Anxiety and surgical recovery. Reinterpreting the literature

Changes in mood state after day case forefoot surgery

Limited published data exploring patients' emotional recovery after day case foot surgery are available. The aim of the present study was to explore the changes in patient mood from preoperatively to 8 weeks postoperatively after outpatient forefoot surgery. The patients completed the Profile of Mood States-Bipolar™ questionnaire, Speilberger State-Trait Anxiety Inventory, and a 10-cm visual analog scale to measure pain preoperatively and again at 1, 2, and 8 weeks postoperatively. Of the 6 mood subscales, 3 showed statistically significant improvements by 8 weeks postoperatively: composed-anxious (Student's t test, t = -5.319; df = 84; p = .05); confident-unsure (t = -2.074; df = 84; p = .02); and clearheaded-confused (t = -2.46; df = 84; p = .007). Furthermore, the decrease in anxiety and pain was statistically significant after foot surgery. These findings have contributed to the understanding of patients' psychological needs in relation to outpatient day case foot surgery, and foot and ankle surgeons' understanding of patients' mood and anxiety levels can contribute to improving patient care and enhancing patient-practitioner relationships, which, in turn, could improve patients' perceived outcomes of their surgery.

Can a brief educational intervention improve sleep and anxiety outcomes for emergency orthopaedic surgical patients?

Abstract An educational intervention (EI) is useful in preparing patients for orthopaedic surgery. This quasi-experimental study examined the effect of a brief EI on pain level, anxiety, pain inference on sleep, and sleep satisfaction among Chinese patients undergoing emergency orthopaedic surgery. The intervention group received usual care plus 20-minute EI which comprised a combination of patient education and a breathing relaxation exercise (BRE) whereas the control group received usual care only. The outcomes were evaluated before the EI and at days 2, 4 and 7 post-surgery. One hundred and fifty two participants completed the study. The intervention group had significantly lower pain levels (Brief pain inventory), anxiety levels (The Chinese state Anxiety scale), and lower pain inference scores on mood and better sleep satisfaction. Therefore, a brief EI with a breathing relaxation exercise is a feasible and useful intervention that can improve post-operative outcomes in emergency orthopaedic surgery.

The measurable cost of complications for outpatient cosmetic surgery in patients with mental health diagnoses

BACKGROUND

Mental health conditions, including psychiatric and substance abuse diagnoses, have been associated with poor postoperative outcomes, but no studies have quantified the relationship to date.

OBJECTIVE

The authors examine the association between mental health conditions and immediate postoperative outcomes as defined by further hospital-based acute care within 30 days of surgery.

METHODS

California State Ambulatory Surgery, Inpatient, and Emergency Department Databases were used to identify all adult patients undergoing outpatient cosmetic plastic surgery between January 2007 and October 2011. Patients were subgrouped by the presence of mental health or substance abuse conditions. Primary outcome was the need for hospital-based acute care (admission or emergency department visit) within 30 days after surgery. Multivariable logistic regression models compared outcomes between groups.

RESULTS

Of 116,597 patients meeting inclusion criteria, 3.9% and 1.4% had either a psychiatric or substance abuse diagnosis, respectively. Adjusting for medical comorbidities, patients with psychiatric disorders more frequently required hospital-based acute care within 30 days postoperatively than those without mental illness diagnoses (11.1% vs 3.6%; adjusted odds ratio [AOR], 1.78 [95% confidence interval, 1.59-1.99]). This was true both for hospital admissions (3.5% vs 1.1%; AOR, 1.61 [1.32-1.95]) and emergency department visits (8.8% vs 2.7%; AOR, 1.88 [1.66-2.14]). The most common acute diagnoses were surgical in nature, including postoperative infection, hemorrhage, and hematoma; the median hospital admission charge was $35 637. Similar findings were noted among patients with a substance abuse diagnosis.

CONCLUSIONS

Mental health conditions are independently associated with the need for more frequent hospital-based acute care following surgery, thus contributing to added costs of care. A patient's mental health should be preoperatively assessed and appropriately addressed before proceeding with any elective procedure.

LEVEL OF EVIDENCE

4.

Biopsychosocial influence on exercise-induced injury: genetic and psychological combinations are predictive of shoulder pain phenotypes

Chronic pain is influenced by biological, psychological, social, and cultural factors. The current study investigated potential roles for combinations of genetic and psychological factors in the development and/or maintenance of chronic musculoskeletal pain. An exercise-induced shoulder injury model was used, and a priori selected genetic (ADRB2, COMT, OPRM1, AVPR1 A, GCH1, and KCNS1) and psychological (anxiety, depressive symptoms, pain catastrophizing, fear of pain, and kinesiophobia) factors were included as predictors. Pain phenotypes were shoulder pain intensity (5-day average and peak reported on numerical rating scale), upper extremity disability (5-day average and peak reported on the QuickDASH), and shoulder pain duration (in days). After controlling for age, sex, and race, the genetic and psychological predictors were entered as main effects and interaction terms in separate regression models for the different pain phenotypes. Results from the recruited cohort (N = 190) indicated strong statistical evidence for interactions between the COMT diplotype and 1) pain catastrophizing for 5-day average upper extremity disability and 2) depressive symptoms for pain duration. There was moderate statistical evidence for interactions for other shoulder pain phenotypes between additional genes (ADRB2, AVPR1 A, and KCNS1) and depressive symptoms, pain catastrophizing, or kinesiophobia. These findings confirm the importance of the combined predictive ability of COMT with psychological distress and reveal other novel combinations of genetic and psychological factors that may merit additional investigation in other pain cohorts.

