Acupuncture as an optional treatment for hospice patients with xerostomia: an intervention study

Identifying Non-Traditional Approaches to Swallowing Rehabilitation: A Scoping Review

In recent years, dysphagia care has shifted toward a more patient-centered approach. This means that dysphagia clinicians are considering more factors in the treatment process including the goals of care, quality of life, and cultural values. The purpose of this scoping review was to examine relevant research and identify dysphagia interventions outside of those traditionally used by dysphagia clinicians that may improve swallowing function. A review of relevant studies was conducted using search terms related to swallowing and treatment. The search yielded 8439 unique studies. Of the 283 articles that underwent a full-text review, 37 articles were included in the final review. These articles highlighted three potential areas of non-traditional dysphagia intervention that may serve to provide holistic care, while also aiming to improve swallowing mechanisms: acupuncture and Eastern medicine interventions, vocal exercises, and physical function exercises. The results suggest that dysphagia clinicians should work collaboratively with other allied health professionals and consider non-traditional approaches to dysphagia care. Through the identification of potentially effective but non-traditional or non-Eurocentric interventions for dysphagia care, clinicians may promote a culturally relevant, patient-centered approach, in turn increasing patient acceptance of treatment plans and compliance. Future research should explore the efficacy and feasibility of these interventions in dysphagia rehabilitation, as well as their effectiveness compared to more traditional approaches.

Interventional Prospective Studies on Xerostomia in Patients Undergoing Palliative and End-of-Life Care: A Scoping Review

Patients undergoing palliative care often develop debilitating oral conditions, including xerostomia. These conditions may significantly impact patients' quality of life. Despite the high prevalence and adverse impact of xerostomia, effective management strategies remain unclear. This scoping review was performed to elucidate effective interventions for xerostomia in patients undergoing palliative and end-of-life care. A comprehensive search strategy was employed to identify relevant studies up to August 2023. Full-text primary articles focusing on xerostomia in patients receiving palliative care were included in the review. Eleven articles were selected for analysis, and data were extracted by six reviewers. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Among the 11 studies, interventions ranged from oral care to saliva substitutes and methods to stimulate saliva secretion. The primary method of assessing xerostomia was the performance of subjective evaluations using visual analog scale scores or numerical rating scale scores. Various interventions including oral care regimens, topical treatments, and mixed efficacy outcomes were reported. Notably, only one study directly measured the saliva volume, highlighting a reliance on subjective endpoints in most studies. Although no definitive conclusions can be drawn regarding the most effective intervention, oral care was a preferred option for managing xerostomia in patients undergoing palliative care. Additionally, adjunctive treatments such as ice cubes, saline, and moisturizers showed promise but require further investigation. Objective measures should be incorporated into future intervention trials to complement subjective assessments and provide a comprehensive evaluation of xerostomia management strategies in this patient population.

World Workshop on Oral Medicine VIII: Development of a Core Outcome Set for Dry Mouth: A Systematic Review of Outcome Domains for Xerostomia

OBJECTIVE

The purpose of this study was to identify all outcome domains used in clinical studies of xerostomia, that is, subjective sensation of dry mouth. This study is part of the extended project "World Workshop on Oral Medicine Outcomes Initiative for the Direction of Research" to develop a core outcome set for dry mouth.

STUDY DESIGN

A systematic review was performed on MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials databases. All clinical and observational studies that assessed xerostomia in human participants from 2001 to 2021 were included. Information on outcome domains was extracted and mapped to the Core Outcome Measures in Effectiveness Trials taxonomy. Corresponding outcome measures were summarized.

RESULTS

From a total of 34,922 records retrieved, 688 articles involving 122,151 persons with xerostomia were included. There were 16 unique outcome domains and 166 outcome measures extracted. None of these domains or measures were consistently used across all the studies. The severity of xerostomia and physical functioning were the 2 most frequently assessed domains.

