Kekecs - The Effectiveness of Suggestive Techniques in Reducing Post-Operative Side-Effects

XXX 2014
Volume XXX
Number XXX www.anesthesia-analgesia.org 1

Copyright 2014 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000466
I
n the middle of the 19th century, suggestive techniques
were frequently used as the only analgesic procedures for
surgical operations until the introduction of pharmaceu-
tical methods.
1
Among these suggestive techniques, hypno-
sis remains the most recognized psychological intervention
in modern medicine that is demonstrated to effectively
alleviate postoperative side effects. Hypnosis particularly
decreases postoperative distress, pain, pain medication
requirement, nausea, treatment time, and improves post-
operative well being and recovery.
18
The distinctive char-
acteristic of hypnosis is that it includes a formal hypnosis
induction before the application of suggestions in order to
increase suggestive effects. Those authors also overtly iden-
tify the applied technique as hypnosis.
Despite its established benefts, there is an ongoing
debate whether hypnosis truly increases susceptibility to
suggestions and whether it is necessary for suggestions to
be effective.
9
Some theories propose that patients in medi-
cal settings (e.g., being in critical condition, or waiting for
an invasive operation, etc.) can experience a spontaneous
trance which in itself enhances suggestibility.
10
Accordingly,
there is evidence that suggestions given without hypnotic
induction (from here on, therapeutic suggestions) can
infuence perioperative outcome.
1
The meta-analysis of
Schnur et al.
5
included 6 studies in which the intervention
was labeled as suggestions, and they concluded that
suggestions were less effective for reducing perioperative
distress than hypnosis. However, this meta-analysis did
not systematically search for suggestion studies, and they
ANE
AAJ
Anesthesia & Analgesia
0003-2999
Lippincott Williams & Wilkins
10.1213/ANE.0000000000000466
AAJ-D-14-00342
Suggestions for Reducing Surgical Side Effects
xxxxxxXXX
XXX
XXX
00
00
5August2014
Copyright 2014 International Anesthesia Research Society
2014
Anesth Analg
xxx
XXX
2014
BACKGROUND: Suggestive interventions such as hypnosis and therapeutic suggestions are fre-
quently used to alleviate surgical side effects; however, the effectiveness of therapeutic sugges-
tion intervention has not yet been systematically evaluated. In the present study, we tested the
hypotheses that (1) suggestive interventions are useful for reducing postoperative side effects;
(2) therapeutic suggestions are comparable in effectiveness to hypnosis; (3) live presentation
is more effective than recordings; and (4) suggestive interventions would be equally effective
used in minor and major surgeries.
METHODS: We performed random effect meta-analysis with meta-regression and sensitivity analysis
by moderating factors on a pool of 26 studies meeting the inclusion criteria (N=1890). Outcome
variables were postoperative anxiety, pain intensity, pain medication requirement, and nausea.
RESULTS: Suggestive interventions reduced postoperative anxiety (g = 0.40; 99% conf-
dence interval [CI] = 0.130.66; P < 0.001) and pain intensity (g = 0.25; 99% CI = 0.00
0.50; P = 0.010), but did not signifcantly affect postoperative analgesic drug consumption
(g = 0.16; 99% CI = 0.16 to 0.47; P = 0.202) and nausea (g = 0.38; 99% CI = 0.06 to
0.81; P = 0.026). No signifcant differences were found for intervention type, presentation
method, and severity of surgery; however, sensitivity analysis only supported the effectiveness
of hypnosis (g=0.62; 99% CI=0.310.92; P < 0.001) and live presentation (g=0.55; 99%
CI=0.230.88; P<0.001) for decreasing postoperative anxiety, and that of live presentation
for alleviating postoperative pain (g=0.44; 99% CI=0.070.82; P=0.002). Sensitivity analy-
ses also suggested that suggestive interventions are only effective for decreasing pain intensity
during minor surgical procedures (g=0.39; 99% CI=0.000.78; P=0.009).
CONCLUSIONS: Suggestive techniques might be useful tools to alleviate postoperative anxiety
and pain; however, strength of the evidence is weak because of possible bias in the reviewed
articles. The lack of access to within-subjects data and the overlap between moderator condi-
tions also limit the scope of the analysis. More methodologically correct studies are required
with sensitivity to moderating factors and to within-subjects changes. For clinical purposes, we
advise the use of hypnosis with live presentation to reduce postoperative anxiety and pain, until
convincing evidence is uncovered for the effectiveness of therapeutic suggestions and recorded
presentation. Pain management with adjunct suggestive interventions is mostly encouraged in
minor rather than major surgeries. (Anesth Analg 2014;XXX:0000)
Banu
The Effectiveness of Suggestive Techniques in
Reducing Postoperative Side Effects: A Meta-Analysis
of Randomized Controlled Trials
Zoltn Kekecs, PhD,* Tams Nagy, MA, and Katalin Varga, PhD*
From the *Department of Affective Psychology, Faculty of Psychology and
Education, Etvs Lornd University, Budapest, Hungary; and Faculty of
Psychology and Education, Doctoral School of Psychology, Etvs Lornd
University, Budapest, Hungary.
Accepted for publication August 5, 2014.
Funding: The study was funded by the 2012 PhD research grant of Etvs
Lornd University, and the Hungarian Scientifc Research Funds (K109187
and K100845).
Confict of Interest: See Disclosures at the end of the article.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journals website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Address correspondence to Zoltan Kekecs, PhD, Department or Affective
Psychology, Faculty of Psychology and Education, Etvs Lornd University,
Budapest, Hungary, 46. Izabella u., Room 118, Budapest, Hungary H-1064.
Address e-mail to kekecs.zoltan@ppk.elte.hu.
RESEARCH REPORT
ECONOMICS, EDUCATION, AND POLICY
Banu 4 Color Fig(s): F7-8 09/29/14 20:46 Art: AAJ-D-14-00342
2 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
only assessed effectiveness on a single outcome variable
(perioperative distress); thus, the generalizability of these
results is limited. Therapeutic suggestions do not require
hypnotic induction; thus, they are quicker and less expen-
sive to use, they can be applied by more health care profes-
sionals because they do not require complex hypnotherapy
training, and the common misconceptions regarding hyp-
nosis can also be overcome by these methods. Therefore, it
is important for decision makers to know whether thera-
peutic suggestions are a real alternative to formal hypno-
sis. (Appendix 1, Supplemental Digital Content 1, http://
links.lww.com/AA/B9 contains more readings on hyp-
nosis induction, whether hypnosis induction results in a
meaningful increase in susceptibility to suggestions, and
increased suggestibility in medical settings.)
The aim of the present study was to systematically inves-
tigate the effectiveness of therapeutic suggestions com-
pared to hypnosis for alleviating postoperative side effects.
Furthermore, we assessed how moderating factors such as
the method of presentation (live or recorded) and severity
of surgery (minor or major) affect the effectiveness of sug-
gestive interventions. We hypothesized that (1) suggestive
interventions signifcantly reduce postoperative anxiety,
pain intensity, pain medication requirement, and nausea;
(2) therapeutic suggestions are comparable in effectiveness
to hypnosis; (3) live suggestions are more effective than
recorded ones; and (4) suggestive interventions are equally
effective used in minor and major surgeries.
METHODS
Data Sources and Search Strategy
A literature search was conducted on 4 online databases
(PubMed, PsycINFO, CINAHL, and ProQuest Dissertations
& Theses Database) for studies published between 1980
and 2014 on hypnosis or therapeutic suggestion interven-
tions applied in surgery with no limitations to language or
publication status. Setting a minimal publication date was
necessary to improve generalizability to modern surgical,
anesthesia, and suggestive procedures.
The literature search was fnished on February 21, 2014.
We used the keywords hypnosis, suggestion, and sur-
gery along with their variants and synonyms (Appendix2,
Supplemental Digital Content 2, http://links.lww.com/
AA/B10 lists the exact search terms).
Selection Criteria
Randomized controlled trials (RCTs) on the effectiveness
of therapeutic suggestions or hypnosis-applied adjunct to
routine surgical care were eligible for inclusion. Non-RCTs,
observational studies, and case reports were excluded from
analysis. Because children are more susceptible to hypno-
sis and respond better to suggestive interventions in clini-
cal settings than adults, studies conducted on a pediatric
population (patients younger than 17 years of age) were also
excluded.
5
Appendix 1 (Supplemental Digital Content 1,
http://links.lww.com/AA/B9) lists reviews on the associa-
tion of age and suggestibility and hypnosis applied during
medical procedures with children. After data extraction, we
decided to exclude studies in which suggestions were given
under general anesthesia, mainly because the distribution of
moderating factors were highly asymmetric in these studies.
Specifcally, when suggestions were presented under general
anesthesia, they were always given without hypnosis induc-
tion and played from a recording. The effectiveness of sug-
gestive techniques was compared to regular treatment (no
psychological intervention) or attention control conditions.
Data Extraction
Data extraction was performed by the frst and second
authors independently. Disagreements were resolved by
consensus. The extracted data included number of partici-
pants by study group, presence or absence of formal hypno-
sis induction, type of presentation (live or recorded; if both
live and recorded presentation were used as part of the inter-
vention, it was coded as live
a
), timing of intervention (before,
during, or after surgery), methodological quality (see Risk
of Bias Assessment), and any special care not related to the
suggestive intervention that could have affected postopera-
tive outcomes (Appendix 3, Supplemental Digital Content
3, http://links.lww.com/AA/B11 is a comprehensive list).
The surgical procedure used in the study was also extracted.
Two physicians independently rated the procedures as
being minor or major surgery according to the defnitions
of McGraw-Hill Concise Dictionary of Modern Medicine.
11
Outcomes
Based on previous meta-analyses
35
and the frequency of
occurrence in the reviewed studies 4 outcome measures
were selected: (1) postoperative anxiety or distress, (2) post-
operative pain intensity, (3) postoperative pain medication
requirement, and (4) postoperative nausea. Appendix 4
(Supplemental Digital Content 4, http://links.lww.com/
AA/B12) is a comprehensive list of measures used in the
included studies to assess the aforementioned outcomes.
Because we were interested in the short-term postoperative
effects, only data measured until the ninth postsurgical day
were extracted. To address ambiguities or the need for addi-
tional data, the corresponding authors of the papers were
contacted via e-mail.
Risk of Bias Assessment
Methodological quality was assessed using the Cochrane
Risk of Bias Assessment Tool.
12
This tool enables the evalu-
ation of selection, performance, detection, attrition, and
reporting bias with several customizable assessment catego-
ries. During the process of evaluation, studies were rated as
having low risk of bias, unclear risk of bias, or high risk
of bias on the following attributes: (1) random sequence
generation, (2) allocation concealment, (3) blinding of per-
sonnel, (4) blinding of outcome assessment, (5) incomplete
outcome data, and (6) selective reporting. Since hypnosis
contrary to therapeutic suggestionsrequires the consent
and participation of the subject, blinding of the participants
is usually inappropriate.
1
Thus, we did not consider lack of
blinding of participants a faw in methodological quality.
a
We see human contact and the possibility to customize the intervention to
the individual patients needs to be the 2 main advantages of a live (face-
to-face) presentation compared to a recorded one. The rationale behind
grouping live presentation and both live and recorded presentation studies
together was that in both study types both human contact and possibility for
individualization are present.

