Effects of perioperative clinical hypnosis on heart rate variability in patients undergoing oncologic surgery: secondary outcomes of a randomized controlled trial.

Introduction: Clinical hypnosis has been proposed for post-surgical pain management for its potential vagal-mediated anti-inflammatory properties. Evidence is needed to understand its effectiveness for post-surgical recovery. Iin this secondary outcome study, it was hypothesized that surgical oncology patients randomized to receive perioperative clinical hypnosis (CH) would demonstrate greater heart-rate variability (HRV) during rest and relaxation at a 1-month post-surgery assessment compared to a treatment-as-usual group (TAU). Methods: After REB approval, trial registration and informed consent, 92 participants were randomized to receive CH (n = 45) or TAU (n = 47). CH participants received a CH session before surgery and during post-surgical in-hospital stay HRV was assessed during rest (5 min) and relaxation (10 min) before and 1-month after surgery. Pain intensity was obtained using a 0-10 numeric rating scale pre and post 1-week and 1-month post surgery. Results: One month after surgery, HRV was significantly higher in CH group (n = 29) during rest and relaxation (both p < 0.05, d = 0.73) than TAU group (n = 28). By contrast, rest and relaxation HRV decreased from pre- to 1-month post-surgery for the TAU (both p < 0.001, d > 0.48) but not the CH group. Pain intensity increased from pre-surgery to 1-week post-surgery (p < 0.001, d = 0.50), and decreased from 1-week to 1-month post-surgery (p = 0.005, d = 0.21) for all participants. Discussion: The results suggest that hypnosis prevents the deleterious effects of surgery on HRV by preserving pre-operative vagal activity. These findings underscore the potential of clinical hypnosis in mitigating the adverse effects of surgery on autonomic function and may have significant implications for enhancing post-surgical recovery and pain management strategies. Clinical Trial Registration: ClinicalTrials.gov, identifier (NCT03730350).

A Randomized Controlled Trial of Clinical Hypnosis as an Opioid-Sparing Adjunct Treatment for Pain Relief in Adults Undergoing Major Oncologic Surgery.

Clinical hypnosis is an effective strategy for managing acute pain in the surgical setting. However, the opioid sparing effects of clinical hypnosis are not as well understood. This pre-registered (NCT03730350) randomized, controlled trial (RCT) examined the impact of clinical hypnosis, pre- and post-surgery, on opioid consumption during hospitalization as well as on measures of pain intensity, pain interference, depressed mood, anxiety, sleep, and pain catastrophizing. Participants (M = 57.6 years; SD = 10.9) awaiting oncologic surgery were randomized to treatment-as-usual (n = 47) or hypnosis (n = 45). Intent-to-treat analyses were conducted using linear mixed effects modeling. A significant Group × Time interaction, F(6, 323.34) = 3.32, p = 0.003, indicated an opioid sparing effect of clinical hypnosis during the acute postoperative period. Hypnosis also protected against increases in pain catastrophizing at one-week after surgery, F (1, 75.26) = 4.04, p = 0.048. A perioperative clinical hypnosis intervention had a sparing effect on opioid consumption in-hospital after major oncologic surgery. These findings extend the efficacy of clinical hypnosis as an adjunct tool for perioperative pain management.

Predictive Validity and Patterns of Change Over Time of the Sensitivity to Pain Traumatization Scale: A Trajectory Analysis of Patients Seen by the Transitional Pain Service Up to Two Years After Surgery.

