KEPERAWATAN MEDIKAL BEDAH III

“Review Jurnal : Terapi Komplementer Untuk

mengatasi Nyeri Luka Bakar ”

Oleh :

Nama : Dila Sintya Unwakoly

NPM : 12114201180157
Kelas/Sem : D/V
Prodi : Keperawatan

FAKULTAS KESEHATAN
UNIVERSITAS KRISTEN INDONESIA MALUKU
2020

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 KATA PENGANTAR

Puji dan syukur penulis panjatkan kehadirat Tuhan Yang Maha Esa. Karena atas kasih
dan karunia yang di berikannya sehingga penulis dapat menyelesaikan riview jurnal ini
dengan baik tanpa halangan yang berarti.

Rivew jurnal dengan judul “Terapi Komplementer Untuk Mengatasi Nyeri Luka
Bakar” ini merupakan salah satu tugas KEPERAWATAN MEDIKAL BEDAH III yang di
berikan oleh dosen mata kuliah. Riview jurnal ini bertujuan agar mahasiswa dapat memahami
apa saja terapi-terapi yang daoat di lakukan untuk mengatasi nyeri luka bakar pada pasien,
mencari terapi yang efektif untuk mengatasi nyeri luka bakar

Penulis mengcapkan terima kasih yang sebesarya bagi dosen mata kuliah yang telah
memberikan tugas ini sehingga penulis dapat lebih memahami aptentang terapi
komplementer untuk menghilangkan nyeri luka bakar.

Penulis sadar betul bahwa riview jurnal ini jauh dari kata sempurna dan oleh karena
itu penulis sangat mengharapkan kritik dan saran yang membangun dari semua pihak. Akhir
kata penulis ucapkan terima kasih dan semoga riview jurnal ini bermanfaat bagi kita semua.

Penulis

Ambon, 29 September 2020

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 DAFTAR ISI

Cover ....................................................................................................................... i

Kata Pengantar ........................................................................................................ ii

Daftar Isi ................................................................................................................. iii

Daftar Tabel ............................................................................................................ iv

Riview Jurnal Terapi Komplementer Untuk Mengatasi Nyeri Luka Bakar

(Format Pico) .......................................................................................................... 1

Analisi PICO ........................................................................................................... 4

Penutup ................................................................................................................... 6

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 DAFTAR TABEL

Tabel 1. Komponen kandungan zat dan fungsinya yang terdapat pada lidah buaya ......... 4

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 REVIEW JURNAL
Terapi Komplementer Untuk Mengatasi Nyeri Luka Bakar
(Format Pico)

Abstrak
Kulit merupakan salah satu organ tubuh yang rentan terjadi kerusakan, salah satunya
akibat suhu tinggi dapat menyebabkan luka bakar. Penyembuhan luka bakar sangat
tergantung dengan manajemen luka yang baik.
Luka Bakar adalah sejenis cedera pada daging atau kulit yang disebabkan oleh panas,
Listrik, zat kimia, gesekan, atau radiasi. Luka bakar jika berada dalam derajat keparahan
tinggi misalnya derajat dua dan tiga sering kali menyebabkan nyeri luka yang tak tertahankan.
Luka bakar yang parah juga dapat beresiko terjadi kematian, kecacatan, hilangnya
kepercayaan diri dan mengeluarkan biaya yang relatif banyak untuk penyembuhan. Penderita
luka bakar memerlukan pengobatan langsung untuk mengembalikan fungsi kulit normal.
Dalam riview jurnal keperawatan yang di ambil dari 5 jurnal ini membahas tentang cara yang
tepat dalam mengatasi nyeri yang terjadi pada luka bakar.

P (Population)
Dalam penelitian ini yang menjadi objek penelitian adalah Tikus Putih (Rattus
Norvegicus ) Jenis penelitian adalah True Eksperimen menggunakan rancangan post-test
with control group design. Sampel penelitian adalah 18 tikus putih dibagi menjadi 2
kelompok yaitu kelompok perlakuan dan kontrol, teknik sampling menggunakan random
sampling, Babi Putih Domestik dan juga Manusia.

I (Intervention)
Dari beberapa jurnal yang di kumpulkan dan di analisis penulis mempereoleh
beberapa terapi yang dapat di lakukan untuk mengatasi Nyeri Luka bakar yaitu, terapi music,
hipnotis, aleovera dan bee polen.
Terapi music bekerja hampir sama dengan terapi hipnotis dimana pasien di alihkn
perhatiannya dari nyeri yang di rasakannya. Sedangkan untuk terapi aleovera dan bee polen

1
memiliki beberapa sumber nutrisi yang kaya akan asam amino, karbohidrat, protein, vitamin
dan mineral yang berperan dalam mempercepat penyembuhan kulit. Selain itu efek sejuk
yang di timbulkan dari kedua bahan ini juga mampu meredakan nyeri Luka bakar.

C (Comparation)
Dalam mengerjakan Review jurnal ini penulis mengambil lima jurnal untuk di
bandingkan dengan satu sama lain. Tindakan ini bertujuan untuk mencari terapi manakah
yang lebih efektif untuk mengatasi nyeri pada luka bakar.
Terapi music memiliki korelasi positif ditemukan antara perawatan termasuk
intervensi musik dan pengurangan nyeri, pereda kecemasan, dan penurunan detak jantung
pada pasien luka bakar. Namun, studi tambahan berkualitas tinggi dengan intervensi musik
yang dipertimbangkan dengan cermat untuk pasien luka bakar masih diperlukan.
Terapi hipnotis mengurangi rasa sakit dibandingkan dengan perawatan standar dan
kelompok kontrol perhatian dan setidaknya sama efektifnya dengan terapi psikologis atau
perilaku tambahan yang sebanding. Selain itu, menerapkan hipnosis dalam beberapa sesi
sebelum hari prosedur menghasilkan persentase hasil yang signifikan tertinggi. Hipnosis
paling efektif dalam prosedur bedah minor. Namun, interpretasi dibatasi oleh risiko bias yang
cukup besar
Salep bee pollen dioleskan untuk pertama kalinya dalam pengobatan luka bakar
topikal. Luka bakar eksperimental terjadi pada dua babi putih domestic. Evaluasi klinis dan
histopatologi menunjukkan bahwa agen apitherapeutic yang diaplikasikan mengurangi waktu
penyembuhan luka bakar dan secara positif mempengaruhi kondisi umum hewan. Selain itu,
sediaan alami yang digunakan terbukti menjadi agen antimikroba yang sangat efektif, yang
tercermin dalam penurunan jumlah mikroorganisme dalam penelitian kuantitatif dan aktivitas
bakterisidal dari strain yang diisolasi. Berdasarkan analisis bakteriologis yang diperoleh,
dapat disimpulkan bahwa salep bee pollen yang dioleskan dapat mempengaruhi proses
penyembuhan luka luka bakar, mencegah infeksi pada jaringan yang baru terbentuk.
Meskipun demikian bee polen tidak cukup efektif dalam mengurangi nyeri. Hal ini di
karenakan tekstur beepolen yang kental mengakibatkan area luka menjadi tertarik dan
menyebabkan nyeri saat di gerakan

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 Pemberian Aleovera terutama lendirnya secara topikal pada luka dapat mempercepat
proses penyembuhan luka karena lendir aliovera mengandung glikoprotein, yang mencegah
inflasi rasa sakit dan mempercepat perbaikan dan glukomanan, yaitu senyawa yang diperkaya
dengan polisakarida yang dapat mempengaruhi faktor pertumbuhan fibroblas dan merangsang
aktivitas dan proliferasi sel dan meningkatkan produksi dan sekresi kolagen sehingga dapat
mempercepat penyembuhan luka dan merangsang pertumbuhan kulit. Selain itu aliovera
memiliki teksture ringan dan lembut juga menyejukan sehingga sangat membantu dalam
meredakan nyeri akibat luka bakar.

O (Outcame)
Dari hasil riview di temukan bahwa penggunaan terapi Hipnotis lebih efektif
dibandingkan terapi music hal di karenakan tidak semua orang memiliki ketertarikan yang
sama terhadap music. Ada sebagian orang yang menginginkan suasaan yang tenag untuk
mengatasi nyeri yang di rasakannya, oleh karena itu terapi hipnotis lebih efektif karena dapat
di kombinasikan dengan berbagai genre misalnya hipnotis music, visual, narasi dan
sebagainya. Hasil dari 29 RCT memenuhi kriteria inklusi menunjukkan bahwa hipnosis
mengurangi rasa sakit dibandingkan dengan perawatan standar dan kelompok kontrol
perhatian dan setidaknya sama efektifnya dengan terapi psikologis atau perilaku tambahan
yang sebanding. Selain itu, menerapkan hipnosis dalam beberapa sesi sebelum hari prosedur
menghasilkan persentase hasil yang signifikan tertinggi. Hipnosis paling efektif dalam
prosedur bedah minor.
Penggunaan aloevera juga sangat membantu dalam mengatasi nyeri luka bakar. aloe
vera berpengaruh terhadap penyembuhan luka bakar derajat pertama dan kedua karena aloe
vera dapat meningkatkan granulasi jaringan, antiseptik dan antiinflamasi. Daun lidah buaya
setiap daunnya terdiri dari tiga lapisan yaitu : sebuah gel yang dibagian dalam mengandung
99% air dan sisanya 75 terbuat dari vitamin, glukomannans, asam amino, lipid, dan sterol.
Bagian dalam lidah buaya mengandung banyak monosakarida dan polisakarida, vitamin B1,
B2, B6, dan C, niacinamide dan kolin, beberapa bahan anorganik, enzim (asam dan alkali
fosfatase, amilase, laktat dehidrogenase, lipase) dan Senyawa organik (aloin, barbaloin, dan
emodin) kandungan-kandungan ini sangat membantu dlaam meredakan nyeri serta
menyembuhkan Luka bakar

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 ANALISI PICO
Terapi Komplementer Untuk Mengatasi Nyeri Luka Bakar

