Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors: A Randomized Clinical Trial | Breast Cancer | JAMA Oncology | JAMA Network
[Skip to Navigation]
Sign In
Figure 1.  Consolidated Standards of Reporting Trials Flow Diagram
Consolidated Standards of Reporting Trials Flow Diagram

BFI indicates Brief Fatigue Inventory; LTQL, Long-Term Quality of Life Instrument; and PSQI, Pittsburgh Sleep Quality Index.

Figure 2.  Fatigue by Week and Group Assignment
Fatigue by Week and Group Assignment

The Brief Fatigue Inventory consists of 9 items, each measuring fatigue on a scale of 0 to 10, and the score is calculated from the mean of completed items. Scores of 4 or higher indicate clinically relevant fatigue. The shaded area represents nonclinical or normal levels of fatigue.

Table.  Sleep Quality and Quality of Life by Group Assignment and Study Visit
Sleep Quality and Quality of Life by Group Assignment and Study Visit
Original Investigation
November 2016

Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Family Medicine, University of Michigan, Ann Arbor
  • 2Department of Nutritional Sciences, University of Michigan, Ann Arbor
  • 3Department of Biostatistics, University of Michigan, Ann Arbor
  • 4College of Nursing, Michigan State University, East Lansing
  • 5Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor
  • 6Geriatric Research, Education and Clinical Center, Ann Arbor, Michigan
  • 7Sleep and Circadian Research Laboratory, University of Michigan, Ann Arbor
  • 8Department of Psychiatry, University of Michigan, Ann Arbor
  • 9Department of Neurology, University of Michigan, Ann Arbor
  • 10Department of Anesthesiology, University of Michigan, Ann Arbor
JAMA Oncol. 2016;2(11):1470-1476. doi:10.1001/jamaoncol.2016.1867
Key Points

Question  What is the efficacy of 2 types of self-administered acupressure compared with usual care for treating chronic fatigue, poor sleep, and low quality of life in fatigued breast cancer survivors?

Findings  In this randomized clinical trial that included 288 breast cancer survivors, the percentages of women who achieved normal fatigue levels at week 6 were 66.2% in relaxing acupressure, 60.9% in stimulating acupressure, and 31.3% in usual care. Only women in the stimulating acupressure arm experienced significant improvement in both sleep quality and quality of life vs usual care.

Meaning  Self-administered relaxing acupressure may be a useful treatment for improving fatigue, sleep, and quality of life.


Importance  Fatigue is a common and debilitating late-term effect of breast cancer that is associated with poor sleep and decreased quality of life, yet therapies remain limited. Acupressure has reduced fatigue in previous small studies, but rigorous clinical trials are needed.

Objectives  To investigate if 6 weeks of 2 types of self-administered acupressure improved fatigue, sleep, and quality of life vs usual care in breast cancer survivors and to determine if changes were sustained during a 4-week washout period.

Design, Setting, and Participants  Phase 3 randomized, single-blind, clinical trial conducted from March 1, 2011, through October 31, 2014. Women were recruited from the Michigan Tumor Registry.

Interventions  Randomization (1:1:1) to 6 weeks of daily self-administered relaxing acupressure, stimulating acupressure, or usual care.

Main Outcomes and Measures  The primary outcome was change in the Brief Fatigue Inventory score from baseline to weeks 6 and 10. Secondary analyses were sleep (Pittsburgh Sleep Quality Index) and quality of life (Long-Term Quality of Life Instrument).

Results  A total of 424 survivors of stages 0 to III breast cancer who had completed cancer treatments at least 12 months previously were screened, and 288 were randomized, with 270 receiving relaxing acupressure (n = 94), stimulating acupressure (n = 90), or usual care (n = 86). One woman withdrew owing to bruising at the acupoints. At week 6, the percentages of participants who achieved normal fatigue levels (Brief Fatigue Inventory score <4) were 66.2% (49 of 74) in relaxing acupressure, 60.9% (42 of 70) in stimulating acupressure, and 31.3% (26 of 84) in usual care. At week 10, a total of 56.3% (40 of 71) in relaxing acupressure, 60.9% (42 of 69) in stimulating acupressure, and 30.1% (25 of 83) in usual care continued to have normal fatigue. At neither time point were the 2 acupressure groups significantly different. Relaxing acupressure, but not stimulating acupressure, showed significant improvements in sleep quality compared with usual care at week 6, but not at week 10. Only relaxing acupressure significantly improved quality of life vs usual care at weeks 6 and 10.

