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Acupressure for prevention of pre-operative

anxiety: A prospective, randomised, placebo
controlled study. Anaesthesia, 60, 978-981
ARTICLE in ANAESTHESIA OCTOBER 2005
Impact Factor: 3.38 DOI: 10.1111/j.1365-2044.2005.04332.x Source: PubMed

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Anaesthesia, 2005, 60, pages 978981

doi:10.1111/j.1365-2044.2005.04332.x
.....................................................................................................................................................................................................................

Acupressure for prevention of pre-operative anxiety:

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

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

Correspondence to: Dr Anil Agarwal

E-mail: aagarwal@sgpgi.ac.in
Accepted: 14 June 2005

The incidence of pre-operative anxiety in adults varies

from 11% to 80%. Pre-operative anxiety correlates with a
high incidence of postoperative pain, increase in analgesic
and anaesthetic requirements, and delayed recovery and
discharge from hospital [14]. In addition, anxiety may
influence adversely the induction of anaesthesia and its
recovery, and decrease patients satisfaction with their
peri-operative experience [1]. Sedative premedication is
routinely administered to reduce pre-operative anxiety;
however, sedatives have their own side-effects, which can
be minimised by the use of non-pharmacological interventions. Acupressure on the extraordinary point extra 1
has been shown to reduce stress in healthy volunteers [5].
As pre-operative anxiety might not be comparable to
the anxiety experienced by volunteers, the present study
was undertaken to evaluate the efficacy of acupressure at
extra 1 point in patients undergoing elective surgical
procedures.
978

Methods

Following approval of the Institutional Ethics Committee

and after obtaining written, informed consent from
patients, this prospective, randomised and observer
blinded study was conducted. Patients taking any sedative, tranquilliser, or acupressure or acupuncture therapy
were excluded from the study.
Assuming that the normal value (SD) of bispectral
index (BIS) is 97 (2) and following acupressure at Extra
1 point, it would reduce to 75 (2), for results to be
statistically significant at a power of 80% and a = 0.05,
we calculated that we needed to evaluate 38 patients in
each group. Therefore, 76 consecutive adult (aged 18
50 years) ASA physical status I and II patients of either sex
undergoing elective surgical procedures were enrolled
in this study. Patients were randomly assigned to two
groups of 38 each with the help of a computer-generated

2005 Blackwell Publishing Ltd

Anaesthesia, 2005, 60, pages 978981

A. Agarwal et al.
Acupressure for pre-operative anxiety
. ....................................................................................................................................................................................................................

Results

There was no significant difference in the demographic

profile of the patients (Table 1). Anxiety was significantly
reduced at the end of pressure application for 10 min in
both the acupressure and control groups when compared
to their respective baseline values: 5 (1) vs. 8 (1) in the
acupressure and 7 (0) vs. 8 (1) in the control groups
(p < 0.001; Fig. 1). However, 30 min after release of
pressure, anxiety in both, groups returned to baseline
(p > 0.05). A significant reduction was observed in

2005 Blackwell Publishing Ltd

Table 1 Demographic data presented as mean (SD).

Variables groups

I: Control

II: Acupressure

Age; year
Height; cm
Weight; kg
Male female ratio

35.53 (7.85)
171.06 (9.40)
59.73 (7.13)
18 18

35.06 (8.02)
167.00 (9.32)
61.00 (9.80)
17 19

120
100
80
BIS

table of random numbers. Patients in Group 1 (control)

received acupressure at an inappropriate site and group 2
(acupressure) received acupressure at extra 1 point.
Extra 1 point is situated between the two eyebrows at
the root of the nose. In the control group, acupressure
was applied 2 cm lateral and horizontal from the lateral
end of the left eyebrow. None of the patients received
any sedative premedication. On the morning of the
surgery, following arrival in the pre-operative area,
patients were allowed to relax for 15 min. Thereafter,
depending upon the group allocation, acupressure was
applied. Acupressure was applied by the pulp of the right
thumb in a rotary fashion at 2025 cycles.min)1 for
10 min by the same investigator. Following release of
acupressure, patients were observed for another 30 min.
Thus the total study period consisted of 40 min (acupressure application for 10 min + 30 min after release of
pressure).
Patients were informed about the study design and use
of the visual stress scale (VSS) for assessment of their
anxiety a day earlier during the pre-anaesthetic assessment. The person applying the acupressure was aware of
the group allocation. Recording of BIS was performed by
a staff nurse blinded to the treatment group. A screen was
placed so that the head end of the patient and the person
performing the acupressure could not be seen by the
observer until the end of the study period.
Patients recorded their anxiety on a VSS from 0 (no
stress) to 10 (maximum stress) at the start of the study,
10 min (end of pressure application) and at 40 min (i.e.
30 min after the release of pressure); and these results
were communicated to the observer. BIS monitoring was
performed using a Model A-2000, 3.1 software version
(Aspect Medical System, Natick, MA). The median of
three consecutive readings of BIS was recorded as
baseline. BIS was recorded in a similar fashion at 2, 5,
10, 12, 15, 30 and 40 min. Data are presented as median
(interquartile range). Intra-group comparison was done
with the Wilcoxon rank test and intergroup comparison
with the MannWhitney test. p < 0.05 was taken as
significant.

