Supplementary Appendix 1. Literature Search Strategies
A) Medline
1. (surgery or surgical or preoperative or postoperative or post-operative or postsurgical or presurgical).mp.
2. Postoperative Complications/pc, px, th
3. Pain, Postoperative/pc, px, th
4. *Patient Education as Topic/
5. *Relaxation Therapy/
6. *Preoperative Care/
7. or/2-6
8. (psychol* or behav* or nursing*).mp,jw.
9. 1 and 7 and 8
10. limit 9 to "therapy (maximizes sensitivity)"
11. remove duplicates from 10
B) PsycINFO
1 (surgery or surgical or preoperative or postoperative or post-operative or postsurgical or presurgical or catheterization).mp.
2 (preparation or preparatory).mp.
3 exp Pain Management/
4 client education/
5 exp relaxation therapy/ or anxiety management/
6 (catastrophization or catastrophizing).mp.
7 (psychol* or behav* or nursing* or relax* or music or education or hypnosis).mp,jw.
8 or/2-7
9 1 and 8
10 (double-blind or random: assigned or control).tw.
11 clinical trials/
12 (controlled adj3 trial*).mp.
13 (clinical adj2 trial*).mp.
14 (randomi?ed adj7 trial*).mp.
15 or/10-14
16 9 and 15
C) CINAHL
S1surgery or surgical or preoperative or postoperative or post-operative or postsurgical or presurgical
S2(MH "Postoperative Complications")
S3(MH "Postoperative Pain")
S4(MH "Preoperative Education")
S5(MH "Patient Education")
S6(MH "Simple Relaxation Therapy (Iowa NIC)") OR (MH "Relaxation Techniques") OR (MH "Relaxation")
S7(MH "Preoperative Care")
S8(MH "Preoperative Period+")
S9S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8
S10S1 AND S9
S11S1 AND S9 Limiters - Clinical Queries: Therapy - Best Balance
S12S1 AND S9 Limiters - Exclude MEDLINE records; Clinical Queries: Therapy - Best Balance
S13S1 AND S9
D) CDSR
#1surgery or surgical or preoperative or postoperative or post-operative or postsurgical or presurgical:ti,ab,kw (Word variations have been searched)
#2(psychol* or behav* or nursing* or relax* or music or education):ti,ab,kw (Word variations have been searched)
#3(psychol* or behav* or nursing* or relax* or music or education):so (Word variations have been searched)
#4#2 or #3
#5#1 and #4 in Cochrane Reviews (Reviews and Protocols)
E) CENTRAL
#1surgery or surgical or preoperative or postoperative or post-operative or postsurgical or presurgical:ti,ab,kw (Word variations have been searched)
#2(psychol* or behav* or nursing* or relax* or music or education):ti,ab,kw (Word variations have been searched)
#3(psychol* or behav* or nursing* or relax* or music or education):so (Word variations have been searched)
#4#2 or #3
#5#1 and #4
#6pain
#7#5 and #6 in Trials
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Appendix Table 1. Characteristics of included trials
Author / Year / Trial design & patients characteristics / Intervention group / Intervention provider / Control groupCupal / 2001 / Single-center parallel trial in USA
Anterior Cruciate Ligament reconstruction
30 patients, 47% female 14; mean age 28 years.
Duration of symptoms: not reported / 1) Relaxation and guided imagery group: 10 individual sessions (30 mins each, every two weeks) over 6 months. All sessions began with several minutes of breath-assisted relaxation.
2) Psychological support group: received attention, encouragement, and support from a clinician. Each participant was asked to devote 10-15min per day to sitting quietly to visualize a peaceful scene.
Start: 2 weeks postop
Length of intervention: 6 months / Not reported / Usual care
Shuldham / 2002 / Single-center parallel trial in UK;
329 CABG patients, 12% female, Mean age 62.5 years. Duration of symptoms: not reported / The hospital education program: once for approximately 4 h in a group of between 10 and 15 people.
Start: Preop, not specified
Length of intervention: 4 hours / nurses, a physiotherapist, and a physician / Usual care
Cheung / 2003 / Multicenter parallel trial in Hong Kong, China
Stoma surgery for colorectal cancer
59 patients, 32% female, mean age 58 years.
