The Science

Research Foundation of the Prepare for Surgery, Heal Faster Workshop:

References and Additional Information for Improved Surgical Outcome

Ashton C, Whitworth GC et al. Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial. Journal of Cardiovascular Surgery 1997, 38:69-75.
Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care population. Southern Medical Journal. 1988; 81(7):826-829.
Contrada RJ, Leventhal EA, Anderson JR. Psychological preparation for surgery: Marshaling individual and social resources to optimize self-regulation. In S. Maes, H. Leventhal, M. Johnson (Eds.), International Review of Health Psychology 1994 (Vol. 3:219-266), New York: Wiley.
Devine EC 1992a Effect of psychoeducational care for adult surgical patients: a theory-probing meta-analysis of intervention studies. In: Cook ID, Cooper H et al (eds) Meta-Analysis for Explanation: A Casebook, New York, NY; Russell Sage Foundation.
Devine EC 192b Effect of psychoeducational care for adult surgical patients, a meta-analysis of 191 studies. Patient Education and Counseling 19: 129-142
Devine EC, Cook TD 1986 Clinical and cost-savings effects of psychoeducational interventions with surgical patients: a meta-analysis. Research in Nursing and Health 9:89-105.
Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. Journal of the American Medical Association 1963; 185:553-555.
Evans C, Richardson PH. Improved recovery and reduced postoperative stay after therapeutic suggestions during general anesthesia. Lancet 1988; ii:491-492.
Disbrow EA, Bennett HL, Owings, JT. Preoperative suggestion hastens the return of gastrointestinal motility. The Western Journal of Medicine May 1993; 158:488-492.
Furlong M. Positive suggestions presented during anesthesia. Memory and Awareness in Anesthesia (Amsterdam: Swets & Zeitlinger, 1990).
Ghoneim MM, Block RI. Learning and memory during anesthesia: an update. Anesthesiology 1997 87:387-410.
Hathaway D 1986 Effect of preoperative instruction on postoperative outcomes: a meta-analysis. Nursing Research 35:269-275.
Holden-Lund C. 1988 Effects of relaxation with guided imagery on surgical stress and wound healing. Research in Healing and Health 11:235-244.
House JS, Robbins, C, Metzner. The association of social relationships and activities with mortality. American Journal of Epidemiology 1982; 116:123-140.
Jasnoski ML, Kulger J. Relaxation, imagery, and neuroimmunomodulation. New York Academy of Sciences Annuals 1987; 496:722-30.
Johnston M and Wallace L (Eds.). (1990). Stress and medical procedures. Oxford, England: Oxford University Press.
Johnston M (1988) Impending surgery. In S. Fisher & J Reeason (Eds.) Handbook of life stress, cognition and health (79-100).
Kiecolt-Glaser J et al. Psychosocial modifiers of immunocompetence in medical students. Psychosomatic Medicine 1984; 46:7-14.
Mainord WA, Rath B, Barnett F. 1983. Anesthesia and suggestion. Paper presented at the 91st annual convention of the American Psychological Association, Los Angeles.
Mathers A, Ridgeway V (1981) Personality and surgical recovery. A review: British Journal of Clinical Psychology, 20, 243-260.
McLintock TTC, Aitken H, Downie CFA, Kenny GNC. Postoperative analgesic requirements in patients exposed to positive intraoperative suggestions. British Medical Journal 1990; 301:788-790.
Mumford E, Schlesinger HJ, Glass GV. The effects of Psychological intervention on recovery from surgery and heart attacks: an analysis of the literature.  American Journal of Public Health 1982; 72:141-151.
Rogers M, Reich P. Psychological intervention with surgical patients: evaluation outcome. Advances in Psychosomatic Medicine 1986; 15:23-50.
Selye H. Stress Without Distress (New York: American Library, 1974).
Steinberg ME, Hord AH, Reed B, Sebels PS. Study of the effect of intraoperative analgesia and well-being. Memory and Awareness in Anesthesia (Englewood Cliffs, NJ:Prentice Hall, 1993.)

