Psychological interventions for acute pain after open heart surgery

103 Pages·2014·1.04 MB·English

Psychological interventions for acute pain after open heart
surgery (Review)
Koranyi S, Barth J, Trelle S, Strauss BM, Rosendahl J
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: Psychologicalinterventionsforacutepainafteropenheartsurgery(Review)
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c Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
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TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Analysis1.1.Comparison1Psychologicalinterventionvscontrolcondition,Outcome1Painintensitymeasuredwith
continuousscales:medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis1.2.Comparison1Psychologicalinterventionvscontrolcondition,Outcome2Painintensitymeasuredwith
continuousscales:long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis1.3.Comparison1Psychologicalinterventionvscontrolcondition,Outcome3Mentaldistress:medium-term. 78
Analysis1.4.Comparison1Psychologicalinterventionvscontrolcondition,Outcome4Mentaldistress:long-term. 79
Analysis1.5.Comparison1Psychologicalinterventionvscontrolcondition,Outcome5Mobility:medium-term. . 80
Analysis1.6.Comparison1Psychologicalinterventionvscontrolcondition,Outcome6Mobility:long-term. . . . 80
Analysis2.1.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome1Pain
intensitymeasuredwithcontinuousscales:medium-term. . . . . . . . . . . . . . . . . . . 81
Analysis2.2.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome2Pain
intensitymeasuredwithcontinuousscales:long-term. . . . . . . . . . . . . . . . . . . . . 82
Analysis2.3.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome3Mental
distress:medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Analysis2.4.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome4Mental
distress:long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Analysis2.5.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome5Mobility:
medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis2.6.Comparison2Subgroupanalysis:Psychologicalinterventionvsstandardcare(TAU),Outcome6Mobility:
long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Analysis3.1.Comparison3Subgroupanalysis:Psychologicalinterventionvsattentioncontrolgroup,Outcome1Mental
distress:medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Analysis3.2.Comparison3Subgroupanalysis:Psychologicalinterventionvsattentioncontrolgroup,Outcome2Mental
distress:long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis4.1.Comparison4Subgroupanalysis:Psychoeducationvscontrolcondition,Outcome1Mentaldistress:medium-
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Analysis4.2.Comparison4Subgroupanalysis:Psychoeducationvscontrolcondition,Outcome2Mentaldistress:long-
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis5.1.Comparison5Subgroupanalysis:Relaxationvscontrolcondition,Outcome1Mentaldistress:long-term. 89
Analysis6.1.Comparison6Subgroupanalysis:Combinedinterventionvscontrolcondition,Outcome1Mentaldistress:
medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) i
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Analysis6.2.Comparison6Subgroupanalysis:Combinedinterventionvscontrolcondition,Outcome2Mentaldistress:
long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis7.1.Comparison7Sensitivityanalysis:Studieswithadequatesequencegeneration,Outcome1Mentaldistress:
medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis7.2.Comparison7Sensitivityanalysis:Studieswithadequatesequencegeneration,Outcome2Mentaldistress:
long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Analysis8.1.Comparison8Sensitivityanalysis:Studieswithadequatehandlingofincompleteoutcomedata,Outcome1
Mentaldistress:medium-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis8.2.Comparison8Sensitivityanalysis:Studieswithadequatehandlingofincompleteoutcomedata,Outcome2
Mentaldistress:long-term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Analysis9.1.Comparison9Sensitivityanalysis:Studieswithstudyprotocolavailable,Outcome1Mentaldistress:medium-
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 100
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) ii
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Psychological interventions for acute pain after open heart
surgery
SusanKoranyi1,JürgenBarth2,SvenTrelle2,3,BernhardMStrauss1,JennyRosendahl1
1InstituteofPsychosocialMedicineandPsychotherapy,UniversityHospitalofJena,Jena,Germany.2InstituteofSocialandPreventive
Medicine,UniversityofBern,Bern,Switzerland.3CTUBern,UniversityofBern,Bern,Switzerland
Contactaddress:SusanKoranyi,InstituteofPsychosocialMedicineandPsychotherapy,UniversityHospitalofJena,Stoystrasse3,Jena,
Thuringia,07743,[email protected].
