J Acupunct Meridian Stud 2017;10(3):165e170
Available online at www.sciencedirect.com
Journal of Acupuncture and Meridian Studies
journal homepage: www.jams-kpi.com
RESEARCH ARTICLE
Effectiveness of Acupuncture Therapy on
Stress in a Large Urban College Population
Stefanie Schroeder*, James Burnis, Antony Denton,
Aaron Krasnow, T.S. Raghu, Kimberly Mathis
ASU Health Services, Arizona State University, Tempe, AZ, USA
Available online 16 January 2017
Received: Aug 3, 2016 Abstract
Revised: Jan 5, 2017 This study is a randomized controlled clinical trial to study the effectiveness of acupunc-
Accepted: Jan 6, 2017 ture on the perception of stress in patients who study or work on a large, urban college
campus. The hypothesis was that verum acupuncture would demonstrate a significant
KEYWORDS positive impact on perceived stress as compared to sham acupuncture.
acupuncture; This study included 111 participants with high self-reported stress levels who either
college students; studied or worked at a large, urban public university in the southwestern United States.
liver qi stagnation; However, only 62 participants completed the study.
stress The participants were randomized into a verum acupuncture or sham acupuncture
group. Both the groups received treatment once a week for 12 weeks. The Cohen’s global
measure of perceived stress scale (PSS-14) was completed by each participant prior to
treatment, at 6 weeks, at 12 weeks, and 6 weeks and 12 weeks post-treatment comple-
tion.
While participants of both the groups showed a substantial initial decrease in perceived
stress scores, at 12 weeks post treatment, the verum acupuncture group showed a signif-
icantly greater treatment effect than the sham acupuncture group.
This study indicates that acupuncture may be successful in decreasing the perception
of stress in students and staff at a large urban university, and this effect persists for at
least 3 months after the completion of treatment.
* Corresponding author. Arizona State University, Health Services, Post-office Box 872104, Tempe, AZ 85287, USA.
E-mail: [email protected] (S. Schroeder).
pISSN 2005-2901 eISSN 2093-8152
http://dx.doi.org/10.1016/j.jams.2017.01.002
ª 2017 Medical Association of Pharmacopuncture Institute, Publishing services by Elsevier B.V. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
166 S. Schroeder et al.
1. Introduction 2.2. Measures
Stress is a part of every person’s life, and the link between Each participant completed the Cohen’s global measure of
stress and negative outcomes is well established [1,2]. A perceived stress questionnaire [8] at five stages:
population of particular interest in stress and coping (Fig. 1)
research are college students. College, for many students,
includes a perfect storm of developmental and social 1) Prior to treatment
challenges and task-specific stressors (e.g., increased aca- 2) at 6 weeks
demic rigor). Research by the American College Health 3) at 12 weeks, at the completion of treatment
Association’s National College Health Assessment indicates 4) 6 weeks post completion and
that in 2015, 42.8% students reported more than average 5) 3 months post completion of treatment.
stress in the past 12 months, with 10.7% reported being
under tremendous stress [3]. Furthermore, 30% of college The treatment group received conventional and auric-
students reported that stress had negatively impacted ac- ular acupuncture consisting of needle placement at a pre-
ademic performance, and 76% of students reported feeling determined set of point:
overwhelmed with all they had to do [3]. Thus, treatment GV 20, HT 7, PC 6, Yintang, Four Gates, CV 17, CV 6, ST
providers of all types in collegiate health are much 36 inserted unilaterally and auricular points: Shen Men,
warranted. Liver, Point 0, and Heart.