PERSPECTIVE

Interactions between genetic and psychological factors were investigated as predictors of different exercise-induced shoulder pain phenotypes. The strongest statistical evidence was for interactions between the COMT diplotype and pain catastrophizing (for upper extremity disability) or depressive symptoms (for pain duration). Other novel genetic and psychological combinations were identified that may merit further investigation.

Effects of patient education and therapeutic suggestions on cataract surgery patients: a randomized controlled clinical trial

OBJECTIVE

This paper describes a randomized controlled single blind study testing the effects of a patient education intervention combined with positive therapeutic suggestions on anxiety for cataract surgery patients.

METHODS

84 patients participated in the study. Physiological and behavioral indicators of anxiety were compared between a regularly treated control and an intervention group receiving an audio CD containing information, relaxation, and positive imagery.

RESULTS

We found that the intervention group was calmer throughout the four measurement points of the study (p=.004; d=0.71) and they were more cooperative (p=.01; d=0.60) during the operation. The groups did not differ in sleep quality before the day of the operation, heart rate during the procedure, and subjective Well-being.

CONCLUSION

Findings indicate that preoperative information combined with positive suggestions and anxiety management techniques might reduce patient anxiety in the perioperative period of cataract surgery, but further research is needed to investigate the benefits of such interventions and to uncover the underlying mechanisms.

PRACTICE IMPLICATIONS

Patient education interventions providing additional anxiety management techniques are recommended for use prior to cataract surgery.

Role of anxiety in the comfort of nonsedated average-risk screening sigmoidoscopy

OBJECTIVES

The aim of this prospective study was to assess the role of generalized anxiety disorder in the comfort of nonsedated, average-risk screening sigmoidoscopy.

METHODS

Patients were asked to complete a screening questionnaire before undergoing average-risk colon cancer screening with nonsedated sigmoidoscopy. The questionnaire included demographic information and a series of Likert-based and visual analog scales designed to assess patient comfort, procedural symptom severity, and satisfaction. The Primary Care Evaluation of Mental Disorders questionnaire was used to assess for generalized anxiety disorder. Comfort levels and postprocedural symptom severity were recorded immediately after the procedure and 1 week postprocedure. χ and t tests were used to analyze the data.

RESULTS

Eighty-one patients were enrolled in the study. Twenty-seven patients tested positive for anxiety (high anxiety), whereas 54 tested negative (low anxiety). There were no differences in anxiety according to sex (P = 0.53), or age (P = 0.32). There was no difference in reaching the splenic flexure between high- and low-anxiety patients (P = 0.15); however, pairwise comparisons revealed patients with high anxiety reported significantly higher levels of abdominal pain after the procedure (P < 0.01) and still recalled higher pain from the procedure 1 week later (P < 0.01) than those patients with low anxiety scores. Furthermore, those patients with high anxiety reported significantly more procedure-related cramping and bloating both immediately after the procedure and again 1 week later (P < 0.01). Finally, patients with high anxiety reported the procedure as being more uncomfortable 1 week later, when compared with low-anxiety patients (P = 0.01).

CONCLUSIONS

The level of anxiety correlated directly to pain and discomfort postprocedure and related inversely to the level of satisfaction. Better management of anxiety may lead to better procedural comfort in nonsedated procedures.

Post-Surgical Pain, Physical Activity and Satisfaction with the Decision to Undergo Hernia Surgery: A Prospective Qualitative Investigation

Surgical repair is a common treatment for inguinal hernias but a substantial number of patients experience chronic pain after surgery. As some patients are pain-free on presentation, it is important to investigate whether patients perceive the treatment to be beneficial. The present study used qualitative methods to explore experiences of pain, activity limitations and satisfaction with treatment as people underwent surgery and recovery. Twenty-nine semi-structured interviews were conducted. Seven participants were interviewed longitudinally: before surgery and two weeks and four months post-surgery. Ten further participants with residual pain four months post-surgery were interviewed once. Semi-structured interviews included experience and perception of pain; activity limitations; reasons for having surgery; satisfaction with the decision to undergo surgery. A thematic analysis was conducted. Pain did not cause concern when perceived as part of the usual surgery and recovery processes. Activity was limited to avoid damage to the hernia site rather than to avoid pain. None of the participants reported dissatisfaction with the decision to have surgery; reducing the risk of life-threatening complications associated with untreated hernias was considered important. These findings suggest that people regarded surgical treatment as worthwhile, despite chronic post-surgical pain. Further research should ascertain whether patients are aware of the actual risk of complications associated with conservative rather than surgical management of inguinal hernia.

