Effect of biofeedback-assisted relaxation training on foot ulcer healing

Relaxation intervention to improve diabetic foot ulcer healing: protocol for a pilot study with a nested qualitative study

OBJECTIVE

A mixed-methods approach nested in a pilot three-arm randomised controlled trial (RCT) was conducted to evaluate the feasibility and acceptability of an intervention of progressive muscle relaxation with guided imagery (experimental group) compared to a neutral guided imagery placebo (active control group) and a group that did not receive any psychological intervention (passive control group). The purpose was to inform a future definitive RCT that will test its effectiveness. Qualitatively, this study examined patients and health professionals' perspectives regarding the relaxation intervention, in order to assess the acceptability and applicability of relaxation as an adjuvant therapy.

METHOD

Participants must have had a diagnosis of diabetes and diabetic foot disease; one or two active hard-to-heal ulcers at the time of the assessment; and clinical levels of stress or anxiety or depression. Participants were randomised and assessed at three timepoints after the first hospital consultation for hard-to-heal diabetic foot ulcer (DFU).

RESULTS

Rates of eligibility, recruitment, refusal, adherence to study protocol, participation in follow-up and dropout, and patients' satisfaction with the relaxation intervention were assessed as primary outcomes. Secondary outcomes were DFU healing; patients' DFU-related quality of life; physical and mental quality of life; perceived stress; emotional distress; adherence to DFU care; perceptions of DFU; as well as arterial systolic/diastolic pressure and heart rate.

CONCLUSION

The results of this pilot study contributed to clarification and better elucidation of the benefits of relaxation techniques regarding patients' HRQoL and DFU healing.

DECLARATION OF INTEREST

Funding: This study was conducted at the Psychology Research Centre (CIPsi/UM) School of Psychology, University of Minho, Portugal and supported by the Foundation for Science and Technology (FCT) through the Portuguese State Budget (UIDB/01662/2020) and by a PhD fellowship from FCT assigned to GF (SFRH/BD/131780/2017) and an FCT grant (PTDC/PSI-GER/28163/2017) assigned to MGP. The authors have no conflicts of interest to declare.

Relax to Heal? Perspectives of Patients with Diabetic Foot Ulcers and Health Professionals on Relaxation Sessions for Wound Healing

OBJECTIVE

To explore patients' and healthcare professionals' (HPs') perspectives on the suitability/acceptability of a relaxation intervention, its effects on patients' well-being and diabetic foot ulcer (DFU) healing, and its incorporation into the multidisciplinary management of patients with diabetic foot.

METHODS

This qualitative study was nested within a three-arm pilot randomized controlled trial. Patients with a chronic DFU received four relaxation sessions. Investigators then interviewed patients, physicians, and nurses involved with diabetic foot consultations. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Five themes emerged from patient's interviews about the suitability/acceptability of the relaxation intervention: perceptions regarding the psychological intervention, distress, the relaxation technique, changes in the patient's life, and changes in DFU/contribution to healing. Three themes emerged from interviews with HPs: perceptions regarding relaxation, changes in the patient, and changes in DFU/healing. Regarding the feasibility of the relaxation intervention, three themes emerged for both patients and HPs: suggested modifications, stressors/difficulties, and impact of COVID-19 pandemic. The utility theme emerged only in HP interviews, with subthemes of patients' distress, psychological interventions, relaxation intervention, and integration of the psychologist in the team.

CONCLUSIONS

These findings provide evidence for the suitability/acceptability, feasibility, and utility of a relaxation intervention in diabetic foot consultations.

Stress reduction interventions for patients with chronic diabetic foot ulcers: a qualitative study into patients and caregivers' perceptions

BACKGROUND

The present study aimed to assess the perceptions of patients with chronic diabetic foot ulcers (DFUs) and their family caregivers regarding the impact of two stress reduction interventions on DFU and psychological wellbeing. The intervention included progressive muscle relaxation and hypnosis sessions.

METHODS

This study used a qualitative exploratory design and included individual interviews with eight patients with chronic DFUs and six family caregivers, using a semi-structured interview guide. Transcript analysis employed thematic content analysis.