One type of treatment that has heretofore been The second group (control group) received sham
understudied is the effectiveness of acupuncture on college acupuncture into three points on the body that are located
student stress and coping. While a few studies have in between meridians and not known to have any effect on
examined acupuncture and stress [4e6], none have exam- stress. Needles were inserted unilaterally and without
ined stress in a collegiate health care setting. The basis of stimulation or manipulation to avoid the needling sensation
stress in traditional Chinese medicine is commonly rooted known as de qi.
in the liver energy imbalance; this pattern of imbalance is Participants in both groups reported to the clinic once a
often referred to as liver qi stagnation. As stagnation builds week; needle retention was 30 minutes.
over time, individuals can experience a wide variety of Both groups received the same supportive interaction with
symptoms ranging from digestive disorders, such as irritable the practitioner, heated acupuncture tables, dimmed light,
bowel syndrome and chest distension (a feeling of fullness and soothing music in the rooms during the treatment phase.
in the chest), to menstrual disharmonies, such as dysmen- Acupuncture needles used were as follows: (1) DBC
orrhea, irregular menses, and premenstrual syndrome in Lhasa OMS Inc. Weymouth MA, Spring Ten Handle, sterile
the female population. Commonly, individuals with liver qi acupuncture needles with guide tube, size 0.22 30 mm;
stagnation experience emotional challenges including (2) Seirin Group B.V 230 Libbey Parkway Weymouth MA, D-
depression, anger, general agitation, and mood swings [7]. Type acupuncture needle No. 3, size 0.20 15 mm; and (3)
This study is an attempt to evaluate the effectiveness of Helio Medical Supplies Inc. San Jose CA, Vinco MicroClean
acupuncture in the perception of stress specifically in pa- acupuncture needle, size 0.20 7 mm.
tients who study or work on a large urban college campus
utilizing the underlying pathology of liver stasis. This 12-
week pilot study focuses to answer the following questions: 2.3. Participants
Will treatment of liver imbalance lead to a decreased stress
perception in our targeted population? Furthermore, if this The study participants included college students, faculty,
occurs, will we see a continuation of this perception when and staff at a large public university in the southwestern
the treatment is completed? In anecdotal practice, patients United States who self-identified as feeling stressed and
in collegiate acupuncture clinics report stress reduction by were interested in acupuncture (Table 1). Recruitment
approximately one-third of the previous stress level. For methods included: (1) primary care clinicians who identi-
this study, using that qualitative report as an overestimate, fied and informed the patients with stress about the trial
we hypothesized a 20% decrease in stress perception. and to contact the research nurse if interested; (2) flyers
were distributed to departments throughout the university,
which included residential Life, counseling center, the
2. Methods Department of Psychology’s training clinic, and by dis-
playing information about the study on video boards in the
entrance hall of the health center; and (3) information
2.1. Design regarding the study was included on the health services
website and on the university intranet login.
This was a two-group, randomized controlled trial. Partic- Potential participants were screened by completing the
ipants were block-randomized to either verum acupuncture Cohen’s global measure of perceived stress questionnaire
or sham acupuncture by the Research Nurse. The study was (Fig. 1). Participants who scored 16 on a scale of 0e56,
approved by the university’s institutional review board. All were aged 18 years, and had never received acupuncture
procedures were in accordance with the ethical standards treatment for stress prior to this study were eligible to
of the responsible committee on human experimentation. participate in the study.
Informed consent was obtained from all the participants Participants were excluded if they were aged < 18 years,
before being included in the study. had scores < 16, were pregnant, were unable to provide
Acupuncture Therapy on Stress 167
The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate how often you felt
or thought a certain way. Although some of the questions are similar, there are differences between them and you should treat each one as a separate
question. The best approach is to answer each question fairly quickly. That is, don't try to count up the number of times you felt a particular way, but
rather indicate the alternative that seems like a reasonable estimate. For each question choose from the following alternatives:
0. Never, 1. Almost Never, 2. Sometimes, 3. Fairly Often, 4. Very Often,
Almost Never
Fairly often
Very Often
Sometimes
Never
1. In the last month, how often have you been upset because of something
that happened unexpectedly?
2. In the last month, how often have you felt that you were unable to
control the important things in your life?
3. In the last month, how often have you felt nervous and "stressed"?
4. In the last month, how often have you dealt successfully with irritating
life hassles?