Editorialgroup:CochranePain,PalliativeandSupportiveCareGroup.
Publicationstatusanddate:New,publishedinIssue5,2014.
Reviewcontentassessedasup-to-date: 17September2013.
Citation: KoranyiS,BarthJ,TrelleS,StraussBM,RosendahlJ.Psychologicalinterventionsforacutepainafteropenheartsurgery.
CochraneDatabaseofSystematicReviews2014,Issue5.Art.No.:CD009984.DOI:10.1002/14651858.CD009984.pub2.
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Acute postoperative pain is one of the most disturbing complaints in open heartsurgery, and is associated with a risk of negative
consequences.Severaltrialsinvestigatedtheeffectsofpsychologicalinterventionstoreduceacutepostoperativepainandimprovethe
courseofphysicalandpsychologicalrecoveryofparticipantsundergoingopenheartsurgery.
Objectives
Tocomparetheefficacyofpsychologicalinterventionsasanadjuncttostandardcareversusstandardcarealoneorstandardcareplus
attentioninadultsundergoingopenheartsurgeryonpain,painmedication,mentaldistress,mobility,andtimetoextubation.
Searchmethods
WesearchedtheCochraneCentralRegisterofControlledTrials(CENTRAL)(TheCochraneLibrary2013,Issue8),MEDLINE(1946
toSeptember2013),EMBASE(1980toSeptember2013),WebofScience(allyearstoSeptember2013),andPsycINFO(allyearsto
September2013)foreligiblestudies.Weusedthe’relatedarticles’and’citedby’optionsofeligiblestudiestoidentifyadditionalrelevant
studies.Wealsocheckedlistsofreferencesofrelevantarticlesandpreviousreviews.WealsosearchedtheProQuestDissertationsand
ThesesFullTextDatabase (allyearstoSeptember2013) andcontactedtheauthorsofprimarystudiestoidentifyany unpublished
material.
Selectioncriteria
Randomisedcontrolledtrialscomparingpsychologicalinterventionsasanadjuncttostandardcareversusstandardcarealoneorstandard
careplusattentioninadultsundergoingopenheartsurgery.
Datacollectionandanalysis
Two review authors (SK and JR) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We
calculatedeffectsizesforeachcomparison(Hedges’g)andmeta-analyseddatausingarandom-effectsmodel.
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 1
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Nineteentrialswereincluded(2164participants).
Nostudyreporteddataonthenumberofparticipantswithpainintensityreductionofatleast50%frombaseline.Onlyonestudy
reporteddataonthenumberofparticipantsbelow30/100mmontheVisualAnalogueScale(VAS)inpainintensity.Psychological
interventionshavenobeneficialeffectsinreducingpainintensitymeasuredwithcontinuousscalesinthemedium-terminterval(g-
0.02,95%CI-0.24to0.20,4studies,413participants,moderatequalityevidence)norinthelong-terminterval(g0.12,95%CI-
0.09to0.33,3studies,280participants,lowqualityevidence).
Nostudyreporteddataonmediantimetoremedicationoronnumberofparticipantsremedicated.Onlyonestudyprovideddataon
postoperative analgesicuse.Studiesreportingdataonmentaldistressinthemedium-termintervalrevealedasmallbeneficialeffect
ofpsychologicalinterventions(g0.36,95%CI0.10to0.62,12studies,1144participants,lowqualityevidence).Likewise,asmall
beneficialeffectofpsychologicalinterventionsonmentaldistresswasobtainedinthelong-terminterval(g0.28,95%CI0.05to0.51,
11studies,1320participants,lowqualityevidence).Therewerenobeneficialeffectsofpsychologicalinterventionsonmobilityinthe
medium-terminterval(g0.23,95%CI-0.22to0.67,3studies,444participants,lowqualityevidence)norinthelong-terminterval
(g0.29,95%CI-0.14to0.71,4studies,423participants,lowqualityevidence).Onlyonestudyreporteddataontimetoextubation.
