Effects of relaxation with guided imagery on surgical stress and wound healing

Effects of a telehealth program for wound healing promotion on the wound healing level in patients with diabetes undergoing coronary artery bypass graft surgery: A randomized controlled trial

Background

Patients with diabetes undergoing coronary artery bypass graft (CABG) are at risk of delayed wound healing. The telehealth program for wound healing promotion (TPWHP) was developed to improve wound healing in patients with diabetes undergoing CABG in a university hospital.

Objective

This study aimed to examine the effects of the TPWHP on the healing of the sternal wound and saphenous vein graft (SVG) donor site in patients with diabetes undergoing CABG.

Methods

In this randomized controlled trial, the participants were randomly assigned to the intervention (n = 30) and control (n = 30) groups. The control group received routine nursing care, whereas the intervention group received routine nursing care along with the TPWHP, which provides education and wound monitoring using multimedia and a surgical wound care booklet and monitors the wound through the LINE application on a smartphone after hospital discharge. Data were collected from June to November 2020 at two university hospitals in Bangkok, Thailand, using the demographic and health-related data form and the Thai wound assessment inventory (WAI). Data were analyzed using the Chi-squared, Fisher's exact, and Mann-Whitney U tests.

Results

The intervention group had significantly lower mean scores-indicating favorable wound healing-for SVG donor site wound healing level than the control group on days 14-21 after surgery (p = 0.012, mean = 0.58 ± 0.54 and 1.08 ± 0.82, respectively). No significant intergroup difference was observed in terms of the sternal wound healing level (p = 0.126); however, the intervention group showed lower mean scores-indicating good wound healing-than the control group.

Conclusion

The TPWHP promotes effective wound healing of the SVG donor site; however, its efficacy on sternal wound healing was uncertain. Therefore, nurses should implement the TPWHP in collaboration with a multidisciplinary team to improve wound healing after hospital discharge.

Trial registration

Thai Clinical Trials Registry (TCTR20211112002).

Stress-Reducing Psychological Interventions as Adjuvant Therapies for Diabetic Chronic Wounds

BACKGROUND

Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and a leading cause of lower limb amputation. Interventions to reduce psychological stress may have the potential to improve self-care and greatly reduce the morbidity and mortality associated with DFU. This review is focused on the consequences of psychological stress in wound healing and reflects on the effects of currently used psychological stress-reducing interventions in patients with DFU, proposing new applications for currently used stress-reduction interventions.

RESULTS

Stress is a natural and fundamental survival mechanism that becomes harmful when chronic. DFU is associated with high levels of anxiety and chronic psychological stress. Chronic stressinduced cortisol and adrenaline release impair wound healing, independently of the stressor. Psychological stress-reducing interventions, such as relaxation with guided imagery, biofeedback-assisted relaxation, mindfulness-based strategies, and hypnosis, can lead to a reduction in perceived stress and improve wound healing by reducing wound inflammation and pain while improving glycemic control. All stress reduction interventions also lead to pain relief and improved patient's quality of life.

CONCLUSION

Psychological stress-reducing interventions are promising adjuvant therapies for DFU. Their clinical application can improve self-care by tackling patient's expectations, anxieties, and fears. They can also help patients manage stress and pain while reducing wound inflammation and improving wound healing.

Use of a Guided Imagery Mobile App (See Me Serene) to Reduce COVID-19-Related Stress: Pilot Feasibility Study

Background

The SARS-CoV-2 pandemic has led to concerns about mental health resulting from regional and national lockdowns, social isolation, job loss, and concern about disease exposure.

Objective

We describe results of the pilot feasibility study of the See Me Serene mHealth app. The app provides users with immersive, vivid, nature experiences to reduce stress and anxiety related to COVID-19 and other isolation. The goals of the study were to develop the See Me Serene app and test the feasibility and acceptability of study procedures, and explore the potential impact of the app on stress and anxiety.

Methods

We developed and tested the See Me Serene app and our study procedures for feasibility, and gathered preliminary data with a goal of 100 participants. The research was conducted in 2 phases: (1) development and internal testing of the app; and (2) feasibility and pilot testing with participants recruited online through earned media (eg, news stories), presentations at a university campus, and social media (eg, online sharing of earned media and presentations). The feasibility study employed a mixed methods, within-subjects, pre-/posttest design. At baseline and 30-day follow-up, we assessed stress-related variables via validated self-report measures and saliva samples for determination of cortisol concentrations.

Results

We met or surpassed all our feasibility benchmarks for recruitment (101 participants recruited), retention (91% [90/99] of 30-day assessment completed), and data collection (99 participants completed all baseline data; 85% [84/99] of salivary cortisol samples returned). Participants adhered to the intervention. On average, participants listened to 48.2 audio files over 30 days or approximately 1.6 audio files per day. Participants were satisfied with the app, with 87% (78/90) rating the app as helpful in dealing with stress and anxiety. The app showed the potential to reduce stress, anxiety, loneliness, and worry. We did not find significant differences (P=.41) in cortisol levels over time. Our findings suggest that future research is warranted to test the efficacy of the See Me Serene app with a representative, diverse sample.

