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

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Systematic review of the efficacy ofpre-surgical mind-body based therapies onpost-operative outcome measures

Elizabeth. A. Nelsona, Michelle. M. Dowseya,Simon. R. Knowlesb,c, David. J. Castlec, Michael. R. Salzbergc,Kaveh. Monshatc, Anthony. J. Dunina, Peter. F.M. Choonga,∗

a The University of Melbourne, Department of Surgery, St Vincent’s Hospital, Melbourne, VIC, Australiab Faculty of Life and Social Sciences, Swinburne University of Technology, Melbourne, VIC, Australiac St Vincent’s Mental Health and The University of Melbourne Department of Psychiatry, Melbourne, VIC,Australia

KEYWORDSMind-body therapies;Post-operativeoutcomes;Surgery

SummaryObjectives: A large body of research has demonstrated that patient factors are strong predic-tors of recovery from surgery. Mind-body therapies are increasingly targeted at pre-operativepsychological factors. The objective of this paper was to evaluate the efficacy of pre-operativemind-body based interventions on post-operative outcome measures amongst elective surgicalpatients.Methods: A systematic review of the published literature was conducted using the electronicdatabases MEDLINE, CINAHL and PsychINFO. Randomised controlled trials (RCTs) with a prospec-tive before—after surgery design were included.Results: Twenty studies involving 1297 patients were included. Mind-body therapies were cat-egorised into relaxation, guided imagery and hypnotic interventions. The majority of studiesdid 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 psychologi-cal well-being measures, and a lack of evidence for beneficial effects for analgesic intake and

Please cite this article in press as: Nelson ElizabethA, et al. Systematic review of the efficacy of pre-surgical mind-body based therapies on post-operative outcome measures. Complement Ther Med (2013),http://dx.doi.org/10.1016/j.ctim.2013.08.020

length of hospital stay. Guided imagery was examined in eight studies, with strong evidence forimprovements in psychological well-being measures and moderate support for the efficacy ofreducing analgesic intake. Hypnosis was investigated in four studies, with partial support forimprovements in psychological well-being measures. Evidence for the effect of mind-body ther-apies on physiological indices was limited, with minimal effects on vital signs, and inconsistentchanges in endocrine measures reported.

∗ Corresponding author at. Department of Orthopaedics, St Vincent’s Hospital (Melbourne), PO Box 2900, Fitzroy, Melbourne, VIC 3065,Australia. Tel.: +61 3 9288 3980; fax: +61 3 9416 3610.

E-mail address: [email protected] (Peter.F.M. Choong).

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Conclusions: This review demonsttherapies for improving post-surgi

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ontents

Introduction............................................................................................................... 00Method.................................................................................................................... 00

Search strategy....................................................................................................... 00Study selection ....................................................................................................... 00Description of mind-body interventions............................................................................... 00

Relaxation ..................................................................................................... 00Guided imagery................................................................................................ 00Hypnosis ....................................................................................................... 00Mindfulness .................................................................................................... 00

Data extraction/collection process and synthesis ..................................................................... 00Assessment of risk of bias ............................................................................................ 00

Results .................................................................................................................... 00Study selection ....................................................................................................... 00Study characteristics ................................................................................................. 00

Participants.................................................................................................... 00Description of intervention .................................................................................... 00Quality Assessment ............................................................................................ 00

Influence of relaxation interventions on improving post-operative outcomes ......................................... 00Influence of guided imagery on improving post-operative outcomes .................................................. 00Influence of hypnosis on improving post-operative outcomes ......................................................... 00Influence of mind-body therapies on physiological indices ............................................................ 00

Discussion ................................................................................................................. 00Limitations ........................................................................................................... 00Recommendations for future research ................................................................................ 00

Conclusion ................................................................................................................ 00Ethical approval........................................................................................................... 00Source of funding ......................................................................................................... 00Conflict of interest statement ............................................................................................. 00

Acknowledgments ....................................................................................................... 00References .............................................................................................................. 00

ntroduction

s the demand for surgical procedures continue to increaseith an expanding and aging population, so does the num-er and range of surgical procedures.1,2 In a report assessinghe global rate of surgery, it was estimated that 234.2illion surgical procedures are performed each year.3 Elec-

ive surgery typically entails a planned, non-emergencyurgical procedure that can be delayed for at least 24-h;ommon examples include hip and knee replacement andoronary artery bypass graft. Although the primary compo-ent of surgery involves some type of physical interventionr manipulation, research demonstrates that non-physicalre-operative patient factors (e.g., psychological state, per-onality factors) are strong predictors of patient recoveryrom surgery.4,5 In some cases, such factors have been showno be stronger predictors of outcomes after surgery than theurgical procedure itself.6

behaviour that is likely to influence pain and recovery(e.g., obesity, smoking, alcohol intake)7,8; and a direct influ-ence on increased pain perception by negative psychologicalstates.9 This field of research where psychology (mind)influences the immune (body) has led to the developmentof mind-body therapies. Mind-body interventions includea range of practices and therapies aimed at facilitatingthe mind’s capacity to affect health.10 Mind-body therapiesassume a bidirectional relationship between the mind andthe body. Bodily sensations including pain and discomfortcan affect mood and behaviour, and enteroceptive (feel-ings, thoughts) information has the ability to affect bodilyprocesses.11

There is increasing evidence for the efficacy of mind-bodytherapies in the treatment of several common clinical con-ditions (for example, coronary heart disease, arthritis)12,13.More recently there has been increasing alignment of mind-body therapies with conventional medical practice.14 Given

Please cite this article in press as: Nelson ElizabethA,surgical mind-body based therapies on post-operative

http://dx.doi.org/10.1016/j.ctim.2013.08.020

Several mechanisms underlying the relationship betweenegative psychological states and surgical recovery haveeen proposed, including: activation of the body’s majorhysiological responses to stress7; the impact of patient

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PRESSElizabeth.A. Nelson et al.

rated that the quality of evidence for the efficacy of mind-bodycal outcomes is limited. Recommendations have been made for

he evidence that patient pre-operative psychological fac-

et al. Systematic review of the efficacy of pre-outcome measures. Complement Ther Med (2013),

ors play an important role in the recovery process afterurgery, together with the wait list for patients requir-ng elective surgery, several mind-body interventions have

dx.doi.org/10.1016/j.ctim.2013.08.020

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ARTICLEYCTIM-1259; No. of Pages 15

Systematic review of the efficacy of pre-surgical mind-body

been developed targeting patient pre-operative psycholog-ical factors.