RESULTS

Four key themes common to patients and their caregivers were found: 1) perspectives regarding the intervention; 2) intervention effectiveness; 3) perceived importance of psychology in the DFU treatment; and 4) emotional consequences associated with DFUs. Although themes were common to both intervention groups, sub-themes from the last two themes differed for patients that received muscle relaxation versus those who received hypnosis.

CONCLUSION

Patients and caregivers reported perceived benefits from both interventions, regarding DFU healing and emotional wellbeing. Patients who received hypnosis and their caregivers also reported lasting effects. Participants suggested that psychological interventions such as stress reduction interventions could be included in the DFU standard treatment as an adjuvant to the clinical protocol for DFU treatment, preferably offered early on, when patients begin treatment at the diabetic foot consultation.

Anxiety and/or depression: which symptoms contribute to adverse clinical outcomes after amputation?

BACKGROUND

One of the most serious complications of diabetes mellitus (DM) is a diabetic foot ulcer (DFU), with lower extremity amputation (LEA).

AIMS

This study aims to explore the role of anxiety and depression on mortality, reamputation and healing, after a LEA due to DFU.

METHODS

A sample of 149 patients with DFU who underwent LEA answered the Hospital Anxiety and Depression Scale and a sociodemographic and clinical questionnaire. This is a longitudinal and multicenter study with four assessment moments that used Cox proportional hazards models adjusted for demographic and clinical variables.

RESULTS

Rate of mortality, reamputation and healing, 10 months after LEA were 9.4%, 27.5% and 61.7%, respectively. Anxiety, at baseline, was negatively associated with healing. However, depression was not an independent predictor of mortality. None of the psychological factors was associated with reamputation.

CONCLUSION

Results highlight the significant contribution of anxiety symptoms at pre-surgery, to healing after a LEA. Suggestions for psychological interventions are made.

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.

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.

Psychological interventions for treating foot ulcers, and preventing their recurrence, in people with diabetes

BACKGROUND

Diabetic foot ulceration (DFU) can be defined as a full-thickness wound below the ankle and is a major complication of diabetes mellitus. Despite best practice, many wounds fail to heal, and when they do, the risk of recurrence of DFU remains high. Beliefs about personal control, or influence, on ulceration are associated with better engagement with self-care in DFU. Psychological interventions aim to reduce levels of psychological distress and empower people to engage in self-care, and there is some evidence to suggest that they can impact positively on the rate of wound healing.

OBJECTIVES

To evaluate the effects of psychological interventions on healing and recurrence of DFU.

SEARCH METHODS

In September 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, Ovid PsycINFO and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and reviewed reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that evaluated psychological interventions compared with standard care, education or another psychological intervention. Our primary outcomes were the proportion of wounds completely healed; time to complete wound healing; time to recurrence and number of recurrences.

DATA COLLECTION AND ANALYSIS

Four review authors independently screened titles and abstracts of the studies identified by the search strategy for eligibility. Three authors independently screened all potentially relevant studies using the inclusion criteria and carried out data extraction, assessment of risk of bias and GRADE assessment of the certainty of the evidence.

MAIN RESULTS

We identified seven trials that met the inclusion criteria with a total of 290 participants: six RCTs and one quasi-RCT. The studies were conducted in Australia, the USA, the UK, Indonesia, Norway and South Africa. Three trials used a counselling-style intervention and one assessed an intervention designed to enhance an understanding of well-being. One RCT used a biofeedback relaxation training intervention and one used a psychosocial intervention based on cognitive behavioural therapy. A quasi-RCT assessed motivation and tailored the intervention accordingly. Due to the heterogeneity of the trials identified, pooling of data was judged inappropriate, and we therefore present a narrative synthesis. Comparisons were (1) psychological intervention compared with standard care and (2) psychological intervention compared with another psychological intervention. We are uncertain whether there is a difference between psychological intervention and standard care for people with diabetic foot ulceration in the proportion of wounds completely healed (two trials, data not pooled, first trial RR 6.25, 95% CI 0.35 to 112.5; 16 participants, second trial RR 0.59, 95% CI 0.26 to 1.39; 60 participants), in foot ulcer recurrence after one year (two trials, data not pooled, first trial RR 0.67, 95% CI 0.32 to 1.41; 41 participants, second trial RR 0.63, 95% CI 0.05 to 7.90; 13 participants) or in health-related quality of life (one trial, MD 5.52, 95% CI -5.80 to 16.84; 56 participants). This is based on very low-certainty evidence which we downgraded for very serious study limitations, risk of bias and imprecision. We are uncertain whether there is a difference in the proportion of wounds completely healed in people with diabetic foot ulceration depending on whether they receive a psychological intervention compared with another psychological intervention (one trial, RR 2.33, 95% CI 0.92 to 5.93; 16 participants). This is based on very low-certainty evidence from one study which we downgraded for very serious study limitations, risk of bias and imprecision. Time to complete wound healing was reported in two studies but not in a way that was suitable for inclusion in this review. One trial reported self-efficacy and two trials reported quality of life, but only one reported quality of life in a manner that enabled us to extract data for this review. No studies explored the other primary outcome (time to recurrence) or secondary outcomes (amputations (major or distal) or cost).

