Effect of acupuncture on short-term pain after standard thoracotomy

Fei-Xiang Ma,Ya-Jun Zhang,Wan-Lang Li,Yun-Lan Huang,Tian-Tian Yuan

1Rehabilitation Department of Yancheng Third People's Hospital, Yancheng 224005, China. 2Cardiothoracic Surgery Department of Yancheng Third People's Hospital,Yancheng 224005,China.

Abstract

Keywords: Perioperative period, Postoperative pain, Post-operative pain syndrome, Rapid rehabilitation surgery,Standard median sternotomy

Background

Standard sternotomy with median incision is widely used in cardiothoracic surgery because of its good exposure of heart, lung, blood vessels, pleural cavity,anterior mediastinum and other fields of vision,as well as its advantages of short operation time, high safety and fast healing. However, in clinical practice, many patients who accept the operation have various types of pain sequelae around the incision, part of ribs or acromioclavicular joint, in different degrees within one week to six months after the operation. Previous reports show [1] that the incidence of such pain is as high as 25%-60%, seriously affecting the quality of life and surgical satisfaction of patients.

Although more and more clinicians begin to pay attention to the prevention and treatment of postoperative pain after thoracotomy, most of the patients still have the sequelae of repeated pain at the operation site 2 months later due to the individual pain difference of the patients,the disparity of the operation level of the doctors, the enthusiasm of the treatment measures, the comprehensive treatment methods and other factors. At present, most of the literature reports on the prevention and treatment of pain after thoracotomy [3, 4] show that the improvement of surgical technology,the selection of narcotic drugs and anesthesia methods, the oral administration of postoperative analgesic drugs, psychological counseling, general nursing, family rehabilitation exercise and other methods are all of good use.

At the same time, many previous literature and research results [5-8] also show that pain after thoracotomy may be related to intercostal nerve injury,nerve sensitization, tumor recurrence, local or central inflammation, soft tissue injury, myofascial pain syndrome, rib fracture or bone fracture, psychogenic factors and other factors. So most of the clinical treatment methods are based on postoperative analgesia, and there is no other treatment. There are some defects, such as the treatment of the root cause,the short time of analgesia, the serious adverse reactions of analgesics (such as gastrointestinal bleeding induced by anticoagulants after operation).Some of the new preoperative interventions or anesthesia methods are difficult for the cooperation,safety and effectiveness of the inherent team in the basic hospital to upgrade in a short period of time.Therefore, it is very important to find out a treatment method which is based on the regional medical level and can effectively solve the patients'demands.

In the early stage of our team, acupuncture assisted analgesia after thoracotomy was taken as the direction,and it was found that the incidence of postoperative pain was significantly reduced after acupuncture intervention. Later, under the multi-disciplinary cooperation mechanism in the hospital, combined with the thought of “treat only those not sick” of traditional Chinese medicine and the concept of acupuncture exceeding the previous pain control [9], through several years of clinical trial and summary,it gradually transited to the perioperative period, i.e. acupuncture treatment before and after the operation at different times.This method is simple and easy to popularize. It can reduce the sensitivity of peripheral and central nervous system, prevent the peripheral pain impulse from transmitting to the center, so as to reduce the incidence of postoperative pain, the level of pain and the dosage of analgesics, improve the quality of life of patients,and obtain better clinical and social benefits.

Materials and methods

Patients

The patients in this study were those who underwent standard midsternal incision thoracotomy in the department of thoracic surgery of the Yancheng Third People's Hospital from January 2017 to June 2019.The study was approved by the ethics committee of the hospital and the informed consent forms were obtained from these patients.

Inclusion criteria

①Patients who chose standard median sternotomy; ②between 18 and 70 years old; ③normal intelligence,able to cooperate with numeric rating scale (NRS)evaluation and pain intervention; ④ no tumor metastasis, no history of chronic chest and flank pain and no history of long-term use of painkillers; ⑤patients who signed informed consent form,voluntarily participated in this study and approved by the ethics committee of our hospital.

Exclusion criteria

①Serious complications such as atelectasis,empyema,pulmonary infection, cardio cerebrovascular accident occurred after operation; ②cases of dropout and loss of union; ③patients who could not cooperate with treatment or examination before or after operation; ④patients who could not cooperate with NRS evaluation after admission education; ⑤patients who did not meet the requirements such as age.

Treatments

Control group.After the pre-operative preparation,all patients adopted the standard sternal median incision thoracotomy under the unified anesthesia method.Then they received observation in the ICU for 72 hours after operation.After that, they were transferred to the general ward. According to the degree of pain, they were given analgesic drugs or analgesic pump.Meanwhile, the patients should be treated with anti-inflammatory, nutritional support, prevention of complications and other basic drugs. The patients should be encouraged and instructed to carry out cough breathing training, cardiopulmonary function training and early adaptive living self-care level training.After the patient's condition was stable, the drainage tube was removed, the suture was removed and discharged,and then the community hospital or family continued treatment and regular follow-up.