5. In the last month, how often have you felt that you were effectively
coping with important changes that were occurring in your life?
6. In the last month, how often have you felt confident about your ability to
handle your personal problems?
7. In the last month, how often have you felt that things were going your
way?
8. In the last month, how often have you found that you could not cope
with all the things that you had to do?
9. In the last month, how often have you been able to control irritations in
your life?
10. In the last month, how often have you felt that you were on top of
things?
11. In the last month, how often have you been angered because of things
that happened that were outside of your control?
12. In the last month, how often have you found yourself thinking about
things that you have to accomplish?
13. In the last month, how often have you been able to control the way you
spend your time?
14. In the last month, how often have you felt difficulties were piling up so
high that you could not overcome them?
Figure 1 A global measure of perceived stress.
consent, or underwent prior treatment for stress by using The duration of the treatment phase was 12 weeks
acupuncture. A power analysis calculated a sample size of 64 during which the subjects underwent weekly 30-minute
to be able to detect a 20% decrease in stress level. acupuncture sessions. The sessions were held in the Well-
ness wing of the University’s Health Services building,
2.4. Procedure which includes two acupuncture rooms. We enrolled par-
ticipants on a rolling basis over a 9-month period.
This was a randomized controlled trial. The acupuncture Each participant completed the Cohen’s global measure
practitioners knew the assignment (verum vs. sham of perceived stress questionnaire prior to treatment, at 6
acupuncture) but were unaware of the participants’ score weeks, at the completion of the treatment phase, 6 weeks
on the Cohen’s global measure of perceived stress. post completion, and 3 months post completion.
168 S. Schroeder et al.
Table 1 Demographic characteristics of the study groups. Table 3 Results of mixed model estimation. (n Z 369;
Age range (y) Female Male Both Wald Chi2 Z 423.89; p > Chi2 Z 0.00)
19e20 2 3 5 Coefficient (SE) z p > jzj
21e25 16 10 26 Acupuncture 1.33 (1.34) 1.00 0.320
26e30 24 5 29 Time
31e35 14 3 17 Week 6 11.11*** (1.22) 9.10 0.000
36e40 8 7 15 Week 12 13.94*** (1.32) 10.55 0.000
41e45 5 3 8 6 weeks post 10.30*** (1.34) 7.68 0.000
46e50 3 0 3 12 weeks post 8.18*** (1.34) 6.10 0.000
51e55 3 1 4 Interactions
56e60 2 2 4 Acu*Week 6 1.39 (1.65) 0.85 0.398
Total 77 34 111 Acu*Week 12 2.12 (1.76) 1.21 0.226
Staff 17 Acu*6 Week Post 4.28** (1.77) 2.42 0.015
Faculty 5 Acu*12 Week Post 5.68*** (1.76) 3.22 0.001
Student 89 Constant 34.47*** (0.95) 36.30 0.000
Total 111 *** p < 0.001; ** p < 0.05.
LR test vs. linear model: Chi2(01) Z 87.63 Prob >Z
Chi2 Z 0.0000.
2.5. Statistical analysis
The fixed effects estimate the coefficients of the
It was initially determined that 64 participants were neces- treatment effects and interactions over multiple mea-
sary to have enough statistical power for analysis. Of the 111 surements, i.e., the slope of the regression line. The
initially participants recruited, 21 never started the clinical random effects present an average deviation of the random
phase and 28 withdrew from the study, leaving 62 participants intercepts from the population mean and within subject
(Table 2). Subsequent statistical analyses indicated that 62 variance. In addition, we conducted Wilcoxon signed-rank
participants did allow for sufficient power for analysis. test for pre- and post-treatment effects for the two
We used a repeated-measures mixed model approach treatment groups. The first score (before receiving treat-
with both fixed and random effects. The estimation results ment) and the final score (3 months post completion) were
of the repeated-measures mixed model are presented in compared using the Wilcoxon signed-rank test. The pre-
Table 3. Based on the estimates in Table 3, contrast tests and post-treatment effects were significant for both the
for main and interaction effects indicate no significant main acupuncture conditions at p < 0.001 [z-score for sham
effect of treatment (Chi2 Z 1.41; p Z 0.23). Significant acupuncture was 3.473 (n Z 25); z-score for verum
main effect of time (Chi2 Z 392.7; p Z 0.001) and inter- acupuncture was 5.252 (n Z 37)].
action between treatment and time (Chi2 Z 12.75;
p Z 0.012) were observed. As observed in Table 3, the
interaction effects of acupuncture with 6 weeks and 12
3. Results
weeks post measurements were significant at p < 0.05.
