Abstract

Acupressure is a helpful and powerful non-pharmacologic intervention used to reduce pain and anxiety through stimulation of the blood circulation, secretion of neurotransmitters and providing comfort for patients post open thoracotomy. The aim of this study was to investigate the effect of acupressure in reduction of pain and anxiety among patients with open thoracotomy. Design: pre and post test quasi-experimental design. Setting: Cardio-thoracic intensive care unit (ICU) and cardio-thoracic department of Mansoura University Hospital. Sample: A purposive sample of 136 patients, 68 in the experimental group and 68 in the control group based on criteria for inclusion and exclusion. Data were collected using the interviewing questionnaire sheet, post thoracotomy anxiety assessment scale, post thoracotomy pain assessment scale and acupressure practice observational checklist. Results: There were statistical significant differences between the control groups and the acupressure group regarding the level of pain and anxiety. Conclusion: Acupressure is an effective technique for reducing the level of pain and anxiety among patients with open thoracotomy.

1. Introduction

An open thoracotomy is a chest wall surgical incision to open and access the thoracic cavity to explore, perform a biopsy or treat a lesion ¹. An open thoracotomy is done to evaluate and treat pulmonary problems when non-invasive procedures are non-diagnostic or unlikely to be definitive. There are several reasons which confirm the need to open the thoracic cavity ².

Thoracotomy is used to gain access to perform the following surgeries: pulmonary surgeries which mean the resection of the whole, or part of the lung (segmentectomy, lobotomy, pneumonectomy) due to malignancies or benign diseases which include chronic lung infections, bronchiectasis, tuberculosis, emphysema and pneumoconiosis Anterior spinal fusions and valve replacement surgery ³.

More than one-third of patients with thoracotomy experience significant pain, emotional distress, anxiety, and/or depression following thoracotomy ⁴. Anticipating thoracotomy can create negative cognitions and emotions, such as anxiety and fear. Psychological distress may adversely impact pain perception, immune-mediated wound healing, and return to physical function. Consequently, it is important to investigate non - pharmacological studies that might help decrease pain and anxiety post thoracotomy ⁵.

One of the challenges facing patients after thoracotomy is pain, anxiety, fatigue, muscle tension, lymphedema, and nausea. Most patients use integrative medicine to supplement conventional health care, such as massage therapy ⁶. Massage therapy is specifically used to target common side effects like pain, anxiety, fatigue, and muscle tension after thoracotomy. Furthermore, massage therapy accounts for 48% of all complementary and alternative medicine services available to patients in hospital ⁷.

Pain after thoracotomy is the result of ongoing inflammation or a manifestation of neuropathic pain caused by injury to major peripheral nerves. The great responsibility and the primary role of nurses are to help patients manage their pain ⁸. The pain may not be completely reduced and controlled. However, the important thing is to reduce the pain so that the patient feels comfortable ⁹.

There are various pharmacological and non-pharmacological approaches to reduce the stress, pain and anxiety of the patients. Nonetheless, there are several problems associated with pharmacological treatment, such as impaired perception level and increased risk of drug dependence. Currently, Non-pharmacological strategies such as meditation, soothing music, relaxation techniques, and massage therapy are commonly used by nurses to reduce anxiety in patients and improve their recovery and overall health ¹⁰. Also, these approaches are simple, cheap, non-invasive, and have less or no adverse effects compared to pharmacological method ¹¹.

Acupressure is a therapy used to treat various symptoms and is rooted in acupuncture in which the hands or elbows are used to apply physical pressure to acupressure points without needles. It based on the belief that the body's healing powers and vital energy (Chi / Qi) circulate through 12 major meridians ¹². On these channels, approximately 365 acupoints were specified and each of these points affects the performance of a specific part of the body ¹³. There is an imbalance in the flow of vital energy in the body causing dysfunctions, and diseases. Furthermore, there is a theory in medical science that acupressure reduces anxiety by adjusting the concentration of neurotransmitters and reducing the concentration of 5-hydroxytryptamine and adrenocorticotropic hormone in neural pathways ¹⁴. Acupressure has many advantage, it alleviates dyspnea, increases immunity, and encourages relaxation ¹¹. Nurses have close and long-term relationships with patients and can use acupressure to alleviate and treat diseases in patients as part of their nursing care ¹⁵.