Two meta-analyses have studied the effects of pre-surgical psychological interventions on post-operativeoutcomes. Devine15 conducted a meta-analysis of 191studies involving either psychoeducational or mind-bodyinterventions, and found small to moderate beneficial treat-ment effects, with average effect sizes of 0.43 for improvedrecovery, 0.38 for pain reduction, and 0.36 for reducedpsychological distress. Johnston and Vogele16 examined pre-operative psychological interventions in 38 studies andfound they were effective in improving psychological andmedical outcomes after surgery, with an average effectsize of 0.85 for pain reduction and 0.61 for improvedrecovery time. The psychological preparations analysed inthese reviews covered a range of strategies including psy-choeducational (procedural, sensory, exercises to perform,social support), behavioural instruction, cognitive interven-tion, relaxation, hypnosis and emotion-focused interviews.Although there is some overlap in these interventions, dis-tinct differences exist in underlying treatment mechanisms,making it difficult to draw overall conclusions.

This systematic review will update and extend uponearlier reviews by Devine15 and Johnston and Vogele16 bydistinguishing mind-body interventions from psychoeduca-tional and psychological interventions. The aim of this paperwas to conduct a systematic review of the available evi-dence of the efficacy of pre-operative mind-body basedinterventions on post-operative outcome measures amongstsurgical patients. Such data can help to determine the util-ity of implementing pre-operative mind-body interventionson post-surgical outcomes for patients undergoing surgery.

Method

This systematic review was conducted according to thepreferred reporting items for systematic reviews and meta-analyses (PRISMA) statement.17

Search strategy

A literature search was undertaken using MEDLINE, CINAHLand PsycINFO. The search included papers published inEnglish up to August 2012, with no restrictions placed onpublication dates of the study. The main search terms ofpre-operative, post-operative and mind-body therapy werecombined. The full electronic search strategy is presentedin Table 1. Additionally, citation tracking was performed bymanually screening the reference lists of identified studiesand review articles to identify any further relevant studies.

Study selection

Mind-body practices encompass a range of therapies includ-ing hypnosis, meditation, biofeedback, guided imagery,relaxation, mindfulness, music therapy, yoga, qigong and



tai chi.18 In this review mind-body therapies were limited totechniques requiring focused concentration, self-motivationand active participation from patients in their own health.19

This included hypnosis, relaxation, guided imagery and

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PRESSd therapies on post-operative outcome measures 3

indfulness-based techniques. Owing to space constraintstudies that examined more body-based therapies, such asoga, qigong, and tai chi were excluded. Spiritual heal-ng practices, such as prayer and distant healing, werelso excluded as clearly manualised instructions are rarelyeported. Furthermore, this review excluded cognitive-ehavioural therapy (CBT), as this is largely considered aype of psychotherapy.19 All titles and abstracts ascertainedere independently assessed by an experienced researcher

EN) to exclude any irrelevant reports. A full manuscriptf all the citations that were thought to be relevant werebtained. Pre-screening was performed independently bywo reviewers (EN, SK) to determine whether they met theligibility criteria (see below). Any disagreements regardinghe selection of a manuscript were resolved by a final deci-ion of a third reviewer (MD).

Studies were eligible for review if they met the follow-ng inclusion criteria: (1) included randomised controlledrials (RCTs) or quasi-randomised controlled clinical trialsCCT); (2) the article was written in English; (3) participantsere aged 16 years or older; (4) participants underwent anlective surgery procedure requiring general anaesthesia,r a combination of several procedures requiring generalnd local or regional anaesthesia; (5) the study had arospective before—after surgery design, where mind-bodyased care was provided to patients in the treatment groupefore the surgery, or where it straddled the procedurei.e., both before and after); (6) outcome measures includedsychosocial measures assessing participant’s psychologicalell-being (e.g., anxiety, depression); (7) the assessment of

hese outcome measures followed the before—after surgeryesign; and (8) inclusion of an effective control group whereatients underwent standard routine medical care or anttention placebo control group matching for the amountf time and attention received by the treatment group.

Studies were ineligible if: (1) the intervention comprisedolely pharmacotherapy, counselling, or provision of specificnformation related to surgery (e.g., educational booklet)r health behaviour (e.g., exercise, dietary counselling);2) the mind-body intervention was combined with phar-acotherapy; (3) interventions required spousal or familyarticipation; (4) the surgical procedure was diagnostic inature (e.g., biopsy) or an ambulatory/day procedure; (5)articipants underwent surgical procedure requiring onlyocal anaesthetic (e.g., removal of facial lesion, toothxtraction); and (6) and the study followed a post-operativenly design where well-being measures were assessed onlyfter surgery.

escription of mind-body interventions

elaxationelaxation interventions are aimed at inducing a state ofeduced anxiety and muscle tension, together with a sensef calmness, and being at ease.20 Relaxation can cover deepreathing practices, progressive muscle relaxation, Benson’selaxation response, or a combination of all.


uided imageryocuses and directs the imagination incorporating allhe senses.21 It is based on positive visualisation to help

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4 Elizabeth.A. Nelson et al.

Table 1 Search strategy..

