Complementary Therapies in Medicine (2015) 23, 339—346
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevierhealth.com/journals/ctim
Acupressure improves the postoperative comfort of gastric cancer patients: A randomised controlled trial Wan-Ting Hsiung a, Yi-Chuan Chang b,c, Mei-Ling Yeh d,∗, Yung-Hsien Chang e a
Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC Department of Nursing, Fooyin University, Taiwan, ROC c National Taipei University of Nursing and Health Sciences, Taiwan, ROC d School of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan, ROC e China Medical University and Hospital, Taiwan, ROC Available online 6 April 2015 b
KEYWORDS Acupressure; Postoperative comfort; Gastric cancer; Pain; Nausea; Vomiting; Flatus; Defecation
Summary Objective: This pilot study evaluated whether acupressure affected the postoperative comfort of gastric cancer patients following a subtotal gastrectomy. Methods: A randomised controlled trial was conducted. Sixty patients were recruited from 141-bed general surgery ward at a 3000-bed medical centre in Northern Taiwan. Participants were randomly assigned to either a control group receiving regular postoperative care or to the experimental group receiving additional acupressure at acupoints of Neiquan (P6) and Zusanli (ST36) for 3 consecutive days. Results: The similarities between two groups were in postoperative pain and the onset of postoperative nausea and vomiting (PONV) at the baseline. Following acupressure, significant differences were found in postoperative pain (P = .03) and time of first flatus (P = .04); but not PONV (P = .49), nor the time of first defecation (P = .34). Conclusions: Acupressure is a simple, noninvasive, safe, and economical procedure for improving the comfort of patients who undergo surgery for gastric cancer. Acupressure at the P6 and ST36 acupoints can improve postoperative comfort by alleviating pain and decreasing the time until first flatus. However, additional research is necessary to elucidate how acupressure can improve postoperative outcomes. © 2015 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: School of Nursing, National Taipei University Nursing and Health Sciences, No. 365, Minte Road, Taipei, Taiwan, ROC. Tel.: +886 2 28227101x3317; fax: +886 2 2821 3233. E-mail address: [email protected] (M.-L. Yeh).
http://dx.doi.org/10.1016/j.ctim.2015.03.010 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
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Introduction Gastric-cancer-related deaths are predicted to rank seventh worldwide by 2030.1 Gastric cancer ranks sixth among the leading causes of cancer-related deaths, causing a mortality rate of 5.5% in Taiwan.2 The guidelines for treating gastric cancer recommend using multimodality algorithms to select surgery, chemotherapy, and radiation therapy regimens, and surgical resection is typically suggested.3,4 However, postoperative pain remains a concern. Gastrointestinal surgery alters the structure and physiological function of the gastrointestinal system, causing extensive tissue damage to the abdominal region and increasing production of inflammatory mediators such as cytokines and neuropeptides.5,6 Consequently, the pain receptors of the skin, muscles, and internal organs transmit signals to the central nervous system (CNS), which, upon cognition, increases the severity of postoperative pain.5,6 Approximately 86% of patients experienced moderate, severe, or extreme pain.7 More details, 26% of patients reported experiencing moderate pain, 33% complained of severe pain at rest, and 8—13% experienced persistent severe pain despite receiving postoperative analgesics.8 In addition, 20—30% of patients exhibited postoperative nausea and vomiting (PONV) after undergoing anaesthesia and surgery.7 Four crucial predictors are associated with an increased incidence of PONV, namely the female sex, a history of motion sickness or PONV, being a nonsmoker, and the use of postoperative opioids.9,10 Treating PONV involves using antiemetic drugs that can cause various side effects, including headache, extrapyramidal disturbance, and tachycardia.11 These conditions are typically treated by correcting fluid levels, electrolyte levels, or nutritional deficiencies12 ; however, treatment increases the cost and length of hospital stays.13 Because a subtotal gastrectomy reduces stomach volume and gastrointestinal motility, yielding postoperative discomfort, nonpharmacological remedies, such as acupoint stimulation, can be used as complementary interventions. According to traditional Chinese medicine (TCM) principles, the meridian system comprises a network of conduits through which qi and blood circulate, connecting the internal organs with the external environment and transmitting qi between them. Specific acupoints can be stimulated along the meridians to treat diseases; thus, acupoint stimulation has become a popular mode of postoperative care.14 Similar to acupuncture, acupressure is categorised as a type of acupoint stimulation, but the manipulation is performed by pressing acupoints with the finger or thumb instead of a needle.15 This treatment is not limited by time, location, or the environment. Stimulating acupoints can release neurotransmitters and improve physical function.16 Numerous studies have reported the benefits of acupoint stimulation in relieving the pain of postoperative patients who underwent spine surgery17,18 and in for reducing the need for opioid consumption following surgery.19,20 However, certain studies have yielded inconclusive findings regarding how acupoint stimulation affects the intensity of postoperative pain.20,21 A review paper concluded that acupuncture and electroacupuncture improved gastrointestinal motility and gastric emptying.22 One study reported that acupressure also yielded such improvements, but some of the findings were
W.-T. Hsiung et al. questionable because the patients’ symptoms were evaluated using only a stethoscope.23 The time of the first flatus and first defecation are recommended times for assessing gastrointestinal motility following abdominal surgery.24 A meta-analysis25 and other studies26,27 have supported the position that jointly administering antiemetic drugs and stimulating the P6 acupoint can prevent the onset of PONV. Numerous studies have indicated that stimulating the P6 acupoint within 24 h of surgery can reduce the incidence of PONV.27—29 However, certain studies have yielded inconclusive findings regarding PONV.18,30 This study investigated various methods of acupoint stimulation. Invasive acupuncture may cause hematomas, and acupuncture needles should not be inserted by a nurse.31 Receiving noninvasive acupressure while wearing a wristband may cause discomfort, red indentations, itching, blistering, and swelling of the wrist,11,25 and a capsicum plaster may cause skin irritation at applied sites.32 Therefore, to minimise the risk of complications, acupressure was performed manually in this study. This pilot study evaluated whether acupressure affected the comfort of gastric cancer patients following a subtotal gastrectomy. Specifically, postoperative pain, gastrointestinal motility, and PONV were hypothesised to significantly differ between the control and acupressure groups.
Methods Research design and participants This study was a randomised controlled trial. Participants were randomly assigned to either the control group or experimental group. The control group received regular postoperative care, whereas the experimental group received acupressure for 3 days in addition to regular care. An independent statistician used a computer programme to randomly generate numbers and information regarding the allocation and provided opaque, sealed envelopes to the researcher. Patients who were diagnosed with gastric cancer and scheduled for subtotal gastrectomy were consecutively recruited from the 141-bed general surgery ward at a 3000bed medical teaching hospital in Northern Taiwan. The inclusion criteria stipulated that patients (1) be at least 18 years of age; (2) be capable of receiving general anaesthesia; (3) be classified as I—III according to the American Society of Anesthetists (ASA); and (4) had no impairment, infection, bruising, or bleeding at acupressure sites. Patients were excluded if they previously underwent abdominal surgery, were receiving concurrent chemotherapy or radiotherapy, were diagnosed with other types of cancer, or participated in similar studies. Based on the primary outcome of pain intensity with an effect size of f = 0.3318 and 80% power at a 5% level of significance using repeated measures, an estimated minimal total sample size of 56 was required for a pilot trial. Fig. 1 shows a flowchart of the participant recruitment process and the research design. Of the 183 patients eligible for participation in this study, 60 were recruited; all of them provided written informed consent before the study and were randomly assigned to a group. One participant in the
Acupressure improves the postoperative comfort
341
Assessed for eligibility (n=183) Not met inclusion criteria (n=73) Refused to parcipate (n=32) Others (n=18) Met inclusion criteria (n=60) Randomized
Acupressure group (n=30)
st
Acupressure for 12 min
Acupressure for 12 min
Acupressure for 12 min
Control group (n=30)
st
Characteriscs of demography & clinic were assessed before surgery
Day 1 (1 ) aer surgery (n=27)
Day 1 (1 ) aer surgery (n=29)
Pain intensity was assessed 20 min aer the intervenon
Day 2 (2nd) aer surgery (n=26)
Day 2 (2nd) aer surgery (n=28)
Pain intensity was assessed 20 min aer the intervenon
rd
Day3 (3 ) aer surgery (n=28)
Day3 (3 ) aer surgery (n=26)
Figure 1
rd
Pain intensity was assessed 20 min aer the intervenon
The flow chart of participants of this study.
experimental group withdrew from the study because of exhaustion, and 3 other patients withdrew after refusing acupressure treatment without citing a reason. In addition, 2 participants withdrew from the control group, stating they were uncomfortable with their data being collected following surgery. The final experimental and control groups comprised 26 and 28 participants, respectively, exhibiting a 10% attrition rate.
