CRITICAL REVIEW EVIDENCE BASED NURSING (EBN)

AKUPRESURE UNTUK MENINGKATKAN KENYAMANAN

PASKA OPERASI KANKER LAMBUNG

disusun oleh
Moh. Afif Jakaria Iksafani
NIM 162310101197

KEMENTERIAN RISET, TEKNOLOGI, DAN PENDIDIKAN TINGGI

UNIVERSITAS JEMBER
FAKULTAS KEPERAWATAN
Jl. Kalimantan No. 37 Kampus Tegal Boto Jember Telp./Fax (0331) 323450
 DAFTAR ISI
DAFTAR ISI.............................................................................................................ii
KATA PEGANTAR.................................................................................................iii
BAB 1. PENDAHULUAN .......................................................................................
1.1 Latar Belakang..........................................................................................1
1.2 Tujuan........................................................................................................3
1.3 Manfaat Penerapan EBN.........................................................................3
BAB 2. METEDOLOGI PENCARIAN .................................................................
2.1 PICO (Promblem, Intervention, Comparative, Outcome)...................4
2.2 Intervention...............................................................................................5
2.3 Pertanyaan Klinis.....................................................................................6
2.4 Metode Penelusuran Journal...................................................................7
2.5 Jurnal Database yang Digunakan...........................................................8
2.6 Temuan Artikel Pilihan dari Kata Kunci PICO yang Digunakan
sebagai Rujukan......................................................................................9
BAB 3. PROSEDUR APLIKASI EVIDANCE BASED NURSING ....................
3.1 Subyek........................................................................................................13
3.2 Proseedur Pelaksanaan Evindance Based Practice...............................13
BAB 4. PEMBAHASAN . ........................................................................................
4.1 Hasil...........................................................................................................15
4.2 Pembahasan...............................................................................................16
BAB 5. PENUTUP....................................................................................................
5.1 Kesimpulan................................................................................................17
5.2 Saran..........................................................................................................17
DAFTAR PUSTAKA ...............................................................................................

ii
 KATA PENGANTAR

Segala puji syukur kami panjatkan kehadirat Tuhan Yang Maha Esa yang telah
melimpahkan rahmat, hidayah dan inayah-Nya berupa kemampuan untuk berpikir
serta menganalisis sehingga kami bisa menyelesaikan makalah ini yang berjudul
“Akupresure untuk meningkatkan kenyamanan pasca operasi kanker lambung.”.
Dalam makalah ini berisikan salah satu solusi untuk mengatasi masalah
kenyamanan pada pasien paska operasi kanker lambung.Selama pembuatan
makalah ini kami banyak mendapatkan bantuaan, maka dari itu penulis
mengucapkan terimakasih kepada :

1. Ns. Mulia Hakam, M.Kep, Sp.Kep. MB selaku PJMK mata kuliah

2. Kedua orang tua yang selalu memberikan dukungan dan motivasi
3. Semua pihak yang secara tidak langsung membantu terciptanya makalah
ini yang tidak dapat disebutkan satu per satu

Akhir kata kami menyadari bahwa tiada sesuatu yang sempurna dan
karya tulis ilmiah ini tentunya. Kami menyadari bahwa kami masih
membutuhkan bimbingan mengingat keterbatasan informasi, ilmu dan
pengetahuan. Oleh sebab itu kami membutuhkan kritik dan saran yang
membangun. Semoga karya tulis ilmiah ini bisa bermanfaat bagi kita semua.
Terimakasih.

Jember, 10 April2019

Penulis
 BAB 1
PENDAHULUAN

1.1 Latar belakang

Kanker adalah penyakit yang disebabkan rusaknya mekanisme
pengaturan dasar perilaku sel khususnya mekanisme pertumbuhan dan
deferensiasi sel. Kanker merupakan pertumbuhan sel abnormal yang disebabkan
adanya berbagai faktor yang berubah ekspresi gen dan menimbulkan disregulasi
antara poliferasi sel dan kematian sel (Kurniasari, 2018).
Kanker lambung biasanya terjadi pada individu yang berusia diatas 40
tahun dan kadang terjadi pada individu yang lebih muda. Kebanyakan kanker
lambung terjadi pada kurvatura minor atau antrum dari lambung dan merupakan
kanker adenokersinoma (Baughman, 2005). Kanker lambung lebih banyak
dijumpai pada laki-laki. Seperti jenis kanker lainnya, penyebab kanker lambung,
peradangan pada lambung (gastritis) yang disertasi penyusutan lambung, atau
faktor genetik. Selain faktor keluarga, orang terkena kanker lambung terdapat
faktor pendorong seperti kebiasaan merokok, minuman beralkohol, dan cara
memproses makanan dan diet tertentu (Wijayakusuma, 2009).
Kanker merupakan penyebab kematian nomor dua di dunia yakni
terhitung 8,8 juta kematian di 2015. Kanker paru-paru, prostat, usus, lambung,
dan hati merupakan kanker yang paling umum diantara laki-laki, sementara
kanker payudara, usus, paru-paru, leher rahim, dan perut merupakan kanker yang
paling umum diantara perempuan (WHO, 2017).
Kanker lambung disebabkan oleh pola makan yang tidak sehat seperti
konsumsi makanan yang diasinkan, diasapi dan jarang mengonsumsi buah-
buahan serta sayuran. Selain itu, penyebab kanker lambung yang lain yakni
riwayat medis keluarga dimana terdapat kanker lambung, infeksi yang
disebabkan oleh Helicobacter pylori, radang lambung kronis, pernicious anemia,
dan merokok. Gejala pada penyakit kanker lambung sangat sulit untuk dideteksi
karena sangat
sedikit gejala yang terjadi. Gejala kanker lambung dapat dideteksi cenderung
pada saat mencapai stadium lanjut seperti nafsu makan menurun, penurunan
berat badan, cepat kenyang, mulas atau gangguan pencernaan, mual, muntah
darah, pembengkakan pada perut karena penumpukan cairan, dan anemia
(Lumongga, 2008).
Kanker lambung pada stadium awal tidak menunjukkan gejala, oleh
karena itu pemeriksaan dini dapat mempermudah penyebuhan kanker lambung.
Cara untuk menentukan stadium awal pada kanker lambung adalah dengan
menggunakan screening. Namun ada beberapa kendala dalam proses screening,
diantaranya adalah: akan banyak populasi yang akan mengikuti tes namun
hasilnya negatif, tes yang sangat sensitif adalah endoscopy atau barium meal
khusus yang tentu saja memerlukan hospitalisasi dan tidakcocok untuk populasi
yang banyak. Oleh karena itu, proses screening kanker lambung diarahkan pada
mereka yang memiliki riwayat keluarga terpapar kanker lambung dan penderita
anemia pernisiosa. Meskipun kanker lambung sering didahului oleh grastitis,
namun diagnosis ini tidak terlalu membantu dalam memprediksi terjadinya
kanker lambung karena kelainan ini ditemukan pada jumlah populasi sehat yang
banyak. Penderita dengan risiko tinggi terjadinya kanker lambung dianjurkan
menjalani pemeriksaan endoscopy dan barium meal khusus sekali dalam 6-24
bulan (Surya, 2009 ).
Setelah hasil kanker terdeteksi maka dilakukan penentuan stadium kanker
lambung untuk mengetahui seberapa jauh kanker telah menyebar ke organ
lainnya. kanker lambung diklasifikasikan menjadi 5 stadium yaitu kanker
lambung stadium 0, stadium I, stadium II, stadium III, dan stadium IV.
Klasifikasi penyakit adalah pengelompokkan kategori penyakit menurut sel
abnormal yang terdapat pada penyakit tersebut sesuai dengan kriteria yang
ditetapkan (Baughman. 2005).
Untuk mengatasi masalah nyeri post operasi kanker lambung dilakukan
beberapa perawatan non konvensional atau perawatan komplementer salah
satunya yaitu terapi akupresur pada pasien post operasi. Prenatal yoga adalah
salah

2
 satu cara terbaik bagi pasien post operasi kanker lambung yang dapat dilakukan
untuk mengatasi masalah gangguan kenyamanan nyeri.

1.2 Tujuan
1.2.1 tujuan umum
Mengetahui pengaruh akupresur untuk mengatasi masalah nyeri post
operasi kanker lambung
1.2.2 tujuan khusus
1. untuk mengetahui pengaruh pemberian terapi akupresur pada pasien
post operasi lambung
2. untuk mengetahui efek terapi akupresur terhadap nyeri post operasi

1.3 Manfaat penerapan EBN

1.3.1 Bagi pasien
Memberikan terapi pengobatan non-farmakologi berupa terapi akupresur yang
bermanfaat menghilangkan masalah nyeri bagi pasien post operasi kanker
lambung dan tidak menimbulkan biaya yang besar serta efek samping.
1.3.2 Bagi pelayanan keperawatan
Hasil penerapan EBN ini dapat menjadi suatu standart baru yang dapat
diterapkan di pelayanan kesehatan dalam mengurangi masalah nyeri pada
pasien post operasi kanker lambung
1.3.3 Bagi perkembangan ilmu keperawatan
Hasil penerapan EBN ini diharapkan dapat memperkaya khazanah
keilmuan keperawatan dan menjadi salah satu acuan dalam pengelolaan
masalah nyeri pada pasien post operasi kanker lambung
 BAB 2
METODOLOGI PENCARIAN

2.1 PICO (Problem, Intervention, Comparative, Outcome)

2.1.1 Problem (dapat berupa masalah yang ditemukan di jurnal)
Kematian terkait kanker lambung diprediksi menempati urutan
ketujuh di seluruh dunia pada tahun 2030. Kanker lambung menempati
urutan keenam di antara penyebab utama kematian terkait kanker,
menyebabkan tingkat kematian 5,5% di Taiwan. Pedoman untuk
mengobati kanker lambung merekomendasikan penggunaan algoritma
multimodality untuk operasi tertentu, kemoterapi, dan rejimen terapi
radiasi, dan reseksi bedah biasanya disarankan. Namun, rasa sakit pasca
operasi tetap menjadi perhatian. Pembedahan gastrointestinal mengubah
struktur dan fungsi fisiologis dari sistem gas-trointestinal, menyebabkan
kerusakan jaringan yang luas pada daerah perut dan meningkatkan
produksi mediator inflamasi seperti sitokin dan neuropeptida.
Akibatnya, reseptor rasa sakit pada kulit, otot, dan organ-organ internal
mengirimkan sinyal ke sistem saraf pusat (SSP), yang, setelah kognisi,
meningkatkan keparahan nyeri pasca operasi.
Selain itu, 20-30% pasien menunjukkan mual dan muntah pasca
operasi setelah menjalani anestesi dan pembedahan. Empat prediktor
penting terkait dengan peningkatan insiden PONV, yaitu jenis kelamin
perempuan, riwayat mabuk perjalanan atau PONV, bukan perokok, dan
penggunaan opioid pasca operasi. Mengobati PONV melibatkan
penggunaan obat antiemetik yang dapat menyebabkan berbagai efek
samping, termasuk sakit kepala, gangguan ekstrapiramidal, dan
takikardia. Kondisi-kondisi ini biasanya diobati dengan memperbaiki
kadar cairan, kadar elektrolit, atau defisiensi nutrisi; Namun, perawatan
meningkatkan biaya dan lamanya tinggal di rumah sakit. Karena
 gastrektomi subtotal mengurangi volume lambung dan motilitas
gastrointestinal, menghasilkan ketidaknyamanan pasca operasi.
Dengan demikian, intervensi non-farmakologis sangat penting
digunakan pada pasien paska operasi lambung untuk mengatasi masalah
kenyamanan (nyeri). Salah satu intervensi non-farmakologi untuk
mengatasi nyeri pada pasien paska operasi adalah akupresure.

