Complementary Therapies for Gynecological and Other Surgery
Complementary Therapies for Gynecological and Other Surgery
June 2001; Volume 3; 41-45
By Judith J. Petry, MD
Current surgical practice addresses primarily technical concerns; the psychological aspects of the surgical experience rarely are addressed. This article reviews the current literature on the effectiveness of relaxation techniques, hypnosis and suggestion, and imagery on modifying surgical outcomes.
Effects of Anxiety and Depression
A high level of anxiety accompanies the need for surgery, and depression is common among surgical patients. Both anxiety and depression are risk factors for surgical complications.
The effect of preoperative anxiety was demonstrated in a study of 24 male patients scheduled for inguinal hernia repair in a Veteran’s Administration hospital. Higher psychosocial stress correlated with lower immune function both preoperatively and postoperatively as well as with poorer surgical outcome.1 Compared to patients with low stress levels, patients with higher stress levels had significantly more postoperative complications (P < 0.05) and used three times more postoperative narcotics (P < 0.05). Those with lower preoperative immune function had the longest hospital stays (P < 0.01). These changes appeared to be related to the stress of surgery; at 30 days postoperative, immune function was comparable between high and low stress patients.
Even minor outpatient surgical procedures may increase anxiety levels and affect immune function. A series of 50 consecutive patients undergoing excision of pigmented nevi under local anesthesia were found to have a significant increase in preoperative anxiety (increased blood pressure, pulse rate, respiratory rate, and pain), as well as a significant change in CD56+ lymphocytes.2 Women were significantly more anxious than men (P < 0.01) in this study.
Preoperative anxiety increased anesthetic requirements in a prospective cross-sectional study of 57 women undergoing laparoscopic tubal ligation under general anesthesia. Patients were divided into low, medium, and high anxiety groups (using the State-Trait Anxiety Inventory). High trait anxiety patients required significantly more propofol (an intravenous anesthetic) than the low trait anxiety group for induction and maintenance of anesthesia (P = 0.01 and 0.03). No correlation was found for state anxiety or coping style.3
A prospective study in 171 cardiac surgery patients found that patients preoperatively identified as "distressed" by a set of questionnaires and the Nottingham Health profile experienced significantly more cardiac events at one-year follow-up (16%) than non-distressed subjects (5%, P < 0.02).4
Preoperative depression may correlate negatively with surgical outcome. Two years after 158 patients underwent coronary artery bypass surgery, three (15.2%) of the 24 patients preoperatively classified as depressed had died compared to three deaths (2.2%) among 134 non-depressed patients (odds ratio 6.24; 95% confidence interval 1.18-32.98; P = 0.046).5 One death in each group was cardiac-related; none of the deaths were by suicide or accident. Another prospective study of 102 lumbar surgery patients found that anxiety and depression, but not hostility, were correlated with poor outcome.6
Personality Factors
A patient’s psychological makeup (rarely taken into account in studies of psychological interventions) also may be an independent predictor of preoperative and postoperative anxiety and depression, as well as surgical outcome. A prospective pilot study of 23 cardiac surgery patients found that those with an internal locus of control (determined by the Multidimensional Health Locus of Control) used 40% less morphine (average 19.85 mg/d) by patient-controlled analgesia than those with an external locus of control (average 33.53 mg/d).7 Of 20 patients awaiting heart transplantation, external locus of control correlated with preoperative anxiety and depression; external locus of control also correlated with postoperative anxiety and depression.8
One review of presurgical psychological interventions concluded that it is important to adjust information to the patients’ personality traits (specifically locus of control and coping style), and that behavioral interventions were most effective when matched with patients coping styles and level of anxiety.9 For example, a study of 40 patients found that a brief formal preoperative visit from an anesthetist increased anxiety in low-anxiety patients, but decreased anxiety in high-anxiety patients.10 Integrating such individualized care into standard medical settings would be complex.
Relaxation Techniques
Several techniques have been employed to decrease anxiety in surgical patients. A randomized, double-blind study of 97 surgical patients reported in 1964 (patients were not even informed that they were in a research study, an ethical violation) compared 51 controls, who received a routine preoperative anesthesia visit the night before surgery with no discussion of postoperative pain, with 46 "Special Care" patients, who also received detailed information about postoperative pain in careful detail including what to expect, treatment, and how to use simple relaxation techniques to reduce pain.11 They were visited again after the surgery and once or twice a day until discharge. The "Special Care" group used 50% less narcotics postoperatively and were deemed ready for discharge 2.7 days earlier than the control group. It is not clear whether the instructions on managing postoperative pain or the individualized daily attention (a combination of psychological methods, relaxation, and human caring contact) affected outcome. Subsequent to this study, the importance of an individualized approach in utilizing psychological preparation for surgery has been underscored by many investigators.
A randomized study of 30 women scheduled for hysterectomy compared desensitization and relaxation training (n = 10) to attention control (a friendly visit) (n = 10) and untreated control groups (n = 10).12 Relaxation training significantly decreased discomfort and reduced hospital stay (5.5 days in the control group, 4.7 days in the visitor group, and 4.2 days in the relaxation group). No significant differences in state and trait anxiety were found between the groups in this small study.