The efficacy of acupressure intervention was established by obtaining qi (de qi) from each acupoint. De qi refers to the process of stimulating an acupoint to induce soreness, numbness, distension, or heaviness proximal to the stimulated acupoint.15 Acupressure was performed by a researcher who had completed 40 academic credits in TCM and received certification from 2 practising TCM physicians. Three TCM physicians with clinical acupuncture experience reviewed
Intervention Acupressure is designed to stimulate the 2 acupoints shown in Fig. 2—–the Neiquan (P6) and Zusanli (ST36).16 Stimulating the P6 acupoint can prevent PONV and relieve gastrointestinal problems, whereas stimulating the ST36 acupoint can improve digestive system function.33 The P6 acupoint is located 5 cm proximal to the midpoint of the transverse crease of the wrist, between the tendons of the flexor carpi radialis and palmaris longus, whereas the ST36 acupoint is located 7.5 cm below the knee, approximately 1.5 cm lateral to the tibia on the anterior tibialis.33 Three 12-min acupressure intervention sessions were held over 3 consecutive days following surgery. To ensure that the order and duration were consistent for each press, the acupressure proceeded sequentially from the right P6 acupoint to the right ST36 acupoint, and subsequently from the left P6 acupoint to the left ST36 acupoint. During the acupressure intervention, the thumb was used to (1) apply pressure for 5 s; (2) release for 1 second; (3) knead for 5 s; and (4) release for 1 second. This process was repeated for up to 3 min at each of the 4 acupoints.34,35
Figure 2
Diagram of acupoint location.
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and verified that the acupressure procedure was appropriate, and 2 other TCM physicians verified the acupressure practice measures (acupoint location, press approach, and press duration). The control group received no acupressure during the study. Prior to surgery, a nurse used multimedia to educate all participants in abdominal surgery. Following surgery, regular postoperative care, including NPO, oral care, chest percussion, steam inhalation, coughing, deep breathing, coach training, using an abdominal binder, and walking, was provided.
Table 1
Data measurement The data set comprised information on demographic characteristics (age, height, weight, sex, education level, and marital status) and medical conditions (time of defecation, symptoms presented upon hospitalisation, ASA status, surgery duration, analgesic methods, and tumour stage). An 11-point scale was used to assess pain intensity, and the anchors of the scale were 0 (no pain or no interference), 1—3 (mild pain), 4—6 (moderate pain), 7—9 (severe pain), and 10 (extreme or uncontrollable pain).
Comparisons of demographic and medical characteristics between groups.
Variables
Control (n = 28)
Experiment (n = 26)
2 /t (p)
Age, years (M ± SD) Height, cm (M ± SD) Weight, kg (M ± SD) Gender (n, %) Male Female Education level (n, %) Elemental & under Junior high Senior high College and above Marital status (n, %) Unmarried Married Divorced Widowed Defecation (n, %) Normal Abnormal Symptoms for hospitalisation (n, %) None Abdominal pain Abdominal distention Tarry stool Nausea or vomit American society of anaesthetists status (n, %) 2 = 0.94 (0.63) I II III Operation duration (M ± SD) Analgesic (n, %) PCA, intravenous PCA, epidural Others Tumour stage (n, %) 1 2 3 Hour for first flatus (M ± SD) Hour for first defecation (M ± SD)
64.11 ± 15.60 161.41 ± 8.31 64.20 ± 10.18
60.54 ± 10.89 164.37 ± 8.22 64.98 ± 11.55
t = 0.98 (0.33) t = −1.31 (0.20) t = −0.26 (0.79) 2 = 0.21 (0.65)
20 (71.43%) 8 (28.57%)
20 (76.92%) 6 (23.08%)
10 (35.71%) 4 (14.29%) 5 (17.86%) 9 (32.14%)
9 5 5 7
PCA: patient-controlled analgesia.
2 = 0.34 (0.95) (34.62%) (19.23%) (19.23%) (26.92%) 2 = 1.93 (0.59) 1 (3.57%) 25 (89.29%) 1 (3.57%) 1 (3.57%)
0 (0%) 25 (96.15%) 0 (0%) 1 (3.85%) 2 = 0.26 (0.61)
25 (89.29%) 3 (10.71%)
22 (84.62%) 4 (15.38%)
11 (39.29%) 12 (42.86%) 6 (21.43%) 6 (21.43%) 4 (14.29%)
8 (30.77%) 6 (23.08%) 12 (46.15%) 3 (11.54%) 4 (15.38%)
5 (17.86%) 17 (60.71%) 6 (21.43%) 326.43 ± 59.00
3 (11.54%) 19 (73.08%) 4 (15.38%) 332.31 ± 52.58
5 (17.86%) 21 (75.00%) 2 (7.14%)
10 (38.46%) 16 (61.54%) 0(0%)
10 (35.71%) 5 (17.86%) 13 (46.43%) 98.09 ± 23.45 114.63 ± 22.65
13 (50.00%) 6 (23.08%) 7 (26.92%) 79.97 ± 37.31 108.55 ± 23.29
2 = 0.93 2 = 2.37 2 = 3.70 2 = 0.95 2 = 0.01
(0.34) (0.12) (0.05) (0.33) (0.91)
t = −0.39 (0.70) 2 = 4.27 (0.12)
2 = 2.21(0.33)
t = 2.12(0.04) t = 0.97(0.34)
Acupressure improves the postoperative comfort 4.673
4.732
5 4.732
3.929
4 3.714 3.904
Pain score
Gastrointestinal motility was evaluated by recording the time of the first flatus and first defecation following surgery. The Rhodes Index of Nausea, Vomiting, and Retching (INVR) were used to assess the severity of PONV. The INVR is an 8item questionnaire that uses a 5-point scale (ranging from 0 to 4) to obtain information regarding symptoms, symptom occurrence, and symptom distress associated specifically with nausea, vomiting, and retching.36,37 In addition to providing a total score for symptoms, symptom occurrence, and symptom distress, the INVR yields subscale scores for the 3 symptoms. High scores are indicative of severe PONV. Doctor Rhodes provided written authorisation for the INVR to be translated into Chinese for use in this study. The INVR exhibited strong reliability in the previous studies,18,38 and was verified in the current study (Cronbach’s ˛ = 0.90).
343
3 2.923
2.596
2 1 0
Figure 3 surgery.
The trend of pain intensity across times after
5
First, ethical approval was obtained from the institutional review board of the study hospital (Ref code 97-01-03A). Second, after suitable participants were identified, the study was thoroughly explained to the participants the day prior to surgery. All participants received the same regimen of preoperative medication. Third, prior to the interventions, the outcome measures were used in evaluating each participant to establish a baseline and, fourth, participants assigned to the experimental group or control group were accommodated in separate wards after surgery. Individual interventions commenced on the second day following surgery. Throughout the interventions, all participants were in the semi-Fowler position and privacy was maintained using curtains. The entire process, including preparation and acupressure or usual care, lasted 20 min. Fifth, the outcomes of the interventions, including adverse effects, were recorded.
Data analysis Data were analysed using IBM SPSS Version 20.0 for Windows. Descriptive statistics (frequency; percentage; mean; standard deviation) were calculated to identify the demographic characteristics, medical conditions, and outcomes. Inferential statistics (chi-square test, t test, and repeated measures analysis of variance, ANOVA) were then used to compare the outcomes of the groups.