Conclusions

There is a need for evidence-based and easily disseminable stress-reduction interventions. See Me Serene is a feasible intervention and has the potential to reduce stress related to COVID-19 and other forms of social isolation. More research on See Me Serene is warranted.

Salivary cortisol levels and anxiety in melanoma patients undergoing sentinel lymph node excision under local anesthesia versus general anesthesia: a prospective study

BACKGROUND

Sentinel lymph node excision (SLNE) can be performed in tumescent local anesthesia (TLA) or general anesthesia (GA). Perioperative cortisol level changes and anxiety are common in surgical interventions and might be influenced by the type of anesthesia. In this study, we intended to determine whether the type of anesthesia impacts the patients' perioperative levels of salivary cortisol (primary outcome) and the feeling of anxiety evaluated by psychological questionnaires (secondary outcome).

METHODS

All melanoma patients of age undergoing SLNE at the University Hospital Essen, Germany, could be included in the study. Exclusion criteria were patients' intake of glucocorticoids or psychotropic medication during the former 6 months, pregnancy, age under 18 years, and BMI ≥ 30 as salivary cortisol levels were reported to be significantly impacted by obesity and might confound results.

RESULTS

In total, 111 melanoma patients undergoing SLNE were included in our prospective study between May 2011 and April 2017 and could choose between TLA or GA. Salivary cortisol levels were measured three times intraoperatively, twice on the third and second preoperative day and twice on the second postoperative day. To assess anxiety, patients completed questionnaires (Hospital Anxiety and Depression Scale (HADS), State-Trait Anxiety Inventory (STAI)) perioperatively. Patients of both groups exhibited comparable baseline levels of cortisol and perioperative anxiety levels. Independent of the type of anesthesia, all patients showed significantly increasing salivary cortisol level from baseline to 30 min before surgery (T3) (TLA: t = 5.07, p < 0.001; GA: t = 3.09, p = 0.006). Post hoc independent t tests showed that the TLA group exhibited significantly higher cortisol concentrations at the beginning of surgery (T4; t = 3.29, p = 0.002) as well as 20 min after incision (T5; t = 277, p = 0.008) compared to the GA group.

CONCLUSIONS

The type of anesthesia chosen for SLNE surgery significantly affects intraoperative cortisol levels in melanoma patients. Further studies are mandatory to evaluate the relevance of endogenous perioperative cortisol levels on the postoperative clinical course.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00003076, registered 1 May 2011.

Effects of Brief Mood-Improving Interventions on Immunity: A Systematic Review and Meta-Analysis

OBJECTIVE

Positive mood has been associated with enhanced immune function. Interventions that improve mood could therefore provide a mechanism for optimizing immune-related health outcomes. Brief interventions that improve mood, also known as mood inductions, potentially offer a pragmatic approach to enhancing immune function for finite periods where this would be beneficial to health (e.g., in advance of vaccination or surgery). This review sought to systematically examine the evidence regarding the effects of brief, single-session positive mood interventions on immunity.

METHODS

Systematic searches of electronic databases were performed from earliest records to July 25, 2018. We identified 42 interventions suitable for inclusion, 6 of which were tested in multiple subpopulations. Random-effects meta-analyses were performed for pre-post experimental group immune outcomes measured in at least five intervention studies.

RESULTS

Although interventions were heterogeneous, 81% resulted in a statistically significant change in at least one immune parameter after the positive mood intervention for one or more of the subpopulations examined. However, studies were, in general, of low-to-moderate quality with small sample sizes (median n = 32) and did not examine the persistence or clinical relevance of the immune changes observed. Random-effects meta-analyses showed a significant medium-sized effect of interventions on increasing secretory IgA concentration (g = 0.65), a small but statistically significant effect for increased Interleukin-6 production (g = 0.12), and nonsignificant effects on natural killer cell activity (g = 0.15).

CONCLUSIONS

The current literature suggests that improvements in mood resulting from brief interventions can influence some immune parameters in ways indicative of enhanced immune function. However, there is a need for higher-quality research in this area that focuses on clinically relevant immune outcomes and mechanisms.

Humanistic medicine in anaesthesiology: development and assessment of a curriculum in humanism for postgraduate anaesthesiology trainees

BACKGROUND

An unintended consequence of medical technologies is loss of personal interactions and humanism between patients and their healthcare providers, leading to depersonalisation of medicine. As humanism is not integrated as part of formal postgraduate anaesthesiology education curricula, our goal was to design, introduce, and evaluate a comprehensive humanism curriculum into anaesthesiology training.

METHODS

Subject-matter experts developed and delivered the humanism curriculum, which included interactive workshops, simulation sessions, formal feedback, and patient immersion experience. The effectiveness of the programme was evaluated using pre- and post-curriculum assessments in first-year postgraduate trainee doctors (residents).

