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ORIGINAL ARTICLES |
From the Departments of Psychological Medicine and Psychotherapy (S.D., F.K., G.R., S.R., B.H., D.S.S., G.S.), Orthopedics (H. Behensky, M.K.), and Anesthesia and General Intensive Care (G.L, P.I., H. Benzer), and the Neurochemical Research Unit, Department of Psychiatry (A.S.), University of Innsbruck, Innsbruck, Austria.
Address reprint requests to: Stephan Doering, MD, Department of Psychological Medicine and Psychotherapy, Sonnenburgstr. 9, A-6020 Innsbruck, Austria. Email: Stephan.Doering{at}uibk.ac.at
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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METHODS: Before elective total hip replacement surgery, 100 patients were randomly assigned to a control group or a preparation group; the latter group was shown the videotape on the evening before surgery. Anxiety and pain were evaluated daily for 5 days, beginning with the preoperative day, by means of the State-Trait Anxiety Inventory and a visual analog scale. Intraoperative heart rate and blood pressure, as well as postoperative intake of analgesics and sedatives, were recorded. Urinary levels of cortisol, epinephrine, and norepinephrine were determined in 12-hour samples collected at night for 5 nights, beginning with the preoperative night.
RESULTS: Compared with the control group, the preparation group showed significantly less anxiety on the morning before surgery and the mornings of the first 2 postoperative days, and significantly fewer of them had an intraoperative systolic blood pressure increase of more than 15%. The pain ratings did not differ significantly between the two groups, but the prepared patients needed less analgesic medication after surgery. Prepared patients had significantly lower cortisol excretion during the preoperative night and the first 2 postoperative nights. Excretion of catecholamines did not differ significantly between groups.
CONCLUSIONS: We conclude that use of the videotape decreased anxiety and stress, measured in terms of urinary cortisol excretion and intraoperative systolic blood pressure increase, in patients undergoing hip replacement surgery and prepared them to cope better with postoperative pain.
Key Words: surgery • preparation • videotape • anxiety • cortisol • catecholamines
Abbreviations: ANOVA = analysis of variance; HPA =hypothalamus-pituitary-adrenal (axis); SBP = systolic bloodpressure; STAI = State-Trait Anxiety Inventory.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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Most frequently, preoperative fear was investigated in relation to surgical outcome. Janis (1) hypothesized a U-shaped correlation between the two, which means that low as well as high levels of anxiety lead to a worse outcome, whereas medium levels are associated with the best recovery. However, almost all subsequent authors found a linear relation, with the lowest levels of anxiety predicting the best outcome (2, 3). Also, depression was shown to influence recovery in a negative way. Kimball (4), for example, found a higher mortality rate in patients who were depressed before they underwent cardiac surgery.
Preoperative (psycho-)physiological parameters were used mostly to objectify and to operationalize anxiety, but the results of these studies are contradictory (2, 5).
Personality traits have a high impact on surgical outcome. High levels of trait anxiety, like high state anxiety, lead to a poorer outcome (6). Evaluation of preoperative locus of control revealed divergent results (7, 8); Johnston (2) pointed out that in the specific situation of surgical intervention, the ability to surrender control might be more adaptive than a controlling style. Cohen and Lazarus (9) found the best outcome in patients with an avoidant coping style and suggested that active coping immediately after an operation will not be adaptive, because this situation does not provide anything that could be actively coped with.
These investigations, as well as the large number of studies on psychological preparation for surgery (see below), used a variety of postoperative outcome variables. Clinical parameters, such as pain, intake of analgesics, duration of hospitalization, complications, and mortality rate, have been used, as have physiological (blood pressure, respiration, plasma and urinary corticoid and catecholamine levels, immunological parameters), psychological (anxiety, distress, positive psychological state), and socioeconomic (return to work, return to social activities, saving of costs) parameters (5, 10). Most frequently, pain, use of analgesics, duration of hospitalization, and psychological states (anxiety, satisfaction) were evaluated. Johnston (2) pointed out that different concepts of recovery are at work, because recovery has been measured with different outcome variables that often correlate with each other to only a limited degree. For this reason, she suggested using a set of outcome parameters that covers the areas mentioned above.