XXX 2014
Volume XXX

Publication bias was assessed using Begg and Mazumdar
rank correlation, the random effect variant of Egger test,
Duval & Tweedie trim and fll method, and the inspection
of the funnel plots.
STATISTICAL ANALYSIS
Calculating Treatment Effect
Corrected Hedges g (g) was used as a measure of effect size.
If the mean and standard deviation were not reported in
the original studies, effect sizes were calculated using other
statistics, using the equations by Johnson and Eagly,
13
and
Lipsey and Wilson.
14
If necessary, effect sizes were aggre-
gated according to Rosenthal and Rubin
15
and Decoster.
16

For studies that did not report any test statistics or signif-
cance values for nonsignifcant results, we imputed g = 0
(referred to as imprecise inference from here on).
Statistical Analysis
Statistical analysis was performed using the metafor package
(v1.9-3)
17
in R (v3.1.1). Statistical heterogeneity (I
2
) yielded
medium to high values that supported the application of a
random-effect approach. Random effect meta-analysis was
used to obtain the general effect size of suggestive methods
on postoperative side effects, to assess publication bias, and
to have a reference point for later sensitivity analyses. Meta-
regression was used to investigate the risk of bias for all out-
come variables including all categories from the Cochrane
Risk of Bias Assessment Tool as binomial variables: 0=low
risk of bias; 1=unclear or high risk of bias. A permutation-
based technique was used to control for multiple hypothesis
testing. Sensitivity analyses were performed to further inves-
tigate signifcant moderator effects by excluding studies with
unclear or high-risk ratings. Moderator effects of imprecise
inference and special care (see data extraction) were tested as
well, accompanied by appropriate sensitivity analyses.
Subsequently 3 meta-regressions were executed for
each outcome testing the moderating effect of hypnosis
induction, live versus recorded presentation, and surgery
type (minor versus major surgery). In addition, sensitivity
analyses were also performed on datasets split by modera-
tor conditions. One study in the anxiety and pain datasets
was omitted from the analysis of the effect of surgery type
because of insuffcient information to determine surgery
type.
18
Because a relatively high risk of bias was uncovered
in the study pool, threshold for statistical signifcance was
set to P < 0.01, and 99% confdence intervals (CIs) are dis-
played in all analyses except for risk of bias assessments
in which the traditional P < 0.05 was retained. (Appendix
1, Supplemental Digital Content 1, http://links.lww.com/
AA/B9, summarizes references of text on statistical meth-
ods used for the assessment of publication bias, calculat-
ing treatment effect, and analysis of the data).
RESULTS
Study Selection
As Figure 1 shows, 139 records were selected for full
text evaluation. Sixteen of these could not be retrieved
(Appendix 5, Supplemental Digital Content 5, http://links.
lww.com/AA/B13), and 16 were duplicate publications.
From the remaining 107 publications, 56 used hypnosis,
49 used therapeutic suggestions, and 2 used both. All non-
RCTs, studies on pediatric patients, studies that did not
report outcome of interest, and trials in which suggestions
were given only during general anesthesia were excluded.
Twenty-six studies were retained at the end of the exclusion
process incorporating 1890 patients (range: n = 12346) of
which 13 applied hypnosis, 11 therapeutic suggestions, and
2 both in separate groups; 13 used live and 13 recorded pre-
sentation; and furthermore 14 were performed in major and
11 in minor surgical procedures (not enough information on
surgery type in 1 study). Cholecystectomy (6 studies) and
hysterectomy (4 studies) were the most commonly used sur-
gical procedures. Four studies contained >1 relevant experi-
mental condition. Table1 lists the study characteristics.
General Effects of Suggestive Techniques
We found a signifcant reduction in postoperative anxiety
(g=0.40; 99% CI=0.130.66; P < 0.001) and pain intensity
(g = 0.25; 99% CI = 0.000.50; P = 0.010), whereas no sig-
nifcant effect was noted for postoperative analgesic drug
consumption (g=0.16; 99% CI=0.16 to 0.47; P=0.202) and
nausea (g=0.38; 99% CI=0.06 to 0.81; P=0.026).
Analysis of Moderators
As apparent in Figures25, there is a considerable amount
of heterogeneity in the total study sample. To account for
this heterogeneity, moderator and sensitivity analyses were
performed, the results of which can be found in Figure6.
Figure 1. Flow diagram.
T
a
b
l
e