Conclusions and Relevance  Both acupressure arms significantly reduced persistent fatigue compared with usual care, but only relaxing acupressure had significant effects on sleep quality and quality of life. Relaxing acupressure offers a possible low-cost option for managing symptoms.

Trial Registration Identifier: NCT01281904


Many breast cancer survivors experience negative late-term physical and psychological effects from their cancer therapies.1,2 Persistent fatigue is one of the most common and bothersome symptoms.3,4 Moreover, persistent fatigue in breast cancer survivors is emerging as a potential independent risk factor associated with shorter times to breast cancer recurrence and overall survival.5 Approximately one-third of women experience moderate to severe persistent fatigue up to 10 years after the end of treatment.6-8 Persistent fatigue is associated with higher rates of depression,9-11 poor sleep,12 and decreased quality of life.13 While the etiology of persistent fatigue is unknown, recent data suggest dysfunction within the central nervous system, including elevations in specific neurotransmitters and metabolites.14,15

Despite the high burden of persistent fatigue in breast cancer survivors, treatments remain limited and have challenges to implementation.16 For instance, cancer-related fatigue is one of the most commonly reported barriers to starting or maintaining physical activity.17,18 Behavioral treatments have been hindered by the poor availability of mental health programs, limited insurance coverage, and the stigma associated with psychological problems.19-22 Therefore, there is a need for inexpensive, easy-to-initiate, self-care treatments for persistent fatigue in breast cancer survivors.

Acupressure, a method derived from traditional Chinese medicine (TCM), is a treatment in which pressure is applied with fingers, thumbs, or a device to acupoints on the body. Acupressure has shown promise for treating fatigue in patients with cancer,23 and in a study24 of 43 cancer survivors with persistent fatigue, our group found that acupressure decreased fatigue by approximately 45% to 70%. Furthermore, acupressure points termed relaxing (for their use in TCM to treat insomnia) were significantly better at improving fatigue than another distinct set of acupressure points termed stimulating (used in TCM to increase energy).24 Despite such promise, only 5 small studies24-28 have examined the effect of acupressure for cancer fatigue.

To develop an inexpensive, easy-to-initiate, self-care treatment for persistent fatigue, we conducted a 10-week phase 3 randomized, single-blind, clinical trial from March 1, 2011, through October 31, 2014, to test the hypothesis that self-administered relaxing acupressure would be significantly better at reducing fatigue, improving sleep, and increasing quality of life than either stimulating acupressure or usual care in persistently fatigued breast cancer survivors. We also examined the carryover effects on fatigue, sleep, and quality of life during a 4-week washout period.


The study design has been previously reported.29 The trial protocol (Supplement 1) was approved by the University of Michigan Medical School, Michigan State University, and Michigan Department of Public Health institutional review boards, and participants provided written informed consent.

Trial Design

A 10-week randomized, single-blind trial comparing self-administered relaxing acupressure with stimulating acupressure once daily for 6 weeks vs usual care with a 4-week follow-up was conducted. There were 5 research visits: at screening, baseline, 3 weeks, 6 weeks (end of treatment), and 10 weeks (end of washout phase). The Pittsburgh Sleep Quality Index (PSQI) and Long-Term Quality of Life Instrument (LTQL) were administered at baseline and weeks 6 and 10. The Brief Fatigue Inventory (BFI) score was collected at baseline and weeks 1 through 10. Study visits were conducted at the Michigan County Extension Office in the county where women resided.


Women were recruited from the Michigan Tumor Registry. The registry sent letters to women diagnosed as having stages 0 to III breast cancer between January 1, 2006, and December 31, 2010, from 6 Michigan counties. Eligible women had to report persistent fatigue starting on or after their cancer diagnosis and a score of 4 or higher on the BFI.30 They also had to be cancer free and have completed cancer treatments (except hormone therapy) at least 12 months previously. Women were ineligible if (1) they had untreated major depressive disorder, other fatigue-causing comorbidities, or a cancer diagnosis other than breast cancer or skin cancer within the previous 10 years; (2) they were planning on changing or starting a new medication during the study period; or (3) they were taking any medications for insomnia or had received acupuncture or acupressure within the previous 6 months.


Usual care was defined as any treatment women were receiving from health care professionals for fatigue. At baseline, women were taught to self-administer acupressure by a trained acupressure educator.29 The 13 acupressure educators were taught by one of the study’s principal investigators (R.E.H.), an acupuncturist with National Certification Commission for Acupuncture and Oriental Medicine training. This training included a 30-minute session in which educators were taught point location, stimulation techniques, and pressure intensity.