Utility of a salivary biosensor for objective assessment of surgery-related stress

PURPOSE

To evaluate the clinical utility of a salivary α-amylase (sAA) biosensor for assessing oral surgery-related stress responses and the differential effect of the personality trait of pain catastrophizing.

PATIENTS AND METHODS

A prospective cohort study was conducted in 76 healthy subjects who underwent elective removal of their third molars. Along with subjects' self-reports of anxiety and pain, biosensor-facilitated measurements of sAA levels were obtained at multiple time points during the preoperative consult, surgery, and postsurgical follow-up visits. In addition, subjects completed the Pain Catastrophizing Scale at baseline. Mixed-effect regression models examined changes in sAA levels and self-report ratings within and across visits and the contribution of pain catastrophizing.

RESULTS

The sAA levels were lower during surgery and postsurgical follow-up compared with the consult visit (P < .01). The sAA levels decreased during the surgery visit (P < .05) and did not change during the consult or follow-up visits. Individuals who reported greater helplessness to pain manifested higher sAA levels during the surgery visit (P < .05). Self-reported anxiety ratings were highest during the surgery visit, and pain ratings were highest during the follow-up visit.

CONCLUSIONS

The sAA levels did not show the predicted increases during the surgery visit compared with the consult and postsurgical follow-up visits or increases during the surgery visit. However, individuals who reported responding to pain with helplessness had higher sAA levels in anticipation of surgery, providing proof of concept for the value of point-of-care assessments of surgery-induced stresses and the differential effect of personality traits.

Needling of the Extra 1 Point Decreases BIS Values and Preoperative Anxiety

Acupuncture has anxiolytic effects. We investigated the effect of acupuncture on the Bispectral Index (BIS) values and anxiety. Fifty patients were randomly assigned to group A to receive acupuncture for 15 minutes on the extra 1 point (yintang) or to group C, where they received the same treatment on a control point located 2 cm lateral to the end of the right eyebrow. BIS values were recorded before acupuncture; during acupuncture every 30 seconds for 15 minutes and every 30 seconds for 90 seconds when the acupuncture treatment was accomplished. Anxiety level was assessed before and after acupuncture by a verbal score scale (VSS) (0=no anxiety, 10=worst anxiety). BIS values were significantly decreased during acupuncture when applied on the extra 1 point (p=0.0001) but not on the control point.

Acupuncture application significantly decreased the VSS values within the A group (p=0.027) and in the C group (p=0.0001), when compared to the baseline (pre-acupuncture) VSS values. However, no differences were found between the two groups regarding BIS or VSS values. In conclusion, needling the extra 1 point preoperatively significantly decreases the BIS values and the VSS for anxiety but needling of a control point decrease only VSS values.

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia

BACKGROUND

Psychological factors are thought to drive inter-patient variations in anaesthetic and analgesic requirements. This cross-sectional study investigated whether preoperative psychological factors can predict anaesthetic requirements and postoperative pain.

METHODS

Before total thyroidectomy, 100 consecutive women completed the Spielberger's State-Trait Anxiety Inventory (STAI) and the pain sensitivity questionnaire (PSQ). Target-controlled propofol was administered for induction of anaesthesia, and sevoflurane-oxygen-air was given to maintain equal depths of anaesthesia, as determined by bispectral index (BIS) monitoring.

RESULTS

Patients with higher anxiety scores (state and trait) required greater amounts of propofol to reach light (BIS=85) and moderate (BIS=75) levels of sedation, but only trait anxiety was significantly associated with propofol requirements in reaching a deep level of sedation (BIS=65). The MAC-hour of sevoflurane was significantly correlated only with PSQ scores. The postoperative pain intensity was significantly correlated with both STAI and PSQ.

CONCLUSIONS

Preoperative anxiety and pain sensitivity are independent predictors of propofol and sevoflurane requirements in general anaesthesia. Anaesthetic and analgesic doses could be modified based on the patient's preoperative anxiety and pain sensitivity.

Impact of preoperative change in physical function on postoperative recovery: argument supporting prehabilitation for colorectal surgery

BACKGROUND

Abdominal surgery represents a physiologic stress and is associated with a period of recovery during which functional capacity is often diminished. "Prehabilitation" is a program to increase functional capacity in anticipation of an upcoming stressor. We reported recently the results of a randomized trial comparing 2 prehabilitation programs before colorectal surgery (stationary cycling plus weight training versus a recommendation to increase walking coupled with breathing exercises); however, adherence to the programs was low. The objectives of this study were to estimate: (1) the extent to which physical function could be improved with either prehabilitation program and identify variables associated with response; and (2) the impact of change in preoperative function on postoperative recovery.

METHODS

This study involved a reanalysis of data arising from a randomized trial. The primary outcome measure was functional walking capacity measured by the Six-Minute Walk Test; secondary outcomes were anxiety, depression, health-related quality of life, and complications (Clavien classification). Multiple linear regression was used to estimate the extent to which key variables predicted change in functional walking capacity over the prehabilitation and follow-up periods.

