We know that catastrophising about pain can shape the way in which the immune system responds to nociception – see the article in Figure 1. Catastrophising refers to the interpretation of pain as signalling something damaging and dangerous and is often preceded by hypervigilance to body sensations. This maintains a negative focus upon the body and alongside a belief that pain is a sign of damage, this can drive behaviours that affect the recovery from an injury or surgery. Pre-existing beliefs that develop from prior experience, knowledge and from what one has been told will combine to create that individual’s ‘truth’ or landscape. The problem is that it may simply be untrue.
What can we do to optimise outcomes?
Identifying hypervigilance and catastrophising pre-operatively allows for interventions to tackle these issues. Understanding pain, the operation, knowing what will happen afterwards in terms of pain control and the post-operative plan for mobilisation can all help. In addition, prehabilitation is often used to develop fitness and function so that the recovery and rehabilitation process are more rapid and successful.
Beyond these more common strategies there are techniques that can tackle the stress and anxiety that naturally develops. Controlling these normal responses to both the thought of, and the actual operation, will create a more positive mindset for recovery and potentially hasten the process along – recall that what we think about has a physiological consequence, i.e. thinking about surgery evokes anxiety that is noted as the churning tummy (actually a change in blood flow) and tension. Priming the nervous and immune systems in a positive way is a way of preparing for the operation and optimising the outcomes.
How can we do this?
The techniques that we use include pain education alongside good explanations from the surgeon and anaesthetist, motor imagery, mental imagery, visualisation, mindfulness, breathing techniques and other bi-directional strategies (using the body and recognising how thinking affects the body as mentioned above).
Prior to these techniques we will have listened to your story, spoken to you about your operation, the build-up, how long you have had pain, learned about your current health and previous experiences you may have had in healthcare. From there we can design a programme for you addressing factors that may affect recovery such as catastrophising about pain, fear of movement, stress and anxiety.
For further information or to book a session please contact us on 07932 689081 – visit our main clinic website here at Specialist Pain Physio Clinics, London
Here are two papers that looked at this issue:
Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial
R. Maddison et al (2012)
Imagery can improve functional outcomes post-anterior cruciate ligament repair (ACLR). Research is needed to investigate potential mechanisms for this effect. The aim of this study was to (a) evaluate the effectiveness of an imagery intervention to improve functional outcomes post-ACLR, and (b) explore potential mechanisms. A randomized-controlled pilot trial was conducted. Participants were randomized to guided imagery and standard rehabilitation or standard rehabilitation alone (control). The primary outcome was knee strength 6-month post-operatively. Secondary outcomes were knee laxity at 6-months, and change in psychological (self-efficacy) and neurohormonal (adrenaline, noradrenaline, dopamine) variables. Participants (n=21; 62% male) were 34.86 (SD 8.84) years. Following the intervention, no statistical differences between groups for knee strength extension at 180°/s (t=−0.43, P=0.67), or at 60°/s (t=−0.72, P=0.48) were found. A statistically significant effect was found for knee laxity, F=4.67, P<0.05, mean difference of −3.02 (95% CI −4.44 to −1.60), favoring the intervention. No differences were found for self-efficacy; however, an overall effect was found for noradrenaline, F(1, 19) 19.65, P<0.001, η2=0.52, and dopamine, F(1, 19) 6.23, P=0.02, η2=0.29, favoring the intervention. This imagery intervention improved knee laxity and healing-related neurobiological factors – link here
A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial.
Broadbent E, Kahokehr A, Booth RJ, Thomas J, Windsor JA, Buchanan CM, Wheeler BR, Sammour T, Hill AG.
Department of Psychological Medicine, The University of Auckland, New Zealand. firstname.lastname@example.org
Psychological stress has been shown to impair wound healing, but experimental research in surgical patients is lacking. This study investigated whether a brief psychological intervention could reduce stress and improve wound healing in surgical patients. This randomised controlled trial was conducted at a surgical centre. Inclusion criteria were English-speaking patients over 18 years booked to undergo elective laparoscopic cholecystectomy; exclusion criteria were cancellation of surgery, medical complications, and refusal of consent. Seventy five patients were randomised and 15 patients were excluded; 60 patients completed the study (15 male, 45 female). Participants were randomised to receive standard care or standard care plus a 45-min psychological intervention that included relaxation and guided imagery with take-home relaxation CDs for listening to for 3 days before and 7 days after surgery. In both groups ePTFE tubes were inserted during surgery and removed at 7 days after surgery and analysed for hydroxyproline as a measure of collagen deposition and wound healing. Change in perceived stress from before surgery to 7-day follow-up was assessed using questionnaires. Intervention group patients showed a reduction in perceived stress compared with the control group, controlling for age. Patients in the intervention group had higher hydroxyproline deposition in the wound than did control group patients (difference in means 0.35, 95% CI 0.66-0.03; t(43)=2.23, p=0.03). Changes in perceived stress were not associated with hydroxyproline deposition. A brief relaxation intervention prior to surgery can reduce stress and improve the wound healing response in surgical patients. The intervention may have particular clinical application for those at risk of poor healing following surgery.