I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Effectiveness of acupressure in improving dyspnoea in chronic obstructive pulmonary disease

Hua-Shan Wu
RN MSN

Instructor, Jen Teh Junior College of Medicine, Nursing and Management, Miaoli, Taiwan, ROC

Shiao-Chi Wu

PhD

Associate Professor, Institute of Health and Welfare Policy, National Yang-Ming University, Taipei, Taiwan, ROC

Jaung-Geng Lin

PhD

Professor, Institute of Chinese Medical Science, Chinese Medical College, Taichung, Taiwan, ROC

and Li-Chan Lin

PhD RN

Professor, Institute of Clinical Nursing, National Yang-Ming University, Taipei, Taiwan, ROC

Submitted for publication 13 August 2002 Accepted for publication 23 May 2003

Correspondence: Li-Chan Lin, Institute of Clinical Nursing, National Yang-Ming University, 155 Li-Nong Street, Section 2, Taipei, Taiwan, ROC. E-mail: lichan@ym.edu.tw

W U H . S . , W U S . C . , L I N J . G . & L I N L . C . ( 2 0 0 4 ) Journal of Advanced Nursing 45(3), 252259 Effectiveness of acupressure in improving dyspnoea in chronic obstructive pulmonary disease Background. Patients with chronic obstructive pulmonary disease (COPD) suffer from dyspnoea in their daily life and this may be increased by anxiety. Acupressure may promote relaxation and relieve dyspnoea. Thus, it is appropriate to explore the effectiveness of acupressure on dyspnoea in patients with COPD. Aims. To compare outcomes of acupressure using sham acupoints on different meridians and ganglionic sections with that using true acupoints, in patients with COPD who are living at home. Methods. Patients diagnosed with COPD were selected from a medical centre and three regional hospitals in Taipei. A randomized block experimental design was used. Using age, sex, pulmonary function, smoking, and steroid use as matching factors, 44 patients were randomly assigned either to a true acupoint acupressure or a sham group. The true acupoint acupressure group received a programme to decrease dyspnoea. Those in the sham group received acupressure using sham pressure points. Both acupressure programmes consisted of ve sessions per week lasting 16 minutes per session, extending over 4 weeks for a total of 20 sessions. Before acupressure was initiated and at the conclusion of the 20th session, the Pulmonary Functional Status and Dyspnoea Questionnaire-modied scale and the Spielberger State Anxiety scale were administered, and a 6-minute walking distance test was performed. Physiological indicators of oxygen saturation and respiratory rate were measured before and after every session. Results. The results of this study showed that the pulmonary function and dyspnoea scores, 6-minute walking distance measurements, state anxiety scale scores, and physiological indicators of the true acupoint acupressure group improved signicantly compared with those of the sham group.

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Conclusions. The ndings suggest that acupressure can be used as a nursing intervention to improve dyspnoea in patients with COPD. Keywords: acupressure, acupoint, dyspnoea, chronic obstructive pulmonary disease, randomized block experimental design, nursing

Introduction
Dyspnoea is the most common reason for patients with chronic obstructive pulmonary disease (COPD) to seek assistance in outpatient departments (OPDs). Acupressure may promote relaxation and relieve dyspnoea in patients. However, sham acupoints that overlap true acupoints on the same meridians may have some effects on acupressure treatment and confound effects from true acupoints. Despite efforts to reduce industrial hazards and smoking, the prevalence of COPD remains high in western and Asian countries. There are approximately 14 million individuals in the United States of America with COPD (American Thoracic Society 1995) and it ranks as the fourth leading cause of death (National Center for Health Statistics 2001). According to estimates made by the National Heart Lung and Blood Institute, the annual cost to the nation for COPD was US$ 304 billion (American Lung Association 2002). In England and Wales, COPD was the fth most common cause of death, accounting for 54% of all male deaths and 32% of all female deaths, in 1994 (Department of Health 2003a). In Taiwan, COPD was ranked as the 11th cause of mortality in 2002 (Department of Health 2003b), and National Health Insurance reported medical expenditures for COPD patients to be 39 million in 2001 (National Health Insurance 2003). Thus, expenditures on caring for people with COPD are signicant. Dyspnoea is a common problem in people with COPD. Lareau et al. (1994) in a study of 131 participants with COPD, found 84% experienced severe dyspnoea, while 59% had at least one daily episode of dyspnoea. In a study by Kroenke et al. (1990), dyspnoea was the most common cause of patients with COPD seeking assistance at OPDs, but only 39% obtained relief using prescribed treatments. The side effects of pharmacotherapy may actually exacerbate respiratory effort and increase respiratory muscle weakness (Beeken et al. 1998). At present, OPD clinics use pulmonary rehabilitation programmes to relieve dyspnoea and increase activity tolerance. Opinions differ as to the effectiveness of such programmes, which are all very costly in terms of time, staff, space and equipment (Albert 1997). Acupressure, a type of massage, is a non-invasive technique and incorporates the principles of Chinese Medi-

