Psychological treatments to reduce pain in people undergoing open heart surgery

Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is related to a risk of negative consequences such as impaired wound healing, chronic pain or depression. Psychological treatment is designed to improve patients' knowledge and to alter surgery-related mental distress, negative beliefs and non-compliance. It aims to reduce pain and anxiety, and to improve the post-operative recovery after open heart surgery. Psychological treatment comprises the provision of information about medical procedures and associated emotional responses and sensations before, during and after surgery, and instructions about how to adhere to medical advice to support the recovery; teaching or instructing patients in different relaxation techniques; or helping patients to understand their thoughts and feelings that influence their behaviours.

This review investigated whether psychological treatment could successfully reduce acute postoperative pain and improve the course of physical and psychological recovery of people undergoing open heart surgery. We found 19 studies including a total of 2164 participants which reported effects of psychological treatment compared to a control group on pain intensity, use of pain medication, mental distress, mobility and duration of intubation after surgery. We did not find evidence that psychological treatment reduces pain intensity or enhances mobility after open heart surgery. Psychological treatment proved to be slightly better than standard care in reducing mental distress. We did not find clear evidence that psychological treatment leads to a reduced intubation time after surgery. No adverse effect of psychological treatment was described in any primary study.

However, studies were of low quality in general, and there was also variation between the results of studies. The latest search was conducted in September 2013. Studies were mostly conducted without external financial support or funded by non-commercial national or regional research associations or student fellowships. Conflicts of interest were not stated in any study.

Further research of high quality is required to answer the question of whether psychological treatment has the potential to reduce postoperative pain and improve recovery after open heart surgery.

Authors' conclusions: 

For the majority of outcomes (two-thirds) we could not perform a meta-analysis since outcomes were not measured, or data were provided by one trial only. Psychological interventions have no beneficial effects on reducing postoperative pain intensity or enhancing mobility. There is low quality evidence that psychological interventions reduce postoperative mental distress. Due to limitations in methodological quality, a small number of studies, and large heterogeneity, we rated the quality of the body of evidence as low. Future trials should measure crucial outcomes (e.g. number of participants with pain intensity reduction of at least 50% from baseline) and should focus to enhance the quality of the body of evidence in general. Altogether, the current evidence does not clearly support the use of psychological interventions to reduce pain in participants undergoing open heart surgery.

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Background: 

Acute postoperative pain is one of the most disturbing complaints in open heart surgery, and is associated with a risk of negative consequences. Several trials investigated the effects of psychological interventions to reduce acute postoperative pain and improve the course of physical and psychological recovery of participants undergoing open heart surgery.

Objectives: 

To compare the efficacy of psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery on pain, pain medication, mental distress, mobility, and time to extubation.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 8), MEDLINE (1946 to September 2013), EMBASE (1980 to September 2013), Web of Science (all years to September 2013), and PsycINFO (all years to September 2013) for eligible studies. We used the 'related articles' and 'cited by' options of eligible studies to identify additional relevant studies. We also checked lists of references of relevant articles and previous reviews. We also searched the ProQuest Dissertations and Theses Full Text Database (all years to September 2013) and contacted the authors of primary studies to identify any unpublished material.

Selection criteria: 

Randomised controlled trials comparing psychological interventions as an adjunct to standard care versus standard care alone or standard care plus attention in adults undergoing open heart surgery.

Data collection and analysis: 

Two review authors (SK and JR) independently assessed trials for eligibility, estimated the risk of bias and extracted all data. We calculated effect sizes for each comparison (Hedges’ g) and meta-analysed data using a random-effects model.

Main results: 

Nineteen trials were included (2164 participants).

No study reported data on the number of participants with pain intensity reduction of at least 50% from baseline. Only one study reported data on the number of participants below 30/100 mm on the Visual Analogue Scale (VAS) in pain intensity. Psychological interventions have no beneficial effects in reducing pain intensity measured with continuous scales in the medium-term interval (g -0.02, 95% CI -0.24 to 0.20, 4 studies, 413 participants, moderate quality evidence) nor in the long-term interval (g 0.12, 95% CI -0.09 to 0.33, 3 studies, 280 participants, low quality evidence).

No study reported data on median time to remedication or on number of participants remedicated. Only one study provided data on postoperative analgesic use. Studies reporting data on mental distress in the medium-term interval revealed a small beneficial effect of psychological interventions (g 0.36, 95% CI 0.10 to 0.62, 12 studies, 1144 participants, low quality evidence). Likewise, a small beneficial effect of psychological interventions on mental distress was obtained in the long-term interval (g 0.28, 95% CI 0.05 to 0.51, 11 studies, 1320 participants, low quality evidence). There were no beneficial effects of psychological interventions on mobility in the medium-term interval (g 0.23, 95% CI -0.22 to 0.67, 3 studies, 444 participants, low quality evidence) nor in the long-term interval (g 0.29, 95% CI -0.14 to 0.71, 4 studies, 423 participants, low quality evidence). Only one study reported data on time to extubation.

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