Purpose: The Sensitivity to Pain Traumatization Scale (SPTS-12) was developed to assess the propensity to develop a traumatic stress response to pain. The SPTS-12 is a reliable and valid scale with a one-factor structure. The aim of the present study is to further examine the psychometric properties of the SPTS-12 by evaluating its criterion validity and how scores change over time in a sample of postsurgical patients at the Toronto General Hospital Transitional Pain Service. Participants and Methods: 361 adults (55% male; M age = 50.6 years, SD age = 14.3) completed questionnaires assessing symptoms of pain, anxiety, depression, and trauma at multiple visits to the Transitional Pain Service after surgery. Latent-class growth mixture modeling defined prototypical longitudinal patterns (latent trajectories) of SPTS-12 scores up to two years after surgery. One-way ANOVAs examined how trajectory classes differed over time on measures of daily opioid use (mg morphine equivalents (MME)), average pain intensity, pain interference, and depressive symptoms. Results: The final model consisted of five SPTS-12 trajectory groups; two characterized by a flat and unchanging pattern and three showing a small but statistically significant decrease over time. Analysis of pain-related outcomes predicted by SPTS-12 trajectories provided evidence of criterion validity of the SPTS-12. SPTS-12 trajectories did not significantly differ on daily MME at any time. Average pain, pain interference, and depression scores significantly differed across SPTS-12 trajectory groups at two or more postsurgical visits (all p < 0.05). Conclusion: The SPTS-12 shows fairly stable patterns and predicts important pain-related and psychosocial outcomes over time. Two SPTS-12 trajectories (#2 and #5) with high scores, comprising ~28% of the total sample, are associated with problematic outcomes on several pain and psychosocial measures. Targeting patients with high SPTS-12 scores for presurgical psychological treatment may prove beneficial in reducing the impact of CPSP.

Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service.

Background: Chronic postsurgical pain is a highly prevalent public health problem associated with substantial emotional, social, and economic costs. Aims: (1) To review the major risk factors for chronic postsurgical pain (CPSP); (2) to describe the implementation of the Transitional Pain Service (TPS) at the Toronto General Hospital, a multiprofessional, multimodal preventive approach to CPSP involving intensive, perioperative psychological, physical, and pharmacological management aimed at preventing and treating the factors that increase the risk of CPSP and related disability; and (3) to present recent empirical evidence for the efficacy of the TPS. Methods: The Toronto General Hospital TPS was specifically developed to target patients at high risk of developing CPSP. The major known risk factors for CPSP are perioperative pain, opioid use, and negative affect, including depression, anxiety, pain catastrophizing, and posttraumatic stress disorder-like symptoms. At-risk patients are identified early and provided comprehensive care by a multidisciplinary team consisting of pain physicians, advanced practice nurses, psychologists, and physical therapists. Results: Preliminary results from two nonrandomized, clinical practice-based trials indicate that TPS treatment is associated with improvements in pain, pain interference, pain catastrophizing, symptoms of anxiety and depression, and opioid use. Almost half of opioid-naïve patients and one in four opioid-experienced patients were opioid free by the 6-month point. Conclusions: These promising results suggest that the TPS benefits patients at risk of CPSP. A multicenter randomized controlled trial of the TPS in several Ontario hospitals is currently underway.

Contexte: La douleur chronique postopératoire est un problème de santé publique très prévalent, associé à des coûts émotionnels, sociaux et économiques considérables.Buts: (1) Étudier les facteurs de risque importants pour la douleur chronique postopératoire; (2) décrire la mise en œuvre du Service de la douleur transitoire à l'Hôpital général de Toronto, une approche préventive multiprofessionnelle, multimodale à la douleur chronique postopératoire fondée sur une prise en charge intensive, périopératoire, psychologique, physique et pharmacologique pour prévenir et traiter les facteurs qui augmentent le risque de douleur chronique postopératoire et l'incapacité qui s'y rattache; et (3) présenter des données probantes empiriques récentes en ce qui concerne l'efficacité du Service de douleur transitoire.Méthodes: Le Service de la douleur transitoire de l'Hôpital général de Toronto a été expressément mis sur pied pour cibler les patients ayant un risque élevé de souffrir de douleur chronique postopératoire. Les principaux facteurs de risque connus pour la douleur chronique postopératoire sont la douleur périopératoire, la consommation d'opiacés et un affect négatif, y compris la dépression, l'anxiété, la catastrophisation de la douleur et les symptômes apparentés au syndrome de stress post-traumatique. Les patients à risque sont repérés de manière précoce et des soins complets leurs sont prodigués par une équipe multidisciplinaire composée de médecins spécialistes de la douleur, d'infirmières en pratique avancée, de psychologues et de physiothérapeutes.Résultats: Les résultats préliminaires de deux essais cliniques non randomisés fondés sur la pratique indiquent que le traitement prodigué par le Service de la douleur transitoire est associé à des améliorations en ce qui concerne la douleur, l'interférence de la douleur, la catastrophisation de la douleur, les symptômes d'anxiété et de dépression, et la consommation d'opiacés. Près de la moitié des patients n'ayant jamais consommé d'opioïdes et un patient sur quatre parmi ceux qui avaient déjà consommé des opioïdes n'en consommaient plus après six mois.Conclusions: Ces résultats prometteurs suggèrent que le Service de la douleur transitoire profite aux patients à risque de douleur chronique postopératoire. Un essai multicentre randomisé et contrôlé du Service de la douleur transitoire est actuellement en cours dans plusieurs hôpitaux ontariens.

