Expressive writing and wound healing in older adults: a randomized controlled trial

Malignant wound aetiology, diagnosis and management: a case series and literature review

OBJECTIVE

Malignant wounds develop when neoplastic cells invade the skin either locally or by lymphatic and haematogenous spread. They can present as hard-to-heal wounds and underlying causes include: primary skin cancer; metastasis of extracutaneous primary malignancy; malignant transformation of a hard-to-heal wound; iatrogenic injury; and cutaneous forms of cancers of non-skin origin. High clinical suspicion for a malignant wound should be confirmed with skin biopsy. The aim of this case series is to highlight a combination of both clinically clear cutaneous malignancies and not-so-obvious wounds caused by malignancy.

METHOD

This case series examines patients with malignant wounds of varying aetiology and appearance. For each case, we explain the pathophysiology, atypical features, diagnostic approach and treatment. We also discuss types of wound biopsy and general wound management principles.

RESULTS

Among the 11 cases analysed using descriptive statistics, median wound duration before presentation at our clinic was one year, while median age at presentation was 65 years. Our case series included the following diagnoses: cutaneous metastasis of invasive ductal carcinoma of the breast (n=2); cutaneous metastasis of colorectal adenocarcinoma (n=1); Marjolin's ulcer (n=1), basal cell carcinoma (BCC) (n=2), primary cutaneous squamous cell carcinoma (SCC) (n=1), metastatic malignant melanoma (n=1), cutaneous T-cell lymphoma (n=1), cutaneous angiosarcoma (n=1), Kaposi sarcoma (n=1) and recurrent tonsillar SCC with osteoradionecrosis (n=1); one case had both BCC and SCC.

CONCLUSION

Punch and excisional biopsies were the most frequently used diagnostic techniques. Local wound therapy addressed bleeding, malodour, exudate, pain and infection. However, wound healing is usually achieved once the underlying malignancy is treated. In advanced or metastatic disease, palliative wound care aims to prevent exacerbation of existing wounds and focuses on patient comfort.

Sleep, Fatigue, and Inflammatory Biomarkers in Older Adults with Chronic Venous Leg Ulcers Receiving Intensive Outpatient Wound Care

Objective: Chronic venous ulcers are a relatively common and distressing condition that disproportionately affects older individuals. Along with multiple concomitant issues such as wound drainage, pain, and mobility impairments, individuals with chronic venous leg ulcers (CVLUs) commonly report sleep disturbances and fatigue; however, limited research has examined these symptoms in relation to inflammatory biomarkers in this population over the intensive wound care treatment trajectory. This study aimed at describing the symptoms of sleep and fatigue in older adults with CVLUs receiving intensive wound treatment with weekly debridement and exploring the relationships between these symptoms and tumor necrosis factor-alpha (TNF-α), c-reactive protein (CRP), and interleukin (IL)-6. Approach: Demographics, clinical characteristics, Pittsburgh Sleep Quality Index (PSQI) scores, Brief Fatigue Inventory (BFI), TNF-α, CRP, and IL-6 levels were collected from 84 older adults with CVLUs at three time points (baseline, week 4, and week 8). Data analysis included descriptive statistics and Bayesian estimation of associations. Results: Findings showed a consistent pattern of poor sleep quality and mild fatigue among these individuals. Lower IL-6 levels at week 4 and higher CRP levels at week 8 were linked to poor sleep quality. Higher CRP levels were linked to greater fatigue at baseline and week 8. Sleep and fatigue were correlated at all time points. Innovation and Conclusion: This study highlights the importance of clinicians evaluating sleep and fatigue in those with CVLUs. Further research is needed to validate circulating inflammatory biomarkers to enhance our understanding of sleep and fatigue's role in wound healing.

The effect of expressive writing on wound healing: Immunohistochemistry analysis of skin tissue two weeks after punch biopsy wounding

OBJECTIVE

To investigate the effects of expressive writing and its timing (pre or post wounding) on re-epithelialisation and leucocyte subsets within healing tissue. We previously showed expressive writing pre-wounding improved re-epithelialisation. Here we investigate cellular processes in the wound.

METHODS

In a 2(writing content) x 2(writing timing) randomized trial, 122 participants were randomized to perform either expressive or control writing, before or after a 4 mm punch biopsy wound. On day 14 post-wounding, participants had a 5 mm punch biopsy of the initial wound. Seven of 16 primary registered outcomes were analysed, including re-epithelialisation from two photographs of the 4 mm biopsy (previously reported). This paper reports immunohistochemistry analysis of five primary outcomes - Langerhans cells, immune cell activation (HLA and CD3+), and macrophages (CD68 and MPO) - in the 5 mm biopsies in a random sample of 96 participants.

RESULTS

Participants who performed either writing task pre-wounding had greater Langerhans cell infiltration, than those who wrote post-wounding (F_(1,85) = 7.86, p = .006, η_p² = 0.08). Those who performed expressive writing also had greater Langerhans cell infiltration than those who performed control writing (F_(1,85) = 4.00, p = .049, η_p² = 0.04). There were no significant group or interaction effects on immune cell activation or macrophages. Healed wounds on day 10 had lower levels of macrophages (z = -1.96, p = .050), and CD3+ cells (z = -1.99, p = .046) than non-healed wounds.