Berdasarkan Review jurnal dengan menggunakan format PICO di atas dapat di

simpulkan bahwa penggunaan terapi hipnotis untuk menghilangkan nyeri akan memiliki
efektifitas yang tinggi bila di jalankan bersama-sama dengan terapi aleovera.
hipnosis secara signifikan menurunkan nyeri dibandingkan dengan kondisi kontrol
yang berbeda dengan karakteristik intervensi yang berbeda (waktu, lama, dosis), dan prosedur
medis. Kemampuan hipnotis dinilai dalam tujuh studi, empat di antaranya melaporkan
hubungan positif yang signifikan antara tingkat kerentanan hipnosis dan hasil terkait nyeri.
Hipnosis memiliki sejarah panjang dalam pengobatan nyeri, dan merupakan salah satu yang
paling teknik manajemen nyeri nonfarmakologis yang diakui. Begitu pula dengan aleovera,
yang memiliki sejarah panjang penggunaannya dan terbukti memiliki efektifitas yang baik
untuk mengatasi nyeri luka bakar. Pada 2000 tahun yang lalu, para ilmuwan Yunani
menganggap lidah buaya sebagai obat mujarab universal dan Lidah buaya (Aloe vera) telah
digunakan sebagai pengobatan di beberapa kebudayaan selama ribuan tahun tertama pada
negara Mesir, India, Meksiko, Jepang dan China. Aloe vera sudah digunakan sejak zaman
dahulu yaitu di Mesir, Ratu Nefertiti dan Cleopatra menggunakan lidah buaya sebagai
kecantikan, sedangkan Alexander Agung, dan Christopher Columbus menggunakannya untuk
mengobati luka prajurit. Aloe vera sudah digunakan sejak zaman dahulu yaitu di Mesir, Ratu
Nefertiti dan Cleopatra menggunakan lidah buaya sebagai kecantikan, sedangkan Alexander
Agung, dan Christopher Columbus menggunakannya untuk mengobati luka prajurit
Berikut ini adalah table 1. yang menunjukan komponen kandungan zat dan fungsinya
yang terdapat pada lidah buaya menurut Rodríguez, Castillo, García dan Sanchez, 2005 yaitu
Senyawa Identifikasi Fungsi
Asam amino Membuat 20 asam amino dan 7 Sebagai dasar untuk
esensial lainnya membangun blok protein dalam
tubuh dan jar
Antrakuin on Membuat Aloe emodin, Aloetic Analgetik dan anti bakteri
acid,alovin, anthracine

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 Enzim Anthranol, barbaloin,
chrysophanic acid, smodin,
ethereal oil, ester of cinnamonic
acid, isobarbaloin, resistannol
Hormon Auxins and gibberellins
Minerals Calcium, chromium, copper,
iron, manganese, potassium,
sodium and zinc
Asam Salisik Seperti kandunga aspirin
Saponins Glikosida
Steroids Cholesterol, campesterol,
lupeol, sistosterol
Gula Monosaccharides: Glucose and
Fructose Polysaccharides:
Glucomannans/po lymannose
Vitamin A, B, C, E, choline, B12, asam
folat
Anti jamur dan antivirus tetapi
beracun apabila konsentrasi
tinggi
Penyembuha luka dan anti
inflamasi
Untuk menjaga kesehatan
tubuh
Anal getik
Pembersihan dan antiseptik
Agen antiinflamasi, sedangkan
lupeol memiliki Sifat antiseptik
dan 76 analgesik
Anti virus dan stimulasi ssm
imunitas dalam tubuh
Sebagai Antioksidan (A, C, E),
dan menetralisir radikal bebas

Lidah buaya juga dapat berfungsi untuk menghambat jalur siklooksigenase,

mengurangi produksi prostaglandin E2 dari asam arakidonat dan mengandung peptidase
bradikinase yang dapat mengurangi pengeluaran bradikinin sehingga mengurangi proses
antiinflamasi. Kemudian, dalam lidah buaya terdapat Lupeol, merupakan kimia yang paling
aktif mengurangi peradangan dalam dosis tertentu dan sterol juga dapat berkontribusi
terhadap anti-inflamasi. Lidah buaya mengandung sterol termasuk campesterol, β-sitosterol,
dan kolesterol yang dapat mengurangi inflamasi, membantu dalam mengurangi peradangan
rasa sakit dan bertindak sebagai analgesik alami.
Penulis menyarankan penggunaan dua terapi ini bersamaan hal ini dapat memiliki
efektifitas yang tinggi dalam mengatasi nyeri luku bakar, selain itu luka dapat sembuh lebih
cepat sehingga, tidak memerluka waktu perawatan yang lama dan memakan biaya yang besar.

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 PENUTUP
Analisis Jurnal

1. Judul : The effects of music intervention on burn patients during treatment

procedures: a systematic review and meta-analysis of randomized controlled
trials
Penulis : Jinyi Li (Department of Humanities and Social Sciences, The Third Military
Medical University, Chongqing, China),
Liang Zhou (Research Institute of Field Surgery, Daping Hospital, The Third
Military Medical University, Chongqing, China. )
Yungui Wang (The Third Military Medical University, Chongqing 400038,
China)
Penerbit : BMC Complementary and Alternative Medicine
Tahun : 2017
Kelebihan dan Kekurangan :
 Penulis membahas secara terperinci terkait terai music
 Studi literasi yang dilakukan juga banyak dan berfariasi sehingga informasi yang
di perolehpun beragam dan luas
 Peneliti tidak melakukan uji coba secara langsung, dan membutuhkan banyak
penelitian yang lebih lanjut untuk menegakan pendapat yang telah di kemukakan

2. Judul : Pengaruh Pemberian Aloevera pada Pasien Luka Bakar

Penulis : Andri Nugraha (Mahasiswa Fakultas Keperawatan Universitas Padjadjaran
Bandung)
Urip Rahayu (Dosen Fakultas Keperawatan Universitas Padjadjaran
Bandung)
Penerbit : -
Tahun :-
Kelebihan dan Kekurangan :

6
  Jurnal membahas secara terperinci terkait aleovera, apa saja kandungan dan
manfaatnya serta cara kerja pada luka bakar
 Leterasi jurnal yang beragam membuat informasi yang di peroleh lengkap
 Bahasa yang digunakan mudah di pahami, sehingga tidak sulit untuk mencerna
dan meneliti kembali isi jurnal
 Informasi terkait jurnal tidak lengkap misalnya pada penerbit jurnal dan tahun
terbit jurnal

3. Judul : Bee Pollen as a Promising Agent in the Burn Wounds Treatment

Penulis : PaweB Olczyk (Departemen Farmasi Komunitas, Sekolah Farmasi dan
Divisi Kedokteran Laboratorium di Sosnowiec, Universitas Kedokteran
Silesia di Katowice, Kasztanowa 3, 41-200 Sosnowiec, Polandia)
Robert Koprowski (Departemen Sistem Komputer Biomedis, Fakultas Ilmu
Komputer dan Ilmu Material, Institut Ilmu Komputer, Universitas Silesia,
Bedzinska 39, 41-200 Sosnowiec, Polandia)
Justyna Kafmierczak, Lukasz Mencner, Krystyna Olczyk, Katarzyna
Komosinska-Vassev (Departemen Kimia Klinis dan Diagnostik
Laboratorium, Sekolah Farmasi dan Divisi Kedokteran Laboratorium di
Sosnowiec, Universitas Kedokteran Silesia di Katowice, Jednosci 8, 41-200
Sosnowiec , Polandia)
Robert Wojtyczka (Departemen dan Institut Mikrobiologi dan Virologi,
Sekolah Farmasi dan Divisi Kedokteran Laboratorium di Sosnowiec,
Universitas Kedokteran Silesia di Katowice, Jagiellonska 4, 41-200
Sosnowiec, Polandia )
Jerzy Stojko (Pusat Pengobatan Eksperimental, Medics 4, Fakultas
Kedokteran di Katowice, Universitas Kedokteran Silesia di Katowice, 40-
752 Katowice, Polandia)
Penerbit : Hindawi Publishing Corporation Pengobatan Pelengkap dan Alternatif
Berbasis Bukti
Tahun : 2016
Kelebihan dan Kekurangan :

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  Metode penulisan dan penelitian yang dilakukan baik dan memadai sehingga data
yang peroleh lengkap dan mudah di pahami
 Penggunaan table dalam menujukan hasil penelitian dan perkembangan membuat
data lebih mudah di pahimi
 Tidak ada penjelasan lebih lengkap tentang symbol dan hasil penelitian

4. Judul : Hypnosis For Acute Procedural Pain

Penulis : Cassie Kendrick, Jim Sliwinski, Yimin Yu, Aimee Johnson, William Fisher,
Zoltán Kekecs, dan Gary Elkins UniversitasBaylor, Waco, Texas, AS
Penerbit : HHS Public Access, Author manuscript
Tahun : Januari 2017
Kelebihan dan Kekurangan :
 Review artikel yang dilakukan terperinci dan meluas sehingga informasi yang di
peroleh juga lengkap
 Terdapat reviw tentang penelitian-penelitian yang telah di lakukan terkait terapi
hipnotis untuk mengatasi nyeri sehingga memiliki bukti yang kuat untuk
menegakan teori yang di kemukakan
 Penulisan abstrak tidak terlalu lengkap, misalnya tidak terdapat tujuan penelitian

5. Judul : Burns: First Aid

Penulis : Singh Kuldeep (HOD)
D. Pramod, Punia Sudhanshu, Singh Bikramjit (Resident )
Singh Bhupender (Assistant Professor)
Burns and Plastic Surgery, PGIMS, Rohtak, Haryana, India.
Penerbit : International Journal of Health Sciences & Research (www.ijhsr.org) 434
Vol.7; Issue: 8
Tahun : Agustus 2017
Kelebihan dan Kekurangan :
 Jurnal menjelaskan secara terperinci terkait luka bakar, derajat luka dan
penanganan yang tepat

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 Menjelaskan secara terperinci terkait pertolongan pertama untuk setiap kategori
dan derajat luka bakar
 Abstrak yang di lampirkan lengkap dan memadai
 Di dalam jurnal tidak terdapat penelitian yang menunjang teori-teori yang di
kemukakan di dalam jurnal

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Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
DOI 10.1186/s12906-017-1669-4

RESEARCH ARTICLE Open Access

The effects of music intervention on burn

patients during treatment procedures: a
systematic review and meta-analysis of
randomized controlled trials
Jinyi Li1, Liang Zhou2 and Yungui Wang3*