Relaxing acupressure points consisted of yin tang, anmian, heart 7, spleen 6, and liver 3. Four acupoints were performed bilaterally, with yin tang done centrally. Stimulating acupressure points consisted of du 20, conception vessel 6, large intestine 4, stomach 36, spleen 6, and kidney 3. Points were administered bilaterally except for du 20 and conception vessel 6, which were done centrally (eFigure in Supplement 2). Women were told to perform acupressure once per day and to stimulate each point in a circular motion for 3 minutes.

The assessments for fidelity of both acupressure educators and participants have been previously described.31 Participants were assessed for how well they performed acupressure at their baseline visits and at weeks 3 and 6. Participants were asked to locate all acupoints and demonstrate the amount of stimulation and treatment duration. These items were scored from 0 (no answers correct) to 100 (all answers correct). The acupressure educators were assessed in the same way as the participants at least twice by the acupuncturist.

Outcome Measures

For the outcome of fatigue, we selected the BFI,30 a scale validated with Cronbach α > .95 in patients with cancer,32 which correlates well with other fatigue measures.33 The BFI assesses the severity and effect of fatigue in patients with cancer during the past 24 hours. The instrument consists of 9 items, each measuring fatigue on a scale of 0 to 10, and the score is calculated from the mean of completed items. Scores of 4 or higher indicate clinically relevant fatigue.30 A 3-point change or a drop below 4 is considered a clinically meaningful change.34

To assess sleep quality, the 19-item PSQI was used. It evaluates sleep disturbance during the past month. The PSQI yields a global score (Cronbach α = .81).32 In women with breast cancer, a score of 8 or higher suggests poor sleep quality.32 A 3-point change or a drop below 8 is considered clinically meaningful.35

Quality of life was measured by the LTQL, a 34-item questionnaire evaluating functional impairment and its effect on quality of life in female cancer survivors during the past month. The LTQL is composed of 4 subscales, including somatic, spiritual and philosophical, fitness, and social support.36 The Cronbach α ranges from α = .86 to α = .92 for the 4 subscales.36

Women in the acupressure arms were given a study logbook. In it, they were instructed to record adherence to acupressure treatments.

Sample Size

The power to detect differences between the 2 types of acupressure and between the 2 acupressure arms and usual care was computed via simulation using linear mixed models (LMMs), with a group, week, group by week interaction, and a random participant effect. The mean BFI scores at baseline were taken to be 6 across all 3 arms and decreased to 2, 3, and 4 at week 6 for usual care, stimulating acupressure, and relaxing acupressure, respectively. The between-participant variance was assumed to be 4 at all time points, while the variance of the random participant component was also 4, with a 0.5 intraclass correlation.24 For this configuration, the power for detecting group differences is greater than 0.95, and the power for detecting a significant group by week interaction is 0.82, with a sample size of 100 per treatment arm and a 5% level of significance.

Randomization, Allocation, and Blinding

Randomization (1:1:1) was computer generated by the study statistician (A.S.) in blocks of 6 and by county. Women were classified into 1 of 2 strata based on sleep quality at baseline (PSQI <8 or ≥8).32,37,38 Participants were enrolled and assigned the next randomization number in their county by the study coordinator. Before enrolling any participants into the study, randomization numbers were written on the outside of opaque envelopes that contained treatment assignments. These envelopes were created by study staff who had no contact with participants. All study staff were blinded. Those randomized to usual care knew their study assignment, but the women randomized to acupressure (and their acupressure educators) were unaware if they were receiving relaxing or stimulating acupressure.

Statistical Analysis

Baseline characteristics were analyzed by treatment groups using means (SDs) for continuous variables and counts and percentages for categorical variables. Balance between groups on baseline characteristics was tested using analysis of variance or a Pearson χ2 test, as appropriate. Adverse events, fidelity, and adherence between groups were analyzed using a Pearson χ2 test.

