Acupressure is a type of acupuncture in East Asian traditional medicine or integrative medicine that involves the application of pressure to specific points (i.e., acupoints) or specific areas of the body using one’s hands or other acupressure devices [1]. Similar to needle acupuncture, acupressure harmonizes the circulation of physiological energy called qi, promotes health, and helps to prevent disease. It is a non-pharmacological therapy for managing a variety of symptoms, including pain conditions [2,3], nausea and vomiting [4,5], and some mental health conditions such as anxiety [6]. The fact that this treatment can be self-administered is one of the reasons it is becoming more popular [7], since it enhances the user’s self-efficacy [8] and allows the patient to actively participate in the treatment process without increasing costs.

At present, information and communication technologies (ICTs) are widely available tools that can be used for scaling up the application of acupressure. ICTs can be defined as “technologies used to convey, manipulate and store data by electronic means” [9]. In the medical field, ICTs have been considered a potential solution in terms of reducing healthcare costs to families, improving equitable access to quality services, enhancing the availability of social protection programs, and increasing accountability and sustainability in health service delivery [10]. Given the minimal face-to-face contact intrinsic to ICTs [11], interest in their use has been fueled around the world since the outbreak of the novel coronavirus disease in late 2019 (COVID-19) in many areas, including the medical field [12]. The COVID-19 era has not only overloaded the current medical quarantine system [13] but also increased the need for non-face-to-face medical services [12] and caused a huge medical burden, including direct physical health problems caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, indirect mental health problems, and residual sequelae [14,15]. Acupressure is an inexpensive and highly diffuse intervention [7] that has the potential to alleviate the overload of healthcare systems in the COVID-19 era. In addition, current clinical studies are revealing that acupressure has the potential to be used to relieve clinical symptoms of COVID-19 patients [16], indirect mental health problems [17], and even its sequelae [18]. In this regard, the ICT tools play an important role in promoting patient self-care, including self-acupressure [19].

This mini review involved collecting and analyzing clinical studies of acupressure using ICTs, with a particular focus on self-acupressure, to explore the combinations of ICTs and acupressure that have been attempted to date. This review can serve as a useful reference for the development of strategies involving the use of acupressure and ICTs in the context of COVID-19 in the future and can potentially contribute to the promotion of human health.

1. Study search

Studies that involved self-acupressure using ICTs were collected through a search of MEDLINE via PubMed, EMBASE via Elsevier, and Cochrane Central Register of Controlled Trials (CENTRAL). The following search strategy was used: “internet-based intervention” [MH] OR smartphone [MH] OR telemedicine [MH] OR “computer systems” [MH] OR “social media” [MH] OR internet [MH] OR internet [TIAB] OR smartphone [TIAB] OR telemedicine [TIAB] OR ICT [TIAB] OR “information and communication technology” [TIAB] OR “information technology” [TIAB] OR online [TIAB] OR web-based [TIAB] OR telehealth [TIAB] OR telecommunication [TIAB] OR “digital health” [TIAB] OR “mobile app” [TIAB] OR mHealth [TIAB] OR “virtual reality” [TIAB] OR VR-based [TIAB] OR “augmented reality” [TIAB] OR AR-based [TIAB] OR computer [TIAB] OR “social media” [TIAB] OR “social platform” [TIAB]. The search was conducted on December 31, 2021, and all clinical studies published up to this date were considered. The search process was conducted by one researcher (CYK), and details regarding the search strategies and results are described in Supplementary Material 1.

2. Study selection

One researcher (CYK) conducted the two-step study selection process, and the other author (CHY) reviewed it. In the first screening step, potentially relevant documents were selected by reviewing the title and abstract. In the second screening step, the full texts of documents selected in the first step were reviewed for final inclusion. The inclusion criteria were as follows: (1) population: any type of human subject, including the general population, individuals at risk, and patients with diagnosed illnesses; (2) intervention: self-acupressure using ICTs, including internet-based interventions, web-based interventions, smartphone applications, telemedicine, telehealth, and telecommunication; (3) comparator: no limits; (4) outcome: no limits; and (5) study design: any type of clinical study, including case reports, case series, cohort studies, before–after studies, non-randomized controlled trials, and randomized controlled trials (RCTs) published in peer-reviewed journals or conference abstracts. Moreover, protocols of clinical studies were included. However, opinion, perspective, and review articles were excluded. There were no restrictions on the sex, race/ethnicity, or age of the population or on the language of the article. The study selection process is presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart form in Fig. 1.

Figure 1. PRISMA flow diagram.

3. Data extraction and analysis

The following data from included studies were extracted onto a pre-planned Microsoft Excel spreadsheet: country of first author, study design, target population or condition, ICT applied, development method, duration, main clinical data, detailed content related to acupressure, and acupressure method. In data analysis, considering the heterogeneity of the interventions used, subjects included, and study settings, a quantitative synthesis was not planned, and only a descriptive analysis was performed. The main analysis concerns were the target population or condition, ICT applied, development method, and detailed content related to acupressure.