1
.

S
t
u
d
y

C
h
a
r
a
c
t
e
r
i
s
t
i
c
s
S
t
u
d
y
n
I
n
d
u
c
t
i
o
n
P
r
e
s
e
n
t
a
t
i
o
n
T
i
m
i
n
g
O
u
t
c
o
m
e
S
u
r
g
i
c
a
l

p
r
o
c
e
d
u
r
e
T
y
p
e

o
f

s
u
r
g
e
r
y
A
s
h
t
o
n
,

e
t

a
l
.
,

1
9
9
7
2
9
3
2
H
y
p
n
o
s
i
s
L
i
v
e
a
,

c
a
n
x
,

p
m
e
C
o
r
o
n
a
r
y

a
r
t
e
r
y

b
y
p
a
s
s

s
u
r
g
e
r
y
m
a
B
l
a
n
k
f
e
l
d
,

e
t

a
l
.
,

1
9
9
5
3
0
6
3
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
b
,

c
a
n
x
,

p
m
e
C
o
r
o
n
a
r
y

a
r
t
e
r
y

b
y
p
a
s
s

s
u
r
g
e
r
y
m
a
C
r
u
i
s
e
,

e
t

a
l
.
,

1
9
9
7
3
1
6
0
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
b
a
n
x
C
a
t
a
r
a
c
t

s
u
r
g
e
r
y
m
i
d
e

K
l
e
r
k
,

e
t

a
l
.
,

2
0
0
6
3
2
5
0
H
y
p
n
o
s
i
s
L
i
v
e
a
,

c
a
n
x
C
o
r
o
n
a
r
y

a
r
t
e
r
y

b
y
p
a
s
s

s
u
r
g
e
r
y
m
a
E
n
q
v
i
s
t
,

e
t

a
l
.
,

1
9
9
7
a
3
3
6
9
H
y
p
n
o
s
i
s
R
e
c
o
r
d
e
d
a
p
a
i
,

p
m
e
R
e
m
o
v
a
l

o
f

t
h
i
r
d

m
a
n
d
i
b
u
l
a
r

m
o
l
a
r
s
m
i
E
n
q
v
i
s
t
,

e
t

a
l
.
,

1
9
9
7
b
3
4
4
8
H
y
p
n
o
s
i
s
R
e
c
o
r
d
e
d
a
p
a
i
,

p
m
e
,

n
a
u
E
l
e
c
t
i
v
e

b
r
e
a
s
t

r
e
d
u
c
t
i
o
n

s
u
r
g
e
r
y
m
a
G
h
o
n
e
i
m
,

e
t

a
l
.
,

2
0
0
0
3
5
6
0
H
y
p
n
o
s
i
s
R
e
c
o
r
d
e
d
a
a
n
x
,

p
a
i
,

p
m
e
,

n
a
u
R
e
m
o
v
a
l

o
f

t
h
i
r
d

m
a
n
d
i
b
u
l
a
r

m
o
l
a
r
s
m
i
G
i
n
a
n
d
e
s
,

e
t

a
l
.
,

2
0
0
3
3
6
1
2
H
y
p
n
o
s
i
s
L
i
v
e
a
,

c
p
a
i
E
l
e
c
t
i
v
e

b
r
e
a
s
t

r
e
d
u
c
t
i
o
n

s
u
r
g
e
r
y
m
a
H
a
r
t
,

1
9
8
0
3
7
4
0
H
y
p
n
o
s
i
s
R
e
c
o
r
d
e
d
a
a
n
x
C
a
r
d
i
o
p
u
l
m
o
n
a
r
y

b
y
p
a
s
s

s
u
r
g
e
r
y
m
a
H
o
l
d
e
n
,

1
9
8
5
3
8
2
4
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
,

c
a
n
x
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
J
a
k
u
b
o
v
i
t
s
,

e
t

a
l
.
,

1
9
9
8
a
*
3
9
2
6
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
a
n
x
,

p
a
i
A
b
d
o
m
i
n
a
l

t
o
t
a
l

e
x
t
i
r
p
a
t
i
o
n
,

a
d
n
e
x
e
c
t
o
m
y
,

c
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
J
a
k
u
b
o
v
i
t
s
,

e
t

a
l
.
,

1
9
9
8
b
*
3
9
2
6
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
,

b
a
n
x
,

p
a
i
A
b
d
o
m
i
n
a
l

t
o
t
a
l

e
x
t
i
r
p
a
t
i
o
n
,

a
d
n
e
x
e
c
t
o
m
y
,

c
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
J
o
h
n
,

e
t

a
l
.
,

1
9
8
3
4
0
5
9
S
u
g
g
e
s
t
i
o
n
L
i
v
e
a
a
n
x
,

p
a
i
R
a
d
i
a
l

k
e
r
a
t
o
t
o
m
y

(
e
y
e

s
u
r
g
e
r
y
)
m
i
K
e
k
e
c
s
,

e
t

a
l
.
,

2
0
1
4
2
8
8
2
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
a
n
x
C
a
t
a
r
a
c
t

s
u
r
g
e
r
y
m
i
L
a
u
d
e
r
,

e
t

a
l
.
,

1
9
9
5
4
1
1
9
0
S
u
g
g
e
s
t
i
o
n
L
i
v
e
a
n
a
u
T
o
t
a
l

a
b
d
o
m
i
n
a
l

h
y
s
t
e
r
e
c
t
o
m
y
m
a
M
a
r
c
,

e
t

a
l
.
,

2
0
0
7
4
2
2
9
H
y
p
n
o
s
i
s
L
i
v
e
a
,

b
a
n
x
,

p
a
i
F
i
r
s
t
-
t
r
i
m
e
s
t
e
r

s
u
r
g
i
c
a
l

a
b
o
r
t
i
o
n
m
i
M
a
r
c
,

e
t

a
l
.
,

2
0
0
8
4
3
3
4
6
H
y
p
n
o
s
i
s
L
i
v
e
a
,

b
a
n
x
,

p
a
i
F
i
r
s
t
-
t
r
i
m
e
s
t
e
r

s
u
r
g
i
c
a
l

a
b
o
r
t
i
o
n
m
i
M
a
s
s
a
r
i
n
i
,

e
t

a
l
.
,

2
0
0
5
1
8
4
2
H
y
p
n
o
s
i
s
L
i
v
e
a
a
n
x
,

p
a
i
N
o
t

s
p
e
c
i
f
e
d
,

b
u
t

p
a
t
i
e
n
t
s

w
e
r
e

r
e
c
r
u
i
t
e
d

f
r
o
m

t
h
e

S
u
r
g
e
r
y

a
n
d

O
r
t
h
o
p
e
d
i
c
s

w
a
r
d
M
i
g
l
y
,

e
t

a
l
.
,

1
9
9
1
4
4
3
0
H
y
p
n
o
s
i
s
L
i
v
e
a
,

c
a
n
x
O
b
s
t
e
t
r
i
c
/
g
y
n
e
c
o
l
o
g
i
c
a
l

s
u
r
g
e
r
y
:

d
i
l
a
t
a
t
i
o
n

a
n
d

c
u
r
e
t
t
a
g
e

o
r

o
n
l
y

c
u
r
e
t
t
a
g
e
m
i
M
o
n
t
g
o
m
e
r
y
,

e
t

a
l
.
,

2
0
0
2
4
2
0
H
y
p
n
o
s
i
s
L
i
v
e
a
a
n
x
,

p
a
i
E
x
c
i
s
i
o
n
a
l

b
r
e
a
s
t

b
i
o
p
s
y
m
i
M
o
n
t
g
o
m
e
r
y
,

e
t

a
l
.
,

2
0
0
7
4
5
2
0
0
H
y
p
n
o
s
i
s
L
i
v
e
a
a
n
x
,

p
a
i
,

p
m
e
,

n
a
u
E
x
c
i
s
i
o
n
a
l

b
r
e
a
s
t

b
i
o
p
s
y

o
r

l
u
m
p
e
c
t
o
m
y
m
i
N
i
l
s
s
o
n
,

e
t

a
l
.
,

2
0
0
3
4
6
1
2
0
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
c
a
n
x
,

p
a
i
,

p
m
e
,

n
a
u
V
a
r
i
c
o
s
e

v
e
i
n

o
r

o
p
e
n

i
n
g
u
i
n
a
l

h
e
r
n
i
a

r
e
p
a
i
r
m
i
S
h
u
l
i
m
s
o
n
,

1
9
8
7
a
*
4
7
3
0
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
c
a
n
x
,

p
a
i
,

p
m
e
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
S
h
u
l
i
m
s
o
n
,

1
9
8
7
b
*
4
7
3
0
H
y
p
n
o
s
i
s
L
i
v
e
a
a
n
x
,

p
a
i
,

p
m
e
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
S
h
u
l
i
m
s
o
n
,

1
9
8
7
c
*
4
7
3
0
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
a
n
x
,

p
a
i
,

p
m
e
C
h
o
l
e
c
y
s
t
e
c
t
o
m
y
m
a
S
z
e
v
e
r
n
y
i
,

e
t

a
l
.
,

2
0
1
2
2
7
6
4
S
u
g
g
e
s
t
i
o
n
L
i
v
e
a
,

b
p
m
e
H
i
p

o
r

k
n
e
e

p
r
o
s
t
h
e
s
i
s

i
m
p
l
a
n
t
a
t
i
o
n
m
a
T
a
e
n
z
e
r
,

1
9
8
3
a
*
4
8
2
0
H
y
p
n
o
s
i
s
L
i
v
e
a
a
n
x
,

p
a
i
,

p
m
e
E
l
e
c
t
i
v
e

g
a
l
l
b
l
a
d
d
e
r

s
u
r
g
e
r
y
m
a
T
a
e
n
z
e
r
,

1
9
8
3
b
*
4
8
2
0
S
u
g
g
e
s
t
i
o
n
L
i
v
e
a
a
n
x
,

p
a
i
,

p
m
e
E
l
e
c
t
i
v
e

g
a
l
l
b
l
a
d
d
e
r

s
u
r
g
e
r
y
m
a
v
a
n

d
e
r

L
a
a
n
,

e
t

a
l
.
,

1
9
9
6
4
9
4
0
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
a
n
x
,

p
a
i
,

p
m
e
,

n
a
u
H
y
s
t
e
r
e
c
t
o
m
y
,

m
y
o
m
e
c
t
o
m
y
,

o
r

g
y
n
e
c
o
l
o
g
i
c

l
a
p
a
r
o
t
o
m
y
m
a
W
o
o
,

e
t

a
l
.
,

1
9
8
7
a
*
5
0
1
4
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
,

b
p
m
e
A
b
d
o
m
i
n
a
l

h
y
s
t
e
r
e
c
t
o
m
y
m
a
W
o
o
,

e
t

a
l
.
,

1
9
8
7
b
*
5
0
1
4
S
u
g
g
e
s
t
i
o
n
R
e
c
o
r
d
e
d
a
,

b
p
m
e
A
b
d
o
m
i
n
a
l

h
y
s
t
e
r
e
c
t
o
m
y
m
a
I
n
t
e
r
v
e
n
t
i
o
n
:

s
u
g
g
e
s
t
i
o
n

r
e
f
e
r
s

t
o

t
h
e
r
a
p
e
u
t
i
c

s
u
g
g
e
s
t
i
o
n
s
;

t
i
m
i
n
g
:

a

=

b
e
f
o
r
e

s
u
r
g
e
r
y
;

b

=

d
u
r
i
n
g

s
u
r
g
e
r
y
;

c

=

a
f
t
e
r

s
u
r
g
e
r
y
;

o
u
t
c
o
m
e
:

a
n
x

=

a
n
x
i
e
t
y
;

p
a
i

=

p
a
i
n
;

p
m
e

=

p
a
i
n

m
e
d
i
c
a
t
i
o
n
;

n
a
u

=

n
a
u
s
e
a
;

t
y
p
e

o
f

s
u
r
g
e
r
y
:

m
a

=

m
a
j
o
r
;

m
i

=

m
i
n
o
r
.
*
D
a
t
a

e
x
t
r
a
c
t
e
d

f
o
r

m
u
l
t
i
p
l
e

i
n
t
e
r
v
e
n
t
i
o
n

g
r
o
u
p
s
.