An intent-to-treat analysis was used, as suggested by White and colleagues.39 This method included performing an analysis of key sociodemographic and clinical characteristics comparing those who completed the trial with those who withdrew and using LMMs. The LMMs were used to investigate the primary outcome of fatigue (BFI score). In the LMMs, a random participant intercept was included to account for participant clustering, and week, group, and the interaction term (group by week) were included as fixed effects. To examine the percentage of women by group who were no longer clinically fatigued at weeks 6 and 10, a Pearson χ2 test was conducted. The LMMs were also used to analyze the global PSQI and the LTQL subscales. For fatigue analyses, multiple testing (change in BFI score and BFI clinical responders) was accounted for using a Bonferroni adjustment such that P ≤ .025 was considered significant. In all other analyses, P ≤ .05 was considered statistically significant. No adjustment was made for other outcomes, which were considered hypothesis generating. All tests were 2 sided.

Screening, Enrollment, and Withdrawals

Of the 424 women screened, 288 were randomized. All study visits were completed by 72.4% (71 of 98) in relaxing acupressure, 73.4% (69 of 94) in stimulating acupressure, and 86.5% (83 of 96) in usual care (P = .04 for acupressure groups vs usual care). There were no significant differences in any sociodemographic or clinical characteristics, including baseline fatigue, between women who completed the study and those who withdrew. Figure 1 shows exclusions and reasons for discontinuing interventions.

Sociodemographic and Clinical Characteristics

No significant baseline differences were found across study groups for any variables. These results are shown in the eTable in Supplement 2.


At week 6, the change in BFI score from baseline was significantly greater in relaxing acupressure and stimulating acupressure compared with usual care (mean [SD], −2.6 [1.5] for relaxing acupressure, −2.0 [1.5] for stimulating acupressure, and −1.1 [1.6] for usual care; P < .001 for both acupressure arms vs usual care), and there was no significant difference between acupressure arms (P = .29). At week 10, the change in BFI score from baseline was greater in relaxing acupressure and stimulating acupressure compared with usual care (mean [SD], −2.3 [1.4] for relaxing acupressure, −2.0 [1.5] for stimulating acupressure, and −1.0 [1.5] for usual care; P < .001 for both acupressure arms vs usual care), and there was no significant difference between acupressure arms (P > .99) (Figure 2). The mean percentage fatigue reductions at 6 weeks were 34%, 27%, and −1% in relaxing acupressure, stimulating acupressure, and usual care, respectively.

The percentages of study participants who achieved normal fatigue levels (BFI score <4) at week 6 were 66.2% (49 of 74) in relaxing acupressure, 60.9% (42 of 70) in stimulating acupressure, and 31.3% (26 of 84) in usual care (P < .001 for comparison across study arms). Similarly, 56.3% (40 of 71) in relaxing acupressure, 60.9% (42 of 69) in stimulating acupressure, and 30.1% (25 of 83) in usual care continued to have normal fatigue levels at week 10 (P < .001 for comparison across study arms).

Sleep Quality

At week 6, participants randomized to relaxing acupressure had significantly lower PSQI scores compared with usual care but were not significantly different from those randomized to stimulating acupressure. The stimulating acupressure arm was not significantly different from the usual care arm. There was no significant difference between the 3 study arms at week 10 (Table). Only relaxing acupressure significantly improved quality of life vs usual care at weeks 6 and 10.

Long-term Quality of Life

Participants in the relaxing acupressure arm improved significantly compared with the usual care arm for 3 of the 4 quality-of-life subscales, including somatic, fitness, and social support at both 6 and 10 weeks. Stimulating acupressure was not significantly different from usual care for any subscale at either time point. There were no significant differences between the relaxing and stimulating acupressure arms for any subscale at either week 6 or 10 (Table).

Fidelity, Adherence, and Adverse Events

At week 6, the mean (SD) fidelity ratings were 94.6% (10.2%) and 95.3% (8.1%) in the relaxing acupressure and stimulating acupressure arms, respectively (P = .23). There was no significant difference in adherence between acupressure arms (P = .11): women in relaxing acupressure self-administered a mean (SD) of 73% (29%) of all possible sessions, while those in the stimulating acupressure self-administered a mean (SD) of 65% (32%) of their sessions. Six adverse events were related to the acupressure treatment. All were nonserious cases of mild bruising at acupressure sites.


Six weeks of daily self-administered relaxing and stimulating acupressure led to significant fatigue reductions compared with usual care in persistently fatigued breast cancer survivors. At posttreatment, 66.2% (49 of 74) of relaxing acupressure participants and 60.9% (42 of 70) of stimulating acupressure participants achieved normal fatigue levels compared with 31.3% (26 of 84) of usual care participants. While both acupressure treatments demonstrated significant, sustained improvements in fatigue, only relaxing acupressure significantly improved both sleep and quality of life compared with usual care.