1. Study selection

As a result of the study search, 146 publications were identified after removing duplicates. In the first screening step, 119 publications were excluded after title and abstract screening. In the second screening step, the full texts of the remaining 27 publications were reviewed. Among them, one study that was not a clinical study, five studies that did not use self-acupressure, seven studies that did not combine ICTs with self-acupressure, and two studies that used the same data as published journal articles (conference abstracts) were excluded. Finally, 12 studies [20-31] were included in this review (Fig. 1).

2. Characteristics of included studies

The 12 included studies were published between 2018 and 2021. In terms of study design, five RCTs [20,23-25,28], three pilot studies with one group [22,27,30], two RCT protocols [26,31], one focus group and online survey [21], and one qualitative study [29] were included. Among the included studies, the rationale for four studies [25,28-30] was the COVID-19 era (4/12, 33.33%). There were six kinds of target populations or conditions, and musculoskeletal injuries or pain was the most common (5/12, 41.67%), followed by cancer-related symptoms (2/12, 16.67%), dysmenorrhea (2/12, 16.67%), mental health issues (2/12, 16.67%), obesity (1/12, 8.33%), and other (1/12, 8.33%) (Fig. 2, Table 1).

AA = auricular acupressure; ICT = information and communication technology; NA = not applicable; NR = not reported; RCT = randomized controlled trial..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Characteristics of included studies.

Study	Study design	Target population or conditions	ICT applied	Development methods	Duration	Main clinical data
Blödt (2018)	Two-armed pragmatic RCT (n = 221) (self-acupressure combined with smartphone application (n = 111) versus usual care (n = 110))	Women with menstrual pain	Smartphone application supporting self-acupressure	Written Delphi consensus with international acupuncture experts from China, Germany, and the USA.	Six menstruation cycle	Self-acupressure supported and evaluated by a smartphone application could achieve a sustainable reduction in pain and medication in comparison to usual care. This self-care intervention showed a high retention rate and was safe.
Mącznik (2018)	Focus groups and online survey	Acute sports injuries	Video on YouTube website	Focus groups and online survey including sports medics and physiotherapists with a special interest in sports physiotherapy.	NA	NA
Priya (2018)	Pilot study with one group (n = 30)	Individuals with knee pain	Self-applicable smartphone-controlled knee pad	NR	Once	Knee pain intensity in the participants self-assessed decreased.
Bao (2019)	Two-armed RCT (n = 223)(acupressure and meditation instructional video (n = 113) versus time- and attention-matched integrative oncology lecture video (n = 110))	Cancer patients in chemotherapy waiting rooms	Video on healthcare application	The script was developed by a mind-body therapist.	Once (15 min)	An integrative medicine self-care app in the waiting room improved patients’ experiences and reduced anxiety.
Suen (2019)	Three-armed feasibility RCT (n = 59)(AA (n = 19) versus AA combined with interactive Internet instruction (n = 19) versus wait-list control (n = 21))	Obesity	Smartphone application promoting self-administered AA	NR	8 weeks	AA group and AA assisted by smartphone application group showed better therapeutic effects in decreasing body mass index, body weight, waist circumference, hip circumference, and fullness before meals compared to the control group.
Kim (2020)	Two-armed RCT (n = 80)(tele-acupressure self-practice (n = 40) versus general online communication (n = 40))	Mental health as well as depression, anxiety and well-being during COVID-19	Live stream	NR	4 weeks	Tele-acupressure self-practice had significant beneficial effects than non-acupressure in participants during COVID-19 pandemic, including depression, anxiety, and happiness.
Wang (2020)	Reports	Women with menstrual pain	Smartphone application supporting self-acupressure	Developed in a collaborative project by the Institute of Complementary and Integrative Medicine of the University of Zurich, Switzerland, the Institute for Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Germany, and Smart Mobile Factory, Berlin, Germany, based on Apple’s ResearchKit modular concept.	Six menstruation cycle	Pragmatic RCT is currently in progress, which is expected to end in March 2021.
Kawi (2021)	Pilot study with one group (Phase I, n = 3; Phase II, n = 30)	Chronic musculoskeletal pain	Smartphone application supporting self-acupressure	In Phase I, AA for three purposive samples was preliminarily applied for 4 weeks, and the smartphone application to act as a self-guided tool to self-administer AA were developed based on their experience.	4 weeks	Participants reported that AA reduced their pain intensity, pain interference, and disability, as well as improved physical function. Approximately 70% of the participants rated global improvements with noticeable changes and the majority were satisfied with the treatment. The participants were able to adhere to the suggested pressing time per day.
Rong (2021)	Two-armed RCT (n = 406)(smartphone-based self-acupressure (n = 191) versus usual care (n = 215))	Emotional distress under the COVID-19 pandemic	Smartphone-based online (not specifically described)	NR	14 days	During COVID-19 pandemic period, treatment with self-administrated auricular acupressure was more effective than usual care in reducing emotional distress of isolated populations.
Tiedt (2021)	Qualitative study (n = 8)	Chronic pain	Telemedicine	NR	NA	The telehealth program included mindfulness-based stress reduction and chronic-pain self-management experientials (acupressure, self-massage, and chair yoga) to patients with chronic pain. Participant reported facilitators to participating in the telehealth program included feeling safer at home during the pandemic, ease of participation, socialization during pandemic-associated social isolation, and no need to find transportation or childcare in comparison to in-person visits.
Yeh (2021)	Pilot feasibility study with one group (Phase I, n = 18; Phase II, n = 19)	Chronic low back pain	Smartphone application and telehealth supporting self-acupressure	In Phase I, smartphone application supporting AA was administered. In Phase II, additional telehealth including e-mail, phone call, and virtual meeting, was added.	4 weeks	It is feasible to learn and self-administer AA with an app, supplemented with either in-person or telehealth sessions, presenting a promising intervention toward chronic low back pain self-management. Telehealth was found to boost this intervention effectively.
Zick (2021)	Protocol of three-armed RCT (n = 165)(smartphone-based self-acupressure (n = 55) versus sham acupressure (n = 55) versus usual care (n = 55))	Cancer-related fatigue in ovarian cancer survivor	Smartphone application supporting self-acupressure	The app came about as a result of a multi-phase “User Centered Design” framework, including pilot survey of adult cancer survivors with fatigue, and involvement of focus group in developing the application.	6 weeks	The overall goal of the research will be to create an app based self-acupressure treatment that could be an easily-accessible, scalable and inexpensive treatment to reduce the significant burden of fatigue in ovarian cancer survivors, thus improving overall quality of life.