cine acupuncture. Acupressure is a manipulative therapy that stimulates meridians or points by means of pressure. Usually the ngers or thumbs are used to apply pressure to regulate qi (Beal 2000). Hare (1988) reports that acupressure promoted relaxation, relieved dyspnoea, and enhanced immunity. Maa et al. (1997) tested acupressure to treat COPD patients during a pulmonary rehabilitation programme; a single-blind pretestpost-test cross-over design was used. The only signicant nding was that real acupressure was more effective than sham acupressure for reducing dyspnoea. A visual analog scale was used to measure the severity of dyspnoea. In a recent study, Chen et al. (1999) report that use of sham acupoints, 13 corresponding body units (cun) away from meridians used in acupuncture, was not as effective in improving quality of sleep in institutionalized residents when compared with use of true acupoints. However, people in the sham group had some improvement following the intervention. The reasons why massage using sham acupoints may have some effect in improving dyspnoea is that sham acupoints may sometimes overlap with true acupoints on the same meridians and thus confound results (Chiu 1999). Based on the above studies, additional research is needed to compare outcomes related to sham and true acupoints when acupressure is used to improve dyspnoea in people with COPD.

The study
Aim
The aim of the study was to compare the results of using sham and actual acupoints on various meridians and ganglionic sections to determine if employing acupressure can improve dyspnoea in COPD patients who live at home.

Research design
A randomized block experimental study was conducted. Patients who were diagnosed with COPD were chosen from the thoracic clinics of OPD at a medical center and three regional hospitals in Taipei. All participants met the following criteria: (a) they had been diagnosed as having COPD and
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complained of dyspnoea, (b) they took steroids in doses <10 mg daily, (c) they were able to walk unassisted, (d) they had never had any health problems affecting the progress of their COPD, (e) they had not been hospitalized in the previous 2 months, (f) they had not received pulmonary rehabilitation in the previous 6 months and (g) they were able to speak Chinese or Taiwanese. Of the 151 patients who met the sampling criteria, 50 (3311%) consented to participate in the study. Using the variables of age, sex, pulmonary function, smoking, and steroid use to match (block), 44 patients were randomly assigned to either the true acupoint or the sham group. The true acupoint group received an acupressure programme to improve dyspnoea, while the sham group received acupressure using different meridians and ganglionic sections that did not correspond to the points advocated by Chinese medicine. Both acupressure programmes lasted 4 weeks (20 sessions) and consisted of 16minute sessions that were given ve times a week. The Pulmonary Functional Status and Dyspnoea QuestionnaireModied (PFSDQ-M) and State Anxiety Inventory were administered before any treatments were given. Additionally, participants completed a 6-minute walking test, and oxygen saturation measurements were collected before and after the 20 sessions. Data were collected at participants homes from April 2000 to December 2000.

