Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery

The Action Cycle Theory of Perception and Mental Imagery

The Action Cycle Theory (ACT) is an enactive theory of the perception and a mental imagery system that is comprised of six modules: Schemata, Objects, Actions, Affect, Goals and Others' Behavior. The evidence supporting these six connected modules is reviewed in light of research on mental imagery vividness. The six modules and their interconnections receive empirical support from a wide range of studies. All six modules of perception and mental imagery are influenced by individual differences in vividness. Real-world applications of ACT show interesting potential to improve human wellbeing in both healthy people and patients. Mental imagery can be applied in creative ways to make new collective goals and actions for change that are necessary to maximize the future prospects of the planet.

Non-pharmacologic Approaches in Preoperative Anxiety, a Comprehensive Review

During the pre-operation period, surgical candidates experience situations that stimulate psychological anxiety leading to stress during and after surgery which is known as preoperative anxiety. This condition can cause psychological and physiological adverse effects on both children and adults. Due to the high prevalence and adverse effects of preoperative anxiety, different treatments have been evaluated including pharmacological and non-pharmacological approaches. As pharmacological treatments may cause adverse effects such as breathing problems, drowsiness, interfering with anesthetic drugs, and prolonged recovery, non-pharmacological interventions are becoming more popular. These methods include cognitive-behavioral therapy, music therapy, pre-op preparation video, aromatherapy, hypnosis, guided imagery relaxation therapy, and massage. In this study, the most popular non-pharmacological approaches to preoperative anxiety are reviewed focusing on more recent evidence provided by clinical studies. The reviewed clinical evidence on the mentioned methods shows the efficacy of non-pharmacological interventions for the treatment of preoperative anxiety, so they can be used in patients of different ages and types of disease and surgery.

Effects of psychological interventions on anxiety and pain in patients undergoing major elective abdominal surgery: a systematic review

A maladaptive response to surgical stress might lead to postoperative complications. A multidisciplinary approach aimed at controlling the surgical stress response may reduce procedural complications and improve patients’ quality of life in the short and long term. Several studies suggest that psychological interventions may interact with the pathophysiology of surgical stress response, potentially influencing wound repair, innate and adaptive immunity, inflammation, perception of pain, and patients’ mood. The aim of this systematic review is to summarise the effects of perioperative psychological interventions on surgical pain and/or anxiety in adult patients scheduled for elective general abdominal and/or urologic surgery.

We conducted a systematic review of controlled clinical trials and observational studies involving psychological interventions for adult patients scheduled for elective general abdominal and/or urologic surgery. Only studies reporting pain and/or anxiety among outcome measures were included in the systematic review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioural therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis and (6) coping strategies.

We examined 2174 papers. Among these, 9 studies were considered eligible for inclusion in this systematic review (1126 patients cumulatively): 8 are randomised controlled trials and 1 is an observational prospective pre/post study.

Psychological characteristics widely influence the pathophysiological mechanisms underlying the neuroendocrine and inflammatory response to surgical stress, potentially interfering with surgical outcomes. Psychological interventions are technically feasible and realistically applicable perioperatively during abdominal and/or urologic surgery; they influence the pathophysiological mechanisms underlying maladaptive surgical stress response and might have positive effects on patients’ surgical outcomes, such as pain and anxiety.

Perioperative pain management for shoulder surgery: evolving techniques

Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.

Preoperative communication with anesthetists via anesthesia service platform (ASP) helps alleviate patients' preoperative anxiety

Female gender has been identified as one of the risk factors closely linked to perioperative anxiety and a lower level of satisfaction. A successful preoperative anesthesia education may improve such negative outcomes. The aim of this study was to investigate whether preoperative anesthesia education via an Anesthesia Service Platform (ASP) could reduce the anxiety levels in female patients scheduled for laparoscopic cholecystectomy under general anesthesia, and accelerate rehabilitation. A total of 222 patients scheduled for elective laparoscopic cholecystectomy were randomly assigned to the control group and the ASP group. Patients’ baseline and post-intervention psychological status was measured by the State-Trait Anxiety Inventory and General Well-Being Schedule. Pain management and recovery were assessed by VAS every 12 h for 48 h after surgery; length of stay (LOS) and postoperative analgesic consumption were also assessed. Patients in the control group experienced higher anxiety levels before surgery and had longer LOS than those in the ASP group. Patients in the ASP group had a higher general well-being score; however, they suffered more pain and consumed more analgesics after surgery. ASP is effective for preventing anxiety in female patients before laparoscopic cholecystectomy, improving patients’ general well-being levels, and shortening their LOS, but negatively influences patients’ postoperative pain levels.

Preoperative Anxiety and Intraoperative Nociception in Patients Undergoing Thoracic Surgery

BACKGROUND

Preoperative anxiety is a common psychological state in cancer patients before surgery, inducing stress responses after surgery. Associations between preoperative anxiety and intraoperative nociception, however, have not been evaluated well. In the present study, we investigated the relationship in patients with lung cancer undergoing thoracic surgery.

MATERIALS AND METHODS

In this prospective study, 27 adult patients were enrolled. Intraoperative nociception during surgery was calculated as mean values of the nociceptive response (NR) throughout surgery. Associations between intraoperative nociception and preoperative patient characteristics including anxiety in addition to intraoperative variables were analyzed using univariate and multivariate regression analyses.

RESULTS

Multiple linear regression analysis revealed that mean NR values during surgery showed a negative correlation with preoperative anxiety (β = -0.353; P = 0.041) after adjustment for body mass index, depression, and total amount of fentanyl used during surgery. Body mass index was a confounder positively associated with mean NR during surgery.

