An interventional study to assess the effectiveness of acupressure at SP6 point on dysmenorrhea among B.Sc Nursing students Esha Sharma, Avinash Kaur Rana, Amarjit Singh Abstract: Dysmenorrhea refers to the painful menstrual cramps of uterine origin. It is a common gynecological condition in women irrespective of age and nationality but most of the women do not seek treatment due to lack of knowledge and social stigma. So there is a need to prove the efficacy of non pharmacological intervention. Present study was conducted with an objective to assess the effectiveness of acupressure at SP 6 point on dysmenorrhea among nursing students of National Institute of Nursing Education, PGIMER, Chandigarh. The study design was pre experimental. Total 78 students were enrolled by total enumeration sampling technique. The study subjects received acupressure for 20 minutes at SP 6 point immediately when they reported moderate to severe pain episode. In this study, pre test pain score was obtained before giving intervention and then intervention ie. acupressure at SP 6 point was given for 20 minutes ( 10 minutes for each leg). The post intervention assessment of the severity of menstrual pain using Numerical Pain Rating Scale was done immediately, 1 hour, 2 hour and 3 hour after intervention. Dysmenorrhea was assessed by using Numerical Pain Rating Scale and Modified Menstrual Distress Questionnaire. Modified Menstrual Distress score was obtained before and 3 hours after the intervention. Analysis of the baseline and post intervention data was done at the end. The data was analyzed using descriptive and inferential statistics. Analysis was carried out with the help of statistical package for social sciences (SPSS-16) program. The findings were interpreted and presented with the help of tables and graphs. The results showed that there was significant difference in the mean pain score of Numerical Pain Rating Scale before intervention, immediately after, at 1 hour, at 2 hour and at 3 hour was 6.05, 4.05, 3.35, 2.68 and 2.24 respectively. Mean score of Modified Menstrual Distress Questionnaire was 24.65 before applying acupressure and after it was reduced to 9.98. The reapeated measure ANOVA was applied in subsequent observations determined statistically significant reduction in the severity of dysmenorrhea (p< 0.001). So, acupressure is an effective way in reducing dysmenorrhea. Keywords Introduction Dysmenorrhea, Acupressure, SP 6 point. Menstruation is a normal physiological phenomenon for females indicating her capability for procreation. However it is often associated with some degree of sufferings Correspondence at and embarrassment. The menstrual morbidities constitute an important area of Dr. Avinash Kaur Rana unmet need for reproductive health services Lecturer, for women in developing countries. About National Institute of Nursing Education 25-50% of adult women and roughly three PGIMER, Chandigarh Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 145 quarters of adolescents experiences some and nervousness. In Korea, 27–40% of girls pain with menstruation, with about 5-20% of in their late teen years complaining of women reporting severe dysmenorrhea or dysmenorrhea take analgesics repeatedly. pain that prevents them from participating in However, these drugs are only temporarily their usual activities.1 effective in relieving pain and may induce side effects, dependency, and unnecessary Dysmenorrhea is defined as painful medical costs. Furthermore, these drugs menstruation usually beginning during need to be taken repeatedly as their puberty. The term dysmenorrhea is derived concentrations in the blood decrease over from the Greek word dys meaning time. Complementary and alternative difficult/painful/abnormal, meno meaning therapies may be adopted as nursing month and rrhea meaning flow. It is also interventions to prevent and/or alleviate known as menstrual cramps; typically feel dysmenorrhea.5 like a dull pain in the lower abdomen before or during menstrual periods. The pain Recent research focusing on sometimes radiates to the low back or thigh complementary and alternative interventions area. Other symptoms may include nausea, for dysmenorrhea include the use of muscle loose stools, sweating, and dizziness. There relaxation therapy, magnetic therapy, are two types of dysmenorrhea: primary and reflexology, hand acupuncture, moxibustion secondary dysmenorrhea. Primary heat therapy, aroma therapy, acupuncture dysmenorrhea, which usually starts after and acupressure. Acupuncture and first menstrual period, involves no physical acupressure are based on traditional Chinese abnormality.2 Another variety of primary medicine and share the main principle of dysmenorrhea is membraneous opening and harmonizing an obstructed dysmenorrhea where there is casting of big