Points 26 were pressed or rubbed once per second. After rubbing or pressing for 5 seconds, they were released for 1 second, and then rotated until the treatment time was completed. Sham group. Because different acupoints related to the same meridian might generate different outcomes and the same ganglionic section in different meridians might produce the same outcomes, acupoints different from the meridians and ganglionic sections of the true acupoint acupressure group were chosen. The research participants were elders, who may have had decreased intestinal function (Wang et al. 1998) so the Shang Hill (Sp5), Supreme White (Sp3) and Large Pile (Liv1) points were chosen to promote intestinal movement and increase intestinal circulation. The protocol included: 1 Efeurage: hold, rub, and press neck and each shoulder for 2 minutes. 2 Rub and press the Shang Hill (Sp5); point for 4 minutes. 3 Rub and press the Supreme White (Sp3) point for 4 minutes. 4 Point (using nger-tip pressure only) and press the large pile (Liv1) point for 4 minutes. Sham acupoints 24 were rubbed, pressed and pointed once per second. After rubbing, pressing or pointing for 5 seconds, the pressure was released for 1 second, and then rotated until the treatment time was completed. Reliability and validity of acupressure protocol 1 Content validity of the true acupoints and the sham acupoints acupressure protocol was determined by ve experts in Chinese medicine (attending physicians or associate professors) who independently rated the appropriateness of the selected acupoints, and the protocol (method and timing) for the two groups. A 4-point Likert scale (4 very appropriate, 3 appropriate, 2 inapinappropriate and 1 very inappropriate) was used. The panel ratings for all items were between 3 and 4. Lynn (1986) points out that if there are ve or fewer experts, all must agree on the content validity for their rating to be considered a reasonable representation of the universe of possible ratings. Revisions were made until the percentage agreement reached 100%. 2 Accuracy of the chosen acupressure points was assessed through observation. Twenty patients at an acupuncture department of a regional hospital in Taipei were given acupressure at all the acupoints used in our study. The acupressure was undertaken by the principal investigator and a Chinese medicine physician observed the acupoints selected. A 99% level of accuracy was achieved.

Treatment programmes
Acupressure protocol True acupoint group. Based on traditional Chinese medicine, COPD is thought to deplete uids and qi (Wu 1988). Qi is the vital energy and needs to be in harmony. Use of the acupoints known as great hammer (GV14), celestial chimney (CV22), lung transport (B13), kidney transport (B23), and sh border (L10) can help to bring qi into harmony in the lungs. The protocol for true acupoint acupressure included: 1 Efeurage: hold, rub and press the neck and each shoulder for 2 minutes to free the qi dynamic and to move qi and blood. 2 Press and rub the Great Hammer (GV14) point for 3 minutes. 3 Press the Celestial Chimney (CV22) point for 15 minutes. 4 Press and rub the Lung Transport (B13) points (two sides at the same time) for 3 minutes. 5 Press and rub the Kidney Transport (B23) points (two sides at the same time) for 15 minutes. 6 Press and rub the Fish Border (L10) point (one side) for 3 minutes.
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3 We measured the stability of acupressure force by using a platform scale, which met the criterion of the Central Standards Measurement Bureau. Acupressure was given to the same points for 5 seconds using the thumbs and forengers of both hands. The force was measured after repeating the acupressure 10 times. The principal investigator was unable to see the platform scale and had to maintain the acupressure force between 3 and 5 kg for at least 5 seconds. Another person recorded the force at the fth second. The force of the thumbs and forengers of both hands averaged between 375404 kg at the same place, height and on different dates and at different times. 4 The acupressure protocols used for the two groups were videotaped and the tapes were observed simultaneously. To achieve inter-rater reliability the difference in timings between the two groups should not exceed 5 seconds. The observed difference between the acupoint and sham procedures ranged from 04 seconds.

Six-minute walking tests Before acupressure treatment began and after the 20 sessions were completed, patients completed a 6-minute walk. They walked at their usual pace and unassisted on a long, at sidewalk. After completing the test, the research assistant measured the distance they had walked. Oxygen saturation A member of the research staff used a pulse oximeter (Nonin model 9500 ONYX, size 33 33 57 cm Nonin Medical Inc., Plymouth, Minnesota, USA) to measure the oxygen saturation in a nger before and after every session. The total weight of the pulse oximeter was 60 g, with a bias of 3%.