2.2 Intervention
Perawat memiliki peran utama yaitu memberi asuhan keperawatan
komprehensif pada pasien nya, tugas perawat adalah sebagai care giver dan
konsultan yang idealnya dapat memberikan asuhan keperawatan yang optimal
pada pasien paska operasi kanker lambung. Namun seiring dengan
berkembangnya teknologi perawat juga harus mampu memberikan asuhan
keperawatan non komprehensif berupa terapi komplementer. Terapi
komplementer merupakan yang dapat digunakan sebagai terapi non farmakologi.
Akupresur dirancang untuk merangsang 2 titik akupuntur yang ditunjukkan
dalam Neiquan (P6) dan Zusanli (ST36). Merangsang acupoint P6 dapat
mencegah PONV dan meringankan masalah pencernaan, sedangkan merangsang
acupoint ST36 dapat meningkatkan fungsi sistem pencernaan. Acupoint P6
terletak 5 cm proksimal ke titik tengah lipatan melintang pergelangan tangan,
antara tendon fleksor karpi radialis dan palmaris longus, sedangkan acupoint
ST36 terletak 7,5 cm di bawah lutut, sekitar 1,5 cm lateral tibia pada tibialis
anterior. Tiga sesi intervensi akupresur selama 12 menit diadakan selama 3 hari
berturut-turut setelah operasi. Untuk memastikan bahwa urutan dan durasi
konsisten untuk setiap pers, akupresur melanjutkan secara berurutan dari titik
akupuntur P6 kanan ke titik akupuntur ST36 kanan, dan kemudian dari titik
akupuntur P6 kiri ke titik akupuntur ST36 kiri.
2.1.2 Comparasion intervention
Intervensi dilakukan oleh seorang peneliti yang merupakan
praktisi akupresur bersertifikat. Poin yang berbeda telah digunakan
dalam penelitian sebelumnya termasuk EX-HN3 (Ekstra), HT7
(ShenMen), dan LI4. Pemilihan titik LI4 atau Hegu yang terletak di
tengah-tengah garis sudut antara metacarpal pertama dan kedua
(Gambar 1) dan titik HT7 pada pergelangan tangan lateral yang terletak
radial menuju tendon fleksor carpi ulnaris (Gambar. 2) dengan meninjau
studi yang berbeda dan dengan meminta saran dari seorang ahli. Titik
LI4 terletak di mana aliran energi lebih dekat ke kulit dan dengan
demikian, dihasut dengan bersantai, tekanan atau jarum jauh lebih
mudah.
Titik-titik tekanan ditekan selama 2 menit secara simetris segera
setelah permulaan dan akhir biopsi. Jari-jari ditekan dengan lembut pada
titik dan tekanan meningkat secara bertahap sampai ada sensasi sakit.
Semua pasien ditempatkan pada posisi yang sama dan 5 mg lidokain
disuntikkan secara lokal.
Untuk kelompok plasebo, titik pada jarak 1,5 cm dari titik utama
(LI4 dan HT7) dipilih. Titik-titik ini disebut titik tekanan tidak efektif
atau palsu. Tidak ada intervensi yang dilakukan pada kelompok kontrol;
hanya prosedur rutin seperti pengukuran tekanan darah, denyut nadi, dan
kontrol pernapasan yang dilakukan.

Gambar. 1. LI 4 titik terletak di antara fipertama dan tulang metakarpal kedua

 Gambar. 2. Shen Men terletak di lipatan melintang dari pergelangan tangan di artikular yangdaerah antara
ulna tulang berbentuk kacang dalam depresi di sisi radial dari tendon flexor karpi ulnaris otot.

2.1.3 Outcome
Nyeri pasca operasi adalah salah satu masalah terapeutik yang paling
umum, tetapi dapat dihindari. Akupresur dapat diterapkan pada titik
akupuntur P6 dan ST36 sebagai alternatif yang efektif untuk
mengurangi rasa sakit dan untuk mengurangi waktu flatus pertama
setelah operasi. Akupresur adalah prosedur sederhana, tidak invasif,
aman, dan ekonomis yang dapat diterapkan dalam perawatan kesehatan
dan praktik klinis. Profesional kesehatan yang menerima pendidikan dan
pelatihan yang sesuai dapat memberikan akupresur kepada pasien.
Dengan mengintegrasikan TCM dengan pengobatan Barat, perawat
dapat meningkatkan kualitas perawatan dan mengurangi biaya terkait.
Ini adalah uji coba, dan penelitian tambahan diperlukan untuk
mengklarifikasi efek akupresur dalam meningkatkan motilitas gastroin-
testinal dan mencegah PONV setelah operasi.

2.3 Pernyataan klinis

Apakah terapi akupresuryang dilakukan pada pasien paska operasi lambung dapat
mengatasi masalah nyeri paska operasi?
2.4 Metode penelusuran jurnal

Unsur Analisis Kata kunci

PICO
(Terapi)
P NyeripasienmenjalanipaskaoperasiGastric cancer patient
kanker lambungPain after surgery
I Terapiakupresur mengatasi masalah nyeri Therapy
setelah operasi kanker lambung complementary pain
Posoperative gastric
cencer
C Terapi akupresur nyeri Acupressure pain
O Terapi akupresur mengatasi masalah Acupressure therapy
kenyamanan (nyeri) pada pasien paska Posoperative gastric
operasi lambung cancer

2.5 Jurnal database yang digunakan

Menggunakan kata kunci dan beberapa sinonimnya dari analisa PICO, peneliti
memasukkannya ke dalam search engine jurnal sebagai berikut :

a. http://www.sciencedirect.com/
b. https://scholar.google.co.id/

didapatkan88 judul artikel tahun 2015-2019, kemudian dipilih sebanyak 8

jurnal yang relevan. Kesesuaian dengan keadaan yang sebenarnya di rumah
sakit membuat peneliti memilih 3 artikel pilihan untuk kemudian memilih 1
artikel sebagai rujukan, 1 artikel sebagai artikel pendukung dan 1 artikel
sebagai pembanding.
2.6 Temuan artikel pilihan dari kata kunci PICO yang digunakan untuk
digunakan sebagai rujukan :

2.6.1 Acupressure improves the postoperative comfort of gastric cancer

patients: A randomised controlled trial

Akupresur meningkatkan kenyamanan pasca operasi pasien kanker

lambung: Sebuah uji coba terkontrol secara acak.

Abstrak
Tujuan :Mengetahui efek dari yoga prenatal pada indikator biologis
yang belum dipelajari secara luas. Penelitian ini membandingkan
perubahan stres dan kekebalan ludah biomarker dari usia kehamilan 16-36
minggu antara wanita yang menerima yoga prenatal dan mereka yang
menerima perawatan prenatal rutin.
Metode : Penelitian ini dilakukan dengan sebuah uji coba terkontrol
secara acak dilakukan. Enam puluh pasien direkrut dari 141 tempat tidur
bedah umum bangsal di pusat medis 3000-tidur di Taiwan Utara. Peserta
secara acak ke salah satu kelompok kontrol yang menerima perawatan
pasca operasi rutin atau untuk kelompok eksperimen menerima akupresur
tambahan di titik akupuntur dari Neiquan (P6) dan Zusanli (ST36) selama
3 hari berturut-turut.
Hasil : Pada jurnal ini didapatkan bahwa Kesamaan antara dua
kelompok berada di nyeri pasca operasi dan timbulnya mual dan muntah
pasca operasi (PONV) di baseline. Berikut akupresur, perbedaan
signifikan yang ditemukan di nyeri pasca operasi (P = 0,03) dan waktu
flatus pertama (P = 0,04); tapi tidak PONV (P = 0,49), maupun saat buang
air besar pertama (P = 0,34).
Kesimpulan: Dari studi ini didapatkan bahwaAkupresur adalah prosedur
sederhana, non-invasif, aman, dan ekonomis untuk improvisasi-ing
kenyamanan pasien yang menjalani operasi untuk kanker lambung.
 Akupresur di P6 dan ST36 titik akupuntur dapat meningkatkan
kenyamanan pasca operasi dengan mengurangi rasa sakit dan mengurangi
waktu sampai flatus pertama. Namun, penelitian tambahan diperlukan
untuk menjelaskan bagaimana akupresur dapat meningkatkan hasil pasca
operasi.

2.6.2 Physical effects of Anma therapy (Japanese massage) for

gynecologic cancer survivors: A randomized controlled trial

Efek fisik terapi Anma (pijat Jepang) untuk penderita kanker ginekologi:
Sebuah uji coba terkontrol secara acak

Abstrak
Tujuan :Padapenderita kanker sering memiliki keluhan fisik dan
psikologis setelah kanker standar memperlakukan-ment. Kami melakukan
uji coba terkontrol secara acak untuk mengevaluasi efek fisik dan
psikologis / emosional terapi Anma (pijat Jepang, AMT) di penderita
kanker ginekologi. Tujuan utama adalah untuk memverifikasi efek 8
minggu berturut-turut dari AMT mingguan. Tujuan kedua adalah untuk
menipufirm efek langsung dari sesi tunggal AMT. Kami melaporkan di
sini hasil dari efek fisik AMT.
Metode : Penelitian ini dilakukan padaempat puluh peserta secara acak
dialokasikan ke grup AMT yang menerima satu 40-menit sesi AMT per
minggu selama 8 minggu dan kelompok tanpa AMT. Titik akhir primer
adalah beratnya keluhan fisik subjektif dinilai menggunakan skala analog
visual (VAS). Tujuan sekunder adalah urine dan analisis air liur dan
Psikolog-ical / skor kuesioner emosional.
Hasil : Pada jurnal ini didapatkan bahwa hasil analisis primer, kuadrat-
cara (LSM) perkiraan peningkatan skor VAS selama 8 minggu yang-21,5
(95% confidence interval [CI], -30,1 untuk -12,8, P = 0,0017)
 pada kelompok AMT (n = 20) dan 0,8 (95% CI, -7,7-9,2, P = 0,89) di no-
AMT kelompok (n = 20). Perbedaan dalam LSM memperkirakan be-tween
kelompok itu-22,2 (95% CI, -34,4 untuk -10.1, P = 0,0007). Ada
signifiperbedaan tidak bisa di skor VAS dan epinefrin kemih antara
sebelum dan sesudah sesi intervensi, menunjukkan keunggulan AMT.
Kesimpulan : Dari studi ini dapat disimpulkan bahwa sebuah sesi AMT
tunggal mengurangi keparahan keluhan fisik subjektif dan mungkin
menghambat sistem saraf simpatik di penderita kanker ginekologi.
Menerima sesi AMT mingguan selama delapan minggu ef-fectively terus
mengurangi keparahan keluhan fisik subjektif.

2.6.3 The effect of acupressure on pain, anxiety, and the physiological

indexes of patients with cancer undergoing bone marrow biopsy

Pengaruh akupresur pada nyeri, kecemasan, dan indeks fisiologis pasien

dengan kanker yang menjalani biopsi sumsum tulang

Abstrak
Tujuan : Tujuan dari dilakukanya penelitian pada jurnal ketiga ini yaitu
untuk mengetahui pengaruh akupresur pada intensitas nyeri, kecemasan,
dan indeks fisiologis pasien dengan kanker yang menjalani biopsi
sumsum tulang dan aspirasi.
Metode :Penelitian ini dirancang sebagai uji coba secara acak terkontrol
buta ganda.Sembilan puluh sampel dipilih dengan menggunakan metode
convenience sampling, maka untuk kelompok alokasi acak blok sampling
digunakan (30 untuk setiap kelompok). Ketiga kelompok adalah serupa
dengan usia dan jenis kelamin. LI4 dan HT7 (Shen Men) akupresur poin
diperiksa untuk intervensi. Tekanan Sham digunakan pada kelompok
plasebo sementara tidak ada intervensi diterapkan pada kelompok kontrol.
Hasil : Pada penelitian ini menghasilkanbahwa menunjukkan bahwa
nilai rata-rata terendah kecemasan (1,5 ±0,5; P¼ 0,01) dan terendah skor
nyeri rata-rata (4,9 ± 0,8) setelah intervensi terkait dengan metode
akupresur (P ¼0,001).
Kesimpulan : Dapat disimpulkan bahwa efektivitas biaya dan
pendidikan sederhana make metode akupresur jangka pendek berguna
dalam pengaturan klinis untuk penyakit yang berbeda
 BAB 3
PROSEDUR APLIKASI EVIDENCE BASED NURSING

Pelaksanaan EBN ini mengacu pada penelitian oleh Hsiung, et.al. 2015

3.1 Subyek
Subjek dalam penerapan EBN ini adalah pasien yang didiagnosis dengan kanker
lambung dan gastrektomi subtotaldengan kriteria berikut:
Kriteria Inklusi:
 berusia minimal 18 tahun,
 mampu menerima anestesi umum
 diklasifikasikan sebagai I-III menurut American Society of Anesthetists (ASA)
 tidak memiliki gangguan, infeksi, memar, atau perdarahan di situs akupresur

Kriteria Eksklusi :

 dikeluarkan dari operasi perut

 menerima kemoterapi bersamaan atau radioterapi
 didiagnosis dengan jenis kanker lain
 berpartisipasi dalam studi serupa.