Authors’conclusions
For the majority of outcomes (two-thirds) we could not performa meta-analysis since outcomes were not measured, or data were
providedbyonetrialonly.Psychologicalinterventionshavenobeneficialeffectsonreducingpostoperativepainintensityorenhancing
mobility.Thereislowquality evidencethatpsychological interventions reduce postoperative mentaldistress. Due tolimitations in
methodologicalquality,asmallnumberofstudies,andlargeheterogeneity,weratedthequalityofthebodyofevidenceaslow.Future
trialsshouldmeasurecrucialoutcomes(e.g.numberofparticipantswithpainintensityreductionofatleast50%frombaseline)and
shouldfocustoenhancethequalityofthebodyofevidenceingeneral.Altogether,thecurrentevidencedoesnotclearlysupportthe
useofpsychologicalinterventionstoreducepaininparticipantsundergoingopenheartsurgery.
PLAIN LANGUAGE SUMMARY
Psychologicaltreatmentstoreducepaininpeopleundergoingopenheartsurgery
Acutepostoperativepainisoneofthemostdisturbingcomplaintsinopenheartsurgery,andisrelatedtoariskofnegativeconsequences
suchasimpairedwoundhealing,chronicpainordepression.Psychologicaltreatmentisdesignedtoimprovepatients’knowledgeandto
altersurgery-relatedmentaldistress,negativebeliefsandnon-compliance.Itaimstoreducepainandanxiety,andtoimprovethepost-
operativerecoveryafteropenheartsurgery.Psychologicaltreatmentcomprisestheprovisionofinformationaboutmedicalprocedures
andassociatedemotionalresponsesandsensationsbefore,duringandaftersurgery,andinstructionsabouthowtoadheretomedical
advicetosupporttherecovery;teachingorinstructingpatientsindifferentrelaxationtechniques;orhelpingpatientstounderstand
theirthoughtsandfeelingsthatinfluencetheirbehaviours.
Thisreviewinvestigatedwhetherpsychologicaltreatmentcouldsuccessfullyreduceacutepostoperativepainandimprovethecourseof
physicalandpsychologicalrecoveryofpeopleundergoingopenheartsurgery.Wefound19studiesincludingatotalof2164participants
whichreportedeffectsofpsychologicaltreatmentcomparedtoacontrolgrouponpainintensity,useofpainmedication,mentaldistress,
mobility and duration of intubation aftersurgery. Wedidnotfind evidencethatpsychological treatmentreducespainintensity or
enhancesmobilityafteropenheartsurgery.Psychologicaltreatmentprovedtobeslightlybetterthanstandardcareinreducingmental
distress.Wedidnotfindclearevidencethatpsychologicaltreatmentleadstoareducedintubationtimeaftersurgery.Noadverseeffect
ofpsychologicaltreatmentwasdescribedinanyprimarystudy.
However, studies were of low quality in general, and there was also variation between the results of studies. The latest search was
conductedinSeptember2013.Studiesweremostlyconductedwithoutexternalfinancialsupportorfundedbynon-commercialnational
orregionalresearchassociationsorstudentfellowships.Conflictsofinterestwerenotstatedinanystudy.
Further researchof high quality is required to answer thequestion of whetherpsychological treatment hasthe potential to reduce
postoperativepainandimproverecoveryafteropenheartsurgery.
