1

The Effect of Acupressure on GCS Value of Moderate Head Injury Patients

in Hasan Sadikin Hospital Bandung

Iwan Purnawan, M.Kep., Ns1, Hartiah Haroen, S.Kp. M.Kes. M.Ng2, Cecep Eli Kosasih,
S.Kp. M.NS3

1
Lecturer. Emergency Nursing Division, Faculty.of Medical and Health Science, University of
Jenderal Soedirman. Central Java, Indonesia Lect

2,3
Lecturer. Faculty of Nursing. Universitas Padjajaran. Bandung, West Java, Indonesia

Corespondence: purnawan08@gmail.com

ABSTRACT

Background: Impairment of consciousness in head injury that is measured

objectively by Glasgow Comma Scale is one of prognosis determinants and
severity indicators. Several studies have shown that stimulation of acupressure can
provide neuroprotective effect that prevents damage to brain cells from ischemic
injury. This study aims to identify the effect of acupressure on the value of GCS in
patients with head injuries in the Hospital of dr. Hasan Sadikin Bandung.
Method:The type of this study was quasy experimental that used pre test and post
test control group design. Sampling was done randomly. The number of samples in
this study was 37 respondents who were divided into two groups, namely the control
group (16 respondents) and intervention group (21 respondents). Besides having
standard therapy, the intervention group also got therapy of acupressure for 5
minutes in 3 days. On the other group, the control group only got standard therapy.
GCS assessment was conducted on the first day prior to acupressure and on the
third day after administration of acupressure. The differences of GCS score in the
control group and the intervention group were analyzed with the Wilcoxon test. The
differences of the increase of the GCS average of the control group and intervention
group were analyzed by using Mann Whitney test.Result finding: The results of
statistical tests showed significant difference of the average value of GCS both
before and after treatment in those two groups, namely: in the control group
(p=0.07) and the intervention (p = 0.01). However, the increase of the GCS average
value of the intervention group was higher than the control group. This was
evidenced by the p-value on Mann Whitney test of 0.037 (p <0.05). The effect of
acupressure on the GCS value was shown through the inhibition of the side effects
of standard therapy and the addition of variety of neuro protective mechanism of
the acupressure therapy itself. Conclusion: The stimulation acupresure point has
significant effect in increasing GCS at moderate head injury patients.

Keywords: acupressure, decreased consciousness, moderate head injury

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PREFACE

Humans is beings bio, psycho, socio-spiritual and unique. Therefore,

biological needs, psychological, social, and spiritual moment for the healthy and

sick individuals are things that must be considered. Thus, comprehensive health

care or holistic become a necessity. This holistic treatment model considers that the

psychosomatic component, biological, psychological, social, and spiritual influence

of the condition and the symptoms of the patient's illness (Dossey, Keegan, &

Guzzeta, 2006).

One of independent nursing intervention that uses a holistic model approach

is acupressure. This modality therapy using finger or thumb pressure on specific

points along the energy meridians of the body with the aim of lowering the tension,

stabilize energy flow along the meridians and restore balance to the human energy

system (Dossey, Keegan, & Guzzeta 2006

cupressure therapy has been known since hundreds of years ago as a way to

deal with various health problems, such as pain, digestive disorders, and others.

Several recent studies show some benefits of acupoint stimulation points include:

preventing postoperative nausea and vomiting (Abraham, J 2008), decrease pain

(Taguchi, R, 2007), as well as a variety of neurological disorders (Parker, JN &

Parker, PM 2004; Lyeth & Hayes, 1992; Society for Neuroscience, 2010; &

Hernandez dkk, 2010)

One cause of neurological problems manifested by disturbance of

consciousness is a head injury. The level of self-awareness is one of the indicators

of severity and prognosis in head injury. Decrease the intake of oxygen and
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nutrients to the brain in head injury, in addition to the damage caused by the primary

(physical impact, cerebral edema, and increased intracranial pressure), also due to

secondary damage (ischemia) (Blank-Reid & Reid, 2000; & Porth, 2002).