AUTHORS' CONCLUSIONS

We are unable to determine whether psychological interventions are of any benefit to people with an active diabetic foot ulcer or a history of diabetic foot ulcers to achieve complete wound healing or prevent recurrence. This is because there are few trials of psychological interventions in this area. Of the trials we included, few measured all of our outcomes of interest and, where they did so, we judged the evidence, using GRADE criteria, to be of very low certainty.

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.

Clinical Benefits of Training Patients to Voluntarily Increase Peripheral Blood Flow

The purpose of this article is to introduce a training pro- gram that can help diabetes educators get a fresh approach to assist their clients with the diabetes complication of limited peripheral blood flow. Biofeedback-assisted relaxation training is an educational and integrative intervention that supplements traditional medical care. Biofeedback-assisted relaxation training can be taught to the patient in a single setting. The relaxation training allows peripheral blood vessels to widen, providing enhanced circulation to peripheral tissues, including nerves. The training includes an explanation of relaxation and its effects on the patient, after which the technique is practiced with the assistance of thermal biofeedback. Biofeedback is an effective physiological training modality that teaches the patient what is going on in his or her own body. As the patient relaxes correctly, peripheral blood vessels dilate and blood flow improves, resulting in increased skin temperature. The change in skin temperature is measured with a small alcohol thermometer. Consistent relaxation yields significant outcomes such as improved peripheral blood flow, a reduction in peripheral pain, enhanced healing, improved ambulation, and increased coping skills in the patient's life.

Methodological quality of randomized trials published in the Journal of the American Podiatric Medical Association, 1999-2013

BACKGROUND

Randomized trials must be of high methodological quality to yield credible, actionable findings. The main aim of this project was to evaluate whether there has been an improvement in the methodological quality of randomized trials published in the Journal of the American Podiatric Medical Association (JAPMA).

METHODS

Randomized trials published in JAPMA during a 15-year period (January 1999 to December 2013) were evaluated. The methodological quality of randomized trials was evaluated using the PEDro scale (scores range from 0 to 10, with 0 being lowest quality). Linear regression was used to assess changes in methodological quality over time.

RESULTS

A total of 1,143 articles were published in JAPMA between January 1999 and December 2013. Of these, 44 articles were reports of randomized trials. Although the number of randomized trials published each year increased, there was only minimal improvement in their methodological quality (mean rate of improvement = 0.01 points per year). The methodological quality of the trials studied was typically moderate, with a mean ± SD PEDro score of 5.1 ± 1.5. Although there were a few high-quality randomized trials published in the journal, most (84.1%) scored between 3 and 6.

CONCLUSIONS

Although there has been an increase in the number of randomized trials published in JAPMA, there is substantial opportunity for improvement in the methodological quality of trials published in the journal. Researchers seeking to publish reports of randomized trials should seek to meet current best-practice standards in the conduct and reporting of their trials.

Coping style and depression influence the healing of diabetic foot ulcers: observational and mechanistic evidence

AIMS/HYPOTHESIS

Experimental evidence suggests that the healing of diabetic foot ulcers is affected by psychosocial factors such as distress. We examined this proposal in a prospective study, in which we considered the role of psychological distress and coping style in the healing of diabetic foot ulcers over a 24 week period. We also explored the role of salivary cortisol and matrix metalloproteinases (MMPs) as potential mechanisms.

