The effects of relaxation before or after skin damage on skin barrier recovery

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Chapter 3: The effects of psychological interventions on wound healing: A systematic review of randomised trials

Preface
Rationale for experimental research: Systematic review

As described in Chapter 2, the direct effects of stress on the neuroendocrine pathways can influence wound healing. In addition, other negative psychological factors, such as anger, depression, and loneliness may also activate these pathways causing impaired wound healing. Finally, wound healing can be affected by physiological process such as pain and sleep that serve to exacerbate or delay wound healing both directly and indirectly by amplifying stress or stress related behaviours. As of yet there is very little research that has looked at whether psychological interventions to improve psychological states can improve wound healing.
Research indicates that psychological interventions to improve physical health outcomes help by improving mood and facilitating adaptive coping strategies for distressful thoughts and events. These are broadly categorized below as stress reduction interventions, cognitive restructuring interventions and interventions to alter perceptions or expectations.
Stress reduction techniques include relaxation exercises, which includes deep breathing exercises, muscle relaxation, guided imagery, mindfulness meditation (mediation focusing on abdominal breathing and accepting in a non-judgemental way distracting cognitions), and gentle stretching exercises, such as yoga or tai chi, that focus on breathing and reducing muscle tension. Experimental research indicates that relaxation interventions can decrease salivary cortisol levels and perceived stress (Kamei et al., 2000; Lucini et al., 1997; Pawlow & Jones, 2005; Smith, Hancock, Blake-Mortimer & Eckert, 2007; Zachariae et al., 1990). As well as decreasing cortisol levels, relaxation interventions have been shown to reduce pain and improve recovery after surgery (Good, Anderson, Ahn, Cong & Stanton‐Hicks, 2005; Roykulcharoen & Good, 2004), and improve sleep latency and sleep duration (Kim & Kim, 2005; Wright, Wright, Courtney & Crowther, 2002), both factors known to influence wound healing.
Psychological interventions that focus on cognitive restructuring through thought identification and replacement have been found to have both immunological and psychological effects. For example, cognitive behavioural stress management programmes that aim to not only teach relaxation skills but also target thought patterns have been found to reduce cortisol levels, anxiety and mood disturbances (Cruess, Antoni, Kumar & Schneiderman, 2000; Phillips et al., 2008). Similarly expressive writing helps process upsetting thoughts around a stressful event, resulting in decreased distress, improved mood and decreased rumination (Pennebaker, 1997). This is because suppression of emotional thoughts has been shown to increase autonomic system arousal (Gross & Levenson, 1993) and keeping emotions contained over an extended period of time can compromise immune competence and lead to poor physical health (Pennebaker, 1989; Temoshok, 1986). Expressive writing has been linked to improvements in immune functioning (Booth, Petrie & Pennebaker, 1997; Esterling, Antoni, Fletcher, Marguiles & Schneiderman, 1994) and decreases in cortisol (Smyth, Hockemeyer & Tulloch, 2008). Furthermore, like other psychological interventions expressive writing has been linked to decreased pain and better mood (Francis & Pennebaker, 1992; Greenberg & Stone, 1992), as well as improved sleep (Arigo & Smyth, 2012; Gillis, Lumley, Mosley-Williams, Leisen & Roehrs, 2006).
Finally psychological techniques to alter perceptions or expectations about the procedure and/or recovery, particularly for patients undergoing a surgical or a medical procedure can be useful. Distraction techniques help to minimize perceptions of fear and discomfort leading to less anxiety during the procedure and recovery and less pain. Distraction techniques such as music, audio visual devices, toys and video games are often employed in paediatric settings (Arts et al., 1994; Vessey, Carlson & McGill, 1994) but are also useful in other setting. For example, audio visual devices are often used during dental procedures to reduce anxiety and pain that shortens the procedure time (Frere, Crout, Yorty & McNeil, 2001). Similarly, in burns patients, watching a distracting video during dressing changes reduces pain and anxiety (Miller, Hickman & Lemasters, 1992).
Similar to distraction interventions, placebo effects and hypnosis strategies both aim to alter expectations about pain and anxiety by using suggestion. Research has found that placebos can diminish pain perception (Colloca & Benedetti, 2005; Montgomery & Kirsch, 1996), illustrating how the brain plays a role in providing external, top-down control that modulates physiological outcomes. Similarly patients under hypnosis report significantly less pain during medical procedures and recovery (Patterson, Everett, Burns & Marvin, 1992; Syrjala, Cummings & Donaldson, 1992). Research has found that hypnosis and placebo can alter neuroendocrine reactivity (Colloca & Benedetti, 2007; Wood et al., 2003), implying that changes in perceptions and expectation promote psychological well-being that is translated into reduced physiological reactivity leading to improvements in immunological functioning (Gruzelier, Smith, Nagy & Henderson, 1997; Neumann, 2005; Ruzyla-Smith, Barabasz, Barabas &, Warner, 1995).
At present there has been no review conducted collating the literature to date that has explored the potential benefits of psychological interventions on wound healing specifically. However, surgical recovery has been extensively researched. A meta-analysis conducted by Devine (1992) included 191 studies that used psychosocial interventions with surgical patients on other surgical outcomes. These interventions could be categorised as healthcare education (details about what to expect before and after surgery and explanation of surgical procedures), teaching of skills (such as relaxation, exercises and breathing) or psychosocial support (providing reassurance, listening to patient concerns). Specifically, almost 80% of the studies indicated a positive benefit as a result of intervention and length of stay was decreased on average by 1.5 days. Similarly, Johnston and Vögele (1993) conducted a meta-analysis with 38 studies, which examined the effects of procedural information, relaxation, hypnosis and emotion focused approaches on surgical outcomes. The results found that the strongest evidence existed for procedural information and relaxation interventions, with benefits in various outcomes including pain, length of stay, mood and clinical indicators of recovery. Although some of these interventions are quite different, making it hard to determine mechanisms behind their effect, they show that psychological and physical outcomes are linked. Another recent review conducted by Nelson et al. (2013) focused primarily on interventions that have been found to be useful for surgical patients including relaxation, mindfulness, hypnosis and guided imagery. They found that of the 20 studies investigated there was strong evidence for improvements in psychological well-being as a result of relaxation interventions, while only partial evidence supporting hypnosis. A common limitation noted in previous literature reviews has been the quality of studies included in each review and this should be taken into account in the conclusions.

