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Effects of a brief and economical intervention in preparing patients for surgery: does coping style matter?
Pain 83 (1999) 471±475 www.elsevier.nl/locate/pain
Effects of a brief and economical intervention in preparing patients for surgery: does coping style matter? Jordi MiroÂ*, Rosa M. Raich Institut de Psicologia Aplicada, Reus, Spain Received 28 January 1999; received in revised form 2 June 1999; accepted 8 June 1999
Abstract The objective of this study was to examine the effects of a brief and economical procedure in the preparation of surgical patients. More speci®cally, the study was intended to test whether patient's monitoring style (high vs. low) makes any difference to the bene®ts of a relaxation technique. Ninety-two patients scheduled for hysterectomy with double oophorectomy were assessed for preferred coping style and randomly assigned to one of two conditions: (a) relaxation training and (b) attention control. It was hypothesized that low monitors would report less pain, less analgesic use and a higher activity level when trained in relaxation than low monitor controls or than high monitors trained in relaxation. Results showed no differences between individuals with different coping styles. On the other hand, however, statistically signi®cant differences were observed between trained patients and controls. Namely, individuals trained in relaxation experienced less pain along the surgical process, pain interfered less with their daily activities, and performed a higher activity level three weeks after surgery, compared to non trained patients. q 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Psychology; Preparation for surgery; Coping style; Surgical pain
1. Introduction Studies by Janis (1958) and Egbert et al. (1963) helped to launch research and the systematic practice of psychologically preparing patients for surgery. Since their pioneering work, a growing number of studies have examined the effectiveness of many different interventions, designed to enhance the coping skills of persons undergoing surgical procedures. Although each of these interventions has shown to improve coping in some situations (Contrada et al., 1994; MiroÂ, 1997a; O'Hallaran and Altmaier, 1995), the factors underlying successful outcomes are not well understood. It has been argued that individual coping styles, and other dispositional variables, may moderate the effects of psychological preparation on response to stress. For example, Miller and her associates (Miller et al., 1988;Miller and Mangan, 1983) have repeatedly observed that individuals trying to cope with stressful and threatening situations and procedures, like surgery, experience less distress when the level of preparatory information they receive is consistent with their coping style. Relaxation training has been extensively used in the preparation of surgical patients, mostly in combination * Corresponding author. Departament de Psicologia, Universitat Rovira i Virgili, Carretera de Valls s/n, 43007 Tarragona, Spain.
with other coping strategies, as a component of `therapeutic packages'. There exist a small number of studies attempting to objectively assess the therapeutic value of relaxation alone, as a preparatory technique for surgical patients. Evidence for its effectiveness in the reduction of postsurgical pain, for example, is equivocal, with some research supportive (Flaherty and Fitzpatrick, 1978; Scott and Clum, 1984), and other research negative (Pickett and Clum, 1982; Fuller et al., 1978). One possible explanation for such a discrepancy may be that relaxation techniques would be effective with patients who display certain characteristics, as it so happens with the provision of surgical information. Miller (1992), for example, has suggested that relaxation would be more appropriate for low monitor patients granted that relaxation would help them distract from the threatening experience of surgery. However, beyond general and anecdotal speculations, there is no clinically relevant data on the effects of relaxation with this speci®c group of individuals, and evidence to empirically support decisions on the use of distraction-based techniques, like relaxation, with this speci®c population, are clearly needed. To address this gap in the literature, the present study was intended to test whether monitoring style makes any difference to the bene®ts of such a technique. It was hypothesized, based on suggestions found in the reviewed
0304-3959/99/$20.00 q 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S 0304-395 9(99)00151-7
472
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
literature, that low monitors would report less pain, less analgesic usage, a lower interference of pain with daily activities and a higher activity level when trained in relaxation than low monitor controls or than high monitor controls trained in relaxation. 2. Methods 2.1. Subjects Permission to participate in the study was asked of 113 hysterectomy patients, 20 of whom refused. In all cases patients busy schedule was argued as their motive for refusal. One other patient was excluded from the analyses because of inadequate data. Patients' age ranged from 29± 59 years, with a mean of 55 years. All patients had at least one child (mean 2, SD 0:89), and underwent a hysterectomy with double oophorectomy. No statistical differences were detected among patient subgroups in terms of their age or socio-economic status. 