Anxiety can be caused by a variety of factors such as extreme pain, diagnostic reaction, long-term care, the side effects of treatment, repeated hospitalization, poor adherence to medication, and, lifestyle changes. Multivariate analysis revealed that thoracotomy was a risk factor for anxiety ¹⁶.

Pain and anxiety for patients with open thoracotomy were recognized as distressing side effects of surgery and pulmonary problems treatment; they affect the functional status of the patient, and consequently the quality of life. Therefore, the management of these side effects represents a great challenge for the nurse. The use of measures that are cheap accessible, patient-induced, easy to learn and free from side effects could be effective in pain management and anxiety prevention. In an attempt to evaluate and test the effect of such measures, this study was conducted to evaluate the effect of acupressure in the reduction of pain and anxiety among patients with open thoracotomy. So that, there is a lot of interest to conduct such research type that might support these patients deal with significant physical and psychological changes in an effective and safe manner hoping to improve their quality of life and their self-efficacy. Researchers have begun to pay attention to the reduction of pain and anxiety for patients with open thoracotomy during the treatment period considering the large number of them. Moreover, because of inadequate understanding of patients on how to reduce the pain and anxiety both healthcare costs and unnecessary suffering increase. Hence, the acupressure techniques are required to guide care planning.

The aim of this study was to investigate the effect of acupressure in the reduction of pain and anxiety among patients with open thoracotomy.

H1: Patients undergoing Open thoracotomy who receive acupressure intervention will have pain level less than those groups who do not receive this intervention (control group).

H2: Patients undergoing Open thoracotomy who receive acupressure intervention will exhibit decreased anxiety level than those groups who do not receive this intervention (control group).

2. Method

A quasi-experimental design (pre and post test control group) was utilized in this study.

It was conducted at cardio-thoracic ICU and cardio-thoracic department of Mansoura University Hospital. This hospital located in delta region. Cardio-thoracic surgeries were performed on a regular basis daily with an average number of 4 cases weekly.

Purposive sample consists of 136 patients who were admitted to the cardio-thoracic ICU and cardiothoracic surgery department during the study period. Patients were enrolled and randomly assigned into two groups (68 patients in each one).

Conscious patients from 21to 59 years old, undergoing open thoracotomy, had at least one chest tube, cooperative, able to communicate, and accepted to participate voluntarily in the study. Patients’ hospital stays for at least 5 days.

Patients suffered from chronic lung diseases or any psychological disorders, anemic patients (hemoglobin less than 8), morbid obesity, uncontrolled diabetes and patient with recurrence thoracotomy were excluded from the study.

Simplified formula was used to calculate the purposive sample size ¹⁷. Based on the 2016 census estimate of patient admission to the Department of Cardio-thoracic Surgery (Mansoura University Hospital Census, 2017), the total of 400 subjects were assigned for open thoracotomy. The sample size at 5% error (95.0%) and 20.0 β error (80.0% study power) Where:

N= Size of population (200),

Z= standardization degree for 95.0% significance, it is equal to 1.96,

d= Percentage of error (0.05),

P= Percentage of occurrence of event or not, it is 0.5.

Four tools were developed by the primary investigator to achieve the aim of the study based upon relevant literature ^{18, 19}.

Tool I: Socio-demographic characteristics and medical data

This tool was developed by the investigator and consisted of two parts:

Category I: Socio-demographic characteristics: it included data such as gender, age, marital status, education level and residence.

Category II: This part involved patients' medical data such as duration of illness, presence of other chronic conditions, and treatment received.

