
10 20 25 20 20 24 6.1% −10.00 [−21.20, 1.20]
(2004, Greece)
Valiee et al. (2012, China) 22 12.36487 35 6.1 12.40121 35 22.6% 15.90 [10.10, 21.70]
Subtotal (95% CI) 225 226 91.2% 19.23 [16.34, 22.12]
Heterogeneity: 𝜒2 = 50.03; df = 7 (P < 0.00001); I2 = 86%
Test for overall effect: Z = 13.06 (P < 0.00001)

3.2.1 acupuncture versus nontreatment

Gioia et al. (2006, Italy) 30 18.68154 25 −4 21.93171 25 6.0% 34.00 [22.71, 45.29]
Karst et al. (2007, Germany) 12.2 26.94958 19 −1.4 24.01041 19 2.9% 13.60 [ −2.63, 29.83]
Subtotal (95% CI) 44 44 8.8% 27.34 [18.07, 36.61]
Heterogeneity: 𝜒2 = 4.09; df = 1 (P = 0.04); I2 = 76%
Test for overall effect: Z = 5.78 (P < 0.00001)

Total (95% CI) 269 270 100.0% 19.95 [17.19, 22.70]

Heterogeneity: 𝜒2 = 56.80, df = 9 (P < 0.00001); I2 = 84% −50 −25 0 25 50
Test for overall effect: Z = 14.19 (P < 0.00001)
Favors [control] Favors [acupuncture]
Test for subgroup differences: 𝜒2 = 2.68; df = 1 (P < 0.10); I2 = 62.7%

(b)

Figure 4: Continued.
Evidence-Based Complementary and Alternative Medicine 9

Acupuncture Control Odds ratio Odds ratio

Study or subgroup Weight
Events Total Events Total M-H, random, 95% CI M-H, random, 95% CI
Karst et al. (2007, Germany) 0 19 0 19 Not estimable
Cabrini et al. (2006, Italy) 0 16 0 0 Not estimable
Wang et al. (2007, USA) 1 29 4 27 12.5% 0.21 [0.02, 1.97]
Wang et al. (2008, USA) 5 26 8 26 32.5% 0.54 [0.15, 1.93]
Michalek-Sauberer et al. 14 61 12 60 55.0% 1.19 [0.50, 2.84]
(2012, Austria)
Total (95% CI) 151 132 100.0% 0.74 [0.32, 1.71]
Total events 20 24
Heterogeneity: 𝜏2 = 0.14; 𝜒2 = 2.58; df = 2 (P = 0.27); I2 = 23% 0.01 0.1 1 10 100
Test for overall effect: Z = 0.71 (P = 0.48) Favors [sham] Favors [acupuncture]

(c)

Figure 4: Forest plot of acupuncture efficacy in reducing preoperative anxiety. (a) STAI acupuncture versus sham acupuncture. (b) VAS
acupuncture versus control groups. (c) Side effect acupuncture versus sham acupuncture. The term “STAIC” in part (a) indicates the State
Anxiety Subscale of the State-Trait Anxiety Inventory in children. The term “events” in part (c) indicates the number of patients who reported
adverse events including PONV. “Weight” refers to the contribution of each study to the side effects total.

0 0

1 2

2 4
SE (MD)
SE (MD)

3 6

4 8

5 10
−10 −5 0 5 10 −50 −25 0 25 50
MD MD
Subgroups Subgroups
STAI Acupuncture versus sham acupuncture
STAIC Acupuncture versus nontreatment
(a) (b)

Figure 5: Funnel plot of the mean difference (MD) in anxiety ratings between acupuncture treatment and control groups, versus standard
error (SE).

significant group differences were observed (MD = 0.38, 𝑃 = of RCTs conducted concerning acupuncture’s efficacy in
.31, 95% CI [−0.35, 1.12]). reducing preoperative anxiety. Moreover, no restrictions were
Another study investigated the comfort level associated applied for age or language, and several literature databases
with acupuncture treatment according to a dichotomous were searched via a comprehensive strategy. A previous
scale comprising “good” or “other” ratings; again, there were meta-analysis indicated that acupuncture treatment reduces
no significant differences (OR = 0.88, 𝑃 = .81, 95% CI postoperative pain and is associated with a lower incidence
[0.30, 2.59]) [24]. Two other studies investigated discomfort of nausea among PONV cases [37]. However, the sample was
according to VAS scale ratings (0–100 points) and reported restricted to adults and there was wide variability in the type
that discomfort was higher in control groups (MD = −12.08,
and timing of acupuncture regimens applied and the duration
𝑃 < .00001, 95% CI [−14.2, −10.13], Figure 6) [21, 22].
and number of treatment sessions.
Acupuncture was generally associated with greater reduc-
4. Discussion tions in anxiety prior to surgery relative to control (nontreat-
This meta-analysis demonstrates that acupuncture therapy, ment) and sham treatment conditions. Based on the findings
administered in isolation, can decrease preoperative anxiety of the current meta-analysis, all varieties of acupuncture
in patients with scheduled surgery. To our knowledge, there therapy, delivered in isolation to patients on the day of
have been no other systematic reviews or meta-analyses surgery, are effective.
10 Evidence-Based Complementary and Alternative Medicine