Cortisol secretion in head injury triggers capillary cerebral vasospasm is an

indication of damage to the brain cells. Besides cortisol, stimulation of the

sympathetic nervous system also triggers the adrenal glands secrete epinephrine and

glucagon production by the pancreas. Spending both these hormones lead to

increased catabolism of the brain, which in turn was followed by an increase in

oxygen demand. Fulfillment inadequate oxygen, can cause ischemia and death of

brain tissue (Markam, Atmaja, and Budijanto, 1999).

Numbers of deaths worldwide due to head injuries has reached 1,095,777

people. While in Indonesia, the number of deaths from head injuries placing ranked

3rd in the world, reaching 37 438 people (WHO, 2011).

One of patient's state of consciousness assessment tool most widely used is

the Glasgow Coma Scale (GCS). GCS was developed primarily to facilitate the

assessment and recording accurately the severity of cerebral dysfunction. (Jennett,

2005).

Loss of consciousness in addition to showing the extent of damage of brain

tissue, also puts the sufferer in a very vulnerable condition. When a patient begins

to experience loss of consciousness, he will lose the ability to defend themselves

against the threat of the surrounding environment. Closing of the airway by the

tongue falling and aspiration of gastric contents is most danger faced by patients

with panurunan consciousness. (Butcher, L & Melander, S 1999).

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Medical interventions to improve perfusion to the brain which hopefully will

be able to restore the patient's level of consciousness include: airway management

, hyperventilation , fluid resuscitation , hemodynamic maintenance , and setting

position . While the pharmacological management is divided into two for the

handling of increased intracranial pressure and brain injury treatment of

pathological conditions that include anticonvulsants and neuroprotectan ( Butcher

& Melander , 1999) . Preliminary studies in the Neuro Critical Care Unit ( NCCU

) showed that standard pharmacologic therapy in patients with head injury include

: dexametason , mannitol , and piracetam . While other supporting therapies include

: ceftriaxon , ranitidine , cetorolax , calnex , vitamin K , and Oxygen . Also

according to Beauchamp K et al (2008 ) on the pharmacological therapy of head

injury include : Glutamate ( NMDA ) receptor antagonists , Corticosteroids ,

Aminosteroids , Monoaminergic substances , Cyclosporine , and Ca - channel

blockers . The use of pharmacological drugs , in addition to preventing and

repairing damage to brain cells caused by head injury , it can also cause side effects

that have a negative impact on some patients . Piracetam for example , including

the type of nootropic drugs and neurotonnic besides fixing cerebral dysfunction , it

is also associated with various conditions such as: insomnia , anxiety , agitation ,

fatigue , gastrointestinal disorders , and so on . Thus non - pharmacologic therapy

as a complementary therapy for effective pharmacological therapy without adverse

side effects is indispensable ( Santoso , A et al , 2008) .

Various measures of nursing care that have been developed to help improve

patient awareness, among others: oxygenation, position control, sound and touch
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stimulation (Muttaqin, 2008; Leigh et al., 2001). One type of therapeutic touch

(Touch Therapy) is acupressure (Tiffany, F 2003)

Effect of acupoint stimulation to repair brain injury either by using

acupressure and acupuncture have been carried out and shown to provide beneficial

effects. Research Hernandez et al (2010), found that acupressure is performed in

patients with head injury can trigger the relaxation response are bigger and faster

and lower stress responses, compared with the control group. This condition is

associated with improved memory function better in patients who received post-

trauma head acupressure intervention.

Laboratory tests to determine the efficacy of stimulation of acupressure points

against brain ischemia and exploration of the molecular mechanisms of the various

approaches have been done . The study shows that stimulation of the acupoint prefix

significantly decreased the infarct size in the ischemic cortex and striatum .