Tool II: Postoperative Anxiety Assessment Scale

Anxiety was assessed using the State-Trait Anxiety Inventory (STAI) by Spelberger et al (1990) ²⁰ that was translated and standardized for Egyptian by Abdel -khalek (1992) ²¹. The STAI is a self-report measure intended to measure postoperative anxiety, the questionnaire done in the day pre and post open thoracotomy; it included 20 items on a four - point Likert scale. Each statement responses rating patients level of anxiety (1 = not at all, 2 = somewhat, 3 = moderately so, 4 = very much). They were asked to pick any one response for each statement. The scores of STAI range from score 20 to score 80.

Scoring system:

Tool III: Postoperative pain assessment scale

- The first part of the pain assessment scale was developed by the investigator based on literature review ²² and included questions related to assessing pain site, character, and duration, aggravating and alleviating factors.

- The second part of pain assessment was carried out using the Numerical Rating Scale (NRS) ^{23, 24} to assess pain intensity. It is a straight line that comprises 10 point scale with the left end of the line “0” representing no pain. 1-3 mild pain .4-6 moderate pain, 7-9 severe pain and the right end of the line “10” represent the worst degree of pain

Numerical Pain Intensity Scale (NAS) #

Tool IV: Acupressure Practice Observational Checklist

This tool was developed by the researcher after training and reviewing literature ²⁵ to ensure that patients master the technique of acupressure and practice it correctly. Scoring of the checklist was done using a 3-point Likert scale. A score of zero (0) was given when the patient not done. A score one (1) was given when the patient incomplete done. A score of two (2) was given when the patient complete done. The total score of acupressure training was 12. Higher score indicates good practice.

All tools were tested for content validity by five experts (jury) in the field of the study including faculty staff members from Faculty of Nursing-Alexandria (1 members), Faculty of Nursing - Mansoura University (3 members), and ICU specialists in the open thoracotomy. Any necessary modifications were done. The reliability testing was done using Cronbach's alpha on a sample of 10 of the subjects that measures the degree of reliability for the entire form. These techniques showed high reliability of the final version of the tool. The correlation coefficient was:

- Tool I ( r) =0.89

- Tool II (r) =0.93

- Tool II (r) =0.93

- Tool IV(r) = 87.

The pilot study was conducted on 10% of the subjects for testing the feasibility, applicability, and timeframe of the tools applications. The needed modification, omission and addition were made. They were excluded from the study sample.

Ethical approval was obtained from the research ethics committee of the Faculty of Nursing at Mansoura University. An Approval to conduct this study was obtained from the administrator of the cardiothoracic ICU and cardiothoracic department at Mansoura University Hospital after explaining the aim of the study.

Verbal consent was taken from the study sample before inclusion in this study, after explaining the purpose of the study. The researcher emphasized that participation in this study was entirely voluntary, anonymity, and the patient can withdraw at any time without any effect of the researcher on them. Privacy and confidentiality were respected and assured.

● Before data collection the researcher had taken a training course on acupressure under the supervision of specialist trainers in the field of acupressure and physiotherapy. The course lasted for four weeks. It included two parts, theoretical part and practical part. The theoretical part included definition of acupressure, importance of acupressure, difference between acupressure and acupuncture, uses and contraindications of acupressure, and theories of acupressure. The practical training included the precautions that should be used before, during and after applying acupressure, the proper selection of acupoints around wrist, the technique of thumb pressure, duration of pressure on each acupoints, and the duration needed for each acupressure session.

● The study was implemented during the period extended from the beginning of May 2019 till the end of October 2019.The study tools were adapted and designed by the researcher after reviewing the relevant recent literatures. The researcher visited the study setting three days per week, for both study and control groups. The sampling was collected during a period of six months.

● The first 3months control group data were collected, while the second 3months acupressure group data were collected.

● Each subject in both the study (acupressure) and the control groups was interviewed individually by the researcher in the above mentioned settings. The researcher used to welcome each patient on admission, and explain the purpose of the study. Then a verbal consent from each study subject to participate in the study was obtained.