3.2 Prosedur pelaksanaan Evidence Based Practice

Prosedur pelaksanaan evidence based practice ini meliputi prosedur teknis.
Adapun prosedur tersebut adalah sebagai berikut :
1. Menjelaskan tujuan dari terapi kepada pasien
2. Meminta persetujuan pasien dengan informed concent
3. Mempersiapkan pasien agar dapat mengikuti seluruh prosedur terapi
4. Semua pasien ditempatkan di posisi yang sama
5. Ibu jari terapis digunakan untuk melakukan pijatan akupresur
6. Memberikan tekanan 5 detik pada titik neiquan (P6) dan zusanli (ST36)
7. Jari ditekan lembut pada titik dan tekanan meningkat secara bertahap
sampai ada sensasi rasa sakit
8. Berpindah titik selama 1 detik
9. Uleni (diputar-putar) selama 5 detik
10. Proses ini diulang hingga 3 menit di masing-masing titik akupoin
11. 3 sesi intervensi akupresur yaitu selama 12 menit
12. Terapi akupresur dilaksanakan selama 3 hari berturut-turut
 BAB 4
PEMBAHASAN

4.1 Hasil
Hasil penelitian dari jurnal Acupressure improves the postoperative comfort of
gastric cancer patients: A randomised controlled trial menunjukkan bahwa usia rata-
rata peserta adalah 62,39 ± 15,53 tahun, dan sebagian besar peserta adalah laki-laki
(74,07%) dan memiliki tingkat pendidikan perguruan tinggi atau lebih tinggi
(29,63%). Menunjukkan karakteristik demografi dan medis pada awal, menunjukkan
tidak ada perbedaan yang signifikan antara kelompok (P> .05). Sebagian besar
peserta (87,03%) menunjukkan status buang air besar yang normal, dan distensi perut
adalah alasan utama untuk mengunjungi dokter (33,33%). Durasi gastrektomi subtotal
rata-rata 329,26 ± 55,55 mnt. Sebagian besar peserta (96,30%) menggunakan
analgesia yang dikendalikan pasien (PCA) untuk mengelola nyeri pasca operasi.
Dalam 10-15 menit setelah operasi, para peserta terhubung ke perangkat PCA di
ruang pemulihan anestesi, dan perangkat digunakan setidaknya selama 3 hari setelah
operasi. Analgesik diberikan secara intravena (100 mg morfin dan 0,1 mg droperidol
per 100 mL) atau melalui injeksi epidural (600 mg marcaine dan 600 mg fentanyl per
600 mL). menunjukkan garis dasar sampai Hari 3 setelah operasi. Tidak ada
perbedaan kelompok yang signifikan yang diamati pada awal (t = 0,09, P = 0,93).
Kecenderungan intensitas nyeri rata-rata menunjukkan penurunan bertahap, dan
perbedaan signifikan diamati antara kelompok (F = 4,86, P = 0,03) dan di dalam
kelompok (F = 7,12, P = 0,001). Gambar. 4 menunjukkan skor PONV grup dari
baseline sampai Hari 3 setelah operasi. Tidak ada perbedaan kelompok yang
signifikan yang diamati pada awal (t = 1,3, P = .2). Selain itu, tren menunjukkan tidak
ada perbedaan yang signifikan antara kelompok (F
= 0,47, P = 0,49) dan di dalam kelompok (F = 0,09, P = 0,86).Motilitas
gastrointestinal setelah operasi, menunjukkan perbedaan yang signifikan antara
kelompok pada saat flatus pertama (t = 2,12, P = 0,04), tetapi tidak pada saat buang
air besar pertama (t = 0,97, P = 0,34). Delapan peserta dalam kelompok eksperimen
dan 17 pada kelompok
kontrol merasakan distensi abdomen pertama, menghasilkan perbedaan yang
signifikan (2 = 4,86, P = 0,03). Tidak ada efek samping yang terjadi selama penelitian
ini.

4.2 Pembahasan
Terapi akupresur mengurangi nyeri akut pasca operasi gastrektomi subtotal
dalam 3 hari pertama. Intensitas nyeri secara bertahap menurun pada kedua
kelompok, namun intensitas nyeri di antara kelompok eksperimen menurun dari
sedang ke ringan, dan berkurang lebih cepat dibandingkan dengan kelompok kontrol.
Intensitas nyeri secara bertahap menurun pada kelompok kontrol karena respon
seluler berkontribusi pada penyembuhan luka. Selain itu, merangsang titik akupuntur
P6 dan ST36 menghasilkan efek analgesik dan mengurangi rasa sakit pasca operasi.
Selain mengurangi rasa sakit, stimulasi acupoint meningkatkan motilitas
gastrointestinal setelah operasi. stimulasi acupoint menimbulkan penurunan PONV
secara bertahap selama 3 hari pertama setelah operasi. Kelompok eksperimen
menunjukkan pemulihan sedikit lebih cepat dari gejala mual, muntah, dan muntah
daripada kelompok kontrol. (Hsiung et al.,2015).
Dalam penelitian pada jurnal pendukung, efek pijatan kuat pada peningkatan
aliran darah lokal lebih tahan lama dibandingkan dengan tekanan lembut dan
mewakili cara ampuh untuk mempercepat penyembuhan. dan pijat secara tradisional
telah digunakan untuk menghilangkan rasa sakit, mengurangi rasa tidak nyaman,
meredakan kejang otot yang terkait, dan memungkinkan peningkatan fungsi. Selain
itu, dengan memijat dan menekan otot-otot, spindel otot ditarik dan diperpanjang, dan
stimulasi itu menyebabkan berbagai refleks, termasuk refleks regangan dan
penghambatan antagonis, serta impuls sensorik somatik untuk bergerak ke otak untuk
mengoordinasikan fungsi otot melalui sirkuit saraf jaringan. Mekanisme ini berfungsi
untuk meningkatkan berbagai keluhan fisik subjektif pada penderita kanker
(Donoyama. et.al. 2016).
 BAB 5
PENUTUP
5.1 Kesimpulan

Nyeri post operasi sering dirasakan oleh pasien kanker, dimana efek
nyeri sering dirasakan tidak nyaman. Secara umum di rumah sakit nyeri
ditangani dengan terapi medis yaitu dengan menggunakan obat-obatan yang
menimbulkan efek samping pada pasien kanker lambung setelah operasi.
Namun saat ini telah banyak di lakukan penelitian terkait terapi
komplementer untuk mengatasi masalah kenyamanan (nyeri) dan stimulasi
untuk meningkatkan motilitas gastrointestinal pada pasien post operasi.
Terapi komplementer yang dapat mengatasi masalah nyeri salah
satunya adalah terapi akupresur. Banyak penelitian yang membuktikan
bahwa pijat pada titik akupoin banyak sekali manfaatnya. Diantaranya dapat
mengatasi masalah nyeri dan meningkatkan mekanisme pada
gastrointestinal. Dengan adanya intervensi terapi akupresur masalah nyeri
dapat menurun secara signifikan.
5.2 Saran
5.2.1 Bagi Profesi Keperawatan
Penerapan terapi komplementer akupresur dapat diterapkan untuk
mendukung implementasi perawat dalam mengatasi masalah nyeri pada
pasien post operasi kanker lambung. Agar pada pasien post operasi tidak
terlalu sering mengkonsumsi obat yang menimbulkan efek samping.
Oleh karena itu perawat pelu banyak belajar dalam melaksanakan tata
cara terapi akupresur dengan benar dan mengimplementasikan kepada
pasien post operasi kanker lambung
5.2.2 Bagi Mahasiswa Keperawatan
Perlunya untuk memperkaya wawasan terkait intervensi-intervensi
keperawatan terbaru guna meningkatkan keterampilan dalam melakukan
asuhan keperawatan. Untuk intervensi-intervensi keperawatan yang
teruji secara klinis dapat meningkatkan pengetahuan sebagai mahasiswa.
 DAFTAR PUSTAKA

Diane, Baughman. 2005. Keperawatan Medikal Bedah: Buku Saku dari Brunner &
Suddarth. Jakarta: EGC
Donoyama, N., Satoh, T., Hamano, T., Ohkoshi, N., & Onuki, M. (2016). Physical
effects of Anma therapy (Japanese massage) for gynecologic cancer survivors:
a randomized controlled trial. Gynecologic oncology, 142(3), 531-538.
Available on:
https://www.sciencedirect.com/science/article/pii/S0090825816308332
Hsiung, W. T., Chang, Y. C., Yeh, M. L., & Chang, Y. H. (2015). Acupressure
improves the postoperative comfort of gastric cancer patients: a randomised
controlled trial. Complementary therapies in medicine, 23(3), 339-346.
Available on:
https://www.sciencedirect.com/science/article/pii/S0965229915000552
Kurniasari, Fuadiyah. 2018. Buku Ajar Gizi dan Kanker. Malang: UB Press.
Lumongga, Namora. 2016. Psikologi Kespro dan Perkembangan Reproduksinya.
Jakarta: Kencana.
Rizi, M. S., Shamsalinia, A., Ghaffari, F., Keyhanian, S., & Nabi, B. N. (2017). The
effect of acupressure on pain, anxiety, and the physiological indexes of
patients with cancer undergoing bone marrow biopsy. Complementary
therapies in clinical practice, 29, 136-141. Available on :
https://www.sciencedirect.com/science/article/pii/S1744388117301172
Surya, Ade. 2009. Perilaku Remaja. Jakarta: Erlangga.
Wijayakusuma, Hembing. 2009. Atasi Kanker dengan Tanaman Obat. Jakarta: Puspa
Swara.
Complementary Therapies in Medicine (2015) 23, 339—346

Available online at www.sciencedirect.com

ScienceDirect

jo ur nal home p ag e: www.elsevierhealth.com/journals/ctim

Acupressure improves the postoperative

comfort of gastric cancer patients:
A randomised controlled trial
Wan-Ting Hsiunga, Yi-Chuan Changb,c, Mei-Ling Yeh d,∗
,
Yung-Hsien Change

a
Department of Nursing, Taipei Veterans General Hospital, Taiwan, ROC
b
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

KEYWORDS Summary
Objective: This pilot study evaluated whether acupressure affected the postoperative
Acupressure;
comfort of gastric cancer patients following a subtotal gastrectomy.
Postoperative
Methods: A randomised controlled trial was conducted. Sixty patients were recruited from
comfort;
141-bed general surgery ward at a 3000-bed medical centre in Northern Taiwan. Participants
Gastric cancer;
were randomly assigned to either a control group receiving regular postoperative care or to
Pain;
the experimental group receiving additional acupressure at acupoints of Neiquan (P6) and
Nausea;
Zusanli (ST36) for 3 consecutive days.
Vomiting;
Results: The similarities between two groups were in postoperative pain and the onset of
Flatus;
postoperative nausea and vomiting (PONV) at the baseline. Following acupressure, significant
Defecation
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
improv- ing 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: meiling@ntunhs.edu.tw (M.-L. Yeh).

http://dx.doi.org/10.1016/j.ctim.2015.03.010
0965-2299/© 2015 Elsevier Ltd. All rights reserved.
340 W.-T. Hsiung et al.

