The Effect of Psychosensory Therapy on Short-term Outcomes of Total Joint Arthroplasty: A Randomized Controlled Trial

• Updated on: 2019-07-03
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Feature Article 
The Effect of Psychosensory Therapy on Short-term Outcomes of Total Joint Arthroplasty: A Randomized Controlled Trial
Zlatan Cizmic, MD; Emmanuel Edusei, BS; Afshin A. Anoushiravani, MD; Joseph Zuckerman, MD; Ronald Ruden, MD; Ran Schwarzkopf, MD, MSc
Orthopedics.
Abstract
Abstract
Poor outcomes associated with increased perioperative opioid use have led investigators to seek alternative pain management modalities after total joint arthroplasty. Nonpharmacological approaches, such as electroceuticals, have shown promise. The purpose of this study was to evaluate the effects of “havening,” a specific form of psychosensory therapy, on postoperative pain scores and narcotic consumption. In this prospective, randomized controlled trial, the authors compared 19 patients who underwent psychosensory therapy with 22 patients who served as the control group. Visual analog scale scores were collected preoperatively, every day during the hospitalization, and at approximately 1-month follow-up. Narcotic consumption during hospitalization was converted into daily morphine milligram equivalents and compared between the cohorts. In addition, postoperative complications, emergency department visits, and readmissions were compared between the cohorts. No difference in visual analog scale pain scores was reported between cohorts on postoperative day 1 (P=.229), at discharge (P=.434), or at 1-month follow-up (P=.256). Furthermore, there was no significant variance in mean daily morphine milligram equivalents (P=.221), length of stay (P=.313), postoperative complications (P=.255), 90-day readmissions (P=.915), and emergency department visits (P=.46) between the cohorts. This study showed that psychosensory therapy was not effective in reducing pain or narcotic consumption following total joint arthroplasty. Nonetheless, future studies assessing the role of psychosensory therapeutic interventions among patients after total joint arthroplasty are warranted to better understand the clinical implications of innovative therapies aimed at alleviating pain. [Orthopedics. 201x; xx(x):xx–xx.]
Full Text
Abstract
Poor outcomes associated with increased perioperative opioid use have led investigators to seek alternative pain management modalities after total joint arthroplasty. Nonpharmacological approaches, such as electroceuticals, have shown promise. The purpose of this study was to evaluate the effects of “havening,” a specific form of psychosensory therapy, on postoperative pain scores and narcotic consumption. In this prospective, randomized controlled trial, the authors compared 19 patients who underwent psychosensory therapy with 22 patients who served as the control group. Visual analog scale scores were collected preoperatively, every day during the hospitalization, and at approximately 1-month follow-up. Narcotic consumption during hospitalization was converted into daily morphine milligram equivalents and compared between the cohorts. In addition, postoperative complications, emergency department visits, and readmissions were compared between the cohorts. No difference in visual analog scale pain scores was reported between cohorts on postoperative day 1 (P=.229), at discharge (P=.434), or at 1-month follow-up (P=.256). Furthermore, there was no significant variance in mean daily morphine milligram equivalents (P=.221), length of stay (P=.313), postoperative complications (P=.255), 90-day readmissions (P=.915), and emergency department visits (P=.46) between the cohorts. This study showed that psychosensory therapy was not effective in reducing pain or narcotic consumption following total joint arthroplasty. Nonetheless, future studies assessing the role of psychosensory therapeutic interventions among patients after total joint arthroplasty are warranted to better understand the clinical implications of innovative therapies aimed at alleviating pain. [Orthopedics. 201x; xx(x):xx–xx.]