CONCLUSIONS

Intraoperative nociception is likely associated with preoperative patient characteristics, having an inverse relationship with preoperative anxiety.

The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis

INTRODUCTION

Preoperative anxiety and postoperative pain are common problems in patients undergoing surgery. The aim of this study is to analyse the effect of using guided imagery prior to surgery in adults and children to reduce preoperative anxiety and acute postoperative pain, compared with conventional preoperative nursing care.

METHODS

A systematic review and meta-analysis were conducted. We searched randomised clinical trials in databases and search engines.

RESULTS

A total of 1101 records were identified, of which 21 were included in the qualitative synthesis. Two random model meta-analysis were performed with eight trials. Guided imagery preoperatively was shown to be effective in relieving preoperative state anxiety in children (d = -3.71), preoperative trait anxiety in adults (d = -0.64) and postoperative pain in adults (d = -0.24). Postoperative pain in children and preoperative state anxiety in adults was reduced but without significant difference.

CONCLUSION

Guided imagery preoperatively is an effective, easy and low-cost intervention.

Role of Yoga in Cancer Patients: Expectations, Benefits, and Risks: A Review

BACKGROUND

The diagnosis and treatment of cancer poses severe psychologic distress that impacts functional quality of life. While cancer directed treatments are directed purely against tumor killing, interventions that reduce treatment related distress and improve quality of life are the need of the hour. Yoga is one such mind body intervention that is gaining popularity among cancer patients.

METHOD

Several research studies in the last two decades unravel the benefits of yoga in terms of improved mood states, symptom reduction, stress reduction and improved quality of life apart from improving host factors that are known to affect survival in cancer patients. However, several metaanalysis and reviews show equivocal benefits for yoga. In this review, we will study the Yoga interventions in cancer patients with respect to expectations, benefits and risks and analyse the principles behind tailoring yoga interventions in cancer patients.

RESULTS

The studies on Yoga show heterogeneity with varied types of Yoga Interventions, duration, exposure, practices and indications. It also elucidates the situational context for reaping benefits and cautions against its use in several others. However, there are several reviews and bibliometric analysis of effects of yoga; most of them have not enlarged the scope of their review to cover the basic principles behind use of these practices in cancer patients.

CONCLUSION

This review offers insight into the principles and practice of yoga in cancer patients.

Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence.

PERSPECTIVE

This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations.

Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia

BACKGROUND

In a review and meta-analysis conducted in 1993, psychological preparation was found to be beneficial for a range of outcome variables including pain, behavioural recovery, length of stay and negative affect. Since this review, more detailed bibliographic searching has become possible, additional studies testing psychological preparation for surgery have been completed and hospital procedures have changed. The present review examines whether psychological preparation (procedural information, sensory information, cognitive intervention, relaxation, hypnosis and emotion-focused intervention) has impact on the outcomes of postoperative pain, behavioural recovery, length of stay and negative affect.

OBJECTIVES

To review the effects of psychological preparation on postoperative outcomes in adults undergoing elective surgery under general anaesthetic.

SEARCH METHODS

We searched the Cochrane Register of Controlled Trials (CENTRAL 2014, Issue 5), MEDLINE (OVID SP) (1950 to May 2014), EMBASE (OVID SP) (1982 to May 2014), PsycINFO (OVID SP) (1982 to May 2014), CINAHL (EBESCOhost) (1980 to May 2014), Dissertation Abstracts (to May 2014) and Web of Science (1946 to May 2014). We searched reference lists of relevant studies and contacted authors to identify unpublished studies. We reran the searches in July 2015 and placed the 38 studies of interest in the `awaiting classification' section of this review.

SELECTION CRITERIA

We included randomized controlled trials of adult participants (aged 16 or older) undergoing elective surgery under general anaesthesia. We excluded studies focusing on patient groups with clinically diagnosed psychological morbidity. We did not limit the search by language or publication status. We included studies testing a preoperative psychological intervention that included at least one of these seven techniques: procedural information; sensory information; behavioural instruction; cognitive intervention; relaxation techniques; hypnosis; emotion-focused intervention. We included studies that examined any one of our postoperative outcome measures (pain, behavioural recovery, length of stay, negative affect) within one month post-surgery.

DATA COLLECTION AND ANALYSIS

One author checked titles and abstracts to exclude obviously irrelevant studies. We obtained full reports of apparently relevant studies; two authors fully screened these. Two authors independently extracted data and resolved discrepancies by discussion.Where possible we used random-effects meta-analyses to combine the results from individual studies. For length of stay we pooled mean differences. For pain and negative affect we used a standardized effect size (the standardized mean difference (SMD), or Hedges' g) to combine data from different outcome measures. If data were not available in a form suitable for meta-analysis we performed a narrative review.

