Clinical hypnosis to reduce clinical and psychological risk factor of post-surgical pain in patients undergoing total knee replacement

Purpose : There has been an increasing interest among clinicians and researchers to develop surgical care strategies to prevent chronic post-surgical pain (CPSP). The objective of this study was to examine the efficacy of clinical hypnosis to alleviate risk factors associated with CPSP in patients undergoing total knee replacement (TKR) surgery. The study hypothesized that participants randomly assigned to clinical hypnosis (HYP condition) would report significantly greater reductions in acute post-surgical pain (APSP) intensity, anxiety, depression, and pain catastrophizing than participants randomly assigned to the minimal-effect treatment (MET) or treatment as usual (TAU) control conditions. Methodology : This was a single-blinded, open-label, three-arm, randomized, parallel-group controlled study. The study population included adult patients with knee injury that required TKR intervention. Individuals awaiting TKR in Hospital Kuala Lumpur (1) aged 18 and above, (2) able to converse in Malay, English, or Mandarin, and (3) able to provide informed consent were screened for eligibility to participate in the randomized-controlled trial (RCT) using the Depression Anxiety Stress Scale (DASS) and the Pain-Related Self-Statement (PRSS). Those diagnosed with (1) any psychiatric disorders, (2) terminal illnesses, and/ or (3) chronic pain conditions other than the reason for surgery were excluded. Upon screening, individuals with (1) an average pain score of ≥ 4/10 in the past week and (2) reported moderate levels of anxiety, depression, and/or catastrophizing were enrolled into the RCT. Randomization was done with replacement by matching randomly generated numbers with a pre-generated list. Twenty-four (N = 24) pariticipants were randomly assigned to receive (1) a pre-recorded hypnotic intervention with music (HYP; n = 8), (2) breathing relaxation training intervention with music (MET; n = 8), or (3) treatment as usual (TAU; n = 8). Immediate pain relief, 72-hour APSP intensity, and pain intensity at 1-, 3-, and 6-months were measured using a 0 - 10 Numerical Rating Scale (NRS). Psychological outcome variables were measured on discharge using the Hospital Anxiety Depression Scale (HADS) and Pain Catastrophizing Scale (PCS). The treatment effects were analyzed using Analysis of Variance (ANOVA) and Fisher's exact test performed with SPSS 21. Results : For immediate pain relief effects of HYP, mixed ANOVA revealed that the Time (before, after) X Treatment (HYP, MET, TAU) interaction effect was medium but not statistically significant (p = .418, ηp2 = .08). In addition, ANOVA showed that the treatment main effect on overall APSP intensity in the first 72 hours was medium but not statistically significant (p = .316, ηp2 = .10). Similarly, the Time (1-, 3-, 6-months) X Treatment (HYP, MET, TAU) interaction effect on pain over the six months follow-up period resulted in a medium but not statistically significant effect (p = .461, ηp2 = .08). ANOVA revealed large and statistically significant treatment main effects for anxiety (p = .025, ηp2 = .30) and pain catastrophizing (p = .043, ηp2 = .26). Post hoc analyses indicated that the HYP group (anxiety: M = 3.13, SD = 3.40; pain catastrophizing: M = 5.00, SD = 4.84) reported large and statistically significant decreases in anxiety (p = .014, ηp2 = .36) and pain catastrophizing (p = .013, ηp2 = .36) relative to TAU (anxiety: M = 7.00, SD = 1.93; pain catastrophizing: M = 18.75, SD = 12.78), while no statistically significant effect was found in the MET group (anxiety: M = 7.88, SD = 4.42; pain catastrophizing: M = 16.75, SD = 13.24), relative to TAU (anxiety: p = .616, ηp2 = .02; pain catastrophizing: p = .763, ηp2 = .01). The observed treatment main effect on depression was very weak (p = .939, ηp2 = .01). Conclusion : The current study shows that pre-recorded hypnosis is largely effective in reducing peri-surgical anxiety and pain catastrophizing. However, the alleviation of anxiety and pain catastrophizing did not result in statistically significantly better pain outcomes in the current sample, relative to treatment as usual. Further research is needed to clarify the mechanisms of risk factors in contributing to the development of CPSP, and identify more effective strategies for the prevention of CPSP

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