RESULTS

The anaesthesiology residents reported high satisfaction scores. Pre-/post-Jefferson Scale of Patient Perceptions of Physician Empathy showed an increase in empathy ratings with a median improvement of 12 points (range; P=0.013). After training, patients rated the residents as more empathetic (31 [4] vs 22 [5]; P<0.001; 95% confidence interval [CI]: 7-12) and professional (47 [3] vs 35 [8]; P<0.001; 95% CI: 9-16). Patient overall satisfaction with their anaesthesia provider improved after training (51 [6] vs 37 [10]; P<0.001; 95% CI: 10-18). Patients rated their anxiety lower in the post-training period compared with pretraining (1.8 [2.3] vs 3.6 [1.6]; P=0.001; 95% CI: 0.8-2.9). Patient-reported pain scores decreased after training (2.3 [2.5] vs 3.8 [2.1]; P=0.010; 95% CI: 0.4-2.8).

CONCLUSIONS

Implementation of a humanism curriculum during postgraduate anaesthesiology training was well accepted, and can result in increased physician empathy and professionalism. This may improve patient pain, anxiety, and overall satisfaction with perioperative care.

The effects of psychological interventions on wound healing: A systematic review of randomized trials

PURPOSE

Psychological stress has been shown to delay wound healing. Several trials have investigated whether psychological interventions can improve wound healing, but to date, this evidence base has not been systematically synthesized. The objective was to conduct a systematic review of randomized controlled trials in humans investigating whether psychological interventions can enhance wound healing.

METHODS

A systematic review was performed using PsychINFO, CINAHL, Web of Science, and MEDLINE. The searches included all papers published in English up until September 2016. The reference lists of relevant papers were screened manually to identify further review articles or relevant studies. Nineteen studies met inclusion criteria and were included in the review.

RESULTS

Fifteen of nineteen studies were of high methodological quality. Six studies were conducted with acute experimentally created wounds, five studies with surgical patients, two studies with burn wounds, two studies with fracture wounds, and four studies were conducted with ulcer wounds. Post-intervention standardized mean differences (SMD) between groups across all intervention types ranged from 0.13 to 3.21, favouring improved healing, particularly for surgical patients and for relaxation interventions. However, there was some evidence for publication bias suggesting negative studies may not have been reported. Due to the heterogeneity of wound types, population types, and intervention types, it is difficult to pool effect sizes across studies.

CONCLUSIONS

Current evidence suggests that psychological interventions may aid wound healing. Although promising, more research is needed to assess the efficacy of each intervention on different wound types. Statement of contribution What is already known on this subject? Psychological stress negatively affects wound healing. A number of studies have investigated whether psychological interventions can improve healing. However, no systematic reviews have been conducted. What does this study add? Synthesis and review of 19 trials conducted on psychological interventions and wound healing. Most evidence supports improved healing, particularly for surgical wounds and relaxation interventions. More research is needed on different intervention types with clinical wounds and into mechanisms of action.

The impact of stress on acute wound healing

Within the literature there is an accumulating body of evidence to suggest that psychological stress may have a negative impact on wound healing. This article examines the psychoneuroimmulogy theory associated with stress and acute wound healing with reference to caring for patients with surgical wounds. The evidence reviewed in this article highlights the value of understanding individual patient need for reducing stress pre and post operatively to benefit the healing process.

The role of resilience in rebuilding lives of injured veterans

The aim of this commentary is to discuss potential clinical implications of introducing resilience-building interventions into care for veterans who are living with a war wound. Some war veterans are expected to live with a wound upon discharge from an active military role and also to fit into civilian life. These lifestyle adjustments can tax the person's coping abilities and in that context may hinder successful adaptation. The experience of living with a wound or wounds, either acute or chronic, is connected to losses, including loss of mobility, loss of financial capacity (unable to work at times) and losses attached to changed social roles. Psychological stress is also a common experience for veterans returning to civilian life. Psychological stress is associated with impaired wound healing. Modern health practice is centred on symptom reduction and working with pathology, however, working with people's adaptive behaviours such as resilience has not been considered. Using the resilience model as a conceptual framework health-care professionals can engage with veterans towards resilience within the context of their personal experience of ill health. Using this contemporary framework for considering these aspects of care has the potential to facilitate resistance to stressors associated with being injured, possibly preventing quality-of-life impairments.

DECLARATION OF INTEREST

There are no declarations of interest.

Guided Imagery for Total Knee Replacement: A Randomized, Placebo-Controlled Pilot Study

OBJECTIVES

To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation.

DESIGN

Investigator-blinded, randomized, placebo-controlled pilot study.

SETTINGS

Hospital, surgeon's office, participant's home.

PARTICIPANTS

82 persons undergoing TKR.

INTERVENTIONS

Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments.

OUTCOME MEASURES

Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale.

RESULTS

Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group.

CONCLUSION

Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.

The Effects of Relaxation Before or After Skin Damage on Skin Barrier Recovery: A Preliminary Study

OBJECTIVES

Psychological interventions administered before wounding can reduce stress and improve healing. However, in many cases, it would be more practical for interventions to be delivered after wounding. This preliminary study investigated whether a brief relaxation intervention could improve healing when administered either before or after skin damage produced by tape stripping in comparison to a control group.

METHODS

One hundred twenty-one healthy adults were randomized into one of three groups: (a) relaxation prestripping group, (b) relaxation poststripping group, or (c) no relaxation. Participants completed measures of stress, fatigue, relaxation, and pain. Relaxation consisted of listening to 20 minutes of guided relaxation, whereas the control condition was quiet reading for 20 minutes. Skin barrier function was measured using transepidermal water loss at baseline, immediately after tape stripping and 25 minutes later.