Abstract
Background: The treatment of burn patients is very challenging because burn injuries are one of the most severe
traumas that can be experienced. The effect of music therapy on burn patients has been widely reported, but the
results have been inconsistent. Thus, we performed a systematic review and meta-analysis of randomized controlled
trials in burn patients to determine the effect of music during treatments.
Methods: We searched a variety of electronic databases, including MEDLINE (via PubMed), EMBASE, Cochrane Library,
Psychinfo, VIP Database for Chinese Technical Periodicals (VIP) and China National Knowledge Infrastructure (CNKI) for
relevant trials on the basis of predetermined eligibility criteria. from their first available date through February 2016. Our
search focused on two key concepts: music interventions (including music, music therapy and music medicine) and
physical activity outcomes (including pain, anxiety, burn characteristics, dressing changes, wound care, debridement and
rehabilitation). Two reviewers independently screened records and extracted data from all eligible studies. Statistical
heterogeneity was determined using Q-test and the I2 statistic. The endpoints included standardized mean differences
(SMDs) and 95% confidence intervals (CIs). Publication bias was tested by Begg’s funnel plot and Egger’s test.
Results: A total of 17 studies met the inclusion criteria, for a total of 804 patients. A statistically significant difference in
pain relief was demonstrated between music and non-music interventions (SMD = −1.26, 95% CI [−1.83, −0.68]),
indicating that music intervention has a positive effect on pain alleviation for burn patients. The results indicated that
music interventions markedly reduced anxiety in individuals compared to non-music interventions (SMD = −1.22, 95% CI
[−1.75, −0.69]). Correspondingly, heart rate decreases were found after treatments that included music interventions
(SMD = −0.60, 95% CI [−0.84, −0.36]).
Conclusion: In summary, a positive correlation was found between treatments including music interventions and pain
alleviation, anxiety relief, and heart rate reduction in burn patients. However, additional high-quality studies with carefully
considered music interventions for burn patients are still needed.
Keywords: Music intervention, Burn patients, Pain, Anxiety, Meta-analysis, Systematic review

* Correspondence: c_q2014@163.com
3
The Third Military Medical University, Chongqing 400038, China
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Background
The treatment of burn patients is very challenging because
burn injuries are one of the most severe traumas that can
be experienced. As medical technology has advanced, the
majority of burn patients are now being successfully
resuscitated and typically undergo early escharotomy, skin
transplantation, and antibiotic administration in addition
to receiving nutritional support, which together dramati-
cally decrease their mortality rate [1]. However, burn
patients must still experience many painful procedures,
including skin grafting, escharectomy, debridement,
dressing changes and physical rehabilitation. Burn patients
usually face a series of physiological and psychological
problems during treatment. Pain is a major problem and
occurs during all stages of treatment. The adequate
management of pain may make recovery more tolerable
and affect morbidity by means of prevention of elevated
metabolism, thereby reducing the chance of malnutrition
and deterioration of the immune system [2]. And the
researchers question the safety of analgaesics and anxio-
lytics in patients with major burns because of their
requirement for massive fluid resuscitation has the poten-
tial for contributing to hemodynamic instability [3]. More-
over, the use of sedation and analgesia must be limited in
pediatric burn patients. There is a very close relationship
between anxiety and pain [4], and anxiety is the most
common emotional issue faced by burn patients, as re-
ported in early studies [5, 6]. As such, the treatment of
burn patients must incorporate a holistic view of pain and
anxiety. Effectively adjusting treatment parameters to
manage pain and anxiety is necessary for burn patients
throughout treatment.
The use of music interventions in the clinic has a long
history. These interventions have typically been used
during treatment and rehabilitation. To date, many studies
have reported the use of music as an intervention during
dental procedures, surgery, chemotherapy, and injections
[7–12]. Music interventions have also been used to
manage pain and anxiety in patients during medical pro-
cedures for many years. A study reported by Bradt showed
the effects of music interventions on preoperative anxiety
in surgical patients [8]. Furthermore, studies conducted by
Chlan et al. have shown that the use of music interven-
tions can reduce anxiety in ICU patients on mechanical
ventilation [13, 14]. Other authors have also demonstrated
anxiety reduction in mechanically ventilated ICU patients
through music interventions [15–17]. Wang et al. [18] has
indicated that the use of music interventions can signifi-
cantly improve pain score, anxiety, heart rate, arterial
pressure, and satisfaction score for patients undergoing a
variety of endoscopic procedures. Notably, Hole et al. [19]
demonstrated that music can help alleviate postoperative
pain, anxiety, and analgesia needs in addition to improving
patient satisfaction during recovery.
Page 2 of 14
Music as an intervention has wide applicability during
burn treatment. Particularly as a form of complementary
and alternative medicine (CAM), music therapy has
been widely used in multiple clinical fields due to its
non-pharmacological, non-invasive and easily accessible
features. The study of music interventions for burn pa-
tients began in the late 1970s. Christenberry published
the first paper regarding the application of music
therapy for burn patients and outlined a corresponding
protocol for the intervention [20].
Music intervention is widely used during dressing
changes and debridement to help decrease pain and
anxiety in burn patients. The majority of past studies have
indicated that music has positive effects with regard to the
alleviation of pain for burn patients, especially non-severe
pain [4, 21–27]. In addition, Robb et al. [28] found that
music assisted relaxation and decreased anxiety in burn
patients and increased their compliance during debride-
ment and dressing changes. However, some discrepancies
exist regarding the outcomes produced by the clinical ap-
plication of music therapy for pain management. Ferguson
[4] studied the effects of relaxing music on perceived
levels of pain and anxiety during range-of-motion
exercises and found that the music produced no
significant effects on pain relief. Furthermore, there were
no significant differences between pretest and post-test
anxiety scores following the music intervention. Another
study published in 2006 showed that the effects of music
interventions on pain and anxiety in pediatric patients
during donor-site dressing changes were not conclusive
[29]. Thus, the effects of music intervention remain un-
clear and require further investigation. In previous studies,
the primary types of music intervention investigated have
included music therapy and music medicine. Music ther-
apy is an interpersonal process during which professional
staff who have completed an approved music therapy
program use music and all of its facets—physical,
emotional, mental, social, aesthetic, and spiritual—to help
clients accomplish individualized goals [30]. Music medi-
cine involves relatively passive listening to pre-recorded
music offered by a researcher or clinician without the
involvement of a music therapist or a defined therapeutic
process.
Few reviews have been reported regarding the use of
music interventions for burn patients; indeed, only two
studies [31, 32] have reviewed the effects of music therapy
on burn patients, and these two studies were not meta-
analyses. Other studies have reviewed the effects of non-
pharmaceutical therapy, which is not restricted to music
therapy or music medicine on burn patients [3, 33]. No
review study thus far has conducted a meta-analysis
examining the effects of music interventions on burn
patients. The purpose of the current systematic review and
meta-analyses was to evaluate the effects of randomized
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158 Page 3 of 14