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 2
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
Psychologicalinterventionscomparedwithcontrolconditionsforacutepainafteropenheartsurgery
Patientorpopulation:Adultsundergoingopenheartsurgery
Settings:inpatient,surgicalcare
Intervention:psychologicalintervention
Comparison:controlcondition(eitherstandardcareorattention)
Outcomes Relativeeffect NoofParticipants Qualityoftheevidence Comments
(95%CI) (studies) (GRADE)
Painintensitymeasured g-0.02(-0.24to0.20) 413(4studies) ⊕⊕⊕(cid:13) No beneficial effects of
with continuous scales: moderate psychological interven-
medium-term tionsinreducingpainin-
variousself-reportscales tensity
(follow-up: 24 hours
postoperatively to dis-
charge)
Painintensitymeasured g0.12(-0.09to0.33) 280(3studies) ⊕⊕(cid:13)(cid:13) No beneficial effects of
with continuous scales: low psychological interven-
long-term tionsinreducingpainin-
variousself-reportscales tensity
(follow-up: after dis-
chargeupto4weeksaf-
terdischarge)
Mental distress: g0.36(0.10to0.62) 1144(12studies) ⊕⊕(cid:13)(cid:13) Interventiongrouppartic-
medium-term low ipantsreportedlessmen-
various self-reported taldistress
scales
(follow-up:1daypostop-
erativelytodischarge)
Mental distress: long- g0.28(0.05to0.51) 1320(11studies) ⊕⊕(cid:13)(cid:13) Interventiongrouppartic-
term low ipantsreportedlessmen-
various self-reported taldistress
scales
(follow-up: after dis-
charge up to 24 months
afterdischarge)
Mobility:medium-term g0.23(-0.22to0.67) 444(3studies) ⊕⊕(cid:13)(cid:13) No beneficial effects of
Jenkins Activity Check- low psychological interven-
list,SicknessImpactPro- tions in enhancing post-
file,IntegratedMotor Ac- operativemobility
tivityMonitor
(follow-up: 2 postopera-
tivedaystodischarge)
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 3
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mobility:long-term g0.29(-0.14to0.71) 423(4studies) ⊕⊕(cid:13)(cid:13) No beneficial effects of
Jenkins Activity Check- low psychological interven-
list,SicknessImpactPro- tions in enhancing post-
file, Nottingam Health operativemobility
Profile
(follow-up: after dis-
charge up to 24 weeks
afterdischarge)
CI:Confidenceinterval;g:Hedge´ sg
GRADEWorkingGroupgradesofevidence
Highquality:Furtherresearchisveryunlikelytochangeourconfidenceintheestimateofeffect.
Moderatequality:Furtherresearchislikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandmaychange
theestimate.
Lowquality: Further research isverylikelytohaveanimportant impact onourconfidence intheestimate ofeffect and islikelyto
changetheestimate.
Verylowquality:Weareveryuncertainabouttheestimate.
ReasonsfordowngradingtheevidencearelistedintheQualityoftheevidencesection.
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BACKGROUND Acutepostoperativepainhasnegativeconsequencesforhealth.It
hasbeenshownthatpeopleundergoingcardiacsurgerywithse-
verelevelsofacutepostoperativepainhavea3.5timeshigherrisk
Descriptionofthecondition ofsufferingfromchronicpainaftercardiacsurgery(Cogan2010).
Evidencealsodemonstratesthatpostoperativepainisasignificant
Openheartsurgeryisoneofthemostfrequentlyconductedma-
predictorofpostoperativewoundhealing(McGuire2006),akey
jorsurgicalproceduresingeneralhospitals.About400,000coro-
variableofpostoperativerecoveryinopenheartsurgery.Moreover,
naryarterybypassgraftsurgeries(CABG)and100,000valvesurg-
poorpainmanagementmayleadtodepression(Cogan2010)in
erieswereperformedintheUnitedStatesin2007(Roger2011).
additiontonegativepulmonary,cardiac,gastrointestinalandmus-
InGermany,about40,000CABGproceduresandabout25,000
culoskeletaleffects.Thereisclearevidence thatpost-CABGde-
valvesurgerieswereregisteredin2010(Gummert2011).
pressionpredictsdecreasedhealth-relatedqualityoflife,reduced
Themostdisturbingcomplaintinopenheartsurgeryisacutepain,
activitylevels,chronicchestpain,poorercardiacsymptomrelief,
which isstillasevere andundertreatedproblem(Cogan 2010).
aswellasincreasedratesofrehospitalisationandmortalityinde-
Acutepainisthemostcommonpatientcomplaintafteropenheart
pendent of cardiac status, somatic comorbidity or the extent of
surgery,andpainreliefisoftenperceivedasinadequateduringthe
surgery (Barth2004;Blumenthal2003;Burg2003;Connerney
hospitalrecoveryperiod(Aslan2009;Valdix1995).