Brief Additional Research/Information Supporting Patient Preparation for Surgery:

PSYCHONEUROIMMUNOLOGY
A Harvard study in the seventies discovered receptors on our immune cells for neuropeptides. Neuropeptides are chemicals produced by the brain that vary with our emotions. The results of this study point to the simple fact that your immune system is listening to your mental talk. How you think is how you feel. When someone tells you that you’re only as old as you feel, believe it.
You are the master of your immune system. There is no better cure for anything than a good attitude.
Below are the results of a study conducted on students, separated into two sections, negative and positive states.
Negative States

  • Bereavement
  • Pessimistic states
  • Academic stress
  • Depression
  • Loneliness
  • Chronic stress
  • Divorce/separation/poor marital quality
  • Expressed need for power and control
  • Negative behavior during discussions of marital problems
  • Decreased lymphocyte proliferation.
  • Decreased lymphocyte reactivity; decreased T-cell effectiveness.
  • Decreased NK cell activity; decreased T-cells; decrease in certain immune chemicals; increased susceptibility to herpes virus; decreased immunoglobulin A; increased blood levels of Epstein-Barr virus.
  • Decreased T-cells; decreased number and function of lymphocytes; decreased NK cells.
    Decreased NK (Natural Killer Cell) activity.
    Decreased T-cells; decreased NK cells; decreased B-cells; increased blood levels of Epstein-Barr virus.
  • Decreased lymphocyte function; increased blood levels of Epstein-Barr virus; decreased T-cell effectiveness.
  • Decreased NK activity; decreased lymphocytes.
  • Decreased NK activity; decreased macrophages; increased blood levels of Epstein-Barr virus; increase in certain T-cells; decreased immunity by mitogen tests.

Positive States

  • Satisfying personal relationships and social support.
  • Personal sharing and disclosure of traumatic experiences.
  • Humor and laughter
  • Hypnosis and relaxation techniques.
  • Physical exertion and aerobic exercise.
  • Group intervention and support
  • Increased lymphocyte function; increased NK activity; increased immunity by mitogen tests; increased immune response to hepatitis B vaccine.
  • Increased lymphocyte response.
  • Increased Immunoglobulin A; increased lymphocyte count and activity.
  • Increased T-cell effectiveness; increased NK cell activity; decreased blood levels of stress hormones; decreased blood levels of herpes virus.
  • Increased number of white blood cells; increase in endorphins; increase in certain immune chemicals; increased NK cell number and activity; increased T-cells; decreased T-cell effectiveness; decreased lymphocyte function.
  • Increased NK cell number and activity; increased number of lymphocytes; decrease in T-helper cells.

Reference: Kiecolt-Glaser, J.K., Garner, W., Speicher, C.E., Penn, G., and Vlaser, R. Psychosocial Modifiers of Immunocompetence in Medical Students." Psychosomatic Medicine 46 (1984).
Guided Imagery Speeds Surgical Recovery 
© David S. Sobel M.D. , Institute for the Study of Human Knowledge