Why might both acupressure arms significantly improve fatigue? In our group’s previous work, we had seen that cancer fatigue may arise through multiple distinct mechanisms.15 Similarly, it is also known in the acupuncture literature that true and sham acupuncture can improve symptoms equally, but they appear to work via different mechanisms.40 Therefore, relaxing acupressure and stimulating acupressure could elicit improvements in symptoms through distinct mechanisms, including both specific and nonspecific effects. These results are also consistent with TCM theory for these 2 acupoint formulas, whereby the relaxing acupressure acupoints were selected to treat insomnia by providing more restorative sleep and improving fatigue and the stimulating acupressure acupoints were chosen to improve daytime activity levels by targeting alertness.

How could acupressure lead to improvements in fatigue? The etiology of persistent fatigue in cancer survivors is related to elevations in brain glutamate levels, as well as total creatine levels in the insula.15 Studies in acupuncture research have demonstrated that brain physiology,41 chemistry,42 and function43 can also be altered with acupoint stimulation. We posit that self-administered acupressure may have similar effects.

Self-administered acupressure appeared to be safe, acceptable, and easy to learn. After a 15-minute training session, women were able to accurately locate their acupoints and apply the correct amount of pressure. Women on average performed more than 70% of daily acupressure sessions and reported few, transient, and minor occurrences of bruising at the acupressure site. Given the brief training required to learn acupressure, this intervention could be a low-cost option for treating fatigue.

Our results are consistent with other investigations in which acupressure was significantly better than usual care at decreasing fatigue. However, these studies25-28 had limitations, including small sample sizes, inclusion of multimodal treatment approaches, patients currently receiving or recently completing cancer treatment, and no examination of carryover effects of acupressure. Moreover, to our knowledge, only one study26 examined acupressure in breast cancer survivors, and our study addressed these limitations and improved fatigue to a greater extent. However, fatigue reduction in our study was considerably less than what was observed in a pilot study,24 despite using the same 2 acupressure treatments and similar baseline fatigue severity. In addition, the pilot study found a significant difference in fatigue reduction between stimulating (45%) and relaxing (70%) acupressure. There are several possible reasons for the discrepant findings. The pilot study included a mixed cancer population, with only some participants being diagnosed as having breast cancer. Cancer-related fatigue in other cancer populations could have different etiologies and mechanisms, making it more amenable to acupressure treatments. We also recruited women from the community in this study, in contrast to a National Cancer Institute–designated comprehensive cancer center. As a consequence, women in this study were on average older, had more comorbidities, and were more racially/ethnically diverse than pilot study participants. Certain comorbidities6,44 and nonwhite race44 are predictors of more severe fatigue in breast cancer survivors. Also, older age may diminish responsiveness to acupressure treatment for fatigue.34

This study had several limitations, including limited participation of minority women. Most participants (89.6% [258 of 288]) were white non-Hispanic women, and almost all nonwhite participants were African Americans. However, this study’s racial makeup is similar to the demographics of breast cancer cases reported in Michigan.45 Another limitation is that some women (11.9% [23 of 192]) found that self-administering daily acupressure was too time consuming and discontinued the study for this reason. Other time-intensive study requirements could also explain why participants found the study too burdensome; however, only 4.2% (4 of 96) of women in usual care indicated that they withdrew owing to time conflicts. These attrition rates are not dissimilar to those of exercise and diet interventions in breast cancer survivors.46 However, unlike other behavioral changes, women may not need to continue doing acupressure to have prolonged benefit. This consideration could be a significant advantage of acupressure because the maintenance of behavioral changes after the end of an intervention is a significant challenge for lifestyle interventions, such as exercise.47 Still, it is difficult to know the long-term efficacy of this treatment beyond 4 weeks. Also, for a small number (6 of 288), this intervention was a suboptimal treatment owing to complaints of bruising or difficulty doing acupressure.

Future acupressure studies should investigate how to best implement acupressure in real-world clinical settings and in the community or more broadly disseminate the therapy through web-based or mobile applications. There is also a lack of studies examining the mechanisms of how acupressure affects fatigue. Such studies could contribute important insights into underlying acupressure mechanisms and chronic fatigue in cancer survivors. Last, investigations of which cancer survivors are most likely to benefit from acupressure would help guide clinical recommendations and improve evidence-based treatment for fatigued breast cancer survivors.