2001; Doering 2005; Goyal 2005; Mallik 2005; Oxlad 2006;
Theworstpainisexperiencedduringthefirst48hourswhichare
Pignay-Demaria2003).However,toourknowledgethereareno
spentintheintensivecareunit(ICU).Followingintensivecare,
empiricalstudieswhichtestthepathwaysbetweenacutepostoper-
thepresenceofchesttubesandtheirremoval,endotrachealtube
ativepainafterCABG,post-CABGdepressionandworsesurgical
suctioning, vomiting,turning, breathingandchangeofdressing
long-termoutcomesinonemodel.Thus,theunderlyingmecha-
arealsoseverelypainfulexperiences(Aslan2009;Gelinas2007).
nismsasyetremainunclear.
Painsymptomsafteropenheartsurgerycanbemultiple,arede-
Itisnotsurprisingthatacutepostoperativepainafteropenheart
scribedasburningorthrobbing,locatedmainlyinthethoraxat
surgeryismainlydeterminedbysurgery-relatedfactors(e.g.dura-
thesiteofsternalincision,andmaybeofvisceral,musculoskeletal
tionandthelocationofsurgery;Sommer2008).However,given
orneurogenicorigin(Cogan2010;Gelinas2007).
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 4
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
theassociationbetweenanxiety,depressionandpostoperativeout- Thereisnoevidence-basedmodelforhowpsychologicalinterven-
comes such as mortality, wound healing and complications (Ai tionsinthecontextofcardiacsurgerymightreducepostoperative
2006; Connerney 2001; Ho 2005; Mavros 2011; Perski 1998; pain. However,itisreasonable toassume thatpsychological in-
Stengrevics1996;Szekely2007;Tully2008),researchhasinvesti- terventionsmightreducepainbythealterationofsurgery-related
gatedthequestionofwhetherthepsychologicalconditionofpa- mentaldistress,negativebeliefsandnon-compliance,aswellasby
tientsinfluencespostoperativepainlevelsafteropenheartsurgery. theirinteractionswitheachother.
Consequently,attemptshavebeenmadetodetermineifpsycho- Psychologicalinterventionsfocusonthereductionofanxiety,de-
logical interventions cansuccessfully reduce acute postoperative pressionandmentaldistress,whichinconsequencemightaffect
painandimprovethecourseofphysicalandpsychologicalrecov- pain.Thereisevidencethatnegativeemotionsdecreasethepain
eryofpeopleundergoingopenheartsurgery. perceptionthreshold(Rainville2005).Instudiesonnon-cardiac
surgicalpatientslevelsofanxietyanddepressionpredictedpost-
operativepain(Arpino2004;Granot2005;Johnston1988;Linn
1988;Mathews1981;Munafo2001).Inaddition,instudieson
Descriptionoftheintervention
peopleundergoingcardiacsurgeryitwasdemonstratedthatpsy-
This review focuses on psychological interventions, defined as chosocialvariablessuchasanxiety,depressionandperceivedsocial
those based on established psychological theories of behaviour support are also associated with postoperative pain (Con 1999;
andbehaviourchange,withidentifiablecomponentsoftreatment, Jette1996;Karlsson1999;Morone2010).
specificallydesignedtoaltersurgery-relatedmentaldistress,neg- Psychologicalinterventionsalsodealwithnon-compliancetoal-
ative beliefsand non-compliance in order to improve the post- terpatients’behaviour.Peopleundergoingopenheartsurgeryare
operative recovery after open heartsurgery. Psychological inter- lesslikelytoremainpassiveintheircourseofrecoveryiftheyare
ventions in the context of cardiac surgery are conducted as an informed about the importance of compliance with early post-
adjunct tostandard surgical care within thetime of hospitalisa- operative mobilisation and thereby might have a decreased rate
tion by physicians, psychologists, nurses or other trained treat- ofpostoperative complicationsandlowerlevelsofpostoperative
mentproviders(e.g.formerpatientmodels),includingpersonal pain.