2.2. Measures Patients' coping style was assessed with the Spanish version of the Miller Behavioral Style Scale (MBSS). This was developed (Miller, 1987) to assess the informationseeking style of patients coping with stressful and threatening events. Both the original MBSS and its Spanish version (MBSS-S) (MiroÂ, 1997b), have produced excellent results with different surgical patient samples and laboratory groups. The MBSS-S has also proved to be reliable and valid with groups having different Spanish dialect usage (MiroÂ, 1997b). Two main scores are derived from the scale: a monitoring score and a blunting score (see Miller, 1987 for a complete description of the scale). Depending on the patients' scores on the monitoring subscale we distinguished between those who look for threat-relevant information (high monitors) and those that avoid the information (low monitors). Reasons for selecting the monitoring subscale are as follows: ®rstly, it shows greater internal consistency, secondly, it presents a less asymmetrical distribution and thirdly, it has been the most used subscale in both clinical and experimental research projects, not only in the original works of Dr. Miller, but in many others conducted by different research groups (Gattuso et al., 1992). Clearly, this scale would facilitate comparative analyses. The mean score of the monitoring subscale, obtained during its Spanish translation, validation, and adaptation (MiroÂ, 1997b) was the cut-off point used to allocate subjects into high and low monitoring groups. Patients with a monitoring score higher than 9.64 were considered high monitoring individuals while those with a lower score were treated as low monitoring. Scores on the monitoring subscale were as follows: low monitoring group, mean 6:04, SD 0:89, n 43; high monitoring group, mean 10:04, SD 2:56, n 49. Internal reliabilty on the monitoring subscale, using Cron-
bach's alpha, was a 0:78 (for the blunting subscale a 0:71). More information on the characteristics of the scale are to be found in Miro (1997b). The level of pain was assessed using numerical scales. In hospital, patients reported their pain level considering three different situations, standing, walking and while moving in bed, and at two different times: 24 and 72 h after surgery. At follow-up, they provided an overall estimation of the pain level. Numerical scales ranged from 0±100. The variable `analgesics' was treated as follows: two physicians, an anesthetist and a gynecologist, blind to subjects' group, rated each patients' use of analgesics relative to other patients in their experience who had the same or similar surgery. This scaling procedure (based on the type and dosage of analgesic medication, as well as the number of requests for medication) allows for differences in drug potencies and dosages which, as Wells et al. (1986) stress, `have been confounding variables in previous research works' (p. 832). Following the recommendation of Wells et al. (1986), the analgesic usage variable was formed by obtaining the linear combination of the standardized scores of the two judges. Scores were standardized to prevent scaling differences from biasing the mean calculations. Numerical scales were also used to assess the return to daily activities. Patients had to provide a number between 0 and 100 for their current activity level, compared with the activity level prior to surgery. They had to provide information concerning the activity level at home and outside of home, during their leisure time. This took place 15 days after surgery. At the same time, the extent to which the level of pain interfered with the execution of daily activities was assessed by means of a numerical scale (endpoints anchors: no activity and same activity level). As a measure of the adherence to the protocol, patients in the relaxation group were asked the number of times they had practiced the relaxation strategy before and after surgery (the assessments took place: the day prior to surgery and at follow-up), and how successful they were in their objective of calming down. They had to provide their answer using a numerical scale from 0±100 (endpoint anchors: no relaxation at all and completely relaxed). Patients' level of satisfaction with the psychological preparation received was evaluated with numerical scales ±101 possibilities ± by asking how satis®ed they were with the training in relaxation (relaxation training group), and how satis®ed they were with the work of the clinical psychologist (attention control group). Satisfaction with care in general was assessed with the following question: `in general, how do you feel you have been treated'? Patients' satisfaction with psychological preparation was assessed the day before surgery, whereas patients' satisfaction with general care was assessed at follow-up. Numerical scales were used, all ranging from 0±100 (endpoint anchors: no satis®ed at all and totally satis®ed). As another control measure, patients' spontaneous use of coping strategies was assessed. Stone and Neale's question-
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
naire was used (Stone and Neale, 1984). This was developed for use in longitudinal studies with repeated assessments. Nine coping categories comprise the most recent form of the questionnaire: distraction, situation rede®nition, direct action, catharsis, acceptance, seeking social support, relaxation, religion and looking for information. They were assessed three times: the day before surgery, 3 days after surgery and at follow-up. 2.3. Procedure Patients were randomly assigned to one of two groups; a random digits table was used to assign individuals to the groups. Individuals in one group were trained in relaxation while the second group of patients acted as an attention control group. One week before surgery, patients were individually interviewed and were trained in relaxation. Those patients in the `relaxation group' were trained in a relaxation strategy in which no references to bodily functions were made (e.g. focusing on the muscles' state of tension/relaxation). Instead, it was based on instructions of deep-breathing, and speci®c instructions were provided to teach patients relax (guided imagery was used so as to help patients