CONCLUSION

Langerhans cells in the healing skin are affected by the timing and topic of writing. More research is needed to further explore timing and corroborate these results.

CLINICAL TRIALS REGISTRATION

Registered at https://www.anzctr.org.au/ (Trial ID: ACTRN12614000971639).

Holistic Psychosocial Approaches in the Care of Hispanic Victims of Trauma: An Overview

The collapse of the Champlain Towers South (CTS), a condominium in Miami, Florida, left a diverse group of survivors and healthcare clinicians tasked with finding ways of coping with the disaster. Within seconds, the CTS collapse became a global tragedy due to the coastal neighborhood's rich international mix of residents. Although this tragedy impacted communities across globe, a large population of Hispanic victims lived in CTS that were deeply affected. Culturally adaptive interventions and holistic healthcare for Hispanic individuals are highly relevant because Hispanic Americans represent one of the fastest growing demographic groups in the United States. To reach, engage, and address the needs of Hispanic victims, this article provides an overview of psychosocial factors that influence Hispanic victims with trauma and discusses holistic psychotherapeutic approaches in nursing care that can be applied to improve victims' well-being. Culture is an important consideration in health; therefore, this article highlights and operationalizes culturally tailored holistic nursing care that draws from the physical, mental, emotional, and spiritual dimensions of health and well-being that can be used in clinical settings with Hispanic clients who have experienced trauma.

I Let Depression and Anxiety Drown Me: Identifying Factors Associated with Resilience Based on Journaling using Machine Learning and Thematic Analysis

Over the years, there has been a global increase in the use of technology to deliver interventions for health and wellness, such as improving peoples mental health and resilience. An example of such technology is the Q-Life app which aims to improve peoples resilience to stress and adverse life events through various coping mechanisms, including journaling. Using a combination of sentiment and thematic analysis, this paper presents the results of analyzing 6023 journal entries from 755 users. We uncover both positive and negative factors that are associated with resilience. First, we apply two lexicon-based and eight machine learning (ML) techniques to classify journal entries into positive or negative sentiment polarity, and then compare the performance of these classifiers to determine the best performing classifier overall. Our results show that Support Vector Machine (SVM) is the best classifier overall, outperforming other ML classifiers and lexicon-based classifiers with a high F1-score of 89.7%. Second, we conduct thematic analysis of negative and positive journal entries to identify themes representing factors associated with resilience either negatively or positively, and to determine various coping mechanisms. Our findings reveal 14 negative themes such as stress, worry, loneliness, lack of motivation, sickness, relationship issues, as well as depression and anxiety. Also, 13 positive themes emerged including self-efficacy, gratitude, socialization, progression, relaxation, and physical activity. Seven (7) coping mechanisms are also identified including time management, quality sleep, and mindfulness. Finally, we reflect on our findings and suggest technological interventions that address the negative factors to promote resilience.

The Effects of Sensory Enrichment After a Laboratory Stressor on Human Skin Barrier Recovery in a Randomized Trial

OBJECTIVE

Environmental enrichment (EE) can reduce stress, alter immunity, and speed wound healing in animals. However, it is not known whether these effects translate to humans. This study aimed to investigate whether sensory EE could improve wound healing after a stressor in humans.

METHODS

A total of 105 participants underwent a tape-stripping procedure and were then stressed using a laboratory stress paradigm. After this, they were randomized to interact for 30 minutes with one of two possible sensory EE interventions (music as auditory enrichment or a Paro robot as multisensory enrichment) or to a control condition. Skin barrier recovery was measured using transepidermal water loss at baseline, after the stressor, and after the intervention. Stress was measured using self-report, heart rate, blood pressure, and salivary stress-related biological measures. Enjoyment during the intervention was measured by self-report as a possible mediator.

RESULTS

The Paro condition had significantly improved skin barrier recovery (mean [M] = 44%, standard error [SE] = 1.92) compared with the control condition (M = 37% SE = 2.01, F(2,88) = 3.25, p = .043), both with and without controlling for covariates. The music condition did not significantly differ from the other conditions (M = 42%, SE = 1.95, p values > .05). Both objective and subjective stress measures did not significantly differ between conditions. Mediational analysis showed that enjoyment levels during the intervention period significantly mediated the relationship between condition and skin barrier recovery (z = 2.00, p = .046).

CONCLUSIONS

Paro, or other companion robots, may be an effective form of enrichment to improve skin barrier recovery in humans after a laboratory stressor, and this effect may be due to enjoyment. Further research with patient groups is required to investigate whether Paro can help heal clinical wounds.

TRIAL REGISTRATION

ACTRN12618000953235, registered at https://anzctr.org.au.

Enhancing sleep quality for nursing home residents with dementia: a pragmatic randomized controlled trial of an evidence-based frontline huddling program

Background

Disturbed sleep places older adults at higher risk for frailty, morbidity, and even mortality. Yet, nursing home routines frequently disturb residents’ sleep through use of noise, light, or efforts to reduce incontinence. Nursing home residents with Alzheimer’s disease and or related dementias—almost two-thirds of long-stay nursing home residents—are likely to be particularly affected by sleep disturbance. Addressing these issues, this study protocol implements an evidence-based intervention to improve sleep: a nursing home frontline staff huddling program known as LOCK. The LOCK program is derived from evidence supporting strengths-based learning, systematic observation, relationship-based teamwork, and efficiency.