MAIN RESULTS

Searches identified 5116 unique papers; we retrieved 827 for full screening. In this review, we included 105 studies from 115 papers, in which 10,302 participants were randomized. Mainly as a result of updating the search in July 2015, 38 papers are awaiting classification. Sixty-one of the 105 studies measured the outcome pain, 14 behavioural recovery, 58 length of stay and 49 negative affect. Participants underwent a wide range of surgical procedures, and a range of psychological components were used in interventions, frequently in combination. In the 105 studies, appropriate data were provided for the meta-analysis of 38 studies measuring the outcome postoperative pain (2713 participants), 36 for length of stay (3313 participants) and 31 for negative affect (2496 participants). We narratively reviewed the remaining studies (including the 14 studies with 1441 participants addressing behavioural recovery). When pooling the results for all types of intervention there was low quality evidence that psychological preparation techniques were associated with lower postoperative pain (SMD -0.20, 95% confidence interval (CI) -0.35 to -0.06), length of stay (mean difference -0.52 days, 95% CI -0.82 to -0.22) and negative affect (SMD -0.35, 95% CI -0.54 to -0.16) compared with controls. Results tended to be similar for all categories of intervention, although there was no evidence that behavioural instruction reduced the outcome pain. However, caution must be exercised when interpreting the results because of heterogeneity in the types of surgery, interventions and outcomes. Narratively reviewed evidence for the outcome behavioural recovery provided very low quality evidence that psychological preparation, in particular behavioural instruction, may have potential to improve behavioural recovery outcomes, but no clear conclusions could be reached.Generally, the evidence suffered from poor reporting, meaning that few studies could be classified as having low risk of bias. Overall,we rated the quality of evidence for each outcome as 'low' because of the high level of heterogeneity in meta-analysed studies and the unclear risk of bias. In addition, for the outcome behavioural recovery, too few studies used robust measures and reported suitable data for meta-analysis, so we rated the quality of evidence as `very low'.

AUTHORS' CONCLUSIONS

The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well-conducted and clearly reported research.

Stress Management in Patients Undergoing Carotid Endarterectomy for Carotid Artery Stenosis: A Pilot Randomized Controlled Trial

BACKGROUND

Psychological stress is common to patients submitted to cardiovascular operations. The purpose of this pilot, single-center, open-label, randomized controlled trial was to investigate the effects of a stress management program (SMP) on patients undergoing carotid endarterectomy (CEA).

METHODS

A sample of 24 patients with significant (>70%) carotid stenosis was finally randomized to SMP (intervention group; n = 12) or no-stress management intervention (control group; n = 12) before CEA. SMP consisted of 2 relaxation techniques (relaxation-breathing and guided imagery) before and 8 weeks after CEA. Measurements included Perceived Stress Scale (PSS), Hospital Anxiety and Depression Scale (HADS), Health Locus of Control Scale (HLC), and blood pressure and heart rate.

RESULTS

The 2 groups did not differ in terms of demographic characteristics, vascular risk factors, and baseline psychometric measurements. No delay on the time of surgery was caused by the practice of the relaxation techniques. Both perceived stress and anxiety improved within the intervention group at the end of the program (P = 0.005 and P = 0.007, respectively). No improvement in PSS-14, HLC, and HADS scores were documented in control group at the end of the 8-week follow-up period. The intervention group had lower PSS-14 scores at 8 weeks after CEA (median PSS-14 score, 20 points; range, 10-28) compared with control group (median PSS, 25 points; range, 11-47; P = 0.026). No significant effect of SMP was found for blood pressure and heart rate measurements.

CONCLUSIONS

Our results indicate that relaxation techniques appear to be beneficial in terms of stress and anxiety reduction in patients undergoing CEA. These findings require independent confirmation in the setting of a larger, double-blind randomized controlled trial.

A randomized trial comparing live and telemedicine deliveries of an imagery-based behavioral intervention for breast cancer survivors: reducing symptoms and barriers to care

OBJECTIVE

This multi-site randomized trial evaluates the quality of life (QOL) benefits of an imagery-based group intervention titled 'Envision the Rhythms of Life'(ERL).

METHODS

Breast cancer survivors >6 weeks post-treatment were randomized to attend five weekly 4-h group sessions at a community center with therapist present (live delivery (LD), n = 48), therapist streamed via telemedicine (telemedicine delivery (TD), n = 23), or to a waitlist control (WL) group (n = 47). Weekly individual phone calls to encourage at-home practice began at session one and continued until the 3-month follow-up. Seven self-report measures of QOL were examined at baseline, 1-month and 3-month post-treatments including health-related and breast cancer-specific QOL, fatigue, cognitive function, spirituality, distress, and sleep.

RESULTS

The Bonferroni method was used to correct for multiple comparisons, and alpha was adjusted to 0.01. Linear multilevel modeling analyses revealed less fatigue, cognitive dysfunction, and sleep disturbance for LD and TD compared with WL across the follow-up (p's < 0.01). Changes in fatigue, cognitive dysfunction, sleep disturbance, and health-related and breast cancer-related QOL were clinically significant. There were no differences between LD and TD.

CONCLUSIONS

Both the live and telemedicine delivered ERL intervention resulted in improvements in multiple QOL domains for breast cancer survivors compared with WL. Further, there were no significant differences between LD and TD, suggesting telemedicine delivered ERL intervention may represent an effective and viable option for cancer survivors in remote areas.

Visualising future behaviour: Effects for snacking on biscuit bars, but no effects for snacking on fruit

In this study, participants ( N = 223) were randomised to visualise snacking on fruit, visualise snacking on biscuit bars or no visualisation, and intentions and attitudes towards fruit and biscuit bars, immediate selection of fruit or biscuit bars and subsequent consumption were measured. No effects of visualising snacking on fruit were found once background variables were taken into account. Visualising snacking on biscuit bars, however, resulted in greater intentions to consume biscuit bars (smallest β = 0.19, p < 0.01). These findings suggest that specifics of the visualised target behaviour may be important in visualisation. Further investigation is needed before recommending visualisation for increasing fruit consumption.

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.