deepen their relaxation state) (see Holden-Lund, 1988 for a complete and detailed description of a similar procedure). At the end of the session, these patients received speci®c instructions on how to practice relaxation at home, and detailed suggestions on how to do it were provided in the handout they received. The second group of patients acted as an attention control group. The amount of time spent with patients was used to focus on neutral topics such as the patient's job, family, interests, concerns, or whatever the patient began to discuss. Questions raised by the patient about the surgical procedure were described as matters appropriate for discussion with the surgeon. Subjects were allocated into the groups before any personal contact had taken place. All interviews and interventions were conducted individually by the same clinical psychologist, who was blind to patients' informational coping style. Regardless of the group, all patients spent, approximately, the same amount of time with the clinical psychologist. The preparation took around 30 min. Means and standard deviations for each group were as follows: relaxation, mean 29:9, SD 1:16; control: mean 28:5, SD 0:83. No statistical differences exist. During the pre-surgical interview with the clinical psychologist, and besides providing demographic and health-related information, patients answered the MBSS-S (MiroÂ, 1997b) (see Section 3). 3. Results The data analysis consisted of multivariate and univariate analyses of variance, in a 2 £ 2 factorial design, with two levels of coping style, and two levels of treatment. No differences were found in patients' satisfaction with
473
preparatory intervention and general care received. Similarly, no differences appeared when groups (relaxation vs. control) or individuals with different coping styles (high vs. low) were compared. 1 In this study, all patients practiced relaxation at home, both before and after surgery, and at least 76% of the time succeeded in their objective of calming down. Table 1 displays means and standard deviations of pain levels, the return to normal daily activities, analgesic use, and the level of interference of pain with patients' daily activities. The interaction effect between coping style and relaxation resulted in a Wilk's lambda 0:72 with P 0:46, thereby signaling that our relaxation training produced similar bene®ts in all our patients. In other words, monitoring coping style (high vs. low) does not seem to make any difference to relaxation outcomes. Even though the interaction effect was non-signi®cant, statistically signi®cant effects were observed after comparing trained and control individuals. The results were as follows: pain level at 24 h: standing, F 1; 89 42:25, P , 0:001; walking, F 1; 89 39:1, P , 0:001; moving in bed, F 1; 89 20:11, P , 0:01; pain level at72 h: standing, F 1; 89 29:67, P , 0:01; walking, F 1; 89 26:94, P , 0:01; moving in bed, F 1; 89 24:16, P , 0:02; pain level at follow-up; F 1; 88 52:13, P , 0:001; pain level on return to normal activities, at home F 1; 88 12:10, P , 0:06; pain level on return to normal activities, at leisure time, F 1; 88 34:75, P , 0:001; level of pain interfering with daily activities, F 1; 88 47:18, P , 0:001; analgesic usage, F 1; 87 10:15, P , 0:06. In summary, trained patients experienced lower pain levels, which seemed to interfere less with daily activities and reported to have returned to a higher activity level, at least during leisure time. No differences were with the variables, `return to normal activities at home' and `analgesic usage'. 4. Discussion The present study examined whether monitoring-style makes any difference to the bene®ts of a brief and economical intervention such as relaxation in the preparation of surgical patients. The hypothesis was not supported, but results demonstrated the utility of the procedure in psychologically preparing patients for surgery, and unlike most available 1 Due to the large number of analyses to be implemented (60 statistical tests listed in Table 4) it was necessary to lower the alpha level required for signi®cance in order to control Type I errors and to increase the con®dence that ®ndings identi®ed as signi®cant would be reliable. However a highly conservative approach, such as the Bonferroni, in which the chosen significance level is divided by the number of analyses to yield a P value so low (i.e. 0:05 4 60 0:0008) that it substantially increases the risk of Type II errors. Thus we elected to compromise between those two risks and chose a P value of 0.001 that must be reached in order for a particular ®nding to be deemed statistically signi®cant.
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
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Table 1 Mean and standard deviations of pain levels, the return to normal daily activities, analgesic use and pain interference with daily activities for high monitoring (HM) and low monitoring (LM) patients Variables
Relaxation
Control
HM 23 LM 23 HM 26 LM 20 Pain at 24 h Standing
Mean SD M SD Mean SD
3.00 1.48 5.36 2.92 4.81 2.63
2.27 1.90 2.90 1.37 4.23 3.94
5.63 2.20 7.27 3.10 6.63 2.01
6.54 a 1.03 a 8.18 a 1.16 6.90 b 1.04
Mean SD Mean SD Mean SD
3.41 2.95 4.90 3.36 4.81 3.28
3.06 2.75 3.27 2.32 4.18 2.27
5.81 2.08 7.54 1.75 7.00 1.41
5.81 b 0.75 5.90 b 1.30 6.36 1.69
Pain at follow-up Overall estimation Mean 3.72 SD 2.97
2.00 1.41
6.72 1.34
7.18 a 1.32
Return to normal daily activities Home Mean 44.54 SD 13.68 Leisure Mean 47.72 SD 20.78
50.54 10.14 52.27 17.08
37.00 20.00 11.81 8.44
38.63 9.51 30.00 a 13.78
1.00 0.73
1.95 0.60
1.75 0.96
65.45 13.68
62.27 a 13.48
Walking Moving in bed Pain at 72 hours Standing Walking Moving in bed
Analgesic use Analgesic
Mean 1.50 SD 0.80
Level of pain interfering with daily activities Pain interference Mean 35.45 32.72 SD 32.05 27.60 a b
P , 0:001. P , 0:01.