XXX 2014
Volume XXX

Hypnosis Induction
The moderating effect of hypnosis was not statistically
signifcant for any outcome; however, sensitivity analysis
led us to different conclusions on the effects of therapeu-
tic suggestions and hypnosis. While pooled effect size and
CIs show a small nonsignifcant effect for therapeutic sug-
gestion studies on all outcomes, hypnosis had a signifcant
medium-sized effect on postoperative anxiety and although
not signifcant, hypnosis effect sizes were generally higher
in all other outcomes as well.
Presentation Method
Live presentation was more effective for decreasing pain rat-
ings than recorded presentation (z = 2.18; P = 0.029); how-
ever, recordings were superior for reducing pain medication
requirement (z=-2.08; P=0.037). Although these moderator
effects are statistically not signifcant, the sensitivity analysis
also indicated differentiation in the effects of the 2 presenta-
tion methods: we found a medium-sized signifcant effect of
live presentation on anxiety and pain intensity, while recorded
presentation yielded no signifcant results on any outcome.
Surgery Type
Moderator analysis did not show signifcant moderator
effect of surgery type; nevertheless, sensitivity analysis led
to somewhat differing conclusions for the effectiveness of
suggestive interventions used in minor and major surger-
ies. Both interventions used in minor and major procedures
reduced anxiety with a similar medium effect size, and nei-
ther had a signifcant effect on pain medication requirement
Figure 2. Effects of suggestive techniques
on postoperative anxiety. The effect is
expressed as corrected Hedges g with
associated 99% confdence intervals (CIs).
Black squares show the point estimates of
the effect of individual studies with hori-
zontal lines corresponding to 99% CIs. The
white diamonds (subtotal) represent the
pooled estimates and 99% CIs for each
subgroup, and the black diamond (total)
shows the pooled estimates and 99% CI
for all studies. The sample sizes of the
suggestion (N sg) and control groups (N
cg) of each study and the heterogeneity
scores for each subgroup analysis are also
displayed.
or nausea. However, while studies on major surgeries
showed negligible effect sizes for reducing pain and analge-
sic requirement, pooled effect sizes were medium sized for
the same outcomes in minor procedures.
Risk of Bias and Effects of Imprecise
Inference and Special Care
A summary graph of risk of bias is displayed in Figure 7,
and the results of risk of bias assessment for each study are
listed in Figure8. Meta-regression identifed 2 methodologi-
cal moderators as signifcant: random sequence generation
in the anxiety dataset (z = 2.48; P = 0.018) and blinding
of personnel in the nausea dataset (z = 3.84; P = 0.003;
Table 2). Sensitivity analysis revealed that with the exclu-
sion of studies having high or unknown risk of bias, the
effect of suggestive techniques on postoperative anxiety
is no more signifcant (g = 0.16; 99% CI = 0.30 to 0.60;
P=0.376). Exclusion of studies with high or unknown risk
on blinding of personnel produced a slightly higher pooled
effect size than the model without moderators in the nau-
sea dataset (g=0.49; 99% CI=0.10 to 1.08; P=0.032); the
effect remained nonsignifcant. Effect on postoperative pain
and pain medication requirement was unaffected by meth-
odological quality. There was no moderator effect of impre-
cise inference, and that studies with special care had higher
effects compared to studies with no special care (Table3).
There was no indication of publication bias based on
funnel plots and asymmetry tests (Fig.9). Duval & Tweedie
trim and fll method does not change our interpretation for
anxiety, pain intensity, and nausea. However, it predicted 4
missing studies from the right (positive) side for the pain
medication dataset yielding a slightly higher but still non-
signifcant effect (g=0.31; 99% CI=0.02 to 0.63; P=0.015).
DISCUSSION
We reviewed the results of 26 studies to investigate the
effects of suggestive interventions in surgical settings
and to explore the factors that moderate their effective-
ness. Results indicate that suggestion interventions had a
benefcial effect on postoperative anxiety and to a lesser
extent on pain intensity, while we did not fnd convinc-
ing evidence to support the effectiveness of suggestive
on postoperative pain intensity. The effect
is expressed as corrected Hedges g with
associated 99% confdence intervals (CIs).
Black squares show the point estimates of
the effect of individual studies with hori-
zontal lines corresponding to 99% CIs. The
white diamonds (subtotal) represent the
pooled estimates and 99% CIs for each
subgroup, and the black diamond (total)
shows the pooled estimates and 99% CI
for all studies. The sample sizes of the
suggestion (N sg) and control groups (N
cg) of each study and the heterogeneity
scores for each subgroup analysis are also
displayed.

XXX 2014
Volume XXX

interventions as a whole in reducing postoperative analge-
sic use and nausea. Our fndings yielded small to medium
effect sizes for the effects of suggestive techniques on the
studied outcome measures, which are comparable to pre-
vious reports
57,b
; however, we were more conservative in
how we interpreted these results. The reason for our cau-
tion is the relatively high risk of bias in these studies mostly
originating from lack of blinding of participants, study
personnel and data assessors, and the lack of description
of random sequence generation and allocation methods.
Particularly, our analysis points out that in a large portion
of the studies showing a benefcial effect on postoperative
anxiety, random sequence generation is described insuff-
ciently, and that if we omit these studies, the previously
highly signifcant effect fades away. Furthermore, the effect
on pain intensity is only at the border of statistical signif-
cance. Thus, we conclude that although results point in the
right direction, we need more methodologically rigorous
studies to get a clear picture of the effectiveness of sugges-
tive interventions in surgery.
Contrary to our hypothesis but consistent with the report
of Schnur et al.,
5
we found that only hypnosis reduced post-
operative anxiety, and we found no signifcant effects for
therapeutic suggestions on any of the assessed outcome
measures.
The effect of presentation method revealed a complex
picture. Our moderator and sensitivity analyses yielded
that only interventions using live presentation were effec-
tive for reducing postoperative anxiety and pain intensity.
However, there was no substantial difference in the effec-
tiveness between therapeutic suggestions and hypnosis
for reducing analgesic requirement and nausea. Previous
research reported mixed results about the effects of pre-
sentation method. While Schnur et al.
5
supported the supe-
riority of live presentation compared to recordings for
reducing postoperative distress, 2 other meta-analyses
did not fnd a signifcant difference between face-to-face
and taped presentation.
4,6
Although Schnur et al.
5
only
addressed 1 outcome, Montgomery et al.
4
used a combined
effect size of several outcomes during the assessment of
this moderator effect. Previous reports also point out the
b
The markedly higher intervention effects reported by Montgomery and
colleagues
4
may be explained by the facts that contrary to the present
meta-analysis non-RCTs were included while studies not reporting ade-
quate statistics were excluded from their analysis, and that they used a
fxed effect model.
Figure 4. Effects of suggestive tech-
niques on postoperative pain medication
requirement. The effect is expressed as
corrected Hedges g with associated 99%
confdence intervals (CI). Black squares
show the point estimates of the effect
of individual studies with horizontal lines
corresponding to 99% CIs. The white dia-
monds (subtotal) represent the pooled
estimates and 99% CIs for each subgroup,
and the black diamond (total) shows the
pooled estimates and 99% CI for all stud-
ies. The sample sizes of the suggestion (N
sg) and control groups (N cg) of each study
and the heterogeneity scores for each
subgroup analysis are also displayed.
high correspondence between moderating factors; that is,
studies using live presentation also tend to use hypno-
sis instead of therapeutic suggestions and preoperative
instead of intra- or postoperative presentation of the inter-
vention. Therefore, reasons for differences in effective-
ness by presentation method could lie in a third variable.
Nevertheless, our results only support the effectiveness of
live intervention.
In line with previous reports, no signifcant moderator
effect was found for surgery type.
6
Suggestive interven-
tions had the same effectiveness for decreasing anxiety
and nausea in minor and major surgeries. However,
according to the sensitivity analysis, suggestions were
only effective for managing pain in minor procedures.
Major surgeries involve more effective analgesics com-
pared to minor surgeries because they infict more post-
operative pain.
19
Thus, it is possible that effects in major
procedures are masked by the rigorous analgesic proto-
cols. It is also possible that pain management techniques
used in suggestive interventions are less effective in cases
of severe pain.
Another important question is how do suggestive
techniques compare in effectiveness to other adjunct non-
pharmacological interventions. Early studies found small
to large effect sizes for preoperative interventions such
as patient education, behavioral instructions, relaxation,
and cognitive interventions for reducing postoperative
side effects such as pain, psychological distress, and anal-
gesic consumption.
3,20,21
In contrast, several studies are
more reserved in their reporting, concluding that there
is no suffcient evidence to support the benefcial effect
of these interventions.
2226
Similarly, the earliest studies
reported very large effects for suggestive techniques
4
;
however, effect size estimates became increasingly tem-
pered throughout the years,
57
and based on our results,
we now argue that the evidence is not yet strong enough to
make precise estimates of effectiveness. Additional studies
are needed in both felds before a meaningful comparison
of effcacy can be made.
Treatment effect of the interventions could be infuenced
by a number of additional moderators such as the number
of intervention sessions, customization of the intervention
to individual needs, the experience level of the surgeon
and the hypnotherapist, the level of procedure-related fear
and anxiety of the patient, or the presence and amount of
anxiolytic medication used. There are several possible mod-
erators specifc to suggestive techniques as well such as
the number of repetitions of suggestions, positive versus
negative phrasing of suggestions, specifc suggestive tech-
niques used, or the patients susceptibility to suggestions.
Information on these factors is generally absent from previ-
ous research reports. A possible direction for future stud-
ies could be to assess the importance of these moderators,
or at least to report relevant data to enable later systematic
comparisons.
LIMITATIONS
The present study has a number of limitations. A large
portion of the studies did not report baseline statistics
for the outcome measures; thus, only between-group
on postoperative nausea. The effect is
expressed as corrected Hedges g with
associated 99% confdence intervals
(CIs). Black squares show the point esti-
mates of the effect of individual studies
with horizontal lines corresponding to 99%
CIs. The white diamonds (subtotal) repre-
sent the pooled estimates and 99% CIs
for each subgroup, and the black diamond
(total) shows the pooled estimates and
99% CI for all studies. The sample sizes of
the suggestion (N sg) and control groups
(N cg) of each study and the heterogene-
ity scores for each subgroup analysis are
also displayed.