Stress, coping and cognitive deficits in women after surgery for breast cancer

Research on neuropsychological difficulties among cancer patients has focused on chemotherapy as a primary cause, yet several studies have now shown that some patients evidence cognitive weaknesses prior to chemotherapy. As an alternative to the 'chemo-brain' theory, this study examined the hypothesis that stress and coping style may be associated with observed neuropsychological difficulties among female cancer patients. Thirty-six women completed neuropsychological testing and psychological questionnaires following surgery for breast cancer and prior to any subsequent treatments. Twenty-seven percent of participants evidenced deficits on at least one measure of verbal fluency, and 14% of participants were impaired on at least one memory measure. Self-reported stress was correlated with deficits in memory, verbal fluency, and attention. Subsequent mediational analyses indicated that use of passive coping styles may underlie this relationship between stress and neuropsychological deficits. These findings highlight the potential relevance of psychological mechanisms, such as coping style, in cancer patients' experience of neuropsychological deficits.

Guided imagery for non-musculoskeletal pain: a systematic review of randomized clinical trials

CONTEXT

Our previous review of the literature concluded that there is encouraging evidence that guided imagery alleviates musculoskeletal pain, but the value of guided imagery in the management of non-musculoskeletal pain remains uncertain.

OBJECTIVES

The objective of this systematic review was to assess the effectiveness of guided imagery as a treatment option for non-musculoskeletal pain.

METHODS

Six databases were searched from their inception to February 2011. Randomized clinical trials were considered if they investigated guided imagery in human patients with any type of non-musculoskeletal pain in any anatomical location and assessed pain as a primary outcome measure. Trials of motor imagery and hypnosis were excluded. The selection of studies, data extraction, and validation were performed independently by two reviewers.

RESULTS

Fifteen randomized clinical trials met the inclusion criteria. Their methodological quality was generally poor. Eleven trials found that guided imagery led to a significant reduction of non-musculoskeletal pain. Four studies found no change in non-musculoskeletal pain with guided imagery in comparison with progressive relaxation, standard care, or no treatment.

CONCLUSION

The evidence that guided imagery alleviates non-musculoskeletal pain is encouraging but remains inconclusive.

Influence of yoga on mood states, distress, quality of life and immune outcomes in early stage breast cancer patients undergoing surgery

Context:

Breast cancer patients awaiting surgery experience heightened distress that could affect postoperative outcomes.

Aims:

The aim of our study was to evaluate the effects of yoga intervention on mood states, treatment-related symptoms, quality of life and immune outcomes in breast cancer patients undergoing surgery.

Settings and Design:

Ninety-eight recently diagnosed stage II and III breast cancer patients were recruited for a randomized controlled trial comparing the effects of a yoga program with supportive therapy plus exercise rehabilitation on postoperative outcomes following surgery.

Materials and Methods:

Subjects were assessed prior to surgery and four weeks thereafter. Psychometric instruments were used to assess self-reported anxiety, depression, treatment-related distress and quality of life. Blood samples were collected for enumeration of T lymphocyte subsets (CD4 %, CD8 % and natural killer (NK) cell % counts) and serum immunoglobulins (IgG, IgA and IgM).

Statistical Analysis Used:

We used analysis of covariance to compare interventions postoperatively.

Results:

Sixty-nine patients contributed data to the current analysis (yoga n = 33, control n = 36). The results suggest a significant decrease in the state (P = 0.04) and trait (P = 0.004) of anxiety, depression (P = 0.01), symptom severity (P = 0.01), distress (P < 0.01) and improvement in quality of life (P = 0.01) in the yoga group as compared to the controls. There was also a significantly lesser decrease in CD 56% (P = 0.02) and lower levels of serum IgA (P = 0.001) in the yoga group as compared to controls following surgery.

Conclusions:

The results suggest possible benefits for yoga in reducing postoperative distress and preventing immune suppression following surgery.

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.

Psychological factors in immunomodulation induced by cancer surgery: a review

The immune system's efficacy in detecting and destroying cancer cells varies considerably throughout the stages of cancer development and its role may be critical particularly during the surgical period. Although surgery causes tumor cells to shed into the blood, immune cells have the capacity to destroy these tumor cells. However, surgery also suppresses cytotoxic capacity. It is particularly during this surgical period that psychological factors can have a significant dampening or strengthening impact on surgery-related immunomodulation response, thus exerting an effect on survival. This review describes the immune changes during the peri-surgical period and the influences psychological factors have on immune function, including the immune effects caused by psychological interventions in cancer patients. We recommend that future studies exploring the role of psychological factors on immune function and survival focus more on their influence during the peri-surgical period.

Psychologic considerations in the management of oral surgical patients

Entering the often-sterile milieu that characterizes most surgical and presurgical environments sets into motion, for most patients, emotional or psychologic reactions. At times, these inner stirrings may manifest in the form of outward behaviors, such as expressions of anxiety or anger or verbalizations suggestive of depression. The essential psychologic issue is that undergoing any surgery--minor, major, elective, or urgent--is far from an emotionally neutral event for typical oral surgical patients.