Acupuncture Sham Mean difference Mean difference

Study or subgroup Weight
Mean SD Total Mean SD Total IV, random, 95% CI IV, random, 95% CI
5.1.1 satisfaction
Karst et al. (2007, Germany) 9.4 1.5 19 8.52 1.74 19 31.1% 0.88 [−0.15, 1.91]
Wang et al. (2007, USA) 9.9 1.2 29 9.8 1.3 27 31.4% 0.10 [−0.56, 0.76]
Subtotal (95% CI) 48 46 62.5% 0.38 [−0.35, 1.12]
Heterogeneity: 𝜏2 = 0.11; 𝜒2 = 1.56; df = 1 (P = 0.21); I2 = 36%
Test for overall effect: Z = 1.02 (P = 0.31)

5.1.2 discomfort
Cabrini et al. (2006, Italy) 44.2 23.7 16 61.7 24 16 7.4% −17.50 [−34.03,−0.97]
Gioia et al. (2006, Italy) 19 3 25 31 4 25 30.1% −12.00 [−13.96,−10.04]
Subtotal (95% CI) 41 41 −10.13]
37.5% −12.08 [−14.02 ,−
Heterogeneity: 𝜏2 = 0.00; 𝜒2 = 0.42; df = 1 (P = 0.52); I2 = 0%
Test for overall effect: Z = 12.16 (P < 0.00001)

Total (95% CI) 89 87 100.0% −4.60 [−9.72, 0.52]

Heterogeneity: 𝜏2 = 21.63; 𝜒2 = 146.23; df = 3 (P < 0.00001); I2 = 98%
Test for overall effect: Z = 1.76 (P = 0.08) −20 −10 0 10 20
Test for subgroup differences: 𝜒2 = 137.76; df = 1 (P < 0.00001); I2 = 99.3% Favors [sham] Favors [acupuncture]

(a)

Acupuncture Sham Odds ratio Odds ratio

Study or subgroup Weight
Events Total Events Total M-H, random, 95% CI M-H, random, 95% CI
Michalek-Sauberer et al. 53 61 53 60 100.0% 0.88 [0.30, 2.59]
(2012, Austria)
Total (95% CI) 61 60 100.0% 0.88 [0.30, 2.59]
Total events 53 53
Heterogeneity: not applicable
Test for overall effect: Z = 0.24 (P = 0.81) 0.002 0.1 1 10 500
Favors [sham] Favors [acupuncture]

(b)

Figure 6: Forest plot depicting various outcomes for postsurgical patient satisfaction. (a) VAS (satisfaction and discomfort after surgery). (b)
Number of patients reporting a “good” level of treatment satisfaction.

Karst et al. [10] compared the effects of pharmaceutical our meta-analysis, two studies included participants under
agents and acupuncture for preoperative stress. They con- the age of 18, for whom the STAI-C, which was used in both
cluded that, although the number of studies included was studies, is considered the gold standard in the assessment
insufficient for meaningful analysis, auricular acupuncture of anxiety in children older than 6 years of age. This ques-
and intranasal midazolam were similarly effective for the tionnaire is well validated, has been used in more than 1,000
treatment of anxiety. studies [44], is easy to read, and can be administrated verbally.
Griffiths et al. [38] assessed the efficacy of interventions Although there are no data regarding the issue of clinical
(pharmacological and nonpharmacological, including acu- significance in the pediatric anxiety literature, we found that a
pressure therapy) aiming to prevent nausea and vomiting minimum difference of 10% in state anxiety levels, as assessed
in women undergoing regional anesthesia for a caesarean by the adult version of the STAI-S, is considered clinically
section. Acupressure was only found to be effective for significant [34, 35]. Borimnejad et al. [16] reported significant
intraoperative nausea and was not effective for postoperative differences not for an acupuncture-treated group but for a
nausea or vomiting. Their review was specifically concerned sham treatment group.
with pregnancy-related underlying risk factors for nausea and The present review has several limitations. The small
vomiting. number of included trials did not allow for the performance
Some reviews have reported on studies involving infants of a metaregression examining all of the possible predictors
and children. Several studies found no significant statistical together, given the suggested threshold of 14 studies required
or clinical differences in the efficacy of nonpharmacological per predictor [28]. The small number of included studies
methods, such as parental acupuncture versus sedative pre- also resulted in wide CIs for the pooled results of many
medications [39–41]. The effects of parental acupuncture on of the reported outcomes, thereby rendering the drawing
children’s anxiety remain unclear and were not evaluated in of definitive conclusions difficult. In addition, we could
this study. Assuming that acupuncture reduces preoperative not combine all of the results of the STAI-S in children
anxiety, the potential mechanisms of action may be similar owing to insufficient data, where postintervention anxiety
to those previously documented for acupuncture [42, 43]. In scores in acupuncture treatment groups were occasionally not
Evidence-Based Complementary and Alternative Medicine 11