Introduction were

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, post- operative pain remains a
concern. Gastrointestinal surgery alters the structure and
physiological function of the gas- trointestinal system,
causing extensive tissue damage to the abdominal region
and increasing production of inflam- matory 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 sys- tem (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 post-
operative analgesics.8
In addition, 20—30% of patients exhibited postoperative
nausea and vomiting (PONV) after undergoing anaesthe-
sia 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 non-
smoker, and the use of postoperative opioids.9,10 Treating
PONV involves using antiemetic drugs that can cause
various side effects, including headache, extrapyramidal
disturb- ance, 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, nonpharmaco- logical remedies, such as
acupoint stimulation, can be used as complementary
interventions.
According to traditional Chinese medicine (TCM) princi-
ples, the meridian system comprises a network of conduits
through which qi and blood circulate, connecting the
inter- nal 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 Sim- ilar 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 neu-
rotransmitters 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 elec-
troacupuncture improved gastrointestinal motility and
gastric emptying.22 One study reported that acupressure
also yielded such improvements, but some of the findings
questionable because the patients’ symptoms were evalu-
ated 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 incon- clusive findings
regarding PONV.18,30
This study investigated various methods of acupoint
stim- ulation. Invasive acupuncture may cause
hematomas, and acupuncture needles should not be
inserted by a nurse. 31 Receiving noninvasive acupressure
while wearing a wrist- band may cause discomfort, red
indentations, itching, blistering, and swelling of the
wrist,11,25 and a capsicum plas- ter may cause skin
irritation at applied sites. 32 Therefore, to minimise the
risk of complications, acupressure was per- formed
manually in this study. This pilot study evaluated whether
acupressure affected the comfort of gastric can- cer
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. Partici-

pants were randomly assigned to either the control group
or experimental group. The control group received reg-
ular 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
3000- bed 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
anaes- thesia; (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 radio- therapy, 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
sig- nificance 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 participate (n=32) Others (n=18)

Met inclusion criteria (n=60)

Randomized

Characteristics of
Acupressure group (n=30) Control group (n=30)
demography & clinic were
assessed before surgery

Day 1 (1st) aGer Day 1 (1st) aGer Pain intensity was assessed
Acupressure for surgery (n=27) surgery (n=29) 20 min aGer the
12 min intervention

Day 2 (2nd) aGer Day 2 (2nd) aGer Pain intensity was assessed
Acupressure for 20 min aGer the
12 min surgery (n=26) surgery (n=28)
intervention

Day3 (3rd) aGer Day3 (3rd) aGer Pain intensity was assessed
Acupressure for 20 min aGer the
surgery (n=26) surgery (n=28)
12 min intervention

Figure 1 The flow chart of participants of this study.

experimental group withdrew from the study because of

The efficacy of acupressure intervention was established
exhaustion, and 3 other patients withdrew after refusing
by obtaining qi (de qi) from each acupoint. De qi refers to
acupressure treatment without citing a reason. In
the process of stimulating an acupoint to induce soreness,
addition, 2 participants withdrew from the control group,
numb- ness, distension, or heaviness proximal to the
stating they were uncomfortable with their data being
stimulated acupoint.15 Acupressure was performed by a
collected fol- lowing surgery. The final experimental and
researcher who had completed 40 academic credits in TCM
control groups comprised 26 and 28 participants,
and received certification from 2 practising TCM
respectively, exhibiting a 10% attrition rate.
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
gastroin- testinal 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
trans- verse 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 acu-
point 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 appropri-

ate, 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, reg-
ular postoperative care, including NPO, oral care, chest
percussion, steam inhalation, coughing, deep breathing,
coach training, using an abdominal binder, and walking,
was provided.
Data measurement
The data set comprised information on demographic char-
acteristics (age, height, weight, sex, education level, and
marital status) and medical conditions (time of defeca-
tion, 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).

Table 1 Comparisons of demographic and medical characteristics between groups.

Variables Control (n = 28) Experiment (n = 26) 32/t (p)

Age, years (M ± SD) 64.11 ± 15.60 60.54 ± 10.89 t = 0.98 (0.33)

Height, cm (M ± SD) 161.41 ± 8.31 164.37 ± 8.22 t = −1.31 (0.20)
Weight, kg (M ± SD) t = −0.26 (0.79)
Gender (n, %) 64.20 ± 10.18 64.98 ± 11.55 32 = 0.21 (0.65)
Male 20 (71.43%) 20 (76.92%)
Female 8 (28.57%) 6 (23.08%)
Education level (n, %) 32 = 0.34 (0.95)
Elemental & under 10 (35.71%) 9 (34.62%)
Junior high 4 (14.29%) 5 (19.23%)
Senior high 5 (17.86%) 5 (19.23%)
College and above 9 (32.14%) 7 (26.92%)
Marital status (n, %) 32 = 1.93 (0.59)
Unmarried 1 (3.57%) 0 (0%)
Married 25 (89.29%) 25 (96.15%)
Divorced 1 (3.57%) 0 (0%)
Widowed 1 (3.57%) 1 (3.85%)
Defecation (n, %) 32 = 0.26 (0.61)
Normal 25 (89.29%) 22 (84.62%)
Abnormal 3 (10.71%) 4 (15.38%)
Symptoms for hospitalisation (n, %)
None 11 (39.29%) 8 (30.77%) 32 = 0.93 (0.34)
Abdominal pain 12 (42.86%) 6 (23.08%) 32 = 2.37 (0.12)
Abdominal distention 6 (21.43%) 12 (46.15%) 32 = 3.70 (0.05)
Tarry stool 6 (21.43%) 3 (11.54%) 32 = 0.95 (0.33)
Nausea or vomit 4 (14.29%) 4 (15.38%) 32 = 0.01 (0.91)
American society of anaesthetists
status (n, %)
32 = 0.94 (0.63)
I 5 (17.86%) 3 (11.54%)
II 17 (60.71%) 19 (73.08%)
III 6 (21.43%) 4 (15.38%)
Operation duration (M ± SD) 326.43 ± 59.00 332.31 ± 52.58 t = −0.39 (0.70)
Analgesic (n, %) 32 = 4.27 (0.12)
PCA, intravenous 5 (17.86%) 10 (38.46%)
PCA, epidural 21 (75.00%) 16 (61.54%)
Others 2 (7.14%) 0(0%)
Tumour stage (n, %) 32 = 2.21(0.33)
1 10 (35.71%) 13 (50.00%)
2 5 (17.86%) 6 (23.08%)
3 13 (46.43%) 7 (26.92%)
Hour for first flatus (M ± SD) 98.09 ± 23.45 79.97 ± 37.31 t = 2.12(0.04)
Hour for first defecation (M ± SD) 114.63 ± 22.65 108.55 ± 23.29 t = 0.97(0.34)
PCA: patient-controlled analgesia.
Acupressure improves the postoperative comfort 343

Gastrointestinal motility was evaluated by recording

the time of the first flatus and first defecation following 4.673
4.732
5
surgery. The Rhodes Index of Nausea, Vomiting, and 4.732 3.929
Retching (INVR) were used to assess the severity of PONV. 4
The INVR is an 8- item questionnaire that uses a 5-point 3.714
3.904
scale (ranging from 0 to 4) to obtain information regarding 3

Pain score
symptoms, symptom occurrence, and symptom distress 2.923
2.596

associated specifically with nausea, vomiting, and 2

retching.36,37 In addition to pro- viding a total score for

1
symptoms, symptom occurrence, and symptom distress,
the INVR yields subscale scores for the 3 symptoms. High 0
scores are indicative of severe PONV. Doc-
tor Rhodes provided written authorisation for the INVR Figure 3 The trend of pain intensity across times after
to be translated into Chinese for use in this study. The surgery.
INVR exhibited strong reliability in the previous
studies,18,38 and was verified in the current study 5

(Cronbach’s ˛ = 0.90).
4

2.68
Data collection 3

First, ethical approval was obtained from the institutional
review board of the study hospital (Ref code 97-01-03A).
Sec- ond, 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 par- ticipant to establish a baseline and,
fourth, participants assigned to the experimental group or
control group were accommodated in separate wards after
surgery. Individ- ual 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 out- comes of the
interventions, including adverse effects, were recorded.
Data analysis
Data were analysed using IBM SPSS Version 20.0 for Win-
dows. Descriptive statistics (frequency; percentage; mean;
standard deviation) were calculated to identify the demo-
graphic 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 col-
lege 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 pri-
mary 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 analge-
sia (PCA) to managing postoperative pain. Within 10—15
min following surgery, the participants were connected to
a PCA
INVR score
2 1.43
1.42
1.21
1.46
1
1.120.62
0.77
0
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 µg 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
grad- ual 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 dif- ferences between the groups
(F = 0.47, P = .49) and within the groups (F = 0.09, P = .
86).
As shown in Table 1, gastrointestinal motility follow-
ing 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 (32 = 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 gastrec-
tomy. 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 acu- points rectifies qi, stabilises the body,
and strengthens bodily functions.34
Acupoint stimulation not only enhanced the allevia-
tion 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, stimu- lating 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
allevi- ates pain.44 Acupressure stimulates large
myelinated fibres that inhibit nociceptive stimuli, resulting
in the release of
μ-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 motil-
ity 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 gastrointesti-
nal 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 experimen-
tal 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 through-
out this study, which may inhibit gastrointestinal
motility.47 In addition, a gastrointestinal anastomosis using
the con- trast 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
recov- ery 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 surgery 30 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 possi- ble
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 mor-
phine 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 his-
tory 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 out-
come 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 dis-
tinct from PONV would strengthen the current findings
regarding the efficacy of acupressure in managing postop-
erative 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 multi-
centre 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 alleviat- ing pain and to reduce the time of
the first flatus following surgery. Acupressure is a simple,
noninvasive, safe, and eco- nomical procedure that can be
applied in health care and clinical practice. Healthcare
professionals receiving appro- priate 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 gastroin-
testinal motility and preventing PONV following surgery.
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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 Gynecologic Oncology 142 (2016) 531–538

Contents lists available at ScienceDirect

Gynecologic Oncology

jou rna l h om e p age : w w w . e l s e v i e r . c o m / l o c a t e / y g y n o

Physical effects of Anma therapy (Japanese massage) for

gynecologic cancer survivors: A randomized controlled trial☆
Nozomi Donoyama a,⁎, Toyomi Satoh b, Tetsutaro Hamano c, Norio Ohkoshi a, Mamiko Onuki b
a
Department of Health, Faculty of Health Sciences, Tsukuba University of Technology, 4-12-7 Kasuga, Tsukuba, Ibaraki 305-8521, Japan
b
Department of Obstetrics and Gynecology, University of Tsukuba, 1-1-1 Tennoudai, Tsukuba, Ibaraki 305-8575, Japan
c
H-STAT Co. Ltd., 5-11-14 Todoroki, Setagaya-ku, Tokyo 158-0082, Japan

HIGHLIGHTS

• This is the first randomized controlled trial on the effects of Anma therapy (Japanese massage).
• Anma therapy reduced subjective physical complaints in gynecologic cancer survivors.
• It is possible that Anma therapy inhibits the sympathetic nervous system.

a r t i c l e in f o
abstract
Article history:
Received 4 April 2016 Objectives. Cancer survivors often have physical and psychological complaints after standard cancer
Received in revised form 16 June treat- ment. We conducted a randomized control trial to evaluate the physical and psychological/emotional
2016 effects of Anma therapy (Japanese massage, AMT) in gynecologic cancer survivors. The primary objective
Accepted 30 June 2016 was to verify the effects of 8 consecutive weeks of weekly AMT. The secondary objective was to confirm the
Available online 16 July 2016
immediate effects of single-session AMT. We report here results of the physical effects of AMT.
Methods. Forty participants were randomly allocated to an AMT group that received one 40-min AMT
Keywords:
session per week for 8 weeks and a no-AMT group. The primary endpoint was severity of subjective physical
Randomized control trial
Massage complaints assessed using a visual analogue scale (VAS). Secondary endpoints were urine and saliva analyses
Gynecologic cancer survivors and psycholog- ical/emotional questionnaire scores.
Subjective physical complaint Results. In the primary analysis, least-squares means (LSM) estimates of VAS score improvement over
Sympathetic nervous system the 8 weeks were −21.5 (95% confidence interval [CI], −30.1 to −12.8, P = 0.0017) in the AMT group (n =
20) and 0.8 (95%CI, −7.7 to 9.2, P = 0.89) in the no-AMT group (n = 20). The difference in the LSM
estimates be- tween the groups was −22.2 (95%CI, −34.4 to −10.1, P = 0.0007). There were significant
differences in VAS score and urinary epinephrine between before and after the intervention session,
demonstrating the superiority of AMT.
Conclusions. A single AMT session reduces the severity of subjective physical complaints and might
inhibit the sympathetic nervous system in gynecologic cancer survivors. Receiving weekly AMT sessions for
eight weeks ef- fectively continues to reduce the severity of subjective physical complaints.
© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

☆ Trial registration: This trial was registered with the UMIN Clinical Trials Registry
as application UMIN000009097 on October 12, 2012: Effects of continuous
traditional Japanese massage therapy (Anma therapy) for cancer survivors: a
randomized controlled trial, https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?
function=brows&action= brows&type=summary&recptno=R000010670&language=E.
⁎ Corresponding author.
E-mail addresses: donoyama@k.tsukuba-tech.ac.jp (N. Donoyama),
toyomi-s@md.tsukuba.ac.jp (T. Satoh), hamano@h-stat.co.jp (T. Hamano),
ohkoshin@k.tsukuba-tech.ac.jp (N. Ohkoshi), monuki@md.tsukuba.ac.jp (M. Onuki).
Cancer has been the leading cause of death in the Japanese popula-
tion since 1981. Average yearly estimates for the period 2025–2029
put the number of cancer deaths at 230,000 men and 160,000 women
and cancer incidence at 530,000 men and 390,000 women in Japan
[1]. Both these estimates are expected to slow after 2015 for men; how-
ever, they are expected to continue increasing at the present rate for
women, especially with regard to incidence of cancers in the oral cavity
and pharynx, kidney and urinary tract, uterus, lung, pancreas, and
cervix

http://dx.doi.org/10.1016/j.ygyno.2016.06.022
0090-8258/© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
532 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538