A randomized controlled study in 40 patients undergoing minor colorectal or anal surgery assigned 21 patients to receive preoperative relaxation instructions. Compared to levels taken immediately before induction of anesthesia, the relaxation group experienced increased post-surgical cortisol and adrenaline levels; in the 19 controls, levels were unaffected or tended to decline.13 Despite this increased endocrine response, relaxation was associated with a significant reduction in state anxiety on the preoperative and first postoperative days, decreased maximal perioperative systolic and diastolic blood pressures (111.5/67.0 mm compared to 120.5/72.1 mm, P < 0.001 systolic, P < 0.05 diastolic), and decreased analgesic use over the two postoperative days (1.1 tablets compared to 2.8, P < 0.05). These apparently paradoxical effects invite more research.
Current research on preoperative relaxation techniques is complex and the best techniques have not been identified conclusively. Behavioral methods, especially if they are individualized, probably are helpful in most patients.
Hypnosis and Suggestion
Hypnosis, defined as "a state of attentive and focused concentration in which ... people are highly responsive to suggestion" has been extensively studied since the early 19th century practice of mesmerism was in vogue.14
A 1991 review of the literature on suggestion, relaxation, and hypnosis in surgery found that the four best-designed randomized studies demonstrated a benefit for surgical patients.15 In three studies, intraoperative suggestion resulted in shorter hospital stays (7.1 vs. 8.4 days, and 8.6 vs. 11.1 days) and fewer postoperative complications (fever, bowel problems) in experimental groups compared to controls. The fourth study has been mentioned previously.11 Other randomized studies reviewed by the authors found significant improvement in postoperative emotional state with preoperative and intraoperative suggestions. One used suggestion and taped hypnotic induction in 40 cardiac surgery patients and demonstrated a similar significant reduction in postoperative anxiety as well as reduction in diastolic blood pressure and blood transfusions compared to controls. Only two of 18 studies reviewed found no benefit for hypnosis: one used self-hypnosis in cardiac surgery patients and the other used intraoperative suggestions.
More recently, mixed results of self-hypnosis in 32 cardiac surgery patients were reported in a small randomized surgeon-blinded study.16 No difference was found in length of ICU stay, hospital stay, morbidity, or mortality between the group that practiced self-hypnosis preoperatively and postoperatively and controls. The study group had low postoperative adherence (65%). Although postoperative tension, depression, anger, and fatigue were lower in the study group, use of postoperative analgesia was higher than the control group.
A prospective, randomized, partially blinded study of 60 oral surgery patients tested daily use of a specially designed hypnotic audiotape for the week prior to surgery.17 Patients in the audiotape group had a smaller mean increase in preoperative anxiety after using the audiotape (5.5 points) compared to the control group (11.7 points, P = 0.03). No difference was noted in pain medication use or complications. Analgesic use was similar between groups; unexpectedly, the experimental group had significantly more vomiting than controls (1.28 episodes compared to 0.27 episodes, P = 0.006). An audiotape may be inadequate for inducing hypnosis and is certainly inferior to a personal approach by a trained hypnotist. A serious flaw in this study was the lack of assessment of whether patients listening to the audiotape entered a hypnotic state.
More recently, a hypnosis study of 60 patients undergoing elective plastic surgery under conscious sedation randomized 35 subjects to hypnosis and 25 to an emotional support group.18 The same anesthesiologist attended all patients; the intervention consisted of immediate preoperative and intraoperative induction of hypnotic trance; the emotional support group received instruction in stress reduction techniques with continuous verbal support, procedural information, reassurance and distraction, and pharmacological conscious sedation. Anxiolytic and analgesic drugs were administered as needed. Compared to the relaxation group, the hypnosis group had a significantly less need for pharmacologic sedation (P < 0.001), reduced intra- and postoperative pain scores (P < 0.02), less postoperative anxiety (P < 0.04), less postoperative nausea and vomiting (6.5% vs. 30.8%, P < 0.001), and increased perception of intraoperative control (P < 0.01). Patient satisfaction and comfort, surgeon satisfaction, and intraoperative stability of vital signs also were significantly better in the hypnosis group compared to the relaxation group. Limitations of the study were lack of blinding, use of the same anesthesiologist/hypnotherapist for both groups, and a short exposure to the relaxation technique.
Other recent studies have found favorable effects of hypnosis. A randomized controlled trial of 50 women undergoing elective breast reduction surgery found that use of preoperative hypnosis and mental preparation (using an audiotape) resulted in significantly less vomiting (39% compared to 68% in the control group), less nausea (43.5% vs. 80%), and less need of postoperative analgesics.19 No differences were found in pain, well-being, or degree of recovery over the first five postoperative days. A prospective clinical trial in 60 hand surgery patients compared preoperative hypnotic suggestion and relaxation to standard care; the treatment group showed significant decreases in pain (intensity and affect) and state anxiety, and fewer complications (P = 0.004). Surgeons who were blinded to group status rated hypnosis patients as making significantly better progress than controls (P = 0.004).20
Comparison of studies on hypnosis in surgery are difficult due to differences in types of hypnotic suggestion, patient expectations, hypnotic induction by audiotape vs. live therapist, and differences in hypnotizability of subjects (15-20% of the population is highly hypnotizable, 15-20% have low susceptibility to hypnosis, and the remainder of the population is in the mid-range). Ideally, patients should be tested for hypnotizability before resources are expended that will have little chance of success in specific individuals who can be identified beforehand. Overall, studies on the effects of hypnosis in surgery indicate that it is beneficial.
