Psychological Stress on Wound Healing: A Silent Player in a Complex Background

The impact of depression on healing outcomes in people with diabetes-related foot ulcers: A systematic review

This systematic review examined the impact of depression on healing outcomes among people with diabetes-related foot ulcers (DFUs). A comprehensive search of MEDLINE, APA PsycINFO, CINAHL, Embase, and The Cochrane Library was conducted from inception (1976) to 11 March 2024 to identify eligible studies. The Mixed Methods Appraisal Tool (MMAT) was used to assess study quality, and a narrative synthesis was conducted. We identified 1403 articles, of which 11 were included in the final analysis and included a total of 1392 participants with DFUs. The included studies used diagnostic interviews and screening tools to assess depression, and healing outcomes were described as healed ulcer, change in ulcer size, and/or changes in ulcer severity classification tool scores. Of the 11 studies, five studies (45.5 %) found that there was a significant negative impact (or association) of depression on healing outcomes of DFUs. On the other hand, six studies (54.5 %) showed there was no significant impact or association. Three studies were considered high quality, four studies medium quality, and four studies low quality. Depression may have a significant negative impact on healing outcomes in people with DFUs. However, the existing evidence is still unclear, and further high-quality studies are needed to investigate this impact.

Factors Influencing Preoperative Psychological Resilience in Patients With Traumatic Lower Extremity Fractures

BACKGROUND

The psychological resilience of patients with traumatic lower extremity fractures is relevant and has been studied in the postoperative rehabilitation phase; yet, few studies have focused on the early preoperative phase.

OBJECTIVE

This study aims to explore preoperative psychological resilience in patients with traumatic lower extremity fractures.

METHODS

This single-center cross-sectional survey design study was conducted over 5 months from December 2022 to April 2023 in a tertiary hospital in Shanghai, China. We used a convenience sampling method to assess psychological resilience in traumatic lower extremity fracture patients electronically. We administered the online surveys using the Questionnaire Star applet prior to surgery using the following tools: (a) general information questionnaire, (b) Numerical Rating Scale, (c) Connor-Davidson Resilience Scale, and (d) General Self-Efficacy Scale.

RESULTS

A total of N = 175 patients were studied, of which n = 166 patients fully completed the survey for a response rate of 95%. Patients with traumatic lower extremity fractures demonstrated a low degree of psychological resilience preoperatively (M = 49.28, SD = 13.64). Patients' psychological resilience and self-efficacy showed a significant positive correlation (r = .577). Factors associated with patients' psychological resilience in multivariate linear analyses included level of education, medical insurance, and self-efficacy (p < .05).

CONCLUSION

We found that preoperative psychological resilience in patients with traumatic lower-extremity fractures is poor and influenced by various factors; thus, future efforts should focus on providing timely, targeted interventions.

Periodontal regeneration risk assessment in the treatment of intrabony defects

BACKGROUND

Regenerative approaches performed in periodontics seems to be efficient in treating intrabony defects. There are, however, many factors that may affect the predictability of the regenerative procedures. The present article aimed to propose a new risk assessment tool for treating periodontal intrabony defects by regenerative therapy.

METHODS

Different variables that could affect the success of a regenerative procedure were considered based on their impact on (i) the wound healing potential, promoting wound stability, cells, and angiogenesis, or (ii) the ability to clean the root surface and maintain an optimal plaque control or (iii) aesthetics (risk for gingival recession).

RESULTS

The risk assessment variables were divided into a patient, tooth, defect, and operator level. Patient-related factors included medical conditions such as diabetes, smoking habit, plaque control, compliance with supportive care, and expectations. Tooth-related factors included prognosis, traumatic occlusal forces or mobility, endodontic status, root surface topography, soft tissue anatomy, and gingival phenotype. Defect-associated factors included local anatomy (number of residual bone walls, width, and depth), furcation involvement, cleansability, and number of sides of the root involved. Operator-related factors should not be neglected and included the clinician's level of experience, the presence of environmental stress factors, and the use of checklists in the daily routine.

CONCLUSIONS

Using a risk assessment comprised of patient-, tooth-, defect- and operator-level factors can aid the clinician in identifying challenging characteristics and in the treatment decision process.

Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing

AIMS AND OBJECTIVES

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds.

DESIGN

This was a 4-week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada.

METHODS

Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory-Short Form, the McGill Pain Questionnaire-Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants.

RESULTS

A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI-I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model.

CONCLUSION

Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

Relaxation intervention to improve diabetic foot ulcer healing: Results from a pilot randomized controlled study