AA = auricular acupressure; ICT = information and communication technology; NA = not applicable; NR = not reported; RCT = randomized controlled trial..

Figure 2. Target conditions of included studies.

3. Results of included studies

1) RCTs

In a two-armed practical RCT, Blödt et al. [20] compared a smartphone app-based self-acupressure group (n = 111) to a usual care group (n = 110) for menstrual pain management for 6 consecutive days during menstruation. They found that the women in the smartphone app-based self-acupressure group experienced significantly less pain (assessed using the Numerical Rating Scale [NRS]) than the women in the usual care group (mean difference –1.4; 95% confidence interval, –2.0 to –0.8; p < 0.001), with clinical significance. Additionally, the self-acupressure group exhibited significantly better results in terms of responder rates (defined as a reduction of at least 50% in mean pain ratings), worst pain intensity, number of days with pain, and proportion of women receiving pain medication. In a two-armed RCT, Bao et al. [23] developed a healthcare application providing an integrative medicine video. A total of 223 participants with cancer in chemotherapy waiting rooms were divided into either the acupressure and meditation instructional video group (n = 113) or the time- and attention-matched integrative oncology lecture video group (n = 110). Both groups showed significant reductions in stress and anxiety (assessed using the NRS) from baseline (all p < 0.05), and the treatment group showed significantly greater improvements than the control group (1.64 vs. 1.15 in stress reduction, p = 0.01; 1.39 vs. 0.78 in anxiety reduction, p = 0.002). However, there were no significant differences between the groups in pain and nausea scores. In a three-armed feasibility RCT, Suen et al. developed a smartphone application promoting the self-administration of auricular acupressure (AA) for weight reduction [24]. A total of 59 participants with obesity were divided into the AA group (n = 19), the AA combined with interactive internet instruction group (AA + application group) (n = 19), or the wait-list control group (n = 21). Although there were no significant differences in the pairwise comparisons, after 8 weeks of intervention, the AA and AA + application groups showed a trend toward better therapeutic effects by a decrease in body mass index, with a medium effect size (d = 0.4928) between the AA and control groups and a large effect size (d = 0.7798) between the AA + application and control groups. Despite a lack of statistical significance, both the AA and AA + application groups showed better improvements in body weight, waist circumference, and hip circumference and reported perceiving more fullness before meals compared to the control group. In a two-armed RCT, Kim [25] compared a tele-acupressure self-practice group (n = 40) to a non-acupressure group (n = 40) for mental health as well as depression, anxiety, and well-being during COVID-19. After 4 weeks of intervention, the depression (assessed using the Hamilton Depression Rating Scale) and anxiety (assessed using the Hamilton Anxiety Rating Scale and the four Office for National Statistics personal well-being questions) scores were significantly lower, and the happiness (assessed using the four Office for National Statistics personal well-being questions) score was significantly higher in the treatment group compared to the control group (all p < 0.05). In a two-armed RCT, Rong et al. [28] compared a smartphone-based online self-acupressure group (n = 191) to a usual care group (n = 215) for emotional distress under COVID-19. After 14 days of intervention, the treatment response rate (defined as a 50% or more reduction in the Hospital Anxiety and Depression Scale score from baseline) was significantly higher in the treatment group than the control group (70.7% vs. 60.6%, p = 0.02).