RESULTS

Relaxation either before or after tape stripping improved skin barrier recovery compared with the control group (F(2,92) = 3.58, p = .032, partial η = 0.074). Participants who took part in the relaxation intervention were significantly more relaxed and reported greater reductions in pain than the control group did 25 minutes after tape stripping. Perceived stress over the last month was not significantly related to healing.

CONCLUSIONS

This study showed that a relaxation intervention had a beneficial effect on skin barrier recovery regardless of whether the intervention was administered before or after wounding. Future research needs to replicate these findings in other wound types and in clinical settings, and investigate the biological mechanisms involved.

The Effects of Guided Imagery on Heart Rate Variability in Simulated Spaceflight Emergency Tasks Performers

Objectives. The present study aimed to investigate the effects of guided imagery training on heart rate variability in individuals while performing spaceflight emergency tasks. Materials and Methods. Twenty-one student subjects were recruited for the experiment and randomly divided into two groups: imagery group (n = 11) and control group (n = 10). The imagery group received instructor-guided imagery (session 1) and self-guided imagery training (session 2) consecutively, while the control group only received conventional training. Electrocardiograms of the subjects were recorded during their performance of nine spaceflight emergency tasks after imagery training. Results. In both of the sessions, the root mean square of successive differences (RMSSD), the standard deviation of all normal NN (SDNN), the proportion of NN50 divided by the total number of NNs (PNN50), the very low frequency (VLF), the low frequency (LF), the high frequency (HF), and the total power (TP) in the imagery group were significantly higher than those in the control group. Moreover, LF/HF of the subjects after instructor-guided imagery training was lower than that after self-guided imagery training. Conclusions. Guided imagery was an effective regulator for HRV indices and could be a potential stress countermeasure in performing spaceflight tasks.

Stress predicts the trajectory of wound healing in living kidney donors as measured by high-resolution ultrasound

BACKGROUND

Psychological stress has been shown to be an influential factor on the rate of wound healing; however these findings have been demonstrated predominantly on artificially created wounds. Due to the absence of major co-morbidities, living kidney donors are a unique group in which to study this relationship. This study investigated the effect of preoperative stress and personality on surgical wound healing through the use of high-resolution ultrasound.

METHODS

Living kidney donors due to undergo a hand-assisted laparoscopic donor nephrectomy were asked to complete the Perceived Stress Scale, the Life Orientation Test-Revised and the Ten Item Personality Inventory prior to surgery. High-resolution ultrasound scans of surgical wounds were performed on the first three post-operative days and once following discharge (mean=15.3 days; s.d. 2.8). Two measurements from each image were obtained: wound width (size of wound) and median intensity (a marker of tissue fluid). Latent Growth Curve Models (LGCMs) were used to evaluate wound healing.

RESULTS

52 living kidney donors participated. Higher pre-operative life stress, lower optimism and lower conscientiousness were associated with delayed wound healing in living kidney donors for both outcomes. Increased emotional stability was associated with faster wound healing as demonstrated by a change in median intensity. Possible confounding factors, such as age, BMI, smoking status, local anaesthetic use and wound drain placement were not influential.

CONCLUSIONS

This study, which measured wound healing in a novel patient sample using a novel technique, has demonstrated a negative association between stress and wound healing and the positive influence of optimism, conscientiousness and emotional stability.

How does this make you feel? A comparison of four affect induction procedures

Affect is a fundamental aspect of the human mind. An increasing number of experiments attempt to examine the influence of affect on other psychological phenomena. To accomplish this research, it is necessary to experimentally modify participants' affective states. In the present experiment, we compared the efficacy of four commonly used affect induction procedures. Participants (38 healthy undergraduate students: 18 males) were randomly assigned to either a pleasant or an unpleasant affect induction group, and then underwent four different affect induction procedures: (1) recall of an affectively salient event accompanied by affectively congruent music, (2) script-driven guided imagery, (3) viewing images while listening to affectively congruent music, and (4) posing affective facial actions, body postures, and vocal expressions. All four affect induction methods were successful in inducing both pleasant and unpleasant affective states. The viewing image with music and recall with music procedures were most effective in enhancing positive affect, whereas the viewing image with music procedure was most effective in enhancing negative affect. Implications for the scientific study of affect are discussed.

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.

Wound treatment and pain management: a stressful time

This review and case study report considers the evidence to indicate that the progress of wound healing is negatively affected by the presence of stressors and in circumstances where patients are in pain. It considers the relationship between perceptions of pain, stress and delayed wound healing with a specific focus on guidance for clinical practice. It is appreciated that although the literature has examined these issues in the management of acute wounds, demonstrating that psychological stress can have detrimental effects on the wound-healing process, the evidence to support this link in relation to chronic wounds is limited. The review considers evidence indicating that punch biopsy wounds heal more slowly in subjects under stress on account of caring for family members with long-term illnesses and also considers briefly the relationship between cortisol secretion in response to stress and the consequent influences on cytokine levels and the wound-healing process.

Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures

OBJECTIVES

A large body of research has demonstrated that patient factors are strong predictors of recovery from surgery. Mind-body therapies are increasingly targeted at pre-operative psychological factors. The objective of this paper was to evaluate the efficacy of pre-operative mind-body based interventions on post-operative outcome measures amongst elective surgical patients.

METHODS

A systematic review of the published literature was conducted using the electronic databases MEDLINE, CINAHL and PsychINFO. Randomised controlled trials (RCTs) with a prospective before-after surgery design were included.

RESULTS

Twenty studies involving 1297 patients were included. Mind-body therapies were categorised into relaxation, guided imagery and hypnotic interventions. The majority of studies did not adequately account for the risk of bias thus undermining the quality of the evidence. Relaxation was assessed in eight studies, with partial support for improvements in psychological well-being measures, and a lack of evidence for beneficial effects for analgesic intake and length of hospital stay. Guided imagery was examined in eight studies, with strong evidence for improvements in psychological well-being measures and moderate support for the efficacy of reducing analgesic intake. Hypnosis was investigated in four studies, with partial support for improvements in psychological well-being measures. Evidence for the effect of mind-body therapies on physiological indices was limited, with minimal effects on vital signs, and inconsistent changes in endocrine measures reported.

CONCLUSIONS

This review demonstrated that the quality of evidence for the efficacy of mind-body therapies for improving post-surgical outcomes is limited. Recommendations have been made for future RCTs.

Expressive writing and wound healing in older adults: a randomized controlled trial

OBJECTIVE

To investigate whether expressive writing could speed wound reepithelialization in healthy, older adults.

METHODS

In this randomized controlled trial, 49 healthy older adults aged 64 to 97 years were assigned to write for 20 minutes a day either about upsetting life events (Expressive Writing) or about daily activities (Time Management) for 3 consecutive days. Two weeks postwriting, 4-mm punch biopsy wounds were created on the inner, upper arm. Wounds were photographed routinely for 21 days to monitor wound reepithelialization. Perceived stress, depressive symptoms, health-related behaviors, number of doctor visits, and lipopolysaccharide-stimulated proinflammatory cytokine production were also measured throughout the study.

RESULTS

Participants in the Expressive Writing group had a greater proportion of fully reepithelialized wounds at Day 11 postbiopsy compared with the Time Management group, with 76.2% versus 42.1% healed, χ(2)(1, n = 40) = 4.83, p = .028. Ordinal logistic regression showed more sleep in the week before wounding also predicted faster healing wounds. There were no significant group differences in changes to perceived stress, depressive symptoms, health-related behaviors, lipopolysaccharide-induced proinflammatory cytokine production, or number of doctor visits over the study period.

CONCLUSIONS

This study extends previous research by showing that expressive writing can improve wound healing in older adults and women. Future research is needed to better understand the underlying cognitive, psychosocial, and biological mechanisms contributing to improved wound healing from these simple, yet effective, writing exercises.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (trial number 343095).

Effects on postoperative salivary cortisol of relaxation/music and patient teaching about pain management

The physiological and psychological stress of surgery and postoperative pain can leave patients more susceptible to infection and complications. The present study was designed to determine whether two interventions, patient teaching (PT) for pain management and relaxation/music (RM), reduced cortisol levels, an indicator of stress, following abdominal surgery. Patients (18-75 years) were randomly assigned to receive PT, RM, a combination of the two, or usual care; the 205 patients with both pre- and posttest cortisol values were analyzed. A 2 × 2 factorial design was used to compare groups for PT effects and RM effects. Stress was measured by salivary cortisol before and after 20-min tests of the interventions in the morning and afternoon of postoperative Day 2. Saliva was stimulated with lemon juice and analyzed with high-sensitivity salivary cortisol enzyme immunoassay. Comparisons using analysis of covariance (ANCOVA), controlling for baseline levels, showed no PT effect or RM effect on cortisol in the morning or afternoon. Post hoc ANCOVA showed no significant effects when intervention groups were compared to the control group. Although in previous studies, RM reduced pain and music reduced cortisol on Day 1, in the present study the cortisol response to surgery was not attenuated by PT or RM on Day 2. The RM intervention can be used for pain but needs to be further tested for effects on plasma cortisol in abdominal surgery patients on their first postoperative day.

A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial

Psychological stress has been shown to impair wound healing, but experimental research in surgical patients is lacking. This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients. This randomised controlled trial was conducted at a surgical centre. Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy; exclusion criteria were cancellation of surgery, medical complications, and refusal of consent. Seventy five patients were randomised and 15 patients were excluded; 60 patients completed the study (15 male, 45 female). Participants were randomised to receive standard care or standard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery. In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing. Change in perceived stress from before surgery to 7-day follow-up was assessed using questionnaires. Intervention group patients showed a reduction in perceived stress compared with the control group, controlling for age. Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients (difference in means 0.35, 95% CI 0.66-0.03; t(43)=2.23, p=0.03). Changes in perceived stress were not associated with hydroxyproline deposition. A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients. The intervention may have particular clinical application for those at risk of poor healing following surgery.