The effects of a presurgical stress management intervention for men with prostate cancer undergoing radical prostatectomy

PURPOSE This study assessed the short-term and long-term efficacy of a presurgical stress management intervention at reducing mood disturbance and improving quality of life (QOL) in men undergoing radical prostatectomy (RP) for prostate cancer. PATIENTS AND METHODS One hundred fifty-nine men were randomly assigned to a two-session (plus two boosters) presurgical stress management intervention (SM), a two-session (plus two boosters) supportive attention group (SA), or a standard care group (SC). Assessments occurred 1 month before surgery; 1 week before surgery; the morning of surgery; 6 weeks after surgery, and 6 and 12 months after surgery. Results Results indicated significant group differences in mood disturbance before surgery (P = .02), such that men in the SM group had significantly less mood disturbance than men in the SC group (P = .006), with no significant differences between the SM and SA or SA and SC groups. In the year after surgery, there were significant group differences on Medical Outcomes Study 36-item short form survey (SF-36) physical component summary (PCS) scores (P = .004); men in the SM group had significantly higher PCS scores than men in the SC group (P = .0009), and there were no significant differences between the SM and SA or SA and SC groups. There were no group effects on prostate-specific QOL or SF-36 mental health scores. CONCLUSION These findings demonstrate the efficacy of a brief presurgical stress management intervention in improving some short-term and long-term outcomes. If these results are replicated, it may be a useful adjunct to standard care for men with prostate cancer undergoing surgery.

Impact of stressors in a natural context on release of cortisol in healthy adult humans: a meta-analysis

Increased hypothalamic-pituitary-adrenal (HPA) activation, culminating in elevated circulating cortisol levels is a fundamental response to stressors. In animals, this neuroendocrine change is highly reliable and marked (approximately 5-10-fold elevations), whereas in humans, the increase of cortisol release is less pronounced, and even some potent life-threatening events (anticipation of surgery) only elicit modest cortisol increases. Meta-analysis of factors that influenced the increase of cortisol release in a laboratory context pointed to the importance of social evaluative threats and stressor controllability in accounting for the cortisol rise. The present meta-analysis, covering the period from 1978 through March 2007, was undertaken to identify the factors most closely aligned with cortisol increases in natural settings. It appeared that stressor chronicity was fundamental in predicting cortisol changes; however, this variable is often confounded by the stressor type, the stressor's controllability, as well as contextual factors, making it difficult to disentangle their relative contributions to the cortisol response. Moreover, several experiential factors (e.g. previous stressor experiences) may influence the cortisol response to ongoing stressors, but these are not readily deduced through a meta-analysis. Nevertheless, there are ample data suggesting that stressful events, through their actions on cortisol levels and reactivity, may influence psychological and physical pathology.

The development and validation of the Pre-operative Intrusive Thoughts Inventory (PITI)

Pre-operative anxiety is common and influences postoperative pain, hospital stay and patient satisfaction. We set out to explore anxiety content and develop a tool to evaluate patient anxiety at the pre-operative assessment clinic. We recruited 128 day surgery patients. Pre-operative anxiety content was explored and six factors (themes) were identified: 'preoccupation', 'outcome concerns', 'being unconscious', 'loss of control', 'dependence on others' and 'pain/discomfort'. The Pre-operative Intrusive Thoughts Inventory (PITI) was constructed and evaluated using exploratory and confirmatory factor analysis. The PITI demonstrated internal consistency for the full scale (Cronbach's alpha = 0.91) and for the subscales (Cronbach's alpha 0.74-0.85) as well as sensitivity (0.88) and specificity (0.60) to clinically significant anxiety assessed using the Hospital Anxiety and Depression Scale. The properties of the PITI suggest that it has potential as an additional tool for the evaluation of pre-operative anxiety.

Guided imagery and relaxation in conventional colorectal resections: a randomized, controlled, partially blinded trial

PURPOSE

The aim of this study was to investigate whether brief psychologic interventions to reduce perioperative stress may improve the postoperative course of patients undergoing abdominal surgery.

METHODS

We used a randomized, controlled, partially blinded trial to evaluate the differential effectiveness of two brief psychologic interventions (guided imagery and progressive muscle relaxation) on analgesic requirement, pain perception, pulmonary function, duration of postoperative ileus, and fatigue after conventional resection of colorectal carcinoma in elderly cancer patients.

RESULTS

Sixty patients (20 guided imagery, 22 relaxation, 18 control) were evaluated. Acceptance of the brief psychologic interventions was high and 90 percent of the patients indicated that they would recommend it to other patients. Analgesic consumption (P = 0.6) and subjective pain intensity at rest (P = 0.3) and while coughing (P = 0.3) were not different between groups. Recovery of pulmonary function, duration of postoperative ileus, and subjective postoperative fatigue were also not influenced. When the data from intervention groups were pooled, again no benefits were detected compared with the control group.

CONCLUSIONS

Brief psychologic interventions such as guided imagery and relaxation yielded a very positive patient response but did not show a clinically relevant influence on the postoperative physiologic course of elderly patients undergoing conventional resections of colorectal cancer.

Funktionsst�rung der hypothalamisch-hyphophys�r-adrenalen Achse bei Patienten mit akuten, chronischen und intervallartigen Schmerzsyndromen

INTRODUCTION

Complex disorders of the hypothalamic-pituitary-adrenal axis constitute phenomena whose etiopathogenetic significance is the subject of controversy. The frequent coincidence with depressive symptoms further complicates interpretation.

PATIENTS AND METHODS

Daily variations in cortisol levels were measured in 20 patients with acute pain, 27 with chronic pain in the lumbar musculoskeletal system, and 44 with episodic forms of headache to determine the daily average and then correlated with differentiated algesimetric data.

RESULTS

Patients with chronic and episodic pain had significantly higher scores on the McGill Pain Questionnaire and more affective items as an expression of depressive symptoms than patients with acute pain. The three groups did not however exhibit significant differences for the depression scale and list of "psychovegetative" disorders. In comparison to an age-matched pain-free control population (n=17), the average daily levels of cortisol were significantly higher in all three groups besides singularly elevated daily levels, but no correlations between the cortisol values and overall algesimetric data could be established. Chronic pain patients with high depression scores had significantly higher cortisol levels irrespective of pain intensity.