reports the ®ndings are based on studying relaxation alone. Patients who received training reported signi®cantly lower levels of pain. Their pain level also interfered signi®cantly less with their functioning; in fact, trained patients reported a higher activity level than controls. It is important to recall that no differences were found on the type of coping strategies these patients had spontaneously used. Our results do not support the claim that a distractionbased technique like relaxation is more appropriate for low monitors than for high monitors (Miller, 1992). On the other hand, they are in agreement with a body of literature showing the bene®ts induced by relaxation training as a strategy to cope with pain, be it of a surgical type (Holden-Lund, 1988), or of a chronic nature (Turk et al., 1983). Different researchers have suggested that distractionbased strategies are effective general coping strategies for acute stressors (Gattuso et al., 1992). Others have even suggested that the individual's coping style, and its effects,
is not as relevant in the surgical context as it may be in other contexts (Auerbach, 1989). Therefore, ®nding no support for the `interactive hypothesis' could not be as surprising as it might initially seem. In conclusion, the results of our investigation demonstrate the utility of relaxation in preparing patients for surgery, at least in terms of reducing patients' pain level, and increasing patients' activity level. Its effects do not seem to interact with patient's monitoring style. Relaxation is a cost-ef®cient technique. It does not require much time, expensive material, or resources, beyond those already available at most hospitals. Acknowledgements This research was supported by a grant from the Generalitat de Catalunya awarded to the ®rst author. Part of this work was done while Dr. Miro was a Visiting Scholar at New York University. References Auerbach SM. Stress management and coping research in the health care setting: an overview and methodological commentary. J Consult Clin Psychol 1989;57:388±395. Contrada RJ, Leventhal EA, Anderson JR. Psychological preparation for surgery: marshalling individual and social resources to optimize selfregulation. In: Maes S, Leventhal H, Johnston M, editors. International review of health psychology 3, New York: Wiley, 1994. pp. 219±266. Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. J Am Med Assoc 1963;185:553±555. Flaherty GG, Fitzpatrick JJ. Relaxation technique to increase comfort level of postoperative patients: a preliminary study. Nursing Res 1978;27:352±355. Fuller SS, Endress MP, Johnson JE. The effects of cognitive and behavioral control on coping with an aversive health examination. J Human Stress 1978;4:18±25. Gattuso SM, Litt MD, Fitzgerald TE. Coping with gastrointestinal endoscopy: self-ef®cacy enhancement and coping style. J Consult Clin Psychol 1992;60:133±139. Holden-Lund C. Effects of relaxation with guided imagery on surgical stress and wound healing. Res Nursing Health 1988;11:235±244. Janis IL. Psychological stress. Psychoanalitic and behavioral studies of surgical patients, New York: Wiley, 1958. Miller SM. Monitoring and blunting: validation of a questionnaire to assess styles of information seeking under threat. J Pers Social Psychol 1987;52:345±353. Miller SM. Individual differences in the coping process: what to know and when to know it. In: Carpenter B, editor. Personal coping: theory, research and application, Westport: Erlbaum, 1992. pp. 77±91. Miller SM, Mangan ChE. Interacting effects of information and coping style in adapting to gynecologic stress. should the doctor tell all? J Pers Social Psychol 1983;45:223±236. Miller SM, Brody DS, Summerton J. Styles of coping with threat: implications for health. J Pers Social Psychol 1988;54:142±148. Miro J. PreparacioÂn psicoloÂgica para intervenciones quiruÂrgicas: una revisioÂn selectiva (Psychological preparation for surgical interventions: a selective review). Revista de PsicologõÂa de la Salud/J Health Psychol 1997a;9:45±91. Miro J. Translation, validation, and adaptation of an instrument to assess the information seeking style of coping with stress: the Spanish version
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475 of the Miller Behavioral Style Scale. Pers Individ Diff 1997b;23:909± 912. O'Hallaran CM, Altmaier EM. The ef®cacy of preparation for surgery and invasive medical procedures. Patient Edu Counsel 1995;25:9±16. Pickett C, Clum GA. Comparative treatment strategies and their interaction with locus of control in the reduction of postsurgical pain and anxiety. J Consult Clin Psychol 1982;50:439±442. Scott LE, Clum GA. Examining the interaction effects of coping style and brief interventions in the treatment of postsurgical pain. Pain 1984;20:279±291.