This pilot randomised controlled study (RCT) aimed to assess the feasibility and acceptability of a progressive muscle relaxation with guided imagery intervention (experimental group [EG]) compared to a neutral guided imagery placebo (active control group [ACG]) and standard care to diabetic foot ulcer [DFU] treatment (passive control group [PCG]), to decide on the need for a definitive RCT. Diabetic foot patients with one or two chronic DFU and significant levels of stress/anxiety/depression were recruited and assessed during a period of 6 months, at three moments. Primary outcomes: feasibility rates and satisfaction with relaxation sessions. Secondary outcomes: DFU healing score, DFU-related quality of life (DFUQoL), physical and mental HRQoL, stress and emotional distress, DFU representations, arterial blood pressure, and heart rate. A total of 146 patients completed the baseline (T0) assessment with 54 participants presenting significant distress being randomised into three groups. Patients were assessed 2 months post-intervention (T1) and 4 months after T1 (T2). Feasibility rates showed reduced values on eligibility, recruitment and inclusion in the study, although with an acceptable rate of refusal lower than 10%. On average, participants reported being satisfied with relaxation sessions and recommended them to other patients. Differences between groups showed that, at T1, PCG participants reported higher levels of stress than those from EG and ACG. Within-group differences showed improvements in stress, distress, DFUQoL and DFU extent over time only in EG and ACG. Only EG showed significant changes in DFU representations at T1. The results suggest that relaxation may be a promising coping strategy to deal with DFU distress and an important adjuvant therapy for DFU healing, supporting the implementation of a definitive RCT.

Accelerating Effect of Cucurbita pepo L. Fruit Extract on Excisional Wound Healing in Depressed Rats Is Mediated through Its Anti-Inflammatory and Antioxidant Effects

Background: Chronic stress can hinder wound healing as it suppresses both the cellular and innate immune responses. Objectives: The study aims to assess the effectiveness of the administration of topical and oral Cucurbita pepo L. (CP) ethanolic extract in prompting excisional wound healing in rats exposed to chronic stress, and to explain how it works. Materials and methods: Fifty albino rats assigned to five groups (n = 10) were utilized in this study. The chronic unpredictable mild stress (CUMS) model was used for 4 weeks to induce depressive-like behavior in rats, and a forced swim test and corticosterone were assessed to confirm its occurrence. During the experiment, an excisional wound was induced in the rats and followed. Oxidant/antioxidants status and pro-inflammatory cytokines levels were measured in the serum and wound area. Gene expression of pro-inflammatory cytokines was also assessed using RT-PCR. Wound closure histopathological changes and immunohistochemical expression of CD68, CD3, and CD4 at the wound area was assessed. Results: The administration of CP, both orally and topically, significantly reduced (p < 0.001) the depressive-like behavior and corticosterone and pro-inflammatory cytokines levels, while it significantly up-regulated the antioxidant activity compared to the untreated and topically CP-treated groups. Both topically CP-treated and combined CP-treated groups showed complete re-epithelialization, reduced inflammatory cells infiltration, collagen fibers deposition, and significantly increased CD3, CD4 positive T cells count, with a superior effect in the combined CP-treated groups. Conclusion: Cucurbita pepo L., administrated both topically and orally, can enhance the wound healing process in rats with depressive-like behavior mostly through the antioxidant, anti-inflammatory, and antidepressant activities observed in this study.

Effectiveness of Two Stress Reduction Interventions in Patients with Chronic Diabetic Foot Ulcers (PSY-DFU): Protocol for a Longitudinal RCT with a Nested Qualitative Study Involving Family Caregivers

Diabetic foot ulcer (DFU) is the leading cause of lower-limb amputations, with a significant impact on patients, families, and society. Since DFU medical treatments represent a major socioeconomic burden, cost-effective interventions are needed. This trial aims to assess the effectiveness of a muscle relaxation intervention compared to a hypnosis intervention versus active and passive control groups on DFU healing, physiological indicators of healing prognosis, and quality of life (QoL) in clinically distressed patients with a chronic DFU. A multicenter, randomized controlled trial with three assessment moments (baseline, two months post-intervention, and four months follow-up) will be conducted. Approximately 170 patients will be randomized and allocated to either treatment or control groups. Primary outcomes will be DFU healing, physiological indicators of healing prognosis, and QoL. Secondary outcomes will include perceived stress, psychological morbidity, and DFU representations. The efficacy of sessions on DFU healing will be qualitatively assessed in 12 patients allocated to the treatment and active control groups, as well as their family caregivers. This study will provide evidence regarding the effectiveness of two psychological interventions for the DFU healing process and the QoL of patients, with direct clinical relevance regarding DFU treatment and recurrence.

Role of neurotransmitters in the regulation of cutaneous wound healing

Wound healing is a highly coordinated and dynamic process of tissue repair after injury. The global burden of disease associated with wounds, both acute and chronic, is a significantly rising health concern. Upon skin wounding, neurons have the ability to sense the disruption to mediate the release of neurotransmitters into the wound microenvironment. Serotonin that has long been recognised as a potential vasoconstrictor is now also being contemplated to play a role in re-epithelialisation of wounds. While the role of neuropeptides in stimulating diabetic wound healing is being increasingly emphasised, on the other hand, dopamine is being widely studied for its dual role in mediating both pro- and antiangiogenic effects at the site of the wounds. Similarly, epinephrine levels that are known to be elevated during stress is now recognised as a contributing factor towards delayed wound closure, thereby serving as an inhibitor of wound healing. Thus, each neurotransmitter regulates wound repair and their active regeneration in a typical way. Strengthening our understanding of the molecular pathways via which the neurotransmitter modulates the immune system to control wound healing can yield potential therapeutic measures. Further investigations regarding the safety, efficacy, and cost-effectiveness of these processes are a prerequisite for their possible translation into clinical trials.