[1]. Also, because early detection and progressive treatment options coordinating office. After receipt, the
have improved the prognosis of cancer patients and increased the
num- ber of cancer survivors in Japan [2], interest has been shifting
from rad- ical treatment options toward ensuring a better quality of
life (QOL) to cope with the disease [3].
Massage therapy is one of the most commonly used complementary
and alternative medicines for cancer patients and survivors to manage
physical, emotional, and psychological complaints. In relation to gyne-
cologic cancers, Mirabeau-Beale et al. revealed that massage is one of
the most commonly used modalities by ovarian cancer survivors pri-
marily to improve QOL [4]. Also, according to Matulonis et al., of the
22.4% of ovarian cancer survivors who used massage to treat their can-
cer, 100% used it to improve QOL, 61.5% used it to improve side effects,
and 15.4% used it for movement and physical therapy [5]. Actually,
20% of ovarian cancer survivors have reported long-term side effects of
treatment, including problems related to abdominal and gynecologic
symptoms and neurotoxicity [6]. Ovarian cancer survivors have also re-
ported significant concerns related to pain and other complaints [7].
One of the most common and popular forms of complementary
and alternative medicine in Japan is Japanese massage therapy, or
Anma massage therapy (AMT). It has long been used by healthy
persons, the elderly, disease-free survivors, patients with disease,
and cancer survi- vors to promote health, manage and cure various
complaints, and pre- vent disease. However, because the
effectiveness of AMT has not been established for cancer survivors
and patients, they must determine for themselves, based solely on
anecdotal information, whether or not to receive AMT. To address
this situation, scientific studies on AMT are needed.
After conducting a preliminary study for cancer survivors who
had undergone surgery for uterine cervical or endometrial cancer
(FIGO stage Ia1 – Iia) and verifying the effects of AMT [8], based on
our preliminary findings we designed and conducted the present
randomized controlled trial. The design has been published previ-
ously [9]. The primary objective of this trial was to verify physical
and psychological/emotional effects of 8 consecutive weeks of week-
ly AMT in gynecologic cancer survivors. The secondary objective was
to confirm the physical and psychological/emotional immediate ef-
fects of single AMT intervention session.
Our hypotheses were that AMT for gynecologic cancer survivors
would: (H1) improve more subjective physical complaints
appearing after standard cancer treatment than in controls
immediately after a single intervention session, and these effects
would be sustained by 8 consecutive weeks of once-weekly AMT
sessions; (H2) enhance psy- chological and mood states more so
than in the controls; (H3) potential- ly improve coping styles in
cancer survivors through the relationship with a massage therapist;
and (H4) change the values of some kinds of biochemical markers
related to stress release, the autonomic nervous system, or the
immune system.

2.Methods

This trial was approved by the Medical Ethics Committee of

Tsukuba University of Technology, Japan, where the study setting and
coordinat- ing office were located, on September 27, 2012 (Approval
No. 5).
Trial gynecologists who worked at another hospital recruited
partic- ipants who met the eligibility criteria, and they confirmed at
every clin- ical session that participants did not fall into the
exclusion criteria. Trial inclusion criteria were: (a) histologically
confirmed uterine cervical, en- dometrial, ovarian, fallopian tubal,
or peritoneal cancer in the past;
(b) no recurrence of such cancer for ≥ 3 years since finishing
standard medical treatment; (c) ≥ 20 years of age at the date of
registration to the trial; and (d) eligibility for the trial confirmed by
gynecologists re- sponsible for the patient. Trial exclusion criteria
were: (a) current active infection(s); (b) serious concurrent disease
of the heart, liver, or kidney; and (c) severe mental disorder(s).
Next, the gynecologists sent intro- duction forms by facsimile to the
coordinating office scheduled a meeting date with each cancer (post-session). Participants returned to the office on the last day
survivor to provide them with trial information (oral and
written) at the coordi- nating office. Patients subsequently
submitted a consent form to partic- ipate in the trial by hand or
via facsimile.
After finishing enrolment, randomization was performed. The
trial statistician generated the allocation sequence by block
randomization. However, allocation adjustment factors were not
set in the trial due to currently insufficient evidence on factors
influencing the effectiveness of AMT. Before the trial began, the
trial statistician created a table of ran- domized assignment for
management by 2 employees at the coordinat- ing office.

2.1. AMT group

This group received treatment by AMT. Protocol treatment

was com- pleted once the participant finished receiving the
eighth and final 40- min AMT session. Sessions were given once
a week during the consecu- tive 8-week intervention period.
Following the AMT protocol, partici- pants were given a full
body AMT session that excluded the face, head, and abdomen
while lying on a massage table. We conducted assess- ments
before the first AMT session (pre-session, baseline), after the
first AMT session (post-session), and before the last (8th) AMT
session (8-week follow-up).

2.1.1. AMT protocol

First, the massage therapist interviewed the participant about
sub- jective physical complaints appearing after standard cancer
treatment and then manually checked the affected area(s) for
muscle tension, stiff- ness, induration, tenderness, knocking pain,
malalignment of the spine, edema, and area of
pain/discomfort/palsy, and other such conditions. Second, while
the participant lay on the right side of the body on a mas- sage
table, the left side of the body was massaged. The massage started
at the upper shoulder and then moved to the back, lower back,
upper limb (shoulder joint to wrist joint), hand (carpus to finger
tips), and neck (superior nuchal line along the neck to the side of
the 7th cervical vertebra). The massage then returned to the trunk
(shoulder to lower back) following these areas: buttock, lower limb
(gluteal fold to ankle joint), and foot (heel to toes). Third, while
the participant was lying on the left side, the opposite side of the
body was massaged in the same order. Finally, while the
participant was lying in a prone position, the massage was
repeated briefly on the shoulders, back, lower back, lower limbs,
and feet simultaneously on both sides. During the massage, the
therapist focused the massage on specific locations related to the
participant's physical complaints. This massage procedure was the
same as that used in our previous studies [8,10], using massage
tech- niques considered standard versions of common AMT and as
described in detail by Kimura [11]. AMT mostly targets the muscles
by kneading (thumb, 2-finger [thumb and forefinger], 4-finger,
carpus, palm, and palm grasp), which is the most commonly used
technique. Thumb kneading is most frequently used, followed by
pressing (thumb, carpus, and palm), and then with lesser amounts
of stroking (2 hands, thumb, and fingertips). AMT is performed
through the clothing, with stimula- tion intensity applied
according to each patient's range of comfort. A therapist with a
national massage practitioner license from Japan and N 20 years of
experience performed all massage sessions to avoid differ- ences in
technical capabilities.

2.2. No-AMT group

The control group was followed as usual by their medical

doctors and did not receive AMT treatment. They met with the
massage thera- pist at the coordinating office on the first day of
their scheduled trial pe- riod to receive a 40-min semi-
structured chat intervention with no massage while seated.
Assessments were conducted before the inter- vention session
(pre-session, baseline) and after the intervention ses- sion
 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538 533
tered pre-session, post-session, and at the 8-week follow-up. Urine and
of their 8-week trial period for another assessment (8-week follow-
up), after which they received a single 40-min AMT session as a gift
for par- ticipating in the study.

2.2.1. Chat protocol and chat policy

The semi-structured chat protocol was designed to facilitate
natural and relaxed conversation that was positive and honest. First,
as with the AMT group, the massage therapist conducted an
interview and checked by hand the participant's physical condition
after standard cancer treat- ment. Second, to enhance self-
disclosure or willingness to reveal per- sonal information to others,
the therapist interviewed the participant stating, “You've had a
huge experience, getting a diagnosis of cancer and then making it
through cancer safely. Could you tell me what you felt, what you
thought, what you did at the time, and anything else you would like
to add?” All participants had much to say about their memories and
thoughts. Next, to facilitate positive thinking, the thera- pist asked,
“Have you had any happy or pleasant things happen to you recently,
and could you tell me about them?” The therapist paid full at-
tention and repeated the participant's words with the same
emotional expression. At the end of the session, using a positive
feedback method, the therapist repeated what she felt were the most
emotionally impact- ful words spoken by the patient, shared her
feelings about the participant's words, and then empathized with the
participant.

2.3. Outcomes

2.3.1. Primary outcome measure

The primary outcome measure was the change in severity of
subjec- tive physical complaints appearing after standard cancer
treatment, de- termined using a visual analogue scale (VAS). The
VAS was a sheet of paper with a 100-mm line from left (no physical
complaint) to right (worst imaginable physical complaint).
Participants were asked to indi- cate the severity of their physical
complaint at the time by placing a tick on the line, and length from
the left side to the tick was measured and used as the VAS score.
Scores ranged from 0 to 100, with higher score in- dicating more
severe degree of physical complaint.

2.3.2. Secondary outcome measures

Secondary outcome measures included biochemical measures
and self-administered questionnaires.

2.3.2.1. Biochemical measures. Urine samples were provided to

assay concentrations of epinephrine, norepinephrine, dopamine,
and 8- hydroxydeoxyguanosine (8-OHdG). Saliva samples were
also taken to assay concentrations of chromogranin A (CgA),
cortisol, and secretory immunoglobulin A (s-IgA). Salivette®
(Sarstedt, Aktiengesellschatt & Co., Germany), was used to take 2-
mL saliva samples. Briefly, a swab was removed from the Salivette,
chewed 120 times gently for two mi- nutes in synch with a
metronome, then returned to the device.

2.3.2.2.Self-administered questionnaires. To clarify the effects on

psycho- logical/mood status, coping style with cancer, and QOL, we
used the fol- lowing instruments.

(1) Hospital Anxiety Depression Scale, Japanese Version (HADS)

(2) Profile of Mood States - Brief Japanese Version (POMS)
(3) Measure of Adjustment to Cancer, Japanese version (MAC)
(4) Japanese version of the European Organization for Research and
Treatment of Cancer QLQ-C30 version 3.0 (EORTC QLQ-C30)

2.4.Data collection

The HADS, MAC, and EORTC QLQ-C30 were administered pre-

session and at the 8-week follow-up. The VAS and POMS were adminis-
 21
saliva samples were also taken pre-session, post-session, and at
the 8- week follow-up. Immediately after finishing interventions,
urine and saliva samples were frozen and taken to a clinical
laboratory testing company the next morning (SRL Inc., Tsukuba
branch, Tsuchiura, Japan) for assaying. To avoid alteration of
quantities of biochemical ma- terials by the circadian rhythm, all
measurement sessions began at 14:30. Fig. 1 shows the timing of
sample and questionnaire collection in detail.

2.5. Statistical methods

Based on our preliminary data [8], we assumed that the mean

differ- ence would be −20.8 in the AMT group, unchanged (e.g., 0) in
the no- AMT group, and that the standard deviation would be 19.6 in
both groups. To test these differences between the two groups using
a 5% Type I error rate and 90% power, we needed a sample size of 14
partic- ipants per group. Based on sensitivity analyses for sample
size calcula- tion, the planned sample size was determined to be 30
participants per group [9]. Although the present sample size did not
reach the planned sample size, sufficient power for primary analysis
was acquired.
We performed all efficacy analysis according to the modified
intention-to-treat principle, which included all participants who
re- ceived at least one AMT session in the AMT group and one
chat session in the no-AMT group. Additionally, we performed as-
treated analyses, in which participants were classified according to
the treatment actually received (not shown).
The primary endpoint was VAS score improvement over the 8-
week trial period. For primary analysis, we used the analysis of
covariance to compare mean changes in VAS score over the 8
weeks between the AMT group and the no-AMT group, adjusting
for baseline VAS score and age. We used a two sample t-test with
Satterthwaite's approximation to compare mean changes and the
paired t-test to evaluate mean changes in VAS score for each
group. For these mean VAS score changes and their differences,
we also calculated two-sided 95% confidence intervals (CIs) to
evaluate clinical effects.
For the secondary endpoints, we did not consider multiplicity
issues. In all analyses, categorical variables are described in terms of
frequency and percentage. The distributions of continuous variables
are described using means, standard deviations (SDs), medians,
quartiles, and ranges. The Wilcoxon signed-rank test or the Mann-
Whitney U test was used for non-normally distributed data.
Pearson's chi-square test was used to test differences in categorical
variables. All reported P-values are two-sided, and all significance
levels were set at 0.05. SAS 9.3 (SAS Insti- tute, Cary, NC, USA) was
used for all analyses.