Research on the electrical activity of the brain using an electroencephalograph

showed that acupoint stimulation somatosensory spur recovery . Based on this

allegation that acupoint stimulation is an effective strategy to protect the brain

damage caused by ischemia . While other studies in laboratory suspected that the

delta - opioid receptor ( DOR ) protects neurons against hypoxic injury and this

may be related to stress tolerance . Stimulation of the acupoint regulate brain opioid

activity . Cortex and striatum has a high density with DOR in the brain . So there is

the possibility of DOR is attached to the brain protective effect against cerebral

ischemia ( Parker , JN and Parker , AM 2004) .

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Preliminary studies conducted in the Neuro Critical Care Unit (NCCU)

General Hospital Hasan Sadikin, shows that from May 2010 - April 2011 the

average number of head injury patients every month to reach 35 people. Type of

head injury that belong to the big 4 include: Subdural hematoma (22.93%),

Intracranial hematoma (18.78), epidural hematoma (18.78), and Scull Fracture

Basic (7.32).

Various evidence base regarding acupressuree, indicates that this action is one

of the non-pharmacologic therapies are proven to provide many benefits to the

recovery process head injury (Hernandez et al, 2010; Society for Neuroscience,

2010; Uchida S & H Hotta, 2008;, and Parker, JM & Parker, PM 2004).

METHODS

The design of this study using Quasi Experimental design , with pretest - posttest

approach Control Group Design . The sample was mostly moderate head injury

patients with simple random sampling technique . Determination of the number of

samples is done by using the formula of the samples in the two population average

( Sastroasmoro & Ismael , 2002) , based on the research results of Hernandez et al

(2008 ) , and then put into the formula , the result of 15 respondents for each group

. However, based on the Table of Random Numbers ( Peacock , SJ 1986) , then

gained 16 respondents to the treatment group and 21 respondents to the control

group . Inclusion criteria include : having a GCS score 9-13 , the patient's family is

willing to be the respondent , and get treatment at least 3 days . While esklusinya

criteria include : patient ventilator mounted , attached endotracheal tube / tube

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tracheostomi , tersedasi patients , restlessness , dyspnoea , agitation , get craniotomy

, has a head tumor , diagnosed encepalitis and or meningitis , and there is trauma or

injury to the acupuncture point PC 6 and or ST 36 .

The research instrument used as an intervention tool used is a cream lotion on

acupressure points for the convenience of respondents and prevents abrasion due to

acupressure.

Every head injury patients treated at NCCU, Kemuning Space, and Space Kana

be selected according to criteria penentukan respondent if the respondent entered

into a treatment group and contrast or referring to the Table of Random Numbers is

then performed informed consent. Initial GCS measurement (pre-test) in the

treatment group performed before the standard combination therapy of acupressure

(post-test). Similarly, the control group who only get standard therapy, GCS

measurements performed on the first and third day of the study.

Analysis of data normality test begins with Shapiro Wilk test and test different

characteristics of respondents with Fisher's Exact. GCS score difference before and

after treatment in both the control group and the treatment group using the

Wilcoxon test because the data are not normally distributed. As for knowing the

difference GCS increased value in the control group and the treatment group using

the Mann Whitney test because the data were not normally distributed.
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RESULTS

Characteristics of Respondents

The results of the analysis that describes the characteristics of respondents

by age, sex, and type of head injury between the control group and the treatment

group are presented in Table 1

Tabel 1 Characteristics of Respondents

Characteristics Group
Treatment (%) Control (%) P
Sex :
- Perempuan 1 (6,25) 2 (9,52) 1,000
- Laki-laki 15 (93,75) 19 (90,47)
Age (years)::
- 10-21 4 (25,0) 8 (38,1)
- 21-30 6 (37,5) 5 (23,8)
- 31-40 3 (18,8) 5 (23,8) 0,756
- 41-50 2 (12,5) 2 (9,5)
- 51-60 0 1 (4,8)
- 61-70 1 (6,3) 0
Head Injury Type
- Subdural hematoma 6 (28,6) 5 (31,3)
- Epidural hematom 3 (14,3) 2 (12,5)
- Sub Arachnoid Bleeding 3 (14,3) 2 (12,5)
- Scull Based Fracture
- Clossed Fracture 5 (13,5) 4 (25,0) 0,514
Diastase Suture
- Intracranial hematom 3 (8,1) 2 (12,5)
1 (6,3)
1 (2,7)