meridian by stimulating surrounding pieces of endometrium. This is said to be run acupuncture points.5 in families.3 Secondary dysmenorrhea, on Experimental studies on acupressure the other hand, has an underlying physical and acupuncture have demonstrated their cause, such as endometriosis, pelvic effectiveness in alleviating discomfort inflammatory disease, uterine fibroids, or through sedative and analgesic effects. Many uterine polyps.3 studies have shown that acupuncture is Dysmenorrhea can decrease effective for pain relief in general and productivity, creativity, and work acupuncture of specific sites such as the SP6 performance due to serious daily stress and point has been reported to alleviate social and economic loss. In a study, dysmenorrhea. The SP6 acupoint is the dysmenorrhea accounted for 600 million lost junction point of the liver, spleen, and kidney work hours and $2 billion in lost productivity meridians, and it is proposed to strengthen annually.4 Beginning a few hours preceding the spleen, resolve and expel dampness, and and immediately after menstruation, restore balance to the Yin and blood, liver, dysmenorrhea typically lasts approximately and kidneys.6 48–72 hours and includes symptoms such The merit of utilizing acupressure as lower abdominal cramps, back pain, therapy as a nursing intervention has been nausea, vomiting, loss of appetite, fatigue, proposed in the literature as a non-invasive Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 146 measure that offers comparable effects to Chen HM et al assessed the effects of acupuncture therapy. Acupressure for acupressure at the Sanyinjiao point (SP6) on dysmenorrhea may offer women a non- symptoms of primary dysmenorrhea among invasive, cost-free, and timely way to adolescent girls. Thirty-one (87%) of the 35 manage dysmenorrhea on their own, thereby experimental participants reported that saving time, cost, and effort.6 Chen and Chen acupressure was helpful, and 33 (94%) were studied to compare between Hegu and satisfied with acupressure in terms of its Sanyinjiao matched points of acupressure providing pain relief and psychological and Hegu, Zusanli single acupressure point support during dysmenorrhea.9 Another on adolescent girls' menstrual distress, pain study by Mirbagher AN et al conducted a and anxiety perception. Hegu and randomized controlled pre and post-test Sanyinjiao(SP6) acupressure points reduced design was employed to verify the effects of the pain, distress and anxiety typical of SP6 acupressure on dysmenorrhea. Results dysmenorrhoea. Acupressure at single point shows significant differences were observed Hegu was found, effectively, to reduce in the scores of dysmenorrhea between the menstrual pain during the follow-up period, two groups immediately after and 3 h after but no significant difference was found in treatment.10 reducing menstrual distress and anxiety Gharlloghi S et.al studied to determine perception.Zusanli acupressure point had no the effects of acupressure at Sanyinjiao significant effects of reducing menstrual (SP6) point and DiJi (SP8) point on pain pain, distress and anxiety perception.7 severity of primary dysmenorrhea and the Another study done by Wong C et.al associated systemic symptoms. The evaluated the effects of Sanyinjiao (SP6) findings of study indicate that the severity of acupressure in reducing the pain level and dysmenorrhea pain diminished significantly menstrual distress resulting from for up to 2 hours following treatment with dysmenorrhea Results of study shows that acupressure at the SP6 and SP8 points (P< there was a statistically significant decrease 0.001). Furthermore, the severity of in pain score for Pain Visual Analogue Scale associated systemic symptoms reduced (p = 0.003) and SF-MPQ (p = 0.02) significantly after acupressure at the SP6 and immediately after the 20 min of SP6 SP8 points, except for nausea and acupressure during the initial intervention vomiting. 11 session. During self-care periods, In recent study (2012) done among participants were taught to perform the students of NINE, PGIMER, Chandigarh, technique for them to do twice a day from the showed the prevalence of dysmenorrhea was first to third days of their menstrual cycle, 3 87.5%12. It decreases productivity, creativity, months subsequent to the first session. and work performance due to serious daily Findings showed significant reduction of stress & a common cause of absenteeism in PVAS (p = 0.008), Short form-McGill Pain students. The common strategy used is over Questionnaire (p = 0.012), and Short form- the counter drugs but these drugs have many Menstrual Distress Questionnaire (p= 0.024) adverse effects. Moreover, it is a social scores was noted in the third month of post- stigma for the girls who wish to get medical intervention.8 Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 147 treatment for dysmenorrhea. So, there is a steps: Development of protocol for need to adopt risk free approach or non- acupressure and tools to collect data. The medicinal treatment which the girls can use tools for data collection were: identification in their homes/hostel. Complementary and performa, Numerical pain rating scale, Alternative therapies are proving to be very modified menstrual distress questionnaire. effective in providing natural pain relief The tools and protocol were developed during dysmenorrhea. Acupressure is one of through review of relevant literature and them. Evidence need to be created for such validated by experts from field of nursing, therapies and experimental design is a good Department of Public Health and Department design for this. There is a need to prove it. So, of Obstetrics and Gynecology. After this study is done for students who had moderate to severe dysmenorrhea validation of tool pilot study was conducted in NINE, PGIMER, Chandigarh for assessing Objectives feasibility of the study. Results of the pilot To assess the effectiveness of study indicated that study was feasible. acupressure on SP 6 point on dysmenorrhea The researcher was trained in among nursing student acupressure by professor of traditional Materials and Methods Chinese medicine for several sessions over a A pre experimental design was period of one month, studying the SP6 employed to study the effect of acupressure literature & participating in practicum at SP 6 point on dysmenorrhea among B.Sc sessions to identify SP6 acupoint and nursing students. Null hypothesis was practice acupressure techniques. After acupressure will not be helpful to reduce the extensive acupressure training, the intensity of pain among nursing students technique of providing acupressure was having dysmenorrhea at 0.05 level of checked with repeated manipulations to significance. The study was carried out in ensure that it would remain correct National Institute of Nursing Education throughout the treatment. After that the (NINE), PGIMER, Chandigarh. Study researcher was certified to perform the subjects were selected from the B.Sc acupressure. Nursing students residing in hostel. The Sample was selected by total target population comprised of all the B.Sc enumeration technique. Total 254 nursing Nursing students (18-23 yrs) residing in students were assessed for dysmenorrhea. hostel who had moderate and severe pain Out of them 95 students were enrolled and had regular periods between 21 to 35 having moderate (51) and severe (44) days during the month of August and dysmenorrhea by using Numerical rating September 2013. The permission from the pain score. Among them 17 subjects principal was sought for conducting study dropped and final sample consisted of 78 and hostel warden was informed. Ethical subjects. Data was collected in the month of Clearance was taken from Institute Ethical July and August 2013. Study subjects were Committee. The study was carried out in four selected on the basis of scoring of Numerical Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 148 Pain Rating Scale and only those students score was obtained by using Numerical pain with moderate and severe dysmenorrhea rating scale Then intervention i.e. were included after taking the written acupressure at SP 6 point was given for 20 informed consent. They were explained minutes ( 10 minutes for each leg). The post about the purpose of the study and were told intervention assessment of the severity of that data so collected will be kept confidential menstrual pain was done by using Numerical & will be used only for research purpose. pain rating scale immediately, 1 hour, 2 hour They were given full autonomy to participate and 3 hour after intervention. Modified in the study. After recruiting the subjects for Menstrual Distress score was obtained 3 the study, socio-demographic details were hours after the intervention. Analysis of the collected. Study subjects were traced & baseline and post intervention data was contacted telephonically around the date of done. The data was analysed using their last menstrual period and told to inform descriptive and inferential statistics. Analysis the researcher when they had dysmenorrhea. was carried out with the help of statistical package for social sciences (SPSS-16) The subjects were given identification program. The findings were interpreted and performa, Modified Menstrual Distress presented with the help of tables and graphs. questionnaire to obtain pre-test Modified Menstrual Distress score and pre-test pain Fig-1:Description of study population Assessedfor eligibility (n=254) Excluded (n=159) Nopain (n=38) Mild pain (n=116) Irregular menses(n=3) h/o Gynecologicaldisorder(n=2) Enrolled (n=95) • Moderate pain(n=51) • Severe