Data analysis
Data were coded and analysed using descriptive analysis, chi-square and MannWhitney U-tests. The Statistical Package for Social Sciences (SPSS Inc., Chicago) version 90 for Windows was used.

Measurement of outcomes
Pulmonary Function Status and Dyspnoea QuestionnaireModied We adminiustered three subscales from the PFSDQ-M (Lareau et al. 1998). The subscales consisted of 30 items, and evaluated activity, fatigue and dyspnoea. Rating ranged from 0 as active as Ive ever been or no shortness of breath/tiredness to 10 omitted the activity entirely or had very severe shortness of breath/tiredness. Leung (1999) translated these subscales into Chinese. Cronbachs alpha coefcients of 093 for the activity subscale, 096 for the dyspnoea subscale, and 096 for the fatigue subscale were reported. Content validity was assessed by having ve experts rate the items on a four-point scale in terms of relevance (4 very relevant, and 3 quite relevant). Permission to use the PFSDQ-M was given by Lareau and Leung. The Chinese version of the PFSDQ-M was used before and after the 20 sessions of acupressure. State Anxiety Inventory Spielberger et al. (1970) developed the State Anxiety Inventory and it was translated into Chinese by Zhong and Long (1984). Permission to use the Chinese version was given by Zhong. Patients rated the level of anxiety associated with their dyspnoea (Gift 1991). The state anxiety dimension has 20 items and anxiety level is rated on a 4-point Likert scale, with higher scores indicate higher anxiety. Zhong and Long (1984) report testretest reliability and the Cronbachs alpha of this inventory to be 074 and 090 respectively. In tests of validity, average state anxiety scores were signicantly higher during illness than in the general population.

Results
Average age was 73 years (SD 97) and most participants were men (818%, n 36). The majority (80%, n 35) were married and lived with their children. A large percentage (864%, n 38) had given up smoking or were nonsmokers. None of the participants used oxygen during the study. Most (545%, n 24) had severe obstruction (FEV1 < 50% predicted). All participants used bronchodilators. Participants had been receiving therapy for COPD for a mean of 791 years (SD 783). There were no signicant differences between the demographics of the true acupoints and sham acupoints groups (see Table 1). Table 2 presents the pretest scores for each variable. These variables were similar for both groups. After true and sham acupressure, signicant differences were found between the PFSDQ-M activity subscale scores of the two groups (Z 4604, P < 0001). Table 3 displays the comparisons between the two groups. The dyspnoea subscale of the PFSDQ-M revealed that the mean score of the true acupoints acupressure group decreased signicantly after intervention, in comparison with that of the of the sham acupressure group (P < 005), indicating that dyspnoea in the true acupressure group improved signicantly more than in the sham acupressure group. The fatigue subscale scores of the PFSDQ-M showed that the mean postintervention score of the true acupressure group decreased signicantly compared with that of the sham acupressure group (P < 001), indicating that more improvement in fatigue level was
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H.S. Wu et al. Table 1. Comparison of demographic variables in true and sham acupoint groups (n 44) True acupoint group (n 22) n (%) Sham group (n 22) n (%) v2

Variables Sex Male Female Age classication <65 yrs 6574 years 7584 years >84 years Marriage Married Single Education No formal school Primary school Junior high school Senior high school or more Job Yes No Live Alone With spouse With children Smoking No smoking or had given up smoking Smoking Oxygen use during intervention No

Total (n 44) n (%)

18 (818) 4 (182) 3 7 8 4 (136) (318) (364) (182)

18 (818) 4 (182) 3 7 8 4 (136) (318) (364) (182)

36 (818) 8 (182) 6 14 16 8 (136) (318) (364) (182) 014

18 (818) 4 (182) 2 6 6 8 (91) (273) (273) (364)

17 (773) 5 (227) 5 8 3 6 (227) (364) (136) (273)

35 (795) 9 (205) 7 14 9 14 (159) (318) (205) (318)