Medline[(MH ‘‘Mind-Body Therapies’’) OR (MH ‘‘Breathing Exercises’’) OR (MH ‘‘Hypnosis’’) OR (MH ‘‘Imagery (Psychotherapy)’’) OR

(MH ‘‘Meditation’’) OR (MH ‘‘Mental Healing’’) OR (MH ‘‘Relaxation Therapy’’) OR (MH ‘‘Therapeutic Touch’’) OR‘‘mindfulness’’ OR ‘‘mind-body’’ OR ‘‘breathing exercise*’’ OR ‘‘hypnosis’’ OR ‘‘guided imagery’’ OR ‘‘visual imagery’’ OR‘‘mental imagery’’ OR ‘‘meditat*’’ OR ‘‘mental healing’’ OR ‘‘relaxation’’ OR ‘‘therapeutic touch*’’] AND [(TI postoperativeAND TI outcome*) OR (MH ‘‘Pain, Postoperative/PC’’) OR (MH ‘‘Perioperative Period’’) OR (MH ‘‘Preoperative Period’’) OR(MH ‘‘Perioperative Care’’) OR (MH ‘‘Preoperative Care’’) OR (MH ‘‘Perioperative Nursing’’) OR ‘‘preoperat*’’ OR‘‘pre-operat*’’ OR ‘‘presurg*’’ OR ‘‘pre-surg*’’ OR ‘‘before surgery’’ OR ‘‘perioperat*’’ OR ‘‘peri-operat*’’]

CINAHL[(MH ‘‘Hypnosis’’) OR (MH ‘‘Meditation’’) OR (MH ‘‘Mind Body Techniques’’) OR (MH ‘‘Mental Healing’’) OR (MH ‘‘Guided

Imagery’’) OR (MH ‘‘Distraction’’) OR (MH ‘‘Relaxation Techniques’’) OR ‘‘mindfulness’’ OR ‘‘mind-body’’ OR ‘‘breathingexercise*’’ OR ‘‘hypnosis’’ OR ‘‘guided imagery’’ OR ‘‘visual imagery’’ OR ‘‘mental imagery’’ OR ‘‘meditat*’’ OR ‘‘mentalhealing’’ OR ‘‘relaxation’’ OR ‘‘therapeutic touch*’’] AND [(TI postoperative AND TI outcome*) OR (MH ‘‘PostoperativePain/PC’’) OR (MH ‘‘Perioperative Care’’) OR (MH ‘‘Preoperative Care’’) OR (MH ‘‘Perioperative Nursing’’) OR (MH‘‘Pretransplantation Period’’) OR (MH ‘‘Preoperative Period’’) OR ‘‘preoperat*’’ OR ‘‘pre-operat*’’ OR ‘‘presurg*’’ OR‘‘pre-surg*’’ OR ‘‘before surgery’’ OR ‘‘perioperat*’’ OR ‘‘peri-operat*’’]

PsychINFO[DE ‘‘Mindfulness’’ OR DE ‘‘Relaxation Therapy’’ OR DE ‘‘Progressive Relaxation Therapy’’ OR DE ‘‘Guided Imagery’’ OR DE

‘‘Hypnotherapy’’ OR DE ‘‘Meditation’’ OR DE ‘‘Muscle Relaxation’’ OR DE ‘‘Hypnosis’’ OR ‘‘mindfulness’’ OR ‘‘mind-body’’OR ‘‘breathing exercise*’’ OR ‘‘hypnosis’’ OR ‘‘guided imagery’’ OR ‘‘visual imagery’’ OR ‘‘mental imagery’’ OR ‘‘meditat*’’OR ‘‘mental healing’’ OR ‘‘relaxation’’ OR ‘‘therapeutic touch*’’] AND [(TI postoperative AND TI outcome*) OR

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‘‘preoperat*’’ OR ‘‘pre-operat*’’ OR ‘‘presurg*’’ OR ‘‘pre-su

vercome physical symptoms and reduce anxiety and stress.n a surgical setting guided imagery involves patients imagin-ng their healing process after surgery and affirming thoughtsf confidence in the health care team.22,23 Guided imagerys designed to empower patients, promote relaxation, anduide patients to a place they feel safe and relaxed.23

ypnosisreating a sense of awareness, arousal and concentrationsed to reduce stress and anxiety and increase relaxation.22

y decreasing the perception of the external environmentdissociation) created by the intense involvement of a cen-ral object of concentration (absorption), patients becomeore likely to accept outside input (suggestibility).12,24 This

ncreased state of suggestibility can help lead to changes inubjective experience, alterations in perception, sensation,motions, thoughts or behaviours.8

indfulnessefined as ‘‘the awareness that emerges through payingttention on purpose, in the present moment, and non-udgmentally to the unfolding of experience moment byoment’’.25 Mindfulness training involves instruction in a

umber of meditation techniques as well as teaching on howo remain focused on the present moment in day to dayctivities.26

ata extraction/collection process and synthesis



ata were extracted using a comprehensive, pre-designedata extraction spread sheet. Extracted informationncluded: (1) participant characteristics (total number, age,

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OR ‘‘before surgery’’ OR ‘‘perioperat*’’ OR ‘‘peri-operat*’’]

ender); (2) type of surgery performed; (3) type of mind-ody intervention; (4) control group details; (5) main dataollection-points; (6) pre-operative outcome measures; (7)ost-operative outcome measures; and (8) statistically sig-ificant trial findings.

ssessment of risk of bias

ach eligible manuscript meeting the selection criteria wasssessed for its methodological quality based on the criteriaroposed by the Cochrane risk of bias tool17,27: (1) gener-tion of random allocation sequence; (2) concealment ofllocation; (3) blinding of study personnel/outcome asses-ors; (4) reporting of incomplete outcome data; and (5)eporting of only selective outcome.

esults

tudy selection

summary of the study selection process is presented inig. 1. The combined search using MEDLINE, CINAHL andsychINFO with the English language limit resulted in a totalf 1570 potentially relevant articles. After duplicates wereemoved 1317 articles remained. Through screening the titlend abstracts, 102 articles were identified as possibly rele-ant for review and full-text articles were retrieved. After


eview of these full-text articles according to the eligibil-ty criteria, a total of 20 articles were identified as eligibleor review. Table 2 provides a summary of the 20 studiesncluded in this systematic review.