pain(n=44) Drop outs(n=17) Analyzed (n=78) Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 149 Results Table 2. Variables showing menstrual characteristics of study subjects Table 1 showed that one third of the study N=78 subjects (30.8%) were 21 years old and 26.9% were 22 years old with the mean age Variables Frequency (%) of 20.9 ± 1.26 years and in age range of 18 to Age at Menarche (years) 23 years. · <12 years 04 (5.1) Table 1. Distribution of study subjects · 12-14 years 55 (70.5) according to age · >14 years 19 (24.4) Variables Frequency (%) *Mean age ± SD, Range:13.7 ± 1.306, 11-16 n=78 Length of menstrual cycle Age (years) · 21-25 days 06 (7.7) Ÿ 18 years 03( 3.8) · 26-30 days 57 (73.1) Ÿ 19 years 08(10.3) · 31-35 days 15 (19.2) Ÿ 20 years 15(19.2) *Mean ± SD, Ÿ 21 years 24(30.8) Range: 29.1 ± 2.391,24-35 Ÿ 22 years 21(26.9) Duration of menstrual cycle Ÿ · 1-3 days 14 (17.9) 23 years 07( 9.0) · 4-6 days 59 (75.6) *Mean age ± SD, Range: 20.9±1.262, 18-23 · >6 days 05 (6.4) *Mean ± SD, Variables showing menstrual Range: 4.6 ± 1.196, 2-7 characteristics of study subjects Amount of blood flow Table 2 depicts that the 70.5% of the · 1-2 pads/day 29(37.2) subjects attain menarche at the age of 12-14 · 3-4 pads/day 47(60.3) years with the mean age of 13.7± 1.306 years. Age of attaining monarche ranged · >4 pads/day 02(2.6) from 11 to 16 yrs. Length of menstrual cycle *Mean ± SD, was 26-30 days in 73.1 % of subjects with Range: 2.8 ± 0.822,1-5 pads mean length of 29.1± 1.19days. Length of menstrual cycle ranged from 24-35 days. Variables associated with dysmenorrhea 75.6% had duration of menstrual cycle of 4-6 Table 3 shows that 51.3% of the study days with mean duration of 4.52± 1.19 days subjects had menstrual pain that starts with and the amount of blood flow was 3-4 the onset of menstruation and 47.4% had pads/day in 60.3% of study subjects with onset of pain before menstruation. Most of mean amount of blood flow of 4.52± 0.822 them had pain that starts with onset of pads. menstruation and continues upto 48 hrs of menstruation and 42.3% had family history of dysmenorrhea. Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 150 Table 3. Variables associated with dysmenorrhea N=78 Variables Frequency (%) Onset of pain · Before menstruation 37 (47.4) · With onset of menstruation 40 (51.3) · After 24 hrs of menstruation 01 (1.3) Duration of pain · Starts before menstruation continues up to 24 hrs 24(30.8) of menstruation · Start with onset of menstruation continues up to 48 hours 40(51.3) · Start before menstruation and continues throughout 13(16.7) the menstruation · Starts after 24 hours and continues throughout 01(1.3) Family history of dysmenorrhea 33(42.3) Practices adopted to manage dysmen- medication, 15.4% use hot water bottle, 9% orrhea among subjects modified their diet including hot tea, 5.1% used diversional activities to relieve As shown in the figure 1, study subjects dysmenorrheal and rest ie. 15.4% used use different practices to manage combination of two or three therapies dysmenorrrhea ie. 29.5% took rest and lie on simultaneously. back, 25.6% took over the counter 29.5% 25.6% 30 25 15.4% 15.4% 20 15 9% 5.1% 10 5 0 H ot w ate rM ob doitftilce atio n of diet Lie oDin vbe ra sciko n alI natcatikvei toyf UOsTiCn gd rmu ogrse th a n o n e .. Fig 1: Practices adopted by subjects to manage dysmenorrhea Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 151 Severity of dysmenorrhea at different time dysmenorrhea. At 1 hour after the intervals as per Numerical Pain Rating intervention, 61.5% had mild and 37.2% had Scale among subjects moderate pain where as none of the subject had severe dysmenorrhea. Two hours after Table 4 depicts that before intervention the intervention, 9% had no pain, percentage all the subjects had moderate to severe of subjects in mild increases upto 70.5% and dysmenorrhea ie. 60.3% had moderate and only 20.5% had moderate dysmenorrhea. At 39.7% had severe dysmenorrhea but 3 hour of intervention, 14.1% had no pain, immediately after the intervention 1.3% had 71.8% had mild, 12.8% had moderate and no pain, 37.2% had mild, 60.3% had only 1.3% had severe pain. moderate and only 1.3% had severe Table 4 Severity of dysmenorrhea at different time intervals as per Numerical Pain Rating Scale among subjects Severity of dysmenorrhea as per After intervention Numerical Pain Before Immidiately 1 hour 2 hours 3 hours Rating Scale intervention(%) n(%) n(%) n(%) n(%) No pain ( 0) --- 1 (1.3) 1 (1.3) 7 (9.0) 11 (14.1) Mild pain (1-3) --- 29 (37.2) 48 (61.5) 55 (70.5) 56 (71.8) Moderate pain(4-6) 47 (60.3) 47 (60.3) 29 (37.2) 16 (20.5) 10 (12.8) Severe pain (7-10) 31 (39.7) 1 (1.3) --- --- 1 (1.3) Mean pain score before and immediately, but immediately after the intervention it was 1hour, 2hours, 3 hours follow up as per reduced