● The researcher assessed each study subject using the study tools (pre-test). The necessary information took about 30-35 minutes. The researcher took the phone numbers of the study subjects to ensure continuous contact.

● The proposed intervention was developed by the researcher based on reviewing the related literatures. The proposed interventions included knowledge and practices required for reduction pain and anxiety for patients with open thoracotomy. It covered items related to the meaning of open thoracotomy, causes of open thoracotomy, types of complementary and alternative medicine, definition of acupressure, benefits of acupressure, and mechanism of acupressure. The interventions were prepared and divided to be in 3 sessions.

● The proposed interventions were covered the three sessions (one session for provision of knowledge and two sessions for training), implemented over one week.

● The researcher used to start each session by re-emphasizing the important points in the previous session.

● The acupressure group received a total of 3 days of acupressure. Each patient was asked to press the thumb at each acupressure point alternately for 2 minutes, perform 2 times per day over a week's time frame. The duration of each acupressure point massage was limited to 5 minutes.

● During each session, an illustrated booklet was used and distributed in order to clarify the knowledge and practices for each patient. Other teaching methods used were audiovisual material, open discussion, demonstration, re-demonstration and real life demonstration. Each patient had acupressure self- instructional module was given after posttest to help use of acupressure at home setting. As well as, the researcher used phone calls to answer any questions and clarify any vague points to maintain the studied patient's motivation and give positive feedback and reinforcement

● Telephone calls were conducted every one week during the first 4 weeks after implementation of the acupressure intervention for the patients in the acupressure group to follow the patients' adherence with the acupressure intervention.

● Immediately after implementation of acupressure training, the patients in the acupressure group were evaluated using tool II (Postoperative Anxiety Assessment Scale), tool III (Postoperative Pain Assessment Scale), and tool IV(Acupressure Practice Observational Checklist) to determine the effect of the training sessions. In addition times of daily analgesic intake among the studied groups.

● Evaluation of the patients in both groups by using tool II (Postoperative Anxiety Assessment Scale), tool III (Postoperative Pain Assessment Scale), and tool IV (Acupressure Practice Observational Checklist) was done after the 4th week from the implementation of acupressure intervention.

Data analysis was performed using IBM SPSS statistical software version 22. The data were explored. Descriptive statistics with mean and standard deviation (SD) for continuous variables and frequency for categorical variables were analyzed. Qualitative variables were compared using qui square test (X²) as the test of significance. A significant level value was considered when p-value ≤ 0.05 and a highly significant level value was considered when p-value ≤ 0.001, while p-value > 0.05 indicates non-significant results.

3. Results

Table 1 revealed that the highest percentage of the acupressure and control groups (80%, 76.7%) respectively were males. Regarding patients’ age, it was observed that in the acupressure group less than half (43.3%) of patients were between 50 to 60 years whereas in the control group it was about one third (36.7%) of patients belonged to the ages of 30 to 39 years and the same proportion for patients between 50 to 60 years. Only about one quarter (26.7%) of patients in the acupressure group was between 30 to 39years. Almost one third (30.0% ) of patients in the study group were between 40 to 49 years and only about one quarter (26.7%) of the control group was belonged to the same age. Mean age was higher in acupressure group (46.667 ± 8.199) years. However the difference was not statistically significant (t=1.306, p>0.202). As for marital status, the majority of both acupressure and control group (80%) were married. In relation to educational level, about one quarter (26.7%) of both acupressure and control groups were illiterate. About (13.3%, 10%) of acupressure and control groups respectively were university education. Half and less than half (50%, 46.7%) of acupressure and control groups respectively were working. Concerning level of activity, more than half (56.7%, 66.7%) of acupressure and control groups respectively had moderate activity level. The results also revealed that the majority (80%) of both groups lived in rural areas.