RESULTS

We included 95 people who completed the prehabilitation phase (median, 38 days; interquartile range, 22-60), and 75 who were also evaluated postoperatively (mean, 9 weeks). During prehabilitation, 33% improved their physical function, 38% stayed within 20 m of their baseline score, and 29% deteriorated. Among those who improved, mental health, vitality, self-perceived health, and peak exercise capacity also increased significantly. Women were less likely to improve; low baseline walking capacity, anxiety, and the belief that fitness aids recovery were associated with improvements during prehabilitation. In the postoperative phase, the patients who had improved during prehabilitation were also more likely to have recovered to their baseline walking capacity than those with no change or deterioration (77% vs 59% and 32%; P = .0007). Patients who deteriorated were at greater risk of complications requiring reoperation and/or intensive care management. Significant predictors of poorer recovery included deterioration during prehabilitation, age >75 years, high anxiety, complications requiring intervention, and timing of follow-up assessment.

CONCLUSION

In a group of patients undergoing scheduled colorectal surgery, meaningful changes in functional capacity can be achieved over several weeks of prehabilitation. Patients and those who care for them, especially those with poor physical capacity, should consider a prehabilitation regimen to enhance functional exercise capacity before colectomy.

[Preoperative mood disorders in patients undergoing cardiac surgery: risk factors and postoperative morbidity in the intensive care unit]

INTRODUCTION AND OBJECTIVES

To estimate the preoperative levels of anxiety and depression in patients awaiting heart surgery and to identify the risk factors associated with the development of these mood disorders. To evaluate the relationship between preoperative anxiety and depression and postoperative morbidity.

METHODS

Prospective longitudinal study in a sample of 100 patients undergoing heart surgery. We carried out a preoperative structured interview in which the patient completed the Hospital Anxiety and Depression Scale, and sociodemographic (age, sex, marital status, and income) and surgical variables (surgical risk, type of surgery, length of preoperative hospital stay, and surgical history) were also recorded. Pain, analgesic use, and postoperative morbidity were evaluated in the intensive care unit.

RESULTS

Thirty-two percent of the patients developed preoperative anxiety and 19%, depression. Age < 65 years (odds ratio=3.05; 95% confidence interval, 1.27-7.3) was the only significant risk factor for developing preoperative anxiety. A length of preoperative hospital stay ≥ 3 days was the main risk factor for preoperative depression (odds ratio=4.59; 95% confidence interval, 1.6-13.17). Preoperative anxiety significantly increased the postoperative pain and analgesic consumption. Neither anxiety nor depression significantly modified the rest of the postoperative variables associated with morbidity in the intesive care unit.

CONCLUSIONS

Anxiety and depression are mood disorders that are detected in patients awaiting heart surgery, with age <65 years and a prolonged preoperative hospital stay being decisive factors in the development of these conditions. Although preoperative anxiety increased the postoperative pain in these patients, their state of mind did not modify their postoperative course.

Predictors of preoperative anxiety in surgical inpatients

AIMS AND OBJECTIVES

The aims of the present study were to identify the levels of preoperative anxiety in patients undergoing elective surgery and the relationship between preoperative anxiety and social support. In addition, predictors of preoperative anxiety were studied in surgical inpatients.

BACKGROUND

Major life changes are significant factors that cause anxiety; hospitalisation and surgery are among such changes. Social support may decrease the anxiety associated with surgery.

DESIGN

This is a descriptive study that included 500 patients in a surgery clinic.

METHODS

The data collected included: A Patient Information Form, Multidimensional Scale of Perceived Social Support and the Surgical Anxiety Scale. The results were analysed using the Chi-square test and logistic regression analysis. RESULTS; Five hundred patients participated in this research: 59·6% were female, 54·6% were 65 years of age or older, 80·6% were married, 70·4% were literate and 62% of the patients had moderate level surgery. There was a significant relationship between the sociodemographic patient features, the level of preoperative anxiety (p < 0·05), the presence of social support and the severity of anxiety (p = 0·001). The age and level of anxiety were not significant factors. The mean anxiety score for all patients was 31·91 (SD 6·30) and the mean social support score was 66·38 (SD 13·69).

CONCLUSION

The results of this study showed that the preoperative anxiety of patients awaiting surgery was associated with demographic characteristics as well as social support resources.

RELEVANCE TO CLINICAL PRACTICE

Anxiety testing is feasible during the preoperative period. Such testing allows for the detection of patients with high anxiety, and for clinicians to take the appropriate steps to ameliorate this problem. Identification of patient anxiety allows for providing a focus on social support in an attempt to reduce the level of anxiety.

[Evaluation of the postoperative acute pain after heart surgery]

INTRODUCTION

Pain is one of the main symptoms reported by patients who have had heart surgery.

OBJECTIVES

To describe the pain and explain the possible association among demographics, psychological and biological variables of the patients subjected to heart surgery with pain intensity during the postoperative in the ICU.