controlled trials (RCTs) of music interventions for burn excluded. Literature studies written in English and Chinese
patients during treatment procedures and to provide have been included in this manuscript.
recommendations for future research and clinical practice.
Data extraction
Primary outcome measurement in this meta-analysis
Methods
was pain intensity, while anxiety was considered a
Search strategy
secondary outcome measurement. Data were carefully
The study was designed in accordance with the Cochrane
and independently extracted from all eligible studies by
Handbook for Systematic Reviews of Interventions. Our
two investigators (JL, ZL according to the inclusion cri-
results were reported according to the Preferred Reporting
teria mentioned above using a prespecified Microsoft
Items for Systematic Reviews and Meta-Analysis
Excel spreadsheet. The extracted data included study
statement [34]. We performed a search of all literature
characteristics (e.g., author name, year of publication,
regarding the clinical application of music therapy on
sample size, patient age, total body surface area (TBSA)
burn patients using the following databases: MEDLINE
and type of music), effect measurements (e.g., pain score,
(via PubMed), EMBASE, Cochrane Library, Psychinfo,
level of anxiety, and heart rate), and quality indicators
VIP and CNKI. We searched the databases from their
(e.g., adequate sequence generation, allocation conceal-
earliest available dates through February 2016. Both
ment, and blinding). Disagreement was resolved by
MESH terms and free text words describing ‘the use of
discussion or consulting with a third reviewer (YW).
music interventions (including music therapy and music
medicine)’ and ‘the measurement of physical activity
Risk of bias assessment
outcomes (including pain, anxiety, burn characteristics,
The methodological quality of the studies was
dressing changes, wound care, debridement and
independently evaluated by two investigators (JL, ZL)
rehabilitation) were used in the search. The articles of
according to the Cochrane Risk of Bias tool for RCTs
these two sets were then combined using the Boolean
[35]. Any differences were resolved by consulting with
‘AND’ operator. The search builders were presented as
a third reviewer (YW).
follows: ‘music’ or ‘music intervention’ or ‘music ther-
apy’ or ‘music medicine’ AND ‘burn’ or ‘burn patient*’
Statistical analysis
or ‘burn pain’ or ‘burn anxiety’ or ‘dressing changes’ or
Statistical heterogeneity was determined using Q-test
‘debridement’ or ‘wound care’ or ‘burn rehabilitation
and the I2 statistic. For cases in which P ≤ 0.10 and I2 ≥
(Additional file 1: Table S1). Reference checking and
50%, a random effects model was applied. Otherwise, a
citation tracking of the included articles were manually
fixed effects model was used. The endpoints were SMDs
performed to identify additional studies meeting the
and 95% CIs. Publication bias was assessed using Begg’s
inclusion and exclusion criteria. In addition, we manu-
funnel plot and Egger’s test.
ally searched the Chinese databases of journals, disser-
tations and magazines for related articles as well as the
Results
references to these articles.
Study selection
After performing an extensive electronic search com-
Inclusion and exclusion criteria bined with a manual search, 491 records were identified,
The inclusion criteria were RCTs with a parallel group, resulting in an initial library of 409 references following
crossover or cluster design that included burn patients the removal of 82 duplicates. 354 records were excluded
undergoing various procedures (e.g., dressing changes, on the basis of title or abstract. Fifty-five full-text articles
debridement, range of motion exercises, and surgery). The reviewed to determine its eligibility for inclusion and
subjects in the intervention group received music interven- exclusion criteria. After an independent review of titles
tion before and/or during and/or after procedures, whereas and abstracts, 38 records were excluded for failing to
the subjects in the control group underwent procedures meet the inclusion criteria. A total of 17 RCTs were
without music. The music interventions included music included in the final review (Fig. 1). The following vari-
therapy and music medicine. The music could be live music ables were extracted from the included studies: length of
or recorded music, and the styles of music were not limited. study, size of trial sample, ages and genders of partici-
Studies were excluded if their raw data could not be pants, and procedures and intervention methods used.
extracted or if music was not the main intervention method These data are shown in Table 1.
used during treatment, such as interventions that involved
music combined with massage. Each article should be Study characteristics
scored according to the Cochrane Collaboration’s tool for The current review included 804 burn patients from 17
assessing risk of bias and those less than 2 points should be RCTs comparing patients undergoing treatments with
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 1 PRISMA flow diagram: study selection
and without music interventions. Table 1 lists characte-
ristics from all included studies. These trials included
nine studies published in Chinese [22, 27, 36–42] and
eight studies published in English [4, 24, 25, 28, 29, 43,
44]. The ages of the included patients ranged between 6
and 86 years old. Five studies reported the average age
of their patients. From a total of 17 literatures, two
literatures with 92 patients didn’t provide gender
information. There is a total of 722 patients in the rest
15 literatures, among them, 67.6% were male patients.
The types of procedures investigated included dressing
change [22, 29, 37, 43, 44], debridement [24, 26, 36, 39],
preoperative procedures [28], range of motion rehabilita-
tion [4], cold therapy [23], daily nursing care [40],
isolation [42] and hospitalization [25, 37, 38].
Most of the music used in the intervention was self-
selected by the patient [4, 28, 29, 38, 42, 44] or based on
a patient’s preferences [22, 24–26, 36]. Recorded music
was used in 15 studies, and live music was used in three
studies [24, 26, 29] (Table 1). The main methods used
for music intervention in the included trials were
attention distraction methods such as Muralvision or
musical alternate engagement (MAE) and relaxation
methods such as music-assisted relaxation (MAR) and
music-based imagery (MBI) (Table 1).
Outcome measurements
Pain intensity was assessed in ten studies [4, 22–26, 29,
36, 43, 44] using the following measurement tools: the
Visual Analogue Scale (VAS) [4, 22–25, 36], the Wong/
Baker Faces Rating Scale (WBFRS) [26, 29], the McGill
Pain Questionnaire (MGPQ) [43], the Nursing Assess-
ment of Pain Index (NAPI) [29] and the 11-point Likert
Page 4 of 14
scales (11-LS) [44]. In one study, pain intensity experi-
enced by pediatric patients was assessed using the
WBFRS and the NAPI [29] (Table 1). Only six studies
were included in this meta-analysis; the remaining four
studies were descriptively reviewed because data could
not be extracted from them.
Fifteen studies assessed anxiety descriptors [4, 22–26,
28, 29, 37–43] using the following measurement tools:
State-Trait Anxiety Inventory forms (STAI) [4, 22, 23,
28, 43], the Self-Rating Anxiety Scale (SAS) [37, 40–42],
the Hamilton Anxiety Scale (HAMA) [39], the Fear
Thermometer (FT) [29] and the VAS [24–26, 38]
(Table 1). However, six studies were excluded due to a
lack of raw data; therefore, only nine studies were
included in our analysis of anxiety descriptors (Table 1).
Blood pressure was evaluated based on measurements of
systolic blood pressure (SBP) and diastolic blood pressure
(DBP). Four studies reported the effects of music interven-
tion on SBP and DBP [22, 25, 28, 41]; of these, three were
included in the meta-analysis [22, 25, 41].
Heart rate, another continuous variable in terms of vital
signs, was extracted in four studies and combined in the
meta-analysis [22, 25, 29, 41]; of these, three studies
provided only descriptive reviews and were not included
in the meta-analysis [26, 28, 37].
Risk of bias
To assess the risk of bias, the patients were randomly
allocated into two groups; however, the majority of
included studies did not describe their exact methods of
randomization [4, 22–26, 28, 29, 36–39, 43, 44]. Only
three studies claimed that allocation was based on the
generation of a random number table [40, 41] or
Table 1 Characteristics of the included studies
Sample Age Gender TBSA(A) % Procedure Interventions Duration of Measurement
(treatment (male/ (range) music tools(D)
Technique(B) Music Selection Intervention Control Other
/ control) female)
description(C)
Miller et al. 17 (9/8) 40.9/27.8 16 M, 1 F 1–39% Dressing Muralvision Recorded Investigator- ①③ Placebo Medication During MGPQ,
(1992) [43] (mean change music selected music effect procedure STAI
treatment
/control)
Robb et al. 20 (10/10) 8–20 N/A N/A During MAR Recorded Self-selected ①②③④ Usual care Medication Before and STAIC
(1995) [28] preoperative music music during
period procedure
Fratianne et al. 25 7–83 16 M, 9 F 1–43% Debridement MBI & MAE Live music Patient’s ①②③④⑤ Usual care Medication Before, WBFRS,
(2001) [26] preferred music during VAS,
and after TOMRI
procedure
Haythronthwaite 42 43.6 32 M, 10 F 3–65% Dressing Music Recorded Self-selected ①③⑤ Sensory Medication 20 min 11-LS,
et al. (2001) [44] (mean) change distraction music music focusing, before and BDI,
usual during Burn-CSQ
care procedure
Ferguson et al. 11 (5/6) 18–75 8 M, 3 F 7–50% Range of Music Recorded Self-selected ①⑤ Usual care Exercise During VAS, STAIC, H-
(2004) [4] motion relaxation music music procedure PCMS
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158

Chen Shujuan 40 (20/20) 23–54 40 M 12–49% Debridement Music Recorded Investigator- ①③ Usual care No Twice a day HAMA,
et al. (2005) [39] process medicine music selected music for 30 min HRSD
each time;
30 days for
a course of
treatment
Whitehead- 14 (8/6) 6–16 5 M, 9 F N/A Dressing Music Live music Self-selected ①②③④ Verbal No During NAPI,
Pleaux et al. change therapy music interaction procedure WBFRS, FT
(2006) [29]
Lin Huiting et al. 40 (20/20) 20–55 40 M 13–50% Debridement Music Recorded Patient’s ①⑤ Usual care No During VAS
(2007) [36] process medicine music preferred music procedure
Tan et al. 29 8–71 24 M, 5 F 3–40% Debridement MBI & MAE Live music Patients’ music ①②③④⑤ Usual care Medication Before, VAS, MTIS
(2010) [24] process and recorded preferences during and
music after
procedure
Liu Chenyuan 120 (60/ 8–86 69 M, 51 F N/A Dressing Music Recorded Patient’s ①④ Usual care No 20 min VAS, STAI
et al. (2010) [22] 60) change medicine music preferred music before and
during
procedure
Liang Wanling 62 (31/31) 17–50 45 M, 17 F N/A Isolation area Music Recorded Self-selected ①③ Usual care No Patient- SAS, SDS
et al. (2010) [42] medicine music music by selected
patient/ family music
played for
1 h at 7:00
and 17:00
Page 5 of 14
Table 1 Characteristics of the included studies (Continued)
Yang Yong 46 (23/23) 36 (mean) 26 M, 20 F N/A During Music Recorded Self-selected ①③④ Usual care No Twice a day VAS, SDS
(2011) [38] hospitalization medicine music music from list for 20–30
min each
time
Zhang Qian 60 (30/30) 19–50 29 M, 31 F 4–5% Cold therapy Music Recorded Investigator- ①⑤ Usual care Cryotherapy During VAS, STAI
et al. (2012) [23] medicine music selected music procedure
Jiang Mingzhu 64 (32/32) 19–63 43 M, 21 F Ocular During Music Recorded Investigator- ①③ Usual care No At 9:00 and SAS
(2013) [41] hospitalization medicine music selected music 15:00 each
day for 30–
60 min each
time
Ren Yue et al. 72 (36/36) N/A N/A 20–60% Dressing Music Recorded Nurse-selected ①⑤ Usual care Medication 15 min SAS
(2014) [37] change medicine music music before and
during
procedure
Zhou Tao 42 (21/21) 47.2/45.1 23 M, 19 F N/A Daily nursing Music Recorded Investigator- ①③④ Usual care No Before and SAS, SDS
(2014) [40] (mean care medicine music selected music during
treatment/ procedure
control)
Najafi et al. 100 (50/ 31.08/31.18 62 M, 38 F 6–48% During Music Recorded Patient’s ①③⑤ Usual care Medication Music VAS
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158