Results The mean age of the participants was 62.39 ± 15.53 years, and most participants were men (74.07%) and had a college education level or higher (29.63%). Table 1 shows the demographic and medical characteristics at the baseline, indicating no significant differences between the groups (P > .05). Most participants (87.03%) exhibited a normal defecation status, and abdominal distension was the primary reason for visiting a doctor (33.33%). The duration of the subtotal gastrectomy averaged 329.26 ± 55.55 min. Most participants (96.30%) used patient-controlled analgesia (PCA) to managing postoperative pain. Within 10—15 min following surgery, the participants were connected to a PCA
INVR score
4
Data collection
2.68
3 2
1.21
1.43 1.46
1.42 1
0.62
1.12 0
0.77
Figure 4 The trend of scores of nausea and vomiting across times after surgery.
device in the anaesthesia recovery room, and the device was used for at least 3 days following surgery. The analgesics were delivered either intravenously (100 mg of morphine and 0.1 mg of droperidol per 100 mL) or through epidural injection (600 mg of marcaine and 600 g of fentanyl per 600 mL). Fig. 3 shows the postoperative abdominal pain from the baseline until Day 3 following surgery. No significant group differences were observed at the baseline (t = 0.09, P = .93). The trend in mean pain intensity exhibited a gradual decrease, and significant differences were observed between the groups (F = 4.86, P = .03) and within the groups (F = 7.12, P = .001). Fig. 4 shows the group PONV scores from the baseline until Day 3 following surgery. No significant group differences were observed at the baseline (t = 1.3, P = .2). In addition, the trend indicated no significant differences between the groups (F = 0.47, P = .49) and within the groups (F = 0.09, P = .86). As shown in Table 1, gastrointestinal motility following surgery, indicating a significant difference between the groups at the time of the first flatus (t = 2.12, P = .04), but not at the time of the first defecation (t = 0.97, P = .34). Eight participants in the experimental group and 17 in the control group perceived the first abdominal distension, yielding a significant difference (2 = 4.86, P = .03). No adverse effects occurred during this study.
Discussion Based on the similar demographic characteristics and medical conditions between the groups, this pilot study supported the hypothesis that acupressure reduces acute postoperative pain in the first 3 days of subtotal gastrectomy. The pain intensity gradually decreased in both groups,
344 as shown in Fig. 3; however, the pain intensity among the experimental group decreased from moderate to mild, and was alleviated sooner compared with that of the control group. This was similar to other studies of spine surgery,17,18 hysterectomy,39 and abdominal surgery.40 Stimulating acupoints rectifies qi, stabilises the body, and strengthens bodily functions.34 Acupoint stimulation not only enhanced the alleviation of postoperative pain but also reduced morphine consumption.19,41 One study did not support that acupoint stimulation reduces the pain of hysterectomy patients; however, a decrease was observed in the consumption of postoperative opioids.20 Although total opioid consumption following surgery was not calculated in this study, 96.3% of the participants used PCA, and participants in both groups exhibited similar PCA use. A study of lumbar spine surgery patients using PCA showed that combining acupressure and electrical stimulation enhanced the efficacy of analgesics and reduced the consumption of opioids.17 The experimental group experienced greater pain relief than did the control group during the first 3 days following surgery, supporting the findings of several previous studies. This is consistent with the alleviation of postoperative pain observed in patients who have undergone hysterectomy39 or spine surgery.17,18 The pain intensity gradually decreased in the control group because cellular response contributes to wound healing.42 Moreover, stimulating the P6 and ST36 acupoints produces an analgesic effect and reduces postoperative pain. According to TCM principles, stimulating the meridian acupoint releases endorphins within the CNS and modulates physiological reactions.16 Although the mechanism of acupressure-induced analgesia remains unclear,43 strong evidence supports that acupressure alleviates pain.44 Acupressure stimulates large myelinated fibres that inhibit nociceptive stimuli, resulting in the release of ␥-aminobutyric acid, which alleviates pain according to the gate control theory.45 This study confirmed that, in addition to alleviating pain, acupoint stimulation improves gastrointestinal motility following surgery. The first flatus and first defecation recorded in the experimental group were respectively 18 and 6 h earlier than those recorded in the control group. These results are similar to those obtained in another study.46 It is an important clinical assessment that the first flatus following abdominal surgery detects gastrointestinal motility.5,24 Enteral nutrition also contributes to the recovery of gastrointestinal motility after gastrointestinal surgery.47 In addition, 53.8% of patients in the experimental group reported passing gas and feeling comfortable and relaxed during and immediately following acupressure. These results are similar to those of a study on hysterectomy patients.23 However, the patients did not consume food throughout this study, which may inhibit gastrointestinal motility.47 In addition, a gastrointestinal anastomosis using the contrast agent tested on the fifth day following surgery, which was close to the time of the first postoperative defecation. Therefore, the time until the first defecation may have been affected. Studies that evaluate how acupressure affects the gastrointestinal motility of abdominal surgical patients are few, and future studies should examine and clarify these effects.
W.-T. Hsiung et al. Opioid analgesics used for relieving postoperative pain reduce gastrointestinal motility and cause PONV. This study observed that acupoint stimulation elicited a gradual decrease in PONV during the first 3 days following surgery. The experimental group exhibited a slight faster recovery from nausea, vomiting, and retching symptoms than the control group did. This observation is consistent with those of previous studies of acupoint stimulation that used wristbands following urological surgery30 and caesarean delivery,48 and acupressure during chemotherapy cycle for postoperative stomach cancer patients49 as well as with those of a previous study that reported inconclusive results regarding how acupoint stimulation alleviates PONV in spinal surgery patients.18 However, the results of this study differ from those of studies of patients undergoing gynaecological surgery,29 strabismus surgery,27 and hysterectomy.50 A possible cause of this inconsistency is the nasogastric tube used in this study; this tube could have reduced the occurrence of nausea and vomiting.5,51 Combining droperidol with morphine through PCA is also associated with a low incidence of PONV,52,53 but suppresses the effects of acupressure on PONV. This study yielded low Apfel risk scores,9 possibly because most participants were men who exhibited no history of motion sickness. The effect of acupressure on nausea and vomiting is relatively inconsistent44 and warrants further research.
Research limitations In accordance with the research design, acupressure was performed for 3 consecutive days following surgery; therefore, the long-term effects of acupressure remain unknown. The lack of placebo acupressure is a limitation. Potential contamination might occur naturally, although the experimental and control groups were separated in different wards. Biochemical outcomes for enkephalin, beta-endorphin, or endomorphin were not assessed. The sample size based on a medium effect size of the outcome of pain intensity may not be sufficient for testing all hypotheses. Assessing the relationships among the level of interference and activity, the frequency and dosage of analgesics, and other morphine-induced side effects distinct from PONV would strengthen the current findings regarding the efficacy of acupressure in managing postoperative comfort. Data collected from one hospital might not be generalisable to other hospitals or settings. Future research should consider using placebo interventions, large sample sizes, biochemical and other measures, and multicentre data collection.
Conclusions Postoperative pain is one the most common, but avoidable, therapeutic problems. Acupressure can be applied at the P6 and ST36 acupoints as an effective alternative to alleviating pain and to reduce the time of the first flatus following surgery. Acupressure is a simple, noninvasive, safe, and economical procedure that can be applied in health care and clinical practice. Healthcare professionals receiving appropriate education and training can administer acupressure to patients. By integrating TCM with Western medicine, nurses
Acupressure improves the postoperative comfort can improve the quality of care and reduce related costs. This was a pilot trial, and additional research is necessary to clarify the effect of acupressure in improving gastrointestinal motility and preventing PONV following surgery.
345
19.
20.
Conflict of interest The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
21.
22.