CONCLUSION

There is considerable heterogeneity in outcome domains and measures reported in clinical studies of xerostomia. This highlights the need for harmonization of dry mouth assessment to enhance comparability across studies and facilitate the synthesis of robust evidence for managing patients with xerostomia.

Implementation and outcomes of complementary therapies in hospice care: an integrative review

Complementary therapies are increasingly integrated into hospice care, emphasizing the need to examine the evidence regarding implementation and effects on end-of-life outcomes. This review synthesizes the evidence regarding the implementation of complementary therapies and effects on end-of-life outcomes in hospice care. Whittemore and Knafl's five-step integrative review process was applied. Using predefined search terms, research-based articles between 2006 and 2020 were reviewed. Twenty-three quantitative/mixed method studies conducted across eight countries met the final review criteria. Most commonly used complementary therapies were music, biofield therapies (reiki, therapeutic touch), and massage therapy. Most studies reported significant findings on physical symptoms (pain, dyspnea, fatigue, gastrointestinal symptoms, agitation) and/or psychosocial/spiritual symptoms (anxiety, depression, spirituality, well-being, quality of life); 40% of studies had both significant and nonsignificant findings. Methodological limitations included study design (few randomized controlled trials), small sample size, high attrition rate, lack of racial/ethnic diversity, unstandardized intervention implementation, and multiple outcome measurement instruments. Complementary therapies are promising components of hospice care; however, rigorous studies are needed to validate the effect on end-of-life outcomes and determine the most efficacious implementation. Complementary therapy studies face challenges consistent with end-of-life research; however, efforts to design rigorous trials and address methodological issues are required to enhance the state of the science.

Perceptions That Influence Acupuncture Use in Hospice Settings: Results of a State-Wide Survey Study

Background: Acupuncture is an effective and low-risk therapy for a wide spectrum of medical conditions. In the hospice setting, where comfort is the top priority, acupuncture could play a vital role in reducing symptom burden at the end of life. Objective: This state-wide survey study explored perceived barriers to acupuncture use in the hospice setting from acupuncturist and hospice staff perspectives. Specific barriers addressed included insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture. Materials and Methods: Acupuncturists and hospice staff in Oregon were recruited by e-mail and/or telephone to complete their survey. Results: Among acupuncturists, a response rate of 50% was obtained. The response rate of hospice staff could not be obtained. There were a total of 270 providers and hospice staff (102 acupuncturists, 16 hospice doctors, 14 hospice directors, 93 hospice nurses, 30 hospice social workers, and 15 hospice chaplains). The majority of acupuncturists (76% and 89%, respectively) and hospice staff (59% and 82%, respectively) strongly agreed or somewhat agreed that insurance coverage/funding for acupuncture and lack of knowledge of acupuncture as a therapeutic modality are important barriers. With respect to the perceived evidence base for acupuncture, the majority of acupuncturists (91%) and hospice staff (69%) strongly agreed or somewhat agreed that acupuncture can help provide a higher quality of life for hospice patients, although knowledge of specific conditions amenable to acupuncture among acupuncturists and hospice staff varied. Conclusions: From the acupuncturist and hospice staff perspectives, insurance coverage/funding for acupuncture, lack of knowledge of acupuncture as a therapeutic modality, and perceived insufficient evidence base for acupuncture are primary barriers to the use of acupuncture in hospice care. Increased awareness/education about acupuncture in the hospice setting, as well as improved funding structures, is critical.

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

Oral health problems among palliative and terminally ill patients: an integrated systematic review

BACKGROUND

High incidence of treatable oral conditions has been reported among palliative patients. However, a large proportion of palliative patients lose their ability to communicate their sufferings. Therefore, it may lead to under-reporting of oral conditions among these patients. This review systematically synthesized the published evidence on the presence of oral conditions among palliative patients, the impact, management, and challenges in treating these conditions.

METHODS

An integrative review was undertaken with defined search strategy from five databases and manual search through key journals and reference list. Studies which focused on oral conditions of palliative patients and published between years 2000 to 2017 were included.

