In patients who experience chronic or acute wound pain, analgesic requirements as well as patient-centered and clinical outcomes can be affected by psychological interventions as explored by considerable research.¹ Psychological interventions are classified as procedural: informing patients of wound or surgery procedures; sensory: describing how the wound or procedure will feel; behavioral: telling patients what to do to facilitate procedures or recovery; cognitive: coaching patients how to think more positively about the wound or procedure; relaxation: systematic muscle relaxing and/or breathing techniques; hypnosis: suggesting changes in patient perceptions; mindfulness: techniques based on meditation or contemplation; emotional: methods of coping with stress related to the wound or procedure; or patient-generated narratives focusing on the procedure or wound. These interventions are often used alongside analgesics or anesthetics. Evidence suggests that various psychological interventions may be effective in managing chronic pain lasting 3 or more months.² In June 2020, a planned systematic review exploring their interactions with pharmacologic agents in managing chronic nonspecific lower back pain was announced.³ Pilot research has initiated a randomized controlled trial (RCT) testing the value of mindfulness training for military veterans dealing with chronic pain.⁴ In this installment of Evidence Corner, 2 recent systematic reviews that explored whether such interventions improve patients’ experiences or clinical outcomes for those undergoing abdominal⁵ and general¹ surgery are reviewed.

Reference: Villa G, Lanini I, Amass T, Bocciero V, Scirè Calabrisotto C, Chelazzi C, Romagnoli S, De Gaudio AR, Lauro Grotto R. Effects of psychological interventions on anxiety and pain in patients undergoing major elective abdominal surgery: a systematic review. Perioper Med (Lond). 2020;9(1):38. doi:10.1186/s13741-020-00169-x

Rationale: Perioperative psychological interventions can affect inflammatory and immune functions, in turn reducing surgical stress responses and complications and improving quality of life for those recovering from breast, cardiac, or orthopedic surgery. The effects of psychological intervention on abdominal surgery have not been systematically reviewed.

Objective: Analyze effects of the most common perioperative psychological interventions on surgical pain and/or anxiety in adult patients undergoing elective general abdominal and/or urologic surgery.

Methods: A PRISMA-compliant systematic review searched the Cochrane Register of Controlled Trials, PubMed, EMBASE, PsycINFO, and CINAHL electronic databases for prospective controlled or observational clinical studies published from January 2000 through December 2019 that applied psychological interventions to adult patients scheduled for elective general abdominal and/or urologic surgery and measured pain and/or anxiety outcomes. Only studies published in English exploring relaxation, mindfulness, cognitive-behavioral therapies, narrative, emotional coping interventions, or hypnosis were included. Studies of emergency procedures and patients under 18 years of age were excluded. Results of qualifying studies were reviewed by 2 authors and tabulated in a uniform spreadsheet displaying study identifiers, methods, studied interventions, and surgical outcomes.

Results: Of the 2714 studies returned by the searches, 8 RCTs with comparable controls, including 1094 patients and 1 observational study on a cohort of 43 patients with obesity qualified for review. Four RCTs and the cohort study addressed abdominal surgery in hospitalized patients, 1 RCT each studied those undergoing abdominal or urologic day surgery, laparoscopic cholecystectomy, esophageal cancer, or prostate needle biopsy. Four RCTs reported reduced postoperative pain and/or anxiety in response to relaxation interventions (P < .001) with less opioid use (2 studies; P < .04). Emotional coping interventions reduced preoperative anxiety (1 RCT; P < .05) and, for those with esophageal cancer, reduced stress and anxiety following surgery (1 RCT; P < .05). Hypnotism before prostate needle biopsy procedures reduced pain and anxiety (P < .01). For the cohort of 43 patients with obesity, cognitive behavioral therapy administered 1 year after surgery reduced postoperative anxiety and distress (P < .02). One-day surgery patients did not experience a significant effect of a preoperative relaxation intervention. Interventions and outcome measures were too heterogeneous to qualify for meta-analyses.

Authors’ Conclusions: Perioperative psychological interventions were effective in improving patients’ anxiety, distress, and pain. It is realistic to apply them perioperatively during abdominal and/or urologic surgery to achieve these effects.