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Stone AA, Neale JN. New measure of daily coping: development and preliminary results. J Pers Social Psychol 1984;46:892±906. Turk DC, Meichenbaum D, Genest M. Chronic pain and behavioral medicine. A cognitive-behavioral perspective, New York: Guilford Press, 1983. Wells JK, Howard GS, Nowlin WF, Vargas MJ. Presurgical anxiety and postsurgical pain and adjustment: effects of a stress inoculation procedure. J Consult Clin Psychol 1986;6:831±835.
Effects of a brief and economical intervention in preparing patients for surgery: does coping style matter? Jordi MiroÂ*, Rosa M. Raich Institut de Psicologia Aplicada, Reus, Spain Received 28 January 1999; received in revised form 2 June 1999; accepted 8 June 1999
Abstract The objective of this study was to examine the effects of a brief and economical procedure in the preparation of surgical patients. More speci®cally, the study was intended to test whether patient's monitoring style (high vs. low) makes any difference to the bene®ts of a relaxation technique. Ninety-two patients scheduled for hysterectomy with double oophorectomy were assessed for preferred coping style and randomly assigned to one of two conditions: (a) relaxation training and (b) attention control. It was hypothesized that low monitors would report less pain, less analgesic use and a higher activity level when trained in relaxation than low monitor controls or than high monitors trained in relaxation. Results showed no differences between individuals with different coping styles. On the other hand, however, statistically signi®cant differences were observed between trained patients and controls. Namely, individuals trained in relaxation experienced less pain along the surgical process, pain interfered less with their daily activities, and performed a higher activity level three weeks after surgery, compared to non trained patients. q 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. Keywords: Psychology; Preparation for surgery; Coping style; Surgical pain
1. Introduction Studies by Janis (1958) and Egbert et al. (1963) helped to launch research and the systematic practice of psychologically preparing patients for surgery. Since their pioneering work, a growing number of studies have examined the effectiveness of many different interventions, designed to enhance the coping skills of persons undergoing surgical procedures. Although each of these interventions has shown to improve coping in some situations (Contrada et al., 1994; MiroÂ, 1997a; O'Hallaran and Altmaier, 1995), the factors underlying successful outcomes are not well understood. It has been argued that individual coping styles, and other dispositional variables, may moderate the effects of psychological preparation on response to stress. For example, Miller and her associates (Miller et al., 1988;Miller and Mangan, 1983) have repeatedly observed that individuals trying to cope with stressful and threatening situations and procedures, like surgery, experience less distress when the level of preparatory information they receive is consistent with their coping style. Relaxation training has been extensively used in the preparation of surgical patients, mostly in combination * Corresponding author. Departament de Psicologia, Universitat Rovira i Virgili, Carretera de Valls s/n, 43007 Tarragona, Spain.
with other coping strategies, as a component of `therapeutic packages'. There exist a small number of studies attempting to objectively assess the therapeutic value of relaxation alone, as a preparatory technique for surgical patients. Evidence for its effectiveness in the reduction of postsurgical pain, for example, is equivocal, with some research supportive (Flaherty and Fitzpatrick, 1978; Scott and Clum, 1984), and other research negative (Pickett and Clum, 1982; Fuller et al., 1978). One possible explanation for such a discrepancy may be that relaxation techniques would be effective with patients who display certain characteristics, as it so happens with the provision of surgical information. Miller (1992), for example, has suggested that relaxation would be more appropriate for low monitor patients granted that relaxation would help them distract from the threatening experience of surgery. However, beyond general and anecdotal speculations, there is no clinically relevant data on the effects of relaxation with this speci®c group of individuals, and evidence to empirically support decisions on the use of distraction-based techniques, like relaxation, with this speci®c population, are clearly needed. To address this gap in the literature, the present study was intended to test whether monitoring style makes any difference to the bene®ts of such a technique. It was hypothesized, based on suggestions found in the reviewed
0304-3959/99/$20.00 q 1999 International Association for the Study of Pain. Published by Elsevier Science B.V. PII: S 0304-395 9(99)00151-7
472
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