Soon after it became clear that a patient’s preoperative psychological state influences surgical outcome, research on psychological preparation for elective surgery was initiated with the aim of improving postoperative recovery. Preparation programs were conducted by physicians, psychologists, or nurses with single patients or groups of patients and contained either personal communication, printed information (leaflets), or audio or video recordings. According to Johnston and Vögele (10), a number of different strategies for presurgical preparation can be defined: Procedural information contains facts on medical and technical issues of the operation (eg, anesthesia, operative procedure, and therapeutic measures after the operation); behavioral instructions give advice about, for example, sequences of movement to be performed during the first days of recovery or careful coughing after surgery; and sensory and emotional information gives advice about what to expect after the operation (eg, intensity and localization of pain, nausea, and restriction of movement). More psychotherapeutically oriented procedures, like cognitive-behavioral preparation for surgery, emotion-centered and psychoanalytical methods, and hypnosis and relaxation techniques, have also been used. In their 1992 meta-analysis of 37 studies, Johnston and Vögele (10) found that procedural information and behavioral instructions result in improvement in all areas of recovery. Relaxation techniques were also judged as being successful. Cognitive-behavioral methods were shown to influence a limited number of outcome variables only, whereas sensory information, hypnosis, and emotion-centered procedures were described as less successful. For a valid evaluation of psychological preparation for surgery, the authors suggest using a number of outcome variables from different areas of recovery.
This study takes into consideration the results of previous research and provides a new combination of methods for psychological preparation before surgery. We prepared a videotape that covers a patient from hospital admission to discharge and keeps strictly to the patient’s perspective. Thus, it provides procedural information as well as behavioral instructions and sensory information; moreover, it gives the preoperative patient the opportunity to identify with a patient who has successfully undergone the same surgery. The issue of a preoperative patient’s identification with a videotaped patient who mastered the process of surgery has not been previously investigated. To evaluate outcome, we used clinical (pain, postoperative intake of analgesics), psychological (anxiety), and physiological (intraoperative blood pressure and heart rate, urinary excretion of cortisol and catecholamines) parameters. This study was conducted with the aim of determining whether preoperative preparation by means of this videotape reduces anxiety and perioperative stress in patients undergoing total hip replacement surgery.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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One hundred patients were enrolled in the study after giving written informed consent. Inclusion criteria were as follows: age of 18 years or above, diagnosis of osteoarthritis of the hip joint, no previous hip replacement surgery, scheduled for elective hip replacement surgery, no comorbidity that might alter cortisol and catecholamine excretion, no comorbidity associated with severe pain that might distort pain ratings, no psychiatric comorbidity that might reduce the ability to understand the videotape and questionnaires (especially no dementia), and no medication that might affect urinary excretion of cortisol and catecholamines (especially no steroids). Sample characteristics are shown in Table 1.
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Patients were invited to take part in the study by an orthopedist on the day of their admission to the hospital. Patients who agreed to take part were randomly assigned to the preparation or control group and were visited by a psychologist or physician of the Department of Psychological Medicine and Psychotherapy on the afternoon of the preoperative day (the operation was performed 1 to 3 days after admission). Physicians of the Departments of Orthopedics and Anesthesia were blind to the assignment of patients to groups. Demographic data were collected, and questionnaires measuring trait and state anxiety, depression, and pain were completed by the patients. Questionnaires of state anxiety and pain to be filled in on the following 4 days were also distributed to the patients. Additionally, patients were instructed to collect urine samples between 7 PM and 7 AM.
On the evening of the preoperative day, patients in the preparation group were visited again by the same member of the hospital staff between 6 and 7 PM and were shown the videotape in the presence of the investigator.
Twelve-hour urine samples for the measurement of cortisol and catecholamine excretion were collected on 5 consecutive nights beginning with the preoperative night, and state anxiety and pain were assessed in the morning on the day of the operation and on the 3 postoperative days.
Information on intraoperative heart rate and blood pressure was obtained from the anesthesia records; information on postoperative intake of analgesics and sedatives and duration of hospitalization, from routine orthopedic documentation; and details about the first day of ambulation and the first attempt at climbing stairs, from the physiotherapist’s records. Chart records were evaluated by the first author only; thus, no reliability tests were performed.
Videotape
A 12-minute film was made of a 55-year-old man with osteoarthritis of the hip joint during his hospital stay in the summer of 1996. (A version of the videotape, which includes English subtitles, can be ordered from the first author.) Informed consent to being filmed, to the film being shown to other patients, and to the film being used for research and education purposes was obtained from the patient. The film keeps strictly to the patient’s perspective, which means that it does not show anything that could not be seen by the patient himself. Parts of the film contain original dialogue; in other parts, a narrator gives procedural information and reports the patient’s thoughts and feelings, which were taken from an interview of the patient before discharge from the hospital.