Psychological treatments for the management of postsurgical pain: a systematic review of randomized controlled trials.

BACKGROUND: Inadequately managed pain is a risk factor for chronic postsurgical pain (CPSP), a growing public health challenge. Multidisciplinary pain-management programs with psychological approaches, including cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based psychotherapy, have shown efficacy as treatments for chronic pain, and show promise as timely interventions in the pre/perioperative periods for the management of PSP. We reviewed the literature to identify randomized controlled trials evaluating the efficacy of these psychotherapy approaches on pain-related surgical outcomes. MATERIALS AND METHODS: We searched Medline, Medline-In-Process, Embase and Embase Classic, and PsycInfo to identify studies meeting our search criteria. After title and abstract review, selected articles were rated for risk of bias. RESULTS: Six papers based on five trials (four back surgery, one cardiac surgery) met our inclusion criteria. Four papers employed CBT and two CBT-physiotherapy variant; no ACT or mindfulness-based studies were identified. Considerable heterogeneity was observed in the timing and delivery of psychological interventions and length of follow-up (1 week to 2-3 years). Whereas pain-intensity reporting varied widely, pain disability was reported using consistent methods across papers. The majority of papers (four of six) reported reduced pain intensity, and all relevant papers (five of five) found improvements in pain disability. General limitations included lack of large-scale data and difficulties with blinding. CONCLUSION: This systematic review provides preliminary evidence that CBT-based psychological interventions reduce PSP intensity and disability. Future research should further clarify the efficacy and optimal delivery of CBT and newer psychological approaches to PSP.

Smoking, Pain Intensity, and Opioid Consumption 1-3 Months After Major Surgery: A Retrospective Study in a Hospital-Based Transitional Pain Service.

Introduction: The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods: A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results: Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions: Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications: In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.

The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review.

Various psychotherapeutic approaches have been developed to address the psychosocial stressors and distress associated with cancer diagnosis and treatment. One such approach, Acceptance and Commitment Therapy (ACT), may be particularly well suited to people with cancer as it offers a model of healthy adaptation to difficult circumstances. This paper provides a description and theoretical rationale for using ACT in psychosocial oncology care that emphasizes emotional distress and cancer-related pain and provides a narrative review of the current state of evidence for this setting. Six studies met eligibility criteria for inclusion in the review. The research designs included one case study, three pre-post cohort studies, and two randomized controlled trials. Cancer diagnoses of patients included breast cancer, ovarian cancer, colorectal cancer, and mixed cancer populations at various stages of disease progression or recovery. ACT interventions demonstrated significant improvements in symptoms including quality of life and psychological flexibility as well as reductions in symptoms including distress, emotional disturbances, physical pain, and traumatic responses. Overall, although there is limited published research currently available, there is some evidence to support ACT as an effective psychotherapeutic approach for cancer patients. Further research is needed for different cancer populations across the illness trajectory. Barriers to implementation are discussed.

The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management.