Table 2 showed the medical data of the studied groups. Concerning the duration of the diseases, 53.8% of the acupressure group and 55.8% of the control group had disease since 5 to less than 10 years, while 23.1% and 26.9% of the study and control groups had disease since 10 years and more. Only 23.1% of the acupressure group and 17.3% of the control group had disease since 1 to less than 5 years. There was no statistical significant difference between the two groups regarding the duration of the disease. For past medical history, it was observed that hypertension and diabetes mellitus were the most prevailing diseases among the study and control groups (30.8%, 23.1%, 30.8%, and 17.3%) respectively. Regarding the history of medications consumed by the study subjects, the table shows that analgesics were used by both study and control groups (100%). Anti-inflammatory drugs were used by 59.6% in the acupressure group and 44.2% in the control group. Anti-hypertensive drugs were used by 30.8% in acupressure group and 23.1% in control group. Vitamins were used by 30.8% in acupressure group and 15.4% in control group, while diabetic drugs were used by 28.8% in acupressure group and 17.3% in control group.

Table 3 showed that there was no statistical significant difference between the two groups regarding level of pain at the pre intervention phase. On the other hand, there was a highly statistical significant difference was indicated between them at 1st, 2nd, 3rd, and 4th week post intervention phase.

Table 4 illustrates level of anxiety at different times of assessment among the studied groups among both study and control groups, it was showed that there was no statistical significant difference between two groups regarding anxiety level at the pre-study phase. On the other hand there was a highly statistical significant difference was indicated between them at 1st, 2nd, 3rd, and 4th week after study.

Table 5 showed the times of daily analgesic intake at different times of assessment among the studied groups among both acupressure and control groups, it was showed that there was no statistical significant difference between two groups regarding times of daily analgesic intake at the pre-intervention. On the other hand there was a highly statistical significant difference was indicated between them at 1st, 2nd, 3rd, and 4th week after study.

Table 6 revealed the total mean score of acupressure practice before, immediate, and after 4 weeks for the acupressure group. This table shows that the total mean score of practice was improved (increased) significantly in the acupressure group post sessions and the improvement maintained at 4^thweek evaluation (p=0.000).

4. Discussion

Acupressure has a positive impact on the reduction of anxiety and pain scores that in turn will result in improving the quality of life of the patient with open thoracotomy ²⁶. Moreover, acupressure improves the emotional disturbance and psychological wellbeing of these patients ^{27, 28}. Therefore this study was conducted to evaluate the effect of acupressure in the reduction of pain and anxiety among patients with open thoracotomy.

The results of the current study supported the study hypothesis that patients who applying acupressure significantly had a decreased pain and anxiety score than patients in the control group, who had the routine care. These finding were supported by Singh et al., ²⁹ in the study to evaluate the effect of “Acupressure on pain and anxiety in cardiothoracic surgery patients”, it was concluded that Acupressure is recommended as a complementary therapy to reduce anxiety in patients undergoing open thoracotomy because of its low cost, safety, and simplicity. Utilization of acupressure for management of pain and anxiety among patients post-thoracotomy was recommended by a variety of research study ³⁰. These findings may be due to that, acupressure stimulates endogenous opioid system, and thus, affects intermediate behaviors and facilitates psychological improvement. Moreover, acupressure had no side effect as pharmacological measures.

Regarding socio-demographic characteristics of the studied patients at both study and control groups, the present study findings indicated that the majority of patients who underwent open thoracotomy were males. This was congruent with Motallebnejad et al., ³¹ who founded that the incidence of this type of surgery is near twice as common among men as it is among women.

In the present study, as regards to age, the results of the acupressure show that the majority of patient’s age (43.3%, 36.7%) of study and control group respectively ranged from 50 to 60 years old. This was consistent with French et al., who reported that the risk of open thoracotomy increases as individuals aged, most cases occur in adults who are middle-aged or older. About seventy-seven percent of all open thoracotomy are diagnosed in persons 55 years and older, although younger people can be affected too.