Duration of pain: not reported / Progressive muscle relaxation training: two teaching sessions and practice at home for 10 weeks.
Start: Postop, not specified
Length of intervention: 2.5 months / Not reported / Usual care
Berge / 2004 / Single-center parallel trial in UK
Total hip replacement
40 patients, 61% female, mean age 71 years
Duration of symptoms: not reported / Pain management program: 1-2 mornings per week over six weeks and occupied 21.5 hours; group sessions (9-10 people per group), including patient education; Exercise; relaxation; using cognitive methods; goal setting, etc.
Start: Preop, not specified
Length of intervention: 1.5 months / Clinical psychologist, occupational therapist and a physiotherapist / Usual care
McGregor / 2004 / Single-center parallel trial in UK
Total hip replacement
35 patients, 71% female, mean age 71.9 years
Duration of symptoms: 40.0 months / Psychoeducation: a pre-operative hip class and an information booklet.
Start: 2-4 weeks preop
Length of intervention: Not reported / Not reported / Usual care
Burns / 2007 / Multicenter parallel trial in UK
Hip fracture surgery
293 patients (121 treatment group, 172 prevention group); 77% female, mean age: 81 years
Duration of pain: not reported / 1) Treatment trial: Nurse-led education intervention: 6 sessions.
2) Prevention trial: Cognitive-behavioral intervention. 7 sessions over 6 weeks.
Start: Within 2 weeks postop
Length of intervention: 1.5 months / Psychiatric nurse for intervention group; assistant psychologist for prevention group / Usual care
Dehdari / 2009 / Single-center parallel trial in Iran
CABG
110 patients, 28% female, mean age 59 years
Duration of pain: not reported / Progressive muscular relaxation training programme: twelve 40-min group education sessions over 6 weeks. Bernstein and Borkovic based on a classic muscle relaxation programme by Jacobson.
Start: 6 weeks postop
Length of intervention: 1.5 months / Rehabilitation therapist (not specified) / Usual care
Furze / 2009 / Single-center parallel trial in UK
CABG
204 patients, 20% female, mean age 65 years
Duration of symptoms: not reported / HeartOp Programme (Psychoeducation): 45–60 minute outpatients clinic education, followed by 10–15 minute phone calls at weeks 1, 3 and 6 (+/−1 week) and then monthly until they were admitted for their operation. Program comprises ofa two-part patient-held booklet (the HeartOp Plan) and relaxation programme on audiotape or CD and a diary for recording activity and risk factor reduction goals.
Start: 8 weeks preop
Length of intervention: 2 months / Nurse / Usual care and a two-part patient-held booklet (the HeartOp Plan)
Rollman / 2009 / Multicenter parallel trial in USA
CABG
302 patients, 41.4% female, mean age 64 years
Duration of symptoms: not reported / Telephone-delivered collaborative care (Psychoeducation): phone call (15-45mins) once biweekly for 8 months.
Start: Postop, but Not specified
Length of intervention: 8 months / Nurse care manager / Usual care
Abbott / 2010 / Single-center parallel trial in Sweden
Lumbar fusion surgery
107 patients, 62% female, mean age 51 years
Duration of symptoms: not reported / Psychomotor therapy: 3 sessions of outpatient psychotherapy and 12-week home exercise program over 3 month-period using Linton’s cognitive-behavioral early intervention program for groups and Richardson's graded motor relearning approach to lumbopelvic stabilization training.