(2015) [25] 50) (mean hospitalization intervention music preferred music intervention
treatment/ was offered
control) once a day
(20 min) for
3
consecutive
days
Abbreviations: MGPQ McGill Pain Questionnaire (including PPI and PRI; PPI Present pain intensity, PRI Pain rating index), WBFRS Wong/Baker Faces Rating Scale, NAPI The Nursing Assessment of Pain Index, STAI The
Spielberger’s State-Trait Anxiety Inventory, BDI The Beck Depression Inventory, VAS Visual analog scale, HAMA Hamilton Anxiety Scale, HRSD Hamilton Rating Scale for Depression, 11-LS 11-point Likert scales, STAIC The
State-Trait Anxiety Index for Children, FT The Fear Thermometer, TOMRI Trippett Objective Muscle Relaxation Inventory, MTIS The Muscle Tension Inventory Scale, H-PCMS Hewlett-Packard Component Monitoring Sys-
tem, SAS Self-Rating Anxiety Scale, SDS Self-Rating Depression Scale
(A) TBSA: Total body surface area. (B) Techniques. Muralvision: A distraction-relaxation music therapy technique combining video or pictures with music for distraction. MAR (music-assisted relaxation): This method in-
cludes music listening, deep diaphragmatic breathing, progressive muscle relaxation, and imagery. MBI (music-based imagery): The MBI component occurred in the patient’s room for 15 to 30 min before and after the
procedure and provided relaxing and safe experiences to the patient through music listening. MAE (musical alternate engagement): The MAE intervention was used to provide more physically engaging activities and
participatory musical tasks during dressing changes in the treatment area. (C) Intervention description①Music intervention form (music medicine or operational process);②Technique introduction (if the techniques of
music intervention has been introduced or not); ③Procedure description (Start time, End time, operational process); ④Materials and Settings (Instruments, stereo equipment, environment); ⑤Music characteristics
(style, genre, tempo, volume, et al.). (D) Measurement tools
Page 6 of 14
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
random lottery [42]. The blinding of treatment alloca-
tion was obtained by concealed envelopes in one study
[24]. Because of the nature of music intervention, the
evaluation criteria used for double-blinding were
obscure for most studies. Blinded methodology was used
as much as possible in the included studies. In one
study, the physicians treating the patients were blinded
regarding whether the patients were listening to music
prior to treatment [26]. In Najafi et al. study, a blinded
co-researcher recorded and measured the experimental
data [25]. In another study, to decrease rater bias, the re-
search nurses were not assigned to the patients in the
research group prior to the study [24]. In addition, two
of the studies did not provide any measurement raw data
but just final results and therefore demonstrated possible
outcome-reporting bias [37, 38] (Fig. 2).
Outcomes of meta-analysis
Primary Outcome
Pain. The meta-analysis of six trials and 260 burn
patients for measures of pain intensity demonstrated
significant heterogeneity (I2 = 81.6%, P < 0.001). The
pooled result from the random effects model
demonstrated significant differences in pain scores
between the music intervention group and the non-
music intervention group (SMD = −1.26, 95% CI
[−1.83, −0.68]) [23–25, 29, 36, 43] (Fig. 3). Music
intervention was found to reduce the pain experienced
by burn patients during treatment procedures.
Fig. 2 Results of bias risk assessments
Page 7 of 14
Four studies were included in descriptive reviews. In
Fratinanne et al. [26] study, self-reported pain was
improved in the music therapy group by over four
intervals during treatment procedures. The self-
reporting of pain was significantly decreased for those
who received music therapy compared to those who
did not. Liu Chenyuan et al. [22] study reported that
98.33% of patients had level 0 or level 1 pain during
dressing changes in the experimental group, while only
80% of patients in the control group had similar low
pain levels. The majority of patients in the control
group had significantly higher pain levels than those in
the experimental group during dressing changes.
However, contrary evidence was reported in other
studies. Haythronthwaite et al. found that patients in a
sensory focusing group experienced greater pain relief
than those in a music distraction group based on serial
pain ratings [44]. In Ferguson’s study, although there
was a difference between pretest and post-test pain
across groups, no difference in pain was found between
the groups [4].
Secondary Outcomes
Anxiety Level. The included anxiety scores
demonstrated statistically significant heterogeneity
(I2 = 87.0%, P < 0.001). The results showed a
statistically significant reduction in the anxiety levels
of the burn patients (SMD = −1.22, 95% CI [−1.75,
−0.69]) in the intervention group compared to those
in the control group [23–26, 29, 36–39, 41–43]
(Fig. 4).
Although the study reported by Robb et al. [28] did not
include sufficient data to be included in the meta-analysis,
a significant decrease in anxiety scores was found for the
experimental group compared to the control group.
Zhoutao reported that music intervention had a significant
positive effect on anxiety alleviation; the effective ratio of
the control group was 9.52%, whereas the effective ratio of
the experimental group was 52.38% (P < 0.05) [40].
Although two studies that were conducted in China were
not included in the meta-analysis due to a lack of pretest
raw data, the results of these studies also indicated that
music interventions significantly reduced anxiety for
severe burn patients [38] during hospitalization or during
dressing change when combined with anesthetics [37].
Fratinanne et al. [26] indicated that self-reported anxiety
during medical procedures was reduced by four intervals
in the music therapy group, but no statistical significance
was observed. Moreover, Ferguson and Voll also reported
that no significant reduction in anxiety was found during
therapy including music relaxation [4].
Heart Rate. The effects of music intervention on heart
rate during burn treatment procedures were extracted
from four studies in the meta-analysis [22, 25, 29, 41],
and the statistical heterogeneity for this variable was
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 3 Forest plot of music therapy for burn patients during treatment procedures, outcome parameter: pain
significant (I2 = 88.8%, P < 0.001). Compared with the
usual care group, heart rate was significantly decreased
in the music intervention group (SMD = −0.60, 95% CI
[−0.84, −0.36]) (Fig. 5).
Three studies that had reported the effects of music
interventions on heart rate were not included in the meta-
analysis due to ineligibility. Robb et al. [28] indicated that
music interventions showed no significant effect on heart
rate between pre- and post-test periods for either group.
Frantianne et al. [26] reported that music therapy had a
slight effect on heart rate, although the difference was not
significant. However, in Renyue et al. [37] study, the post-
test results revealed that music interventions decreased
heart rate significantly during dressing changes compared
to the control group.
Blood Pressure. Four studies reported on the effects of
music interventions on blood pressure [22, 25, 28, 41]; of
these, three were included in the meta-analysis. The
random effects pooled result did not demonstrate
differences between the intervention group and the
control group with regard to blood pressure during
treatment procedures (SBP: SMD = −0.37, 95% CI [−1.18,
0.45]; DBP: SMD = −0.24, 95% CI [−0.68, 0.20]) [22, 25,
Page 8 of 14
41] (Figs. 6 and 7). Similarly, Robb et al. [28] study found
no significant differences in heart rate between the pre-
and post-test period for either group.
Respiration Rate. Two of the four studies that
included information regarding the effect of music
therapy on respiration rate showed statistically
significant differences between pre- and post-
treatment measurements of respiratory rate across
the groups [4, 25]. The other two studies showed no
significant difference in respiration between groups
during the preoperative period or during dressing
changes [28, 29].
Publication bias
Publication bias was estimated using Begg’s test (for
pain, z = −1.43, P = 0.202; for anxiety, z = 0.36, P = 0.721)
and Egger’s linear regression test (for pain, z = 1.11, P
= 0.266; for anxiety, t = −1.18, P = 0.271). The results
suggested that there was no significant evidence of publica-
tion bias (Additional file 2: Figure S1). Furthermore, the
results of sensitivity analysis indicated that the overall
results in the meta-analysis were robust and reliable.
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 4 Forest plot of music therapy for burn patients during treatment procedures, outcome parameter: anxiety
Discussion
The purpose of the current systematic review was to
evaluate the effects of music interventions on burn
patients undergoing medical procedures.
During burn treatment and nursing, many factors
cause patients to experience pain, including the wound
itself, dressing changes, bathing, debridement, excision
and grafting. Furthermore, escharotomy, plastic surgery,
routine occupational therapy, physical therapy, nursing
care and rehabilitation therapy also induce pain. In the
current systematic review and meta-analysis, music was
used as an intervention in seven different types of proce-
dures, including dressing change, debridement, range of
motion exercise, preoperative preparations, cold therapy,
nursing care and isolation. The effects of music inter-
vention in other clinical fields, including for critically ill
patients receiving mechanical ventilatory support [13]
and coma patients [45], has been well studied. These
studies provide a reference for the application of music
therapy for burn patients in the ICU.
The current meta-analysis showed a significant decline
in pain intensity before and after patients received music
interventions. The majority of studies showed that music
Page 9 of 14
had a positive effect on pain relief; the burn patients
exposed to music typically reported low to moderate
amounts of pain during treatment. This result is consis-
tent with results from studies of the use of music for the
relief of chronic, non-severe pain [46]. However, one of
the studies included in the current systematic review
and meta-analysis showed that music therapy not only
reduced chronic pain but also severe pain [24]. A
prospective, randomized crossover clinical trial was
conducted in an inpatient burn unit using MBI and
MAE. The study indicated that music therapy decreased
pain, anxiety, and muscle tension in burn patients
during acute procedures [24]. So far, Tan’s findings were
different than that of Fratianne [26] and Prensner [47].
Therefore, larger sample studies regarding the effect and
application field of MBI & MAE are needed in the
future.
It is well known that the most widely accepted neuro-
logical principle underlying the mechanism for the asso-
ciation of music and pain relief is the gate control theory
of pain reported by Melzack and Wall [24, 29, 48]. This
theory asserts that stimulation by non-noxious input is
able to suppress pain. However, a recent study reported
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 5 Forest plot of music therapy for burn patients during treatment procedures, outcome parameter: heart rate
that music therapy modulates pain perception through
at least two different mechanisms that involve changes
in the activity of delta and gamma bands at different
stages of pain processing [49]. These results provided
novel insights into the neurological principals that
underlie the achievement of pain relief following music
therapy. It is necessary to find a solution to resolve the
pain and anxiety felt by burn patients undergoing treat-
ment procedures.
The use of music as an intervention has shown the
potential to reduce pain during burn treatment. Hay-
thronthwaite’s study indicated that the effect of music
on pain relief was more obvious in a sensory focusing
group compared with a music distraction group [44]. It
is worth noting that the music intervention methods
used in the music distraction group fell under the
purview of medicine rather than music therapy. Thus, if
rigorous music therapy methods were introduced into
this research according to treatment target, they may
produce the same effects as those observed in the
sensory focusing group. Tan’s study also proved this
point [24]. More studies are needed to reveal the roles
of music intervention, especially music therapy, in severe
pain control. However, based on the above-referenced
study by Hauck et al. [49], the combination of relaxation
Page 10 of 14
and distraction with music intervention may help
patients cope with pain. Although individual studies
have shown that submitting burn patients to music
interventions provides some evidence of decreased pain
intensity and anxiety, there have been no indications
that any specific type of music offers more benefits.
Consistent with previous studies, our study believed that
it is vital to establish appropriate standard protocols of
music therapy during different burn treatment procedures
[32]. In this study, four kinds of music therapy protocols
including Muralvision, MAR, MBI and MAE have been
used in these included studies. One literature which was
not included in this Meta-analysis introduced the effect of
other music therapy protocols including Song Phrase
Cued Response (SPCR)、Adapted Progressive Muscle Re-
laxation (APMR)、MBI and the Relaxation Response
Elicitation (RRE) during burn treatment. Those different
protocols have been adapted to meet the specific needs of
burn patients during specific procedures [47]. However,
further researches are still needed to provide evidence-
based clinical practice of music therapy protocol for
patients with specific needs.
Furthermore, in most studies, the music was selected
by patients from existing music lists or was the patient’s
own preferred music. However, in Chinese studies,
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 6 Forest plot of music therapy for burn patients during treatment procedures, outcome parameter: SBP
music interventions have mainly relied on music medi-
cine. In China, the quality of music intervention still
needs improvement due to the lack of professional
music therapists and standardized training. The im-
provement of professional music therapy may promote
future research into music therapy in China.
Eleven studies reported significant anxiety relief
between the intervention group and the control group.
Correspondingly, patient satisfaction also improved dur-
ing treatment in three studies [37, 38, 42]. However, the
results of these trials differed from those in other studies
in the review, and they did not provide enough raw data
on specific indicators to support the meta-analysis or
answer our email requests for more detailed data [4, 44].
More appropriate measurement scales and methods
for relieving pain and anxiety are needed for burn
patients. In the 17 studies included here, many different
scales were used to measure pain and anxiety. The VAS,
the MGPQ, the WBFRS and the NAPI were used to
measure pain, while the STAI, the VAS, the FT, the
HAMA and the SAS were used to measure anxiety.
However, Tan’s research showed that the graphic rating
scale, the MGPQ and the STAIR are not suitable for the
study of burn patients since these measurements are all
subjective self-reports. However, this point of view is still
controversial Furthermore, Whitehead-Pleaux et al. [29]
Page 11 of 14
found that the FT could not capture the effects of music
on pain and anxiety on pediatric patients undergoing
painful procedures due to their limited understanding of
the terms.
Meanwhile, we found that the application of analgesic
during burn treatment has received more and more at-
tentions [24, 26, 47]. One study demonstrated a positive
correlation between burn patient increased comfort
levels when music therapy was used in conjunction with
pharmaceutical treatments [32]. However, no data could
be extracted from the included literatures regarding the
effect of music therapy on analgesic use. Thus, further
studies are needed to investigate the effect of music
therapy on pain medication during burn treatment. In
addition, burn patients not only faced physical pain, but
also psychological distress. Therefore, to establish a
physical-psychological intervention program becomes
necessary for burn patients. The current systematic
review and meta-analysis is the first to assess the effect-
iveness of music interventions on burn patients under-
going treatment. However, the study results should be
interpreted in light of its limitations, most of which are
related to the original trials. First, in the majority of the
17 included studies, the risk of bias was moderate. The
overall trial quality was reduced due to the lack of con-
cealed allocation or blinded therapists assessing outcome
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Fig. 7 Forest plot of music therapy for burn patients during treatment procedures, outcome parameter: DBP
measures. Second, the sample sizes in most of the trials
were small. Third, there was heterogeneity in the types
of patient populations studied, types of music interven-
tions applied, and types of treatment used. Although
heterogeneity existed among the studies, the standar-
dized mean differences per group were calculated, and
the results for the pain and anxiety intensity outcomes
were pooled. In addition, we would have attempted to
adjust for the heterogeneity by performing a subgroup
analysis or a meta-regression analysis, but the number of
studies was insufficient to perform these analyses.
Moreover, some of the studies lacked quantitative mea-
surements of specific indicators, making their inclusion
in the meta-analysis risky. However, we included these
study results in the review to avoid potential bias.
Conclusions
In conclusion, our study presents limited evidence from 17
individual trials that burn patients may experience cumula-
tive benefits from music interventions in terms of decreased
pain and anxiety, leading to better treatment prognosis.
Music intervention has a positive effect on pain alleviation,
anxiety reduction and heart rate control, which provides evi-
dence to support the advantages of its use during burn treat-
ment. Further high-quality studies with carefully considered
Page 12 of 14
music interventions are recommended to provide more solid
evidence on both the short-term and long-term effects of
this intervention strategy on burn patients.
Additional files
Additional file 1: Table S1. Search strategy. (DOC 31 kb)
Additional file 2: Figure S1. Begg’s funnel plot and Egger’s linear
regression test. (A) Begg’s funnel plot for pain. (B) Begg’s funnel plot for
anxiety. (C) Egger’s linear regression test for pain. (D) Egger’s linear
regression test for anxiety. (JPG 237 kb)
Abbreviations
11-LS: 11-point Likert scales; CAM: Complementary and alternative medicine;
CIs: Confidence intervals; CNKI: Chinese National Knowledge Infrastructure;
CqVip: Chongqing Vip of Chinese Science and Technology Periodical
Database; DBP: Diastolic blood pressure; FT: Fear Thermometer;
HAMA: Hamilton Anxiety Scale; I2: I-square; MAE: Musical alternate
engagement; MAR: Music-assisted relaxation; MBI: Music-based imagery;
MGPQ: McGill Pain Questionnaire; NAPI: Nursing Assessment of Pain Index;
RCTs: Randomized controlled trials; SAS: Self-Rating Anxiety Scale;
SBP: Systolic blood pressure; SMDs: Standardized mean differences;
STAI: State-Trait Anxiety Inventory forms; TBSA: Total body surface area;
VAS: Visual Analogue Scale; WBFRS: Wong/Baker Faces Rating Scale
Acknowledgments
We are grateful to the contribution of Dr. Jun Wu from burn center of
southwest hospital for providing helpful advice and comments on the
quality appraisal of the included studies.
Li et al. BMC Complementary and Alternative Medicine (2017) 17:158
Funding
This research was supported by 2014 Chongqing Youth Social Science
Projects, Grant Reference Number: 2014QNYS35.
Availability of data and materials
All the data and materials which supporting this manuscript are authentic.
We would like to share all these data to readers of your journal.
Authors’ contributions
YG W supervised JY L and L Z to perform this review and revised the
manuscript. JY L and L Z conducted the database search, assessed studies
for inclusion, extracted and analyzed the data, and drafted the manuscript.
YG W assessed studies for inclusion, extracted the data which followed by
cross checking with JY L. L Z was responsible for the statistics analysis. JY L
amended English writing of this review. YG W and JY L arbitrated any
disagreements. All authors have read and approved the final version of the
manuscript.
Competing interests
The authors declare that they have no competing interests.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable. All analyses were based on previous published studies, thus
no ethical approval and patient consent are required.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Humanities and Social Sciences, The Third Military Medical
University, Chongqing, China. 2Research Institute of Field Surgery, Daping
Hospital, The Third Military Medical University, Chongqing, China. 3The Third
Military Medical University, Chongqing 400038, China.
Received: 4 June 2016 Accepted: 7 March 2017
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 PENGARUH PEMBERIAN ALOE VERA PADA PASIEN LUKA BAKAR
“STUDI LITERATUR”
1
Andri Nugraha, 2 Urip Rahayu