Opioids are frequently used to manage acute pain after total joint arthroplasty (TJA); however, narcotics are frequently associated with adverse outcomes. 1 As a result of the increased morbidity associated with opioids, health care organizations have developed pathways to reduce narcotic consumption via a multimodal approach. 2–4 Despite the implementation of multimodal pain pathways, TJA candidates often require high narcotic doses for adequate pain control. This is particularly true among pain catastrophizers with a preoperative history of narcotic use, 5–9 often resulting in longer length of stay (LOS), higher risk for discharge, increased readmission rates, and suboptimal outcomes. 10–12
In response to the opioid epidemic, clinical psychologists and orthopedic surgeons have worked together to develop and study the effects of a new class of antinociceptive agents, known as electroceuticals. Electroceuticals can be broadly defined as stimulation of electrical waves that can alter the body's response. 13 Psychosensory therapy aims to provide soothing visual and soft-touch feedback to help control pain. The visual aspect induces a calm emotional state to condition the brain that the pursuing soft-touch protocol provides positive outcomes. In doing so, the implementation of psychosensory therapy uses the delta waves as anxiolytic and analgesic pathways to transition the thoughts of pain away from the patients' brains. 14,15
The purpose of this randomized controlled pilot trial was to use “havening,” a specific light-touch psychosensory therapeutic technique, to manage postoperative pain among TJA candidates. The aim of this study was to assess (1) whether electroceutical interventions reduce the inhospital narcotic burden while improving postoperative visual analog scale (VAS) pain scores and (2) if frequently evaluated quality metrics including hospital readmissions, reoperation, and emergency department (ED) visits decrease among patients who participate in electroceutical therapies. The authors hypothesized that TJA candidates who received psychosensory therapy would consume fewer narcotics and report superior VAS pain scores.
Materials and Methods
Study Design
The authors conducted a prospective, randomized controlled trial at an urban tertiary academic medical center. The study protocol and methodology were approved by the institutional review board, and written informed consent was obtained from all study participants. The sample size estimate was based on the VAS score. The authors defined an important between-group difference to be approximately 2 points. The power was set to 0.85, and the overall type I error probability was set at 0.05. Applying these assumptions yielded an approximate required sample of 36 subjects. To account for approximately 30% patient withdrawal, loss of follow-up, and cancellations, the authors expanded the sample size to 47 patients. Following written informed consent, 47 patients were enrolled. Only patients between the ages of 18 and 75 years undergoing elective, primary total hip or total knee arthroplasty (TKA) who were willing to participate in pre- and postoperative surveys were eligible. Patients with a history of TJA or a history of chronic narcotic use (≥30 morphine milligram equivalents) were excluded. Patients undergoing revision surgery or operative management following fracture (eg, hip fracture) were also excluded.
A total of 47 patients were enrolled in the study. Patients were randomized into 1 of 2 study cohorts by a trained research coordinator (E.E.) using Excel's random integer generator (Microsoft Corporation, Redmond, Washington). Group 1 served as the control cohort and used the same touch techniques as the havening group but counted backward from 50 to 1 while removing petals from a flower and performed the technique only in the preoperative holding room. Group 2 received a psychosensory havening technique for 10 minutes in the preoperative area and repeated the technique once a day while hospitalized. The havening technique consisted of the following protocol: (1) addressing the patients' current emotional difficulty using a word or phrase; (2) clearing their mind and thinking about something positive; (3) using both hands to tap on both collarbones while opening and closing their eyes twice; (4) continued tapping while keeping their head still and moving their eyes from side to side; (5) placing their arms across their chest with eyes closed and counting from 1 to 20; (6) gently rubbing the sides of their arms for the duration of counting; (7) repeating the procedure while humming “Happy Birthday” instead of counting; (8) stroking the sides of their arms 5 final times while repeating, “Let it go”; and (9) relaxing their arms to the side while opening their eyes and moving them in circles. 14,16
Twenty-four of the 47 patients were randomized to the psychosensory therapy cohort, while 23 patients were randomized to the control group. One patient from the control group was withdrawn from the study because of surgical cancellation. Five patients from the psychosensory treatment group did not repeat the havening technique after surgery and were excluded from the study. The total number of patients in the psychosensory treatment and control groups was 19 and 22, respectively.
Study Outcomes
Visual analog scale pain scores (0=none, 10=severe) were completed by the patient preoperatively, each day of hospitalization until discharge, and at 1-month follow-up. The total hospital LOS and pain medication consumption were retrospectively assessed via the electronic medical record. The total amount of opioid consumption during patients' hospital stay was converted into morphine milligram equivalents using a validated opioid calculator. 17
Statistical Analysis
All patient variables were reported using a combination of descriptive statistics, including means, standard deviations, absolute counts, and percentages. Comparative analyses of independent continuous variables were conducted using a 2-tailed unpaired t test and a binomial linear regression model for race and American Society of Anesthesiologists score. Categorical variables were analyzed using chi-square test for comparisons involving more than 2 groups. The relationship of all independent variables to all outcomes was determined using a simple linear regression analysis. Sex, race, age, procedure, treatment group, body mass index, and American Society of Anesthesiologists score were controlled for using a multivariable regression analysis. P<.05 was considered statistically significant. Statistical analyses were performed using SPSS version 23.0 software (IBM Corporation, Armonk, New York).