PATIENTS AND METHOD

A descriptive, longitudinal study conducted between February 2008 and January 2009 on patients subjected to heart surgery with admission to the ICU of the Hospital of Navarra was conducted. A preoperatory interview was made with registration of sociodemographic, biological and psychological variables. Pain intensity was monitored during the first 48 hours of ICU stay with the Verbal Numeric Scale (VNS) of pain. Accepted level of significance was p<0.05.

RESULTS

A sample of 69 patients with mean age of 62, 26% women and 74% men was included. A superior statistical association was found between postoperative pain levels for age<65 years, bypass grafting with internal mammary artery and preoperatory anxiety variables. There was a significant increase in analgesic consumption for incomes>1400 €/month, bypass grafting with internal mammary artery and preoperatory anxiety.

CONCLUSIONS

Postoperative pain after heart surgery show significant individual variability. In our study, age, bypass grafting with internal mammary artery and preoperatory anxiety were shown as predictive variables of postoperative pain in patients undergoing heart surgery.

Do psychological variables affect early surgical recovery?

Background

Numerous studies have examined the effect of psychological variables on surgical recovery, but no definite conclusion has been reached yet. We sought to examine whether psychological factors influence early surgical recovery.

Methods

We performed a systematic search in PubMed, Scopus and PsycINFO databases to identify studies examining the association of preoperative psychological variables or interventions with objectively measured, early surgical outcomes.

Results

We identified 16 eligible studies, 15 of which reported a significant association between at least one psychological variable or intervention and an early postoperative outcome. However, most studies also reported psychological factors not influencing surgical recovery and there was significant heterogeneity across the studies. Overall, trait and state anxiety, state anger, active coping, subclinical depression, and intramarital hostility appeared to complicate recovery, while dispositional optimism, religiousness, anger control, low pain expectations, and external locus of control seemed to promote healing. Psychological interventions (guided relaxation, couple support visit, and psychiatric interview) also appeared to favor recovery. Psychological factors unrelated to surgical outcomes included loneliness, perceived social support, anger expression, and trait anger.

Conclusion

Although the heterogeneity of the available evidence precludes any safe conclusions, psychological variables appear to be associated with early surgical recovery; this association could bear important implications for clinical practice. Large clinical trials and further analyses are needed to precisely evaluate the contribution of psychology in surgical recovery.

What Are Thyroidectomy Patients Really Concerned About?

Objective. To better appreciate perioperative concerns affecting patients considering thyroidectomy and to understand how they may vary according to patient characteristics.

Study Design. Cross-sectional analysis.

Setting. Tertiary referral center.

Subjects and Methods. The authors recruited patients scheduled for thyroid surgery at the McGill University Thyroid Cancer Center. A total of 148 patients completed the 18-item Western Surgical Concern Inventory–Thyroid (WSCI-T) questionnaire. Psychometrics of the WSCI-T were assessed through a principal component analysis with varimax rotation and reliability analyses. Independent-samples t tests and 2-tailed Pearson correlations were ran, identifying areas of elevated concerns and their relationship to gender, age, and surgical procedure (total vs hemithyroidectomy).

Results. The principal component analysis revealed the presence of 3 domains of presurgical concerns on the WSCI-T: Surgery-Related Concerns, Psychosocial Concerns, and Daily-Living Concerns. Reliability coefficients for the WSCI-T Total and subscales were satisfactory. Responses on the WSCI-T indicated on average a moderate overall level of concerns before thyroidectomy. Surgery-Related Concerns was the highest domain of concerns, followed by Daily-Living and Psychosocial Concerns, respectively. Patients were mainly worried about the nodule being cancerous, experiencing a change in voice, and surgical complications. Areas of minor concern included being judged or treated differently, becoming depressed, and feeling embarrassed. Women had higher overall levels of concern than men did. Although there were no significant differences in overall levels of concern according to age and surgical procedure, differences were noted at a subscale and item level.

Conclusion. This study establishes a mean that will permit adequate physician counseling and a better management of patients’ perioperative worries.

Predictors of physical and emotional recovery 6 and 12 months after surgery

Background

A proportion of patients do not recover fully from surgery or they develop chronic postsurgical pain. The aim of this study was to examine the incidence and predictors of unfavourable long-term outcome after surgery using a prospective cohort design.

Methods

Some 401 patients undergoing various elective surgical procedures filled in the RAND 36-item Health Survey 1·0 health-related quality-of-life questionnaire before operation and at 6 and 12 months of follow-up to assess changes in pain, physical functioning, mental health and vitality. Preoperative psychological assessment was obtained.

Results

Most patients showed improvement in the various aspects of health-related quality of life after surgery, but a considerable proportion (14–24 per cent) still showed deterioration at 6 and 12 months. Multivariable linear regression analysis identified acute postoperative pain, duration of the operation and preoperative physical condition as the most important predictors of long-term pain and physical functioning. Preoperative surgical fear also had a small but significant contribution. The main predictors of mental health and vitality were physical condition before surgery, surgical fear and optimism.

Conclusion

Up to a quarter of patients experienced suboptimal recovery after surgery. Both somatic and psychological factors were associated with the long-term outcome. Optimal recovery could be promoted by effective interventions on malleable factors.