3.Results

The start date for recruitment was October 13, 2012. The first
participant's trial began on November 2, 2012 and the 8-week
follow- up of the 40th participant concluded on November 1, 2014. In
this arti- cle, we present the results for the physical effects of AMT as
change in VAS score as the primary endpoint and change in
biomarker levels to verify (H1) and (H4). The results for the
psychological/emotional ef- fects, discussed in relation to (H2) and
(H3), will be reported separately.

3.1. Baseline characteristics

Fifty-eight participants were eligible for the study and 40 partici-

pants submitted the consent form and were enrolled (Fig. 2). Twenty
participants were randomized to the AMT group and 20 to the no-
AMT group (median age, 53.0 and 55.5 years; median age at cancer
onset, 42.5 and 43.5 years; median duration from onset, 8.3
and
8.6 years, respectively) (Table 1). One participant was randomized to
the no-AMT group but actually received AMT intervention. Thus,
534 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538

Fig. 1. Intervention and measurement procedure.

participants actually received AMT and 19 received no-AMT. All partic-

3.2. VAS score
ipants completed their interventions.
Twenty-five (62.5%) participants had uterine cervical cancer, 10
In the primary analysis, least-squares mean (LSM) estimates of
(25.0%) had endometrial cancer, and 5 (12.5%) had ovarian cancer. Sev-
VAS score improvement over the 8-week trial period were −21.5
enty percent of participants had stage I cancer. Surgery was undertaken
(95%CI,
in 37 (92.5%) participants and lymph node dissection in 30 (75.0%).
−30.1 to −12.8, P = 0.0017) in the AMT group and 0.8 (95%CI, −7.7
Eleven participants (27.5%) had received chemotherapy and 13
to 9.2, P = 0.89) in the no-AMT group. The difference in the LSMs
(32.5%) had received radiation therapy. Sociodemographic and clinical
be- tween the two groups was − 22.2 (95%CI, − 34.4 to − 10.1, P
variables revealed no significant differences between the AMT and no-
= 0.0007), demonstrating the superiority of AMT. A statistical
AMT groups (Table 1). difference in the LSMs was also observed in the supportive as-
treated analysis (LSM [95%CI], 23.3 [−35.2 to −11.4], P = 0.0003).
Mean improvement
 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538 535

Fig. 2. CONSORT flowchart of participant recruitment.

between the pre- and post-session VAS scores was − 31.8 (95%CI,
− 41.1 to − 22.4, P b 0.0001) in the AMT group and − 7.2 (95%CI,
− 11.9 to − 2.5, P = 0.0045) in the no-AMT group. The difference
Table 1
in the means between the two groups was −24.6 (95%CI, −34.7
Demographic and clinical characteristics of cancer survivors.
to
Characteristic AMT No AMT P −14.3, P b 0.0001), indicating the immediate efficacy of AMT (Table 2).
(n = 20) (n = value
20) 3.3. Biomarkers
Age, median (min-max) 53.0 (40–69) 55.5 (41–75) 0.60†
Age at cancer onset, years, median Between the two groups, a significant difference was found
42.5 (33–59) 43.5 (26–70) 0.68†
(min-max)
during the 8-week trial period in salivary CgA (median difference,
Duration from cancer onset, years,
median (min-max)
8.3 (3.1–21.3) 8.6 (3.2–27.8) 0.80† 0.6 in AMT and −1.2 in no-AMT, P = 0.025). Moreover, significant
Site of gynecologic cancer differences in pre- and post-session levels were found in urinary
Uterine cervix 11 (55%) 14 (70%) 0.34†† difference,
epinephrine−1.5 in AMT and 5.1 in no-AMT, P = 0.0011), norepineph-
(median
Endometrium 7 (35%) 3 (15%) rine (median difference, −21 in AMT and 37 in no-AMT, P = 0.0048),
Ovary 2 (10%) 3 (15%) and dopamine (median difference, −131 in AMT and 168 in no-AMT,

FIGO stage
I 13 (65%) 15 (75%) 0.73†† P = 0.010). In the AMT group, a significant decrease was found
II–IV 7 (35%) 5 (25%) between the pre- and post-session levels of epinephrine (P =
Surgery
Yes 20 (100%) 17 (85%) 0.23††
0.0018). In the no- AMT group, significant increases were seen in
No 0 (0%) 3 (15%) epinephrine (P = 0.014), norepinephrine (P = 0.033), and
Lymph node dissection dopamine (P = 0.030) and a signifi- cant decrease was seen in CgA
Yes 16 (80%) 14 (70%) 0.72†† (P = 0.0046) (Table 2).
No 4 (20%) 6 (30%)
Chemotherapy
4.Discussion
Yes 6 (30%) 5 (25%) 1.00††
No 14 (70%) 15 (75%)
Radiotherapy The results of the primary outcome, namely significant changes
Yes 8 (40%) 5 (25%) 0.50†† in VAS score, indicate the severity of subjective physical complaints
No 12 (60%) 15 (75%)
appearing after standard cancer treatment. Therefore, hypothesis (H1)
AMT: Anma therapy. was verified. In a review of the physiological and therapeutic effects
†
P value calculated using the Mann-Whitney U test. of massage, Goats found that effects of forceful massage on
††
P value calculated using Pearson's chi-square test.
increased local blood flow were longer lasting than those of gentle
pressure and represented a potent means to accelerate healing, and
that massage
536 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538

Table 2
Changes in physical outcomes (modified intention-to-treat population).

Visual analogue scale (VAS) AMT No AMT P value

N Mean (SD) N Mean (SD)

−24.6 (−34.7 to −14.3) b0.0001⁎⁎⁎
††
Pre-session 20 50 ± 23 20 50 ± 19
Post-session 20 18 ± 16 20 43 ± 22
Change from pre-session mean (95%CI) 20 −31.8 (−41.1 to −22.4) 20 −7.2 (−11.9 to −2.5)
P value† b 0.0001⁎⁎⁎ 0.0045⁎⁎
−22.2 (−34.4 to −10.1) 0.0007⁎⁎⁎
§
8-week follow-up 20 30 ± 25 20 51 ± 20
8-week change LSM (95%CI) § 20 −21.5 (−30.1 to −12.8) 20 0.8 (−7.7 to 9.2)
P value† 0.0017⁎⁎ 0.8860

Biomarkers AMT No AMT P value††

N Median (quartiles) N Median (quartiles)

Urinary epinephrine μg/L

Pre-session 20 11.5 (6.5 to 23.7) 20 7.0 (4.9 to 12.9) 0.0011⁎⁎
Post-session 20 7.4 (3.5 to 18.9) 20 11.4 (7.8 to 15.6)
Change from pre-session 20 −1.5 (−5.4 to −0.2) 20 5.1 (0.3 to 9.0)
P value† 0.0018⁎⁎ 0.0140⁎
8-week follow-up 20 9.4 (4.6 to 12.9) 20 6.4 (4.7 to 12.7)
8-week change 20 −0.9 (−8.2 to 1.3) 20 −0.5 (−4.7 to 3.8) 0.3993
P value† 0.2731 0.8052

Urinary norepinephrine μg/L

Pre-session 20 125 (50 to 193) 20 100 (37 to 137) 0.0048⁎⁎
Post-session 20 81 (55 to 161) 20 113 (74 to 150)
Change from pre-session 20 −21 (−43 to 16) 20 37 (18 to 62)
P value† 0.0973 0.0328⁎
8-week follow-up 20 116 (60 to 151) 20 97 (44 to 148)
8-week change 20 −15 (−86 to 67) 20 5 (−45 to 41) 0.5642
P value† 0.3683 0.7841

Urinary dopamine μg/L

Pre-session 20 759 (358 to 1158) 20 503 (204 to 1215) 0.0104⁎
Post-session 20 596 (425 to 803) 20 635 (445 to 1337)
Change from pre-session 20 −131 (−452 to 156) 20 168 (62 to 362)
P value† 0.0826 0.0296⁎
8-week follow-up 20 637 (394 to 1500) 20 649 (360 to 1034)
8-week change 20 −201 (−687 to 369) 20 106 (−179 to 287) 0.3847
P value† 0.3884 0.4304

Urinary 8-hydroxydeoxyguanosine (8-OHdG) ng/mL

Pre-session 20 10.6 (9.3 to 14.4) 14 11.4 (9.4 to 13.7) 0.2113
Post-session 19 10.4 (9.0 to 15.6) 20 10.6 (9.7 to 12.7)
Change from pre-session 19 0.3 (−1.5 to 1.9) 14 −0.6 (−1.5 to 0.5)
P value† 0.5871 0.0991
8-week follow-up 18 11.8 (9.7 to 14.4) 17 11.3 (9.1 to 13.0)
8-week change 18 1.0 (−1.6 to 2.5) 14 −1.1 (−4.8 to 3.1) 0.4420
P value† 0.3987 0.8672

Salivary chromogranin A (CgA) pmoL/mg protein

Pre-session 20 3.3 (2.1 to 5.5) 17 3.8 (2.5 to 5.5) 0.0965
Post-session 20 2.7 (2.2 to 4.3) 19 2.9 (1.5 to 6.7)
Change from pre-session 20 −0.4 (−1.2 to 0.8) 17 −1.2 (−1.7 to −0.6)
P value† 0.5039 0.0046⁎⁎
8-week follow-up 20 3.3 (1.8 to 8.2) 19 3.3 (1.4 to 4.2)
8-week change 20 0.6 (−1.3 to 1.8) 17 −1.2 (−2.7 to 0.0) 0.0254⁎
P value† 0.4980 0.0067⁎⁎

Salivary cortisol μg/dL

Pre-session 20 0.07 (0.06 to 0.08) 18 0.08 (0.06 to 0.15) 0.4030
Post-session 20 0.06 (0.06 to 0.07) 19 0.08 (0.06 to 0.12)
Change from pre-session 20 −0.01 (−0.02 to 0.00) 18 0.00 (−0.02 to 0.00)
P value† 0.0801 0.2686
8-week follow-up 20 0.09 (0.06 to 0.13) 19 0.07 (0.06 to 0.12)
8-week change 20 0.00 (−0.01 to 0.03) 18 −0.02 (−0.06 to 0.00) 0.1605
P value† 0.4716 0.4257