communication,printedinformation(leaflets),oraudioorvideo Cognitiveinterventionsfocusprimarilyonchangingnegativeor
recordings(Tigges-Limmer2011).Thefollowingtypesofpsycho- dysfunctionalbeliefsandattitudestowardssurgeryintomorepos-
logicalinterventionarecommoninthecontextofcardiacsurgery: itiveandhelpfulones.Forexample,apositiveandconfidentatti-
Psychoeducational interventions, which are defined as the provi- tudetowardssurgeryandtherecoveryperiodisassociatedwithre-
sion of information about pre-, intra- and postoperative medi- ducedanxiety,facilitatespostoperativebehaviouralactivationand
cal procedures with a special focus on associated psychological therebymightdecreasepainlevels(Heye2002).
responses,sensationsandemotions.Theseinterventionsalsoin-
volvebehaviouralinstructionsaboutappropriatewayspeoplecan
adheretomedicaladvicetosupporttheirrecovery(Devine1992). Whyitisimportanttodothisreview
Cognitive-behaviouralmethods,comprising methodsof cognitive
Clinical trials have investigated whetherpsychological interven-
restructuring,reframingandreappraisalbasedontheevaluation
tionsweresuccessful inreducingacute postoperative painlevels
ofpatients’specificneedsaccordingtotheirindividual situation
andinenhancingphysicalandpsychologicalpostoperativerecov-
(Powell2010).
eryafteropenheartsurgery.However,nocomprehensivesystem-
Relaxationtechniquesaredescribedasteachingorinstructingpa-
aticreviewormeta-analysisofthisevidencehasbeencarriedout
tientssystematicallyin,forexample,progressivemusclerelaxation,
sofar.
relaxingbreathingtechniques,(self)hypnosis,guidedimageryor
autogenictraining(Green2005;Michie2008).
Theseinterventionscanpartiallyoverlapwithotherkindsofinter-
ventions,suchasthosethatfocusonpsychologicalpreparationof
OBJECTIVES
adultsundergoingsurgeryundergeneralanaesthesia,whichwillbe
coveredbyaforthcomingCochranereview(Powell2010).More- Tocomparetheefficacyofpsychologicalinterventionsasanad-
over,theanalgesiceffectsofclinicalhypnosiswillbethefocusof juncttostandardcareversusstandardcarealoneorstandardcare
anotherCochranereviewalsoconsideringthecontextofmedical plusattentioninadultsundergoingopenheartsurgeryonpain,
procedures(Hallquist2013). pain medication, mental distress, mobility, and time to extuba-
tion.
Howtheinterventionmightwork
METHODS
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 5
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Criteriaforconsideringstudiesforthisreview Comparatorintervention
• ’treatmentasusual’(TAU),definedasthestandardcareof
thehospitalwithnopsychologicalinterventionprovidedtothe
Typesofstudies controlgroup;
• ’attentioncontrol’,definedasprovidingthesameamount
Weincludedrandomisedcontrolledtrials(RCTs)irrespectiveof
oftimeandattention,butwithnospecificpsychological
language,publicationdateorpublicationstatus.Welimitinclu-
interventionofferedtothecontrolgroup.
siontostudieswithasamplesizeofatleast20participantsineach
trialarmatfirstpostoperativeassessment(Moore2010;Eccleston
2012).
Typesofoutcomemeasures
Wereportedpostoperative outcomesaccording tothefollowing
timeintervals:
Typesofparticipants
• 1stinterval-short-termeffects:outcomemeasureswithin
Weconsideredaseligibleforinclusionalladultparticipants(men thefirst48hourspostoperatively.
and women aged 18 and over) undergoing open heart surgery • 2ndinterval-medium-termeffects:measuresthattook
(valveprocedureswithorwithoutcardiopulmonarybypass(CPB), placeafterthefirstpostoperative48hoursandbeforedischarge.
coronarysurgerywithorwithoutCPB,congenitallesion,surgery • 3rdinterval-long-termeffects:outcomemeasuresafter
ofthoracicaorta,othercardiacsurgery,e.g.resectionofheartneo- discharge.
plasmandassistdevices).Weexcludedstudiesonemergencypro-
ceduresandhearttransplantationbecausepatientsdifferindisease
severityandtimetobepsychologicallypreparedforsurgery,among Primaryoutcomes
otherfactors.Weincludedparticipantsindependentoftheirpre-
1. Numberofparticipantswithself-reportedpainintensity
andpostoperativementalhealthstatus.
reductionofatleast50%frombaseline.