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System

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review

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efficacy

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pre-surgical

m

ind-body

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therapies

on

post-operative

outcome

m

easures.

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Table 2 Summary of pre-surgical mind-body based interventions included.

Author (year) Participants Type ofsurgery

Controlgroup

Timing ofintervention

Data collectionpoints

Main outcomemeasures

Main findings

RelaxationDaltroy

et al.36N = 216; age (yrs) = 64,range 20—88; female(%) = 66; relaxationTG: N = 58; CG: N = 54

Orthopaedic Usual care 18-min audiotapewith oral & writteninstructions daybefore surgery.Reminder fromresearcher to usetechnique 1 to 2PODs

Pre-op, POD 4 Pre-op: anxiety, denial,pain, desire for info,sense of control overpainPost-op: anxiety,mental status, lengthof hospital stay,analgesic intake

No significant influence ofrelaxation intervention onpost-op outcomes, howeverlikely due to timeconstraints

Gavin et al.39 N = 49; TG: N = 27,female (%) = 74%, age(yrs) = 56 ± 16; CG:N = 22, female(%) = 68%, age(yrs) = 56 ± 18

Lumbar andspine

Usual care 20—30 min sessionwith researcher aweek beforesurgery. Encouragedto practice beforesurgery. Seenimmediatelypost-op byresearcher to goover technique

Pre-op, POD 1,POD 2

Pre-op: anxiety,physical & mentalhealth, distress,positive & negativeaffectPost-op: pain,analgesic intake, vitalsigns (oxygensaturation, respiratoryrate, sedation score)

Analgesic use wassignificantly higher in therelaxation group on POD 1and POD 2 compared to thecontrol group

Lesermanet al.37

N = 27; TG: N = 13, age(yrs) = 65.3 ± 7.1,male (%) = 69; CG:N = 14, age(yrs) = 69.6 ± 9.7,male (%) = 64

Cardiac Usual care Training received2—7 days pre-op.Asked to practicetwice/day before &after surgery withaid of tape (lengthunspecified)

Baseline (2—7days pre-op),each day aftersurgery untildischarge,excluding POD 1

Pre- & post-op: systolic& diastolic BP, heartrate, SVT, sleep,tension, depression,anger, fatigue, vigor,confusion

Intervention group hadsignificantly lower post-opSVT than CG. Relaxationgroup also had significantlygreater decrease in tension& anger; however this mayhave reflected regression tothe mean

Manyandeet al.29

N = 40, male (%) = 55;TG: N = 21, age(yrs) = 42 ± 12.6; CG:N = 19, age(yrs) = 47 ± 14

Abdominal Attentioncontrol

15-min audiotapeday before surgery,morning of surgery,as much as desiredpost-op

Questionnairemeasures:pre-op, 1 & 2POD’s; Endocrinemeasures:recruitment,immediatelypre-& post-op

Pre & post-op:endocrine: cortisol,adrenaline,noradrenaline; Vitalsigns: systolic &diastolic BP, heart rate;analgesic intake;Questionnaire:state/trait anxiety,personality recovery,pain intensity &distress, coping

Significant increase incortisol & adrenaline fromimmediately pre-op toimmediately after in TG.Noradrenaline wasunaffected. Significantreduction in state-anxiety &BP on POD 1 and 2 in TG.Analgesic intake wassignificantly less in the TGon POD’s 1 & 2 compared tocontrols

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System

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m

ind-body

based

therapies

on

post-operative

outcome

m

easures.

Complem

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Table 2 (Continued)


Controlgroup




Main findings

Manyande andSalmon30

N = 118, female(%) = 51, age(yrs) = 42, range16—79; TG: N = 59,age (yrs) = 42 ± 15;CG: N = 59, age(yrs) = 38 ± 20


15-min audiotwice/day on pre-opday. Asked to listento tape once whilewaiting for surgery,and as much asdesired post-op

Pre-op,immediatelyafter listening totape, each of the7 POD’s

Pre-op: state/traitanxiety, recovery,coping, pain (intensity& distress)Post-op: state/traitanxiety, recovery,coping, pain (intensity& distress), length ofhospital stay, analgesicintake

TG had lower intensity ofpain throughout the post-opperiod, & distress wasreduced early in the post-opperiod only. There weremixed findings relating toanalgesic intake

Scott andClum41

N = 64, age (yrs) = 43,range 19—70,female = (%) 86


10-min session withexaminer daybefore surgery.Instructed topractice at least 4times/day post-op

Pre-op, POD 2and 4

Pre- & post-op: coping,state/trait anxiety,painPost-op: analgesicintake

No significant effects oftreatments on any outcomemeasures. However, forpatients with a sensitizingcoping style, TG resulted inreduced post-surgical pain.For patients with anavoiding coping style therewas no significant benefit ofthe treatment

Wells42 N = 12, age(yrs) = 53.5, range30—70; TG: N = 6,male (%) = 67; CG:N = 6, female (%) = 67


45—70 min sessionwith assistant daybefore surgery.10—25 min sessionPOD’s 1 and 2

Pre-op, POD 1, 2& 3

Pre-op: abdominalmuscle tension, pain(intensity and distress)Post-op: abdominalmuscle tension, pain,analgesic intake, timein surgery & recoveryroom, complications,discomfort

Experimental groupreported significantly lessdistress caused by painfulsensations post-op, howeverno significant differences inphysiologic measures

Wilson31 N = 70, age(yrs) = 42.3 ± 10.47,female (%) = 90

Abdominal Usual care 25-min audiotapeonce the eveningbefore surgery. Asoften as desiredpost-op

Pre-op, POD 1, 2& 3

Pre-op: personalityvariables (denial, fear,aggressiveness) mood,social support, copingPost-op: Length ofhospital stay, analgesicintake, recovery, pain,ambulation,epinephrine &norepinephrine

Relaxation group hadreduced hospital stay, pain,analgesic intake, &increased strength, energy& epinephrine levels.Pre-op personality variablefear significantly influencedthe effectiveness ofrelaxation in reducinglength of hospital stay

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post-operative

outcome

m

easures.