There was no statistical difference between the sham and
verum acupuncture groups on PSS-14 scores pretreatment.
The mean pretreatment PSS-14 score was 34.4 in the sham
Table 2 Attrition rate and composition during study. group and 35.8 in the verum acupuncture group (t
Completed Never Withdrawn Total score Z 1.2; p Z 0.25); the median was 34 and 35,
started Rx respectively. At 6 weeks both groups’ scores dropped to
Acupuncture Female 24 7 8 39 23.5 or 31.7% for the sham group and 23.1 or 35.5% for the
Male 12 0 5 17 acupuncture group. By week 12, at the completion of the
Sub total Rx 36 7 13 56 treatment phase, the sham group’s score was 20.6, a 40.1%
Sham Female 18 9 11 38 decrease from the pretreatment score, and the acupunc-
Male 8 5 4 17 ture group’s score decreased to 19.4, a 45.8% decrease. The
Sub total 26 14 15 55 differences in the PSS-14 scores for the two groups were
Sham statistically significant at week 12 (t score Z 2.2; p < 0.05).
Total 62 21 28 111 However, pre- and post-treatment effects for both groups
Total 111 were statistically significant. The Wilcoxon signed-rank test
Recruited z-score was 3.5 (p < 0.001; n Z 25) for the sham group and
5.3 (p < 0.001; n Z 37) for the acupuncture group (Fig. 2).
Staff Students The decrease in stress level persisted after the
Completed 11 51 completion of treatment. At 6 weeks post completion of
Not Completed 11 38 the treatment, the sham and acupuncture groups had a
Total 22 89 mean score of 24.1 (29.9%) and 20.8 (41.9%), respectively.
Grand total 111 At 12 weeks post completion of treatment, the mean score
for the sham group was 26.2 (23.8%) and that for the
Acupuncture Therapy on Stress 169
Figure 2 Maintained stress reduction after intervention.
Figure 3 PSS-14 scores over the study period.
170 S. Schroeder et al.
acupuncture group was 21.4, which is a 40.2% decrease in been impossible to maintain for 12 weeks in this popula-
the perception of stress (Fig. 3). tion. We already had a high dropout rate because of the
The difference between verum acupuncture and sham weekly time commitment for our participants.
acupuncture was 18.3%. Stress is ubiquitous yet difficult to treat. This study is an
early step in examining the effectiveness of acupuncture in
4. Discussion a collegiate health environment and showed that
acupuncture may have a lasting beneficial effect on the
perception of stress, even beyond the conclusion of treat-
There was a 45.8% improvement in the perception of stress
ment. A randomized control trial of at least 640 students
in the verum acupuncture group at the conclusion of the
would be the definitive study in showing the beneficial ef-
treatment phase, similar to the sham acupuncture group,
fects of acupuncture on the perception of stress in a college
which showed a 40.3% difference. While both verum and
environment.
sham acupuncture patients showed a substantial initial
decrease in perceived stress scores, at 12 weeks post-
treatment, verum acupuncture showed a significantly Disclosure statement
greater treatment effect than sham acupuncture. After 3
months post completion, the mean PSS-14 score only The authors declare that they have no conflicts of interest
slightly increased and maintained a 40.2% decrease as and no financial interests related to the material of this
compared to the pre-treatment score. The sham group’s manuscript.
PSS-14 score went to a 24.1 % decrease from the pre-
intervention score.
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