provided; in some instances, attempts to contact authors were patient anxiety,” Regional Anesthesia and Pain Medicine, vol. 24,
also unsuccessful. Despite a general lack of relevant data, we no. 2, pp. 158–164, 1999.
did not exclude data in an effort to avoid publication bias. [7] P. F. White, “Pharmacologic and clinical aspects of preoperative
Even when considering the caveats described above, medication,” Anesthesia & Analgesia, vol. 65, no. 9, pp. 963–974,
our analyses support the possibility that acupuncture treat- 1986.
ment is able to reduce preoperative anxiety better than [8] A. Agarwal, R. Ranjan, S. Dhiraaj, A. Lakra, M. Kumar,
sham acupuncture. Clinically important differences were and U. Singh, “Acupressure for prevention of pre-operative
observed in the reduction of preoperative anxiety between anxiety: a prospective, randomised, placebo controlled study,”
acupuncture-treated and control (nontreatment) conditions, Anaesthesia, vol. 60, no. 10, pp. 978–981, 2005.
although the overall sample size was small. The findings of [9] C. Zollman and A. Vickers, “ABC of complementary medicine:
our analyses are clinically important, in which the results users and practitioners of complementary medicine,” British
support the proposition that acupuncture is beneficial in Medical Journal, vol. 319, no. 7213, pp. 836–838, 1999.
reducing preoperative anxiety. Based on this assumption, [10] M. Karst, M. Winterhalter, S. Münte et al., “Auricular acupunc-
potential mechanisms of action may be similar to those ture for dental anxiety: a randomized controlled trial,” Anesthe-
documented in the acupuncture literature [42, 45]. sia and Analgesia, vol. 104, no. 2, pp. 295–300, 2007.
Our study has identified some areas in which further [11] J. A. Astin, “Why patients use alternative medicine: results of
research on acupuncture treatment is warranted. For exam- a national study,” Journal of the American Medical Association,
ple, it remains unclear as to whether there is a difference in vol. 279, no. 19, pp. 1548–1553, 1998.
the efficacy of acupuncture therapy versus conventional pre- [12] B. M. Berman, L. Lao, P. Langenberg, W. L. Lee, A. M. K.
medication treatments. Additional studies are also required Gilpin, and M. C. Hochberg, “Effectiveness of acupuncture as
in order to establish objective assessment methods and ideal adjunctive therapy in osteoarthritis of the knee. A randomized,
techniques for blinding. controlled trial,” Annals of Internal Medicine, vol. 141, no. 12, pp.
901–910, 2004.
[13] R. Zhang, L. Lao, K. Ren, and B. Berman, “Mechanisms of
5. Conclusion acupuncture—electroacupuncture on persistent pain,” Anesthe-
siology, vol. 120, no. 2, pp. 482–503, 2014.
In conclusion, this meta-analysis suggests that acupuncture
[14] H. V. Acar, Ö. Cuvaş, A. Ceyhan, and B. Dikmen, “Acupuncture
therapy aiming at reducing preoperative anxiety has some on yintang point decreases preoperative anxiety,” Journal of
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context. Fassoulaki, “Needling of the extra 1 point decreases BIS values
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Conflict of Interests
[16] L. Borimnejad, N. Arbabi, N. Seydfatemi, M. Inanloo, and H.
The authors declare that there is no conflict of interests Haghanii, “The effects of acupressure on preoperative anxiety
regarding the publication of this paper. reduction in school aged children,” HealthMED, vol. 6, no. 7,
pp. 2359–2361, 2012.
[17] S. Valiee, S. S. Bassampour, A. N. Nasrabadi, Z. Pouresmaeil,
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