Start: 3 weeks postop
Length of intervention: 3 months / Physiotherapist / Usual care and Richardson's graded motor relearning approach to lumbopelvic stabilization training
McGregor / 2011 / Multicenter factorial trial in UK
Spinal surgery
338 patients, 53% female, mean age 53.8 years
Duration of symptoms: not reported / Psychoeducation:
Booklet (only or booklet plus rehabilitation: 12 standardized 1-hour classes run twice weekly)
Start: 6-8 weeks postop
Length of intervention: 3 months / Physiotherapist / Usual Care
Louw / 2014 / Multicenter parallel trial in USA
Lumbar surgery
67 patients, 54% female, mean age 50 years
Duration of symptoms: 92 days / Psychoeducation: one averaged 30 min one-to-one neuroscience education (NE) + pre-operative NE booklet
Start: within 1-week preop
Length: 30 minutes / physiotherapist
/ Usual care
Feng / 2015 / Single-center parallel trial in Mainland, China
Colonic cancer surgery
120 patients, 43% female, mean age 54 years
Duration of pain: not reported / Cognitive-behavioral intervention: individualized psychological nursing intervention, including cognitive-behavioral intervention by lectures, discussion and booklets; establishing good patient nurse relationship, value rebuilt, positive reinforcement, encouragements, family support.
Start: Postop, not specified
Length of intervention: not reported / Nurses / Usual care
Rolving / 2015 / Multicenter parallel trial in Denmark
Lumbar Spinal Fusion
90 patients, 57% female, mean age 50.1 years
Duration of symptoms: not reported / Psychoeducation: six 3-hour group sessions (4 sessions pre-operatively and 2 sessions postoperatively).
Start: Preop, not specified
Length of intervention:6 months / psychologist, occupational therapist, physiotherapist, social worker, spine surgeon / Usual care
Archer / 2016 / Single-center parallel trial in USA
Lumbar laminectomy surgery
86 patients, 56% female, mean age 58 years
Duration of symptoms: 24.1 months / Cognitive-behavioral–based physical therapy and education: 6 sessions for 6 weeks, 60 mins for initial session, 30mins for subsequent sessions.
Start: 6 weeks postop
Length of intervention: 1.5 months / Physiotherapist / Usual care and 6 sessions of education
*USA: United States of America; UK: United Kingdom; CABG: Coronary artery bypass grafting;postop: post-operatively; preop: pre-operatively
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Appendix Table2. Risk of bias of included studies
Author / Year / Appropriate Sequence generation / Adequate concealment of treatment allocation / Blinding of patients / Blinding of intervention providers / Blinding of data collectors / Blinding of outcome assessors / Blinding of data analysts / Selective reporting / Loss to follow-upCupal / 2001 / No / No / No / No / No / No / No / No / 0%
Shuldham / 2002 / Yes / Yes / Yes / Yes / Yes / Yes / No / Yes / 8%
Cheung / 2003 / No / Yes / No / No / No / No / No / No / 6%
Berge / 2004 / Yes / No / No / No / No / No / No / No / 16%
McGregor / 2004 / No / No / No / No / No / No / No / Yes / 10%
Burns / 2007 / Yes / Yes / Yes / No / Yes / Yes / No / No / 36%
Dehdari / 2009 / No / No / No / No / No / No / No / No / 0%
Furze / 2009 / Yes / Yes / Yes / Yes / Yes / Yes / Yes / Yes / 14%
Rollman / 2009 / Yes / Yes / No / No / Yes / Yes / No / No / 16%
Abbott / 2010 / Yes / Yes / No / No / Yes / Yes / No / No / 19%
McGregor / 2011 / Yes / Yes / No / No / No / No / No / No / 13%
Louw / 2014 / Yes / Yes / Yes / Yes / Yes / Yes / Yes / No / 9%
Feng / 2015 / Yes / No / No / No / No / No / No / No / 0%