Results
Patient Demographics
A total of 41 patients were included in the analysis, of whom 19 (46.3%) were assigned to the psychosensory treatment group and 22 (53.7%) were assigned to the control group. No statistically significant variance was found regarding patient demographics, including age, sex, procedure type, body mass index, race, and American Society of Anesthesiologists score ( Table ).
Table:
Patient Demographics
Pain
The mean VAS pain scores were not found to be significantly different on postoperative day 1. Visual analog scale pain scores were significantly higher in the psychosensory group at the time of discharge; however, at 1-month follow-up, psychosensory VAS pain scores had improved, while the control cohort experienced significantly higher VAS pain scores. On postoperative day 1, the mean VAS pain score was 4 and 3 for the psychosensory and control groups, respectively (P=.709). On discharge, the mean VAS pain score had increased to 4.63 and 4.36 for the psychosensory and control cohorts, respectively (P=.025). Moreover, at 1-month follow-up, the VAS pain score had improved to 2.59 for the psychosensory group, while the VAS pain score remained significantly higher at 3.27 for the control group (P=.043). However, after controlling for sex, race, procedure, age, body mass index, and American Society of Anesthesiologists score, VAS pain scores were not found to be significantly different between the 2 groups on postoperative day 1 (P=.229), at discharge (P=.434), and at 1-month follow-up (P=.256).
Narcotic Consumption
Additionally, the mean amount of narcotics consumed per day during the hospitalization did not vary substantially between the study groups. Patients who underwent psychosensory therapy consumed 17.46±9.32 morphine milligram equivalents daily, while the control group consumed 13.48±8.06 morphine milligram equivalents daily (P=.221).
Length of Stay
The mean LOS was not significantly different between the psychosensory cohort and the control cohort. Patients who performed psychosensory therapy stayed a mean of 2.5±1.7 days, while the control group stayed a mean of 3.0±2.7 days (P=.313).
Complications
Two patients experienced complications following TJA. One patient from the control group reported continued stiffness after TKA, which required manipulation under anesthesia 3 months after index surgery. One patient from the psychosensory therapy group experienced superficial wound dehiscence 1 month after surgery. The patient did not respond to oral antibiotic treatment and required irrigation and debridement 2 months after the index TKA. No significant difference was found in rates of postoperative complications between the groups (P=.255).
Emergency Department Visits
Three patients visited the ED: 2 from the psychosensory therapy group and 1 from the control group. One of the patients who received psychosensory therapy went to the ED for drainage and redness surrounding the surgical wound 2 months after initial surgery. The other went to the ED for dyspnea and upper back spasms. The patient from the control group went to the ED 3 months after the index procedure for continued stiffness of the knee. No significant difference was noted between patients who visited the ED following TJA (P=.46).
Readmissions
Only 1 patient was readmitted within 90 days of TJA. This patient, in the psychosensory therapy group, was readmitted 2 months after index TKA for a superficial wound dehiscence that failed to respond to oral antibiotic treatment and was successfully managed with irrigation and debridement. No statistical significance was noted in 90-day readmissions (P=.915).
Discussion
Significant perioperative pain following TJA can adversely influence outcomes, leading to increased risk of complications, LOS, and cost. 1 The relationship between emotional disorders and their effects on pain following TJA has emerged as a growing area of study. The purpose of this study was to evaluate the association between psychosensory therapy and pain and narcotic consumption after TJA.
In this study, there was no difference in VAS pain scores on postoperative day 1 between patients who received psychosensory therapy and those who did not. Although initial analysis found a difference in VAS pain scores at the time of discharge and at 1-month follow-up, these results did not continue after controlling for other factors. Furthermore, there was no difference in the in-hospital mean narcotic consumption nor LOS between the 2 cohorts.