Methods

This study protocol outlines a NIH Stage III, real-world hybrid efficacy-effectiveness pragmatic trial of the LOCK sleep intervention. Over two phases, in a total of 27 non-VA nursing homes from 3 corporations, the study will (1) refine the LOCK program to focus on sleep for residents with dementia, (2) test the impact of the LOCK sleep intervention for nursing home residents with dementia, and (3) evaluate the intervention’s sustainability. Phase 1 (1 year; n = 3 nursing homes; 1 per corporation) will refine the intervention and train-the-trainer protocol and pilot-tests all study methods. Phase 2 (4 years; n = 24 nursing homes; 8 per corporation) will use the refined intervention to conduct a wedge-design randomized, controlled, clinical trial. Phase 2 results will measure the LOCK sleep intervention’s impact on sleep (primary outcome) and on psychotropic medication use, pain and analgesic medication use, and activities of daily living decline (secondary outcomes). Findings will point to inter-facility variation in the program’s implementation and sustainability.

Discussion

This is the first study to our knowledge that applies a dementia sleep intervention to systematically address known barriers to nursing home quality improvement efforts. This innovative study has future potential to address clinical issues beyond sleep (safety, infection control) and expand to other settings (assisted living, inpatient mental health). The study’s strong team, careful consideration of design challenges, and resulting rigorous, pragmatic approach will ensure success of this promising intervention for nursing home residents with dementia.

Trial registration

NCT04533815, ClinicalTrials.gov, August 20, 2020. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02189-8.

Emotional approach coping in older adults as predictor of physical and mental health

Emotional approach coping involves active attempts at emotional expression and processing in response to stressful circumstances. This study tested whether dispositional emotional approach coping processes predict changes in physical and mental health in community-dwelling older adults, particularly within the context of higher perceived stress. To test this, older adults (N = 150) completed assessments of emotional expression and emotional processing at study entry. They also completed measures of perceived stress, depressive symptoms, and ill-health (a composite of subjective and objective physical health indicators, which included blood draw for collection of biomarkers), every 6 months over 4.5 years. Emotional processing and emotional expression were not related significantly to ill-health at study entry. However, emotional processing (but not emotional expression) significantly predicted changes in ill-health. At higher levels of emotional processing, ill-health remained low and stable; at lower levels of emotional processing, ill-health increased over time. However, when perceived stress was high, higher emotional processing and emotional expression were related to lower depressive symptoms at study entry, but higher emotional processing was associated with increasing depressive symptoms over time. Emotional approach coping processes evidence prospective relations with health outcomes, which are partially conditioned by stress perceptions. Emotional processing appears to have a protective impact against declining physical health. Predictive relationships for depressive symptoms are more complex. Older adults with chronically high perceived stress might benefit from interventions that target emotion-regulating coping processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Health Care Practitioners and Families Writing Together: The Three-Minute Mental Makeover

INTRODUCTION

Expressive writing, the process of self-expression through writing, appears to have beneficial effects. Our hospital's narrative medicine group developed an expressive writing tool, the Three-Minute Mental Makeover (3MMM).

OBJECTIVE

To evaluate the effectiveness of the 3MMM to reduce stress and optimize communication between health care practitioners and their patients/families.

METHODS

Patients and families were recruited from a Chicago-area children's hospital from December 2016 through July 2017, from the neonatal intensive care unit, pediatric intensive care unit, inpatient pediatric unit, and outpatient pediatric clinics. Health care practitioners included a pediatric cardiologist, pediatric residents, child development specialists, and pediatric nurses. Practitioner and patient family participants completed prestudy and poststudy surveys to assess perceived stress and communication levels. Using a standardized script, practitioners led the 3MMM activity, writing concurrently with patients/families. Participants then shared their responses. Presurvey and postsurvey data were compared using nonparametric tests.

RESULTS

Eight practitioners led 96 patient/family members in 3MMM activities and study surveys. At baseline, all patients, family members, and practitioners reported experiencing 1 or more symptoms of stress. After participating in the 3MMM, patients/family members and practitioners reported reduced stress compared with baseline (p < 0.001). A significant improvement in communication was reported by practitioners (p < 0.001). Eighty-eight percent of patients/families reported that the 3MMM activity was helpful, even though only 35% had used writing or journaling in the past.

CONCLUSION

The 3MMM is a short writing exercise that reduces stress for practitioners, patients, and families. Future studies may help determine long-term effects of the 3MMM.

Open-label Placebos for Wound Healing: A Randomized Controlled Trial

Background

Open-label placebos are a novel treatment option, in which participants take placebos with full knowledge that they do not contain active medicine. Open-label placebo treatments have been shown to result in patient-reported symptom improvements, but they have not been tested on objectively measurable physiological outcomes such as wound healing.

Purpose

The current study aimed to determine whether open-label placebos improved wound healing in punch biopsy wounds compared with no treatment.

Methods

In a randomized controlled trial, 70 participants (mean age 27.6 ± 10.1, 58 female) were provided with information about the beneficial effects of placebos and given a 4 mm punch biopsy wound. Participants were then randomized to either an open-label placebo intervention (two placebo tablets twice a day for 10 days) or a no-treatment control group. Wounds were photographed at 7 days and 10 days to determine reepithelialization of the wound surface.