Abstrak

Luka bakar mengakibatkan berbagai masalah yaitu masalah kematian, kecacatan, hilangnya
kepercayaan diri dan mengeluarkan biaya yang relatif banyak untuk penyembuhan. Penderita
luka bakar memerlukan pengobatan langsung untuk mengembalikan fungsi kulit normal.
Oleh karena itu, aloe vera digunakan sebagai terapi alternatif yang efektif serta biaya yang di
keluarkan lebih terjangkau. Penelusuran literatur ini bertujuan untuk menganalisa hasil
penelitian yang berfokus pada efek penggunaan aloe vera terhadap penyembuhan luka bakar
Metode : Penelaahan ini dilakukan dengan metode review literatur dari 9 jurnal yang
didapatkan melalui media elektronik, dengan kata kunci aloe vera, burn injury, management
burn injury, dan therapy. Hasil: aloe vera berbentuk segitiga, daun berdaging dengan tepi
bergerigi, memiliki bunga tubular kuning, mempunyai banyak biji dan memiliki panjang 30 -
50 cm dan luas dasarnya 10 cm. aloe vera diberikan untuk mengobati pasien luka bakar
derajat pertama dan derajat ke dua. Luka bakar yang diberikan aloe vera lebih cepat
mengalami proses penyembuhan dan epitalisasi jaringan kulit karena didalam aloe vera
terdapat kandungan antiseptik, antiinflamasi dan meningkatkan granulasi jairngan.
Kesimpulan: aloe vera berpengaruh terhadap penyembuhan luka bakar derajat pertama dan
kedua karena aloe vera dapat meningkatkan granulasi jaringan, antiseptik dan antiinflamasi.
Kata kunci : Aloe vera, luka bakar, terapi

Abstract

Burn injury give some effects, there are death, disabilities, loss of confidence and the high
cost of healing. Burn injury patient needs treatment conducted directly to return the skin
function. Therefore, aloe vera can be used as an inexpensive alternative treatment. Aims of
the study: This literature search aimed to analyzethe results ofstudythat focuses oneffects
ofthe use ofaloeveraforthe healing of burn injury. Method of the study:This study use
literature review method ofnine electronic journal andthe keywords used are aloe vera, burn
injury, management burn injury and therapy. Result of study:Aloeverahas a shapesuch asa
triangle with tubular yellow flowers, fleshy leaveswithjagged edges, a lot of seeds and has a
length of 30-50 cm and width 10 cm. Aloe vera given to treat first and second degree burn
injury patients. Burn injuries were treated by aloe vera can heal faster and epithelializationof
skin tissue because aloe vera contains antiseptic,anti-inflammatory and increase granulation
tissue. Conclusions: aloe verais possible to heal first and second degree of burn injury
because aloe vera can improve thegranulationtissue, antisepticandanti-inflammatory.
Keyword: Aloe vera, burn injury, therapy

PENDAHULUAN bahan kimia. Smeltzer & Bare, 2010). luka

Luka bakar adalah rusaknya bakar mengakibatkan berbagai masalah
sebagian jaringan tubuh yang disebabkan yaitu masalah kematian, kecacatan,
karena perubahan suhu yang tinggi, hilangnya kepercayaan diri dan
sengatan listrik, ledakan, maupun terkena mengeluarkan biaya yang relatif banyak

72
untuk penyembuhan (Sjamsuhidajat & Vermeulen, 2010). Namun, hal ini
Wim, 2005). membuat perawatan luka bakar
Luka bakar merupakan salah satu mengeluarkan biaya yang mahal sehingga
trauma yang sering terjadi dalam dibutuhkan aloe vera sebagai terapi yang
kehidupan sehari-hari, bahkan sering kali efektif dan biaya yang di keluarkan lebih
pada kecelakaan masal dan paling terjangkau (Shahzad & Ahmed, 2013).
terbanyak ditemukan terjadi di rumah Lidah buaya (Aloe vera) merupakan
adalah luka bakar derajat II (Nurdiana, , tanaman asli Afrika, yang memiliki ciri
Hariyanto, & Musrifah, 2008). Luka fisik daun berdaging tebal, sisi daun
bakar tergolong kasus epidemik yang berduri, panjang mengecil pada ujungnya,
serius dalam setiap tahun. Sebuah berwarna hijau, dan daging daun berlendir
penelitian di Amerika menunjukkan (Yeh, Eisenberg, Kaptchuk and Phillips,
prevalensi pasien dengan luka bakar 2003).
sebanyak 10 juta kasus (Driscoll, Patrick, Tujuan dari literature review ini
2009) dan setiap tahun, sekitar 1 juta orang adalah untuk menganalisa hasil penelitian
menderita luka bakar (Edelman, 2009), yang berfokus pada efek penggunaan Aloe
sedangkan menurut Departemen vera sebagai pengobatan pada pasien luka
Kesehatan Replublik Indonesia (2008) bakar untuk meminimalkan potensi
prevalensi luka bakar di Indonesia sebesar terjadinya infeksi selama proses
2,2%. perawatan.
Untuk mengatasi luka bakar harus
dilakukan perawatan kompleks yaitu METODE PENELITIAN
mengurangi nyeri pada tubuh, memerlukan Penelusuran ini dilakukan dengan
perawatan di rumah sakit yang lama metode telaah literatur yang didapat
dengan berbagai macam prosedur operasi melalui media elektronik (internet). Kata
dan waktu rehabilitasi yang lama kunci yang digunakan dalam penelusuran
(Khorasani, 2009). Penderita luka bakar literatur adalah aloe vera, burn injury,
memerlukan pengobatan langsung untuk management burn injury, dan therapy.
mengembalikan fungsi kulit normal Literatur didapat dari website EBSCOhost,
(Cuttle et al., 2006). Salah satu terapi luka Proquest dan google scholar. Jurnal yang
bakar saat ini adalah dengan diperoleh berjumlah 23 jurnal dan yang
mengoleskan hidrogel sebagai obat memenuhi kriteria berjumlah 9 jurnal.
topikal (Erizal, 2008) dan silver Penulis dari jurnal yang didapat memiliki
sulphadiazine (Versloot, Vos, Ubbink, & latar belakang tenaga kesehatan dengan