Table 4.1. Fisher Exact test shows performed on variables of age, gender,
and type of head injury get nilap P> 0.05. This implies that the third variable in the
control and treatment groups were homogeneous
While the results of the analysis of the characteristics of respondents GCS
values can be seen in Table 2.
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Table 2. Distribution and Frequency Value GCS Pre Test and Post Test
between the control group and the treatment group
Control Treatment
Value GCS
Pre-Test Post-Test Pre-Test Post-Test
n % N % n % n %
8 0 0 1 4,7 0 0 0 0
9 5 23,8 2 9,5 9 56,2 1 6,25
10 3 14,2 4 19,0 2 12,5 4 25,0
11 5 23,8 4 19,0 3 18,7 0 0
12 8 38,0 0 0 2 12,5 3 18,7
13 0 0 3 14,2 0 0 1 6,25
14 0 0 3 14,2 0 0 5 31,25
15 0 0 4 19,0 0 0 2 12,5
Total 21 100 21 100 16 100 16 100

able 4.2. shows that the distribution of the average GCS score in the control

group was higher than the treatment group.

The mean difference GCS value of pre-test to post-test GCS value in the
control group and the treatment group.

Mean difference GCS score of pre-test to post-test GCS score in the control

group and the treatment can be seen on the graph. 1

p=0,007 p=0,001

PRE-TEST
POST-TEST

Figure 1 Differences mean GCS score of pre-test to post-test GCS score in

the control group and the treatment
Wilcoxon test as shown in Figure 1 concluded that there are significant

differences in the mean values of GCS pre-test to post-test both in the control group

(p = 0.007) and the treatment group (p = 0.001). However, the increase in mean
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GCS score in the treatment group (2.5) was higher than the increase in the value of

GCS in the control group (1.19).

Differences Mean GCS on Increased Value Control Group and Treatment

Group

Table 3. Differences mean improvement of GCS score in the control group and
the treatment group
Group P
Control Treatment
The mean increase
in the value of the 1,19 2,029 0,037
GCS

Different test mean improvement of GCS score in the control group to the

treatment group tested using the Mann Whitney test. The test scores p = 0, 037.

Thus, it can be concluded that there is an influence on the value of the GCS

acupressure moderate head injury patients.

Discussion

Effect of acupressure on the value of GCS in patients with moderate head

injury.
Man - Whitney test performed on the mean improvement of GCS score and

the control group showed that there was significant difference ( p = 0.037 ) . Thus

there is the effect of acupressure on the GCS score of patients with moderate head

injury .

The high increase in mean GCS score in the treatment group , in addition to

standard therapy neuroprotective effects , is also supported by the neuroprotective

effects of acupressure therapy alone . Moreover , endorphin secretion via relaxation

acupressure effect which can overcome some of the side effects of standard therapy

therapy such as restlessness , insomina , agitation , and gastrointestinal disorders .

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Thus, in this case acupressure helps maximize the functionality of the standard

therapy . This was confirmed by the study of Han JS (2004 ) and Hernandez et al (

2010) that the stimulation of acupressure points to stimulate the secretion of

endorphins which provide a therapeutic effect against damage to brain cells due to

a head injury . In addition to the research conducted by Soltani AE et al ( 2010)

showed that acupressure can reduce the incidence of nausea and vomiting is one of

the side effects of standard therapy head injury .

Besides a role in maximizing the therapeutic effect of standard therapy with

minimal side effects , acupressure itself has some neuroprotective mechanisms that

may help maintain brain cells from damage caused by ischemia . According to

Bucher & Melander (1999 ) , ischemic injury to the head due to decreased blood

flow to the brain under 20cc/100 g brain / min . In this condition , although the brain

cells are still alive , but it has lost its function . So if it occurs in the cerebral cortex

hemisper , ARAS area , or other parts of the brain consciousness raiser , it will be

followed by loss of consciousness .