DISCUSSION

Pain experiences cause increased plasma cortisol levels with significant elevation of the daily average. Whereas in cases of acute pain, a direct but unspecific stress reaction not connected with the pain seems to be likely, the underlying cause in cases of chronic and episodic pain appears to be a complex and enduring activation of the hypothalamic-pituitary-adrenal axis, likewise independent from pain, probably associated with concomitant depressive symptoms and disruption of the circadian rhythm of release controlled by the hypothalamus.

Interactive Guided ImagerySMTherapy with Medical Patients: Predictors of Health Outcomes

OBJECTIVES

To assess whether Interactive Guided Imagery (IGI) is helpful to medical patients and to identify factors that contribute to positive outcomes.

DESIGN

A prospective cohort study of 323 medical patients who received 6 IGI sessions on a weekly basis. Patients and practitioners completed questionnaires at the beginning, middle, and end of the 6 IGI sessions. The questionnaires assessed the patients' ability to do IGI, the quality of the practitioner-patient interaction, possible confounding variables, and enabling factors. The hypothesis was that measures of the process of doing IGI and the practitioner-patient relationship would predict outcomes.

SUBJECTS/SETTING

The subjects were all patients seeking treatment at California Pacific Medical Center in San Francisco, and Marin General Hospital in Greenbrae, CA.

INTERVENTION

Using IGI interactively is a cognitive-behavioral intervention designed to help patients relax by using mental images to discover and cultivate healing intentions, and to reflect on the meaning of these images.

MEASURES

The individual measures to assess the patients' ability to do IGI and measures of the practitioner-patient relationship were factor-analyzed to use as predictor variables in a multiple regression. Similarly, the questionnaire items measuring cognitive, emotional, behavioral, and spiritual benefits of IGI were factor-analyzed into factors representing "insight" and "all other" benefits.

RESULTS

The multiple regression shows that both process and practitioner-patient interaction factors significantly contributed to a combined 40% of the variance in patients' ratings of insight into the nature of their problem and to becoming aware of an aspect of self, F(4,56) = 9.4, p < 0.005. The same process and interaction factors were less strongly related to the other outcomes, r2 = 0.14, F(4,56) = 2.3, p = 0.06. None of the demographic, confounding, or enabling factors was related to the outcome measures.

CONCLUSIONS

The process of doing IGI and the relationship with the practitioner were both independently associated with the patients' insight into their health problems.

The impact of preoperative information on state anxiety, postoperative pain and satisfaction with pain management

The primary objective of this study was to test whether specific information given prior to surgery can help patients obtain better pain relief after total knee arthroplasty (TKA). Secondary objectives were to study the impact of preoperative information on state and trait anxiety, satisfaction with pain management and satisfaction with nursing care. The study was an intervention study with two groups of equal size (n=30). The intervention group was given specific information while the control group received routine information. Pain assessments were made preoperatively and every 3h for the first three postoperative days, using the visual analogue scale (VAS). The results of this study suggest that information does influence the experience of pain after surgery and related psychological factors. The postoperative pain declined more rapidly for patients in the treatment group, the degree of preoperative state anxiety was lower and they were more satisfied with the postoperative pain management.

The effect of two nursing interventions on the postoperative outcomes of gynecologic laparoscopic patients

Anecdotal reports support research findings in documenting the high incidence of negative postoperative outcomes after gynecologic (GYN) laparoscopic surgery. Three outcome measures, postoperative pain, postoperative nausea and vomiting (PONV), and length of stay, have received considerable attention. Two nursing interventions frequently suggested for their positive effects are guided imagery and music therapy. An experimental pilot study was conducted to determine the effects of these nursing inventions on postoperative pain, PONV, and length of stay for GYN laparoscopic patients (n = 84). During the perioperative period, patients were randomly assigned to one of 3 interventions: guided imagery audiotapes (GI), music audiotapes (MU), or standard care (C), and outcome measures were evaluated. Results indicated that patients in both the guided imagery and music groups had significantly less pain on PACU discharge to home than the patients in the control group. These findings suggest that both guided imagery and music are effective strategies in improving pain, a difference that becomes apparent when the patient is ready to be discharged. It is possible that these interventions act as distractions in reducing the report of negative postoperative outcomes.

Stress, coping, and immune function in breast cancer

Research has found suggestive links between emotional distress and immune and neuroendocrine measures in cancer patients. Furthermore, several studies have reported that participation in psychological support groups is associated with better health outcomes for cancer patients. However, controversy exists surrounding these findings, and the mechanisms behind such effects are unclear. This article integrates current evidence from several lines of research concerning the relations among coping, psychological adjustment, cortisol and immune function, and disease progression in breast cancer patients. A biopsychosocial model is evaluated in which coping and psychological adjustment are associated with alterations in cortisol levels, immune function, and potential long-term medical outcomes in breast cancer patients. Although strong evidence suggests that coping and psychosocial intervention can improve psychological outcomes for breast cancer patients, potential effects on physiological outcomes remain speculative.

Effects of adjunctive Swedish massage and vibration therapy on short-term postoperative outcomes: a randomized, controlled trial

OBJECTIVE

To examine the effects of adjunctive postoperative massage and vibration therapy on short-term postsurgical pain, negative affect, and physiologic stress reactivity.

DESIGN

Prospective, randomized controlled trial. The treatment groups were: (1) usual postoperative care (UC); (2) UC plus massage therapy; or (3) UC plus vibration therapy.