Effectiveness of an educational intervention on levels of pain, anxiety and self-efficacy for patients with musculoskeletal trauma

AIM

This paper is a report of a study of the effectiveness of a pain management educational intervention on level of pain, anxiety and self-efficacy among patients with musculoskeletal trauma and consequent orthopaedic surgery.

BACKGROUND

Substantial evidence supports the use of preoperative education to improve patient outcomes. Educational interventions are common in preparing patients for orthopaedic surgery.

METHODS

A pre- and post-test design (quasi-experimental) was employed in 2006 with patients assigned either to a control (usual care) or an experimental group (usual care plus educational intervention). The 30-minute educational intervention consisted of information about pain, coping strategies and breathing relaxation exercises. The outcome measures were scores for pain, anxiety, self-efficacy, analgesic use and length of hospital stay and these were measured before surgery and on day 2, day 4, day 7, 1 month and 3 months after surgery.

RESULTS

A total of 125 patients completed the study (control, n = 63; experimental = 62). The experimental group reported statistically significantly lower levels of pain, less anxiety and better self-efficacy during hospitalization (before surgery to day 7), as compared to the control group. The experimental group had more requests for analgesics at day 2 only. There were no statistically significant effects on length of stay. At the 3-month evaluation, a statistically significant effect on anxiety level was found in favour of the experimental group.

CONCLUSION

Patients may benefit from this educational intervention in terms of relieving pain, anxiety and improving self-efficacy, and the educational intervention could be incorporated as part of routine care to prepare musculoskeletal trauma patients for surgery.

The diagnostic accuracy of brief screening questions for psychosocial risk factors of poor outcome from an episode of pain: A systematic review

OBJECTIVE

To determine the diagnostic accuracy of brief screening questions for psychosocial risk factors predictive of poor outcome from an episode of pain.

METHODS

Six electronic databases were searched, content experts contacted, and reference and citation tracking performed. Studies were included that examined the diagnostic accuracy of 1-item screening or 2-item screening questions for depression, anxiety, fear-avoidance beliefs, social isolation, catastrophization, or somatization and were published in English. Studies were assessed for quality, and data extracted describing study characteristics and the diagnostic accuracy of brief screening questions.

RESULTS

Four cross-sectional studies met the inclusion criteria and all met 4 or more of our 6 method quality criteria. These studies examined the diagnostic accuracy of brief screening tools for depression (sensitivity = 50.5% to 82.1%, specificity = 71.0% to 90.6%, and overall accuracy = 74.6% to 80.6%) and anxiety (sensitivity 63.0% to 94.0%, specificity = 53.0% to 71.2%, and overall accuracy = 60.0% to 68.1%). No studies were identified that examined the diagnostic accuracy of brief screening questions for fear-avoidance beliefs, social isolation, catastrophization, and somatization.

DISCUSSION

Data were only available on the accuracy of brief screening instruments for depression and anxiety, and there was variability in the results. Head-to-head studies are required to determine if this variability reflects differential question accuracy or population characteristics, and studies that determine the diagnostic accuracy of brief screening questions for other common psychosocial risk factors would be useful.

Information and behavioural instruction along the health-care pathway: the perspective of people undergoing hernia repair surgery and the role of formal and informal information sources

BACKGROUND

Provision of information and behavioural instruction has been demonstrated to improve recovery after surgery. However, patients draw on a range of information sources and it is important to establish which sources patients use and how this influences perceptions and behaviour as they progress along the surgical pathway. In this qualitative, exploratory and longitudinal study, the use of information and instruction were explored from the perspective of people undergoing inguinal hernia repair surgery.

METHODS

Seven participants undergoing inguinal hernia repair surgery were interviewed using semi-structured interviews 2 weeks before surgery and 2 weeks and 4 months post-surgery. Nineteen interviews were conducted in total. Topic guides included sources of knowledge, reasons for help-seeking and opting for surgery and factors influencing return to activity. Data were analysed thematically according to Interpretative Phenomenological Analysis.

FINDINGS AND CONCLUSIONS

Participants sought information from a range of sources, focusing on informal information sources before surgery and using information and instruction from health-care professionals post-surgery. This information influenced behaviours including deciding to undergo surgery, use of pain medication and returning to usual activity. Anxiety and help-seeking resulted when unexpected post-surgical events occurred such as extensive bruising. Findings were consistent with psychological and sociological theories. Overall, participants were positive about the information and instruction they received but expressed a desire for more timely information on post-operative adverse events.

HYPNOSIS TO MANAGE DISTRESS RELATED TO MEDICAL PROCEDURES: A META-ANALYSIS

This meta-analysis evaluates the effect of hypnosis in reducing emotional distress associated with medical procedures. PsycINFO and PubMed were searched from their inception through February 2008. Randomized controlled trials of hypnosis interventions, administered in the context of clinical medical procedures, with a distress outcome, were included in the meta-analysis (26 of 61 papers initially reviewed). Information on sample size, study methodology, participant age and outcomes were abstracted independently by 2 authors using a standardized form. Disagreements were resolved by consensus. Effects from the 26 trials were based on 2342 participants. Results indicated an overall large effect size (ES) of 0.88 (95% CI = 0.57-1.19) in favour of hypnosis. Effect sizes differed significantly (p < 0.01) according to age (children benefitted to a greater extent than adults) and method of hypnosis delivery, but did not differ based on the control condition used (standard care vs. attention control).