2) RCT protocols

Wang et al. [26] developed a smartphone application using self-acupressure to manage primary dysmenorrhea in women aged 18-34 years and conducted a pragmatic RCT to examine its effectiveness in 594 women. Participants were classified into the smartphone application supporting self-care and self-acupressure group, the smartphone application supporting self-care only group, or the smartphone application supporting self-acupressure only group. The primary outcome of this trial was the mean pain intensity difference assessed by the NRS at the sixth cycle (trial registration: NCT03432611). Zick et al. [31] developed a smartphone application supporting self-acupressure to manage cancer-related fatigue in ovarian cancer survivors. A three-armed RCT was planned, and participants were classified into the smartphone application-based self-acupressure group, the sham acupressure group, or the usual care group. The primary outcome of this trial was change in level of fatigue assessed by the Brief Fatigue Inventory at Weeks 6 and 24 (trial registration: NCT03763838).

3) Other

Mącznik et al. [21] used focus group interviews and online surveys to evaluate the prototype of a video used to teach acupressure for pain management in acute sports injuries. In the focus group interviews, 12 sports physiotherapists and 12 sports medics participated and made the following key suggestions regarding the video design: 1) offering both demonstration and verbal instructions on the acupressure technique, 2) minimizing the video content, and 3) ensuring professionalism in the video production and highlighting the presenter’s expertise and qualifications. Moreover, eight sports physiotherapists and 11 sports medics participated and provided feedback on the video through online surveys. The survey questions included the overall impression of the video, the professionalism of the video, whether the video contained enough information to reproduce the technique, the strengths of the video, recommended improvements, and other comments. Using this feedback, the researchers produced a final version of the video and posted it on YouTube (https://youtu.be/f6-9yYWSCWY). Priya et al. [22] developed a home-based self-applicable smartphone-controlled kneepad, which combined vibrations with heating and cooling treatments on acupressure points (six points on the front and back of the knee) for knee pain. Thirty participants with moderate knee pain (NRS score of 4-8) participated in the study. Participants wore the vibration pads for 25 minutes (participants chose one of the three vibration intensity levels based on their tolerance), which consisted of 15 minutes of vibration with thermal stimulation and 10 minutes of vibration with cooling stimulation. As a result, the mean intensity of the knee pain assessed immediately after the intervention decreased from 5.67 to 2.46 (NRS). Kawi et al. [27] conducted a study of 30 subjects with chronic musculoskeletal pain that consisted of two phases (Phases I and II). In Phase I, three AA-naïve adult participants were recruited and instructed to self-administer AA for 4 weeks after being provided with the appropriate kit. In Phase II, a self-guided smartphone application for the self-administration of AA was developed based on their experience. After 4 weeks of AA, 30-50% of participants reported reduced pain intensity, pain interference, and disability as well as improved physical function. Moreover, approximately 70% of the participants reported noticeable global improvements, and the majority (88%) were satisfied with the treatment. Tiedt et al. [29] conducted a qualitative study of eight subjects with chronic pain who received a telehealth integrative chronic pain program including acupressure, self-massage, and chair yoga during the COVID-19 pandemic. Participants participated in the program for a total of nine sessions, 2 hours per week and reported that it alleviated barriers to care associated with transportation, mobility, and childcare during COVID-19. Yeh et al. [30] conducted a pilot feasibility study of subjects with chronic lower back pain that consisted of two phases (Phases I and II). In Phase I, 18 adult participants were recruited and instructed to self-administer AA for 4 weeks after being provided with the smartphone application supporting self-acupressure and the appropriate kit. In Phase II, in addition to the smartphone application and the kit, telehealth supporting self-acupressure was provided to the 18 adult participants recruited. They found that the additional telehealth service boosted the intervention effectively.

4. Analysis of intervention

Among the 12 studies [20-31], seven studies (7/12, 58.33%) [20,21,23,25,26,29,31], four studies (4/12, 33.33%) [24,27,28,30], and one study (1/12, 8.33%) [22] described the self-acupressure type as manual stimulation on body acupoints, AA, and self-applicable smartphone-controlled kneepad, respectively. Only three studies [20,21,26] reported the stimulation time per acupoint, ranging from 1 to 3 minutes, with an average of 1.67. Nine studies [20-22,24-27,30,31] reported the stimulation time per session, ranging from 3 to 40 minutes, with an average of 13.78. Seven studies [20,24-27,30,31] reported the stimulation frequency per day, ranging from 1 to 3 sessions, with an average of 2.14.

