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Anesth Analg 2003;97:1196-1197
© 2003 International Anesthesia Research Society

LETTERS TO THE EDITOR

Suggesting the Optimal Control Procedure for Acupressure Studies

Taras I. Usichenko, MD, and Dragan Pavlovic, MD

Anaesthesiology and Intensive Care Medicine Department, University of Greifswald, Greifswald, Germany

To the Editor:

Fassoulaki et al. deserve applause for their idea to test the sedative effect of Yintang acupuncture extraordinary point by means of bispectral index (BIS) in a crossover design (1). Despite this, the choice of control procedure and interpretation of the results need further discussion. From the very beginning of the study, the control procedure was not neutral towards the outcome measures and that could have influenced the stress score. Assuming that the "unpleasant feeling" produced by the pressure on the control point was painful, it was likely that the effect of that control procedure on BIS was nothing more than the effect of painful stimulus, an effect previously described under sedation (2). Moreover, according to the standard acupuncture topography, the described control point might have been the Taiyang acupuncture extraordinary point (3), which would influence the interpretation of the results.

To design an appropriate control for acupuncture studies seems to be more difficult than for pharmacological trials (4). For performing studies on specific effects of acupressure according to the accepted standards for randomized trials we suggest the following restrictions:

  1. The intensity of acupressure should be standardized. This could be achieved by using, for example, the elastic bands (5) and adjusting the "zero" pressure at the beginning of each treatment session, or by blinding of practitioners and applying acupressure below the pain threshold (6).
  2. The following control groups are necessary: nonintervention group, placebo acupressure (nonacupuncture point) and sham acupressure (inappropriate acupuncture point) groups.
  3. The control points should lie in the same dermatomes and have comparable density of innervation as the points for a true acupressure.

References

  1. Fassoulaki A, Paraskeva A, Patris K, et al. Pressure applied on the extra 1 acupuncture point reduces bispectral index values and stress in volunteers. Anesth Analg 2003; 96: 885–90.[Abstract/Free Full Text]
  2. Guignard B, Menigaux C, Dupont X, et al. The effect of remifentanil on the bispectral index change and hemodynamic responses after orotracheal intubation. Anesth Analg 2000; 90: 161–7.[Abstract/Free Full Text]
  3. Cheng Xinnong, ed. Chinese acupuncture and moxibustion. 1st ed. Beijing: Foreign Languages Press, 1987: 231–2.
  4. MacPherson H, White A, Cummings M, et al. Standards for reporting interventions in controlled trials of acupuncture: the STRICTA recommendations. J Altern Complement Med 2002; 8: 85–9.[ISI][Medline]
  5. Gieron C, Wieland B, von der Laage D, Tolksdorf W. Acupressure in the prevention of postoperative nausea and vomiting. Anaesthesist 1993; 42: 221–6.[ISI][Medline]
  6. Kober A, Scheck T, Greher M, et al. Prehospital analgesia with acupressure in victims of minor trauma: a prospective, randomized, double-blinded trial. Anesth Analg 2002; 95: 723–7.[Abstract/Free Full Text]
 

Response

Argyro Fassoulaki, MD PhD, DEAA

Department of Anesthesiology, Aretaieion Hospital, Athens, Greece

In Response:

A control point cannot be neutral, nor a placebo effect is neutral. Both BIS values and verbal sedation scores were reduced during treatment of the control point, but significantly less when compared with the Extra 1 point (1). Pressure application on several points, though not pleasant, depending upon the degree of pressure, is not necessarily painful. As explained in the letter addressing Dr. Chernyak’s comments, the control point we applied pressure on lies above the Taiyang acupuncture point, not on this acupuncture point.

1. Drs. Usichenko and Pavlovic suggest that the intensity of acupressure should be standardized. It would be nice to conduct the study using a device, like elastic bands or a device applying current. However, to proceed to a construction of such a device is more logical after demonstrating that pressure on the Yintang point is associated with a pleasant and antistress effect. Applying pressure below the pain threshold is not necessarily the same pressure to all volunteers, as the pain threshold varies from person to person.

2. I agree regarding the inclusion of a nonintervention group. However, regarding the nonacupuncture and the inappropriate acupuncture points, the control point in this study was selected to be close to the BIS sensor, so that possible interference with the BIS sensor would be observed in both the treatment and the control group. This interference problem does not exist in the classic acupuncture studies.

3. The selection of the control points in our study is subjected to the limitations mentioned above. I do not believe that comparable density of innervation is a prerequisite for the control points. First, it is difficult to demonstrate this "comparable density," and second, acupuncture points are points with a high density of innervation. Thus searching such control points may end up to undetermined or undiscovered new acupuncture points. Besides, density of innervation is a matter of quantity, but the type of nerve terminals is also important.

Reference

  1. Fassoulaki A, Paraskeva A, Patris K, et al. Pressure applied on the extra 1 acupuncture point reduces bispectral index values and stress in volunteers. Anesth Analg 2003; 96: 885–90.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press