METHODS

For this prospective observational study we recruited 93 (68 men; mean age 60 years) patients with neuropathic or neuroischaemic diabetic foot ulcers from specialist podiatry clinics in secondary care. Clinical and demographic determinants of healing, psychological distress, coping, salivary cortisol and both MMP2 and MMP9 were assessed at baseline. Ulcers were assessed at baseline and at 6, 12 and 24 weeks post-baseline. The primary outcome was ulcer status at 24 weeks, i.e. healed vs not healed.

RESULTS

After controlling for clinical and demographic determinants of healing, ulcer healing at 24 weeks was predicted by confrontation coping, but not by depression or anxiety. Patients with unhealed ulcers exhibited greater confrontation coping (model including depression: OR 0.809, 95% CI 0.704-0.929, p = 0.003; model including anxiety: OR 0.810, 95% CI 0.704-0.930, p = 0.003). However, change in ulcer size over the observation period was associated with depression only (p = 0.04, d = 0.31). Healed ulcers by 24 weeks were also associated with lower evening cortisol, higher precursor MMP2 and a greater cortisol awakening response.

CONCLUSIONS/INTERPRETATION

Confrontation coping and depression predict ulcer healing. Our preliminary enquiry into biological mechanisms suggests that cortisol and precursor MMP2 may underlie these relationships.

Pharmacotherapy of painful diabetic neuropathy

The scope of this review is to describe the epidemiology, physiology, symptomatology, and treatment of diabetic painful neuropathy, which is a common complication of diabetes with significant morbidity. This article focuses on treatment options. Various clinical trials of several classes of medications (eg, antidepressants, anticonvulsants, and topical medications) and alternative treatments (eg, acupuncture, electrostimulation, magnets) are reviewed. Physicians have a large panel of medications that can be used effectively solely or in combination at their disposal. However, a number of these treatments have significant side effects, which are noted, that limit their use. As the understanding of the pathophysiologic mechanisms of diabetic neuropathy improves, new medications are under investigation, which are reviewed in this article. There is great hope that the future may hold treatments that would prevent nerve damage.

Psychologic factors in scleroderma

CB interventions have been shown to reduce pain and improve psychosocial functioning in patients who have chronic illnesses, particularly chronically painful rheumatologic syndromes. These interventions are typically administered by specially trained professionals and are conducted during weekly individual or group sessions. When focused on pain and chronic illness, these interventions seem to have, at best, small effects on depression. Data from the headache literature and recent data about patients who have dental/facial pain indicate that minimal-contact CB therapy, the combination of some professional contact with audiotaped and written materials, may reduce pain in many patients, but the impact on functioning is less clear. Future studies should examine the impact of CB interventions on pain, depression, concerns about disfigurement, and physical and psychosocial functioning in scleroderma. Such knowledge is necessary for the optimal care of persons who have this debilitating illness. Although complicated, the advent of disease-specific interventions that are administered by way of the Internet may prove particularly useful in a rare illness, such as scleroderma. Psychologic factors with demonstrated relevance to scleroderma include pain, depression, and distress about disfigurement, physical function, and social function. Although these dimensions of quality of life are interrelated, pain, depression, and distress about disfigurement are common and may respond to psychologic interventions.

Current status of mind-body interventions for vascular complications of diabetes

Impaired peripheral blood flow causes complications, disabilities, expenses, and deaths among persons with diabetes mellitus. Many individuals suffer from lower-extremity pain, reduced functional status, and impaired quality of life. Current conventional treatments include lifestyle modification, exercise, medication, and surgery. However, these approaches are often impractical or insufficient. Thermal biofeedback, however, alone or in conjunction with other mind-body techniques, improves peripheral circulation, pain, neuropathy, ulcer healing, ambulatory activity, and quality of life. It is noninvasive, inexpensive, and consistent with community-based approaches to diabetes self-management. As an adjunct to the medical management of diabetes, thermal biofeedback may help ameliorate some of the vascular complications.