SETTING

The University of Virginia Hospital Surgical Units, Gynecology-Oncology Clinic, and General Clinical Research Center.

SUBJECTS

One hundred and five (N = 105) women who underwent an abdominal laparotomy for removal of suspected cancerous lesions.

INTERVENTIONS

All patients received UC with analgesic medication. Additionally, the massage group received standardized 45-minute sessions of gentle Swedish massage on the 3 consecutive evenings after surgery and the vibration group received 20-minute sessions of inaudible vibration therapy (physiotones) on the 3 consecutive evenings after surgery, as well as additional sessions as desired.

OUTCOME MEASURES

Sensory pain, affective pain, anxiety, distress, analgesic use, systolic blood pressure, 24-hour urine free cortisol, number of postoperative complications, and days of hospitalization.

RESULTS

On the day of surgery, massage was more effective than UC for affective (p = 0.0244) and sensory pain (p = 0.0428), and better than vibration for affective pain (p = 0.0015). On postoperative day 2, massage was more effective than UC for distress (p = 0.0085), and better than vibration for sensory pain (p = 0.0085). Vibration was also more effective than UC for sensory pain (p = 0.0090) and distress (p = .0090). However, after controlling for multiple comparisons and multiple outcomes, no significant differences were found.

CONCLUSIONS

Gentle Swedish massage applied postoperatively may have minor effects on short-term sensory pain, affective pain, and distress among women undergoing an abdominal laparotomy for removal of suspected malignant tissues.

Development and evaluation of a video program for presentation prior to elective cardiac surgery

BACKGROUND

: The objective of the present study was to develop and evaluate the effects of a preparatory videotape on endocrine stress responses of patients prior to cardiac surgery and to analyze patient acceptance of this video for preoperative preparation.

METHODS

: 101 male patients prior to elective cardiac surgery were enrolled into the study. On the day before surgery, patients were assigned to one of the following groups: group 1 (n = 51) saw a video with realistic information about the upcoming perioperative procedure, and group 2 (n = 50) saw a video of the same length without surgery-related information. Venous blood was sampled before and 15 min after the video presentation. On the second postoperative day, patients filled in a questionnaire concerning their experiences of having preoperatively watched the video.

RESULTS

: After viewing the video, blood levels of cortisol, adrenocorticotropic hormone (ACTH), beta-endorphin, prolactin, epinephrine and norepinephrine in patients of group 1 were not significantly different compared to values measured before the video presentation. In patients of group 2, blood levels of cortisol, ACTH, prolactin and norepinephrine were significantly lower after video presentation compared to values obtained before the video. Patients of group 1 (compared to group 2) were significantly more often of the opinion that the video had helped in the preparation for surgery, and that they would like to repeat this adjunct preoperative video preparation in another similar situation.

CONCLUSION

: We conclude from our results that (i); cardiac surgical patients prefer preoperatively an adjunct surgery-related video preparation to a non-specific video presentation, and that (ii); preoperative preparation with realistic information about the upcoming medical procedure in patients undergoing cardiac surgery does not lead to an increase in endocrine stress hormone levels.

Mind-body medicine. An introduction and review of the literature

MBM is a well-established phenomenon in modern medicine. If one accepts a model of mind/body that is truly nondualistic, it could be said that the MBM phenomenon is inherent to medicine. Because of its popularity and efficacy for common chronic conditions, MBM may have its greatest presence in primary care medicine. The flourishing of MBM techniques resulting from the public's enthusiastic embrace of these therapies has created a great need for rigorous scientific examination. The MBM literature may be said to be in its adolescence, having grown out of its early years of enthusiastic case reports and small studies, but not yet fully grown into a broad catalogue of large controlled experimental trials. Nevertheless, clinical trials suggest that certain MBM therapies are effective in improving quality of life, anxiety, and pain intensity for a variety of conditions. There is moderate evidence to suggest these techniques improve chronic pain, headache, insomnia, and other common conditions. There is preliminary evidence to suggest these techniques may affect coronary artery disease and cancer. MBM techniques ultimately may prove to be most effective in combinations or in conjunction with traditional treatment.

Anxiety and surgical recovery. Reinterpreting the literature

OBJECTIVE

To critically evaluate the interpretation of the findings reported in the peer-reviewed literature concerning the association of state and trait anxiety with surgical recovery and response to surgery.

METHODS

The Social Science Citation Index (SSCI), Science Citation Index (SCI), Medline and Psychological Abstracts (PsycInfo) databases were searched for studies published since 1981. Reference lists from previous reviews were also searched for additional references. Studies that were not in the public domain were not searched for.

RESULTS

Twenty-seven studies were identified by the search strategy, met the inclusion criteria and contributed to the review.

CONCLUSIONS

Associations between preoperative measures of anxiety and postoperative mood and pain have been consistently reported. Associations with regard to other recovery variables are less consistent. The existing evidence does not rule out an interpretation of the results as reflecting consistent self-reporting bias rather than causal association.

Videotape preparation of patients before hip replacement surgery reduces stress

OBJECTIVE

Elective surgery represents a considerable source of stress for the patient. Many attempts have been made to prepare patients before surgery with the aim of reducing stress and improving outcome. This study used a novel approach to fulfill this aim by showing a videotape of a patient undergoing total hip replacement surgery, covering the time period from hospital admission to discharge, that strictly keeps to the patient's perspective.

