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Acupressure for prevention of pre-operative

anxiety: A prospective, randomised, placebo
controlled study. Anaesthesia, 60, 978-981

ARTICLE in ANAESTHESIA OCTOBER 2005

Impact Factor: 3.38 DOI: 10.1111/j.1365-2044.2005.04332.x Source: PubMed

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Anaesthesia, 2005, 60, pages 978981 doi:10.1111/j.1365-2044.2005.04332.x
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Acupressure for prevention of pre-operative anxiety:

a prospective, randomised, placebo controlled study
A. Agarwal,1 R. Ranjan,2 S. Dhiraaj,3 A. Lakra,2 M. Kumar2 and U. Singh4
1 Additional Professor, 2 Senior Resident, 3 Assistant Professor, Department of Anaesthesiology, 4 PhD, Assistant
Professor, Department of Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226 014,
India

Summary
Pre-operative anxiety is associated with many unwanted effects such as increased analgesic and
anaesthetic requirement, postoperative pain and prolonged hospital stay. In the present study,
we investigated the effects of acupressure on pre-operative anxiety and bispectral index (BIS)
values. Seventy-six adults, ASA grade I and II, undergoing elective surgery, were randomly
assigned to two equal groups. Group 1 (control) received acupressure at an inappropriate site
and group 2 (acupressure) received acupressure at extra 1 point. The study was conducted
during the pre-operative period and the duration of the study was 40 min (acupressure was
applied for 10 min and thereafter patients were observed for another 30 min). Anxiety was
recorded on a visual stress scale (VSS) at the start of the study and thereafter at 10 and 40 min.
BIS was recorded at 0, 2, 5, 10, 12, 15, 30 and 40 min. The VSS decreased in both groups
following pressure application for 10 min: median VSS (interquartile range) were 5 (1) vs. 8 (1)
in the acupressure and 7 (0) vs. 8 (1) in the control groups (p < 0.001). Both pre-operative
anxiety and BIS decreased significantly during acupressure application at extra 1 point
(p < 0.001). Acupressure is effective in decreasing both pre-operative anxiety and BIS; how-
ever, these effects are not sustained 30 min following release of acupressure. Further studies are
needed to elucidate the duration for which acupressure is effective.
. ......................................................................................................
Correspondence to: Dr Anil Agarwal
E-mail: aagarwal@sgpgi.ac.in
Accepted: 14 June 2005

The incidence of pre-operative anxiety in adults varies

Methods
from 11% to 80%. Pre-operative anxiety correlates with a
high incidence of postoperative pain, increase in analgesic Following approval of the Institutional Ethics Committee
and anaesthetic requirements, and delayed recovery and and after obtaining written, informed consent from
discharge from hospital [14]. In addition, anxiety may patients, this prospective, randomised and observer
influence adversely the induction of anaesthesia and its blinded study was conducted. Patients taking any sedat-
recovery, and decrease patients satisfaction with their ive, tranquilliser, or acupressure or acupuncture therapy
peri-operative experience [1]. Sedative premedication is were excluded from the study.
routinely administered to reduce pre-operative anxiety; Assuming that the normal value (SD) of bispectral
however, sedatives have their own side-effects, which can index (BIS) is 97 (2) and following acupressure at Extra
be minimised by the use of non-pharmacological inter- 1 point, it would reduce to 75 (2), for results to be
ventions. Acupressure on the extraordinary point extra 1 statistically significant at a power of 80% and a = 0.05,
has been shown to reduce stress in healthy volunteers [5]. we calculated that we needed to evaluate 38 patients in
As pre-operative anxiety might not be comparable to each group. Therefore, 76 consecutive adult (aged 18
the anxiety experienced by volunteers, the present study 50 years) ASA physical status I and II patients of either sex
was undertaken to evaluate the efficacy of acupressure at undergoing elective surgical procedures were enrolled
extra 1 point in patients undergoing elective surgical in this study. Patients were randomly assigned to two
procedures. groups of 38 each with the help of a computer-generated

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Anaesthesia, 2005, 60, pages 978981 A. Agarwal et al. Acupressure for pre-operative anxiety
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table of random numbers. Patients in Group 1 (control) Table 1 Demographic data presented as mean (SD).
received acupressure at an inappropriate site and group 2
(acupressure) received acupressure at extra 1 point. Variables groups I: Control II: Acupressure
Extra 1 point is situated between the two eyebrows at
Age; year 35.53 (7.85) 35.06 (8.02)
the root of the nose. In the control group, acupressure Height; cm 171.06 (9.40) 167.00 (9.32)
was applied 2 cm lateral and horizontal from the lateral Weight; kg 59.73 (7.13) 61.00 (9.80)
end of the left eyebrow. None of the patients received Male female ratio 18 18 17 19
any sedative premedication. On the morning of the
surgery, following arrival in the pre-operative area,
patients were allowed to relax for 15 min. Thereafter,
120
depending upon the group allocation, acupressure was
applied. Acupressure was applied by the pulp of the right
thumb in a rotary fashion at 2025 cycles.min)1 for 100
10 min by the same investigator. Following release of
acupressure, patients were observed for another 30 min. 80 * *
*
Thus the total study period consisted of 40 min (acu-

