This Invited Commentary accompanies the following original article:
Noll E, Shodhan S, Romeiser JL, et al. Efficacy of acupressure on quality of recovery after surgery. Randomised controlled trial. Eur J Anaesthesiol 2019; 36:557–565.
The prevention of postoperative complications is a major focus for peri-operative medicine physicians.1 Improving the peri-operative period for the 300 million patients undergoing a surgical procedure every year worldwide is a major public health challenge.2,3
Recently, additional dimensions of patients’ postoperative health have been the object of interest and more attention has been paid to patient-reported quality of recovery.4–6 As opposed to the usual sole medical assessment, patient-reported quality of recovery corresponds to the self-evaluation of several aspects of postoperative recovery according to the patient's own perspective.
Monitoring of postoperative quality of recovery is complementary to the prevention and treatment of postoperative complications. One interesting feature of the self-evaluation of patients’ quality of recovery is that it involves all patients in the postoperative period and not only the subgroup of patients who develop a complication. By association, postoperative quality of recovery and complications are correlated5; however, treatments may affect these dimensions differently, and their perception by the patient may vary.
In this issue of the European Journal of Anaesthesiology, Noll et al. report the results of a randomised controlled trial studying acupoint stimulation by manual pressure (described as acupressure) with respect to its influence on the quality of recovery.12 The scientific rationale for such an influence relies on neurophysiology studies suggesting that stimulation of acupoints may induce modulation of spinal and cerebral neurotransmission,7 with potential positive effects on symptoms that impair the recovery phase, for example pain8 or emesis.9–11 However, few studies have focused on acupressure as a tool for enhancement of the quality of recovery.
For the reader concerned about peri-operative quality of recovery, the study by Noll et al., despite being negative on its primary endpoint, offers several interesting points. Firstly, the monitoring of the postoperative quality of recovery was with the QoR-15 scale. This 15-question scale has been psychometrically validated to reflect important dimensions from the point of view of the postoperative patient.5 These dimensions include physical comfort, physical independence, psychological support and emotional state. Each question is scored from 0 to 10 leading to a total score ranging from 0 to 150 (the latter number representing an ideal health status). This scale has recently been praised by the American Society for Enhanced Recovery as a ‘responsive and validated’ tool for monitoring the quality of recovery in enhanced recovery programmes.4 The results from the study by Noll et al. suggest that the quality of recovery as evaluated with the QoR-15 scale is different from patient satisfaction. The changes in the QoR-15 scores between postoperative days 1 and 3 were not statistically different between study groups, whereas the global patient satisfaction scores were different across study groups.
Secondly, this study also stresses the importance of staff interaction with the patients. The study7 included three groups: a control group with no visit from staff, a sham group (with staff involvement) applying light touch to the acupoints and the experimental acupressure group (with staff involvement). Compared with the no visit group, patient satisfaction was higher in the sham group. Although for some, the observed effects may simply represent the well known ‘placebo-effect’, it may also highlight the fact that patients being cared for with a personal interaction with staff usually feel better and express a higher level of satisfaction with a given treatment when compared with less staff interaction. As there is still no clear consensus on the optimal control group for acupoint stimulation studies,13 further research in the field should take these data into account.
Thirdly, this study illustrates an interesting application of technologically enhanced simulation to improve internal (and external) validity of studies focusing on manual pressure application. The investigators involved in acupressure interventions first underwent a simulation-based training plan14 aimed at standardising the amount of force applied for acupressure and sham interventions, respectively. Proficiency was confirmed at an individual level with the cumulative sum (CUSUM) statistical approach.
In conclusion, the study reported by Noll et al. is an original step towards assessing acupressure therapy for postoperative quality of recovery. Despite being negative, this study has to be considered as an interesting example of modern evidence-based medicine assessing traditional complementary medicine.
Acknowledgements relating to this article
Assistance with the Invited Commentary: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Comment from the Editor: this Invited Commentary was checked by the editors but was not sent for external peer review. PD is an Associate Editor of the European Journal of Anaesthesiology.
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