In summary, both acupressure arms significantly reduced fatigue compared with usual care, but only relaxing acupressure had a significant effect on improving both sleep and quality of life. Improvements in fatigue, sleep, and quality of life were sustained for 4 weeks after cessation of acupressure. Self-administered relaxing acupressure could offer an inexpensive, easy-to-learn intervention for improving fatigue, sleep, and quality of life in fatigued breast cancer survivors.

Back to top
Article Information

Accepted for Publication: April 17, 2016.

Corresponding Author: Suzanna M. Zick, ND, MPH, Department of Family Medicine, University of Michigan, 24 Frank Lloyd Wright Dr, Ann Arbor, MI 48105 (

Published Online: July 7, 2016. doi:10.1001/jamaoncol.2016.1867.

Author Contributions: Drs Zick and Harris had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Zick, Harris.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Zick, Sen.

Administrative, technical, or material support: Zick, Wyatt, Harris.

Study supervision: Zick, Harris.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by grants R01 CA151445 and 2UL1 TR000433-06 from the National Institutes of Health.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Schmidt  ME, Chang-Claude  J, Seibold  P,  et al.  Determinants of long-term fatigue in breast cancer survivors: results of a prospective patient cohort study.  Psychooncology. 2015;24(1):40-46.PubMedGoogle ScholarCrossref
Schmidt  ME, Chang-Claude  J, Vrieling  A, Heinz  J, Flesch-Janys  D, Steindorf  K.  Fatigue and quality of life in breast cancer survivors: temporal courses and long-term pattern.  J Cancer Surviv. 2012;6(1):11-19.PubMedGoogle ScholarCrossref
Reinertsen  KV, Cvancarova  M, Loge  JH, Edvardsen  H, Wist  E, Fosså  SD.  Predictors and course of chronic fatigue in long-term breast cancer survivors.  J Cancer Surviv. 2010;4(4):405-414.PubMedGoogle ScholarCrossref
Noal  S, Levy  C, Hardouin  A,  et al.  One-year longitudinal study of fatigue, cognitive functions, and quality of life after adjuvant radiotherapy for breast cancer.  Int J Radiat Oncol Biol Phys. 2011;81(3):795-803.PubMedGoogle ScholarCrossref
Groenvold  M, Petersen  MA, Idler  E, Bjorner  JB, Fayers  PM, Mouridsen  HT.  Psychological distress and fatigue predicted recurrence and survival in primary breast cancer patients.  Breast Cancer Res Treat. 2007;105(2):209-219.PubMedGoogle ScholarCrossref
Bower  JE, Ganz  PA, Desmond  KA,  et al.  Fatigue in long-term breast carcinoma survivors: a longitudinal investigation.  Cancer. 2006;106(4):751-758.PubMedGoogle ScholarCrossref
Minton  O, Stone  P.  How common is fatigue in disease-free breast cancer survivors? a systematic review of the literature.  Breast Cancer Res Treat. 2008;112(1):5-13.PubMedGoogle ScholarCrossref
Harrington  CB, Hansen  JA, Moskowitz  M, Todd  BL, Feuerstein  M.  It’s not over when it’s over: long-term symptoms in cancer survivors: a systematic review.  Int J Psychiatry Med. 2010;40(2):163-181.PubMedGoogle ScholarCrossref
Kim  SH, Son  BH, Hwang  SY,  et al.  Fatigue and depression in disease-free breast cancer survivors: prevalence, correlates, and association with quality of life.  J Pain Symptom Manage. 2008;35(6):644-655.PubMedGoogle ScholarCrossref
Romito  F, Cormio  C, Giotta  F, Colucci  G, Mattioli  V.  Quality of life, fatigue and depression in Italian long-term breast cancer survivors.  Support Care Cancer. 2012;20(11):2941-2948.PubMedGoogle ScholarCrossref
Galiano-Castillo  N, Ariza-García  A, Cantarero-Villanueva  I, Fernández-Lao  C, Díaz-Rodríguez  L, Arroyo-Morales  M.  Depressed mood in breast cancer survivors: associations with physical activity, cancer-related fatigue, quality of life, and fitness level.  Eur J Oncol Nurs. 2014;18(2):206-210.PubMedGoogle ScholarCrossref