Genetic and environmental determinants of postthoracotomy pain syndrome

PURPOSE OF REVIEW

Pain after thoracic surgery may persist for up to a year or longer in as many as 50% of patients undergoing lung resection. There is currently no specific therapy, and our ability to predict who will develop a persistent pain syndrome is poor at best. Persistent pain after thoracotomy is not an acute somatic pain, rather it is a complex syndrome with many of the characteristics of neuropathic, dysesthetic pain.

RECENT FINDINGS

The pain genetics field has been dominated by reports of single variants leading to severe phenotypes. These (Mendelian) diseases are not representative of the more common, complex phenotype that is characterized by the lay term 'pain threshold'. Recently, work describing the association of genetic variants with idiopathic pain disorders has appeared in the literature, and here the authors suggest that these concepts are applicable to postthoracotomy pain syndrome.

SUMMARY

Postthoracotomy pain syndrome likely arises as a direct result of an environmental stress (surgery) occurring on a landscape of susceptibility that is determined by an individual's behavioral, clinical and genetic characteristics.

The effect of preoperative uncertainty and anxiety on short-term recovery after elective arthroplasty

AIMS AND OBJECTIVES

This study examined the effect of preoperative anxiety and uncertainty on short-term physical and mental recovery after elective arthroplasty.

BACKGROUND

Uncertainty and anxiety accompany all medical procedures. Although preoperative uncertainty plays a central role in the development of stress, only a few studies explicitly examine this issue in terms of its impact on postoperative recovery.

DESIGN

Quazi-experimental study.

METHODS

Two self-administered questionnaires were used to collect data, before and five to six days after surgery. Participants (n = 87) admitted for elective arthroplasty completed the study.

RESULTS

Preoperative anxiety negatively affected postoperative recovery variables and preoperative uncertainty negatively affected mental and physical recovery after surgery. Furthermore, postoperative symptoms were related to the patients' subjective readiness to be discharged.

CONCLUSIONS

Separately, reduction of preoperative anxiety and uncertainty could have a positive impact on postoperative recovery and on perceived readiness to be discharged.

RELEVANCE TO CLINICAL PRACTICE

The unique contribution of each preoperative variable (uncertainty and anxiety) to postoperative recovery emphasizes the need for clinical and educational interventions that separately relieve uncertainty and anxiety.

Depressive symptoms predict mucosal wound healing

OBJECTIVE

There is mounting evidence that psychosocial stress can delay wound healing, but this literature almost exclusively pertains to dermal wound healing. Many surgical procedures involve damage to mucosal tissues and the time course and the role of repair processes, such as inflammation, in the healing of these tissues are markedly different from those in dermal healing. Feelings of depression and social isolation are common among surgical patients, and the present study therefore investigated if these factors predict the rate of mucosal wound healing.

METHODS

Undergraduate students were invited to participate in the study if they reported high or low levels of loneliness or depressive symptoms, corresponding to the upper or lower quintile of their peer group. The UCLA loneliness scale and the Beck Depression Inventory [short form] were used for this screening. A sample of 193 healthy young adults (age range 18-31 years) received a 3.5-mm circular wound on the oral hard palate, under local anesthesia. Healing was monitored by daily videographs of the wound.

RESULTS

The median healing rate was 7 days. High dysphoric participants were, however, more likely to heal slower than this median healing rate (odds ratio 3.57 (1.58-8.07); p < .001). This association remained robust after correction for a broad range of demographic and behavioral variables, including gender, age, ethnicity, and health behaviors. High dysphoric individuals also exhibited significantly larger average wound sizes from day 2 post wounding onward. Loneliness and diurnal cortisol secretion (measured over 5 days) were unrelated to healing.

CONCLUSION

Depressive symptoms predict the rate of mucosal wound healing in healthy young adults. We discuss potential pathways that warrant further investigation.

Somatic and psychologic predictors of long-term unfavorable outcome after surgical intervention

OBJECTIVE

To identify somatic and psychologic predictors of pain, functional limitations, global perceived recovery, and quality of life 6 months after surgical intervention.

SUMMARY BACKGROUND DATA

Recent studies have indicated that chronic pain after surgical intervention is more common than previously assumed. Several demographic and somatic predictors of long-term unfavorable outcome have been identified, but little is known about the contribution of psychologic risk factors.

METHODS

A prospective cohort study, including 625 patients undergoing elective surgery at the University Hospital Maastricht, The Netherlands, was conducted between February and August 2003. Psychologic questionnaires were completed preoperatively and acute postoperative pain was recorded until 4 days after the operation. Six months later, all patients received follow-up questionnaires to assess pain, functional limitations, global perceived recovery, and quality of life. Multivariable logistic regression analyses were used to estimate relative risk of poor outcome in terms of pain, functional limitations, and global recovery. Multivariable linear regression analysis was used to assess associations with quality of life at 6 months.