References 1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. Public Libr Sci 2006;3: 2015—30. 2. Department of Health, Executive Yuan, R.O.C. Statistics cause of death statistic http://www.doh.gov.tw/CHT2006/DM/ DM2 2.aspx?class no=440&level no=1 [accessed 09.01.11]. 3. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: gastric cancer. http:// www.nccn.org/professionals/physician gls/PDF/gastric.pdf [accessed 03.10.13]. 4. Meyer HJ, Wilke H. Treatment strategies in gastric cancer. Deutsches Arzteblatt International 2011;108:698—706. 5. Mochiki E, Asao T, Kuwano H. Gastrointestinal motility after digestive surgery. Surg Today 2007;37:1023—32. 6. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;13:1618—25. 7. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Post-operative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534—40. 8. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002;89:409—23. 9. Apfel CC, Laara E, Koivuranta M, Greim CA. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693—700. 10. Golembiewski JA, O’Brien DJ. A systematic approach to the management of postoperative nausea and vomiting. J Perianesth Nurs 2002;7:364—76. 11. Doran K, Halm MA. Integrating acupressure to alleviate postoperative nausea and vomiting. Am J Crit Care 2010;19:553—6. 12. Ali T, Hasan M, Hamadani M, Harty RF. Gastroparesis. South Med J 2007;100:281—6. 13. Mack LA, Kaklamanos IG, Livingstone AS, Levi JU, Robinson C, Sleeman D, et al. Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy. Ann Surg 2004;240:845—51. 14. Yang ES, Li PW, Nilius B, Li G. Ancient Chinese medicine and mechanistic evidence of acupuncture physiology. Pflugers Arch 2011;462:645—53. 15. WHO international standard terminologies on traditional medicine in the western Pacific region. Western Pacific Region: World Health Organization; 2007. 16. Yeh ML, Chen HH, Lin IH. Contemporary meridians and acupoints in practice. Taipei city, Taiwan, ROC: Farseeing; 2004. 17. Chung YC, Tsou MY, Chen HH, Lin JG, Yeh ML. Integrative acupoint stimulation to alleviate postoperative pain and morphine-related side effects: a sham-controlled study. Int J Nurs Stud 2013;51:370—8. 18. Yeh ML, Chung YC, Chen KM, Tsou MY, Chen HH. Acupoint electrical stimulation reduces acute postoperative pain in surgical
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
35.
36.
37.
patients with patient-controlled analgesia: a randomized controlled study. Altern Ther 2010;16:10—8. Chung YC, Chien HC, Chen HH, Yeh ML. Acupoint stimulation to improve analgesia quality for lumbar spine surgical patients. Pain Manag Nurs 2015;15:738—47. Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The effect of high and low frequency electoacupuncture in pain after lower abdominal surgery. Pain 2002;99:509—14. Wu HC, Liu YC, Ou KL, Chang YH, Hsieh CL, Tsai-Angela HC, et al. Effects of acupuncture on post-cesarean section pain. Chin Med J 2009;122:1743—8. Yin J, Chen JDZ. Gastrointestinal motility disorders and acupuncture. Auton Neurosci 2010;157:31—7. Chen LL, Hsu SF, Wang MH, Chen CL, Lin YD, Lai JS. Use of acupressure to improve gastrointestinal motility in women after trans-abdominal hysterectomy. Am J Chin Med 2003;31:781—90. Madsen D, Sebolt T, Cullen L, Folkedahl B, Mueller T, Richardson C, et al. Listening to bowel sounds: an evidence-based practice project: nurses find that a traditional practice isn’t the best indicator of returning gastrointestinal motility in patients who’ve undergone abdominal surgery. Am J Nurs 2005;105:40—9. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2009;15:1—120. Agarwal A, Bose N, Gaur A, Singh U, Gupta MK, Singh D. Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth 2002;49:554—60. Ebrahim-Soltani A, Mohammadinasab H, Goudarzi M, Arbabi S, Mohtaram R, Afkham K, et al. Acupressure using ondansetron versus metoclopramide on reduction of postoperative nausea and vomiting after strabismus surgery. Arch Iran Med 2010;13:288—93. Amir SH, Bano S, Khan RM, Ahmed M, Zia F, Nasreen F. Electrostimulation at P6 for prevention of PONV. J Anaesth Clin Pharmacol 2007;23:383—6. Turgut S, Ozalp G, Dikmen S, Savli S, Tuncel G, Kadiogullari N. Acupressure for postoperative nausea and vomiting in gynaecological patients receiving patient-controlled analgesia. Eur J Anaesth 2007;24:87—91. Agarwal A, Pathak A, Gaur A. Acupressure wristbands do not prevent postoperative nausea and vomiting after urological endoscopic surgery. Can J Anaesth 2000;47:319—24. Abraham J. Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults. J Perioper Pract 2008;18:543—51. Misra MN, Pullani AJ, Mohamed ZU. Prevention of PONV by acustimulation with capsicum plaster is comparable to ondansetron after middle ear surgery. Can J Anesth 2005;52:485—9. Yeh ML, Chen HH, Lin IH. Meridians and Acupoints of Chinese Medicine. Taipei city, Taiwan, ROC: Farseeing; 2004. Yeh ML, Chung YC, Chen KM, Chen HH. Pain reduction of acupoint electrical stimulation for spinal surgery patients: a placebo-controlled study. Int J Nurs Stud 2011;48: 703—9. Yeh ML, Hung YL, Chen HH, Lin JG, Wang YJ. Auricular acupressure combined with an Internet-based intervention or alone for primary dysmenorrhea: a control study. Evid Based Complement Alternat Med 2013. http://dx.doi.org/10.1155/2013/316212 [accessed 19.03.14]. Rhodes VA, Watson PM, Johnson MH. Development of a reliable and valid measures of nausea and vomiting. Cancer Nurs 1984;7:33—41. Rhodes VA, McDaniel RW. The index of nausea, vomiting, and retching: a new format of the index of nausea and vomiting. Oncol Nurs Forum 1999;26:889—94.
346 38. Chou FH, Avant KC, Kuo SH, Cheng HF. Assessing the psychometric and language equivalency of the Chinese versions of the index of nausea, vomiting and retching, and the prenatal self-evaluation questionnaire. Kaohsiung J Med Sci 2005;21: 314—21. 39. Kim KS, Nam YM. The analgesic effects of capsicum plaster at the Zusanli point after abdominal hysterectomy. Anesth Analg 2006;103:709—13. 40. Kotani N, Hashimoto H, Sato Y, Sessler D, Yoshioka H, Kitayama M, et al. Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology 2001;95: 349—56. 41. Chen YC, Liu HJ, Lin JG. Assessment on the effect of postoperative acupuncture stimulation to pain relief after total knee replacement. Taiwan J Chin Med 2005;34:5—23. 42. Reinke JM, Sorg H. Wound repair and regeneration. Eur Surg Res 2012;49:35—43. 43. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth 2008;101:151—60. 44. Robinson N, Lorenc A, Liao X. The evidence for Shiatsu: a systematic review of Shiatsu and acupressure. BMC Complement Altern Med 2011;11:88. 45. Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965;150:971—9.
W.-T. Hsiung et al. 46. Wang SG, Tian S, Li GH. Use of drugs at Zusanli to exercise a influence on gastrointestinal motility. Chin J Surg Integr Tradit West Med 2007;13:143—5. 47. Kawasaki N, Suzuki Y, Nakayoshi T, Hanyu N, Nakao M, Takeda A, et al. Early postoperative enteral nutrition is useful for recovering gastrointestinal motility and maintaining the nutritional status. Surg Today 2009;39:225—30. 48. Ho CM, Tsai HJ, Chan KH, Tsai SK. P6 Acupressure does not prevent emesis during spinal anesthesia for cesarean delivery. Obstet Gynecol Surv 2006;61:498—9. 49. Shin YH, Kim TI, Shin MS, Juon HS. Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients. Cancer Nurs 2004;27:267—74. 50. Frey UH, Scharmann P, Lohlein C, Peters J. P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients. Br J Anaesth 2009;102:620—5. 51. Chen CJ, Liu TP, Yu JC, Hsua SD, Hsieh TY, Chu HC, et al. Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy. World J Gastroenterol 2012;18:251—6. 52. Apfel CC, Cakmakkaya OS, Frings G, Kranke P, Malhotra A, Stader A, et al. Droperidol has comparable clinical efficacy against both nausea and vomiting. Br J Anaesth 2009;103:359—63. 53. Aubrun F, Mazoit JX, Riou B. Postoperative intravenous morphine titration. Br J Anaesth 2012;108:193—201.