Results

No significant differences were observed between the open-label placebo and control conditions in the percentage of wound area healed or for the number of participants with fully reepithelialized wounds at 7 days (placebo 7/32 wounds healed, control 10/33 wounds healed, (χ2[1, N = 65] = 0.60, p = .440, φ = 0.10) and 10 days after wounding (placebo 17/32, control 25/33 wounds healed (χ2[1, N = 65] = 3.64, p = .056, φ = 0.24).

Conclusions

Open-label placebo treatment does not improve the healing rate of wounds. Open-label placebos may be beneficial for subjective patient-reported outcomes but do not influence wound healing.

Australian New Zealand Clinical Trials Registration

ACTRN12616000411448.

Effectiveness of Stress-Reducing Interventions on the Response to Challenges to the Immune System: A Meta-Analytic Review

BACKGROUND

There is consistent evidence showing an interplay between psychological processes and immune function in health and disease processes.

OBJECTIVES

The present systematic review and meta-analysis aims to provide a concise overview of the effectiveness of stress-reducing psychological interventions on the activation of immune responses in both healthy subjects and patients.

METHODS

Included are 3 types of challenges: in vivo, in vitro, and psychophysiological. Such challenges are designed to mimic naturally occurring immune-related threats.

RESULTS

A systematic literature search was conducted using PubMed, EMBASE, and PsychInfo, resulting in 75 eligible studies. The risk of bias was assessed with the Cochrane risk-of-bias tool. Across all studies, a small-to-medium effect size was found for the effects of psychological interventions on optimization of the immune function (g = 0.33; 95% CI 0.22-0.43). While the largest effects were found for in vivo immune-related challenges (g = 0.61; 95% CI 0.34-0.88; especially on studies that incorporated skin tests and wound healing), studies incorporating psychophysiological challenges and in vitro immune-related stimulations similarly suggest more optimal immune responses among those receiving stress-reducing interventions (g = 0.28; 95% CI 0.15-0.42).

CONCLUSION

These findings showed substantial heterogeneity depending on the type of challenge, the study populations, and the intervention types. These data demonstrate support for the effectiveness of stress-reducing psychological interventions in improving immunity in studies that tested immune function by means of incorporating an in vivo,in vitro, or psychophysiological challenge. Future research should more consistently incorporate challenges into the study design to gather more insights in the mechanisms underlying the optimized immune function following a psychological intervention. This is also relevant for clinical practice, as psychological interventions can possibly supplement, or at least partially replace, current drug treatments in various somatic conditions to reduce side effects.

The Influence of Preoperative Interventions on Postoperative Surgical Wound Healing in Patients Without Risk Factors: A Systematic Review

BACKGROUND

Poor wound healing and scar formation remain critical problems in daily surgical practice. Generally, most attention is paid to intra- and postoperative interventions to improve wound healing after surgery, while preoperative interventions remain unsatisfactorily explored.

OBJECTIVES

In this systematic review, the available literature on the beneficial effects of preoperative interventions on wound healing and scar formation have been summarized and compared.

METHODS

A comprehensive and systematic search has been conducted in MEDLINE, Pubmed, Embase, Web of Science, and Cochrane, supplemented by reference and citation tracking. All preoperative interventions and all clinically relevant outcome parameters have been considered for inclusion, due to the expected limited availability of literature.

RESULTS

A total of 13 studies were included, which were all randomized trials. No cohort studies or retrospective studies have been identified. All studies described different preoperative interventions and outcome parameters and could hence not be pooled and compared. Eight studies showed significantly better wound healing after a preoperative intervention. The individual studies have been summarized in this review.

CONCLUSIONS

This systemic review shows that preoperative interventions can be beneficial in improving wound healing and scar formation. In selected cases, wound healing was found to benefit from a higher preoperative body temperature, topical vitamin E application, and low patient stress levels.

LEVEL OF EVIDENCE 2

Bringing Creative Writing Instruction into Reminiscence Group Treatment

OBJECTIVES

This article describes the program evaluation of a group intervention combining reminiscence with literary creative writing instruction.

METHOD

This 10-week, 1-hour group was completed seven times in an outpatient geriatric mental health clinic. Each session introduced a different reminiscence theme and creative writing practice. Feasibility and acceptability were assessed through group monitoring and qualitative feedback. Effectiveness was assessed with pre- and post-test depression screening (PHQ-9) and qualitative feedback.

RESULTS

A total of 34 veterans participated in the groups, with a mean group size of 4.86 (SD = .69). Participants were 85% male (n = 29) and 15% female (n = 5) with a mean age of 70.89 (SD = 8.30). To increase accessibility, several adaptations were made. There were statistically significant reductions in PHQ-9 depression scores (p = .005). Veterans reported qualitative improvements including increased motivation and self-expression.

CONCLUSIONS

This intervention was feasible and acceptable to the veterans being served. Randomized controlled research is needed to better understand efficacy.

CLINICAL IMPLICATIONS

Clinicians may consider ways to augment or adapt reminiscence interventions to meet the needs of their patient population. Clinicians may find it useful to integrate creative writing instruction into reminiscence interventions.