XXX 2014
Volume XXX

comparisons were used in the analysis. Access to within-
subjects data could have led to more accurate estimation
of effect sizes. The meta-regressions also indicated that
effects on anxiety might be biased by inappropriate ran-
dom sequence generation. Because of the overlap between
moderator conditions (e.g., studies with hypnosis induc-
tion were typically presented live, while therapeutic sug-
gestions were mostly presented from recordings), the
effects of live presentation and formal hypnosis are dif-
fcult to distinguish. The majority of the included studies
Figure 6. Moderator and sensitivity analyses for all outcomes. The effect is expressed as corrected Hedges g with associated 99% conf-
dence intervals (CIs). Black squares (Therapeutic suggestions or Hypnosis), discs (Recorded or Live presentation), and triangles (Minor or
Major surgery) show the point estimates of the pooled effects of studies with the same moderating factor with horizontal lines corresponding
to 99% CIs.
Figure 7. Summary graph of risk of bias
assessment results.
used single-blind design (no blinding of participants) and
passive control conditions (i.e., regular treatment) that
might have resulted in a bias favoring the intervention
because of expectancy effects. Furthermore, 16 of the 139
studies selected for detailed full text assessment could
not be retrieved. We also have to keep in mind that our
results only apply to the selected outcomes and cannot be
generalized. Clinically relevant outcome measures differ
between procedures, and there is a possibility that some
of the suggestive interventions were tailored to address
these specifc issues (e.g., the main aim of the intervention
in the study of Szevernyi et al.
27
was to reduce bleeding
during orthopedic surgery).
The novelty of the present study is that it included a
systematic search for both therapeutic suggestion inter-
ventions and hypnosis. This way we were able to draw
conclusions on suggestive interventions in general and
address the difference between hypnosis and therapeu-
tic suggestions in particular. Our results indicate that
suggestive interventions might help surgical patients to
cope with postoperative anxiety and pain; however, the
evidence is inconclusive, mainly because of the risk of
bias originating from methodological factors. For thera-
peutic purposes, we encourage the use of suggestions
with hypnosis induction and face-to-face presentation to
alleviate postoperative anxiety and pain. Further stud-
ies are needed with proper randomization, allocation,
and blinding with sensitivity to within-subjects changes
and incorporating rare combinations of moderator
factors (e.g., recorded hypnosis, live suggestions during
and after surgery and during general anesthesia, etc.).
We also encourage researchers to publish full-length
suggestion scripts used in their studies either as an
appendix or as an online supplement so that possible
suggestion-specifc moderators of effectiveness can be
evaluated.
E
DISCLOSURES
Name: Zoltn Kekecs, PhD.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Zoltn Kekecs has seen the original study data,
reviewed the analysis of the data, approved the fnal manu-
script, and is the author responsible for archiving the study
fles.
Conficts of Interest: One of the papers (Kekecs, et al., 2014
28
)
included in the review is a work of the frst authors (Zoltn
Kekecs).
Name: Tams Nagy, MA.
Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
Attestation: Tams Nagy has seen the original study data,
reviewed the analysis of the data, and approved the fnal
manuscript.
Conficts of Interest: This author declares no conficts of
interest.
Name: Katalin Varga, PhD.
Contribution: This author helped design the study and write
the manuscript.
Attestation: Katalin Varga has seen the original study data and
approved the fnal manuscript.
Conficts of Interest: Two of the papers (Szevernyi, et al.,
2012
27
; Kekecs, et al., 2014
28
) included in the review are works
of the third authors (Katalin Varga).
This manuscript was handled by: Franklin Dexter, MD, PhD.
Figure 8. Results of risk of bias assessment for each study.