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Acupressure improves the postoperative comfort of gastric cancer patients: A randomised controlled trial Wan-Ting Hsiung a, Yi-Chuan Chang b,c, Mei-Ling Yeh d,∗, Yung-Hsien Chang e a
Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC Department of Nursing, Fooyin University, Taiwan, ROC c National Taipei University of Nursing and Health Sciences, Taiwan, ROC d School of Nursing, National Taipei University of Nursing and Health Sciences, Taiwan, ROC e China Medical University and Hospital, Taiwan, ROC Available online 6 April 2015 b
KEYWORDS Acupressure; Postoperative comfort; Gastric cancer; Pain; Nausea; Vomiting; Flatus; Defecation
Summary Objective: This pilot study evaluated whether acupressure affected the postoperative comfort of gastric cancer patients following a subtotal gastrectomy. Methods: A randomised controlled trial was conducted. Sixty patients were recruited from 141-bed general surgery ward at a 3000-bed medical centre in Northern Taiwan. Participants were randomly assigned to either a control group receiving regular postoperative care or to the experimental group receiving additional acupressure at acupoints of Neiquan (P6) and Zusanli (ST36) for 3 consecutive days. Results: The similarities between two groups were in postoperative pain and the onset of postoperative nausea and vomiting (PONV) at the baseline. Following acupressure, significant differences were found in postoperative pain (P = .03) and time of first flatus (P = .04); but not PONV (P = .49), nor the time of first defecation (P = .34). Conclusions: Acupressure is a simple, noninvasive, safe, and economical procedure for improving the comfort of patients who undergo surgery for gastric cancer. Acupressure at the P6 and ST36 acupoints can improve postoperative comfort by alleviating pain and decreasing the time until first flatus. However, additional research is necessary to elucidate how acupressure can improve postoperative outcomes. © 2015 Elsevier Ltd. All rights reserved.
∗ Corresponding author at: School of Nursing, National Taipei University Nursing and Health Sciences, No. 365, Minte Road, Taipei, Taiwan, ROC. Tel.: +886 2 28227101x3317; fax: +886 2 2821 3233. E-mail address: [email protected] (M.-L. Yeh).
http://dx.doi.org/10.1016/j.ctim.2015.03.010 0965-2299/© 2015 Elsevier Ltd. All rights reserved.
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Introduction Gastric-cancer-related deaths are predicted to rank seventh worldwide by 2030.1 Gastric cancer ranks sixth among the leading causes of cancer-related deaths, causing a mortality rate of 5.5% in Taiwan.2 The guidelines for treating gastric cancer recommend using multimodality algorithms to select surgery, chemotherapy, and radiation therapy regimens, and surgical resection is typically suggested.3,4 However, postoperative pain remains a concern. Gastrointestinal surgery alters the structure and physiological function of the gastrointestinal system, causing extensive tissue damage to the abdominal region and increasing production of inflammatory mediators such as cytokines and neuropeptides.5,6 Consequently, the pain receptors of the skin, muscles, and internal organs transmit signals to the central nervous system (CNS), which, upon cognition, increases the severity of postoperative pain.5,6 Approximately 86% of patients experienced moderate, severe, or extreme pain.7 More details, 26% of patients reported experiencing moderate pain, 33% complained of severe pain at rest, and 8—13% experienced persistent severe pain despite receiving postoperative analgesics.8 In addition, 20—30% of patients exhibited postoperative nausea and vomiting (PONV) after undergoing anaesthesia and surgery.7 Four crucial predictors are associated with an increased incidence of PONV, namely the female sex, a history of motion sickness or PONV, being a nonsmoker, and the use of postoperative opioids.9,10 Treating PONV involves using antiemetic drugs that can cause various side effects, including headache, extrapyramidal disturbance, and tachycardia.11 These conditions are typically treated by correcting fluid levels, electrolyte levels, or nutritional deficiencies12 ; however, treatment increases the cost and length of hospital stays.13 Because a subtotal gastrectomy reduces stomach volume and gastrointestinal motility, yielding postoperative discomfort, nonpharmacological remedies, such as acupoint stimulation, can be used as complementary interventions. According to traditional Chinese medicine (TCM) principles, the meridian system comprises a network of conduits through which qi and blood circulate, connecting the internal organs with the external environment and transmitting qi between them. Specific acupoints can be stimulated along the meridians to treat diseases; thus, acupoint stimulation has become a popular mode of postoperative care.14 Similar to acupuncture, acupressure is categorised as a type of acupoint stimulation, but the manipulation is performed by pressing acupoints with the finger or thumb instead of a needle.15 This treatment is not limited by time, location, or the environment. Stimulating acupoints can release neurotransmitters and improve physical function.16 Numerous studies have reported the benefits of acupoint stimulation in relieving the pain of postoperative patients who underwent spine surgery17,18 and in for reducing the need for opioid consumption following surgery.19,20 However, certain studies have yielded inconclusive findings regarding how acupoint stimulation affects the intensity of postoperative pain.20,21 A review paper concluded that acupuncture and electroacupuncture improved gastrointestinal motility and gastric emptying.22 One study reported that acupressure also yielded such improvements, but some of the findings were
W.-T. Hsiung et al. questionable because the patients’ symptoms were evaluated using only a stethoscope.23 The time of the first flatus and first defecation are recommended times for assessing gastrointestinal motility following abdominal surgery.24 A meta-analysis25 and other studies26,27 have supported the position that jointly administering antiemetic drugs and stimulating the P6 acupoint can prevent the onset of PONV. Numerous studies have indicated that stimulating the P6 acupoint within 24 h of surgery can reduce the incidence of PONV.27—29 However, certain studies have yielded inconclusive findings regarding PONV.18,30 This study investigated various methods of acupoint stimulation. Invasive acupuncture may cause hematomas, and acupuncture needles should not be inserted by a nurse.31 Receiving noninvasive acupressure while wearing a wristband may cause discomfort, red indentations, itching, blistering, and swelling of the wrist,11,25 and a capsicum plaster may cause skin irritation at applied sites.32 Therefore, to minimise the risk of complications, acupressure was performed manually in this study. This pilot study evaluated whether acupressure affected the comfort of gastric cancer patients following a subtotal gastrectomy. Specifically, postoperative pain, gastrointestinal motility, and PONV were hypothesised to significantly differ between the control and acupressure groups.
Methods Research design and participants This study was a randomised controlled trial. Participants were randomly assigned to either the control group or experimental group. The control group received regular postoperative care, whereas the experimental group received acupressure for 3 days in addition to regular care. An independent statistician used a computer programme to randomly generate numbers and information regarding the allocation and provided opaque, sealed envelopes to the researcher. Patients who were diagnosed with gastric cancer and scheduled for subtotal gastrectomy were consecutively recruited from the 141-bed general surgery ward at a 3000bed medical teaching hospital in Northern Taiwan. The inclusion criteria stipulated that patients (1) be at least 18 years of age; (2) be capable of receiving general anaesthesia; (3) be classified as I—III according to the American Society of Anesthetists (ASA); and (4) had no impairment, infection, bruising, or bleeding at acupressure sites. Patients were excluded if they previously underwent abdominal surgery, were receiving concurrent chemotherapy or radiotherapy, were diagnosed with other types of cancer, or participated in similar studies. Based on the primary outcome of pain intensity with an effect size of f = 0.3318 and 80% power at a 5% level of significance using repeated measures, an estimated minimal total sample size of 56 was required for a pilot trial. Fig. 1 shows a flowchart of the participant recruitment process and the research design. Of the 183 patients eligible for participation in this study, 60 were recruited; all of them provided written informed consent before the study and were randomly assigned to a group. One participant in the
Acupressure improves the postoperative comfort
341
Assessed for eligibility (n=183) Not met inclusion criteria (n=73) Refused to parcipate (n=32) Others (n=18) Met inclusion criteria (n=60) Randomized
Acupressure group (n=30)
st
Acupressure for 12 min
Acupressure for 12 min
Acupressure for 12 min
Control group (n=30)
st
Characteriscs of demography & clinic were assessed before surgery
Day 1 (1 ) aer surgery (n=27)
Day 1 (1 ) aer surgery (n=29)
Pain intensity was assessed 20 min aer the intervenon
Day 2 (2nd) aer surgery (n=26)
Day 2 (2nd) aer surgery (n=28)
Pain intensity was assessed 20 min aer the intervenon
rd
Day3 (3 ) aer surgery (n=28)
Day3 (3 ) aer surgery (n=26)
Figure 1
rd
Pain intensity was assessed 20 min aer the intervenon
The flow chart of participants of this study.
experimental group withdrew from the study because of exhaustion, and 3 other patients withdrew after refusing acupressure treatment without citing a reason. In addition, 2 participants withdrew from the control group, stating they were uncomfortable with their data being collected following surgery. The final experimental and control groups comprised 26 and 28 participants, respectively, exhibiting a 10% attrition rate.