RESULTS

Xerostomia, oral candidiasis and dysphagia were the three most common oral conditions among palliative patients, followed by mucositis, orofacial pain, taste change and ulceration. We also found social and functional impact of having certain oral conditions among these patients. In terms of management, complementary therapies such as acupuncture has been used but not well explored. The lack of knowledge among healthcare providers also posed as a challenge in treating oral conditions among palliative patients.

CONCLUSIONS

This review is first in its kind to systematically synthesize the published evidence regarding the impact, management and challenges in managing oral conditions among palliative patients. Although there is still lack of study investigating palliative oral care among specific group of patients such as patients with dementia, geriatric or pediatric advanced cancer patients, this review has however provided baseline knowledge that may guide health care professionals in palliative settings.

Acupuncture for Radiation-Induced Xerostomia in Cancer Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Radiation-induced xerostomia is one of the most common symptoms experienced by cancer patients. The aim of our study is to evaluate the preventive and therapeutic effect of acupuncture for radiation-induced xerostomia in cancer patients.

METHODS

Eight databases were searched for all published randomized clinical trials (RCTs) on acupuncture for radiation-induced xerostomia in cancer patients up to December 31, 2019. Manual searching included other conference abstracts and reference lists. Meta-analysis was conducted using Revman V.5.3, and risks of bias for included studies was assessed following the Cochrane Handbook.

RESULTS

Eight clinical trials (725 participants) were analyzed, and 3 were included in a meta-analysis. All included trials had a high risk of bias, such as selection, performance, and detection bias. Analysis indicated favorable effects of acupuncture regarding the improvement of xerostomia symptoms (MD -3.05, P = 0.02, 95% CI -5.58 to -0.52), compared with sham acupuncture. There were no significant differences between real acupuncture and sham acupuncture regarding the stimulated salivary flow rate (MD 0.37, P = 0.08, 95% CI -0.05 to 0.79) and unstimulated salivary flow rate (MD 0.09, P = 0.12, 95% CI -0.02 to 0.21), which were whole salivary flow rate. Compared with no acupuncture (standard oral care, usual care, or no treatment), acupuncture produced a significant improvement in patient-reported xerostomia, without causing serious adverse effects. However, a Grading of Recommended Assessments analysis revealed that the quality of all acupuncture outcome measures was low.

CONCLUSION

The present meta-analysis and systematic review suggests that acupuncture is effective at improving xerostomia symptoms in cancer patients but not at objective salivary flow measurements. The evidence is still limited due to the low quality of the published studies.

Acupuncture for patients with cancer-induced xerostomia: a systematic review protocol

INTRODUCTION

Xerostomia is a common symptom in patients with cancer. Currently available methods to manage xerostomia include stringent oral hygiene using fluoride agents and antimicrobials, saliva substitutes and sialagogic agents, but side effects such as headache, dizziness and sweating can occur with these therapies. Clinical trials have shown that acupuncture may be effective in treating xerostomia. The objective of this systematic review is to assess the effectiveness and safety of acupuncture treatment for xerostomia caused by cancer.

METHODS AND ANALYSIS

This systematic review will incorporate articles identified by electronically searching the following databases: PubMed, MEDLINE, the Cochrane Library, AMED, EMbase, WorldSciNet, Nature, Science Online, China National Knowledge Infrastructure, the Chongqing VIP Chinese Science and Technology Periodical Database, the Wanfang Database and China Biology Medicine Disc from inception to 1 December 2019. Other sources including conference proceedings and reference lists of identified publications and existing systematic reviews will also be searched. Two reviewers will independently search the databases, perform data extraction and assess the quality of studies. Data will be synthesised using either a fixed-effects model or a random-effects model, according to heterogeneity testing. Patient-reported change in the Visual Analogue Scale or the Xerostomia Inventory will be assessed as the primary outcome. Saliva collection, whole saliva production and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 will be evaluated as secondary outcomes. RevMan V. 5.3 will be employed for data analysis. The results will be expressed as risk ratios for dichotomous data and mean differences for continuous data.