literature, that low monitors would report less pain, less analgesic usage, a lower interference of pain with daily activities and a higher activity level when trained in relaxation than low monitor controls or than high monitor controls trained in relaxation. 2. Methods 2.1. Subjects Permission to participate in the study was asked of 113 hysterectomy patients, 20 of whom refused. In all cases patients busy schedule was argued as their motive for refusal. One other patient was excluded from the analyses because of inadequate data. Patients' age ranged from 29± 59 years, with a mean of 55 years. All patients had at least one child (mean 2, SD 0:89), and underwent a hysterectomy with double oophorectomy. No statistical differences were detected among patient subgroups in terms of their age or socio-economic status. 2.2. Measures Patients' coping style was assessed with the Spanish version of the Miller Behavioral Style Scale (MBSS). This was developed (Miller, 1987) to assess the informationseeking style of patients coping with stressful and threatening events. Both the original MBSS and its Spanish version (MBSS-S) (MiroÂ, 1997b), have produced excellent results with different surgical patient samples and laboratory groups. The MBSS-S has also proved to be reliable and valid with groups having different Spanish dialect usage (MiroÂ, 1997b). Two main scores are derived from the scale: a monitoring score and a blunting score (see Miller, 1987 for a complete description of the scale). Depending on the patients' scores on the monitoring subscale we distinguished between those who look for threat-relevant information (high monitors) and those that avoid the information (low monitors). Reasons for selecting the monitoring subscale are as follows: ®rstly, it shows greater internal consistency, secondly, it presents a less asymmetrical distribution and thirdly, it has been the most used subscale in both clinical and experimental research projects, not only in the original works of Dr. Miller, but in many others conducted by different research groups (Gattuso et al., 1992). Clearly, this scale would facilitate comparative analyses. The mean score of the monitoring subscale, obtained during its Spanish translation, validation, and adaptation (MiroÂ, 1997b) was the cut-off point used to allocate subjects into high and low monitoring groups. Patients with a monitoring score higher than 9.64 were considered high monitoring individuals while those with a lower score were treated as low monitoring. Scores on the monitoring subscale were as follows: low monitoring group, mean 6:04, SD 0:89, n 43; high monitoring group, mean 10:04, SD 2:56, n 49. Internal reliabilty on the monitoring subscale, using Cron-
bach's alpha, was a 0:78 (for the blunting subscale a 0:71). More information on the characteristics of the scale are to be found in Miro (1997b). The level of pain was assessed using numerical scales. In hospital, patients reported their pain level considering three different situations, standing, walking and while moving in bed, and at two different times: 24 and 72 h after surgery. At follow-up, they provided an overall estimation of the pain level. Numerical scales ranged from 0±100. The variable `analgesics' was treated as follows: two physicians, an anesthetist and a gynecologist, blind to subjects' group, rated each patients' use of analgesics relative to other patients in their experience who had the same or similar surgery. This scaling procedure (based on the type and dosage of analgesic medication, as well as the number of requests for medication) allows for differences in drug potencies and dosages which, as Wells et al. (1986) stress, `have been confounding variables in previous research works' (p. 832). Following the recommendation of Wells et al. (1986), the analgesic usage variable was formed by obtaining the linear combination of the standardized scores of the two judges. Scores were standardized to prevent scaling differences from biasing the mean calculations. Numerical scales were also used to assess the return to daily activities. Patients had to provide a number between 0 and 100 for their current activity level, compared with the activity level prior to surgery. They had to provide information concerning the activity level at home and outside of home, during their leisure time. This took place 15 days after surgery. At the same time, the extent to which the level of pain interfered with the execution of daily activities was assessed by means of a numerical scale (endpoints anchors: no activity and same activity level). As a measure of the adherence to the protocol, patients in the relaxation group were asked the number of times they had practiced the relaxation strategy before and after surgery (the assessments took place: the day prior to surgery and at follow-up), and how successful they were in their objective of calming down. They had to provide their answer using a numerical scale from 0±100 (endpoint anchors: no relaxation at all and completely relaxed). Patients' level of satisfaction with the psychological preparation received was evaluated with numerical scales ±101 possibilities ± by asking how satis®ed they were with the training in relaxation (relaxation training group), and how satis®ed they were with the work of the clinical psychologist (attention control group). Satisfaction with care in general was assessed with the following question: `in general, how do you feel you have been treated'? Patients' satisfaction with psychological preparation was assessed the day before surgery, whereas patients' satisfaction with general care was assessed at follow-up. Numerical scales were used, all ranging from 0±100 (endpoint anchors: no satis®ed at all and totally satis®ed). As another control measure, patients' spontaneous use of coping strategies was assessed. Stone and Neale's question-
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