The efficacy of acupressure intervention was established by obtaining qi (de qi) from each acupoint. De qi refers to the process of stimulating an acupoint to induce soreness, numbness, distension, or heaviness proximal to the stimulated acupoint.15 Acupressure was performed by a researcher who had completed 40 academic credits in TCM and received certification from 2 practising TCM physicians. Three TCM physicians with clinical acupuncture experience reviewed
Intervention Acupressure is designed to stimulate the 2 acupoints shown in Fig. 2—–the Neiquan (P6) and Zusanli (ST36).16 Stimulating the P6 acupoint can prevent PONV and relieve gastrointestinal problems, whereas stimulating the ST36 acupoint can improve digestive system function.33 The P6 acupoint is located 5 cm proximal to the midpoint of the transverse crease of the wrist, between the tendons of the flexor carpi radialis and palmaris longus, whereas the ST36 acupoint is located 7.5 cm below the knee, approximately 1.5 cm lateral to the tibia on the anterior tibialis.33 Three 12-min acupressure intervention sessions were held over 3 consecutive days following surgery. To ensure that the order and duration were consistent for each press, the acupressure proceeded sequentially from the right P6 acupoint to the right ST36 acupoint, and subsequently from the left P6 acupoint to the left ST36 acupoint. During the acupressure intervention, the thumb was used to (1) apply pressure for 5 s; (2) release for 1 second; (3) knead for 5 s; and (4) release for 1 second. This process was repeated for up to 3 min at each of the 4 acupoints.34,35
Figure 2
Diagram of acupoint location.
342
W.-T. Hsiung et al.
and verified that the acupressure procedure was appropriate, and 2 other TCM physicians verified the acupressure practice measures (acupoint location, press approach, and press duration). The control group received no acupressure during the study. Prior to surgery, a nurse used multimedia to educate all participants in abdominal surgery. Following surgery, regular postoperative care, including NPO, oral care, chest percussion, steam inhalation, coughing, deep breathing, coach training, using an abdominal binder, and walking, was provided.
Table 1
Data measurement The data set comprised information on demographic characteristics (age, height, weight, sex, education level, and marital status) and medical conditions (time of defecation, symptoms presented upon hospitalisation, ASA status, surgery duration, analgesic methods, and tumour stage). An 11-point scale was used to assess pain intensity, and the anchors of the scale were 0 (no pain or no interference), 1—3 (mild pain), 4—6 (moderate pain), 7—9 (severe pain), and 10 (extreme or uncontrollable pain).
Comparisons of demographic and medical characteristics between groups.
Variables
Control (n = 28)
Experiment (n = 26)
2 /t (p)
Age, years (M ± SD) Height, cm (M ± SD) Weight, kg (M ± SD) Gender (n, %) Male Female Education level (n, %) Elemental & under Junior high Senior high College and above Marital status (n, %) Unmarried Married Divorced Widowed Defecation (n, %) Normal Abnormal Symptoms for hospitalisation (n, %) None Abdominal pain Abdominal distention Tarry stool Nausea or vomit American society of anaesthetists status (n, %) 2 = 0.94 (0.63) I II III Operation duration (M ± SD) Analgesic (n, %) PCA, intravenous PCA, epidural Others Tumour stage (n, %) 1 2 3 Hour for first flatus (M ± SD) Hour for first defecation (M ± SD)
64.11 ± 15.60 161.41 ± 8.31 64.20 ± 10.18
60.54 ± 10.89 164.37 ± 8.22 64.98 ± 11.55
t = 0.98 (0.33) t = −1.31 (0.20) t = −0.26 (0.79) 2 = 0.21 (0.65)
20 (71.43%) 8 (28.57%)
20 (76.92%) 6 (23.08%)
10 (35.71%) 4 (14.29%) 5 (17.86%) 9 (32.14%)
9 5 5 7
PCA: patient-controlled analgesia.
2 = 0.34 (0.95) (34.62%) (19.23%) (19.23%) (26.92%) 2 = 1.93 (0.59) 1 (3.57%) 25 (89.29%) 1 (3.57%) 1 (3.57%)
0 (0%) 25 (96.15%) 0 (0%) 1 (3.85%) 2 = 0.26 (0.61)
25 (89.29%) 3 (10.71%)
22 (84.62%) 4 (15.38%)
11 (39.29%) 12 (42.86%) 6 (21.43%) 6 (21.43%) 4 (14.29%)
8 (30.77%) 6 (23.08%) 12 (46.15%) 3 (11.54%) 4 (15.38%)
5 (17.86%) 17 (60.71%) 6 (21.43%) 326.43 ± 59.00
3 (11.54%) 19 (73.08%) 4 (15.38%) 332.31 ± 52.58
5 (17.86%) 21 (75.00%) 2 (7.14%)
10 (38.46%) 16 (61.54%) 0(0%)
10 (35.71%) 5 (17.86%) 13 (46.43%) 98.09 ± 23.45 114.63 ± 22.65
13 (50.00%) 6 (23.08%) 7 (26.92%) 79.97 ± 37.31 108.55 ± 23.29
2 = 0.93 2 = 2.37 2 = 3.70 2 = 0.95 2 = 0.01
(0.34) (0.12) (0.05) (0.33) (0.91)
t = −0.39 (0.70) 2 = 4.27 (0.12)
2 = 2.21(0.33)
t = 2.12(0.04) t = 0.97(0.34)
Acupressure improves the postoperative comfort 4.673
4.732
5 4.732
3.929
4 3.714 3.904
Pain score
Gastrointestinal motility was evaluated by recording the time of the first flatus and first defecation following surgery. The Rhodes Index of Nausea, Vomiting, and Retching (INVR) were used to assess the severity of PONV. The INVR is an 8item questionnaire that uses a 5-point scale (ranging from 0 to 4) to obtain information regarding symptoms, symptom occurrence, and symptom distress associated specifically with nausea, vomiting, and retching.36,37 In addition to providing a total score for symptoms, symptom occurrence, and symptom distress, the INVR yields subscale scores for the 3 symptoms. High scores are indicative of severe PONV. Doctor Rhodes provided written authorisation for the INVR to be translated into Chinese for use in this study. The INVR exhibited strong reliability in the previous studies,18,38 and was verified in the current study (Cronbach’s ˛ = 0.90).
343
3 2.923
2.596
2 1 0
Figure 3 surgery.
The trend of pain intensity across times after
5
First, ethical approval was obtained from the institutional review board of the study hospital (Ref code 97-01-03A). Second, after suitable participants were identified, the study was thoroughly explained to the participants the day prior to surgery. All participants received the same regimen of preoperative medication. Third, prior to the interventions, the outcome measures were used in evaluating each participant to establish a baseline and, fourth, participants assigned to the experimental group or control group were accommodated in separate wards after surgery. Individual interventions commenced on the second day following surgery. Throughout the interventions, all participants were in the semi-Fowler position and privacy was maintained using curtains. The entire process, including preparation and acupressure or usual care, lasted 20 min. Fifth, the outcomes of the interventions, including adverse effects, were recorded.
Data analysis Data were analysed using IBM SPSS Version 20.0 for Windows. Descriptive statistics (frequency; percentage; mean; standard deviation) were calculated to identify the demographic characteristics, medical conditions, and outcomes. Inferential statistics (chi-square test, t test, and repeated measures analysis of variance, ANOVA) were then used to compare the outcomes of the groups.
