Qom University of Medical Sciences Journal

With the increase of life expectancy, the number of older patients visiting the urology outpatient clinics for the treatment of bladder stones, is gradually increasing. Since the 1980s, extracorporeal shock wave lithotripsy (ESWL) has been widely used in the treatment of bladder stones because of its non-invasiveness, low morbidity, and high efficacy. The preoperative period is one of the most stressful periods in the life of patients with bladder stones. They experience anxiety during ESWL. Anxiety can cause reduced patient tolerance and irregular respirations, leading to difficulty targeting the stone and preventing maximal energy delivery. Thus, failure in stone fragmentation can increase the duration of the procedure and patients may not accept further sessions because of having anxiety. Pharmacological and non-pharmacological methods are used to modify anxiety. One of the most common pharmacological methods is the use of benzodiazepines that cause transient changes but have some side effects; thus, different studies have been conducted in developing countries using non-pharmacological methods such as complementary medicine. Acupressure is one of these methods, in which pressure is applied to acupoints by fingers. It can increase the levels of dopamine, enkephalin, endorphin, and serotonin in the central nervous system, and induce relaxation. It is cost-effective and does not need specialized equipment. It is also a safe and non-invasive method that is easy to learn and apply. Since most patients get anxious due to injection, acupressure is a better method. Nurses play an important role in management of pain and anxiety for the patient. They are not only responsible for drug administration, but also can help patients manage their pain and anxiety using a variety of complementary therapies. This study aims to determine the impact of acupressure on anxiety in older women candidates for ESWL.
Methods
This randomized controlled clinical trial was performed on 66 eligible older women candidates for ESWL referred to Ordibehesht Surgical Center in Isfahan, Iran in 2021. They were selected by continuous sampling method and assigned to intervention and control groups by the block randomization method. Sixty minutes before ESWL, the researcher sat beside the patient on a chair and performed acupressure while they were lying on the bed. Acupressure intervention was applied on four points by thumb on both hands (First on the right hand and then on the left hand). The points were: LI4 (Large Intestine 4) located on the dorsum of the hand between the first and second metacarpal bones, radial to the midpoint of the second metacarpal bone, H7 (Heart7) located on the ulnar end of the distal wrist crease, on the medial side of flexor carpi ulnaris tendon, K1 (Kidney1) located on the sole of the foot in a depression created when the foot is in plantar flexion, at the junction of the anterior 1/3 and the posterior 2/3 of the line connecting the base of the second and third toes with the heel, and Lu7 (Lung7) located above the wrist on the inside of the arm. It was performed for 20 minutes in the intervention group, and repeated twice with an interval of 20 minutes. First the initial pressure was applied on the specific point; then, when the pulse was felt in the specific point, direct pressure was applied on the specific point, such that 1/3 of the nail bed became white and the patient felt tingling or warmth at that point. The correctness of pressure was determined when the patient felt warmth, heaviness, or numbness at that point. The reliability of the acupressure technique, selection of correct points, and amount of pressure was evaluated by an acupressure specialist. In this regard, the points to apply pressure were first selected by the researcher for 5 patients. Then, the specialist observed the accuracy of the selected points in each patient and and confirmed the amount of pressure applied on each point. In the control group, the points were only touched without any pressure. Data collection tools included a demographic form, Spielberger State-Trait Anxiety Inventory, and Visual Anxiety Scale (VAS). The anxiety was measured 60 minutes before and immediately after the intervention by a research assistant who was unaware of the group allocation. Data analysis was done by using descriptive and inferential statistics (Independent t-test, paired t-test, Chi-square test, and Mann-Whitney U test) in SPSS v.21 software.
Results
Mean age of participants was 71.83±6.04 years, 47.1% were illiterate, and 86.7% were married. The demographic characteristics of the two groups were similar. Before the intervention, there was no statistically significant difference between the two groups in anxiety (P>0.05). After the intervention, the mean severity of anxiety was 3.70±0.77 in the intervention group and 7.36±0.55 in the control group. The mean posttest quality of anxiety was 35.48±5.97 in the intervention group and 61.39±2.42 in the control group. There was a significant difference between the two groups (P<0.001).

Discussion
Acupressure is a safe and non-pharmacological intervention that can reduce the severity and quality of anxiety in older women candidates for ESWL.
Ethical Considerations
Compliance with ethical guidelines
This study has been approved by the ethics code of IR.SHAHED.REC.1400.09 in Shahed University.
Funding
This article is a part of Fariba Zia'i Azarkhavarani's master's thesis, which was approved by Shahid University's Research Vice-Chancellor and is its financial sponsor.
Authors contributions
Conceptualization, research and writing-main draft: Fariba Ziaei Azarkhavarani and Nahid Reje; Financing: Nahid Reje; Methodology, writing-review and editing, sources and supervision: all authors.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The researchers would like to thank all the older patients for their cooperation in the research.