286

20 (909) 2 (91) 0 2 (91) 20 (909) 19 (864) 3 (136) 22 (100) True acupoint group (n 22) n (%) Mean (SD ) Sham group (n 22) n (%)

20 (909) 2 (91) 1 (45) 1 (45) 20 (909) 19 (864) 3 (136) 22 (100) Total (n 44) n (%)

40 (909) 4 (91) 1 (23) 3 (68) 40 (909) 38 (864) 6 (136) 44 (100)

000

133

Mean (SD )

Mean (SD )

v2

MannWhitney U-test

Demographic Distribution of Two Groups (n 44) Pulmonary function Mild (FEV1 70% predicted) 2 (91) Moderate (FEV1 5069% predicted) 8 (364) Severe (FEV1 < 50% predicted) 12 (545) Drugs Bronchodilators 22 (100) Steroid 14 (636) To relieve cough and reduce phlegm 9 (409) Age (years) 740 (106) COPD treatment time 84 (81) COPD, chronic obstructive pulmonary disease.

2 (91) 8 (364) 12 (545) 22 (100) 14 (636) 8 (364) 745 (100) 74 (77)

4 (91) 16 (364) 24 (545) 44 (100) 28 (636) 17 (386) 742 (102) 79 (78)

010 0247 0788

present in the true acupressure group than in the sham (see Table 3). The 6-minute walking test was undertaken to determine if acupressure improved tolerance of activity. The difference in the mean pre- and postintervention scores of the true
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acupoint acupressure group was signicantly greater than in the sham group (Z 4812, P < 0001), indicating that, following the intervention, the true acupoint acupressure group had more tolerance for activity than the sham group (see Table 3).

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Issues and innovations in nursing practice Table 2 Comparisons variables of true and sham acupoint groups before acupressure began (n 44)

Acupressure in improving dyspnoea

Variables PFSDQ-M activity subscale PFSDQ-M dyspnea subscale PFSDQ-M fatigue subscale 6-Minute walking distance (m) State Anxiety Scale

True acupoint group (n 22) Mean (SD ) 181 209 117 20014 4273 (127) (115) (084) (8839) (781)

Sham group (n 22) mean (SD ) 193 229 112 19647 3977 (159) (164) (107) (7601) (902)

Total (n 44) mean (SD ) 187 219 114 20831 4125 (142) (140) (096) (8234) (847)

Mann Whitney U-test 002 026 087 108 118

PFSDQ-M, Pulmonary Functional Status and Dyspnoea Questionnaire-Modied.

Table 3 Comparisons of mean differences in pre- and postsores between the true and sham acupoint groups (n 44)

Variables PFSDQ-M activity subscale PFSDQ-M dyspnea subscale PFSDQ-M fatigue subscale 6-Minute walking distances (m) State Anxiety Scale scores Respiratory rates (times/minute) Oxygen saturation (%)

True acupoint group (n 22) M (SD ) 039 098 048 1021 850 216 107 (042) (141) (082) (1164) (427) (060) (067)

Sham group (n 22) M (SD ) 028 041 004 912 014 053 065 (042) (043) (037) (2330) (512) (083) (047)

Total (n 44) M (SD ) 005 028 026 054 432 082 021 (054) (125) (067) (2066) (629) (153) (104)

Mann Whitney U-test 460* 544* 337* 481* 489* 5588* 5640*

*P < 0.001. M mean (post-test scores) mean (pretest scores). PFSDQ-M, Pulmonary Functional Status and Dyspnoea Questionnaire-Modied.

Spielbergers State Anxiety Inventory was used to determine if acupressure lessened anxiety. The difference in mean pre- and postintervention scores in the true acupressure group was signicantly greater than that in the sham group, and indicated that state anxiety was lowered more in the true acupressure group than in the sham group (see Table 3). Respiratory rate and oxygen saturation were measured before and after each treatment to determine the effect on pulmonary function. The difference between mean pre- and postintervention oxygen saturation scores in the true acupressure group was signicantly greater than in the sham group (P < 0001). This change indicated that pulmonary function in the true acupressure group improved (see Table 3).