naire was used (Stone and Neale, 1984). This was developed for use in longitudinal studies with repeated assessments. Nine coping categories comprise the most recent form of the questionnaire: distraction, situation rede®nition, direct action, catharsis, acceptance, seeking social support, relaxation, religion and looking for information. They were assessed three times: the day before surgery, 3 days after surgery and at follow-up. 2.3. Procedure Patients were randomly assigned to one of two groups; a random digits table was used to assign individuals to the groups. Individuals in one group were trained in relaxation while the second group of patients acted as an attention control group. One week before surgery, patients were individually interviewed and were trained in relaxation. Those patients in the `relaxation group' were trained in a relaxation strategy in which no references to bodily functions were made (e.g. focusing on the muscles' state of tension/relaxation). Instead, it was based on instructions of deep-breathing, and speci®c instructions were provided to teach patients relax (guided imagery was used so as to help patients deepen their relaxation state) (see Holden-Lund, 1988 for a complete and detailed description of a similar procedure). At the end of the session, these patients received speci®c instructions on how to practice relaxation at home, and detailed suggestions on how to do it were provided in the handout they received. The second group of patients acted as an attention control group. The amount of time spent with patients was used to focus on neutral topics such as the patient's job, family, interests, concerns, or whatever the patient began to discuss. Questions raised by the patient about the surgical procedure were described as matters appropriate for discussion with the surgeon. Subjects were allocated into the groups before any personal contact had taken place. All interviews and interventions were conducted individually by the same clinical psychologist, who was blind to patients' informational coping style. Regardless of the group, all patients spent, approximately, the same amount of time with the clinical psychologist. The preparation took around 30 min. Means and standard deviations for each group were as follows: relaxation, mean 29:9, SD 1:16; control: mean 28:5, SD 0:83. No statistical differences exist. During the pre-surgical interview with the clinical psychologist, and besides providing demographic and health-related information, patients answered the MBSS-S (MiroÂ, 1997b) (see Section 3). 3. Results The data analysis consisted of multivariate and univariate analyses of variance, in a 2 £ 2 factorial design, with two levels of coping style, and two levels of treatment. No differences were found in patients' satisfaction with
473
preparatory intervention and general care received. Similarly, no differences appeared when groups (relaxation vs. control) or individuals with different coping styles (high vs. low) were compared. 1 In this study, all patients practiced relaxation at home, both before and after surgery, and at least 76% of the time succeeded in their objective of calming down. Table 1 displays means and standard deviations of pain levels, the return to normal daily activities, analgesic use, and the level of interference of pain with patients' daily activities. The interaction effect between coping style and relaxation resulted in a Wilk's lambda 0:72 with P 0:46, thereby signaling that our relaxation training produced similar bene®ts in all our patients. In other words, monitoring coping style (high vs. low) does not seem to make any difference to relaxation outcomes. Even though the interaction effect was non-signi®cant, statistically signi®cant effects were observed after comparing trained and control individuals. The results were as follows: pain level at 24 h: standing, F 1; 89 42:25, P , 0:001; walking, F 1; 89 39:1, P , 0:001; moving in bed, F 1; 89 20:11, P , 0:01; pain level at72 h: standing, F 1; 89 29:67, P , 0:01; walking, F 1; 89 26:94, P , 0:01; moving in bed, F 1; 89 24:16, P , 0:02; pain level at follow-up; F 1; 88 52:13, P , 0:001; pain level on return to normal activities, at home F 1; 88 12:10, P , 0:06; pain level on return to normal activities, at leisure time, F 1; 88 34:75, P , 0:001; level of pain interfering with daily activities, F 1; 88 47:18, P , 0:001; analgesic usage, F 1; 87 10:15, P , 0:06. In summary, trained patients experienced lower pain levels, which seemed to interfere less with daily activities and reported to have returned to a higher activity level, at least during leisure time. No differences were with the variables, `return to normal activities at home' and `analgesic usage'. 4. Discussion The present study examined whether monitoring-style makes any difference to the bene®ts of a brief and economical intervention such as relaxation in the preparation of surgical patients. The hypothesis was not supported, but results demonstrated the utility of the procedure in psychologically preparing patients for surgery, and unlike most available 1 Due to the large number of analyses to be implemented (60 statistical tests listed in Table 4) it was necessary to lower the alpha level required for signi®cance in order to control Type I errors and to increase the con®dence that ®ndings identi®ed as signi®cant would be reliable. However a highly conservative approach, such as the Bonferroni, in which the chosen significance level is divided by the number of analyses to yield a P value so low (i.e. 0:05 4 60 0:0008) that it substantially increases the risk of Type II errors. Thus we elected to compromise between those two risks and chose a P value of 0.001 that must be reached in order for a particular ®nding to be deemed statistically signi®cant.