XXX 2014
Volume XXX

ACKNOWLEDGMENTS
The authors express their warmest gratitude to Klra Horvth
and the library staff of Etvs Lornd University, Budapest,
for the help they provided in retrieving the papers included
in the review. The authors are also grateful to Dr. Carlton A.
Evans for his invaluable feedback on a previous version of the
manuscript. The authors also thank the contacted authors for
their cooperation in sharing details and data of their studies.
Table 2. Meta-Regressions with Risk of Bias Factors as Moderators
Model component Estimate SE z P 95%CI lower 95%CI upper
Anxiety
Intercept 0.41 0.33 1.22 0.828 0.25 1.06
Random sequence generation 0.69 0.28 2.48 0.018* 0.14 1.23
Allocation concealment 0.51 0.35 1.45 0.154 0.18 1.20
Blinding personnel 0.62 0.33 1.88 0.058 1.26 0.03
Blinding outcome assessment 0.13 0.32 0.39 0.642 0.50 0.75
Incomplete outcome data 0.27 0.27 1.02 0.304 0.81 0.26
Selective reporting 0.40 0.33 1.19 0.240 1.05 0.26
Pain
Intercept 0.02 0.69 0.03 >0.999 1.32 1.37
Random sequence generation 0.13 0.36 0.36 0.678 0.58 0.85
Selective reporting 0.09 0.47 0.18 >0.999 0.83 1.00
Pain medication
a
Intercept 0.32 0.68 0.47 0.490 1.66 1.01
Nausea
b
Intercept 0.18 0.43 0.41 >0.999 0.66 1.01
Blinding personnel 0.91 0.24 3.84 0.003* 1.38 0.45
CI = confdence interval.
a
All of the studies in the Pain medication dataset had Unclear risk of bias rating on Selective reporting.
b
All of the studies in the Nausea dataset had Unclear risk of bias rating on Blinding of outcome assessment and Selective reporting.
*P < 0.05.
Table 3. General Effects of Suggestive Interventions and Effects of Risk of Bias, Imprecise Inference and
Special Care
Pooled effect size, Lower and upper bounds and Z test Heterogeneity Moderator effect
Database involved Mean
g
SE Z P 99%CI
lower
99%CI
upper
k I
2
H
2
z P
Anxiety (all studies) 0.40 0.10 3.90 <0.001* 0.13 0.66 24 66.64% 3.00
Anxiety (with trim and fll) 0.31 0.10 3.06 0.002* 0.05 0.58 27 12.59% 3.32
Anxiety (without imprecise inference) 0.43 0.11 4.02 <0.001* 0.16 0.71 22 67.92% 3.12 1.19 0.235
Anxiety (without special care) 0.45 0.14 3.29 0.001* 0.10 0.80 15 66.99% 3.03 0.65 0.518
Pain intensity (all studies) 0.25 0.10 2.57 0.010* 0.00 0.50 19 52.39% 2.10
Pain intensity (with trim and fll) 0.32 0.10 3.33 <0.001* 0.07 0.57 22 60.01% 2.25
Pain intensity (without imprecise inference) 0.32 0.12 2.73 0.006* 0.02 0.62 15 57.66% 2.36 0.65 0.518
Pain intensity (without special care) 0.24 0.10 2.39 0.017 0.02 0.49 11 14.37% 1.17 0.11 0.910
Pain medication (all studies) 0.16 0.12 1.28 0.202 0.16 0.47 16 62.63% 2.68
Pain medication (with trim and fll) 0.31 0.13 2.43 0.015 0.02 0.63 20 78.40% 3.30
Pain medication (without imprecise inference) 0.16 0.12 1.28 0.202 0.16 0.47 16 62.63% 2.68
Pain medication (without special care) 0.21 0.18 1.14 0.256 0.26 0.68 10 73.40% 3.76 0.60 0.545
Nausea (all studies) 0.38 0.17 2.23 0.026 0.06 0.81 6 74.55% 3.93
Nausea (with trim and fll) 0.38 0.17 2.23 0.026 0.06 0.81 6 78.62% 3.93
Nausea (without imprecise inference) 0.45 0.19 2.39 0.017 0.03 0.93 5 76.47% 4.25 0.94 0.349
Nausea (without special care) 0.23 0.13 1.82 0.068 0.09 0.55 5 34.81% 1.53 2.58 0.010*
*P < 0.01.
REFERENCES
1. Wobst AH. Hypnosis and surgery: past, present, and future.
Anesth Analg 2007;104:1199208
2. Flory N, Salazar GM, Lang EV. Hypnosis for acute distress
management during medical procedures. Int J Clin Exp Hypn
2007;55:30317
3. Johnston M, Vgele C. Benefts of psychological preparation for
surgery: a meta-analysis. Ann Behav Med 1993;15:24556
4. Montgomery GH, David D, Winkel G, Silverstein JH, Bovbjerg
DH. The effectiveness of adjunctive hypnosis with surgical
patients: a meta-analysis. Anesth Analg 2002;94:163945
5. Schnur JB, Kafer I, Marcus C, Montgomery GH. Hypnosis to
manage distress related to medical procedures: a meta-analysis.
Contemp Hypn 2008;25:11428
6. Tefkow S, Barth J, Maichrowitz S, Beelmann A, Strauss B,
Rosendahl J. Effcacy of hypnosis in adults undergoing surgery
or medical procedures: a meta-analysis of randomized con-
trolled trials. Clin Psychol Rev 2013;33:62336
7. Flammer E, Bongartz W. On the effcacy of hypnosis: a meta-
analytic study. Contemp Hypn 2003;20:17997
8. Nelson EA, Dowsey MM, Knowles SR, Castle DJ, Salzberg
MR, Monshat K, Dunin AJ, Choong PF. Systematic review of
the effcacy of pre-surgical mind-body based therapies on
post-operative outcome measures. Complement Ther Med
2013;21:697711
9. Mazzoni G, Venneri A, McGeown WJ, Kirsch I. Neuroimaging
resolution of the altered state hypothesis. Cortex 2013;49:
40010
10. Varga K. The possible explanation of metaphors in re-interpret-
ing negative life events: our experiences with the critically ill.
Hypnos 2004;31:2017
11. Segen JC. Concise Dictionary of Modern Medicine. New York,
NY: McGraw-Hill, 2002
12. Higgins JPT, Altman DG, Sterne JAC. Assessing risk of bias
in included studies. In: Higgins JPT, Green S, eds. Cochrane
Handbook for Systematic Reviews of Interventions, Version
510 [updated March 2011]. Oxford, UK: The Cochrane
Collaboration, 2011. Available at: www.cochrane-handbook.
org., 2008:187241
13. Johnson BT, Eagly AH. Quantitative synthesis of social psy-
chological research. In: Reis HT, Judd CM, eds. Handbook of
Research Methods in Social Psychology London: Cambridge
University Press, 2000:496528
14. Lipsey MW, Wilson DB. Practical meta-analysis Thousand
Oaks, CA: SAGE Publications, Incorporated, 2001
15. Rosenthal R, Rubin D. Meta-analytic procedures for combin-
ing studies with multiple effect sizes. Psychological Bulletin
1986;99:4006
16. Decoster J. Meta-analysis. In: Kempf-leonard K, ed. The ency-
clopedia of social measurement. San Diego, CA: Academic
Press, 2004:119
17. Viechtbauer W. Conducting meta-analyses in R with the meta-
for package. J Stat Softw 2010;36:148
18. Massarini M, Rovetto F, Tagliaferri C. A controlled study to
assess the effects on anxiety and pain in the postoperative
period. European Journal of Clinical Hypnosis 2005;6:811
Figure 9. Funnel plots of all 4 datasets. Funnel plots of effect size (expressed as corrected Hedges g [g]) against standard error. The black dia-
monds show the pooled estimates and 95% CIs. Begg and Mazumdar rank correlation (anxiety:
B
= 0.08; P = 0.606; pain intensity:
B
= 0.09;
P = 0.629; pain medication:
B
= <0.01; P > 0.999; nausea:
B
= 0.07; P >0.999) and Egger test for funnel plot asymmetry (anxiety: z = 0.29;
P = 0.774; pain intensity: z = 0.65; P = 0.519; pain medication: z = 0.81; P = 0.418; nausea: z = 0.11; P = 0.913) did not indicate bias.