Nine studies [20,21,23-27,30,31] reported the acupoints stimulated, and 18 kinds of acupoints were described. Six studies [20,21,23,25,26,31] used body acupoints, while the other three studies used ear acupoints. The number of acupoints used in each study ranged from 1 to 6, with an average of 3.67. The most frequently used body acupoints were LI4 and LR3 (4/6, 66.67%), followed by SP6 (3/6, 50%). On the other hand, the most frequently used ear acupoints were Shenmen (3/3, 100%), followed by subcortex (2/3, 66.67%). The acupoints used in the studies were expected to have systemic effects (e.g., SP6, LI4, and LR3 for menstrual pain management [20,26], LI4 for acute sports injuries [21], and HT7 for mental health [25]). The ear acupoints for chronic musculoskeletal pain corresponded to the location of the participants’ body pain on both sides of the ears (Shenmen and subcortex) [27,30]. The ear acupoints for obesity management included Shenmen, large intestine, stomach, external nose, endocrine, and forehead, which are known to help control appetite and endocrine function [24].

Smartphone applications were the most frequently used ICT method to promote adherence to self-acupressure. Most of them included acupressure information, such as acupressure point locations and self-acupressure methods [20,22,24,26,27,30,31]. Common methods of offering acupressure content included providing images [20,23,24,26,27,31] or instructional videos [20,21,23,24,26,27,30] representing acupressure points. Four studies provided participants the theoretical background and/or therapeutic mechanisms of acupressure [21,24,27,30]. Moreover, to promote self-acupressure, most smartphone applications had a reminder function in addition to information about acupressure [20,24,26,31]. To support self-acupressure, information on the condition, self-assessment tools, and self-care recommendations were included in the smartphone applications [20,24,26,31]. In addition, there were studies that posted videos on YouTube [21] and on a healthcare application [23], and in one study [25], education on self-acupressure was provided by offering a live streaming service. Finally and most recently, Yeh et al. provided a smartphone application that promotes self-acupressure, but it is also worth noting that they additionally provided a virtual meeting to supplement this (Table 2) [30].

1) Information of acupressure: Explanations of the acupressure procedure, drawings, videos, and photos of the acupressure points.

2) Promotion of acupressure: Timer to guide the one-minute acupressure of each point.

3) Reminder: Every noon reminder to apply acupressure starting five days before the anticipated menstruation.

1) Information of the condition: Visualization of the menstrual cycle.

2) Self-assessment tools: Questionnaires and diaries.

1) Acupoints: both SP6, LI4, LR3.

2) Stimulation time: 1 min of acupressure for each point bilaterally, in total 6 min per session.

3) Stimulation duration: starting 5 days before menstruation to the end of the menstruation.

4) Stimulation frequency: once up to twice daily and when the pain is present twice up to five times daily.

Mącznik (2018)

1) Information of acupressure: Explanations of the acupressure points, acupressure methods, indications/contraindications, and mechanisms of acupressure.

NA

1) Acupoints: LI4.

2) Stimulation time: 3 min.

Priya (2018)NANA

1) Acupoints: six points at each legs without the name of acupoints described.

2) Stimulation time: 25 min (vibration with thermal stimulation for 15 min, vibration with cooling stimulation for 10 min).

3) The patient wears a knee pad on the affected side and uses a smartphone application to determine the stimulation intensity including thermal, cooling, and vibration stimulations..

Bao (2019)

1) Information of acupressure: Locations of three acupressure points, video scripts demonstrating proper self-acupressure method.

1) Other therapeutic components: guided meditation video.

1) Acupoints: HT6, EX-HN3, ST36.

Suen (2019)

1) Information of acupressure: Ear diagram indicating the locations and functions of the six ear points, video scripts demonstrating proper ear pressing method, and precautions for performing AA.

2) Checker: weekly schedule list to input the compliance of pressing.

3) Reminder: Everyday reminder to perform self-pressing on the ear acupoints.

1) Self-assessment tools: Diaries to input the number of bowel movement daily.

AA was performed by practitioner, while self-acupressure was encouraged by the application.

1) Acupoints: Shenmen, Large intestine, Stomach, External nose, Endocrine, Forehead.

2) Stimulation time: 20 times using a constant rhythm per session.

3) Stimulation duration: 8 weeks.

4) Stimulation frequency: three times daily, preferably within 30 min before meals.

Kim (2020)

1) Information of acupressure: Locations of acupressure points, self-practical skills for acupressure.

NA

1) Acupoints: HT7, ST36, P6, LI4, LR3, EX-HN5.

2) Stimulation time: no longer than 40 min.

3) Stimulation duration: 4 weeks.

4) Stimulation frequency: once daily.

Wang (2020)

1) Information of acupressure: Image and description of locations of acupoints, and an instruction animation for self-acupressure.

2) Promotion of acupressure: Timer to guide the one-minute acupressure of each point.

3) Reminder.

1) Self-care recommendation: exercises, dietary supplementations, heating pad/hot water bottle, yoga, medication.

2) Self-assessment tools: Questionnaires and diaries.

1) Acupoints: both SP6, LI4, LR3.

2) Stimulation time: 1 min of acupressure for each point bilaterally, in total 6 min per session.

3) Stimulation duration: starting 5 days before menstruation to the end of the menstruation.

4) Stimulation frequency: at least twice a day, up to five times per day.