73
spesialisasi di bidang keperawatan,
kedokteran spesialis kecantikan
biologi. Jurnal yang diambil merupakan
original article sehingga data
disajikan lengkap dan memudahkan dalam
penelahaan penelitian.
HASIL DAN PEMBAHASAN
Sejarah Aloe Vera
Lidah buaya atau dikenal juga
sebagai Aloe barbadensis Mill., Aloe
indica Royle, Aloe perfoliata L. var. vera
dan A. vulgaris Lam merupakan tanaman
milik keluarga Liliaceae, yang ada lebih
dari 360 spesies yang diketahui (Dat AD,
Poon F, Pham KBT, Doust J, 2011). Nama
tanaman Aloe Vera (lidah buaya) berasal
dari berbagai bahasa diantaranya yaitu kata
Arab "Alloeh" yang berarti "zat pahit yang
bersinar," sementara "vera" dalam bahasa
Latin berarti "benar". Sedangkan, menurut
bahasa mesir Aloe yang berarti "tanaman
keabadian" Surjushe, A., Vasani, R., &
Saple, 2008).
Aloe vera digunakan sebagai obat
dilakukan sejak dahulu. Pada 2000 tahun
yang lalu, para ilmuwan
menganggap lidah buaya sebagai obat
mujarab universal dan Lidah buaya (Aloe
vera) telah digunakan sebagai pengobatan
di beberapa kebudayaan selama ribuan
tahun tertama pada negara Mesir, India,
Meksiko, Jepang dan China. (Pankaj,
Sahu, 2013). Aloe vera sudah digunakan
sejak zaman dahulu yaitu di Mesir, Ratu
dan Nefertiti dan Cleopatra menggunakan lidah
buaya sebagai kecantikan, sedangkan
yang Alexander Agung, dan Christopher
Columbus menggunakannya untuk
mengobati luka prajurit (Marshall, 1990;
Surjushe, A., Vasani, R., & Saple, 2008).
Referensi pertama tentang Aloe vera yang
di terjemahkan dalam bahasa Inggris
adalah sebuah terjemahan oleh John
Goodyew pada tahun 1655 dari
Dioscorides De Materia Medic (risalah
medis). Aloe vera Pada awal 1800-an telah
digunakan sebagai pencahar di Amerika
Serikat, tetapi di pertengahan 1930 terjadi
perubahan penggunaan lidah buaya
digunakan untuk mengobati dermatitis
kronis dan berat (Surjushe, A., Vasani, R.,
& Saple, 2008)
Anatomi, Fisiologi Dan Kandungan
Kimia Pada Aloe Vera
Aloe vera (Lidah buaya) memiliki
bentuk yang khas dibandingkan dengan
tanaman yang lainnya yaitu aloe vera
berbentuk segitiga, daun berdaging dengan
tepi bergerigi, memiliki bunga tubular
Yunani kuning, mempunyai banyak biji dan
memiliki panjang 30 - 50 cm dan 10 cm
luas dasarnya (G. Y. Yeh, D. M.
Eisenberg,T. J. Kaptchuk and R. S.
Phillips, 2003; Pankaj, Sahu, 2013). Daun
lidah buaya setiap daunnya terdiri dari tiga
lapisan yaitu : sebuah gel yang dibagian
dalam mengandung 99% air dan sisanya
74
terbuat dari vitamin, glukomannans, asam Bruneton, 1995; Surjushe, A., Vasani, R.,
amino, lipid, dan sterol. (Brown, 1980; T. & Saple, 2008; Pankaj, Sahu, 2013).
Reynolds & A. C. Dweck, 1999; Surjushe, Dibawah ini merupakan komponen
A., Vasani, R., & Saple2008; Pankaj, kandungan zat dan fungsinya yang
Sahu, 2013). Bagian dalam lidah buaya terdapat pada lidah buaya menurut
mengandung banyak monosakarida dan Rodríguez, Castillo, García dan Sanchez,
polisakarida, vitamin B1, B2, B6, dan C, 2005 yaitu
niacinamide dan kolin, beberapa bahan Senyawa Identifikasi Fungsi
Asam Membuat 20 asam Sebagai
anorganik, enzim (asam dan alkali amino amino dan 7 dasar untuk
esensial lainnya membangun
fosfatase, amilase, laktat dehidrogenase, blok protein
dalam tubuh
lipase) dan Senyawa organik (aloin, dan jaringan
barbaloin, dan emodin) (Hayes. 1999; otot
Antrakuin Membuat Aloe Analgetik
Surjushe, A., Vasani, R., & Saple, 2008; on emodin, Aloetic dan anti
acid,alovin, bakteri
Pankaj, Sahu, 2013). anthracine
Enzim Anthranol, Anti jamur
Lapisan tengah aloe vera yang barbaloin, dan antivirus
chrysophanic tetapi
terdiri dari lateks yang merupakan getah
acid, smodin, beracun
kuning terasa pahit dan mengandung ethereal oil, apabila
ester of konsentrasi
antrakuinon dan glikosida (Brown, 1980; cinnamonic acid, tinggi
isobarbaloin,
Surjushe, A., Vasani, R., & Saple, 2008; resistannol
Hormon Auxins and Penyembuha
Pankaj, Sahu, 2013), dan lapisan luar gibberellins n luka dan
yang tebal teridiri dari 15-20 sel yang anti
inflamasi
disebut dengan kulit, memiliki fungsi Minerals Calcium, Untuk
chromium, menjaga
pelindung dan mensintesis karbohidrat dan copper, iron, kesehatan
manganese, tubuh
protein. Dalam kulit lidah buaya terdapat potassium,
sodium and zinc
ikatan pembuluh yang bertanggung jawab Asam Seperti kandunga Anal getik
untuk transportasi zat seperti air (xilem) Salisik aspirin
Saponins Glikosida Pembersihan
dan pati (floem) (Tyler V. 1993; dan
antiseptik
Surjushe, A., Vasani, R., & Saple, 2008).
Lapisan luar ini mengandung turunan dari Senyawa Identifikasi Fungsi
hidroksiantrasena, antrakuinon dan Steroids Cholesterol, Agen anti-
campesterol, inflamasi,
glikosida aloin A dan B hydroxyanthrone, lupeol, sistosterol sedangkan
lupeol
emodin-antron 10-C-glukosida dan memiliki
Sifat
khrones. (Saccu, P. 2001; Bradley, 1992; antiseptik
dan

75
 analgesik (Ito et al,1993; Haller. 1990; Pankaj, Sahu,
Gula Monosaccharides: Anti virus 2013). Kemudian, dalam lidah buaya
Glucose and dan stimulasi
Fructose ssm imunitas terdapat Lupeol, merupakan kimia yang
Polysaccharides: dalam tubuh
Glucomannans/po
paling aktif mengurangi peradangan dalam
lymannose dosis tertentu dan sterol juga dapat
Vitamin A, B, C, E, Sebagai
choline, B12, Antioksidan berkontribusi terhadap anti-inflamasi.
asam folat (A, C, E),
dan Lidah buaya mengandung sterol termasuk
menetralisir
radikal bebas campesterol, β-sitosterol, dan kolesterol
yang dapat mengurangi inflamasi,
Fungi Aloe vera membantu dalam mengurangi peradangan
aloe vera memiliki fungsi yang rasa sakit dan bertindak sebagai analgesik
sangat bermanfaat bagi tubuh yaitu alami (Madan, Sharma, Inamdar, Rao &
mempercepat penyembuhan luka, Singh, 2008).
antiinflamasi, efek laksatif, melembabkan Lidah buaya juga mengandung
kulit, antidiabetes, antiseptik dan Antrakuinon yang terdapat dalam lateks
antimikrobial. Penyembuhan luka berfungsi sebagai pencahar yang kuat,
disebabkan oleh glukomanan dan giberelin merangsang sekresi lendir, meningkatkan
berinteraksi dengan reseptor faktor penyerapan dan peristaltik usus (Ishii,
pertumbuhan dari fibrobroblast yang Tanizawa & Takino, 1994; Pankaj, Sahu,
merangsang aktivitas dan proliferasi 2013). Selain itu, mengandung glikosida 8-
sehingga meningkatkan sintesis kolagen, dihydroxyanthracene, aloin A dan B
meningkatkan sintesis dari asam memiliki efek yang sama. Efek pencahar
hyaluronic dan dermatan sulfate sehingga dari Aloe Vera umumnya terjadi sebelum 6
mempercepat granulasi untuk jam setelah diminum dan kadang-kadang
penyembuhan luka (Chithra, G. B. Sajithal tidak sampai 24 jam atau lebih.
and G. Chandrakasan, 1998; Hayes. 1999; (Reynolds. 1993; Che, et al, 1991; Pankaj,
Pankaj, Sahu, 2013). Sahu, 2013).
Lidah buaya juga dapat berfungsi Muco-polisakarida juga terdapat
untuk menghambat jalur siklooksigenase, pada lidah buaya yang memiliki fungsi
mengurangi produksi prostaglandin E2 membantu dalam mengikat kelembaban
dari asam arakidonat dan mengandung kulit dan mengandung asam amino yang
peptidase bradikinase yang dapat menyebabkan sel kulit yang mengeras
mengurangi pengeluaran bradikinin menjadi lembab dan bertindak sebagai zat
sehingga mengurangi proses antiinflamasi. untuk mengencangkan pori-pori,