METHODS

Before elective total hip replacement surgery, 100 patients were randomly assigned to a control group or a preparation group; the latter group was shown the videotape on the evening before surgery. Anxiety and pain were evaluated daily for 5 days, beginning with the preoperative day, by means of the State-Trait Anxiety Inventory and a visual analog scale. Intraoperative heart rate and blood pressure, as well as postoperative intake of analgesics and sedatives, were recorded. Urinary levels of cortisol, epinephrine, and norepinephrine were determined in 12-hour samples collected at night for 5 nights, beginning with the preoperative night.

RESULTS

Compared with the control group, the preparation group showed significantly less anxiety on the morning before surgery and the mornings of the first 2 postoperative days, and significantly fewer of them had an intraoperative systolic blood pressure increase of more than 15%. The pain ratings did not differ significantly between the two groups, but the prepared patients needed less analgesic medication after surgery. Prepared patients had significantly lower cortisol excretion during the preoperative night and the first 2 postoperative nights. Excretion of catecholamines did not differ significantly between groups.

CONCLUSIONS

We conclude that use of the videotape decreased anxiety and stress, measured in terms of urinary cortisol excretion and intraoperative systolic blood pressure increase, in patients undergoing hip replacement surgery and prepared them to cope better with postoperative pain.

Patients' reactions to attempts to increase passive or active coping with surgery

It is generally regarded as valuable for patients to exercise control over aspects of their medical treatment. Although psychological and other interventions are commonly used with the aim of increasing patients' ability or willingness to control events, it is not known whether patients experience these procedures in the way assumed. The present study compared responses to (i) a psychological intervention designed to increase patients' readiness to exercise control and cope actively and (ii) a comparable intervention intended to induce acceptance and passive coping. Hip or knee arthroplasty patients were visited preoperatively by a researcher who administered the active (N = 15) or passive (N = 15) intervention in a dialogue with the patient. Patients' verbal responses to the interventions were analyzed qualitatively to identify the range of reactions to each type of intervention. Patients readily accepted the passive message on the grounds of doctors' and nurses' authority and the value of the patients' emotional detachment from their surgery. Few responses to the active message indicated acceptance that patients have control over their care and its outcomes; instead, recipients typically interpreted it in terms of the need for obedience to medical and nursing authority. In conclusion, patients do not automatically accept messages intended to change ways of coping. In particular, the attempt to increase patients' readiness to take control over aspects of care can be perceived by patients in an opposite way to that intended. This and previous studies suggest that patient control over aspects of treatment is a professional and theoretical construction that often means little to patients.

Predictors of quality of life and adjustment after lung transplantation

STUDY OBJECTIVE

Few studies have examined predictors of quality of life and adjustment after lung transplantation. This study determined whether pretransplant psychological measures predicted physical health, quality of life, and overall adjustment posttransplant. Cross-sectional analyses also examined differences in adjustment and quality of life for lung transplant candidates and recipients.

DESIGN AND PARTICIPANTS

Seventeen transplant candidates and 60 transplant recipients completed questionnaires measuring adjustment and quality of life. In addition, we examined archival data on 107 transplant candidates who had received pretransplant psychological assessments, and posttransplant physical health status data were collected on these patients. Of the 107 patients who provided a pretransplant psychological assessment, 32 completed the questionnaires measuring posttransplant adjustment and quality of life.

SETTING

University medical center transplant service.

RESULTS

Cross-sectional analyses indicated significantly better adjustment and quality of life posttransplant. Pretransplant psychological variables were not associated with measures of posttransplant physical health. Hierarchical multiple regression analyses found that pretransplant anxiety and psychopathology predicted posttransplant adjustment (beta's ranging from 0.32 to 0.68) and greater pretransplant anxiety also predicted worse posttransplant quality of life (beta's ranging from 0.29 to 0.62). Subjective sleep disturbances were associated with poorer adjustment and quality of life (beta's ranging from 0.36 to 0.75), and were found to mediate the relationship between presurgical anxiety and posttransplant adjustment and quality of life.

CONCLUSIONS

This study found that psychological status pretransplant predicted adjustment and quality of life posttransplant. Moreover, increased anxiety levels pretransplant predicted subsequent subjective sleep disturbances, which were, in turn, associated with poorer adjustment and quality of life. The benefits of pretransplant stress management interventions are discussed.

Relaxation techniques for acute pain management: a systematic review

This review aims to document the effectiveness of relaxation techniques, when used alone for the management of acute pain, after surgery and during procedures. A systematic review of randomized controlled trials (RCTs) was undertaken. Seven studies involving 362 patients were eligible for this review. One hundred and fifty patients received active relaxation as the sole intervention. Reports were sought by searching MEDLINE, psycLIT, CINAHL, and the Oxford Pain Relief Database. The outcome measures used were pain and psychological factors. A meta-analysis was not possible, due to lack of primary data. Three of the seven studies demonstrated significantly less pain sensation and or pain distress in those who had relaxation. Four studies did not detect any difference. There was some weak evidence to support the use of relaxation in acute pain. However, this was not conclusive and many of both the positive and the negative studies suffered from methodological inadequacies. Well designed and executed randomized controlled trials are needed before the clinical use of relaxation in acute pain management can be firmly underpinned by good quality research evidence. Until this evidence is available we recommend that the clinical use of relaxation in acute pain settings is carefully evaluated and not used as the main treatment for the management of acute pain.

Mind-body therapies for primary care physicians

Evidence is accumulating that mental and emotional processes can affect disease states. Mind-body therapies are effective adjuncts to conventional medical treatments, and they are easy to teach and learn. This article offers a review of relevant literature and introduces several mind-body techniques.