The film begins with a scene showing the patient entering the hospital and his room. The next scene shows the patient in bed on the evening before the operation, talking with a nurse; his thoughts and feelings are reported by the narrator. On the morning of the operation, the patient receives preoperative medication, and the speaker explains the purpose of the drug and the ureteral catheter. The patient, in bed, is wheeled into the operating room and lifted onto the operating table, and the preparation procedures are shown and described (positioning of monitoring equipment, administration of intravenous infusion, administration of spinal anesthesia, and disinfection and covering of the patient). The patient is moved into the operating room, his head is shown with the anesthetist next to him. He is wearing headphones and listening to an audiotape he had chosen before; the noises of the operation can be heard and are explained by the narrator. After the operation, the patient receives a transfusion of preoperatively donated autologous blood and is brought back to the orthopedic ward. On the same day, he is visited by the anesthetist and orthopedic surgeon. Subsequent scenes show the patient getting up from the bed for the first time with the help of a physiotherapist and climbing stairs for the first time. The last sequence shows his discharge from hospital; the patient is shown with his wife and son saying goodbye to the nurses and leaving the hospital.
Questionnaires
Anxiety was measured by means of the STAI (11); the trait questionnaire (STAI-X2) was to be filled in on the preoperative day, and the state version (STAI-X1), on 5 consecutive days beginning with the preoperative day.
Depression was measured with the Von Zerssen Depression Scale (12), which is similar to the STAI-X1 and contains 16 items on actual mood state to be rated by the patient. Each item can be rated using one of four responses, ranging from "is very much the case" to "is not the case at all." The instrument has adequate construct properties. The retest reliability (1-day interval) was r = .76 in a group of healthy subjects (N = 1666) and r = .82 in psychiatric patients (N = 127). The validity of the instrument was demonstrated to be sufficient by the authors of the instrument and is reported in the test manual (12).
For assessment of pain, 100-mm horizontal visual analog scales were used. On the preoperative day, patients were asked to rate their average pain level during the previous week; actual pain was rated on 5 consecutive days beginning with the preoperative day.
Physiological Measures
Details of intraoperative blood pressure and heart rate were taken from the anesthesia records. An intraoperative increase of 15% or more of SBP and heart rate was regarded as relevant.
To assess secretion of stress hormones from the adrenal glands, 12-hour urine samples, collected at night, were used. We prefer this method, especially for assessment of cortisol, because it reveals the integrated hormone production during the day, whereas plasma sampling allows only for assessment of momentary HPA axis activity. Cortisol excretion in 24-hour urine samples has been demonstrated to correlate reliably with daily secretion of the hormone from the adrenal glands (13–15), and cortisol excretion in 12-hour night urine samples correlates sufficiently with that in 24-hour urine samples (16). Another advantage of collecting urine samples at night is that the procedure is noninvasive and is not in itself a stressor that might increase stress hormone production in the patient, as is, for instance, venipuncture.
Patients were provided with a 2000-ml plastic container that contained 0.5 g of ethylenediaminetetraacetic acid and 0.5 g of sodium metabisulfite for conservation of the sample. They were instructed to empty their bladder at the beginning of the sampling period at 7 PM (this portion was rejected), to collect urine from then on, and to empty their bladder again at 7 AM the next morning (this portion was collected). After the operation, the nursing staff collected urine from the urinary bags. In the morning, the total amount of urine excreted was documented, the urine in the containers was stirred, and two 10-ml aliquots were placed in plastic vials with a nonadherent surface (to prevent the hormone from sticking to it). All samples were stored at -80°C until assayed.
Cortisol was determined by means of a commercial radioimmunoassay (DSL-2100, Diagnostic Systems Laboratories, Inc., Webster, TX); for the assessment of epinephrine and norepinephrine, high-pressure liquid chromatography was used. A commercial kit (ChromSystems 6000, Chromosystems, MA) was used for extraction of hormone. Concentrations measured in the samples (µg/liter) were multiplied by the total amount of urine excreted in 12 hours (liters), giving the total amount of hormone excreted during the night.
Intake of Analgesics and Sedatives
Medication given before surgery consisted of 7.5 mg of midazolam (spinal anesthesia) or 10 mg of diazepam (general anesthesia); after surgery, every patient routinely received 100 mg/d indomethacin. These medications were not included in the calculations of analgesic use. Details on the intake of additional analgesics were obtained from the routine documentation of the Department of Orthopedics and recorded for each of the 4 postoperative days; subsequently, the total amount of analgesic use was calculated for these 4 days by simple addition. These assessments were made by the first author only; thus, no reliability tests were necessary.