2. Numberofparticipantsbelow30/100mmonthevisual
analoguescale(VAS)inself-reportedpostoperativepainintensity.
Typesofinterventions
3. Participant-reportedpostoperativepainintensitymeasured
oncontinuousorcategoricalscales,orotherpatient-reported
painintensityscalesorquestionnaireswithsatisfactoryreliability
Experimentalintervention andvalidity.
Asdescribedabove(see’Descriptionoftheintervention’section)
wefocusedonthefollowingtypesofpsychologicalinterventions
Secondaryoutcomes
providedwithinthetimeofhospitalisation:
• Psychoeducationalinterventions; 1. Observer-reportedpostoperativemediantimeto
• Cognitive-behaviouralmethods; remedication.
• Relaxationtechniques. 2. Observer-reportedpostoperativenumberofparticipants
remedicated.
Weincludedstudiesinwhichinterventiongroupparticipantsre- 3. Observer-reportedpostoperativeanalgesicusemeasuredvia
ceivedatleastoneoftheinterventionsdescribedabove. patient-controlledanalgesia(PCA),whichwillbeconvertedinto
Weexcludedstudiesinwhichinterventiongroupparticipantsre- morphineequivalents.
ceivedacombinationofapsychologicalinterventionandanon- 4. Participant-reportedpostoperativementaldistress(defined
psychologicalintervention. asnegativeaffect,anxiety,depression,mood,well-being,
Studies which focused onlife-stylechanges, pharmacological or relaxation)measuredvia:
psychotherapeuticlong-termtreatmentafterdischargeofhigh-risk i) visualanaloguescales(VAS),numericalratingscales
cardiacsurgerypatientswithanapriorioraposteriordiagnosis (NRS),verbalratingscales(VRS);
of major depression or anxiety disorder were not in the scope ii) ProfileofMoodScale(POMS,McNair1971);
ofourreview.Long-termpsychologicalinterventionsincludedin iii) BriefSymptomInventory(BSI,Derogatis1983);
cardiacrehabilitationprogrammeshavebeencoveredbyanother iv) StateAnxietyformofState-Trait-Anxiety-Inventory
Cochranereview(Whalley2011). (STAI-S,Spielberger1983);
We excluded music interventions, as pain, distress and anxiety- v) HospitalAnxietyandDepressionScale(HADS,
reducing effectsof music in various cardiac patient populations Zigmond1983);
havealreadybeenaddressedinarecentCochranereview(Bradt vi) Otherpatient-reportedpsychologicaldistressrating
2013). scaleswithsatisfactoryreliabilityandvalidity.
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 6
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
5. Participant-andobserver-reportedpostoperativelevelsof Datacollectionandanalysis
mobilitymeasuredvia,forexample,thesix-minutewalktest
(Guyatt1985).
6. Observer-reportedtimetoextubation.
Selectionofstudies
Wepreferreddichotomousoutcomesifstudiesreportedbothcon-
Tworeviewauthors(SKandJR)independentlyscreenedtitlesand
tinuousanddichotomousoutcomesonpainintensityoranalgesic
abstractsofretrievedarticlesforeligibility.
use.