Writing interventions in older adults and former children of the World War II: impact on quality of life and depression

OBJECTIVES

The aim of the current study was to analyze whether biographical writing interventions have an impact on depression and QoL compared to daily diary writing. We also wanted to investigate differential effects between structured and unstructured interventions.

METHOD

In two Northern regions of Germany, 119 older adults aged 64-90 were randomly assigned to three different types of narrative writing interventions: written structured and unstructured biographical disclosure as well as daily diary writing. Depression (PHQ-9), QoL (SF-12, EUROHIS) and trauma-related symptoms (PCL-C) were obtained pre- and post-interventions as well as at three-month follow-up.

RESULTS

Follow-up measures were obtained from 85 participants (29% loss to follow-up; mean age = 73.88; 68.2% female). Results of repeated measurement analysis demonstrated a significant effect on depression with the daily diary writing group showing lower depressive symptoms than structured biographical writing. We did not find a significant impact on QoL. Post-hoc analyses showed that posttraumatic symptoms lead to increases in depressive symptoms.

CONCLUSION

In a non-clinical sample of community-dwelling older adults, biographical writing interventions were not favorable to daily diary writing concerning the outcomes of the study. This might be related to the association of traumtic reminiscences of former children of World War II and outcome measures.

Mental health interventions among older adults: A systematic review

BACKGROUND

The aim of the present study was to conduct a systematic review to identify documented mental health promotion interventions developed and tested among population-based older adults.

METHODS

A systematic review based on PRISMA guidelines. The literature was searched in PsycINFO and PubMed between June and September 2016. The Effective Public Health Practice Project tool was used to assess the quality of the included study.

RESULTS

In total 53 randomized controlled trial studies qualified for the systematic review. Across studies, three types of common conceptual themes emerged for interventions, including: 1) individual characteristics; 2) content and structure of the interventions; and 3) implementation of the interventions.

CONCLUSIONS

No specific interventions could be recommended on the aforementioned basis. We conclude that a number of factors are of central importance for an intervention to have the desired effect. If these factors are considered, mental health can be successfully promoted among older adults.

Investigating the Relationship Between Religiosity and Psychological Distress Among Surgical Inpatients: A Pilot Study

Psychological distress may hinder recovery following surgery. Studies examining the relationship between psychological distress and religiosity in the acute post-operative setting are lacking. The present study investigated this relationship, evaluated protocol design, and explored coping mechanisms. Psychological distress of surgical inpatients was assessed using the Hospital Anxiety and Depression Scale (HADS) and Rotterdam Symptom Checklist (RSCL). Religiosity was assessed using the Santa Clara Strength of Religious Faith Questionnaire. Correlations were obtained using Minitab software. Qualitative analysis identified coping mechanisms. Of eligible inpatients, 13/54 were recruited. No significant correlation was found between religiosity and psychological distress. The RSCL had a strong correlation with HADS (R = 0.82, p = 0.001). Assessment of distress was >2 min faster using RSCL compared to HADS. Relationships with pets, friends or family, and God emerged as the most common coping mechanism. Given study limitations, no conclusion was drawn regarding the relationship between religiosity and psychological distress. Weaknesses in study protocol were identified, and recommendations were outlined to facilitate the definitive study. This includes use of RSCL instead of HADS. Further study is warranted to explore how to strengthen relationships for inpatients.

The effect of Mindfulness-Based Stress Reduction on wound healing: a preliminary study

Psychological factors have been shown to influence the process of wound healing. This study examined the effect of Mindfulness-Based Stress Reduction (MBSR) on the speed of wound healing. The local production of pro-inflammatory cytokines and growth factors was studied as potential underlying mechanism. Forty-nine adults were randomly allocated to a waiting-list control group (n = 26) or an 8-week MBSR group (n = 23). Pre- and post-intervention/waiting period assessment for both groups consisted of questionnaires. Standardized skin wounds were induced on the forearm using a suction blister method. Primary outcomes were skin permeability and reduction in wound size monitored once a day at day 3, 4, 5, 6, 7, and 10 after injury. Secondary outcomes were cytokines and growth factors and were measured in wound exudates obtained at 3, 6, and 22 h after wounding. Although there was no overall condition effect on skin permeability or wound size, post hoc analyses indicated that larger increases in mindfulness were related to greater reductions in skin permeability 3 and 4 days after wound induction. In addition, MBSR was associated with lower levels of interleukin (IL)-8 and placental growth factor in the wound fluid 22 h after wound induction. These outcomes suggest that increasing mindfulness by MBSR might have beneficial effects on early stages of wound healing. Trial Registration NTR3652, http://www.trialregister.nl.

The effects of psychological interventions on wound healing: A systematic review of randomized trials

PURPOSE

Psychological stress has been shown to delay wound healing. Several trials have investigated whether psychological interventions can improve wound healing, but to date, this evidence base has not been systematically synthesized. The objective was to conduct a systematic review of randomized controlled trials in humans investigating whether psychological interventions can enhance wound healing.

METHODS

A systematic review was performed using PsychINFO, CINAHL, Web of Science, and MEDLINE. The searches included all papers published in English up until September 2016. The reference lists of relevant papers were screened manually to identify further review articles or relevant studies. Nineteen studies met inclusion criteria and were included in the review.