Rolving / 2015 / Yes / No / No / No / No / No / No / No / 14%
Archer / 2016 / Yes / Yes / Yes / Yes / Yes / Yes / Yes / No / 7%
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Appendix Table3. Subgroup analyses of psychological therapy
# Studies / WMD / 95%CI / interaction pSubgroup analyses for persistent post-surgical pain
Type of psychotherapy / Active psychotherapy / 8 / -0.94 / -1.46 / -0.42 / 0.01
Education/Support / 8 / -0.22 / -0.43 / 0.00
Blinding of patients / Yes / 5 / -0.40 / -0.85 / 0.05 / 0.64
No / 11 / -0.60 / -0.99 / -0.21
Blinding of intervention providers / Yes / 4 / -0.63 / -1.11 / -0.15 / 0.77
No / 12 / -0.51 / -0.86 / -0.17
Blinding of data collectors / Yes / 7 / -0.28 / -0.50 / -0.06 / 0.32
No / 9 / -0.74 / -1.28 / -0.21
Blinding of outcome assessors / Yes / 7 / -0.28 / -0.50 / -0.06 / 0.32
No / 9 / -0.74 / -1.28 / -0.21
Blinding of data analysts / Yes / 2 / -0.92 / -1.73 / -0.11 / 0.43
No / 14 / -0.49 / -0.80 / -0.17
Selective reporting / Yes / 2 / -0.40 / -1.09 / 0.29 / 0.87
No / 14 / -0.55 / -0.87 / -0.22
Type of surgery / Orthopedic surgery / 12 / -0.64 / -1.07 / -0.20 / 0.69
CABG / 3 / -0.51 / -1.27 / 0.25
Colonic cancer surgery / 1 / -0.44 / -0.84 / -0.04
Subgroup analyses for physical impairment
Type of psychotherapy / Active psychotherapy / 7 / -8.20 / -11.56 / -4.85 / 0.01
Education / 6 / -1.38 / -3.17 / 0.41
Blinding of patients / Yes / 3 / -1.61 / -6.23 / 3.02 / 0.24
No / 10 / -6.11 / -8.87 / -3.35
Blinding of intervention providers / Yes / 3 / -1.61 / -6.23 / 3.02 / 0.24
No / 10 / -6.11 / -8.87 / -3.35
Blinding of data collectors / Yes / 5 / -2.18 / -4.55 / 0.18 / 0.20
No / 8 / -6.70 / -9.89 / -3.51
Blinding of outcome assessors / Yes / 5 / -2.18 / -4.55 / 0.18 / 0.20
No / 8 / -6.70 / -9.89 / -3.51
Blinding of data analysts / Yes / 3 / -1.61 / -6.23 / 3.02 / 0.24
No / 10 / -6.11 / -8.87 / -3.35
Selective reporting / Yes / 2 / -1.00 / -6.85 / 4.85 / 0.34
No / 11 / -5.83 / -8.48 / -3.19
Type of surgery / Orthopedic surgery / 8 / -6.50 / -10.19 / -2.82 / 0.86
CABG / 3 / -5.96 / -14.89 / 2.98
Colonic or colorectal cancer surgery / 2 / -6.43 / -11.29 / -1.57
*CABG: Coronary artery bypass grafting
Appendix Table4. Sensitivity analyses
# Studies / Sample size / Effect / 95% CI1. Sensitivity analyses for active psychotherapy vs usual care
1.1 Persistent post-surgical pain
Primary analysis (WMD) / 8 / 632 / -1.06 / -1.56 to -0.55
Standard mean difference* / 7 / 522 / -0.66 / -1.05 to -0.27
No imputation for non-significant results (WMD)* / 7 / 522 / -1.16 / -1.69 to -0.63
1.2 Physical impairment
Primary analysis (WMD) / 7 / 566 / -9.87 / -13.42 to -6.32
Standard mean difference / 7 / 566 / -1.08 / -1.67 to -0.49
No imputation for non-significant results (WMD) / 7 / 566 / -9.87 / -13.42 to -6.32
2. Sensitivity analyses for education or support vs usual care
2.1 Persistent post-surgical pain
Primary analysis (WMD) / 8 / 1098 / -0.12 / -0.33 to 0.09
Standard mean difference* / 7 / 1022 / -0.11 / -0.24 to 0.01
No imputation for non-significant results (WMD)* / 7 / 1022 / -0.13 / -0.34 to 0.09
2.2 Physical impairment
Primary analysis (WMD) / 6 / 907 / -1.38 / -3.17 to 0.41
Standard mean difference† / 4 / 681 / -0.07 / -0.26 to 0.13
No imputation for non-significant results (WMD)* / 5 / 703 / -1.56 / -3.47 to 0.35
*Excluding one study with imputed data for non-significant result.
†Excluding two studies with imputed data for non-significant resultor no arm-level data
Appendix Figure1 Funnel plot of psychological therapy on persistent post-surgical pain and physical function
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