RESULTS

The most important somatic predictors of unfavorable outcome were duration of the operation and high levels of acute postoperative pain. Patients reporting high levels of pain 4 days after the operation and patients undergoing an operation of longer than 3 hours were at risk for increased pain, increased functional limitations, poor global recovery, and reported lower levels of quality of life 6 months after the operation. Psychologic variables that influenced long-term outcome were preoperative fear of surgery and optimism. Fear of the long-term consequences of the operation was associated with more pain, poor global recovery, and worse quality of life 6 months later, whereas optimism was associated with better recovery and higher quality of life.

CONCLUSIONS

This study was the first to identify the joint contribution of somatic and psychologic factors to chronic pain, functional limitations, and quality of life 6 months after surgical interventions. It replicates previous findings that intense acute postoperative pain is a risk factor for long-term adverse outcome and also identified additional risk factors, namely, long duration of the operation, ASA status, and preoperative fear of surgery.

Prediction of post-operative pain by an electrical pain stimulus

BACKGROUND

Treatment of post-operative pain is still a significant problem. Recently, interest has focused on pre-operative identification of patients who may experience severe post-operative pain in order to offer a more aggressive analgesic treatment. The nociceptive stimulation methods have included heat injury and pressure algometry. A simple method, Pain Matcher (PM), using electrical stimulation, is validated for pain assessment, but has not been evaluated as a tool for prediction of post-operative pain. Our aim was to assess the predictive value of pre-caesarean section pain threshold on intensity of post-caesarean section pain using the PM.

PATIENTS AND METHODS

Thirty-nine healthy women scheduled for elective caesarean section were studied. The anaesthetic/analgesic procedures included spinal anaesthesia, paracetamol, diclofenac, controlled-release (CR) oxycodone and morphine on request. Pre-operatively, the sensory and pain thresholds were measured using the PM. Post-operatively, a midwife, blinded for pre-caesarean pain threshold assessments, assessed the pain at rest and during mobilization every 12 h for 2 days. Consumption of analgesics was also recorded.

RESULTS

Pre-operative pain threshold correlated significantly with post-caesarean pain score (VAS) at rest and mobilization: [Spearman's rho =-0.65 (-0.30 to -0.75), P < 0.01] and [Spearman's rho =-0.52 (-0.23 to -0.72), P < 0.01], respectively. There was no significant correlation between pre-operative PM assessment of sensory threshold and post-operative pain.

CONCLUSION

Electrical pain threshold before caesarean section seems to predict the intensity of post-operative pain. This method may be used as a screening tool to identify patients at high risk of post-operative pain.

Evidence that trait-anxiety and trait-depression differentially moderate cortical processing of pain

OBJECTIVES

The purpose of this study was to examine the influence of neuroticism (N) and its different subfacets anxiety (N-anx) and depression (N-dep) on cortical pain processing expressed as event-related potentials (ERPs).

METHODS

Seventy-five healthy participants received electrical pain stimuli under condition of simultaneous electroencephalogram registration. Multiple regression analyses were conducted to study the amount of pain-ERP variance. ERP variance was explained by N and its subfacets.

RESULTS

N moderated the way pain was processed cortically. Higher levels of N were associated with higher pain-ERP amplitudes. Within this association, differential subfacet effects were observed: N-anx reduced, whereas N-dep augmented pain-ERP amplitudes.

DISCUSSION

A personality trait reflecting bias toward negative emotions may moderate the way pain is processed cortically, with directionally different effects depending on whether the trait is expressed predominantly in the realm of anxiety or depression.

Risk factors for chronic pain following breast cancer surgery: a prospective study

Chronic pain following breast cancer surgery is associated with decreased health-related quality of life and is a source of additional psychosocial distress in women who are already confronting the multiple stresses of cancer. Few prospective studies have identified risk factors for chronic pain following breast cancer surgery. Putative demographic, clinical, and psychosocial risk factors for chronic pain were evaluated prospectively in 95 women scheduled for breast cancer surgery. In a multivariate analysis of the presence of chronic pain, only younger age was associated with a significantly increased risk of developing chronic pain 3 months after surgery. In an analysis of the intensity of chronic pain, however, more invasive surgery, radiation therapy after surgery, and clinically meaningful acute postoperative pain each independently predicted more intense chronic pain 3 months after surgery. Preoperative emotional functioning variables did not independently contribute to the prediction of either the presence or the intensity of chronic pain after breast cancer surgery. These findings not only increase understanding of risk factors for chronic pain following breast cancer surgery and the processes that may contribute to its development but also provide a basis for the development of preventive interventions.

PERSPECTIVE

Clinical variables and severe acute pain were risk factors for chronic pain following breast cancer surgery, but psychosocial distress was not, which provides a basis for hypothesizing that aggressive management of acute postoperative pain may reduce chronic pain.