Imagery
Imagery has been defined as "both a mental process (as in imagining) and a wide variety of procedures used in therapy to encourage changes in attitude, behavior, or physiological reactions. It includes, as well as the visual, all the senses—aural, tactile, olfactory, proprioceptive, and kinesthetic."21 Jeanne Achterberg, PhD, president of the Association for Transpersonal Psychology, has stated that imagery is "the communication mechanism between perception, emotion, and bodily change." In guided imagery, specific narratives are used in an attempt to focus and direct the imagination to enhance physical and emotional healing. Treatment imagery asks patients to imagine, for example, blood flow slowing at the surgical site during surgery to decrease blood loss. Healing or end-state imagery asks patients to imagine themselves the way they want to be. Imagery is a component of many practices, including biofeedback, neurolinguistic programming, autogenic training, and desensitization techniques; the discussion here of imagery focuses on studies that used imagery techniques.
A randomized controlled trial of 51 abdominal surgery patients compared controls (who received background information about the hospital preoperatively) to a group that received imagery training aimed not at anxiety reduction, but at increasing the patient’s confidence to cope with surgical stress.22 State anxiety was similar in both groups, but imagery patients experienced less postoperative pain (P < 0.05), were less distressed (P < 0.01), felt they coped with pain better (P < 0.01), and requested less pain medication (P < 0.05) than controls. Compared to controls, cortisol levels were lower and noradrenaline levels higher immediately preoperatively and postoperatively in imagery patients (P < 0.01).
A randomized study of 32 general surgery patients (90.5% female) gave all patients procedural information; 16 also underwent imagery training designed to relieve postoperative pain (n = 16).23 Study subjects experienced significantly less postoperative pain (P < 0.001), measured by visual analog scale, and took fewer postoperative analgesics (P < 0.03) than controls.
The best study to date of imagery and surgical outcome is a randomized controlled trial that compared guided imagery to standard preoperative preparation in 130 patients undergoing elective colorectal surgical procedures.24 Compared to controls, the 65 imagery patients experienced significantly less preoperative and postoperative anxiety (P < 0.001), less postoperative pain (P < 0.001), earlier first bowel movements (P < 0.001), and required almost 50% less postoperative narcotics (P < 0.001). Different researchers using a similar design and similar imagery technique reported a follow-up. A randomized controlled study of 86 patients undergoing anorectal surgery for benign disease, utilizing a similar imagery technique, found that imagery patients experienced better quality of sleep (P = 0.01) than control patients.25
Some types of imagery may have adverse effects; a study using hypnotic suggestion in cardiac surgery patients found that patients who used muscle relaxation imagery had significantly more chest tube drainage than those who used suggestion related to optimal surgical outcome and controls.26
Conclusion
In appropriately designed interventions, relaxation techniques, hypnosis and suggestion, and imagery are safe; techniques designed specifically to improve surgical outcomes deserve more attention and careful implementation in surgical settings. Mind/body techniques may be of significant benefit with regard to patient satisfaction, preoperative and postoperative anxiety and depression, anesthetic requirements, intraoperative vital signs, postoperative pain, nausea and vomiting, analgesic requirements, complications, and hospital stay. Improvements in these outcomes would offer significant cost savings, as well as improved physical and emotional results. Cost-benefit studies for specific interventions are needed.
Dr. Petry is an Independent Consultant in Holistic Medicine and Medical Director, Vermont Healing Tools Project, Brattleboro, VT.
References
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20. Mauer MH, et al. Medical hypnosis and orthopedic hand surgery: Pain perception, postoperative recovery, and therapeutic comfort. Intl J Clin Exp Hypn 1999;47:144-161.
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22. Manyande A, et al. Preoperative rehearsal of active coping imagery influences subjective and hormonal responses to abdominal surgery. Psychosom Med 1995;57:177-182.
23. Daake DR, Gueldner SH. Imagery instruction and the control of postsurgical pain. Appl Nurs Res 1989;2: 114-120.
24. Tusek DL, et al. Guided imagery: A significant advance in the care of patients undergoing elective colorectal surgery. Dis Colon Rectum 1997;40:172-178.
25. Renzi C, et al. The use of relaxation techniques in the perioperative management of proctological patients: Preliminary results. Int J Colorectal Dis 2000;15: 313-316.
26. Greenleaf M, et al. Hypnotizability and recovery from cardiac surgery. Am J Clin Hypn 1992;35:119-128.
June 2001; Volume 3; 41-45
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