XXX 2014
Volume XXX

19. Gould TH, Crosby DL, Harmer M, Lloyd SM, Lunn JN, Rees
GA, Roberts DE, Webster JA. Policy for controlling pain after
surgery: effect of sequential changes in management. BMJ
1992;305:118793
20. Devine EC. Effects of psychoeducational care for adult surgi-
cal patients: a meta-analysis of 191 studies. Patient Educ Couns
1992;19:12942
21. Hathaway D. Effect of preoperative instruction on postopera-
tive outcomes: a meta-analysis. Nurs Res 1986;35:26975
22. McDonnell A. A systematic review to determine the effective-
ness of preparatory information in improving the outcomes of
adult patients undergoing invasive procedures. Clin Eff Nurs
1999;3:413
23. Johansson K, Nuutila L, Virtanen H, Katajisto J, Salanter S.
Preoperative education for orthopaedic patients: systematic
review. J Adv Nurs 2005;50:21223
24. Crowe L, Chang A, Fraser JA, Gaskill D, Nash R, Wallace K.
Systematic review of the effectiveness of nursing interventions
in reducing or relieving post-operative pain. Int J Evid Based
Healthc 2008;6:396430
25. Sindhu F. Are non-pharmacological nursing interventions for
the management of pain effective?A meta-analysis. J Adv
Nurs 1996;24:11529
26. Evans D. The effectiveness of music as an intervention for hos-
pital patients: a systematic review. J Adv Nurs 2002;37:818
27. Szevernyi C, Cserntony Z, Varga K. Ortopdsebszeti
nagymttek eltt s alatt alkalmazott pozitv szuggesztik
hatsa a betegre [The effect of therapeutic suggestions applied
before and during major orthopedic surgery] XXIII Hungarian
Hypnosis Meeting. Dobogk, Hungary, 2012
28. Kekecs Z, Jakubovits E, Varga K, Gombos K. Effects of patient
education and therapeutic suggestions on cataract surgery
patients: a randomized controlled clinical trial. Patient Educ
Couns 2014;94:11622
29. Ashton C Jr, Whitworth GC, Seldomridge JA, Shapiro PA,
Weinberg AD, Michler RE, Smith CR, Rose EA, Fisher S, Oz
MC. Self-hypnosis reduces anxiety following coronary artery
bypass surgery. A prospective, randomized trial. J Cardiovasc
Surg (Torino) 1997;38:6975
30. Blankfeld RP, Zyzanski SJ, Flocke SA, Alemagno S, Scheurman
K. Taped therapeutic suggestions and taped music as adjuncts
in the care of coronary-artery-bypass patients. Am J Clin Hypn
1995;37:3242
31. Cruise CJ, Chung F, Yogendran S, Little D. Music increases sat-
isfaction in elderly outpatients undergoing cataract surgery.
Can J Anaesth 1997;44:438
32. de Klerk JE, du Plessis WF, Steyn HS. The effect of hypnotherapeu-
tic ego strengthening with female spouses of South African coro-
nary artery bypass surgery patients. Am J Clin Hypn 2006;49:5972
33. Enqvist B, Fischer K. Preoperative hypnotic techniques reduce
consumption of analgesics after surgical removal of third man-
dibular molars: a brief communication. Int J Clin Exp Hypn
1997;45:1028
34. Enqvist B, Bjrklund C, Engman M, Jakobsson J. Preoperative
hypnosis reduces postoperative vomiting after surgery of the
breasts. A prospective, randomized and blinded study. Acta
Anaesthesiol Scand 1997;41:102832
35. Ghoneim MM, Block RI, Sarasin DS, Davis CS, Marchman JN.
Tape-recorded hypnosis instructions as adjuvant in the care
of patients scheduled for third molar surgery. Anesth Analg
2000;90:648
36. Ginandes C, Brooks P, Sando W, Jones C, Aker J. Can medical
hypnosis accelerate post-surgical wound healing? Results of a
clinical trial. Am J Clin Hypn 2003;45:33351
37. Hart RR. The infuence of a taped hypnotic induction treatment
procedure on the recovery of surgery patients. Int J Clin Exp
Hypn 1980;28:32432
38. Holden CA. A study of the effects of relaxation with guided
imagery on psychophysiological stress factors mediating sur-
gical wound healing. Austin, TX: The University of Texas,
1985
39. Jakubovits E, Janecsk M, Varga K. Mtt eltti-alatti szug-
gesztik hatsa a betegek posztoperatv llapotra [The effect
of pre- and intra-operative suggestions on patients post-
operative condition]. Aneszteziolgia s Intenzv Terpia
1998;28:39
40. John ME Jr, Parrino JP. Practical hypnotic suggestion in oph-
thalmic surgery. Am J Ophthalmol 1983;96:5402
41. Lauder GR, McQuillan PJ, Pickering RM. Psychological adjunct
to perioperative antiemesis. Br J Anaesth 1995;74:26670
42. Marc I, Rainville P, Verreault R, Vaillancourt L, Masse B, Dodin
S. The use of hypnosis to improve pain management during
voluntary interruption of pregnancy: an open randomized pre-
liminary study. Contraception 2007;75:528
43. Marc I, Rainville P, Dodin S. Hypnotic induction and therapeu-
tic suggestions in frst-trimester pregnancy termination. Int J
Clin Exp Hypn 2008;56:21428
44. Migly P, Krovits J, Jakab T, Gal K. Effects of ketamine anes-
thesia and stress-reducing psychological methods on surgery
patients. In: Spielberger CD, Sarason IG, Kulcsr Z, Van Heck
GL, eds. Stress and Emotion: Anxiety, Anger, and Curiosity. Vol
14. The series in clinical psychology and The series in stress
and emotion: Anxiety, anger, and curiosity. New York, NY:
Hemisphere Publishing Corp., 1991:21524
45. Montgomery GH, Bovbjerg DH, Schnur JB, David D, Goldfarb
A, Weltz CR, Schechter C, Graff-Zivin J, Tatrow K, Price DD,
Silverstein JH. A randomized clinical trial of a brief hypnosis
intervention to control side effects in breast surgery patients. J
Natl Cancer Inst 2007;99:130412
46. Nilsson U, Rawal N, Enqvist B, Unosson M. Analgesia follow-
ing music and therapeutic suggestions in the PACU in ambula-
tory surgery; a randomized controlled trial. Acta Anaesthesiol
Scand 2003;47:27883
47. Shulimson AD. The Effect of Postanesthetic Suggestion on
Postoperative Recovery. Lubbock, TX: Texas Tech University, 2011
48. Taenzer P. Self-Control of Postoperative Pain: Effects of
Hypnosis and Waking Suggestion. Montral, QC, Canada:
McGill University, 1983
49. van der Laan WH, van Leeuwen BL, Sebel PS, Winograd E,
Baumann P, Bonke B. Therapeutic suggestion has not effect on post-
operative morphine requirements. Anesth Analg 1996;82:14852
50. Woo R, Seltzer JL, Marr A. The lack of response to suggestion
under controlled surgical anesthesia. Acta Anaesthesiol Scand
1987;31:56771

Kekecs - The Effectiveness of Suggestive Techniques in Reducing Post-Operative Side-Effects

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Kekecs - The Effectiveness of Suggestive Techniques in Reducing Post-Operative Side-Effects

Caricato da

Copyright:

Formati disponibili

XXX 2014

Number XXX www.anesthesia-analgesia.org 1

Number XXX www.anesthesia-analgesia.org 3

Number XXX www.anesthesia-analgesia.org 5

Number XXX www.anesthesia-analgesia.org 7

Number XXX www.anesthesia-analgesia.org 9

Number XXX www.anesthesia-analgesia.org 11

Number XXX www.anesthesia-analgesia.org 13

Potrebbero piacerti anche