The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Fatigue is one of the main complaints after surgery and may last longer than physical symptoms. It prevents return to normal function and activity. Relaxation interventions, performed prior to abdominal surgery, have been shown to reduce pain, wound erythema, and systemic cortisol levels. However, there is a lack of data on the impact of this intervention on patient well-being, functional recovery, activities of daily living, and fatigue after discharge from hospital.

METHODS

The study was a randomised single-blinded trial. Patients who were to undergo elective laparoscopic cholecystectomy for any indication between April 2008 and May 2010 were screened for inclusion. Those in the intervention group attended a standardised 45 min relaxation session with a health psychologist and were given relaxation exercise CDs to take home. The control group did not have the intervention. Patients were followed for 30 days. Fatigue was measured using the identity-consequence fatigue scale.

RESULTS

Seventy-five patients were randomised. Fifteen patients were excluded after randomization for various reasons; hence, 60 patients were followed up and analysed. Both groups had similar fatigue at baseline. There was improved fatigue and consequence of fatigue on postoperative day 30 in the intervention group. There was no difference in fatigue at any other time point postoperatively.

CONCLUSION

This was the first interventional study targeting fatigue after laparoscopic cholecystectomy by using a brief psychological relaxation intervention. It has shown a reduction of fatigue and impact of fatigue at 30 days postoperatively in the intervention group.

Influence of yoga on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery

CONTEXT

Pre- and postoperative distress in breast cancer patients can cause complications and delay recovery from surgery.

OBJECTIVE

The aim of our study was to evaluate the effects of yoga intervention on postoperative outcomes and wound healing in early operable breast cancer patients undergoing surgery.

METHODS

Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited in a randomized controlled trial comparing the effects of a yoga program with supportive therapy and exercise rehabilitation on postoperative outcomes and wound healing following surgery. Subjects were assessed at the baseline prior to surgery and four weeks later. Sociodemographic, clinical and investigative notes were ascertained in the beginning of the study. Blood samples were collected for estimation of plasma cytokines-soluble Interleukin (IL)-2 receptor (IL-2R), tumor necrosis factor (TNF)-alpha and interferon (IFN)-gamma. Postoperative outcomes such as the duration of hospital stay and drain retention, time of suture removal and postoperative complications were ascertained. We used independent samples t test and nonparametric Mann Whitney U tests to compare groups for postoperative outcomes and plasma cytokines. Regression analysis was done to determine predictors for postoperative outcomes.

RESULTS

Sixty-nine patients contributed data to the current analysis (yoga: n = 33, control: n = 36). The results suggest a significant decrease in the duration of hospital stay (P = 0.003), days of drain retention (P = 0.001) and days for suture removal (P = 0.03) in the yoga group as compared to the controls. There was also a significant decrease in plasma TNF alpha levels following surgery in the yoga group (P < 0.001), as compared to the controls. Regression analysis on postoperative outcomes showed that the yoga intervention affected the duration of drain retention and hospital stay as well as TNF alpha levels.

CONCLUSION

The results suggest possible benefits of yoga in reducing postoperative complications in breast cancer patients.

Acute hyperglycemia is related to gastrointestinal symptoms in motion sickness: an experimental study

Motion sickness is caused by exposure to unfamiliar motions and typical symptoms of motion sickness include nausea and vomiting. To observe the metabolic and hormonal differences between nausea/vomiting (NAV) subjects and non-nausea/vomiting (NNV) ones, and to understand how the differences in metabolites and hormones affect the tolerance of organism to acceleration, 60 volunteers were exposed to repetitive acceleration using a 6-degree-of-freedom ship motion simulator. Meanwhile, 36 rats were randomly divided into three groups: an acceleration model group (n=14, exposed to acceleration), insulin group (n=14, intraperitoneal injection of insulin 30 min before exposure to acceleration), and control group (n=8). Gas chromatography coupled to time-of-flight mass spectrometry (GC-TOF/MS) was applied to analyze the serum metabolites in human subjects. Serum glucocorticoid, insulin, and glucagon levels were determined by radioimmunoassay in the NAV and NNV subjects as well as in rats, and serum epinephrine level was determined by ELISA. After acceleration exposure, 9 metabolites, including L-histidine, L-ornithine, L-serine, L-tyrosine, pyroglutamic acid, fumaric acid, urea, n-dodecanoic acid and n-tetradecanoic acid, had different changes in the NAV and NNV groups. The serum levels of 4-hydroxy-L-proline, glucose, oleic acid and urea were significantly higher in the NAV group than in the NNV group after exposure; however, only the elevation degree of serum glucose was significantly greater in the NAV group than in the NNV group (P<0.05). Serum cortisol and epinephrine were increased in both groups. Before exposure, insulin level in the NAV group was significantly lower than that in the NNV group (P<0.05). After rotation exposure, rat serum glucose in the insulin group was significantly lower than that in the acceleration model group (P<0.001), and the motion sickness index was significantly lower than that in the acceleration model group (P<0.05). Our study provides the first evidence that stable glucose level can help to relieve gastrointestinal symptoms in motion sickness, and suggests that acute hyperglycemia is related to gastrointestinal symptoms in motion sickness.

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.

The effect of add-on yogic prana energization technique (YPET) on healing of fresh fractures: a randomized control study

OBJECTIVES

The objective was to study the effect of the add-on yogic prana energization technique (YPET) on healing of fresh fractures.