Wereportedtheincidenceofpostoperativecomplications;how-
ever,we didnot runmeta-analytic proceduresfor thisoutcome
Dataextractionandmanagement
aspoolingof variouspostoperative complications withdifferent
severity levels leads to pooled heterogeneous estimates with no Two review authors (SK and JR) extracted data independently
clearinterpretation.Postoperativecomplicationsweredefinedas usingapilot-testedelectronicdataextractionform.Weresolved
commonconsequencesoreventsthatareassociatedwiththesur- disagreements through discussion andconsultation with athird
gicalprocedureadverselyaffectingthepatient’sprognosis(Jacobs review author (JB). In order to obtain missing information, we
2007;Rosendahl2009):myocardialinfarction,reoperation,car- contactedstudyauthorsforclarification.
diac arrest, prolonged ventilation (> 24 hours), rethoracotomy, Weextractedthefollowinginformationfromprimarystudies:
wound infection, renal failure, pneumothorax, pericardial effu- • Informationonpublication(title,authors,year,publication
sion,pleuraleffusion,arrhythmiaandtransientdelirium. status,language,country).
• Population(clinicalparticipantcharacteristics,samplesize,
age,gender).
Searchmethodsforidentificationofstudies • Interventiontype.
• Controlgrouptype.
• Outcomes(timeintervalofmeasurement,effectsize-related
parameters(includingfrequencies,changescores,means,
Electronicsearches
standarddeviations,torFvalues,andprobabilitylevels)).
Wecarriedoutelectronicsearchesforthisreviewinthefollowing
databases:
• CENTRAL(TheCochraneLibrary,allyearsto2013,Issue Assessmentofriskofbiasinincludedstudies
8)
Tworeviewauthors(SKandJR)independentlyassessedtheriskof
• MEDLINE(1946toSeptember2013)
biasforeachincludedstudyusingtheCochrane’Riskofbias’tool
• EMBASE(1980toSeptember2013)
(Higgins 2011a).Weassessedtheriskofselectionbias(random
• WebofScience(allyearstoSeptember2013)
sequencegeneration,allocationconcealment),theriskofattrition
• PsycINFO(allyearstoSeptember2013)
bias(incompleteoutcomedata)andtheriskofreportingbias(se-
• ProQuestDissertationsandThesesFullTextDatabase(all
lectivereporting).Asblindingofparticipantsandtherapistsisnot
yearstoSeptember2013)
possibleinpsychologicalinterventionresearch,weassessedtherisk
AMEDLINEsearchstrategy,basedonbothindexedandfree-text ofperformancebiasbyevaluatingtheblindingstatusofmedical
terms and incorporating the Cochrane Highly Sensitive Search personnelonly.Medicalpersonnelweredefinedascareproviders
Strategyforidentifyingrandomisedcontrolledtrials,isshownin (physicians,surgeons,nurses)whowerenotinvolvedinthepro-
Appendix 1. We adapted thestrategy for the Cochrane Central visionofadjunctivepsychologicalinterventions.Weassessedthe
RegisterofControlledTrials(CENTRAL,Appendix2),andEM- riskofdetectionbias(blindedoutcomeassessment)forobserver-
BASEdatabase(Appendix3)aswellasforPsycINFO(Appendix reportedoutcomes and for participant-reported outcomes sepa-
4)andWebofScience(Appendix5).Weusedthe’relatedarticles’ rately.Weusedaconsensusmethodtoresolvedisagreements.
and’citedby’optionsofeligiblestudiestoidentifyadditionalrel-
evantstudies.
Measuresoftreatmenteffect
Weusedtheriskratio(RR)asameasureoftreatmenteffectfor
Searchingotherresources
alldichotomousoutcomes.Additionally,wecalculatedthenum-
Wecheckedlistsofreferencesofrelevantarticlesandpreviousre- berneededtotreatforanadditionalbeneficialoutcome(NNTB)
viewsinordertoidentifyeligiblestudies.Additionally,wesearched for dichotomous outcomes. We used Hedges’ adjusted g for all
the ProQuest Dissertations and Theses Full Text Database (all continuousoutcomes.Hedges’gissimilartoCohen’swell-known
yearstoSeptember2013)andcontactedtheauthorsofprimary effectsizedbutincludesanadjustmenttocorrectforsmallsample
studiestoidentifyanyunpublishedmaterial. size.Itwascalculatedbydividingthedifferencesinmeanvalues
Psychologicalinterventionsforacutepainafteropenheartsurgery(Review) 7
Copyright©2014TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.