RESULTS

Fifteen of nineteen studies were of high methodological quality. Six studies were conducted with acute experimentally created wounds, five studies with surgical patients, two studies with burn wounds, two studies with fracture wounds, and four studies were conducted with ulcer wounds. Post-intervention standardized mean differences (SMD) between groups across all intervention types ranged from 0.13 to 3.21, favouring improved healing, particularly for surgical patients and for relaxation interventions. However, there was some evidence for publication bias suggesting negative studies may not have been reported. Due to the heterogeneity of wound types, population types, and intervention types, it is difficult to pool effect sizes across studies.

CONCLUSIONS

Current evidence suggests that psychological interventions may aid wound healing. Although promising, more research is needed to assess the efficacy of each intervention on different wound types. Statement of contribution What is already known on this subject? Psychological stress negatively affects wound healing. A number of studies have investigated whether psychological interventions can improve healing. However, no systematic reviews have been conducted. What does this study add? Synthesis and review of 19 trials conducted on psychological interventions and wound healing. Most evidence supports improved healing, particularly for surgical wounds and relaxation interventions. More research is needed on different intervention types with clinical wounds and into mechanisms of action.

Helping Yourself by Offering Help: Mediators of Expressive Helping in Survivors of Hematopoietic Stem Cell Transplant

BACKGROUND

A randomized experiment by Rini et al. (Health Psychol. 33(12):1541-1551, 2014) demonstrated that expressive helping, which involves three expressive writing sessions regarding hematopoietic stem cell transplant, followed by one writing session directed toward helping other stem cell transplant recipients, reduced psychological distress and bothersome physical symptoms among stem cell transplant recipients with elevated survivorship problems, relative to a neutral writing control condition.

PURPOSE

The current study evaluated whether word use reflective of emotional expression, cognitive processing, and change in perspective mediates the effects of expressive helping.

METHOD

The essays of 67 stem cell transplant recipients with high survivorship problems were analyzed with Linguistic Inquiry and Word Count. Multiple mediation modeling was used to test the hypothesized mechanisms of expressive helping on distress and bothersome physical symptoms.

RESULTS

Relative to the control condition, expressive helping produced significant reductions in psychological distress and marginal reductions in physical symptom bother in the analyzed subset of participants from the parent study. Results indicated that positive emotion word use significantly mediated effects of expressive helping on reduced distress, but only for participants who used average (compared to above or below average) rates of negative emotion words. Cognitive processing and change in perspective did not significantly mediate benefits of expressive helping.

CONCLUSIONS

Expressive helping carried its positive effects on distress through participants' higher expression of positive emotions when coupled with moderate rates of negative emotions. Findings highlight the benefit of expressing both positive and negative emotions in stressful situations.

The effects of expressive writing before or after punch biopsy on wound healing

OBJECTIVE

Recent studies have shown that written emotional disclosure (expressive writing) performed in the two weeks prior to wounding improves healing of punch biopsy wounds. In many clinical settings, it would be more practical for patients to perform this intervention after wounding. The aim of this study was to investigate whether expressive writing could speed the healing of punch biopsy wounds if writing was performed after wounds were made.

METHODS

One hundred and twenty-two healthy participants aged between 18 and 55years were randomly allocated to one of four groups in a 2 (intervention) by 2 (timing) design. Participants performed either expressive writing or neutral writing, either before or after receiving a 4mm punch biopsy wound. Wounds were photographed on day 10 (primary endpoint) and day 14 after the biopsy to measure epithelisation. Participants also completed questionnaires on stress and affect two weeks prior to the biopsy, on the day of biopsy and two weeks after biopsy.

RESULTS

There was a significant difference in healing at day 10 between groups, χ²(3, N=97)=8.84, p=0.032. A significantly greater proportion of participants who performed expressive writing before the biopsy had fully reepithelialised wounds on day 10 compared to participants who performed neutral writing either before or after wounding, with no other significant differences between groups. Amongst people who wrote expressively after wounding, those who finished writing over the first 6days were significantly more likely to be healed at 14days than those who finished writing later. There were significant differences in positive and negative affect over the healing period between the pre and post expressive writing groups.

CONCLUSIONS

Expressive writing can improve healing if it is performed prior to wounding. Performing expressive writing after wounding may be able to improve healing depending on the timing of writing and wound assessment. Expressive writing causes affect to worsen followed by subsequent improvement and it is important to consider this in the timing of intervention delivery. Further research with patient groups is required to determine the clinical relevance of these findings.

Capturing the Experience: Reflections of Women With Breast Cancer Engaged in an Expressive Writing Intervention

BACKGROUND

Expressive writing has been shown to improve quality of life, fatigue, and posttraumatic stress among breast cancer patients across cultures. Understanding how and why the method may be beneficial to patients can increase awareness of the psychosocial impact of breast cancer and enhance interventional work within this population. Qualitative research on experiential aspects of interventions may inform the theoretical understanding and generate hypotheses for future studies.

AIM

The aim of the study was to explore and describe the experience and feasibility of expressive writing among women with breast cancer following mastectomy and immediate or delayed reconstructive surgery.

METHODS

Seven participants enrolled to undertake 4 episodes of expressive writing at home, with semistructured interviews conducted afterward and analyzed using experiential thematic analysis.