Secretory immunoglobulin A (s-IgA) μg/mL

Pre-session 20 281 (170 to 433) 19 299 (205 to 415) 0.9889
Post-session 20 276 (168 to 407) 19 287 (176 to 458)
Change from pre-session 20 −7 (−123 to 108) 19 −8 (−133 to 70)
P value† 0.9854 1.0000
8-week follow-up 20 177 (135 to 281) 19 259 (152 to 356)
8-week change 20 −56 (−219 to 99) 19 −51 (−212 to 64) 0.7696
P value† 0.5459 0.1819
 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538
has traditionally been used to relieve pain, reduce discomfort, relieve
associated muscle spasms, and permit improved function [12]. Also,
connective tissue manipulation that manually stimulates skin over the
thoracic and lumbar spine triggers cutaneovisceral reflexes that cause
vasodilation [12]. The same mechanisms observed in Western massage
techniques are thought to operate in AMT. Moreover, by kneading and
pressing muscles, muscle spindles are pulled and extended, and that
stimulation causes various reflexes, including the stretch reflex and an-
tagonistic inhibition, as well as somatic sensory impulses to travel up to
the brain to coordinate muscle function through the neural circuit net-
work. On the way, these afferent neurons undergo changes in the me-
dulla and thalamus, possibly affecting the autonomic nervous system
and endocrine/hormonal systems. We suggest that these mechanisms
function in AMT to improve various subjective physical complaints in
cancer survivors.
According to a literature review by Moraska et al. [13], seven
studies have reported data on urinary catecholamines following
massage ther- apy. Five of those studies reported no significant
change in epinephrine or norepinephrine over the study duration
[14–18]. These results are in line with those of the present study.
Additionally, the present study revealed a significant reduction
in epinephrine, but no changes in norepinephrine and dopamine
immedi- ately after an AMT session; in contrast, immediately after
the chat ses- sion, there was a significant increase in
norepinephrine and dopamine. Norepinephrine, indeed, may be
known as a stress marker; however, it has been reported that
norepinephrine may contribute to cognitive function [19,20].
Serotonin & norepinephrine reuptake inhib- itors have recently been
used to increase serotonin, norepinephrine, and dopamine to treat
mood disorders such as depression. These differ- ences between the
two groups were significant and suggest that the sympathetic
nervous system might be inhibited by AMT and mental ac- tivity
might be activated [21] by the chat session.
Studies have recently used salivary CgA concentration as a new
stress index to reflect the sympathetic nervous system [22,23]. In
the present study, both groups showed CgA concentration had
decreased post-session compared with pre-session values; however,
only the no- AMT group showed a significant reduction, with no
significant differ- ence between the two groups. However, at 8
weeks, the reduction remained significant in the no-AMT group,
with a significant difference between the two groups. These results
suggest that the sympathetic nervous system might also be inhibited
in the no-AMT group. According to O'Connor et al. [24], salivary
CgA might have the property of not being easily affected by physical
stress, which is different from other sympathoneural biomarkers.
Thus, Miki suggests that the secretory mechanism of salivary CgA
might differ from that of urinary norepi- nephrine excretion [25].
Based on the present results, epinephrine out- put might be
primarily influenced by physical activity through AMT, whereas
CgA might be more responsive to mental activity by the chat
intervention. This chat intervention might have dimensions of
psycho- therapy due to its inclusion of self-disclosure [26,27],
positive thinking [28–30], and a positive feedback method. It might
possibly act directly on the brain to inhibit sympathetic nervous
system activity and sustain the effect longer than physical
stimulation.
No significant differences were observed in urinary 8-OHdG (as
an oxidative stress marker), salivary cortisol (which becomes
synonymous
Notes to Table 2:
AMT: Anma therapy; CI: confidence interval; LSM: least-squares mean; VAS: visual analogue scale scores.
* P b 0.05.
** P b 0.01.
*** P b 0.001.
VAS:
† P value calculated using paired t-test.
†† P value calculated using a two-sample t-test.
§ LSM and P value calculated using analysis of covariance.
Biomarkers:
† P value calculated using Wilcoxon's signed-rank test.
537
with stress hormone), or s-IgA (which is thought to reflect immune
activity).
This was a pilot RCT study on the use of individualized AMT for
gyne- cologic cancer survivors. This study has some limitations. First,
the study was conducted in a small city (population 200,000), so the
sample size was small. Furthermore, eligibility criteria were very open.
Thus, it is dif- ficult to generalize the results from this RCT to the
wider effectiveness of AMT for cancer survivors. A subsequent
multicenter RCT should be used to verify our findings and recruit a
more consistent population, as well as limit the characteristic of the
sample population, such as the tumor type, cancer stages, duration
from cancer onset, or physical complaint. Second, we should
consider what intervention method is appropriate as a control group
for AMT. In this study, we used a semi-structured chat, which might
include psychotherapeutic dimensions, which made com- parison
difficult. A subsequent RCT might incorporate non-Anma relaxa- tion
practices like yoga or meditation for the control group. In addition,
we may review more suitable outcome measures, such as interleukin 6
or 10, which may be good candidates for outcomes for AMT.
Moreover, AMT is Japanese medical massage that is specifically
tailored to a recipi- ents' individual physical and mental state, and this
makes it difficult to de- velop a standard AMT pragmatic protocol
because the degree of stimulation must be adjusted to the individual.
These limitations might have led to the low levels of evidence in the
present study. Nevertheless, our findings can help medical
professionals explain the benefits of AMT to gynecologic cancer
survivors and provides higher quality information to better inform
patients in their decision whether to receive AMT or not.
5.Conclusion
A simple 40-min AMT session reduced the severity of subjective
physical complaints and the effect was sustained by continuous once
weekly AMT in gynecologic cancer survivors. These results imply that
AMT has benefits in oncology.
Funding support
This study was funded by a Grant-in-Aid (No. 22531058) for
Scien- tific Research from the Ministry of Education, Culture,
Sports, Science and Technology, Japan, 2010–2014 (PI: N
Donoyama). The study was also partially supported by competitive
research project programme grants from Tsukuba University of
Technology in 2012, 2013, and 2014 (PI: N Donoyama). These
sponsors had no role in study design; in the collection, analysis and
interpretation of data; in the writing of the report; or in the
decision to submit the paper for publication.
Conflict of interest disclosures
The authors declare no competing interests.
Acknowledgments
We thank Toshiko Ueda and Yoshie Koike, who were blinded to the
study procedures and were engaged by the coordinating office to assign
participants, input and manage research data, and help prepare for the
study trial.
†† P value calculated using the Mann-Whitney U test.
538 N. Donoyama et al. / Gynecologic Oncology 142 (2016) 531–538
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 Complementary Therapies in Clinical Practice 29 (2017) 136e141

Contents lists available at ScienceDirect

Complementary Therapies in Clinical Practice

journalhomepage:

The effect of acupressure on pain, anxiety, and the physiological indexes of

patients with cancer undergoing bone marrow biopsy
a a a, * b
Moloud Sharifi Rizi , Abbas Shamsalinia , Fatemeh Ghaffari , Shahrbanoo Keyhanian , Bahram
c
Naderi Nabi
a
Ramsar Nursing Care Research Center, Babol University of Medical Sciences, Babol, Mazandaran, Iran
b
Department of Oncology, Azad University of Tonekabon, Tonekabon, Mazandaran, Iran
c
Anesthesiology Department, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran

article info
abstract
Article history:
Received 21 March 2017
Objectives: This study aimed to determine the effect of acupressure on pain intensity, anxiety, and physiological indexes of
Received in revised form 1 patients with cancer undergoing bone marrow biopsy and aspiration. Methods: The study was designed as a randomized,
September 2017 Accepted 2 double-blinded, controlled trial.
September 2017 Ninety samples was selected using the convenience sampling method, then for allocation groups random block sampling was
used (30 for each group). The three groups were similar by age and gender. LI4 and HT7 (Shen Men) acupressure points were
Keywords: examined for the intervention. Sham pressure was used in the placebo group while no intervention was applied in the control
Acupressure group.
Pain Results: The results showed that the lowest average anxiety score (1.5 ± 0.5; P ¼ 0.01) and the lowest average pain score (4.9
Anxiety ± 0.8) after the intervention were related to the acupressure method (P ¼ 0.001). Conclusion: Cost effectiveness and short-
Physiological indexes term simple education make acupressure method useful in clinical settings for different illnesses.
Bone marrow
Biopsy
© 2017 Elsevier Ltd. All rights reserved.
Aspiration

1. Introduction analgesics, sublingual fentanyl, benzodiazepine, or nitrous oxide/ oxygen are

Cancer is a global problem that causes 552,200 deaths yearly [1]. In 2015,
there were 17.5 million cancer cases worldwide [2]. Pa-tients with cancer
undergo painful procedures such as lumbar puncture (LP) or bone marrow
biopsy and aspiration (BMBA) dur-ing their treatment process, which not
only cause pain and anxiety but may also affect the quality of life, treatment
duration, or further examinations [3]. Moreover, the side effects may lead to
tachycardia or hypertension [4].
treatment options for reducing pain and anxiety in a patient [8].
However, pharmacotherapy is not very effective [9]. It also has different
side effects such as respiratory depression, nausea, and vomiting. The patient's
situation needs to be accurately monitored, which is time-consuming for the
nursing staff [10]. Bao (2011) explained that local anaesthesia as a standard
procedure was effective in relieving the pain due to the needle entering the
body but it is not able to relieve the pain due to bone marrow aspiration [7].

Numerous studies have shown that the highest level of pain in patients
with cancer undergoing different kinds of intensive diag-nostic or evaluation
procedures was related to BMBA, lumbar puncture, and insertion of a central
venous catheter (CVC) [5,6]. Moderate to unbearable pain was reported by
50%e70% of patients who had undergone BMBA [7]. Prescription of a
combination of
Another common problem of patients with cancer before and after painful
procedures is anxiety, which can influence the quality of life [7]. Anxiety
increases sympathetic responses and changes some vital signs, which may
lead to tachycardia and hypertension [11]. Therefore, studying non-medical
methods for relieving pain, decreasing anxiety, and controlling vital signs is
necessary [12]. The use of complementary and alternative medicine is now
emphasized [13].

* Corresponding author. Ramsar Nursing Care Research Center, Babol University of Medical
Sciences, Babol, Mazandaran 4691714141, Iran.
E-mail addresses: sharifi.molod@gmail.com (M. Sharifi Rizi), abbasshamsalinia@
yahoo.com (A. Shamsalinia), ghafarifateme@yahoo.com (F. Ghaffari), Keyhani_333@
yahoo.com (S. Keyhanian), naderi_bahram@gums.ac.ir (B. Naderi Nabi).
Acupuncture, acupressure, homeopathy, energy healing, and yoga are
among the complementary and alternative therapie-s'practices used by
patients with cancer [14]. Acupressure has been

http://dx.doi.org/10.1016/j.ctcp.2017.09.002
1744-3881/© 2017 Elsevier Ltd. All rights reserved.
 M. Sharifi Rizi et al. / Complementary Therapies in Clinical Practice 29 (2017) 136e141
getting more attention recently [15]. Simplicity, effectiveness, and safety are
the strengths of this method [16]. Appropriate points are pressed using the
hand, foot, or a special device in some cases [17]. It is a method which can
control pain and anxiety [13].
There are reports that the acupressure method can have rapid and average
effects on relieving pain, reducing anxiety, and con-trolling vital signs,
although more studies with accurate findings are needed to support this
statement [12]. In a study by Bao and his colleagues. (2011), application of
magnetic acupressure to the LI4 point relieved pain significantly in a group of
patients suffering from severe pain [7].
One theory suggest that acupressure reduces anxiety by reducing 5-
hydroxytryptamine and adrenocorticotropic hormone concentrations in nerves
and adjusting the concentrations of neu-rotransmitters [13]. Beikmoradi et al.
(2015) concluded that acupressure was significantly effective in reducing
patients' anxiety after the intervention [13]. Studying the use of acupressure
among nurses can help improve the quality of nursing care and reduce the
side- effects of the invasive methods [12]. The increasing prevalence rate of
cancer and limited number of studies on acupressure led us to conduct a
research and explore the effectiveness of acupressure on pain, anxiety, and
physiological indexes in patients with cancer undergoing BMBA.
2. Trial design
This research was a randomized double-blinded clinical trial in which the
patients were not aware about the grouping orders. The acupressure and
BMBA operators were blinded to baseline pain and anxiety scores. The
questionnaires were seen only by an indepen-dent data collector. The proposal
is registered in the Iranian Reg-istry of Clinical Trials with the registration
number of “IRCT 2016080229159N1”.
3. Participants
The participants included cancer patients who were undergoing BMBA
and who were referred to oncology wards or oncology doctors' offices in the
western regions of Mazandaran province,. The sample was selected using the
convenience sampling method, then for allocation groups random block
sampling was used. The three groups were similar by age and gender.
4. Sample size
Estimates of variability for the three key outcomes (pain, anxi-ety, and
physiological indexes) were obtained from a pilot study and power calculation
(a ¼ 0.05; (1 b) ¼ 0.90; effect size ¼ 0.84). Therefore, 30 participants were
required for each group.
5. Inclusion criteria
The inclusion criteria were as follows: a pathology test result confirming
the cancer, being fully aware, 18e65 years of age, no intake of anxiolytic and
analgesic medications 12 h before the BMBA, no surface limitation like
wounds or angiocath at the point of acupressure, platelet levels greater than
100000 mg/dl, new to the whole procedure, no visual impairment, and no
previous knowledge about acupressure.
6. Interventions
The intervention was performed by a researcher who was a certified
acupressure practitioner. Different points have been used in previous studies
[18e20] including EX-HN3 (Extral), HT7 (Shen
137
Men), and LI4 [12].
The researcher selected the LI4 or Hegu point located at the middle of the
bisector of the angle between the first and second metacarpal (Fig. 1) and the
HT7 point on the lateral wrist located radial towards the tendon of the flexor
carpi ulnaris (Fig. 2) by reviewing different studies [21,22] and by soliciting
advice from an expert. The LI4 point is located where the energy flow is
closer to the skin and thus, is incited by chilling out, pressure or a needle
much easier.
The pressure points were pressed for 2 min [23] symmetrically
immediately after the start and the end of the biopsy. Fingers were pressed
gently on the point and pressure was increased gradually until there was a
sensation of soreness. All the patients were placed in the same position and 5
mg of lidocaine was injected locally. The same doctor performed the BMBA
for all patients.
For the placebo group, a point at 1.5 cm distance from the main points
(LI4 and HT7) was selected. These points are called ineffec-tive or sham
pressure points. No intervention was performed in the control group; only
routine procedures like blood pressure mea-surement, pulse, and breathing
controls were performed.
Ninety patients participated in this study.Thirty patients were randomized
to receive acupressure at LI4, and 30 to receive acupressure at HT7. Another
30 patients were randomized to the sham acupressure group. The remaining
30 patients were ran-domized to the control group (Fig. 3).
Three patients were excluded from analysis because they did not meet the
eligibility criteria for this study. They had platelet counts less than 100,000
mg/dl and an obstacle on the pressure points. One of the patients experienced
severe bleeding and severe dyspnoea during the bone marrow aspiration,
which caused his exit from the probing process. None of the patients
withdrew during the intervention.
11
Fig. 1. The LI 4 point is located between the first and second metacarpal bones.
Fig. 2. The Shen Men is located on the transverse crease of the wrist in the articular region
between the pisiform bone ulna in the depression on the radial side of the tendon of the flexor
carpi ulnaris muscle.
138 M. Sharifi Rizi et al. / Complementary Therapies in Clinical Practice 29 (2017) 136e141

Fig. 3. Consort diagram.