The present study pointed out that the majority of patients were from rural, the majority of the study and the control group. This may explain different aspects of the sample as, the acceptance of the acupressure group to apply acupressure instead of conventional pharmacological therapy. This was referred to as the advantage of being easily available, highly nutritive, culturally believed in, less costly and free from side effects. This was following Geoff et al., ³³ they illustrated that integrated medicine is a holistic approach to patient care, and congruent too with Scardina et al., ³⁴ who mentioned that complementary and alternative medicine therapies can be effective and more safety.

As regard co-morbidity is common among patients, and this is by the results of the present study where nearly two-thirds of the studied subjects had one or more co-morbid conditions. These findings supported by studies carried out by Leite et al., ³⁵ and Zullig et al., ²² who stated co morbidity is common among patients undergoing open thoracotomy. This may be attributed to the fact that the prevalence of open thoracotomy increases with advancing age, so coexistence with other chronic conditions is common.

Concerning the level of pain among the studied patients, the present study finding showed that there was no statistically significant difference between two groups regarding pain level at the pre-intervention stage. These study findings agreed with Taha et al., ³⁷ who indicated that there was no statistically significant difference between the two groups regarding the level of pain at the pre-intervention phase.

Regarding the effect of acupressure after open thoracotomy on pain among the studied patients, the present study indicated that there was a highly statistically significant difference between both study and control group, The present study findings come in the same line with El-Sayed & Ali ³⁸ who studied “ Effect of Counseling Intervention for Patients Undergoing Post Thoracotomy on their Quality of Life “and added that there was a decrease in pain among the acupressure group after intervention, then after four months.

Regarding the level of anxiety among the studied patients, the present study finding showed that there was no statistically significant difference between the two groups regarding anxiety level at the pre-intervention phase. These study findings agreed with Soliman., et al., 2017 ³⁹ who studied “ Effect of Massage Therapy for segmentectomy Recipients”, it was revealed that there was no statistically significant difference between both study and control groups regarding the level of anxiety at the pre-intervention phase(p>0.05).

Concerning the level of anxiety among the studied patients, the present study finding showed that there was a highly statistically significant difference was indicated between studied groups at the 1st, 2nd, 3rd, and 4th weeks post intervention. These findings are agreed with Soliman., et al., 2017 ³⁹ who added that acupressure as a non-pharmacological measure is highly decreased level of anxiety, and there was a highly statistical significance between both the study and control regarding the level of anxiety at the different times of assessment

Moreover, the results of the current study showed significant improvement in practicing the acupressure on wrist among the subjects in the acupressure group immediately after the intervention with a statistically significant difference was found between the study and control groups. This difference is still significant after 4thweek's evaluation. This is following a study carried out in Egypt by Ali et al., (2017) ⁴⁰ who revealed a significant improvement in knowledge and training of the acupressure group post-implementation of the training sessions. This finding may be attributed to acquiring knowledge about open thoracotomy and acupressure during the intervention, providing with necessary considerations to master the technique of self- administered acupressure, and effectiveness of applying acupressure on the wrist point for patients with open thoracotomy.

Finally this study, it can be said that the implementation of acupressure proved to be effective in a reduction level of pain and anxiety of patients who received the study intervention. The research hypothesis of the present study approved and came true. The research study can be considered as the start point and initiation of the provision of education and training on self-administered acupressure on improving physical function and the psychological health status to improve coping with chronic pain.

6. Conclusion

Based on the result of the current study, the present study concluded that acupressure is recommended as a complementary therapy to reduce level of pain and anxiety among patients with open thoracotomy.

7. Recommendations

Acupressure technique for relieving pain and anxiety should be added to the health care protocols for patients with open thoracotomy. Training programs on applying acupressure for ICU nurses are needed.

Acknowledgements

Our sincere thanks to all patients in cardio-thoracic ICU and cardio-thoracic department who agreed to take part in our study.

References