MATERIALS AND METHODS

Thirty (30) patients (22 men and 8 women) between 18 and 55 years with simple extra-articular fractures of long and short bones were selected from the outpatient department of Ebnezar Orthopaedic Centre and Parimala Speciality Hospital, Bengaluru. They were randomized into yoga (n = 15) and control (n = 15) groups. Compound, complicated, pathologic fractures, old fractures, and those associated with dislocations were excluded. Both groups received the conventional plaster of paris immobilization of the fracture site as the primary treatment. The yoga group, in addition, practiced YPET twice a day (30 minutes/session) for 2 weeks using taped audio instructions after learning under supervision for 1 week. YPET is an advanced yoga relaxation practice that involves breath regulation, chanting, and visualization, which according to yogic science revitalizes the tissues by activating the subtle energies (prana) within the body. Both the groups were assessed on the 1st and 21st day by the Numerical Pain Rating Scale for pain (NRS), tenderness (0-4), swelling (0-4), fracture line density (1-4), and the bridging of cortices (1-4).

RESULTS

Two (2) groups were matched on all variables. The Wilcoxon test showed significant improvement in both groups on all variables. Pain reduction (NRS) was better (p = 0.001 Mann-Whitney test) in the YPET group (94.5%) than in the control group (58.6%); Tenderness reduced (p = 0.001) better in the YPET group (94.4 %) than in the control group (69.12%); Swelling reduced by 93% in the YPET group and by 69.4% in controls (between-groups p = 0.093, i.e., nonsignificant); increase in fracture line density was better (p = 0.001) in the YPET group (48%) than in the control group (18.25%). The number of cortices united was significantly better (p = 0.001) in the YPET group (81.4%) than in controls (39.7 %).

CONCLUSIONS

Add-on yoga-based YPET accelerates fracture healing.

The ability of environmental healthcare design strategies To impact event related anxiety in paediatric patients: A comprehensive systematic review

EXECUTIVE SUMMARY

Background Children's' hospitals are by definition hospitals specialized in all aspects of children's care, but are they and if so, how is that achieved? Are healthcare facilities more than a 'space' in which to ask medical questions, seek answers and obtain treatment? Some suggest that the very design of a space can positively or negatively impact healing, hence the term referred to by those in the architectural community as 'healing spaces'. To date empirical studies to provide evidence to this effect, although growing in number, are still few. What is known is that hospitals, doctor's offices and dental offices alike unintentionally create an atmosphere, particularly for children, that add to an already heightened level of anxiety and fear. Designing a children's hospital, unlike a generalist facility, presents a unique and significant challenge. Those involved in designing such hospitals are faced with the opportunity and responsibility to care for and respond to the needs of children across the age spectrum; infants to toddlers, school aged children to adolescents. As healthcare professionals and architects, it is our responsibility to create healthcare facilities that are of purposeful design; anticipating and alleviating children's anxiety and fear wherever possible.Objectives The objective of this systematic review is to evaluate the effects of environmental design strategies in healthcare institutions such as hospitals and dental offices on event-related anxiety in the paediatric population.Inclusion Criteria This comprehensive systematic review involved children from the age of 1 to 18 years of age admitted to a healthcare facility with the primary outcomes of interest being four key design strategies: positive distraction; elimination of environmental stressors; access to social support and choice (control); and connection to nature.Search Strategy Using the Joanna Briggs defined three step search strategy, both published and unpublished studies were sought from the period of 1980 to 2010.Methods of the Review Data for each study was extracted and assessed by two independent reviewers for methodological validity prior to inclusion in the review using the Joanna Briggs Institute standardised critical appraisal instruments for Qualitative data (JBI-QARI) and for the Meta Analysis of Statistics Assessment (JBI-MAStARI).Results Twenty studies were reviewed, seven of a descriptive experimental design, three of mixed methodologies and thirteen of various qualitative research design methodologies inclusive of Observational, Grounded Theory, Ethnography and Phenomenology.Conclusions The design of the built environment does have the ability to impact either positively or negatively the level of anxiety and fear that children experience when exposed to a healthcare setting. The coping strategies engaged by and unique to each paediatric age group need to not only be understood but supported and reflected in the built environment.Implications for research Architects and healthcare researchers need to collaborate to establish a solid base of evidence related to this important area of interest. Irrespective of the challenges that researchers face in attempting to randomise, manipulate and control the numerous environmental variables that impact a question such as this, such challenges need not, nor should not, prevent or discourage future research. An innovative solution to the challenges faced by researchers in this field is the use of computer modelling and/ or simulation of the hospital environment. Through the use of simulated environments researchers can directly observe user preferences and/ physiological responses.Implication for practice This review highlights an insightful look into the preferences of children as consumers. Although sample sizes were small and results were not quantified in measurable outcomes, the ability for such studies to inform design should not be underestimated. Design strategies both from a practical perspective of minimal cost to construction projects warranting extensive resources are discussed.

Psychological stress and pain in wound care, part 2: a review of pain and stress assessment tools

Several tools are available for the assessment and measurement of stress and pain. While it takes time and money to train practitioners in their use, this will soon be offset by benefits in terms of patient care, satisfaction and reduced costs.