ETHICS AND DISSEMINATION

This protocol will not evaluate individual patient information or affect patient rights and therefore does not require ethical approval. Results from this review will be disseminated through peer-reviewed journals and conference reports.

TRIAL REGISTRATION NUMBER

CRD42019129069.

Use of Acupuncture in Hospices and Palliative Care Services in the Uk

Purpose

The aim of the present work was to evaluate the availability of acupuncture in UK hospices and specialist palliative care services and to identify any barriers to the use of acupuncture in these settings, to determine the characteristics of available acupuncture services and of practitioners providing acupuncture, and to determine awareness of the evidence base for the use of acupuncture in palliative care.

Methods

An online questionnaire with an invitation to participate was circulated by email to 263 hospices and specialist palliative care services in the UK.

Results

A response rate of 54% was obtained. Acupuncture was provided by 59% of services that responded. In general, small numbers of patients receive acupuncture as part of their palliative care treatment as inpatients, day patients or outpatients. Most practitioners were regulated health professionals who had received a Western-style training in acupuncture and used a Western-style medical acupuncture approach. Where acupuncture was not available the commonest reason given was the lack of a suitable practitioner. Most agreed that if funding and a suitable practitioner were available, acupuncture would be a useful addition to their service. The level of awareness of specific types of evidence supporting the use of acupuncture in palliative care was low, but most respondents were aware that some evidence existed.

Conclusions

There is a need to increase training in acupuncture for healthcare professionals working in palliative care. There is also a need to raise awareness of the potential benefits to patients and the evidence base supporting the use of acupuncture in palliative care.

The standardization of acupuncture treatment for radiation-induced xerostomia: A literature review

OBJECTIVE

To assess the relative standardization of acupuncture protocols for radiation-induced xerostomia.

METHODS

A literature search was carried out up to November 10, 2012 in the databases PubMed/MEDLINE, EMBASE and China National Knowledge Infrastruction with the terms: radiation-induced xerostomia, acupuncture, acupuncture treatment, and acupuncture therapy. Five ancient Chinese classic acupuncture works were also reviewed with the keywords "dry mouth, thirst, dry tongue, dry eyes and dry lips" to search the effective acupuncture points for dry mouth-associated symptoms in ancient China.

RESULTS

Twenty-two full-text articles relevant to acupuncture treatment for radiation-induced xerostomia were included and a total of 48 acupuncture points were searched in the 5 ancient Chinese classic acupuncture works, in which the most commonly used points were Chengjiang (CV24), Shuigou (GV 26), Duiduan (GV 27), Jinjin (EX-HN 12), and Yuye (EX-HN 13) on head and neck, Sanjian (LI 3), Shangyang (LI 1), Shaoshang (LU 11), Shaoze (SI 1), Xialian (LI 8) on hand, Fuliu (KI 7), Dazhong (KI 4), Zuqiaoyin (GB 44), Taichong (LR 3), Zhaohai (KI 6) on foot, Burong (ST 19), Zhangmen (LR 13), Tiantu (CV 22), Qimen (LR 14) on abdomen, Feishu (BL 13), Danshu (BL 19), Xiaochaogshu (BL 27), Ganshu (BL 18) on back, Shenmen (TF 4), Shen (CO10, Kidney), Yidan (CO11, Pancreas) and Pi (CO13, Spleen) on ear.

CONCLUSION

There were considerable heterogeneities in the current acupuncture treatment protocols for radiation-induced xerostomia. Based on the results of the review and the personal perspectives, the authors provide a recommendation for manual acupuncture protocols in treating radiationinduced xerostomia patients with head and neck cancer.