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Systematic

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Table 2 (Continued)


Controlgroup




Main findings

Guided imageryBroadbent

et al.34TG: N = 30, age(yrs) = 52.1 ± 18female (%) = 80; CGN = 29, age(yrs) = 50.5 ± 15.5,female (%) = 70%

Abdominal Usual care 45-min session withpsychologist at least3 days pre-op.20-min audio eachday prior to surgery(reminder frompsychologist).Practiced PODs 1—7

Baseline (at least3 days prior tosurgery, range3—132 days),POD 7

Pre- & post-op:perceived stressPost-op:hydroxyprolinedeposition in wound,fatigue

Significant reduction inperceived stress frompre-op to POD 7 in the TGcompared to CG. TG hadsignificantly higherhydroxyproline wounddeposition (indication ofwound healing) comparedto CG

Holden-Lund32

TG: N = 12,female = (%) = 96, age(yrs) = 49 ± 12.1; CG:N = 12, female = (%)96%, age(yrs) = 46 ± 15.4


20-min audio dayprior to surgery.20-min audio POD1—3

Baseline (2 daysprior to surgery),POD’s 1, 2 and 3

Pre- & post-op: stateanxiety, urinary cortisolPost-op: surgicalwound healinginventory (edema,erythema, exudate)

TG had significantly lessstate anxiety post-opcompared to the CG, andsignificantly lower cortisollevels on POD 1 only. TheTG had significantly lesserythema at wounds thatdid controls

Kahokehret al.35

TG: N = 30, age(yrs) = 51, range19—84, female(%) = 81; CG: N = 30,age (yrs) = 51, range21—82, female(%) = 70%

Abdominal Usual care 45-min session withpsychologist at least3 days prior tosurgery. Instructedto listen to 20-minaudio each day priorto surgery and eachof the 7 PODs

Pre-op, POD’s 7,14 and 30

Pre-op: body massindexPre-op & post-op:fatigue, vigour, mentalfunction, impact onpatient energy, impacton activities of dailyliving

There was improved post-opfatigue experienced andconsequence of fatigue onday 30 only in theintervention group

Lin33 N = 93, age(yrs) = 71.0 ± 11.1,female (%) = 65; TG:N = 45; CG: N = 48

Orthopaedic Usual care Researcher taughtrelaxation topatients on pre-opday. From POD’s1—3 researcherassisted patientslistening to 20-minaudio. Patientsencouraged topractice whendesired

Measures wereassessed beforeand after theinterventionfrom pre-op toPOD 3

Pre-op & post-op: pain,anxiety & state/traitanxiety, BP (systolic &diastolic), heart rate

Pain was reducedsignificantly after relaxationtherapy in the TG. Themean differences in pain inthe TG were higher thanthose in the CG on pre-op &POD 1. Differences inseverity of anxiety in theTG on pre-op, POD1 & 2were greater than the CG.Systolic BP in the TG weresignificantly lower thanthose in the CG

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outcome

m

easures.

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Elizabeth.A. N

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Controlgroup




Main findings

Manyandeet al.28

N = 51; TG: N = 26, age(yrs) = 47 ± 13.8, male(%) = 58; CG: N = 25,age (yrs) = 44 ± 15.4,male (%) = 60


15-min audiotapeday before surgery,morning of surgery,as much as desiredpost-op

Questionnaire:Pre-op, POD’s 1& 2; Endocrine:recruitment,immediatelypre-and post-op

Pre-op & post-op:endocrine: cortisol,adrenaline,noradrenaline; Vitalsigns: systolic &diastolic BP, heart rate;Questionnaire:state/trait anxiety,type A personality,recovery, pain intensity& distress, coping,health opinion, desirefor controlPost-op: analgesicintake

TG experienced less post-oppain, were less distressedby it, felt they coped betterwith it, & requested lessanalgesia than CG; Cortisollevels were significantlylower in TG group than inCG pre- & post-op.Noradrenaline levels weresignificantly greater in TG &did not decline as in theCG. There was no significantdifference in post-opadrenaline levels

Mogan et al.40 N = 72, age(yrs) = 41.5; TG:N = 40, female(%) = 85; CG: N = 32,female (%) = 78


Researcher taughttechnique pre-op,length unspecified.Reminder to usetechnique fromexperimenter themorning aftersurgery

Pre-op, POD 1, 2,3, & 4

Pre-op & post-op: pain(sensation & distress);vital signs: BP, pulseand respirationPost-op: analgesicintake

There were no significantdifferences between the TGand CG for vital signs,analgesic intake, & painsensation. Distress causedby painful sensations wassignificantly lower in the TG

Stein et al.21 Guided imagery:N = 20, age(yrs) = 68.7 ± 8.7,male (%) = 55; CG:N = 19, age(yrs) = 65.4 ± 11.0,male (%) = 95

Cardiac Usual care Instructed to listento audiotape atleast 1/dayeveryday for 1 weekbefore surgery.Listened to tapesintra-operatively.No post-op practicespecified

Baseline (2—4weeks), 1 week& 6 monthspost-op

Pre-op & post-op:anxiety, depression,mood (disturbance,tension-anxiety,tension-depression,anger-hostility,fatigue-inertia,confusion-bewilderment,vigour-activity)

No significant differencebetween TG and CG inpost-op scores at either 1week or 6 months for anyoutcome measures

Tusek et al.23 N = 130, age (yrs) = 40,range 17—78; TG:N = 65, age (yrs) = 40;CG: N = 65, age(yrs) = 39

Abdominal Usual care 20-min audiotwice/day for 3consecutive dayspre-op. Listened toaudio twice/day forPODs 1—6

Baseline (pre-intervention),immediatelypre-op; duringthe morning &evening of POD’s1—6

Baseline, pre-op,post-op: Anxiety, pain(worst and least levelsexperienced)Post-op: analgesicintake, length ofhospital stay, time tofirst bowel movement