Presurgical affective symptoms, such as depression, anxiety, or catastrophizing behaviors, have been associated as risk factors for postsurgical pain. 18,19 It has been suggested that patients should be screened for pain catastrophizing behavior, depression, and anxiety risk factors, as such patients may benefit from psychological therapy prior to surgery to help mitigate their pain and dissatisfaction following TJA. 20 Patient empowerment sessions and relaxation interventions have been correlated with a significantly increased wellness state of patients. 21 The use of stress biomarkers during empowerment sessions may serve as feedback or references to enhance operative outcomes. 21,22 Psychosensory therapy works in a neuro-physiological manner to increase global serotonin levels and help treat phobic or anxious patients. 15 Previous studies have found the havening technique to be beneficial for phobic and anxious dental patients and that it may produce positive effects in a similar subset of patients undergoing TJA. 23
Although opioids have been the historical norm for controlling pain, the associated negative outcomes have shifted management toward multimodal pain protocols and reduced opioid consumption. 5,10 Drug-free interventions have been studied for their ability to reduce pain or opioid consumption after TJA. Li and Song 24 found significantly decreased pain and opioid consumption after TKA with the use of transcutaneous electrical nerve stimulation. Furthermore, they found that patients who received transcutaneous electrical nerve stimulation experienced fewer adverse effects following surgery. 24 Other studies 25,26 have reported that electrotherapy reduces pain severity for up to 6 months following TKA and that acupuncture is the most beneficial drug-free therapy to reduce early pain; however, it is less effective long term. Moreover, acupuncture and electrotherapy have been associated with reduced opioid consumption. 25,26 Psychosensory therapy uses sensory stimulation to involve a conditioning stimulus and unconditioned stimulus in the prefrontal cortex and amygdala. 15 Although the current study did not find differences in pain levels or narcotic consumption following TJA, patients were not stratified by risk factors for affective symptoms, which may have influenced the level of patient response to psychosensory therapy. Moreover, although the LOS was not statistically significant, the decreased time in hospital and associated costs can be considered clinically significant. The decreased LOS may be attributed to improved function after TKA, which is similar to the results of Cai et al. 27
Limitations
This study had several limitations. First, this study had a small sample. However, on the basis of previous VAS pain scores, the authors used a power analysis of 0.85 to justify the low scores. The small sample may have been confounded by the fact that patients were not stratified based on mental health risk factors, such as anxiety, pain catastrophizing, and kinesiophobia, as the patient subgroup with mood disorders has been shown to be at an increased risk for suboptimal outcomes, including increased postoperative pain. Additionally, although this study comparatively evaluated various outcomes, including morphine milligram equivalents, and various quality metrics (eg, LOS, complications, ED visits, and hospital readmissions), it was not powered to assess differences between these secondary endpoints. Another limitation was a lack of means to record patient adherence with psychosensory interventions. Patients subjectively reported the number of times and actual time spent participating in psychosensory therapy after surgery in an adherence log and were called after surgery to record their participation. However, the number of times or actual time spent doing the havening technique may have been overestimated. Despite these limitations, this is the only prospective study assessing the role of psychosensory therapy for TJA recipients.
Recommendations
Although the authors did not find perioperative psychosensory therapy to be effective in the TJA patients, the study was not adequately powered to assess the efficacy of psychosensory therapy for patients with anxiety, kinesiophobia, mood disorders, or pain catastrophizing. Klement et al 28 reported that 20% of TJA patients have preexisting behavioral issues that require a multidisciplinary approach including psychiatric evaluation, psychosocial support, and coping skills training. One study suggested a multi-component protocol consisting of counselors for support, education, and coping skills training to address anxiety, pain management, and depression. 29 Patients with psychiatric disorders often experience the best results when treated with medication in combination with psychotherapy. Cognitive-behavioral therapy is a form of psychotherapy that uses behavior modification to help control patients' thoughts and redirect them toward positive thinking. The use of cognitive-behavioral therapy has been suggested to allow better control of anxiety around surgery and anesthesia. 30 Cai et al 27 applied 1 of 4 individually tailored 4-week cognitive-behavioral therapy protocols to high-risk pain catastrophizers undergoing TKA. They found that the patients who underwent 1 of the cognitive-behavioral therapy protocols had significantly reduced pain, kinesiophobia, and pain catastrophizing. Furthermore, patients who underwent cognitive-behavioral therapy exhibited increased knee function. The havening technique is a form of psycho-sensory therapy that uses a combination of touch and behavior modification to exchange negative perceptions with positive thoughts. Havening has proven successful for anxious patients undergoing dental procedures and could provide comparable results as part of a multicomponent treatment protocol for similar patients undergoing TJA.
Conclusion
Although psychosensory therapy was not shown to be effective in reducing pain or narcotic consumption in this pilot study, its effects on patients with mood disorders remain unknown. The havening technique may have a part in the coping strategies of multicomponent treatment protocols for patients with mood disorders (eg, depression, anxiety, catastrophizing). Further studies investigating the role of psychosensory therapy among TJA candidates with mood disorders are necessary.
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