In an era of considerable advances in anaesthesiology and pain medicine, chronic pain after major surgery continues to be problematic. This article briefly reviews the known psychological risk and protective factors associated with the development of chronic postsurgical pain (CPSP). We begin with a definition of CPSP and then explain what we mean by a risk/protective factor. Next, we summarize known psychological risk and protective factors for CPSP. Psychological interventions that target risk factors and may impact postsurgical pain are reviewed, including the acceptance and commitment therapy (ACT)-based approach to CPSP prevention and management we use in the Transitional Pain Service (TPS) at the Toronto General Hospital. Finally, we conclude with recommendations for research in risk factor identification and psychological interventions to prevent CPSP. Several pre-surgical psychological risk factors for CPSP have been consistently identified in recent years. These include negative affective constructs, such as anxiety symptoms, depressive symptoms, pain catastrophizing and general psychological distress. In contrast, relatively few studies have examined psychological protective factors for CPSP. Psychological interventions that target known psychological risk factors while enhancing protective psychological factors may reduce new incidence of CPSP. The primary goal of our ACT intervention is to teach patients a mindful way of responding to their postsurgical pain that empowers them to interrupt the negative cycle of pain, distress, behavioural avoidance and escalating opioid use that can limit functioning and quality of life while paradoxically amplifying pain over time. Early clinical outcome data suggest that patients who receive care from TPS physicians reduce their pain and opioid use, yet patients who also receive our ACT intervention have a larger decrease in daily opioid dose while reporting less pain interference and lower depression scores.

A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone.

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service.

Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. Aims: The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice-based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. Methods: Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). Results: Patients referred to ACT were more likely to report a mental health condition preoperatively (P < 0.001), had higher opioid use (P < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization (P < 0.05) and anxiety (P < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit (P < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood (P = 0.001) by the end of treatment compared to the no ACT group. Conclusion: Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.

Contexte: La douleur chronique post-chirurgicale (DCPC) et l'usage à long terme d'opioïdes qui y sont associées sont des préoccupations majeures en santé publique.Objectifs: Le Service de la douleur transitionnelle (STD) de l'Hôpital général de Toronto est un programme multidisciplinaire qui a été mis sur pied au sein même de l'hôpital pour prévenir et prendre en charge la douleur chronique post-chirurgicale et diminuer l'usage d'opioïdes. Cette étude clinique axée sur les pratiques porte sur les résultats préliminaires du programme de psychologie du STD. Ce programme offre une thérapie d'acceptation et d'engagement (ACT) aux patients à risques de douleur post-chirurgicale chronique et d'usage persistant d'opioïdes.Méthodes: Quatre-vingt onze patients ont bénéficié de l'ACT, tandis que deux-cent cinquante-deux patients n'en ont pas bénéficié (groupe sans ACT). Les résultats obtenus ont été comparés pour les patients des deux groupes lors de la première et de la dernière visite d'ACT. Une analyse de variance à deux facteurs (groupe [ACT - sans ACT] x moment [première, dernière visite]) a été effectuée pour la douleur, l'interférence de la douleur, la sensibilité au traumatisme de la douleur, la catastrophisation de la douleur, l'anxiété, la dépression et l'usage d'opioïdes.Résultats: Les résultats suggèrent que les patients référés à l'ACT étaient plus susceptibles de souffrir d'un problème de santé mentale avant l'opération chirurgicale (p < 0,001) et présentaient un plus grand usage d'opioïdes (p < 0,001) au moment de la première visite post-chirurgicale. De plus, ils manifestaient une plus grande prédisposition a la douleur en lien avec un sensibilité au traumatisme (p < 0,05) et à l'anxiété (p < 0,05) comparativement au groupe sans ACT. Une diminution de la douleur, de l'interférence de la douleur, de la catastrophisation en lien à la douleur et de l'usage d'opioïdes au moment de la dernière visite au STD (p < 0,05) a été observée chez les sujets des deux groupes. Une plus grande diminution de l'usage d'opioïdes, de l'interférence de la douleur et de l'humeur dépressive (p = 0,001) ont été observées chez le groupe avec ACT à la fin du traitement, ceci comparativement au groupe sans ACT.Conclusion: Les résultats préliminaires suggèrent que l'ACT a été efficace pour réduire l'usage d'opioïdes tout en diminuant l'interférence de la douleur et en améliorant l'humeur des patients.