BIS
pressure application for 10 min + 30 min after release of 60 *
pressure). * *
Patients were informed about the study design and use 40
of the visual stress scale (VSS) for assessment of their
anxiety a day earlier during the pre-anaesthetic assess- Control
20
ment. The person applying the acupressure was aware of Acupressure
the group allocation. Recording of BIS was performed by
a staff nurse blinded to the treatment group. A screen was 0
placed so that the head end of the patient and the person 0 2 5 10 12 15 20 30 40
performing the acupressure could not be seen by the Time (min)
observer until the end of the study period. Figure 1 Changes in BIS value as observed in the two groups.
Patients recorded their anxiety on a VSS from 0 (no Data are presented as median. *p < 0.05 intra-group compar-
stress) to 10 (maximum stress) at the start of the study, ison of BIS values during pressure application when compared
10 min (end of pressure application) and at 40 min (i.e. with their respective baseline and values obtained after the
30 min after the release of pressure); and these results release of pressure. p < 0.05 during intergroup comparison of
BIS values. Interquartile ranges have been omitted for clarity.
were communicated to the observer. BIS monitoring was
performed using a Model A-2000, 3.1 software version
(Aspect Medical System, Natick, MA). The median of anxiety in the acupressure group compared with the
three consecutive readings of BIS was recorded as control group at the end of pressure application for
baseline. BIS was recorded in a similar fashion at 2, 5, 10 min (5 (1) vs. 7 (0)).
10, 12, 15, 30 and 40 min. Data are presented as median BIS values during pressure application at 2, 5, 10 min
(interquartile range). Intra-group comparison was done were lower than their respective baseline values in both
with the Wilcoxon rank test and intergroup comparison the groups (p < 0.05; Fig. 1). BIS values recorded during
with the MannWhitney test. p < 0.05 was taken as pressure application were lower than BIS values observed
significant. following release of pressure, i.e. at 12, 15, 20, 30, 40 min
in both the groups (p < 0.05). During the application of
acupressure at extra 1 point, BIS values were lower than
Results
the corresponding values in the control group (p < 0.05)
There was no significant difference in the demographic (Fig. 1).
profile of the patients (Table 1). Anxiety was significantly
reduced at the end of pressure application for 10 min in
Discussion
both the acupressure and control groups when compared
to their respective baseline values: 5 (1) vs. 8 (1) in the We observed a significant decrease in pre-operative
acupressure and 7 (0) vs. 8 (1) in the control groups anxiety at the end of pressure application for 10 min in
(p < 0.001; Fig. 1). However, 30 min after release of both the acupressure and control groups. The decrease in
pressure, anxiety in both, groups returned to baseline anxiety was significantly more in the acupressure group
(p > 0.05). A significant reduction was observed in when compared with control group. Thirty minutes after

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A. Agarwal et al. Acupressure for pre-operative anxiety Anaesthesia, 2005, 60, pages 978981
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release of pressure, anxiety returned to baseline in both Fassoulaki et al. [5] applied acupressure for 10 min at
the groups. extra 1 point in 25 volunteers and observed a 50%
Anxiety can be divided into state and trait [6]. Trait reduction in anxiety and BIS at the end of acupressure
anxiety is a life-long pattern of anxiety, a personality application. In their study, BIS returned to the baseline
feature, whereas state anxiety refers to acute situational values 3 min after release of pressure. This study differed
driven episodes of anxiety that do not persist beyond the from ours in various ways. Firstly, we applied acupressure
situations that trigger them. The latter is a transitory on patients who were undergoing elective surgical
emotional condition that consists of feelings of apprehen- procedures in contrast to healthy volunteers. Secondly,
sion, nervousness and worry. The activity of the auto- we observed our patients for an additional 30 min after
nomic nervous system is heightened, as can be seen in release of pressure in contrast to 3 min in their study.
patients scheduled for surgery, and can result in a high Thirdly, we applied acupressure for 10 min in both the
incidence of postoperative pain, increased analgesic and groups, whereas they could not apply pressure for more
anaesthetic requirements and a prolongation of hospital than 5 min in the control group. Fassoulaki et al. have
stay [1]. Sedatives and opioids are often used as pre- also been criticised for their choice of control point
medicants, but at times are associated with undesirable [16, 17]. The problem remains that there are no defined
side-effects such as drowsiness and respiratory depression effects and criteria for acupuncture points; every control
[4]. Benzodiazepines, the most commonly used drug for point may turn out to be another acupuncture point with
alleviation of pre-operative anxiety, may interact with unknown side-effects.
anaesthetic agents and thus prolong patient recovery and We monitored anxiety after completion of 10 min of
discharge. acupressure application and 30 min following its release.
Both acupressure and acupuncture have been used The reason for the reduction in BIS in the control
to prevent postoperative nausea and vomiting, reduce group may be due to the massage effect of pressure
postoperative pain, analgesic requirements, and opioid application or to the fact that patients felt that something
related side-effects after both upper and lower abdominal was being done actively for their benefit.
surgery, as well as reducing anxiety and behaviour To conclude, acupressure is effective in decreasing
dysfunction [79]. Auricular acupuncture at the relax- both pre-operative anxiety and BIS; however, these
ation point has been reported to decrease pre-operative effects are not sustained 30 min following release of
anxiety [10]. Acupressure application during prehospital acupressure. Further studies are needed to elucidate the
transport yields similar results [11]. The advantages of duration of acupressure efficacy in minimising pre-
acupressure over acupuncture are that it is non-invasive, operative anxiety.
does not affect the integrity of the epidermis and can
be applied easily [5]. The exact mechanism of how
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