Patients undergoing surgery often experience a loss of control, feeling more like victims than participants. Anxiety, fear of the unknown, fear of pain, dependency, uncertainty, and helplessness are common emotions which can intensify the perception of pain associated with invasive medical procedures.
Physical and psychological stress can also contribute to prolonged postoperative recovery and a suppressed immune system.
To help retain a sense of control, patients can learn a range of positive skills including imagery, relaxation, self-talk, and positive outcome expectations.
Guided imagery is a technique that draws on the power of thought to influence psychological and physiological states. The patient listens to an audio tape to create mental images that bring about a state of focused concentration. This state, in turn, allows relaxation and produces a sense of physical and emotional well-being. Patients can use this technique to control their reactions to anxiety, depression, and stressful situations.
Guided imagery may also help patients strengthen their immune system and enhance their own healing.
A recent study at the Cleveland Clinic Foundation investigated the effect of guided imagery on 130 patients undergoing colorectal surgery. A control group received standard surgical care. Another group listened to a guided imagery tape to help them become calm and focused.
The guided imagery tape included soft, soothing music, and a story that brought patients to a "special place" in their mind - a place that was safe, secure, protected, supported, and relaxed. The imagery story encouraged patients to confront and work through any feelings of fear, anxiety, and negativity.
Patients were instructed to listen to the tape without interruption twice per day, once in the morning and once in evening, for three days before the operation and for six days after. During surgery and in the recovery room they listened to a tape with only the music.
Those who listened to guided imagery tapes fared much better--both before and after surgery. Before surgery, anxiety increased in the control group but decreased in the guided imagery group. After surgery, pain and anxiety levels were significantly lower for the imagery patients. They needed only about half the amount of narcotic pain medications as the control group and their bowel function also returned much more quickly.
The number of patients experiencing postoperative complications such as nausea, vomiting, or disrupted bowel function did not differ significantly in the two groups. Nor were there enough participants to detect a statistically significant difference in length of hospital stay.
But virtually all of the guided imagery patients reported that they appreciated using the tapes and attributed benefits including improved quality of sleep, speeded recovery, and reduced anxiety and pain after surgery. Most believed that all patients having major abdominal surgery should have the opportunity to use the guided imagery tapes.
How do the guided imagery tapes improve the surgical experience? The answer is not clear at this point. Using the tapes may increase patients' sense of control and active participation, which in turn may reduce anxiety and change physiology. Music has been shown to influence mood and, perhaps, immune function. The tapes also provide a temporary escape, blocking out annoying noises, and distracting the patients from pain and anxious thoughts.
Guided imagery can help you relax, clear your mind, and engage physiologically and psychologically supportive images. Of course, you don't have to be facing surgery to enjoy these benefits. Imagery tapes can be used for general relaxation and stress reduction as well as management of a variety of diseases.
For More Information:
Academy for Guided Imagery, P.O. Box 2070, Mill Valley, CA 94942: Relaxation and imagery tapes, books, and courses.
Davis, Martha; Eshelman, Elizabeth; and McKay, Matthew: The Relaxation & Stress Reduction Workbook. Oakland, CA: New Harbinger Publications, 1995.
Fanning, Patrick: Visualization for Change. Oakland, CA: New Harbinger Publications, 1988.
"Health Journeys" by Belleruth Naparstek, Image Paths, Inc., Box 5714, Cleveland, OH 44101-0714 (1-800-800-8661): Relaxation and imagery tapes and books.
Lusk, Julie T.: 30 Scripts for Relaxation Imagery and Inner Healing. Volumes 1 and 2. Duluth, MN: Whole Person Associates, 1992-1993.
Naparstek, Belleruth: Staying Well with Guided Imagery. New York: Warner Books, 1994.
New Harbinger Publications, 5674 Shattuck Avenue, Oakland, CA 94609 (1-800-748-6273): Relaxation and imagery tapes and books.
Rossman, Martin: Healing Yourself: A Step-by-Step Program for Better Health Through Imagery. New York: Pocket Books, 1987.
Tusek DL, et al: Guided Imagery: A Significant Advance in the Care of Patients Undergoing Elective Colorectal Surgery. Diseases of the Colon and Rectum 1997;40:172-178.
Whole Person Associates, Inc., 210 West Michigan, Duluth, MN 55802-1908 (218-727-0500): Relaxation and imagery tapes and books.

Excerpted from the Quarterly Newsletter, Mind/Body Health Newsletter.

David S. Sobel, M.D., M.P.H., is a practicing physician in adult medicine and Medical Director of Patient Education and Health Promotion for Kaiser Permanente Northern California. He is physician lead for the national initiative in Self-Care and Shared Decision-Making for Kaiser Permanente. He is coauthor of Living a Healthy Life with Chronic Conditions, The Healing Brain, Healthy Pleasures, The Healthy Mind, Healthy Body Handbook and editor of the Mind/Body Health Newsletter. He is the 2001 recipient of the national Healthtrac Foundation Health Education Award.

MIND-BODY SURGERY Referrences:

Lang, E.V., Hamilton, D. (1994). Anodyne imagery: an alternative to i.v. sedation in interventional radiology. AJR Am J Roentgenol, May;162(5):1221-6.
Lang, E.V., Joyce, J.S., Spiegel, D., Hamilton, D., Lee, K.K.. (1996). Self-hypnotic relaxation during interventional radiological procedures: effects on pain perception and intravenous drug use. Int J Clin Exp Hypn, Apr;44(2):106-19. 
Ashton, C. Jr., Whitworth, G.C., Seldomridge, J.A., Shapiro, P.A., Weinberg, A.D., Michler, R.E. Smith, C.R., Rose, E.A., Fisher, S., Oz, M.C. (2000). Self-hypnosis reduces anxiety following coronary artery bypass surgery. A prospective, randomized trial. J Cardiovasc Surg, Apr;41(2):335-6.
Faymonville, M.E., Fissette, J., Mambourg, P.H., Roediger, L., Joris, J. Lamy, M. (1995). Hypnosis as adjunct therapy in conscious sedation for plastic surgery. Reg. Anesth. Mar-Apr;20(2):145-51.
Tusek, D.L., Church, J.M., Strong, S.A., Grass, J.A., Fazio, V.W. (1997). Guided imagery: a significant advance in the care of patients undergoing elective colorectal surgery. Dis Colon Rectum. Feb;40(2):172-8.
Lang, E.V., Benotsch, E.G., Fick., L.J., Lutgendorf, S., Berbaum, M.L., Berbaum, K.S., Logan, H., Spiegel, D. (2000).  Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial.  Lancet, Apr 29;355(9214) :1486-90.
Weinstein E.J., Au, P.K. (1991). Use of hypnosis before and during angioplasty. Am J Clin Hypn. Jul;34(1):29-37.
Syrjala, K.L., Donaldson, G.W., Davis, M.W., Kippes, M.E., Carr, J.E., (1995). Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial.  Pain, Nov;673 (2):189-98.
Rensi, C, Peticca, L., Pescatori, M. (2000). The use of relaxation techniques in the periopperative management of proctological patients: preliminary results. Int J Colorectal Dis, Nov;15(5-6):313-6.
Disbrow, E.A., Bennett, H.L., Owings, J.T. (1993). Effect of preoperative suggestion on postoperative gastrointestinal motility. West J Med, May;158(5);488-92.
Rapkin, D.A., Straubing, M., Holroyd, J.C.  (1991). Guided imagery, hypnosis and recovery from head and neck cancer surgery: an exploratory study. Int J Clin Exp Hypn, Oct;39(4) :215-26.
Cowan, G.S. Jr., Buffington, C.K., Cowan, G.S. 3rd, Hathaway, D. (2001). Assessment of the effects of taped cognitive behavior message on postoperative complications (therapeutic suggestions under anesthesia). Obes Surg, Oct;11(5):589-93.
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Enqvist, B. von Konow, L., Bystedt H. (1995). Pre-and perioperative suggestion in maxillofacial surgery: effects on blood loss and recovery. Int J Clin Exp Hypn. Jul;43(3):284-94.
Lucas, O.N., (1975). The use of hypnosis in hemophilia dental care. Ann N Y Acad Sci, Jan 20;240:263-6.
Bennet, H.L., D.R. Benson, and D.A. Kuiken. (1986). Preoperative instructions for decreased bleeding during spine surgery." Anesthesiology, 65 (1986):A245.
Holden-Lund, C. (1988). Effects of relaxation with guided imagery on surgical stress and wound healing. Research in Nursing and Health, 11 Aug. 235-244.
Jones,C.W. (1977). Hypnosis and spinal fusion by Harrington instrumentation. Am. Journal of Clinical Hypnosis, Jan;19(3):155-7.
Crawford, A.H., Jones, C.W., Perisho, J.A., Herring, J.A. (1976). Hypnosis for monitoring intraoperative spinal cord function. Anesth Analg, Jan-Feb;55(1):42-4.
Meurisse, M., Hamoir, E., Defecheueux, T., Gollogly, L., Derry, O., Postal, A., Joris, J., Faymonville, M.E.  (1999). Bilateral neck exploration under hypnosedation: a new standard of care in primary hyperparathyroidism? Ann Surg. Mar;229(3):401-8.
Schwab, D., R.N., Director, New Product Development, Blue Shield of California. From her presentation at the 2002 National Managed Health Care Congress (NMHCC).  To be published.
Fontana, G.P, M.D. (2000). From Reuters Health press release:  Acupuncture, Massage, Guided Imagery Ease Pain After Bypass Surgery.  Reported by Steve Mitchell June 9.
Oz, M., M.D.  (2000). Quoted in the article, Healing From the Heart: A Leading Heart Surgeon Explores the Power of Complementary Medicine.  Dec. 12.