60
40

Control
Acupressure

20
0
0

10

12
15
Time (min)

20

30

40

Figure 1 Changes in BIS value as observed in the two groups.

Data are presented as median. *p < 0.05 intra-group comparison of BIS values during pressure application when compared
with their respective baseline and values obtained after the
release of pressure. p < 0.05 during intergroup comparison of
BIS values. Interquartile ranges have been omitted for clarity.

anxiety in the acupressure group compared with the

control group at the end of pressure application for
10 min (5 (1) vs. 7 (0)).
BIS values during pressure application at 2, 5, 10 min
were lower than their respective baseline values in both
the groups (p < 0.05; Fig. 1). BIS values recorded during
pressure application were lower than BIS values observed
following release of pressure, i.e. at 12, 15, 20, 30, 40 min
in both the groups (p < 0.05). During the application of
acupressure at extra 1 point, BIS values were lower than
the corresponding values in the control group (p < 0.05)
(Fig. 1).
Discussion

We observed a significant decrease in pre-operative

anxiety at the end of pressure application for 10 min in
both the acupressure and control groups. The decrease in
anxiety was significantly more in the acupressure group
when compared with control group. Thirty minutes after
979

A. Agarwal et al.
Acupressure for pre-operative anxiety
Anaesthesia, 2005, 60, pages 978981
. ....................................................................................................................................................................................................................

release of pressure, anxiety returned to baseline in both

the groups.
Anxiety can be divided into state and trait [6]. Trait
anxiety is a life-long pattern of anxiety, a personality
feature, whereas state anxiety refers to acute situational
driven episodes of anxiety that do not persist beyond the
situations that trigger them. The latter is a transitory
emotional condition that consists of feelings of apprehension, nervousness and worry. The activity of the autonomic nervous system is heightened, as can be seen in
patients scheduled for surgery, and can result in a high
incidence of postoperative pain, increased analgesic and
anaesthetic requirements and a prolongation of hospital
stay [1]. Sedatives and opioids are often used as premedicants, but at times are associated with undesirable
side-effects such as drowsiness and respiratory depression
[4]. Benzodiazepines, the most commonly used drug for
alleviation of pre-operative anxiety, may interact with
anaesthetic agents and thus prolong patient recovery and
discharge.
Both acupressure and acupuncture have been used
to prevent postoperative nausea and vomiting, reduce
postoperative pain, analgesic requirements, and opioid
related side-effects after both upper and lower abdominal
surgery, as well as reducing anxiety and behaviour
dysfunction [79]. Auricular acupuncture at the relaxation point has been reported to decrease pre-operative
anxiety [10]. Acupressure application during prehospital
transport yields similar results [11]. The advantages of
acupressure over acupuncture are that it is non-invasive,
does not affect the integrity of the epidermis and can
be applied easily [5]. The exact mechanism of how
acupuncture and acupressure works is not known.
Considerable evidence supports the claim that certain
peptides are released and that the analgesic effects of
acupressure are at least partially explained by the actions
of these peptides [12]. Acupuncture analgesia also
reduces the activation of the sympathoadrenal system
that normally accompanies surgery [9].
We wished to evaluate the efficacy of a nonpharmacological technique, acupressure, to alleviate
pre-operative anxiety. We evaluated the effect of
acupressure 30 min following its release. Usually, it
takes around 2030 min for a patient to be moved from
the pre-operative area to being anaesthetised. If the
anxiolytic effect of acupressure lasts for 30 min or more,
then there would be a calm and less anxious patient until
the time of induction of anaesthesia. This would avoid
the need for sedative premedication with its associated side-effects. BIS has been shown to correlate
with clinically assessed sedation levels and is useful
for differentiating adequate from inadequate sedation
[1315].
980

Fassoulaki et al. [5] applied acupressure for 10 min at

extra 1 point in 25 volunteers and observed a 50%
reduction in anxiety and BIS at the end of acupressure
application. In their study, BIS returned to the baseline
values 3 min after release of pressure. This study differed
from ours in various ways. Firstly, we applied acupressure
on patients who were undergoing elective surgical
procedures in contrast to healthy volunteers. Secondly,
we observed our patients for an additional 30 min after
release of pressure in contrast to 3 min in their study.
Thirdly, we applied acupressure for 10 min in both the
groups, whereas they could not apply pressure for more
than 5 min in the control group. Fassoulaki et al. have
also been criticised for their choice of control point
[16, 17]. The problem remains that there are no defined
effects and criteria for acupuncture points; every control
point may turn out to be another acupuncture point with
unknown side-effects.
We monitored anxiety after completion of 10 min of
acupressure application and 30 min following its release.
The reason for the reduction in BIS in the control
group may be due to the massage effect of pressure
application or to the fact that patients felt that something
was being done actively for their benefit.
To conclude, acupressure is effective in decreasing
both pre-operative anxiety and BIS; however, these
effects are not sustained 30 min following release of
acupressure. Further studies are needed to elucidate the
duration of acupressure efficacy in minimising preoperative anxiety.
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