Discussion
We found a signicantly greater improvement in patients receiving acupressure at true acupoints compared with those receiving acupressure at sham points. This improvement related to all the variables studied and suggests that people with COPD would benet from acupressure at true acupoints. These ndings are similar to those reported by Maa et al. (1997).

Fatigue improved in the true acupoint acupressure group more than in the sham group. One possible reason for the positive outcome in the true acupoints group is that pressure was applied to the back and hands. Pressure on the back may have helped to produce relaxation and thus improve the other indices. Fraser and Kerr (1993), Ferrell-Torry and Glick (1993), and Yang (2000) used back massage or acupressure to achieve the same results as this study. Activity tolerance improved in subjects receiving acupressure at the true acupoints. Maa et al. (1997), however, did not report any improvements in activity after acupressure. This difference might be explained by the use of different acupoints in the two studies. In our study we used the Lung Transport (B13), Kidney Transport (B23), and Celestial Chimney (CV22) points in addition to those used by Maa et al. The Lung Transport (B13) acupoint can regulate lung qi, clear vacuity heat, and manufacture blood (Yang 1990). The Celestial Chimney acupoint can aid diffusion in the lung, calm panting, suppress coughs, transform phlegm, clear and liquefy material in the throat, transport qi and stop vomiting (Liu & Wang 1994). Matching two acupoints can decrease inspiratory and expiratory airway resistance (Yang 1990). Pressure on the kidney transport acupoint can promote absorption of clearing qi by the lung (Shao 1996).
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What is already known about this topic

Dyspnoea is the most common reason for patients with chronic obstructive pulmonary disease to seek assistance in out-patient departments. Both true and sham acupressure have been noted to relieve dyspnoea, although true acupressure is more effective than sham acupressure. The argument has centred on the problem of confounding effects, where sham acupoints can overlap true acupoints on the same meridians resulting in a true accupressure effect.

measurement of arterial blood gases, and chest X-rays would provide more comprehensive data about the effectiveness of acupressure in lessening dyspnoea in COPD patients.

Conclusion
Kinsman et al. (1983) and Lareau et al. (1994) found that 84 95% of COPD patients had dyspnoea, and more than half of these patients experienced dyspnoea on a daily basis. The acupressure programme used in our study took only 16 minutes to administer, but it appeared to improve dyspnoea. Use of non-pharmacological treatments may help to lessen the incidence of medication side effects. Because acupressure is an alternative therapy that is quite new to many nurses, content on acupressure needs to be included in nursing curricula, and in-service education programmes for nurses are needed in clinical practice. Additional studies are needed to validate the ndings of our study. The effectiveness of acupressure using true acupoints, sham true acupoints and sham non-acupoints needs to be explored, and long-term follow-up studies are necessary.

What this paper adds

This study randomly assigned subjects to true and sham accupressure groups, with sham pressing acupoints different from the meridians and ganglionic section of the true acupoints to avoid confounding effects due to overlap. This study conrmed that acupressure using true pressure points relieved anxiety and dyspnoea, and enhanced tolerance for activity, while the effects from the sham acupressure points did not produce similar outcomes.

Acknowledgements
We would like to thank all the participants and the thoracic physicians for helping with recruitment of subjects. We are also grateful to Mr Williams and Dr Mariah Snyder for editing the manuscript in English.

In addition to improving respiratory function, the acupoints used in this study strengthen life energy, improve lung function, and lessen shortness of breath during activity. The relationship between anxiety and dsypnoea is demonstrated by Gift et al. (1986). Because dyspnoea evokes fear, discomfort, feelings of distress, and panic, improving dyspnoea might alleviate anxiety. Our ndings conrm that pressure at true acupoints can decrease anxiety. The results of our study are similar to those of Fraser and Kerr (1993) and Ferrell-Torry and Glick (1993), who found that massage could signicantly decrease anxiety in institutionalized older people and patients with cancer. Acupressure could be used along with massage to promote relaxation.

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Limitations
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