Results The mean age of the participants was 62.39 ± 15.53 years, and most participants were men (74.07%) and had a college education level or higher (29.63%). Table 1 shows the demographic and medical characteristics at the baseline, indicating no significant differences between the groups (P > .05). Most participants (87.03%) exhibited a normal defecation status, and abdominal distension was the primary reason for visiting a doctor (33.33%). The duration of the subtotal gastrectomy averaged 329.26 ± 55.55 min. Most participants (96.30%) used patient-controlled analgesia (PCA) to managing postoperative pain. Within 10—15 min following surgery, the participants were connected to a PCA
INVR score
4
Data collection
2.68
3 2
1.21
1.43 1.46
1.42 1
0.62
1.12 0
0.77
Figure 4 The trend of scores of nausea and vomiting across times after surgery.
device in the anaesthesia recovery room, and the device was used for at least 3 days following surgery. The analgesics were delivered either intravenously (100 mg of morphine and 0.1 mg of droperidol per 100 mL) or through epidural injection (600 mg of marcaine and 600 g of fentanyl per 600 mL). Fig. 3 shows the postoperative abdominal pain from the baseline until Day 3 following surgery. No significant group differences were observed at the baseline (t = 0.09, P = .93). The trend in mean pain intensity exhibited a gradual decrease, and significant differences were observed between the groups (F = 4.86, P = .03) and within the groups (F = 7.12, P = .001). Fig. 4 shows the group PONV scores from the baseline until Day 3 following surgery. No significant group differences were observed at the baseline (t = 1.3, P = .2). In addition, the trend indicated no significant differences between the groups (F = 0.47, P = .49) and within the groups (F = 0.09, P = .86). As shown in Table 1, gastrointestinal motility following surgery, indicating a significant difference between the groups at the time of the first flatus (t = 2.12, P = .04), but not at the time of the first defecation (t = 0.97, P = .34). Eight participants in the experimental group and 17 in the control group perceived the first abdominal distension, yielding a significant difference (2 = 4.86, P = .03). No adverse effects occurred during this study.
Discussion Based on the similar demographic characteristics and medical conditions between the groups, this pilot study supported the hypothesis that acupressure reduces acute postoperative pain in the first 3 days of subtotal gastrectomy. The pain intensity gradually decreased in both groups,
344 as shown in Fig. 3; however, the pain intensity among the experimental group decreased from moderate to mild, and was alleviated sooner compared with that of the control group. This was similar to other studies of spine surgery,17,18 hysterectomy,39 and abdominal surgery.40 Stimulating acupoints rectifies qi, stabilises the body, and strengthens bodily functions.34 Acupoint stimulation not only enhanced the alleviation of postoperative pain but also reduced morphine consumption.19,41 One study did not support that acupoint stimulation reduces the pain of hysterectomy patients; however, a decrease was observed in the consumption of postoperative opioids.20 Although total opioid consumption following surgery was not calculated in this study, 96.3% of the participants used PCA, and participants in both groups exhibited similar PCA use. A study of lumbar spine surgery patients using PCA showed that combining acupressure and electrical stimulation enhanced the efficacy of analgesics and reduced the consumption of opioids.17 The experimental group experienced greater pain relief than did the control group during the first 3 days following surgery, supporting the findings of several previous studies. This is consistent with the alleviation of postoperative pain observed in patients who have undergone hysterectomy39 or spine surgery.17,18 The pain intensity gradually decreased in the control group because cellular response contributes to wound healing.42 Moreover, stimulating the P6 and ST36 acupoints produces an analgesic effect and reduces postoperative pain. According to TCM principles, stimulating the meridian acupoint releases endorphins within the CNS and modulates physiological reactions.16 Although the mechanism of acupressure-induced analgesia remains unclear,43 strong evidence supports that acupressure alleviates pain.44 Acupressure stimulates large myelinated fibres that inhibit nociceptive stimuli, resulting in the release of ␥-aminobutyric acid, which alleviates pain according to the gate control theory.45 This study confirmed that, in addition to alleviating pain, acupoint stimulation improves gastrointestinal motility following surgery. The first flatus and first defecation recorded in the experimental group were respectively 18 and 6 h earlier than those recorded in the control group. These results are similar to those obtained in another study.46 It is an important clinical assessment that the first flatus following abdominal surgery detects gastrointestinal motility.5,24 Enteral nutrition also contributes to the recovery of gastrointestinal motility after gastrointestinal surgery.47 In addition, 53.8% of patients in the experimental group reported passing gas and feeling comfortable and relaxed during and immediately following acupressure. These results are similar to those of a study on hysterectomy patients.23 However, the patients did not consume food throughout this study, which may inhibit gastrointestinal motility.47 In addition, a gastrointestinal anastomosis using the contrast agent tested on the fifth day following surgery, which was close to the time of the first postoperative defecation. Therefore, the time until the first defecation may have been affected. Studies that evaluate how acupressure affects the gastrointestinal motility of abdominal surgical patients are few, and future studies should examine and clarify these effects.
W.-T. Hsiung et al. Opioid analgesics used for relieving postoperative pain reduce gastrointestinal motility and cause PONV. This study observed that acupoint stimulation elicited a gradual decrease in PONV during the first 3 days following surgery. The experimental group exhibited a slight faster recovery from nausea, vomiting, and retching symptoms than the control group did. This observation is consistent with those of previous studies of acupoint stimulation that used wristbands following urological surgery30 and caesarean delivery,48 and acupressure during chemotherapy cycle for postoperative stomach cancer patients49 as well as with those of a previous study that reported inconclusive results regarding how acupoint stimulation alleviates PONV in spinal surgery patients.18 However, the results of this study differ from those of studies of patients undergoing gynaecological surgery,29 strabismus surgery,27 and hysterectomy.50 A possible cause of this inconsistency is the nasogastric tube used in this study; this tube could have reduced the occurrence of nausea and vomiting.5,51 Combining droperidol with morphine through PCA is also associated with a low incidence of PONV,52,53 but suppresses the effects of acupressure on PONV. This study yielded low Apfel risk scores,9 possibly because most participants were men who exhibited no history of motion sickness. The effect of acupressure on nausea and vomiting is relatively inconsistent44 and warrants further research.
Research limitations In accordance with the research design, acupressure was performed for 3 consecutive days following surgery; therefore, the long-term effects of acupressure remain unknown. The lack of placebo acupressure is a limitation. Potential contamination might occur naturally, although the experimental and control groups were separated in different wards. Biochemical outcomes for enkephalin, beta-endorphin, or endomorphin were not assessed. The sample size based on a medium effect size of the outcome of pain intensity may not be sufficient for testing all hypotheses. Assessing the relationships among the level of interference and activity, the frequency and dosage of analgesics, and other morphine-induced side effects distinct from PONV would strengthen the current findings regarding the efficacy of acupressure in managing postoperative comfort. Data collected from one hospital might not be generalisable to other hospitals or settings. Future research should consider using placebo interventions, large sample sizes, biochemical and other measures, and multicentre data collection.
Conclusions Postoperative pain is one the most common, but avoidable, therapeutic problems. Acupressure can be applied at the P6 and ST36 acupoints as an effective alternative to alleviating pain and to reduce the time of the first flatus following surgery. Acupressure is a simple, noninvasive, safe, and economical procedure that can be applied in health care and clinical practice. Healthcare professionals receiving appropriate education and training can administer acupressure to patients. By integrating TCM with Western medicine, nurses
Acupressure improves the postoperative comfort can improve the quality of care and reduce related costs. This was a pilot trial, and additional research is necessary to clarify the effect of acupressure in improving gastrointestinal motility and preventing PONV following surgery.
345
19.
20.
Conflict of interest The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
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22.