Stimulation of acupressure points , will increase the signal in certain areas

in the brain . Research conducted by Hao C et al ( 2011) showed that the stimulation

point ST 36 ( zusanli ) consistently able to increase brain signals in the limbic

system and subcortical areas , among others : the anterior cingulate cortex ,

parahippocampus , hypotalamus , periaquaductal gray , secondary somatosensory

cortex ( SII ) , secondary somatosensory cortex ( SI ) , paracental lobes , motors are

supplementary ( SMA ) , and temporal cortex and prontal . While the stimulation
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point PC 6 proved to boost the signal , especially in the amygdala and insula , SII ,

SI , and the premotor cortex .

According to research by Pang J et al ( 2003) an increase in the signal in the

brain area to improve regional cerebral blood flow ( rCBF ) is not accompanied by

an increase in blood pressure in general . Improvement of regional perfusion is

associated with activation of nicotinic receptors acethylcholine as the effect of

stimulation of acupressure at the point ST 36 and PC 6 . This was confirmed by a

study conducted on rats by Uchida S & Hotta H (2008 ) , in which the stimulation

of acupressure points on the extremities can increase cerebral blood flow without

being accompanied by an increase in mean artery pressure ( MAP ) . Increased

blood flow to the brain stimulation of acupressure point is the effect of excitation

of afferent fibers in groups III and IV somatic nerves . In addition to the activation

of the cholinergic system by intracranial stimulation of acupressure points are very

important in increasing brain blood flow , which is free from the influence of blood

pressure . The increase in rCBF during ischemia is one of the neuroprotective

mechanisms , which protect nerve cells from damage .

Ischemia that occurs in head injury , other than due to a decrease in cerebral

blood flow , brain volume was also due to pressure on the brain tissue occurs when

cerebral edema , as well as the effects of the sympathetic nervous system activity

triggered by the occurrence of head injury . Inhibition of sympathetic nerve activity

by endorphin hormone produced by acupressure in addition to preventing ischemic

can also prevent the development of cerebral edema . According to Bucher &

Melander (1999 ) sympathetic nerve activity would trigger mineralkortikoid and

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glucocorticoid secretion . Mineralkortikoid responsible for the occurrence of

cerebral edema because it is water and sodium retention . While glucocorticoids

trigger an increase in the metabolism of carbohydrates , fats , and proteins . This is

in addition to increasing needs of brain cells against the risk of causing an imbalance

of oxygen suply and demand of O2 , CO2 levels will also increase , as the waste

products of metabolism of carbohydrates . Increased CO2 levels will cause

vasodilatation of blood vessels of the brain which can aggravate cerebral edema .

Thus inhibition of the sympathetic nervous system , in addition to preventing the

occurrence of ischemia , also can prevent cerebral edema process .

Neuroprotective effects such as in research Pang J et al ( 2003) are

acupressure can inhibit glutamate spending triggered by changes in capillary

permeability due to ischemic conditions . This expenditure will trigger the entry of

glutamate into the intracellular Ca that activates proteolytic enzymes that cause the

death of nerve cells .

Recovery of integrity and interactions between cells maintainer

consciousness ( ARAS , hemisper cerebral cortex , thalamus , hypothalamus , and

mecencefalon ) will be followed by the recovery of the patient's consciousness is

shown by the increase in the value of GCS . ( Schiff , ND 2010; Parker , JN and

Parker , AM 2004; Kavakh , A et al , 2009; & Pang , J et al 2003) .

CONCLUSION AND RECOMMENDATIONS

General conclusion of this study is acupressure can increase the value of

GCS in patients with moderate head injury significantly.

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Based on the research results obtained, it is suggested the following

points: 1) for nursing services in order to make acupressure as a nursing intervention

in dealing with loss of consciousness in patients with moderate head injury 2) for

education in order to increase the knowledge of nurses by making acupressure as a

matter komplementer.3 teaching eye therapy) for researchers in order to perform

the study by measuring hormones endorphins and glutamate levels in the blood

plasma of patients who received head injuries acupressure therapy.

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