Nonsteroidal antirheumatic agents and opiates were recorded separately; calculation of the amount of analgesic intake was performed according to the usual single dose given in clinical practice and recommended by the manufacturer (Table 2).
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2 tests were calculated for dichotomous variables (intraoperative increase of blood pressure and heart rate), the Wilcoxon rank sum test was used for ordinal data (anxiety, pain, intake of analgesics), and a t test was computed for continuous data (excretion of hormones). Repeated-measures ANOVA was conducted on the variables anxiety, pain, and cortisol excretion. |
RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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The day before surgery, patients in both groups showed roughly the same level of state anxiety. On the morning of surgery, after the preparation group had seen the videotape the evening before, the mean level of state anxiety had increased in the control group, whereas it remained almost unchanged in the preparation group. After the operation, mean levels of state anxiety decreased in both groups, but levels in the preparation group stayed lower during the 4 postoperative days. These differences reached significance on the morning before surgery (p = .032) and on the first 2 postoperative days (p = .022 and .048 on the first and second postoperative day, respectively; Figure 1). The repeated-measures ANOVA revealed a significant difference of the complete temporal trajectory (F = 2.59, p = .042).
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During the postoperative period until the fourth postoperative day, the preparation group needed less analgesic medication than the control group; these results were significant for nonsteroidal antirheumatics (p = .012), opioids (p = .037), and total amount of analgesics (p = .012; Figure 3). There were no significant differences in intake of sedatives during the 4 postoperative days (control group, 0.77 doses; preparation group, 0.83 doses). Both groups got out of bed at almost the same time postoperatively (control group, 1.1 days; preparation group, 1.2 days), climbed stairs at the same time (control group, 6.4 days; preparation group, 6.7 days), and were discharged at the same time (control group, 11.2 days; preparation group, 11.5 days).
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Cortisol was measured in all study patients (N = 100), whereas catecholamines were assessed only in the first 30 patients, because the results at this time did not reveal any tendencies toward group differences.
Patients in the preparation group had a significantly lower excretion of cortisol on the preoperative (p = .001) and first 2 postoperative nights (p = .016 and .003 for the first and second postoperative night, respectively) than patients in the control group; these differences decreased during the following 2 nights (Figure 4). ANOVA also revealed a significant difference in complete temporal trajectories between the groups (F = 3.24, p = .013). There were no significant differences between groups in excretion of epinephrine and norepinephrine.
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Separate calculations for gender subgroups did not reveal any significant differences between women and men in the preparation and control groups. Again, the tendencies of the results for all outcome variables corresponded with those of the whole sample. Significant differences rarely occurred in the small subsamples: Men in the preparation group had significantly lower levels of state anxiety on the second and third postoperative days (p = .003 and .018, respectively) and needed a significantly lower total amount of analgesics (p = .038) compared with men in the control group; these significant differences were not be observed in women. In women who saw the videotape, cortisol excretion was significantly lower than in control subjects on the preoperative night (p < .001) and the first 3 postoperative nights (p = .001, .017, and .026 for the first, second, and third nights, respectively); this effect was not significant in men. Also, the significant difference (p = .006) in fewer intraoperative SBP increases observed in women in the preparation group was not observed in men in the preparation group.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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Intake of analgesics was lower in patients in the preparation group during the postoperative 4 days, although patients in both groups suffered almost the same amount of pain. Again, we assume that this result is due to improved coping abilities: Prepared patients may be able to cope better with postoperative pain because they have a more concrete idea of and anticipate their early recovery after surgery.
Our preparation procedure influences psychological as well as physiological and clinical variables, which increases the validity of its effect. The fact that the outcome variables getting out of bed, climbing stairs, and duration of hospitalization did not show any group differences may be mainly due to clinical routine: Total hip replacement surgery, intraoperative anesthesiological management, and the early recovery period are highly standardized procedures. At the University of Innsbruck Department of Orthopedics, getting out of bed is scheduled for the first postoperative day; climbing stairs, for the sixth day; and discharge, for day 11 after the operation. Deviations from this timetable are due to external reasons, such as nonavailability of the physiotherapist on the weekends or early discharge before bank holidays, and are not dictated by the individual course of recovery.
As far as hormonal parameters are concerned, only cortisol excretion revealed significant group differences, whereas catecholamines did not. In two studies on the effect of different preparation procedures, Manyande et al. (17, 18) reported an increase of cortisol plasma levels immediately after the operation in patients trained in a relaxation technique and a decrease in patients who underwent an active coping imagery exercise before surgery in comparison to control subjects. The authors argued that according to Janis’ theory (1), the reduced state anxiety in patients trained in relaxation techniques might have contributed to the increase of cortisol levels. Our preparation procedure is closer to Manyande’s active coping imagery exercise than to the relaxation technique, because its strategies are aimed toward anticipation rather than toward distraction. Our results are in line with those of Manyande et al.’s 1995 study (18), but our prepared patients showed significantly decreased anxiety, whereas Manyande et al. did not find group differences between patients who underwent active coping imagery and control patients.