Psychological stress and wound healing in humans: a systematic review and meta-analysis

OBJECTIVE

The current review aims to synthesize existing knowledge about the relationship between psychological stress and wound healing.

METHODS

A systematic search strategy was conducted using electronic databases to search for published articles up to the end of October 2007. The reference lists of retrieved articles were inspected for further studies and citation searches were conducted. In addition, a meta-analysis of a subset of studies was conducted to provide a quantitative estimation of the influence of stress on wound healing.

RESULTS

Twenty-two papers met the inclusion criteria of the systematic review and a subsample of 11 was included in a meta-analysis. The studies assessed the impact of stress on the healing of a variety of wound types in different contexts, including acute and chronic clinical wounds, experimentally created punch biopsy and blister wounds, and minor damage to the skin caused by tape stripping. Seventeen studies in the systematic review reported that stress was associated with impaired healing or dysregulation of a biomarker related to wound healing. The relationship between stress and wound healing estimated by the meta-analysis was r=-0.42 (95% CI=-0.51 to -0.32) (P<.01).

CONCLUSION

Attention now needs to be directed towards investigating potential moderators of the relationship, mediating mechanisms underpinning the association, as well as the demonstration of a causal link by the development of experimental interventions in healthy populations.

Stress management during pregnancy: designing and evaluating a mind-body intervention

The objective of this 12-week study was to determine whether a relaxation-guided imagery (R-GI) intervention designed as a primary prevention strategy for stress management was perceived as beneficial to African American women during the second trimester of pregnancy. All participants documented perceived benefits of the R-GI intervention that included the following: (1) improved breathing; (2) ability to relax, clear one's mind, and become calm; (3) ability to channel and decrease stress; (4) release of anxiety; (5) use of R-GI throughout the day helped control anger and state of mind, leading to a smoother day; and (6) improved ability to fall and stay asleep.

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.

Imagery in the Clinical Setting: A Tool for Healing

This article addresses the why and how of imagery and its relation with holistic theories. The description of clinical applications, program development, and research demonstrates successful interventions in virtually every area of nursing. Case examples show the profound healing that is experienced by the patient and the nurse simultaneously through this work. Imagery is harmless, is time- and cost-effective, and creates a healing partnership between the nurse and patient.

Anxiety, stress, depression, and patients' responses to periodontal treatment: periodontists' knowledge and professional behavior

BACKGROUND

Anxiety, stress, and depression affect the use of health care services, treatment decision-making, and responses to periodontal treatment. This study explored periodontists' confidence in detecting patient anxiety, stress, or depression, as well as their knowledge concerning the relationships between these factors and patients' pain, use of pain medication, and wound healing after periodontal treatment. In addition, this research surveyed if (and which) special accommodations were offered when treating patients with high levels of anxiety, stress, or depression.

METHODS

Data were collected from 171 members of the American Academy of Periodontology (response rate = 34.41%). Most respondents were male (82.2%), white (88.2%), and practiced in solo practices (60.9%).

RESULTS

The respondents were more knowledgeable about the effects of anxiety and stress on pain, the use of pain medication, and wound healing than about the impact of depression on these outcomes. They agreed more strongly with statements that they were more confident in their ability to perceive when patients were anxious and stressed than when they were depressed. They also offered more special accommodations for patients with anxiety and stress than for patients with depression.

CONCLUSIONS

The respondents were significantly less knowledgeable about the impact of depression on patients' responses to periodontal treatment than about the effect of anxiety and stress. Given the evidence concerning the relationships among depression, pain, pain medication use, and wound healing, it is important to educate periodontists about the role of anxiety and stress and the significance of depression on their patients' responses to periodontal therapy.

Surgical Versus Non-Surgical Periodontal Treatment: Psychosocial Factors and Treatment Outcomes

BACKGROUND

This research explored how patients with surgical versus non-surgical periodontal treatment differ in trait anxiety, depression, perceived stress, and well-being on the day of surgery and in their reported pain and use of pain medication 2 and 4 weeks after treatment. In addition, it was investigated how psychosocial factors affected reported pain, use of pain medication, and wound healing.

METHODS

Data were collected from 70 dental patients (34 males and 36 females; average age: 54.79 years; SD=13.206) on the day of their periodontal treatment and 2 and 4 weeks after this treatment. The psychosocial factors (i.e., trait anxiety, depression, perceived stress, and well-being) were measured with standardized scales. The patients' providers assessed their wound healing 2 weeks after treatment.

RESULTS

On the day of treatment, non-surgical patients had higher anxiety, depression, and stress, and poorer well-being than surgical patients. However, surgical patients reported a higher level of pain during the second week, and greater consumption of analgesics during the second and fourth week. Anxiety, depression, stress, and well-being correlated with the reported level of pain, the use of pain medication, and wound healing after periodontal treatment.

CONCLUSIONS

Psychosocial factors (i.e., anxiety, depression, stress, and well-being) can affect the patients' quality of life on the day of periodontal treatment and the pain experience and medications used after surgical and non-surgical periodontal therapy (4-week period). Patient-provider communication should address the role of these factors in the treatment process.