Acupuncture for Neoplasms: An Update from the PubMed Database

Background: The therapeutic mainstays of cancer remain surgery, radiotherapy, and chemotherapy. However, radiotherapy and chemotherapy are often associated with serious side-effects, such as nausea and vomiting. Acupuncture has been used widely to treat disorders in clinical practice for at least 3000 years. According to the National Institutes of Health (NIH) Consensus Statement, chemotherapy-induced nausea and vomiting are suitable for acupuncture intervention. Objectives: The goal of this review is to analyze the applications of acupuncture for treating cancer and to look ahead at the potential advantages of acupuncture for patients with cancer. Materials and Methods: The PubMed database was searched for articles on acupuncture therapy and neoplasms. The different distributions of scientific papers were analyzed preliminarily. Results: The articles found showed that acupuncture was used to address various symptoms related to different types of cancer. Conclusions: The results of clinical trials in acupuncture have provided important clues in oncologic practice. The evidence suggests that acupuncture is a safe and effective therapy for managing cancer and treatment-related symptoms, such as nausea and vomiting and fatigue caused by chemotherapy. As more evidence emerges, the potential advantages of acupuncture in tumor treatment will eventually be clear.

[Complementary therapy in palliative medicine]

Even in the palliative context complementary therapy has a high value for patients and their relatives. In contrast to the methods of conventional medicine naturopathy as a holistic system has positive meanings for patients and their family. Complementary medicine in the palliative setting can be used as a supportive therapy in carefully selected cases. Doctors and patients should be careful regarding effect and side effects and should make sure that supportive therapy is given adequately and in effective doses. Complementary therapy should not be used in order to avoid the question of life and death. An adequate approach to the topic is mandatory, which acknowledges the needs of patients but also looks for their safety. Patients following alternative therapies sometimes neglect helpful therapeutic options. Carefully providing information on these therapies is mandatory. Physicians should avoid losing patients' confidence in their competence and attention in their final course of disease. Also in palliative medicine a sensitive approach to the topic of complementary medicine is mandatory, which accounts for the eligible wishes of patients and their relatives but puts the patients safety first.

Clinical effectiveness and safety of acupuncture in the treatment of irradiation-induced xerostomia in patients with head and neck cancer: a systematic review

BACKGROUND

Irradiation-induced xerostomia seriously reduces quality of life for patients with head and neck cancer (HNC). Anecdotal evidence suggests that acupuncture may be beneficial.

OBJECTIVE

To systematically review evidence on clinical effectiveness and safety of acupuncture in irradiation-induced xerostomia in patients with HNC.

METHODS

A detailed search was performed to identify randomised controlled trials (RCTs) and systematic reviews of RCTs on acupuncture in irradiation-induced xerostomia, using AMED, BNIA, CINAHL, Cochrane, Embase, HPSI, PsycInfo and Medline. Grey literature was explored and 11 journals hand searched. Search terms included: acupuncture, xerostomia, salivary hypofunction, hyposalivation, dry mouth, radiotherapy, irradiation, brachytherapy, external beam. Two authors independently extracted data for analysis using predefined selection criteria and quality indicators.

RESULTS

43 of the 61 articles identified were excluded on title/abstract. 18 articles underwent full-text review; three were deemed eligible for inclusion. Two trials had moderate risk of bias; one had high risk. Two trials compared acupuncture with sham acupuncture; one control arm received 'usual care'. Outcome measurements included salivary flow rates (SFRs) in two trials and subjective questionnaires in three. All three trials reported significant reduction in xerostomia versus baseline SFR (p<0.05); one reported greater effect in the intervention group for stimulated SFR (p<0.01). Subjective assessment reported significant differences between real acupuncture and control in two trials (p<0.02-0.05). Insufficient evidence was presented to undertake risk/benefit assessment.

CONCLUSIONS

Limited evidence suggests that acupuncture is beneficial for irradiation-induced xerostomia. Although current evidence is insufficient to recommend this intervention, it is sufficient to justify further studies. Highlighted methodological limitations must be dealt with.