Pre-surgery, anxietyincreased significantly in CGbut decreased in TG.Analgesic consumption &time to first bowelmovement was significantlylower in TG compared withCG. Guided imagerysignificantly reducedpost-op anxiety & pain

dx.doi.org/10.1016/j.ctim.2013.08.020

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Main findings

HypnosisAshton

et al.24N = 22, male (%) = 86;TG: N = 13, age(yrs) = 64, range47—81; CG: N = 9, age(yrs) = 67, range57—71

Cardiac Usual care Training nightbefore surgery,length unspecified.Asked to practicehourly the nightprior to surgery andas often as possiblepost-op

Pre-op & POD 5 Pre-op & post-op:tension, depression,anger, vigour, fatigue,& concentration

Compared with CG, the TGwere significantly morerelaxed post-op thanpre-op. There were alsonon-significant trendstoward improvements indepression, anger & fatigue

Ashtonet al.38

TG: N = 20, age(yrs) = 64 ± 3, male(%) = 85; CG: N = 12,age (yrs) = 62 ± 3,male (%) = 92

Cardiac Usual care Training nightbefore surgery,length unspecified.Asked to practicehourly the nightprior to surgery andas often as possiblepost-op

Pre-op & POD 5 Pre-op & post-op:tension, depression,anger, vigour, fatigue,confusionPost-op: painmanagement, analgesicintake, length ofhospital stay, operativeparameters

The TG were significantlymore relaxed post-opcompared to the CG

Field43 N = 60, male (%) = 97;TG: N = 30; CG: N = 30

Orthopaedic Attentioncontrol

20-min audiotapeday before surgery.No post-op practicespecified

Pre-op &between 2 and 7days post-op

Pre-op: emotionalreactions to surgery,nervousnessPost-op: emotionalreactions to surgery,speed of recovery &length of hospital stay

No significant differencesbetween the TG and CG onlength of hospital stay,degree of nervousness orspeed of recovery. However,in the TG there was asignificant correlation withdepth of relaxation &absence of nervousness dayof operation & speed ofrecovery

Massariniet al.44

N = 42, male (%) = 52,age (yrs) = 51.12,range 16—79; TG:N = 21; CG: N = 21

Orthopaedic Usual care 15-30 min sessionduring 24-h pre-op.No post-op practicespecified

Baselinequestionnaire &physiologicalmeasurescollected weekspre-op, everyday for first 4POD’s

Pre-op & post-op:state/trait anxiety,depressive values,physiological indices(heart rate, BP, bodytemperature)Post-op: painperception (sensory &affective)

TG showed significantlylower levels of anxiety(state & trait) compared tobaseline levels &significantly lower painperception (sensory &affective) in the first 2POD’s compared to the CG

TG, Treatment group; CG, Control group; Baseline, pre-operatively before surgery; POD, Post-operative day; Pre-op, day before surgery; SVT, supraventricular tachycardia; BP, bloodpressure.

dx.doi.org/10.1016/j.ctim.2013.08.020



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articipantshe 20 reviewed studies were all RCTs or CCTs, involving

total of 1297 participants. The number of participants inach study ranged from 12 to 216, and 54.3% were female.ge ranged from 16 to 88 years, (mean age of 54.4). Ofhe 20 studies, 11 (55%) studies involved participants under-oing abdominal surgery, 4 (20%) cardiac surgery, 4 (20%)rthopaedic surgery, and 1 (5%) study involved participantsndergoing lumbar and cervical spine surgery.

escription of interventionight (40%) studies examined the influence of the mind-bodyntervention ‘relaxation’ on post-operative measures, 840%) studies examined relaxation combined with guidedmagery, and 4 (20%) studies examined hypnosis combinedith relaxation. The timing of pre-operative teaching of the



ind-body interventions varied amongst the reviewed stud-es. The majority of studies taught participants mind-bodyechniques the day before surgery (70%), and 3 studies,t least 3 days before surgery (15%). Participants from 2

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tudies received training one week prior to surgery (10%),nd in one study, 2—7 days pre-operatively (5%).

Most studies encouraged some form of practice of theind-body technique after surgery. Eleven studies used

he aid of audiotapes to help patients practice the tech-iques, with four studies instructing participants to practices much as desired28—31; two studies instructed use ofhe audiotape from post-operative days 1—332,33 and fromost-operative days 1—7,34,35 one study instructed par-icipants to listen to the audiotape from post-operativeays 1—236 or from twice a day from post-operative days—6.23 Leserman et al.37 also asked participants to practicewice per day post-operatively, but the number of post-perative days was not specified. The remaining nine studiesid not use audiotapes. Two of these instructed partic-pants to practice the technique as often as possibleost-operatively,24,38 in a further three studies, partici-ants were seen post-operatively by a researcher to gover the techniques39—41 and in one study participants were


isited by a researcher on post-operative days one andwo.42 Three studies did not specify whether participantsere provided instructions on post-operative practice of

echniques.21,43,44

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Quality AssessmentThe results of the risk of bias assessment are presented inTable 3. Each of the five components were rated as either ‘−’low risk for bias, ‘+’ high risk for bias, or ‘U’ unreported. Twoout of 20 studies were determined as low risk for potentialbias, meeting all five quality assessment components.34,35

Two studies were determined as having a high risk of biasas randomisation methods (sequence allocation and alloca-tion concealment) and blinding were not adequate).33,41 Twostudies were rated as having a moderate risk of bias, withinadequate randomisation and insufficient detail of blind-ing of personnel/outcome assessors.28,29 Many studies didnot adequately address or ignored reporting of sequenceallocation (75%), allocation concealment (18 studies, 90%),and blinding of personnel/outcome assessors (50%). Overall,the majority of studies were judged as having a low risk ofbias for incomplete outcome/attrition (70%), and no clearevidence of selective reporting bias was identified.