RESULTS

Three themes emerged through analysis: writing as process, writing as therapeutic, and writing as a means to help others.

CONCLUSIONS

Findings illuminate experiential variations in expressive writing and how storytelling encourages a release of cognitive and emotional strains, surrendering these to reside in the text. The method was said to process feelings and capture experiences tied to a new and overwhelming illness situation, as impressions became expressions through writing. Expressive writing, therefore, is a valuable tool for healthcare providers to introduce into the plan of care for patients with breast cancer and potentially other cancer patient groups.

IMPLICATIONS FOR PRACTICE

This study augments existing evidence to support the appropriateness of expressive writing as an intervention after a breast cancer diagnosis. Further studies should evaluate its feasibility at different time points in survivorship.

Stress-related changes to immune cells in the skin prior to wounding may impair subsequent healing

Higher psychological stress is associated with slower dermal wound healing, but the immunological mechanisms behind this effect are only partially understood. This paper aims to investigate whether immune cells present in the skin prior to wounding can affect subsequent healing in high-stress and low-stress participants. Two studies are presented in which skin biopsies were analysed using immunohistochemistry for numbers of macrophages and Langerhans cells, and immune cell activation (Study 2 only). Immune cells were related to perceived stress levels and subsequent healing. Study 1 included 19 healthy older adults and showed that higher stress was associated with significantly fewer macrophages in the skin. Study 2 included 22 younger adults and showed that higher stress was associated with significantly lower activation of immune cells in the skin. Furthermore, lower activation of immune cells (as measured by human leukocyte antigen (HLA expression)) and fewer Langerhans cells were associated with slower healing. Together these studies show the first preliminary evidence that the number and activation of immune cells in the skin prior to wounding are affected by stress and can impact healing. Larger studies are needed to confirm these effects.

The Effects of Relaxation Before or After Skin Damage on Skin Barrier Recovery: A Preliminary Study

OBJECTIVES

Psychological interventions administered before wounding can reduce stress and improve healing. However, in many cases, it would be more practical for interventions to be delivered after wounding. This preliminary study investigated whether a brief relaxation intervention could improve healing when administered either before or after skin damage produced by tape stripping in comparison to a control group.

METHODS

One hundred twenty-one healthy adults were randomized into one of three groups: (a) relaxation prestripping group, (b) relaxation poststripping group, or (c) no relaxation. Participants completed measures of stress, fatigue, relaxation, and pain. Relaxation consisted of listening to 20 minutes of guided relaxation, whereas the control condition was quiet reading for 20 minutes. Skin barrier function was measured using transepidermal water loss at baseline, immediately after tape stripping and 25 minutes later.

RESULTS

Relaxation either before or after tape stripping improved skin barrier recovery compared with the control group (F(2,92) = 3.58, p = .032, partial η = 0.074). Participants who took part in the relaxation intervention were significantly more relaxed and reported greater reductions in pain than the control group did 25 minutes after tape stripping. Perceived stress over the last month was not significantly related to healing.

CONCLUSIONS

This study showed that a relaxation intervention had a beneficial effect on skin barrier recovery regardless of whether the intervention was administered before or after wounding. Future research needs to replicate these findings in other wound types and in clinical settings, and investigate the biological mechanisms involved.

A multidisciplinary approach to scars: a narrative review

The purpose of this article is to carry out a narrative review regarding the approach to scars through complementary and alternative medicine focusing on osteopathy, naturopathy, and other minor methods and traditional rehabilitative medicines, such as physiotherapy and manual therapies. We analyzed the existing literature regarding the possible influences of techniques relaxing the diaphragm – both manual and psychophysical relaxing techniques – and the consequent local response to events leading to scar tissue healing. The objective of the study is to become a useful instrument of knowledge for those manual therapists and professionals who deal with patients affected by discontinuity of the skin surface due to trauma or surgery. This article also intends to stimulate research in order to find and propose new methods of scar treatment, taking into consideration the information gained so far from other complementary and alternative disciplines.

Positive and negative mood in men with advanced prostate cancer undergoing androgen deprivation therapy: considering the role of social support and stress

Advanced prostate cancer patients often undergo androgen deprivation therapy (ADT). Advanced disease and adverse ADT side effects are often debilitating and negatively impact mood. Social support has been shown to mitigate detrimental effects of stress on mood.

OBJECTIVE

This study sought to characterize positive and negative mood in this select patient population and determine whether social support moderated relations between stress and mood.

METHODS

Participants (N = 80) completed the Interpersonal Support Evaluation List, Perceived Stress Scale, and Derogatis Affect Balance Scale at a single time point. Hierarchical regression models evaluated relations among social support, stress, and mood controlling for relevant covariates. Standard moderation analyses were performed.

RESULTS

Participants reported higher levels of negative and positive mood compared with published means of localized prostate cancer patients. Overall, mood was more positive than negative. Stress levels were comparable to cancer populations with recurrent disease. Moderated regression analyses showed that social support partially buffered the effects of stress on positive mood; men with high stress and low support reported the lowest levels of positive mood. The model with negative mood as the dependent measure did not support moderation; that is, the relationship between stress and negative mood did not differ by level of social support.