We did not find any group differences in plasma norepinephrine and epinephrine levels. This is most probably due to the fact that plasma catecholamine levels are known to rise immediately in an acute stressful situation and to decrease again within a very short time; a longer stressful situation leads to activation of the HPA axis, resulting in elevated cortisol levels (19). One could hypothesize that during nighttime, less significant short-term stressors act on the patient or that catecholamine production is much more influenced by the bodily stress of surgery, whereas cortisol secretion is more sensitive to psychosocial stressors. Pooled 12-hour night urine samples, which are valid for the assessment of HPA axis activity, might be less useful for evaluation of catecholamine secretion under stress; repeated measurements of plasma levels might be more appropriate in that situation.
The significant group difference in intraoperative increases in SBP confirms the result of Manyande et al. (17), who reported significantly lower maxima of intraoperative blood pressure in patients prepared with preoperative relaxation training. Although one could assume that the physical stress of the surgical procedure itself would have a much higher impact on the cardiovascular system than the psychological preparation, the lower levels of anxiety in prepared patients might have had some stabilizing effect on the cardiovascular system, keeping the blood pressure within the boundaries of 15% fluctuation.
The kind of anesthesia administered (spinal or general) did not change the tendency of the results. Because of the small size of the subsamples, most of the comparisons between the preparation and control groups failed to reach significance when calculated separately for patients who underwent spinal and general anesthesia. Because we did not find any significant differences in outcome between the preparation/spinal anesthesia and preparation/general anesthesia groups, we assume that our videotape improves the outcome in patients given either spinal or general anesthesia. Nevertheless, the fact that a number of significant differences occurred in the subgroups of spinal anesthesia patients that were not found in general anesthesia patients suggests that patients in whom spinal anesthesia will be used might benefit more from viewing the videotape than those who will receive general anesthesia. A film that shows general anesthesia being administered instead of spinal anesthesia might lead to more significant results in general anesthesia patients.
The ratio of men to women was somewhat higher in the control group than in the preparation group. Although this difference was nonsignificant, to rule out a bias, we calculated group comparisons between male and female patients. Women had higher anxiety levels on the preoperative day and lower cortisol excretion on the preoperative and second and third postoperative nights. Separate group comparisons between the preparation and control groups revealed the same tendencies in women and men as in the total sample. Significant effects of the preparation could be observed with regard to analgesic intake and anxiety in men and with regard to cortisol excretion and SBP increases in women. We interpret these differences between gender subgroups as most probably due to chance; the effect might have reached significance in one subgroup, whereas it stayed below the threshold in the other one.
One limitation of this study is that we did not include a personal attention control group. Because of practical and mainly ethical concerns, we did not let the patients watch the film by themselves; thus, every patient of the preparation group, in addition to watching the film, received about 30 minutes of "attention" from a researcher. (This was done to prevent single patients from being left alone with severe anxiety that might have been provoked by the videotape.) On one hand, the presence of the researcher might have contributed to the positive effect of the preparation procedure. On the other hand, the fact that control patients had agreed to watch a preparatory videotape and then were shown none might have significantly affected their levels of stress and anxiety. A strong argument for a significant effect of the film itself is provided by previous investigations (eg, those using emotion-centered procedures) that were not as successful as ours despite the presence of a researcher (10).
Our sample of patients cannot be regarded as representative of surgical patients in general, because it comprises older subjects with relatively low education living mainly in rural areas. This might be one reason that 45 patients (31%) refused to take part in the study, most of them stating that they did not want to be confronted with the details of imminent operation. Nevertheless, keeping in mind that an avoidant coping style has been shown to be adaptive in the process of surgery (9), the decision to not take part in a study that might give information about the operation may be regarded as a potentially meaningful part of an adaptive way of coping. For this group of patients, preparation by means of an informative videotape might be maladaptive, whereas a different form of presurgical preparation that uses distraction techniques, like relaxation procedures, might be helpful to them. It can be assumed that different coping styles demand different procedures for preoperative preparation.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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This study was supported by the Jubilaeumsfond der Oesterreichischen Nationalbank, Project 6937.
Received for publication May 24, 1999.
Revision received September 30, 1999.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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