Diurnal cortisol dysregulation, functional disability, and depression in women with ovarian cancer.

BACKGROUND: Multiple alterations in circadian rhythms have been observed in cancer patients, including the diurnal rhythm of the adrenal hormone cortisol. Diurnal cortisol alterations have been associated with cancer-related physiological processes as well as psychological stress. Here we investigate alterations in diurnal cortisol rhythm in ovarian cancer patients, and potential links with depression, life stress, and functional disability. METHODS: Women (n = 177) with suspected ovarian cancer completed questionnaires and collected salivary cortisol 3× daily for 3 consecutive days before surgery. One hundred women were subsequently diagnosed with ovarian cancer and 77 with benign disease. In addition, healthy women (n = 33) not scheduled for surgery collected salivary cortisol at the same time points. RESULTS: Ovarian cancer patients demonstrated significantly elevated nocturnal cortisol (P = .022) and diminished cortisol variability (P = .023) compared with women with benign disease and with healthy women (all P values <.0001). Among ovarian cancer patients, higher levels of nocturnal cortisol and less cortisol variability were significantly associated with greater functional disability, fatigue, and vegetative depression, but not with stress, distress, or depressed affect. There were no significant associations between functional or psychological variables and diurnal cortisol in women with benign disease. CONCLUSIONS: Nocturnal cortisol and cortisol variability show significant dysregulation in ovarian cancer patients, and this dysregulation was associated with greater functional disability, fatigue, and vegetative depression. These findings suggest potential hypothalamic-pituitary-adrenal involvement in functional disability in ovarian cancer, and may have implications for disease progression.

Interleukin-6, cortisol, and depressive symptoms in ovarian cancer patients.

PURPOSE: Inflammatory processes have been implicated in the pathogenesis of both depression and cancer. Links between depressive symptoms, interleukin-6 (IL-6), and cortisol dysregulation have been demonstrated in cancer patients, but vegetative versus affective components of depression have been minimally examined. The objective of the current study was to examine associations between IL-6, diurnal cortisol rhythms, and facets of depression in epithelial ovarian cancer patients. PATIENTS AND METHODS: Patients awaiting surgery for a pelvic mass suspected for ovarian cancer completed questionnaires, collected salivary samples for 3 days presurgery, and gave a presurgical blood sample. Ascites was obtained during surgery. IL-6 was measured by enzyme-linked immunosorbent assay and cortisol by a chemiluminescence immunoassay. The final sample included 112 invasive ovarian cancer patients (86 advanced stage, 26 early stage) and 25 patients with tumors of low malignant potential (LMP). RESULTS: Advanced-stage ovarian cancer patients demonstrated elevations in vegetative and affective depressive symptoms, plasma IL-6, and the cortisol area under the curve (AUC) compared with patients with LMP tumors (all P < .05). Among invasive ovarian cancer patients, greater vegetative depression was related to elevated IL-6 in plasma (P = .008) and ascites (P = .024), but affective depression was unrelated to IL-6. Elevations in total depression (P = .026) and vegetative depression (P = .005) were also related to higher evening cortisol levels. Plasma IL-6 was related to greater afternoon and evening cortisol and cortisol AUC (all P values < .005). CONCLUSION: These results demonstrate significant relationships between IL-6, cortisol, and vegetative depression, and may have implications for treatment of depression in ovarian cancer patients.

The assessment and validity of stress-related growth in a community-based sample.

In an investigation of the assessment and construct validity of stress-related growth, community-dwelling women (N = 163) wrote essays about the impact of a stressful life event that had occurred in the previous few years and completed the Posttraumatic Growth Inventory (PTGI). Independent ratings of growth in the essays were positively correlated with PTGI scores, suggesting that endorsement of growth on questionnaires can be substantiated by personal accounts. There was no relation between reports of growth on the PTGI and socially desirable responding or negative mood. Higher PTGI scores were associated with greater positive mood and greater depth of processing in the essays. These findings support the validity of stress-related growth as a construct and its assessment via questionnaire.