References 1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. Public Libr Sci 2006;3: 2015—30. 2. Department of Health, Executive Yuan, R.O.C. Statistics cause of death statistic http://www.doh.gov.tw/CHT2006/DM/ DM2 2.aspx?class no=440&level no=1 [accessed 09.01.11]. 3. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: gastric cancer. http:// www.nccn.org/professionals/physician gls/PDF/gastric.pdf [accessed 03.10.13]. 4. Meyer HJ, Wilke H. Treatment strategies in gastric cancer. Deutsches Arzteblatt International 2011;108:698—706. 5. Mochiki E, Asao T, Kuwano H. Gastrointestinal motility after digestive surgery. Surg Today 2007;37:1023—32. 6. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet 2006;13:1618—25. 7. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Post-operative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 2003;97:534—40. 8. Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I. Evidence from published data. Br J Anaesth 2002;89:409—23. 9. Apfel CC, Laara E, Koivuranta M, Greim CA. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999;91:693—700. 10. Golembiewski JA, O’Brien DJ. A systematic approach to the management of postoperative nausea and vomiting. J Perianesth Nurs 2002;7:364—76. 11. Doran K, Halm MA. Integrating acupressure to alleviate postoperative nausea and vomiting. Am J Crit Care 2010;19:553—6. 12. Ali T, Hasan M, Hamadani M, Harty RF. Gastroparesis. South Med J 2007;100:281—6. 13. Mack LA, Kaklamanos IG, Livingstone AS, Levi JU, Robinson C, Sleeman D, et al. Gastric decompression and enteral feeding through a double-lumen gastrojejunostomy tube improves outcomes after pancreaticoduodenectomy. Ann Surg 2004;240:845—51. 14. Yang ES, Li PW, Nilius B, Li G. Ancient Chinese medicine and mechanistic evidence of acupuncture physiology. Pflugers Arch 2011;462:645—53. 15. WHO international standard terminologies on traditional medicine in the western Pacific region. Western Pacific Region: World Health Organization; 2007. 16. Yeh ML, Chen HH, Lin IH. Contemporary meridians and acupoints in practice. Taipei city, Taiwan, ROC: Farseeing; 2004. 17. Chung YC, Tsou MY, Chen HH, Lin JG, Yeh ML. Integrative acupoint stimulation to alleviate postoperative pain and morphine-related side effects: a sham-controlled study. Int J Nurs Stud 2013;51:370—8. 18. Yeh ML, Chung YC, Chen KM, Tsou MY, Chen HH. Acupoint electrical stimulation reduces acute postoperative pain in surgical
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33. 34.
35.
36.
37.
patients with patient-controlled analgesia: a randomized controlled study. Altern Ther 2010;16:10—8. Chung YC, Chien HC, Chen HH, Yeh ML. Acupoint stimulation to improve analgesia quality for lumbar spine surgical patients. Pain Manag Nurs 2015;15:738—47. Lin JG, Lo MW, Wen YR, Hsieh CL, Tsai SK, Sun WZ. The effect of high and low frequency electoacupuncture in pain after lower abdominal surgery. Pain 2002;99:509—14. Wu HC, Liu YC, Ou KL, Chang YH, Hsieh CL, Tsai-Angela HC, et al. Effects of acupuncture on post-cesarean section pain. Chin Med J 2009;122:1743—8. Yin J, Chen JDZ. Gastrointestinal motility disorders and acupuncture. Auton Neurosci 2010;157:31—7. Chen LL, Hsu SF, Wang MH, Chen CL, Lin YD, Lai JS. Use of acupressure to improve gastrointestinal motility in women after trans-abdominal hysterectomy. Am J Chin Med 2003;31:781—90. Madsen D, Sebolt T, Cullen L, Folkedahl B, Mueller T, Richardson C, et al. Listening to bowel sounds: an evidence-based practice project: nurses find that a traditional practice isn’t the best indicator of returning gastrointestinal motility in patients who’ve undergone abdominal surgery. Am J Nurs 2005;105:40—9. Lee A, Fan LT. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2009;15:1—120. Agarwal A, Bose N, Gaur A, Singh U, Gupta MK, Singh D. Acupressure and ondansetron for postoperative nausea and vomiting after laparoscopic cholecystectomy. Can J Anaesth 2002;49:554—60. Ebrahim-Soltani A, Mohammadinasab H, Goudarzi M, Arbabi S, Mohtaram R, Afkham K, et al. Acupressure using ondansetron versus metoclopramide on reduction of postoperative nausea and vomiting after strabismus surgery. Arch Iran Med 2010;13:288—93. Amir SH, Bano S, Khan RM, Ahmed M, Zia F, Nasreen F. Electrostimulation at P6 for prevention of PONV. J Anaesth Clin Pharmacol 2007;23:383—6. Turgut S, Ozalp G, Dikmen S, Savli S, Tuncel G, Kadiogullari N. Acupressure for postoperative nausea and vomiting in gynaecological patients receiving patient-controlled analgesia. Eur J Anaesth 2007;24:87—91. Agarwal A, Pathak A, Gaur A. Acupressure wristbands do not prevent postoperative nausea and vomiting after urological endoscopic surgery. Can J Anaesth 2000;47:319—24. Abraham J. Acupressure and acupuncture in preventing and managing postoperative nausea and vomiting in adults. J Perioper Pract 2008;18:543—51. Misra MN, Pullani AJ, Mohamed ZU. Prevention of PONV by acustimulation with capsicum plaster is comparable to ondansetron after middle ear surgery. Can J Anesth 2005;52:485—9. Yeh ML, Chen HH, Lin IH. Meridians and Acupoints of Chinese Medicine. Taipei city, Taiwan, ROC: Farseeing; 2004. Yeh ML, Chung YC, Chen KM, Chen HH. Pain reduction of acupoint electrical stimulation for spinal surgery patients: a placebo-controlled study. Int J Nurs Stud 2011;48: 703—9. Yeh ML, Hung YL, Chen HH, Lin JG, Wang YJ. Auricular acupressure combined with an Internet-based intervention or alone for primary dysmenorrhea: a control study. Evid Based Complement Alternat Med 2013. http://dx.doi.org/10.1155/2013/316212 [accessed 19.03.14]. Rhodes VA, Watson PM, Johnson MH. Development of a reliable and valid measures of nausea and vomiting. Cancer Nurs 1984;7:33—41. Rhodes VA, McDaniel RW. The index of nausea, vomiting, and retching: a new format of the index of nausea and vomiting. Oncol Nurs Forum 1999;26:889—94.
346 38. Chou FH, Avant KC, Kuo SH, Cheng HF. Assessing the psychometric and language equivalency of the Chinese versions of the index of nausea, vomiting and retching, and the prenatal self-evaluation questionnaire. Kaohsiung J Med Sci 2005;21: 314—21. 39. Kim KS, Nam YM. The analgesic effects of capsicum plaster at the Zusanli point after abdominal hysterectomy. Anesth Analg 2006;103:709—13. 40. Kotani N, Hashimoto H, Sato Y, Sessler D, Yoshioka H, Kitayama M, et al. Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology 2001;95: 349—56. 41. Chen YC, Liu HJ, Lin JG. Assessment on the effect of postoperative acupuncture stimulation to pain relief after total knee replacement. Taiwan J Chin Med 2005;34:5—23. 42. Reinke JM, Sorg H. Wound repair and regeneration. Eur Surg Res 2012;49:35—43. 43. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related techniques for postoperative pain: a systematic review of randomized controlled trials. Br J Anaesth 2008;101:151—60. 44. Robinson N, Lorenc A, Liao X. The evidence for Shiatsu: a systematic review of Shiatsu and acupressure. BMC Complement Altern Med 2011;11:88. 45. Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965;150:971—9.
W.-T. Hsiung et al. 46. Wang SG, Tian S, Li GH. Use of drugs at Zusanli to exercise a influence on gastrointestinal motility. Chin J Surg Integr Tradit West Med 2007;13:143—5. 47. Kawasaki N, Suzuki Y, Nakayoshi T, Hanyu N, Nakao M, Takeda A, et al. Early postoperative enteral nutrition is useful for recovering gastrointestinal motility and maintaining the nutritional status. Surg Today 2009;39:225—30. 48. Ho CM, Tsai HJ, Chan KH, Tsai SK. P6 Acupressure does not prevent emesis during spinal anesthesia for cesarean delivery. Obstet Gynecol Surv 2006;61:498—9. 49. Shin YH, Kim TI, Shin MS, Juon HS. Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients. Cancer Nurs 2004;27:267—74. 50. Frey UH, Scharmann P, Lohlein C, Peters J. P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients. Br J Anaesth 2009;102:620—5. 51. Chen CJ, Liu TP, Yu JC, Hsua SD, Hsieh TY, Chu HC, et al. Roux-en-Y reconstruction does not require gastric decompression after radical distal gastrectomy. World J Gastroenterol 2012;18:251—6. 52. Apfel CC, Cakmakkaya OS, Frings G, Kranke P, Malhotra A, Stader A, et al. Droperidol has comparable clinical efficacy against both nausea and vomiting. Br J Anaesth 2009;103:359—63. 53. Aubrun F, Mazoit JX, Riou B. Postoperative intravenous morphine titration. Br J Anaesth 2012;108:193—201.