Acupuncture group. The basic treatment before and after operation and the intervention measures such as anesthesia and operation mode were completely the same as the control group. The difference was that the patients in this group received ten times of acupuncture therapy in three days before operation and one week after operation. Acupoints selected by acupuncture were as follows: the second and fourth rib spaces beside the sternum, Zhongfu (LU 1), Qihu (ST 13),Shenmen (HT 7), Hegu (LI 4), Zusanli (ST 36) and Yanglingquan (GB 34), all of which were selected from both sides. According to the depth of acupoints and the degree of obesity,0.25* 25 mm and 0.25* 40 mm disposable sterile acupuncture needles (Dongbang brand, China) were used for acupuncture treatment.Among them, the second and fourth intercostal spaces adjacent to the sternum were treated with flat needling,and the tip of the needle pointed to the incision of the sternal stalk.After the selected acupoints are sterilized,the needle is quickly inserted and the air is obtained by the needle, and then the twirling and rotation of the needle is performed for 5 to 10 seconds. Keep the needle for half an hour. During this period, the needle should be used every ten minutes. The degree of local pain is acid,numbness,distention and pain.

Observation indicators

①The patients were evaluated with NRS score on the first day before operation, the first day after operation,the second day after operation, the 10th day after operation and the 30th day after operation (telephone follow-up). The assessment was carried out by a professional trained physician. The assessment time was before the patient applied analgesic drugs on the day, and the actual implementation time was completed during the morning rounds between 8 and 9 am on the day. In NRS, 0-10 represents different degrees of pain, 0 represents no pain, 10 represents severe pain. ② The incidence of postoperative complications was compared between the two groups,such as secondary hemothorax, arrhythmia, atelectasis,empyema, infection, depression, mood fluctuation,lower extremity venous thrombosis and so on.

Statistical methods

In this paper, SPSS 23.0 statistical software was used for data analysis. According to data type, Chi square test was selected for counting data, and mean ±standard deviation (± S) is used for measuring data.For the measurement data, the homogeneity of variance was tested,and two independent sample t-test was selected if the data was consistent with the normal distribution and the homogeneity of variance. For those that were inconsistent, we tested the Mann Whitney u-rank sum. The statistical analysis of the data between the two samples in this project was in accordance with the t-test of two independent samples.The paired t-test method was used for the statistical analysis of the same sample before and after the control,and the test level was α=0.05.

Results

General information

From January 2017 to June 2019, 60 patients were included in this study, including 38 males and 22 females. After admission, patients were randomly selected an opaque envelope containing random numbers,and divided into acupuncture group(32 cases)and control group (28 cases) according to the random number grouping requirements. In the actual research process, 1 case in the acupuncture group had serious postoperative complications (pulmonary infection), 1 case lost follow-up (returned to the original place), 1 case in the control group intervened in other postoperative analgesia methods(costal nerve block),a total of 3 cases quit the study, and 57 cases were included in the statistics. There was no difference between the two groups in terms of age,gender,weight and other general information(Table 1).

Comparison of postoperative monitoring data of patients

It can be seen from Table 2 that there was no significant difference in pain score between the two groups on the first day before and after the operation,indicating that the pain level of the two groups was similar during the application of analgesia treatment before and after the operation (the first day after the operation). However, on the 2nd, 10th and 30th day after operation, there was significant difference in pain score between the two groups. At the same time, the pain score of patients in the acupuncture group was lower than that in the control group, and the pain degree of patients in the acupuncture group was lighter than that the control group in the short term (one month after operation), indicating that the perioperative acupuncture treatment could reduce the pain course of surgical incision in the short term degree.

Comparison of postoperative complications

In the whole research stage, thanks to the cooperation of multidisciplinary teams such as thoracic surgery,anesthesiology, nursing, ICU, pain department and acupuncture department, the patients in both groups were in stable condition, and no obvious postoperative adverse reactions were found.Among them, 3 patients developed secondary postoperative depression, which was nearly cured by special treatment.

Table 1 Comparison of general data of patients in acupuncture group and control group

Table 2 Comparison of clinical monitoring data of patients

Discussion

Pain after thoracotomy [10] is a common and serious postoperative complication of thoracic surgery.According to the statistics of pain diary of patients,almost all patients complained of pain in the relevant parts of the operation after anesthesia. This kind of pain is one of the most serious pain problems after surgery. Its particularity [4] lies in that it can lead to various serious complications. The most common one is the post-operative pain syndrome, also known as chronic post-operative pain, which refers to the post-operative pain of patients after thoracotomy.When the mouth has healed,the pain symptoms around the incision, shoulder and other parts persist for more than 2 months or recur.