Chapter 1: Overview 
Chapter 2: Introduction: Psychological factors and wound healing 
Overview
The stress response
Impact of stress hormones on the immune system and healin
Experimental research examining the link between stress and wound healing
Methods of assessing wound healing
Wound healing in clinical settings
Stress and wound healing summary of literature
Other psychological factors influencing wound healing
Depression
Anger and hostility
Positive affect and optimism
Social isolation and loneliness
Interactions between psychological and physiological factors that influence healing
Pain
Sleep
Indirect effects of stress and health behaviours
Summary and conclusions
Chapter 3: The effects of psychological interventions on wound healing: A systematic review of randomised trials
Preface
Rationale for experimental research: Systematic review
Aims
Citation
Abstract
Introduction
Methods
Eligibility
Search strategy
Study selection
Effect size
Quality assessment and publication bias
Results
Study selection
Study characteristics
Quality assessment of studies
Publication bias
Study outcomes
Discussion
Conclusions
Chapter 4: The effects of relaxation before or after skin damage on skin barrier recovery: A preliminary study
Preface
Aims
Citation
Abstract
Introduction
Methods
Sample
Procedure
Relaxation intervention
Measures
Data analysis
Results
Demographics
Effects of relaxation on skin barrier recovery
Self-rated relaxation
Self-rated pain
Discussion
Chapter 5: Role of sleep in skin permeability barrier recovery after disruption by tape stripping 
Preface
Rationale
Aims
Citation
Abstract
Introduction
Methods
Sample
Procedure
Results
Recovery after tape stripping
Discussion
Chapter 6: The effects of expressive writing before or after punch biopsy on wound healing 
Preface
Rationale
Aims
Citation
Abstract
Introduction
Methods
Sample recruitment
Procedure
Expressive writing intervention
Measures
Wound healing assessment
Data analysis
Results
Participant attrition and baseline characteristics
Manipulation check
Primary outcome: Wound re-epithelialisation
The effects of writing before or after wounding on stress and affect
Post hoc analyses
Discussion
Conclusions
Chapter 7: Expressive writing influences wound healing: Preliminary immunohistochemistry analysis of skin tissue two weeks after punch biopsy wounding. 
Preface
Rationale
Aims
Citation
Abstract
Introduction
Methods
Sample
Procedure
Expressive writing intervention
Measures
Data analysis
Results
Baseline Characteristics
Manipulation check
Primary outcome: Immunohistochemistry results
Discussion
Chapter 8: The role of social closeness during tape stripping to facilitate skin barrier recovery: Preliminary findings
Preface
Rationale
Aims
Citation
Abstract
Introduction
Methods
Sample
Procedure
Relationship Induction Closeness Task (RCIT)
Measures
Data analysis
Results
Demographics
Social closeness
Effects of social closeness on skin barrier recovery
Effects of social closeness on self-reported stress
Moderation effects on skin barrier recovery
Salivary cortisol
Salivary alpha-amylase
Discussion
Conclusions
Chapter 9: Discussion
Summary of key findings
Integration into current literature
Relaxation
Sleep
Expressive writing
Social support
Clinical implications
Limitations and areas for future research
Conclusions
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The Impact of Psychological Interventions onWound Healing