CONCLUSION

Among individuals living with advanced prostate cancer, social support may be an important factor that sustains positive mood in the presence of stress. Future work should examine the extent to which social support prospectively impacts health-related quality of life by promoting positive mood. Limitations include cross-sectional design, which precludes causal inferences.

The effects of expressive writing on lung function, quality of life, medication use, and symptoms in adults with asthma: a randomized controlled trial

OBJECTIVES

Asthma is a chronic condition affecting 300 million people worldwide. Management involves adherence to pharmacological treatments such as corticosteroids and β-agonists, but residual symptoms persist. As asthma symptoms are exacerbated by stress, one possible adjunct to pharmacological treatment is expressive writing (EW). EW involves the disclosure of traumatic experiences which is thought to facilitate cognitive and emotional processing, helping to reduce physiological stress associated with inhibiting emotions. A previous trial reported short-term improvements in lung function. This study aimed to assess whether EW can improve lung function, quality of life, symptoms, and medication use in patients with asthma.

METHODS

Adults (18-45 years) diagnosed as having asthma requiring regular inhaled corticosteroids were recruited from 28 general practices in South East England (n = 146). In this double-blind randomized controlled trial, participants were allocated either EW or nonemotional writing instructions and asked to write for 20 minutes for 3 consecutive days. Lung function (forced expired volume in 1 second [FEV1]% predicted), quality of life (Mark's Asthma Quality of Life Questionnaire), asthma symptoms (Wasserfallen Symptom Score Questionnaire), and medication use (inhaled corticosteroids and β-agonist) were recorded at baseline, 1, 3, 6, and 12 months.

RESULTS

Hierarchical linear modeling indicated no significant main effects between time and condition on any outcomes. Post hoc analyses revealed that EW improved lung function by 14% for 12 months for participants with less than 80% FEV1% predicted at baseline (β = 0.93, p = .002) whereas no improvement was observed in the control condition (β = 0.10, p = .667).

CONCLUSIONS

EW seems to be beneficial for patients with moderate asthma (<80% FEV1% predicted). Future studies of EW require stratification of patients by asthma severity.

TRIAL REGISTRATION

ISRCTN82986307.

Stress predicts the trajectory of wound healing in living kidney donors as measured by high-resolution ultrasound

BACKGROUND

Psychological stress has been shown to be an influential factor on the rate of wound healing; however these findings have been demonstrated predominantly on artificially created wounds. Due to the absence of major co-morbidities, living kidney donors are a unique group in which to study this relationship. This study investigated the effect of preoperative stress and personality on surgical wound healing through the use of high-resolution ultrasound.

METHODS

Living kidney donors due to undergo a hand-assisted laparoscopic donor nephrectomy were asked to complete the Perceived Stress Scale, the Life Orientation Test-Revised and the Ten Item Personality Inventory prior to surgery. High-resolution ultrasound scans of surgical wounds were performed on the first three post-operative days and once following discharge (mean=15.3 days; s.d. 2.8). Two measurements from each image were obtained: wound width (size of wound) and median intensity (a marker of tissue fluid). Latent Growth Curve Models (LGCMs) were used to evaluate wound healing.

RESULTS

52 living kidney donors participated. Higher pre-operative life stress, lower optimism and lower conscientiousness were associated with delayed wound healing in living kidney donors for both outcomes. Increased emotional stability was associated with faster wound healing as demonstrated by a change in median intensity. Possible confounding factors, such as age, BMI, smoking status, local anaesthetic use and wound drain placement were not influential.

CONCLUSIONS

This study, which measured wound healing in a novel patient sample using a novel technique, has demonstrated a negative association between stress and wound healing and the positive influence of optimism, conscientiousness and emotional stability.

Randomized controlled trial of expressive writing for patients with renal cell carcinoma

PURPOSE

This randomized controlled trial examined the quality-of-life benefits of an expressive writing (EW) intervention for patients with renal cell carcinoma (RCC) and identified a potential underlying mechanism of intervention efficacy.

PATIENTS AND METHODS

Patients (N = 277) with stage I to IV RCC were randomly assigned to write about their deepest thoughts and feelings regarding their cancer (EW) or about neutral topics (neutral writing [NW]) on four separate occasions. Patients completed the Center for Epidemiologic Studies Depression Scale (CES-D), MD Anderson Symptom Inventory (MDASI), Brief Fatigue Inventory (BFI), Pittsburgh Sleep Quality Index (PSQI), Medical Outcomes Study Short Form-36 (SF-36), and Impact of Event Scale (IES) at baseline and 1, 4, and 10 months after the intervention.

RESULTS

The mean age of participants (28% stage IV; 41% female) was 58 years. Multilevel modeling analyses, using a Bonferroni-corrected α = .021 for six outcomes adjusted for the correlation among outcomes, revealed that, relative to the NW group, patients in the EW group reported significantly lower MDASI scores (P = .003) and higher physical component summary scores on the SF-36 (P = .019) at 10 months after the intervention. Mediation analyses revealed that significant group differences for MDASI scores at 10 months were mediated by lower IES scores at 1 month after the intervention in the EW group (P = .042). No significant group differences were observed in the BFI, CES-D, PSQI, and mental component summary of the SF-36.

CONCLUSION

EW may reduce cancer-related symptoms and improve physical functioning in patients with RCC. Evidence suggests that this effect may occur through short-term improvements in cognitive processing.