7. Outcome measurements
7.1. Demographic characteristics questionnaire
This questionnaire was filled out by the researcher before the start of the
procedure. It includes data on age, sex, marital status, education level, and
body mass index (BMI).
7.2. Spielberger anxiety questionnaire
State-Trait Anxiety Inventory (STAI): The STAI has 20 questions with a
1e4 scoring system. The total score is between 20 and 80 [24]. The reliability
and validity of this questionnaire has been examined in different studies
[25,26]. This is a psychometric tool that has been used since 1994 in Iran.
Cronbach's alpha of state anxiety is reported to be 0.93 [24,27].The anxiety
questionnaire was filled out 10 min before and after the procedure for each
group in this study.
7.3. Visual analog scale (VAS)
This tool is a pain severity ruler divided into 10 states catego-rizing pain
into 5 levels: no pain (0), mild pain (1e3), moderate pain (3e6), strong pain
(7e9), and maximum possible intense pain (9e10) [28]. VAS is applied to
many cases and its standard is approvable [29]. In this study to determine the
reliability of VAS, the Cronbach a coefficient was used to check its internal
consis-tency. In this regard, 10 patients from the research population who
had the profile of the patients with cancer under the study filled out the
questionnaires, and by using the results, the Cronbach a coef-ficient for VAS
(r ¼ 0.81) was calculated. The severity of pain was measured right after the
procedure for each group in this study.
7.4. Measurement of physiological indexes
A digital barometer (Omron M6) was used to calibrate the blood pressure
data measured. Pulse and respiratory rates were measured using an analog
clock. The physiological indexes were measured 10 min before and after the
procedure for each group in this study.
8. Statistical analysis
All data were analysed using the Statistical Package for the So-cial
Sciences (version 18.0). Descriptive statistics such as mean and standard error
of the mean were calculated and reported. Kolmo-goroveSmirnov test was
used to test the normality of data. As a normal distribution was obtained for
the data, parametric tests were used in the statistical analysis, the Analysis of
Variance (ANOVA) and LSD testes for repeated measures. The p-value of the
outcomes is less than 0.50.
9. Ethical considerations
The study was approved by the Research Committee of the Babol
University of Medical Sciences.

The participant was informed about the aims and methods of the study.
1
Dabiri, F. and A. Shahi (2014). “The Effect of LI4 Acupressure on Labor Pain Intensity and
Duration of Labor: A Randomized Controlled Trial.” Oman Med J 29(6): 425e429. Written consent for participation was obtained from all participants.
 M. Sharifi Rizi et al. / Complementary Therapies in Clinical Practice 29 (2017) 136e141
Confidentiality was observed.
The proposal was registered in the Iranian Registry of Clinical Trials
(www.irct.ir/; Registration number: IRCT 201608022 9159N1).
10. Findings
The average duration of the procedure was very similar in pa-tients in the
placebo group, the LI4 and HT7 groups, and control group (1 vs. 1.1 min, P ¼
0.51). No serious side effects or discomfort related to acupressure were
reported by patients in any of the groups.
The results show that the participant's age average was
56.67 ± 10.9 years. The average BMI was 25.2 ± 5.1. None of the participants
had a university degree but 40% of them had a high school diploma. Most of
the patients (95.6%) were married. The three groups had no square difference
in demographic character-istics including age (P ¼ 0.61), sex (P ¼ 0.11),
weight (P ¼ 0.42), height (P ¼ 0.81), and BMI (P ¼ 0.51). Bone marrow
aspiration was performed for all the patients during the biopsy.
The ANOVAwas used to test the null hypothesis. The results show that
the least anxiety average score was related to the acupressure (1.5 ± 0.5) after
the intervention. The acupressure successfully resulted in less anxiety in the
intervention group (F ¼ 4.189, df ¼ 2, P0 ¼ 0.01). Before the intervention,
the anxiety average score had no statistical difference between the groups (P
¼ 0.415) (Table 1). A post hoc test was used to determine the square
difference between each pair of average scores. The results of least square
difference (LSD) test show that there is a statistical square difference between
the anxiety average of acupressure and placebo (P ¼ 0.02) and control group
(P ¼ 0.008).
ANOVA statistical test results show that the least pain average score was
related to the acupressure group (4.9 ± 0.8). The F-test also had square results
(F ¼ 17.824, df ¼ 2, P ¼ 0.001) (Table 1). The results of LSD test show that
there is a statistical square difference between acupressure and placebo (P ¼
0.04) and control group (P ¼ 0.001). The difference between the placebo and
control groups (P ¼ 0.001) is evident but the difference between the pain
average scores of acupressure and control groups (1.3 ± 0.2) is greater than
that of the placebo and control groups (0.8 ± 0.2), which means that the effect
of acupressure on decreasing pain is greater than sham pressure.
The results of this study show that the systolic (F ¼ 16.154, df ¼ 2, P ¼
0.93) and diastolic (F ¼ 14.118, df ¼ 2, P ¼ 0.66) blood pressure average
scores had no square difference with each other after the intervention while
the same results for respiratory rate (F ¼ 17.554, df ¼ 2, P ¼ 0.05) and
pulse (F
¼ 14.639, df ¼ 2, p ¼ 0.02) had square differences in all groups (Table 2).
LSD test results also show square differences between the respiratory rate
average in acupressure and placebo groups (P ¼ 0.04) and the control group
(P
¼ 0.03). The difference is also evident between the acupressure
Table 1
Comparison of the pain and anxiety average scores before and after the intervention.
Variable Group Pre-intervention
(n ¼ 30)
mean ± SD
Pain score Experimental 7.9 ± 1.31
Placebo 7.6 ± 1.35
Control 7.5 ± 1.61
Anxiety score Experimental 2.1 ± 0.54
Placebo 1.9 ± 0.54
Control 2 ± 0.64
139
and the placebo group (P ¼ 0.05) while it is not been seen between the
acupressure and the control group (P ¼ 0.5). There is square difference
between the placebo and the control group (P ¼ 0.01) in average pulse rate,
which means that the effect of pressing sham pressure points on decreasing
the pulse rate was greater than the acupressure ones.
11. Discussion
The results of this study show that acupressure was effective in decreasing
anxiety level in patients with cancer after BMBA. The results of other studies
also showed a decrease in anxiety scores of the intervention group compared
with the sham pressure groups [11,18e20,30]. Other studies have explored the
role of acupressure on the release of neurotransmitters like serotonin which
affects the patient's sense of calm [31,32].
The results of this study show that acupressure is effective in decreasing
the pain caused by BMBA. This finding is in agreement with the results of
previous studies [20,30]. Decrease in pain has also been seen in the placebo
group which is statistically square. Possible reasons for this might be the
hypnosis of the intervention, the safety felt by the patient due to the presence
of the researcher, or the Hawthorne effect. In the study conducted by Bao et
al. (2011), no significant difference in median pain scores was observed in
patients treated at the LI4 site vs. the sham site (3.0 vs. 3.0, P ¼ 0.8, Mann-
Whitney test) [7].
Our results show no square differences between the average scores of
systolic and diastolic blood pressures after intervention in each group. This
might be related to the short duration of acupressure (2 min) and the
sympathetic system's response to anxiety.
The square difference between the average score of respiratory rate and
pulse rate in three groups after the intervention is observed. Decreased pulse
and respiratory rates are statically reasonable but clinically meaningless since
both of the numbers are in the normal range and might have decreased due to
the patient's steady situation and feeling calm while being observed during the
intervention. Padmanabhan et al. (2005) stated that subjective parameters
including heartbeat, blood pressure, respiratory rate, catecholamine and
cortisol levels, and skin's temperature have weak relationship to mental
changes and acute anxiety felt by patients before surgery [33].
Barker (2006) believes that the cardiovascular system is highly reactive to
the psychological and behavioural states. Heartbeat and blood pressure are
two dependent variables to the anxiety levels in behavioural studies [11].
The results of a study byBassampour et al. (2008) show statically square
differences (P < 0.001) in vital signs of the intervention group before and
right after the intervention. Such a difference is also observed in the vital
signs of the placebo group (pulse rate (P ¼ 0.016) and respiratory rate (p ¼
0.007)). The square difference is reported by comparing the anxiety of the two
groups (P < 0.001)
Post-intervention F P Value
(n ¼ 30)
mean ± SD
4.9 ± 0.84 17.824 0.000
5.3 ± 0.99
6.2 ± 0.77
1.5 ± 0.50 4.189 0.018
1.8 ± 0.48
1.8 ± 0.57
140 M. Sharifi Rizi et al. / Complementary Therapies in Clinical Practice 29 (2017) 136e141

Table 2
Comparison of the physiological indexes average scores before and after the intervention.

Physiological indexes Group Pre-intervention Post-intervention F P Value

(n ¼ 30) (n ¼ 30)
mean ± SD mean ± SD
Respiratory/min Experimental 18.13 ± 2.34 18.60 ± 2.41 3.032 0.053
Placebo 17.93 ± 1.92 17.66 ± 1.18
control 17.53 ± 1.35 17.60 ± 1.42
Pulse/min Experimental 80.16 ± 5.48 81.03 ± 4.95 3.772 0.027
Placebo 80.33 ± 5.35 79 ± 3
control 80 ± 3.48 81.73 ± 3.81
Systolic Blood pressure (mmHg) Experimental 124.66 ± 17.36 123.66 ± 14.73 0.070 0.932
Placebo 126.66 ± 18.63 124 ± 13.54
control 122.33 ± 13.56 125 ± 14.79
Diastolic Blood pressure (mmHg) Experimental 68.33 ± 21.50 75 ± 15.25 0.408 0.666
Placebo 75.03 ± 15.55 77.66 ± 9.35
control 75.33 ± 8.60 76.33 ± 8.50

where the respiratory rate p was equal to 0.013 and systolic blood pressure p
was equal to 0.008 [4].
Valiee (2012) has reported a greater decrease in systolic blood pressure in
the acupressure group compared to the sham control group [19]. The results of
other studies show a similar decrease in pulse rate [11,25]. Hosseinabadi
(2015) reported significant differ-ences in pain scores (P ¼ 0.004) between
the 3 groups (acupressure, placebo, and control) after the intervention only.
No significant differences between the 3 groups were found after the
intervention with regard to pulse rate, systolic blood pressure, or diastolic
blood pressure (P
> 0.05) [34].
Implications for Practice:
Our results show that application of acupressure in patients undergoing
BMBA prevents pain, anxiety, and an increase in some of the
physiological indexes.
Acupressure would be a suitable intervention in clinical settings where the
patient experiences high levels of pain and anxiety.
Acupressure is cost-effective and doesn't require professional and long-
term education for patients and nurses.
Teaching acupressure to patients can be effective in reducing pain and
anxiety in patients with cancer.
11.1. Limitations
This study is limited by its relatively small sample size and the overall
number of patients experiencing severe pain. Numerous factors could
influence the pain and anxiety scores. Controlling for these factors was
impossible for the researcher because of personal differences and cultural,
mental, and psychological factors. The study was carried out at a single
treatment centre, and an operator experienced in BMBA and an experienced
acupressure practitioner were involved in the procedures. It is unknown if the
same results would be obtained if these persons were inexperienced. Thus,
more studies are needed to verify the results of this study.
Local anesthesia by infiltration with sodium channel blockers, such as
lidocaine is the most basic and widely used means of providing analgesia,
indexes of patients with cancer undergoing bone marrow biopsy.
Funding
None of the authors have any financial or personal relationship with other
persons or organizations that could inappropriately influence the work
reported here.
Conflict of interest statement
None declared.
Acknowledgment
The study was approved by the Research Committee of the Babol
University of Medical Sciences, No MUBABOL.HRI. REC.1395.39. The
researchers express their gratitude and appreci-ation to all the participants in
the study.
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