Kawi (2021)

1) Information of acupressure: Instructional video including the theoretical background of AA, a breakdown of the AA kit, and a brief introduction about the AA treatment protocol..

2) Promotion of acupressure: Demonstration video including how to use the probe to find the corresponding ear points, how to tape the seeds on the points, and how to stimulate the ear points..

NAParticipants were encouraged to attach seeds and tape to specific ear points for performing AA. This seed was maintained for 5 day, and after removing the seed, a rest period was taken for 2 days.

1) Acupoints: specific ear points corresponding to participant’s body pain locations on both sides of the ears, front and back, Shenmen, Subcortex.

2) Stimulation time: total 3 min per session.

3) Stimulation duration: 5 consecutive days of the week.

4) Stimulation frequency: three times daily.

Rong (2021)NRNRNRTiedt (2021)NANANAYeh (2021)

1) Information of acupressure: Instructional video including the theoretical background of AA, a breakdown of the AA kit, and a brief introduction about the AA treatment protocol..

2) Promotion of acupressure: Demonstration video including how to use the probe to find the corresponding ear points, how to tape the seeds on the points, and how to stimulate the ear points..

3) Virtual meeting: asked the participants about their experiences in self-administering ear acupressure, confirmed accuracy of the seed placements, and verified whether there was a perceived pain reduction..

NAParticipants were encouraged to attach seeds and tape to specific ear points for performing AA. This seed was maintained for 5 day, and after removing the seed, a rest period was taken for 2 days.

1) Acupoints: Shenmen, Subcortex, Low back.

2) Stimulation time: total 3 min per session.

3) Stimulation duration: 5 consecutive days of the week.

4) Stimulation frequency: three times daily.

Zick (2021)

1) Information of acupressure: The location of the acupoints, how long to apply pressure, how to stimulate the acupoints, and the duration and frequency of treatments..

2) Reminder.

1) Self-assessment tools: symptom tracker.

1) Acupoints: EX-HN3, EX17, HT7, SP6, LR3.

2) Stimulation time: total 3 min per session.

3) Stimulation duration: 6 weeks.

4) Stimulation frequency: once daily.

AA = auricular acupressure; NA = not applicable; NR = not reported..

&md=tbl&idx=2' data-target="#file-modal"">Table 2

Contents of interventions and acupressure methods.