Reference: Powell R, Scott NW, Manyande A, Bruce J, Vögele C, Byrne-Davis LMT, Unsworth M, Osmer C, Johnston M. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev. 2016;(5):CD008646. doi:10.1002/14651858.CD008646.pub2

Rationale: Psychological preparation for surgery has been shown to improve negative emotions, pain, pain medication use, and length of hospital stay. Research and reviewing methods have improved since the last systematic review of these effects on surgical patients undergoing general anesthesia in 1993.⁶

Objective: The authors conducted a systematic review of the effects on postoperative outcomes of psychological preparation of adult patients planning to undergo elective surgery under general anesthesia.

Methods: Using methods from the Cochrane Handbook for Systematic Reviews of Interventions, the authors searched the Cochrane Register of Controlled Trials, Web of Science, MEDLINE, PsycINFO, EMBASE, and CINAHL electronic databases from inception through May 2014 for terms related to all types of elective surgeries with general anesthesia combined with synonyms for each form of psychological or mindful therapy previously described. The RCTs were included if they measured at least 2 primary and 2 secondary outcomes on adults receiving at least 1 form of psychological intervention prior to operation compared with similar adults not receiving the same psychological intervention. Primary outcomes included standardized pain following operation or behavioral measures of capacity to perform activities of daily living. Secondary outcomes were postoperative standardized measures of negative emotions including anxiety, fear, and/or depression and length of hospital stay in days. Non-RCTs or RCTs comparing differing delivery formats for the same intervention or partial interventions were excluded as were those on patient samples with clinically diagnosed psychological morbidity. Studies including individual patients with such disorders were not excluded.

Results: Among 6781 records returned by the searches, 105 RCTs qualified for summary and/or analyses. A total of 61 reported pain outcomes, 14 reported behavioral recovery, 58 reported length of hospital stay, and 50 reported negative emotion measures. Evidence was generally of low to very low quality, owing to heterogeneity of results. Meta-analysis, appropriate for 38 of the pain RCTs using standardized scores, revealed substantial pain reduction after surgery resulting from patient preparation prior to operation using all psychological interventions except behavioral ones (P = .007). Effects on functional activities of daily living (behavioral recovery) were too heterogeneous to qualify for meta-analysis, but these functions generally improved in response to psychological preparation of patients before surgery (P < .05). Length of stay was shorter for those who received psychological preparation prior to surgery in the 36 RCTs qualifying for meta-analysis (P = .007), but the results were heterogeneous, suggesting caution in interpreting this evidence. Among 31 RCTs meta-analyzed, anxiety, distress, and depression were consistently reduced by preoperative psychological interventions (P = .003). This result was mainly driven by interventions preparing patients with procedural or sensory information, relaxation techniques, or hypnosis, with no clear effect of behavioral instruction, cognitive, or emotion-focused interventions.

Authors’ Conclusions: Low-quality evidence indicates that psychological preparation may improve postoperative pain, behavioral outcomes, anxiety or distress, and length of hospital stay. Such interventions are unlikely to harm patients.

These 2 systematic reviews suggest the merit of psychological interventions in reducing pain, anxiety, distress, and opioid use following surgery. Their conclusions would have been stronger if pain management medication use had been measured uniformly across all studies and at least 1 valid, reliable pain or anxiety outcome had been used in all studies, setting the stage for a bona fide meta-analysis of these outcomes. Researchers have content-validated, patient-centered pain and depression as reasonable, reliable outcomes making a difference in patients’ lives.⁷ If multidisciplinary wound care organizations were to collaborate in standardizing valid, reliable outcome measures for each key outcome like pain, analgesic use, activities of daily living, depression, and anxiety, RCT outcomes would be more compelling in supporting related claims. Published systematic reviews and meta-analyses can represent high-quality evidence only if RCT subjects, methods, and outcome measures are sufficiently similar to provide reviewers homogeneous data. Perioperative psychological interventions may trim hospital stays and help improve surgical pain, analgesic use, anxiety, depression, and functional activities of daily living. There will be definitive confirmation once studies standardize measures documenting these postoperative outcomes. Oncology advances became clear once standardized terms and outcomes were used. Imagine the strides that could be made in advancing wound practice and science if the same clinically relevant, reliable, valid terms and measures to document wound care outcomes were used.