Influence of relaxation interventions on improvingpost-operative outcomes

There was a high level of heterogeneity in the primary focusof relaxation interventions examined in this review. Overallthe support for relaxation therapy as an effective pre-surgical intervention for improving post-operative outcomeswas varied. Of the examined studies, all but one assessedanalgesic intake as an indicator of treatment success.The majority of reviewed studies failed to find significanteffects of relaxation on reducing post-operative analgesicintake.30,36,39,41,42 The lack of evidence for the effectivenessof relaxation therapy is also supported by length of hospitalstay, with two out of the three studies assessing this measurefailing to find significant reductions.30,36

In terms of patient self-report of psychological well-being, there was only partial support for efficacy ofrelaxation therapy. Overall, three out of the eight relaxationintervention studies failed to show a reduction on thesemeasures,36,39,41 whilst the remaining five studies found onlypartial support for beneficial effects. Significant differencesbetween the relaxation group and control group existedfor select variables including tension and anger,37 stateanxiety,29 and pain.30,31,42 Several studies found no supportfor relaxation intervention benefitting levels of pain.29,36,41

Only one of five studies measuring anxiety provided par-tial support for the impact of relaxation therapy on anxietylevels.29 This study found that relaxation patients weresignificantly less anxious than controls immediately after lis-tening to the relaxation tape and on the first post-operativeday, but this difference disappeared by the second post-operative day.

Influence of guided imagery on improvingpost-operative outcomes

Overall, the current systematic review provided consid-erable evidence for the efficacy of guided imagery on



post-operative outcomes. In terms of psychological well-being, only one out of eight studies failed to find anybeneficial effects of guided imagery.21 All studies thatassessed pain, found guided imagery to be effective in

bea


educing post-operative levels.23,28,33,40 However, effects onost-operative anxiety were less consistent, with half of thetudies measuring anxiety finding significant benefits.23,32,33

here was moderate support for the efficacy of guidedmagery in reducing analgesic intake, with two out of threetudies assessing post-operative levels finding significanteductions amongst the guided imagery group.23,28 Only onetudy assessed the impact of guided imagery on length ofospital stay, with non-significant effect.23

nfluence of hypnosis on improving post-operativeutcomes

e found only partial support for the efficacy of hypno-is on post-operative anxiety levels, pain perception44 andension.24,38 One of the four reviewed studies examiningypnosis did not find any significant effect on psychologi-al variables.43 Only one of the four hypnosis interventiontudies reviewed assessed the effect on analgesic intake.shton et al.,38 found a non-significant difference in painedication use between patients practicing hypnosis and

ontrol patients. The authors noted that this was relatedo adherence to instructions for the practice of hypno-is, with adherent patients using less pain medication. Theffect of hypnosis on length of hospital stay was assessedy Ashton et al.,38 and Field43, with both studies reportingon-significant effects.

nfluence of mind-body therapies on physiologicalndices

n this review just over half of the studies assessed ahysiological measure, mostly measuring patient vital signse.g., heart rate, blood pressure, respiration). There wasinimal support for the efficacy of mind-body therapies

n improving vital signs, with only two studies reportingignificant reductions in blood pressure.29,33 Four studiesssessing endocrine measures (i.e., cortisol, adrenaline,oradrenaline) demonstrated significant changes,28,29,31,32

lbeit, there were somewhat inconsistent results regardinghe direction of change on these measures.

iscussion

espite continued advances in technology, there stillemains a significant proportion of patients with moderateo severe negative post-operative outcome measures.45 Forxample, up to 40% of patients who undergo elective jointeplacement surgery report suboptimal pain relief, func-ional improvements and satisfaction after surgery.46 Theffective management of post-operative pain is a majoroncern for patient well-being and healthcare resource uti-ization. Pre-operative patient psychological factors haveeen identified as strong predictors of post-operativeutcomes, with the increasing integration of mind-bodyherapies with conventional medical practice.14,22


Mind-body therapies typically focus on the relationshipsetween the brain, mind, body, and behaviour, and theirffect on health and disease.8 Mind-body therapies encour-ge patients to take responsibility for their own health

dx.doi.org/10.1016/j.ctim.2013.08.020



Table 3 Assessment of risk of bias.

Sequenceallocation

Allocationconcealment

Blinding ofpersonnel/outcomeassessors

Incompleteoutcome, attrition

Selectivereporting

Ashton et al.24 − U − U −Ashton et al.38 U U − − −Broadbent et al.34 − − − − −Daltroy et al.36 U U − − −Field43 U U − U −Gavin et al.39 U U − − −Holden-Lund32 U U U − −Kahokehr et al.35 − − − − −Leserman et al.37 U U + − −Lin33 + + + U −Manyande et al.29 + + U − −Manyande et al.28 + + U − −Manyande and Salmon30 U + − − −Massarini et al.44 U U − U −Mogan et al.40 − U + U −Scott and Clum41 + + + − −Stein et al.21 + U U − −Tusek et al.23 − U U − −Wells42 U U U U −Wilson31 U U − − −

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nd to become actively involved in their care and well-eing. Mind-body therapies are also relatively low cost sincehey can be administered by nurses and other health careroviders, and are largely free from adverse side effects.14

his supports the need for a current evaluation of theffectiveness of pre-operative mind-body interventions onost-operative outcomes. The scope of this review wasimited to relaxation, guided imagery, hypnotic, and mind-ulness based mind-body techniques.

This systematic review identified 20 studies examin-ng mind-body therapies amongst surgical patients. Thearge variation in methodology and study quality of theeviewed studies made it difficult to compare the resultsrom different studies and limited the ability to make overallonclusions regarding the efficacy of pre-surgical mind-bodynterventions on post-operative outcomes. The efficacy ofelaxation was assessed in eight studies, with overall resultsnding partial support for improvements in psychologicalell-being measures. Eight studies examined the efficacyf guided imagery, with strong evidence for improvementsn psychological well-being measures. Hypnosis was investi-ated in four studies, with partial support for improvementsn psychological well-being measures.