Ancoli-Israel  S, Liu  L, Rissling  M,  et al.  Sleep, fatigue, depression, and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study.  Support Care Cancer. 2014;22(9):2535-2545.PubMedGoogle ScholarCrossref
Wu  HS, Harden  JK.  Symptom burden and quality of life in survivorship: a review of the literature.  Cancer Nurs. 2015;38(1):E29-E54. doi:10.1097/NCC.0000000000000135.PubMedGoogle ScholarCrossref
Hampson  JP, Zick  SM, Khabir  T, Wright  BD, Harris  RE.  Altered resting brain connectivity in persistent cancer related fatigue.  Neuroimage Clin. 2015;8:305-313.PubMedGoogle ScholarCrossref
Zick  SM, Zwickey  H, Wood  L,  et al.  Preliminary differences in peripheral immune markers and brain metabolites between fatigued and non-fatigued breast cancer survivors: a pilot study.  Brain Imaging Behav. 2014;8(4):506-516.PubMedGoogle ScholarCrossref
Berger  AM, Mooney  K, Alvarez-Perez  A,  et al; National comprehensive cancer network.  Cancer-Related Fatigue, Version 2.2015.  J Natl Compr Canc Netw. 2015;13(8):1012-1039.PubMedGoogle Scholar
Brunet  J, Taran  S, Burke  S, Sabiston  CM.  A qualitative exploration of barriers and motivators to physical activity participation in women treated for breast cancer.  Disabil Rehabil. 2013;35(24):2038-2045.PubMedGoogle ScholarCrossref
Blaney  JM, Lowe-Strong  A, Rankin-Watt  J, Campbell  A, Gracey  JH.  Cancer survivors’ exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire-survey.  Psychooncology. 2013;22(1):186-194.PubMedGoogle ScholarCrossref
Owen  JE, Klapow  JC, Roth  DL, Nabell  L, Tucker  DC.  Improving the effectiveness of adjuvant psychological treatment for women with breast cancer: the feasibility of providing online support.  Psychooncology. 2004;13(4):281-292.PubMedGoogle ScholarCrossref
Leykin  Y, Thekdi  SM, Shumay  DM, Muñoz  RF, Riba  M, Dunn  LB.  Internet interventions for improving psychological well-being in psycho-oncology: review and recommendations.  Psychooncology. 2012;21(9):1016-1025.PubMedGoogle ScholarCrossref
Muriel  AC, Hwang  VS, Kornblith  A,  et al.  Management of psychosocial distress by oncologists.  Psychiatr Serv. 2009;60(8):1132-1134.PubMedGoogle ScholarCrossref
Holland  JC, Andersen  B, Breitbart  WS,  et al.  Distress management.  J Natl Compr Canc Netw. 2013;11(2):190-209.PubMedGoogle Scholar
Ling  WM, Lui  LY, So  WK, Chan  K.  Effects of acupuncture and acupressure on cancer-related fatigue: a systematic review.  Oncol Nurs Forum. 2014;41(6):581-592.PubMedGoogle ScholarCrossref
Zick  SM, Alrawi  S, Merel  G,  et al Relaxation acupressure reduces persistent cancer-related fatigue.  Evid Based Complement Alternat Med. 2011;2011:142913. PubMedGoogle ScholarCrossref
Lan  SC, Lin  YE, Chen  SC, Lin  YF, Wang  YJ.  Effects of acupressure on fatigue and depression in hepatocellular carcinoma patients treated with transcatheter arterial chemoembolization: a quasi-experimental study.  Evid Based Complement Alternat Med. 2015;2015:496485. PubMedGoogle ScholarCrossref
Molassiotis  A, Sylt  P, Diggins  H.  The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: a randomised controlled trial.  Complement Ther Med. 2007;15(4):228-237.PubMedGoogle ScholarCrossref
Tang  WR, Chen  WJ, Yu  CT,  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.PubMedGoogle ScholarCrossref
Xu  J, Gu  L, Qiao  H.  Effect of traditional Chinese and Western medicine joint exercise therapy on cancer-related fatigue after operation of mammary cancer [in Chinese].  Zhong Guo Quan Ke Yi Xue. 2010;13:3225-3226.Google Scholar
Zick  SM, Wyatt  GK, Murphy  SL, Arnedt  JT, Sen  A, Harris  RE.  Acupressure for persistent cancer-related fatigue in breast cancer survivors (AcuCrft): a study protocol for a randomized controlled trial.  BMC Complement Altern Med. 2012;12(1):132.PubMedGoogle ScholarCrossref