to 4.05, 3.35 after 1 hour of Numerical Pain Rating Scale intervention, 2.68 after 2 hours and 2.24 after 3 hours of the intervention. Figure 2 shows the mean pain scores as per Numerical Pain Rating Scale. Before the intervention the mean pain score was 6.05 Numerical Pain Score N=78 7 6.05 6 e r co 5 S 4.05 n 4 ai 3.35 2.68 P 3 n 2.24 a 2 e M 1 0 Before Immediately At 1 hour of At 2 hour of At 3 hour of Intervention After Intervention Intervention Intervention Fig 2: Mean pain score before and after intervention according to MMDQ Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 152 Mean pain score of the subjects among all hour shows the mean difference of 2.705, consecutive observations as per Numerical 3.372 and 4.038 respectively with significant Pain rating Scale p value. Similarly, comparison of pain score immediately after intervention with the pain Table 5 depicts the comparison of mean score at 1 hour, at 2 hour and 3 hour showed pain score of numerical Pain Rating Scale of significant reduction in the severity of study subjects during subsequent dysmenorrhoea. Also significant difference observations. The mean pain score was observed between the pain score at difference between before and immediately 1hour with the pain score at 2 hour and 3 after intervention was 2.000 with significant hour. So, the comparison of all observation p value of <0.001. Further comparison of among themselves shows significant pain score immediately after intervention reduction of pain after each observation. with subsequent observations ie, immediately after, at 1 hour, at 2 hour and at 3 Table 5: A repeated measures ANOVA with mean pain score of the subjects among all consecutive observations as per Numerical Pain rating Scale Pain score Pain score Pain score Mean difference Std. Error p** value Before intervention: Immeditely after 2.000 0.121 < 0.001 At 1 hour 2.705 0.135 < 0.001 At 2 hour 3.372 0.154 < 0.001 At 3 hour 4.038 0.136 < 0.001 Immediately after: At 1 hour 0.705 0.097 < 0.001 At 2 hour 1.372 0.117 < 0.001 At 3 hour 2.038 0.133 < 0.001 At 1 hour: At 2 hour 0.667 0.091 < 0.001 At 3 hour 1.333 0.130 < 0.001 At 2 hour: At 3 hour - 0.669 0.118 < 0.001 ** Repeated Measure ANOVA (post hoc benforrni) Severity of dysmenorrhea before and after had severe dysmenorrheal. After the interventionas per Modified Menstrual intervention ie. acupressure at SP 6 point Distress Questionnaire among subjects most of the study subjects, i.e, 89.7% had mild, 9% had moderate, 1.3% had strong Table 6 depicts the score of Modified and none of subject had severe Menstrual Distress Questionnaire. Before dysmenorrhea. giving intervention 26.9% had mild, 57.7% had moderate, 14.1% had strong and 1.3% Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 153 Table 6. Severity of dysmenorrhea before and after interventionas per Modified Menstrual Distress Questionnaire among subjects Modified Menstrual Distress Before Intervention After Intervention Questionnaire n (%) n (%) Mild dysmenorrhea (1-18) 21 (26.9) 70 (24.4) Moderate dysmenorrhea (19-36) 45 (57.7) 7 (9.0) Strong dysmenorrhea (37-54) 11 (14.1) 1 (1.3) Severe dysmenorrhea (55-72) 1 (1.3) 0 (0) Comparison of mean scores before and 2.24±1.46. Paired t test showed that there after intervention as per Numerical Pain was significant difference in the mean pain Rating Scale (NRS) &Modified Menstrual score (p < 0.001). The mean score of MMDQ Distress Questionnaire (MMDQ) before and after intervention for dysmenorrhea was 24.65± 10.57 and 9.98 ± Table 7 infers the comparison of mean 6.17 respectively. Paired t test showed that pain score of before and after intervention. there was significant difference in the mean According to Numerical Pain Rating Scale score before intervention and after (NRS) pain score before intervention was intervention (p < 0.001). 6.05±1.23 and after it was reduced to Table 7. Comparison of mean scores before and after intervention as per Numerical Pain Rating Scale (NRS) &Modified Menstrual Distress Questionnaire (MMDQ) Pain Score Before Intervention After intervention t-value, df (Mean ± SD) (Mean ± SD) p* value NRS 6.05± 1.23 2.24± 1.46 22.36, 77 < 0.001 MMDQ 24.65± 10.57 9.99± 6.17 16.26, 77 <.0.001 * Paired t test Discussion using one's right hand for the left leg SP6 point and left hand for the right leg SP6 point, Acupressure for dysmenorrhea is a administering simultaneous pressure. natural way to relieve pain. It is safe, non- invasive, economical and cost free pain A randomised control trail conducted relieving technique. SP6 acupoint can by Chen and Chen (2010), determined that relieve dysmenorrhea. It can be self- acupressure was effective in reducing administered by sitting cross-legged and severity of dysmenorrhea when it was given Nursing and Midwifery Research Journal, Vol-10, No.4, October 2014 154