Analgesic intake is used as an index of surgical pain,nd certain pain medications can lead to several sideffects (e.g., nausea, drowsiness47;). Therefore, reductionsn analgesic intake can be interpreted as a reduction inost-operative pain. In the current review there was lack



f evidence for beneficial effects for analgesic intake.herefore from this measure it could be concluded thatverall the mind-body therapies did not have an effect onecreasing patient’s post-operative pain. However, several

miae

U’ indicates the information was unreported.

uthors have cautioned over the use of analgesic intake as measure of pain, as levels are also a function of patients’eluctance to request medication and nurses assessment ofatient need.30 There was also lack of evidence for the effi-acy of mind-body therapies in reducing length of hospitaltay. Length of hospital stay was largely a secondary mea-ure, which raises concerns over whether the studies weredequately powered to detect small differences of in theean length of stay between two groups.48 Furthermore, asith analgesic intake, length of hospital stay is also influ-nced by medical system factors, such as insurance.

One of the proposed mechanisms by which complemen-ary therapies work is through the influence of mind-bodynteractions on the immune system.49 Negative emotions canlso have a direct influence on increased pain perception.9

vidence for the efficacy of mind-body therapies improvinghysiological indices remains limited, with minimal effectsn vital signs, and inconsistent changes in endocrine meas-res. These contradictory results point to the importancef measuring these together with self-report questionnaireell-being measures when assessing mind-body therapies.

imitations

his systematic review has several limitations. Firstly, thiseview may be susceptible to language bias as the searchtrategy was limited to studies published in English. The


ajority of trials were evaluated as having a low qual-ty of evidence. This was largely the result of studies notdequately addressing or providing insufficient detail tonable the accurate judgement of randomisation methods

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(sequence allocation and allocation concealment) and blind-ing of personnel/outcome assessors. The quality of evidencewas rated ‘high’ in only two of the reviewed studies. There-fore, caution needs to be taken over the generalizability ofthe reported findings.

Many of the reviewed studies had a small sample size,indeed, only three had 50 or more participants in eachallocation group. Therefore, most studies may not havebeen adequately powered to detect improvements in post-surgical outcome measures amongst mind-body therapyparticipants. Although several of these studies noted smallsample size as a limitation, a power calculation was per-formed in only two studies.34,35 Conversely, a small samplesize may be associated with greater risk of inflated effectsize as a result of higher participant adherence rates thanwould be expected in clinical settings due to concentratedresearcher attention.50

Recommendations for future research

The mind-body therapies reviewed largely involve alteringthe context of the negative experience and pain. Researchsuggests that strategies which instead promote an accep-tance and openness of experiences, without focusing onignoring or avoiding pain, could be more effective, includingmindfulness.51 Evidence suggests that mindfulness trainingused to manage chronic disease (e.g., multiple sclerosis,fibromyalgia) helps alleviate associated psychological dis-tress and enhance patients’ wellbeing.26,52 However, we didnot identify any published studies exploring the effective-ness of mindfulness training in improving post-operativeoutcomes. Clearly this is an important area for futureresearch.

An important research question involves the influence ofthe frequency and timing of mind-body therapies on effi-cacy. In the current review the majority of studies taughtmind-body techniques on the day before surgery. It could beargued that participants did not have sufficient time to learnand practice the techniques.38 Furthermore, training on thepre-operative day may be problematic as this is usually whenanxiety levels are heightened, interfering with the ability tolearn.53 The efficacy of mind-body therapies are also likelyto be influenced by how often patients practice the inter-vention throughout the recovery period. In this review mostof the studies encouraged some form of practice of the tech-nique after surgery. However, the majority of studies did notprovide specific instructions. Future research should explorethis dose-response effect to determine optimal conditionsfor timing and reinforcement of the intervention.20

The timing of assessment of outcome measures is alsoan important factor to consider. Measuring outcomes inthe immediate post-operative period may lead to reducedtreatment efficacy as patients may still be suffering fromeffects of anaesthetic, making it difficult to apply thetechniques learnt pre-operatively. In the current reviewpost-operative outcomes measures were largely assessedbetween 1 and 7 days post-operatively. This review also



demonstrates the importance of measuring post-operativeoutcomes on more than one occasion, with several stud-ies finding significant effects for select post-operative daysonly.29,30,32,33,35,44 Future research may find greater support

R


or pre-surgical mind-body interventions if the assessmenteriod for outcome measures is extended beyond the firstew post-operative days. Extending this period will allowuture research to evaluate possible long-term effects.

onclusion

his review demonstrates the limited quality evidence forhe efficacy of mind-body therapies for improving post-urgical outcomes. In order to make recommendationsegarding the appropriateness of mind-body interventionsor pre-surgical patients, future studies need to addresshe limitations identified in this review. Specifically, tomprove the quality of conducting and reporting RCTs futureesearch should follow formal guidelines, for example CON-ORT guidelines,.54 Trials need to be adequately powered toetect clinically significant treatment effects, and futureesearch should include an adequate follow-up period toetermine the long-term efficacy of interventions. Futureesearch should attempt to explore the underlying mech-nisms involved in the efficacy of mind-body therapiesy further exploring potential moderating variables (e.g.,ersonality factors and individual characteristics). Further-ore, continuing to incorporate measures of physiological

ndices of stress may provide greater evidence for thefficacy of mind-body therapies, and may provide furthernsight into the mechanisms underlying treatment effects.his will lead to more targeted and effective integration ofind-body therapies with medical practices.

thical approval

ot applicable.

ource of funding

his research was supported by an Australian Research Coun-il Discovery Project Grant no. DP120101249.

onflict of interest statement

one.

cknowledgments

he authors thank Helen Shipperlee, Reference Librarian,arl de Gruchy Library, St. Vincent’s Hospital, for her assis-ance with the preparation of electronic literature searchesor this systematic review.

This research was supported by an Australian Researchouncil Discovery Project Grant no. DP120101249. Drowsey holds an NHMRC Early Career Australian Clinical Fel-

owship (APP1035810).


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