Study	Contents related to acupressure	Contents related to others	Acupressure methods
Blödt (2018)	1) Information of acupressure: Explanations of the acupressure procedure, drawings, videos, and photos of the acupressure points. 2) Promotion of acupressure: Timer to guide the one-minute acupressure of each point. 3) Reminder: Every noon reminder to apply acupressure starting five days before the anticipated menstruation.	1) Information of the condition: Visualization of the menstrual cycle. 2) Self-assessment tools: Questionnaires and diaries.	1) Acupoints: both SP6, LI4, LR3. 2) Stimulation time: 1 min of acupressure for each point bilaterally, in total 6 min per session. 3) Stimulation duration: starting 5 days before menstruation to the end of the menstruation. 4) Stimulation frequency: once up to twice daily and when the pain is present twice up to five times daily.
Mącznik (2018)	1) Information of acupressure: Explanations of the acupressure points, acupressure methods, indications/contraindications, and mechanisms of acupressure.	NA	1) Acupoints: LI4. 2) Stimulation time: 3 min.
Priya (2018)	NA	NA	1) Acupoints: six points at each legs without the name of acupoints described. 2) Stimulation time: 25 min (vibration with thermal stimulation for 15 min, vibration with cooling stimulation for 10 min). 3) The patient wears a knee pad on the affected side and uses a smartphone application to determine the stimulation intensity including thermal, cooling, and vibration stimulations..
Bao (2019)	1) Information of acupressure: Locations of three acupressure points, video scripts demonstrating proper self-acupressure method.	1) Other therapeutic components: guided meditation video.	1) Acupoints: HT6, EX-HN3, ST36.
Suen (2019)	1) Information of acupressure: Ear diagram indicating the locations and functions of the six ear points, video scripts demonstrating proper ear pressing method, and precautions for performing AA. 2) Checker: weekly schedule list to input the compliance of pressing. 3) Reminder: Everyday reminder to perform self-pressing on the ear acupoints.	1) Self-assessment tools: Diaries to input the number of bowel movement daily.	AA was performed by practitioner, while self-acupressure was encouraged by the application. 1) Acupoints: Shenmen, Large intestine, Stomach, External nose, Endocrine, Forehead. 2) Stimulation time: 20 times using a constant rhythm per session. 3) Stimulation duration: 8 weeks. 4) Stimulation frequency: three times daily, preferably within 30 min before meals.
Kim (2020)	1) Information of acupressure: Locations of acupressure points, self-practical skills for acupressure.	NA	1) Acupoints: HT7, ST36, P6, LI4, LR3, EX-HN5. 2) Stimulation time: no longer than 40 min. 3) Stimulation duration: 4 weeks. 4) Stimulation frequency: once daily.
Wang (2020)	1) Information of acupressure: Image and description of locations of acupoints, and an instruction animation for self-acupressure. 2) Promotion of acupressure: Timer to guide the one-minute acupressure of each point. 3) Reminder.	1) Self-care recommendation: exercises, dietary supplementations, heating pad/hot water bottle, yoga, medication. 2) Self-assessment tools: Questionnaires and diaries.	1) Acupoints: both SP6, LI4, LR3. 2) Stimulation time: 1 min of acupressure for each point bilaterally, in total 6 min per session. 3) Stimulation duration: starting 5 days before menstruation to the end of the menstruation. 4) Stimulation frequency: at least twice a day, up to five times per day.
Kawi (2021)	1) Information of acupressure: Instructional video including the theoretical background of AA, a breakdown of the AA kit, and a brief introduction about the AA treatment protocol.. 2) Promotion of acupressure: Demonstration video including how to use the probe to find the corresponding ear points, how to tape the seeds on the points, and how to stimulate the ear points..	NA	Participants were encouraged to attach seeds and tape to specific ear points for performing AA. This seed was maintained for 5 day, and after removing the seed, a rest period was taken for 2 days. 1) Acupoints: specific ear points corresponding to participant’s body pain locations on both sides of the ears, front and back, Shenmen, Subcortex. 2) Stimulation time: total 3 min per session. 3) Stimulation duration: 5 consecutive days of the week. 4) Stimulation frequency: three times daily.
Rong (2021)	NR	NR	NR
Tiedt (2021)	NA	NA	NA
Yeh (2021)	1) Information of acupressure: Instructional video including the theoretical background of AA, a breakdown of the AA kit, and a brief introduction about the AA treatment protocol.. 2) Promotion of acupressure: Demonstration video including how to use the probe to find the corresponding ear points, how to tape the seeds on the points, and how to stimulate the ear points.. 3) Virtual meeting: asked the participants about their experiences in self-administering ear acupressure, confirmed accuracy of the seed placements, and verified whether there was a perceived pain reduction..	NA	Participants were encouraged to attach seeds and tape to specific ear points for performing AA. This seed was maintained for 5 day, and after removing the seed, a rest period was taken for 2 days. 1) Acupoints: Shenmen, Subcortex, Low back. 2) Stimulation time: total 3 min per session. 3) Stimulation duration: 5 consecutive days of the week. 4) Stimulation frequency: three times daily.
Zick (2021)	1) Information of acupressure: The location of the acupoints, how long to apply pressure, how to stimulate the acupoints, and the duration and frequency of treatments.. 2) Reminder.	1) Self-assessment tools: symptom tracker.	1) Acupoints: EX-HN3, EX17, HT7, SP6, LR3. 2) Stimulation time: total 3 min per session. 3) Stimulation duration: 6 weeks. 4) Stimulation frequency: once daily.

AA = auricular acupressure; NA = not applicable; NR = not reported..

1. Findings of this review

The studies included in this mini review mainly conducted interventions that combined acupressure and ICTs for pain, cancer-related symptoms, dysmenorrhea, mental health issues, and obesity. Among the included studies, more than half were published after the declaration of the COVID-19 pandemic [25-31], and in four studies [25,28-30], the research rationale was the COVID-19 era. The most commonly used ICT to support self-acupressure was smartphone applications [20,22,24,26-28,30,31], and in one study [22], a Bluetooth-operated kneepad was developed. Two studies [21,23] developed and used instructional videos for self-acupressure. In one study [25], a live streaming service for self-acupressure education and implementation was provided to participants. The most frequently used body acupoints were LI4 and LR3, while the most frequently used ear acupoint was Shenmen.

2. Clinical implications

Given the publication dates of the included studies, it appears that the interest in combining self-acupressure and ICTs has recently increased. In particular, the fact that 57.14% (4/7) [25,28-30] of the papers published after 2020 included the COVID-19 era in their study rationale suggests that the combination of self-acupressure and ICTs is being attempted to address health issues related to the pandemic. In terms of the studies’ target conditions, musculoskeletal injuries or pain, cancer-related symptoms, dysmenorrhea, mental health issues, and obesity were included, and of these, all except mental health issues had been studied before the pandemic. However, both studies [25,28] using the combination of self-acupressure and ICTs for mental health issues described rationales related to COVID-19, and there were no studies published before the pandemic on this topic. Although the small number of studies included limits the interpretation, given that the COVID-19 era has hindered the use of mental health services and that ICT use is being encouraged to overcome this [32], the use of self-acupressure and ICTs to address mental health issues in the context of COVID-19 may be a new and growing research topic.