Mendoza  TR, Wang  XS, Cleeland  CS,  et al.  The rapid assessment of fatigue severity in cancer patients: use of the Brief Fatigue Inventory.  Cancer. 1999;85(5):1186-1196.PubMedGoogle ScholarCrossref
Wyatt  GK, Frambes  DA, Harris  RE, Arnedt  JT, Murphy  SL, Zick  SM.  Self-administered acupressure for persistent cancer-related fatigue: fidelity considerations.  Altern Ther Health Med. 2015;21(4):18-23.PubMedGoogle Scholar
Beck  SL, Schwartz  AL, Towsley  G, Dudley  W, Barsevick  A.  Psychometric evaluation of the Pittsburgh Sleep Quality Index in cancer patients.  J Pain Symptom Manage. 2004;27(2):140-148.PubMedGoogle ScholarCrossref
Minton  O, Stone  P.  A systematic review of the scales used for the measurement of cancer-related fatigue (CRF).  Ann Oncol. 2009;20(1):17-25.PubMedGoogle ScholarCrossref
Vickers  AJ, Straus  DJ, Fearon  B, Cassileth  BR.  Acupuncture for postchemotherapy fatigue: a phase II study.  J Clin Oncol. 2004;22(9):1731-1735.PubMedGoogle ScholarCrossref
Troxel  WM, Conrad  TS, Germain  A, Buysse  DJ.  Predictors of treatment response to brief behavioral treatment of insomnia (BBTI) in older adults.  J Clin Sleep Med. 2013;9(12):1281-1289.PubMedGoogle Scholar
Wyatt  G, Kurtz  ME, Friedman  LL, Given  B, Given  CW.  Preliminary testing of the Long-Term Quality of Life (LTQL) instrument for female cancer survivors.  J Nurs Meas. 1996;4(2):153-170.PubMedGoogle Scholar
Carpenter  JS, Andrykowski  MA.  Psychometric evaluation of the Pittsburgh Sleep Quality Index.  J Psychosom Res. 1998;45(1):5-13.PubMedGoogle ScholarCrossref
Carpenter  JS, Elam  JL, Ridner  SH, Carney  PH, Cherry  GJ, Cucullu  HL.  Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes.  Oncol Nurs Forum. 2004;31(3):591-5598.PubMedGoogle ScholarCrossref
White  IR, Carpenter  J, Horton  NJ.  Including all individuals is not enough: lessons for intention-to-treat analysis.  Clin Trials. 2012;9(4):396-407.PubMedGoogle ScholarCrossref
Harris  RE, Zubieta  JK, Scott  DJ, Napadow  V, Gracely  RH, Clauw  DJ.  Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on µ-opioid receptors (MORs).  Neuroimage. 2009;47(3):1077-1085.PubMedGoogle ScholarCrossref
Xing  GG, Liu  FY, Qu  XX, Han  JS, Wan  Y.  Long-term synaptic plasticity in the spinal dorsal horn and its modulation by electroacupuncture in rats with neuropathic pain.  Exp Neurol. 2007;208(2):323-332.PubMedGoogle ScholarCrossref
Harris  RE, Sundgren  PC, Pang  Y,  et al.  Dynamic levels of glutamate within the insula are associated with improvements in multiple pain domains in fibromyalgia.  Arthritis Rheum. 2008;58(3):903-907.PubMedGoogle ScholarCrossref
Napadow  V, Lee  J, Kim  J,  et al.  Brain correlates of phasic autonomic response to acupuncture stimulation: an event-related fMRI study.  Hum Brain Mapp. 2013;34(10):2592-2606.PubMedGoogle ScholarCrossref
Wright  F, D’Eramo Melkus  G, Hammer  M,  et al.  Predictors and trajectories of morning fatigue are distinct from evening fatigue.  J Pain Symptom Manage. 2015;50(2):176-189.PubMedGoogle ScholarCrossref
Michigan Cancer Surveillance Program. Age-adjusted invasive cancer incidence rates in Michigan: all sites, 2008-2012. Accessed June 1, 2015.
Campbell  KL, Neil  SE, Winters-Stone  KM.  Review of exercise studies in breast cancer survivors: attention to principles of exercise training.  Br J Sports Med. 2012;46(13):909-916.PubMedGoogle ScholarCrossref
Spark  LC, Reeves  MM, Fjeldsoe  BS, Eakin  EG.  Physical activity and/or dietary interventions in breast cancer survivors: a systematic review of the maintenance of outcomes.  J Cancer Surviv. 2013;7(1):74-82.PubMedGoogle ScholarCrossref