Due to the disunity of the definition criteria and other reasons, the existing literature has a large difference in the incidence of pain after thoracotomy,ranging from 5% to 65%, and most reports are about 50% [11]. However, in our work, we found that patients with standard median sternotomy had a high degree of postoperative pain and incidence, for unknown reasons. The pain sites of the patients were all around the sternal incision, the anterior area of the shoulders, the anterior chest and so on. The nature of the pain was mainly dull pain,acupuncture like pain or burning pain, which lasted for a month or even several years. Induced or aggravated by coughing, weather changes,upper limb activities, emotional changes,etc.,have a great impact on patients'postoperative life[12].Some patients even suffer from depression, anxiety,fear, autism and other psychological or behavioral abnormalities. On a certain level, it has a certain negative impact on the satisfaction and clinical promotion of standard sternotomy. Therefore, the pain after thoracotomy has attracted a lot of attention of clinical workers,and the research on the mechanism of postoperative pain [2, 4] and prevention scheme [11,13-15]has been emerging.

Pain is one of the common diseases in acupuncture and moxibustion, and also one of the dominant diseases in Chinese medicine.As early as in the era ofHuangdi Neijing(Yellow Emperor's Canon of Internal Classic; 221 B.C.E.-220 C.E.), ancient doctors [16]had a profound study on the treatment of pain. In modern acupuncture clinic, acupuncture analgesia has also been widely used. For example, Jiang's [17]research shows that for Ashi point and Jiaji point, the use of Hui acupuncture and bloodletting therapy can better treat myofascial pain syndrome. Zhu [18]believed that acupuncture analgesia not only lies in postoperative analgesia,but also has a certain effect on preoperative nerve regulation and neurotransmitter conduction. Fang's [19] confirmed the feasibility of acupuncture participating in multidimensional regulation of pain, and proposed that acupuncture analgesia not only lies in emotional dimension, but also exists in the cognitive dimension of intervention pain.

In this study, we selected Ashi acupoint, Zhongfu(LU 1), Qihu (ST 13) and other local points, such as the second, fourth costal space beside the sternum,which are all prone to pain after thoracotomy. We speculate that the perioperative local acupuncture treatment of pain prone areas can improve the pain threshold of these areas, so as to reduce the incidence and degree of postoperative pain.At the same time, in view of the theory that “all pain and itch sores belong to the heart”, “the diseases of five internal organs can be treated by twelve Yuan-source points” and “Shu acupoints predominate the weight and pain of the body”, we selected Shenmen (HT 7) point to calm the heart and keep the spirit, tonify the heart and replenish the Qi. At the same time, Hegu (LI 4) point and Zusanli (ST 36) point are combined to regulate the gastrointestinal tract in order to maintain the healthy Qi and blood; because “Yanglingquan (GB 34) is the place where the tendons meet” and “Yanglingquan(GB 34) is the only place where the hypochondriac pain occurs”, Yanglingquan (GB 34) point is used to regulate the tendons and calm the liver,relieve the pain in a slow and urgent way. The combination of acupoints can regulate Qi and blood, dredge channels and collaterals,and nourish muscles and muscles,so as to reduce the degree of postoperative pain in a short time.

Analysis of the results of this study shows that there is no difference in the level of preoperative pain, the length of operation and the length of incision, which conforms to the principle of consistent inclusion criteria. The pain level of the two groups was not statistically significant because most patients used analgesics on the first day after operation.However,on the 2nd, 10th and 30th day after operation, the pain level of the acupuncture group was lower than that of the control group, indicating that the perioperative acupuncture treatment had a significant effect on the short-term acupuncture analgesia of patients undergoing thoracotomy through anterior midline incision (Pvalues are 0.01, 0.02 and 0.01,respectively).

The purpose of this study is to explore the effect of perioperative acupuncture on postoperative analgesia in a randomized controlled clinical study. The results show that perioperative acupuncture has a significant clinical effect on postoperative analgesia in a short period of time, and it has clinical guiding significance for improving the quality of life of patients and accelerating postoperative rehabilitation.However,due to the factors such as low recurrence rate, insufficient funding and insufficient medical follow-up staff, we did not conduct in-depth study on the effect of longer-term analgesia over one month. At the same time, due to the limited depth of scientific research in basic hospitals, we have not been able to further explore the mechanism of perioperative acupuncture on postoperative pain from objective indicators and pain transmission mechanism. Here, we are willing to do more work, looking forward to colleagues to do more long-term, more systematic and more scientific research, to explore the mechanism of pain and analgesia after thoracotomy,so as to better relieve pain for patients.