In the included studies, most of the acupoints stimulated were those considered to have complex effects. For example, the most frequently used body acupoints in the included studies, LI4 and LR3, were the most frequently used acupoints across all diseases, including musculoskeletal symptoms, psychiatric symptoms, and several symptoms of diseases of internal medicine, according to previous findings [33,34]. LI4 and LR3 are a combination commonly referred to as Siguan, and as described in Shan et al. [35], stimulation of these two acupoints can increase a wide range of activities in the somatosensory cortex, limbic–paralimbic system, and basal ganglia. In addition, the modulating effect of gastrointestinal motility [36], improvement of dysmenorrhea [37], improvement of migraine [38], and neuroprotective effects [39] related to the stimulation of these acupoints have been reported. Shenmen, the most frequently used ear acupoint in the included studies, is also considered to have multiple complex effects. In particular, the parasympathetic activation induced by the stimulation of this acupoint suggests that stimulation of this acupoint may be utilized for various stress-related symptoms [40,41]. Moreover, Shenmen was found to be the most frequently used acupoint for AA for insomnia [42]. Since this acupoint is located in the auricular branch of the vagus nerve, it has the potential to be used for the prevention and treatment of diseases related to vagal regulation [43]. In future combinations of self-acupressure and ICTs, it may be simple to use those acupoints that have such complex effects and are easy to discover.

In terms of ICT used, smartphone applications were most common, being employed in 66.67% (8/12) of the included studies [20,22,24,26-28,30,31]. Considering that mobile health solutions including smartphone applications among ICTs are expected to play an important and positive role in the COVID-19 era [44], these results seem natural. In order to support self-acupressure, the basic content included in the smartphone applications was acupressure information, but timers, reminders, and schedule checkers were included to promote self-acupressure in some cases. In addition, as in Yeh et al. [30], a method of supplementing smartphone applications with virtual meetings may also be adopted. Since self-acupressure includes not only the accurate identification of acupoints but also the administration of appropriate acupressure, produced videos can also be useful.

As such, self-acupressure combined with ICTs may be a promising strategy, especially in the COVID-19 era, but the following should be considered. While self-acupressure is considered generally safe [7], the user should be educated on the benefits and harms of self-acupressure so that they do not consider acupressure to be a panacea. According to a survey conducted in Europe, the use of complementary and alternative medicine (CAM) was found to be common in the general population at 25.9%, and while the use of acupressure was found to be < 1% [45], it is one of the most preferred modalities of alternative users (more than 12%), that is, users of CAM modalities who do not visit biomedical professionals [45]. Therefore, patients and physicians must transparently discuss how and when to appropriately apply self-acupressure using ICTs, which requires physicians to have the knowledge to explain the expected effects and concerns of the modality. To facilitate this and to enhance the benefits of self-acupressure, the implementation of an interaction function between clients and managers (ideally medical professionals) in a web-based or application-based approach is encouraged.

3. Limitations

The limitations of this review should be considered. First, this study was conducted as a mini review to review research trends in this field and was not conducted with a rigorous methodology such as a systematic review. In particular, since the search databases used in this review were limited to MEDLINE, EMBASE, and CENTRAL, a future systematic review that uses more comprehensive search strategies for this topic would likely yield more related studies. Therefore, the results of this review may not be representative of the entire field of research in this field. Second, this study did not analyze the effectiveness and safety of self-acupressure combined with ICTs. That is, some of the studies included in this review did not report clinical data. Due to the limited comprehensiveness of search strategies and differences in scope of this review, the findings do not provide evidence to demonstrate the effectiveness and safety of self-acupressure in combination with ICTs. Third, this review focused on published articles. However, in addition to published articles, the combination of self-acupressure and ICTs can be further explored through protocols of registered clinical trial registries or searches in smartphone application stores. This limited comprehensiveness can be supplemented in a systematic review conducted with a rigorous methodology in the future.

The mHealth services market is growing very rapidly, and ICTs are the technological foundation of such telemedicine healthcare. Recently, there have been some attempts to combine ICTs and acupressure, a non-invasive and convenient self-health management method. These studies have mainly focused on musculoskeletal pain or injuries, but recent studies related to mental health issues have emerged in relation to COVID-19. The most commonly used ICT to support self-acupressure was smartphone applications, and most of them provided images representing acupressure points as well as instructional videos. However, few studies have been conducted to date, making it difficult to fully grasp the trends in this field. Therefore, more studies are needed to evaluate the feasibility and efficacy of combining self-acupressure and ICTs in more diverse clinical areas.

Supplementary data to this article can be found online at https://doi.org/10.51507/j.jams.2022.15.4.214

Thanks to Dr. Daniel Pach at Charité - Universitätsmedizin Berlin for reviewing the draft of this article.

This research was supported by the MSIT (Ministry of Science and ICT), Korea, under the Grand Information Technology Research Center support program (IITP-2022-2020-0-01791) supervised by the IITP (Institute for Information & communications Technology Planning & evaluation).

Chan-Young Kwon: Conceptualization, Methodology, Data curation, Writing-Original draft preparation, Writing-Reviewing and Editing. Chao Hsing Yeh: Methodology, Writing-Original draft preparation.

The authors declare no conflict of interest.