J. MiroÂ, R.M. Raich / Pain 83 (1999) 471±475
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Table 1 Mean and standard deviations of pain levels, the return to normal daily activities, analgesic use and pain interference with daily activities for high monitoring (HM) and low monitoring (LM) patients Variables
Relaxation
Control
HM 23 LM 23 HM 26 LM 20 Pain at 24 h Standing
Mean SD M SD Mean SD
3.00 1.48 5.36 2.92 4.81 2.63
2.27 1.90 2.90 1.37 4.23 3.94
5.63 2.20 7.27 3.10 6.63 2.01
6.54 a 1.03 a 8.18 a 1.16 6.90 b 1.04
Mean SD Mean SD Mean SD
3.41 2.95 4.90 3.36 4.81 3.28
3.06 2.75 3.27 2.32 4.18 2.27
5.81 2.08 7.54 1.75 7.00 1.41
5.81 b 0.75 5.90 b 1.30 6.36 1.69
Pain at follow-up Overall estimation Mean 3.72 SD 2.97
2.00 1.41
6.72 1.34
7.18 a 1.32
Return to normal daily activities Home Mean 44.54 SD 13.68 Leisure Mean 47.72 SD 20.78
50.54 10.14 52.27 17.08
37.00 20.00 11.81 8.44
38.63 9.51 30.00 a 13.78
1.00 0.73
1.95 0.60
1.75 0.96
65.45 13.68
62.27 a 13.48
Walking Moving in bed Pain at 72 hours Standing Walking Moving in bed
Analgesic use Analgesic
Mean 1.50 SD 0.80
Level of pain interfering with daily activities Pain interference Mean 35.45 32.72 SD 32.05 27.60 a b
P , 0:001. P , 0:01.
reports the ®ndings are based on studying relaxation alone. Patients who received training reported signi®cantly lower levels of pain. Their pain level also interfered signi®cantly less with their functioning; in fact, trained patients reported a higher activity level than controls. It is important to recall that no differences were found on the type of coping strategies these patients had spontaneously used. Our results do not support the claim that a distractionbased technique like relaxation is more appropriate for low monitors than for high monitors (Miller, 1992). On the other hand, they are in agreement with a body of literature showing the bene®ts induced by relaxation training as a strategy to cope with pain, be it of a surgical type (Holden-Lund, 1988), or of a chronic nature (Turk et al., 1983). Different researchers have suggested that distractionbased strategies are effective general coping strategies for acute stressors (Gattuso et al., 1992). Others have even suggested that the individual's coping style, and its effects,
is not as relevant in the surgical context as it may be in other contexts (Auerbach, 1989). Therefore, ®nding no support for the `interactive hypothesis' could not be as surprising as it might initially seem. In conclusion, the results of our investigation demonstrate the utility of relaxation in preparing patients for surgery, at least in terms of reducing patients' pain level, and increasing patients' activity level. Its effects do not seem to interact with patient's monitoring style. Relaxation is a cost-ef®cient technique. It does not require much time, expensive material, or resources, beyond those already available at most hospitals. Acknowledgements This research was supported by a grant from the Generalitat de Catalunya awarded to the ®rst author. Part of this work was done while Dr. Miro was a Visiting Scholar at New York University. References Auerbach SM. Stress management and coping research in the health care setting: an overview and methodological commentary. J Consult Clin Psychol 1989;57:388±395. Contrada RJ, Leventhal EA, Anderson JR. Psychological preparation for surgery: marshalling individual and social resources to optimize selfregulation. In: Maes S, Leventhal H, Johnston M, editors. International review of health psychology 3, New York: Wiley, 1994. pp. 219±266. Egbert LD, Battit GE, Turndorf H, Beecher HK. The value of the preoperative visit by an anesthetist. J Am Med Assoc 1963;185:553±555. Flaherty GG, Fitzpatrick JJ. Relaxation technique to increase comfort level of postoperative patients: a preliminary study. Nursing Res 1978;27:352±355. Fuller SS, Endress MP, Johnson JE. The effects of cognitive and behavioral control on coping with an aversive health examination. J Human Stress 1978;4:18±25. Gattuso SM, Litt MD, Fitzgerald TE. Coping with gastrointestinal endoscopy: self-ef®cacy enhancement and coping style. J Consult Clin Psychol 1992;60:133±139. Holden-Lund C. Effects of relaxation with guided imagery on surgical stress and wound healing. Res Nursing Health 1988;11:235±244. Janis IL. Psychological stress. Psychoanalitic and behavioral studies of surgical patients, New York: Wiley, 1958. Miller SM. Monitoring and blunting: validation of a questionnaire to assess styles of information seeking under threat. J Pers Social Psychol 1987;52:345±353. Miller SM. Individual differences in the coping process: what to know and when to know it. In: Carpenter B, editor. Personal coping: theory, research and application, Westport: Erlbaum, 1992. pp. 77±91. Miller SM, Mangan ChE. Interacting effects of information and coping style in adapting to gynecologic stress. should the doctor tell all? J Pers Social Psychol 1983;45:223±236. Miller SM, Brody DS, Summerton J. Styles of coping with threat: implications for health. J Pers Social Psychol 1988;54:142±148. Miro J. PreparacioÂn psicoloÂgica para intervenciones quiruÂrgicas: una revisioÂn selectiva (Psychological preparation for surgical interventions: a selective review). Revista de PsicologõÂa de la Salud/J Health Psychol 1997a;9:45±91. Miro J. Translation, validation, and adaptation of an instrument to assess the information seeking style of coping with stress: the Spanish version
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