76
mengurangi munculnya kerut jerawat atau sistem kekebalan tubuh serta antibakteri
penuaan dan penurunan eritema (West and dan anti efek viral (Pankaj, Sahu, 2013).
Y. F. Zhu. 2003; Pankaj, Sahu, 2013). Pembahasan
Lidah buaya digunakan sebagai Aloe vera dapat digunakan untuk
antiseptik karena adanya enam agen mengobati berbagai luka terutama pada
antiseptik yaitu lupeol, asam salisilat, urea luka bakar. Hal ini didukung dengan
nitrogen, asam sinamat, fenol dan penelitian Maenthaisong, et al, 2007
belerang. Senyawa ini memiliki efek menyatakan bahwa aloe vera diberikan
menghambat pertumbuhan jamur, bakteri untuk mengobati pada pasien luka bakar
dan virus (Madan, Sharma, Inamdar, Rao untuk derajat pertama dan derajat ke dua,
& Singh, 2008). bila dibandingkan dengan perawatan luka
Selain itu, Terdapat lima pitosterol konvensional maka aloe vera lebih efektif
dari Aloe vera, lophenol, 24-metil- untuk mempercepat proses penyembuhan
lophenol, 24-etil-fenol, cycloartenol dan dan epitalisasi jaringan kulit.
24-metil siklopentanol menunjukkan efek Efektivitas aloe vera lebih baik
anti-diabetes tipe-2 tikus diabetes (Tanaka, apabila dibandingkan dengan obat lain
et al, 2006). Aloe vera mengandung yang digunakan untuk mengobati luka
polisakarida yang dapat meningkatkan bakar dan biaya yang di keluarkan lebih
insulin dalam tubuh dan menunjukkan terjangkau. Hal ini didukung dalam sebuah
penurunan kadar gula dalam darah (Yagi, penelitian membandingkan lidah buaya
et al, 2006). krim yang mengandung Aloe vera gel
Aloe vera juga mengandung emodin bubuk 0,5% dengan sulfadiazin perak 1%
yang efektif terhadap infektivitas herpes cream. Hasil penelitian menunjukkan dari
simplex virus tipe I dan tipe II dan juga kelompok yang diberikan Aloe vera 30/30
mampu menonaktifkan semua virus, (100%) mencatat luka benar-benar sembuh
termasuk varisela virus zoster, virus pada 19 hari sedangkan dengan dari krim
influenza, dan virus pseudorabies perak sulfadiazine 24/30 (80%) dan tingkat
(Sydiskis, 1991). Selain itu juga, re-epitelisasi dan penyembuhan parsial
mengandung saponin yang berfungsi ketebalan luka bakar secara signifikan
sebagai anti-mikroba terhadap bakteri, lebih cepat diobati dengan lidah buaya
virus, dan jamur (Peter, 2002). daripada di diobati dengan SSD (Silver
Glukomanan dan acemannan telah Sulfadiazine Cream) (15,9 ± 2 vs 18,73 ±
terbukti mempercepat penyembuhan luka, 2,65 hari, masing-masing; P <0,0001)
mengaktifkan makrofag, merangsang (Khorasani, et al, 2009). Sedangkan,

77
menurut Shahzad & Ahmed, (2013) bakar sebanyak 3x dalam sehari
perawatan luka bakar menggunakan aloe (Ramachandra and Rao, 2008).
vera lebih murah biaya yang di keluarkan Aloe vera memiliki kontra indikasi
dan lebih mengurangi nyeri pada pasien di dalam mengobati luka bakar yaitu tidak
bandingkan dengan perawatan luka bakar boleh digunakan pada orang yang
dengan menggunakan SSD. Penelitian lain mengalami alergi terhadap aloe vera
pada 12 ekor tikus putih diberikan luka karena menyebabkan iritasi pada kulit
bakar kemudian diberikan alow vera gel sehingga memperberat penyakit pasien dan
dan diukur hispatologinya. Hasil penelitian disarankan tidak boleh digunakan pada
menunjukan bahwa tikus yang di berikan pasien yang sedang hamil atau ibu
aloe vera gel akan meningkatkan menyusi namun harus di lakukan
pembentukan pembuluh darah, penelitian lebih lanjut (Grundmann, 2012).
meningkatkan kolagenasi dan proliferasi Efek aloe vera terhadap luka bakar
(Hidayat, Noer & Rizaliyana, 2013). yaitu menstimulasi fibroblas dan
aloe vera memiliki kekurangan yaitu makrofag, meningkatkan pembentukan
tidak efektif digunakan untuk mengobati kolagen dan sistesis proteoglikan,
luka bakar parsial, berdasarkan penelitian meningkatkan fungsi hormon faktor
Cuttle, et al (2008) perawatan luka dengan pertumbuhan dan granulasi, antiseptik dan
menggunakan aloe vera sebagai antiinflamasi sehingga mempercepat
pertolongan pertama perawatan luka bakar penyembuhan luka bakar (Rodríguez,
pada binatang babi menunjukan tidak Castillo, García dan Sanchez, 2005; Sahu,
efektif untuk mengurangi pertumbuhan 2013).
bakteri, mencegah terjadinya skar (bekas
luka), mengurangi kedalaman skar dan KESIMPULAN DAN SARAN
kecantikan tampilan skar sehingga tidak di Aloe vera (lidah buaya) terbukti
rekomendasikan aloe vera untuk sebagai pengobatan alternatif yang efektif
pertolongan pertama luka bakar parsial. untuk luka bakar, tetapi tidak boleh
Aloe vera yang di gunakan untuk digunakan pada orang yang alergi. Namun
mengobati luka bakar yaitu dengan aloe perlu dilakukan penelitian lebih lanjut
vera olahan atau murni yang mengandung mengenai dosis yang digunakan untuk
10-70% gel terutama pada bagian dalam mengobati luka bakar.
aloe vera, kemudian di pasteurisasi pada 1. Mahasiswa Fakultas Keperawatan
0 Universitas Padjadjaran Bandung
suhu 75-80 C selama kurang dari 3 menit
2. Dosen Fakultas Keperawatan
dan setelah itu, dioleskan pada area luka Universitas Padjadjaran Bandung

78
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81
Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2016, Article ID 8473937, 12 pages
http://dx.doi.org/10.1155/2016/8473937

Research Article
Bee Pollen as a Promising Agent in the Burn Wounds Treatment

PaweB Olczyk,1 Robert Koprowski,2 Justyna Kafmierczak,3 Lukasz Mencner,3

Robert Wojtyczka,4 Jerzy Stojko,5 Krystyna Olczyk,3 and Katarzyna Komosinska-Vassev3
1
Department of Community Pharmacy, School of Pharmacy and Division of Laboratory Medicine in Sosnowiec,
Medical University of Silesia in Katowice, Kasztanowa 3, 41-200 Sosnowiec, Poland
2
Department of Biomedical Computer Systems, Faculty of Computer Science and Materials Science, Institute of Computer Science,
University of Silesia, Bedzinska 39, 41-200 Sosnowiec, Poland
3
Department of Clinical Chemistry and Laboratory Diagnostics, School of Pharmacy and Division of Laboratory Medicine in
Sosnowiec, Medical University of Silesia in Katowice, Jednosci 8, 41-200 Sosnowiec, Poland
4
Department and Institute of Microbiology and Virology, School of Pharmacy and Division of Laboratory Medicine in Sosnowiec,
Medical University of Silesia in Katowice, Jagiellonska 4, 41-200 Sosnowiec, Poland
5
Center of Experimental Medicine, Medics 4, Faculty of Medicine in Katowice, Medical University of Silesia in Katowice,
40-752 Katowice, Poland

Correspondence should be addressed to Paweł Olczyk; polczyk@sum.edu.pl

Received 10 February 2016; Revised 18 April 2016; Accepted 24 April 2016

Academic Editor: José Maurı́cio Sforcin

Copyright © 2016 Paweł Olczyk et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The aim of the present study was to visualize the benefits and advantages derived from preparations based on extracts of bee pollen
as compared to pharmaceuticals commonly used in the treatment of burns. The bee pollen ointment was applied for the first time
in topical burn treatment. Experimental burn wounds were inflicted on two white, domestic pigs. Clinical, histopathological, and
microbiological assessment of specimens from burn wounds, inflicted on polish domestic pigs, treated with silver sulfadiazine or
bee pollen ointment, was done. The comparative material was constituted by either tissues obtained from wounds treated with
physiological saline or tissues obtained from wounds which were untreated. Clinical and histopathological evaluation showed that
applied apitherapeutic agent reduces the healing time of burn wounds and positively affects the general condition of the animals.
Moreover the used natural preparation proved to be highly effective antimicrobial agent, which was reflected in a reduction of
the number of microorganisms in quantitative research and bactericidal activity of isolated strains. On the basis of the obtained
bacteriological analysis, it may be concluded that the applied bee pollen ointment may affect the wound healing process of burn
wounds, preventing infection of the newly formed tissue.

1. Introduction microbiological contamination, presence of necrotic tissue,

Wound healing, being the result of dynamic cooperation
between many molecular factors, is a dynamic reaction whose
undisturbed course enables restoring the continuity and
functionality of damaged skin [1–3]. The process consists of 4
specific phases which smoothly proceed and change from one
to the other even coexisting at times. The duration period of
particular healing phases may vary depending on the type of
the damage and possible coexistence of interfering additional
factors, that is, the size and place of the damage, blood supply
of the wound edges, cleanness of the wound, the degree of
and properly conducted healing management [1, 2, 4, 5].
The therapy of burn wounds may be properly conducted
either by applying surgical methods or by topical application
of therapeutic preparations. Besides contemporary, conven-
tional treatment methods of thermal skin damage, apitherapy,
which uses the therapeutic effect of standardized, pharma-
cologically active fractions obtained from bee products, is
becoming more and more noticeable. Apitherapeutic agents
have a beneficial effect on the skin condition, due to the
reduction of water loss, and influence the reconstruction of
2 Evidence-Based Complementary and Alternative Medicine
the lipid barrier. One of the most frequently used apithera-
peutic agents is bee pollen. This is a varied, natural product
which is rich in such biologically active substances as amino
acids, fatty acids, phytosterols, phospholipids, nucleic acids,
carbohydrates, vitamins, mineral substances, enzymes, and
coenzymes as well as phenolic compounds including pheno-
lic acids and flavonoids [6–9]. The plethora of biologically
active substances gives this natural raw material significant
biotic properties such as antimicrobial, anti-inflammatory,
immunomodulatory, or antioxidative activity [7, 10].
Such a high efficiency of this natural bee product with a
significantly low risk of adverse reactions makes bee pollen
a potentially optimal remedial factor in the therapy of local
burn wounds [11, 12]. Therefore, the subject of this study was
the assessment of efficiency and therapeutic usability of the
bee pollen which has not been studied before.
Bee pollen, also flower pollen, is male reproductive
organs produced by flowers of entomophilous plants. It is
collected by worker bees, transported, and stored in beehives.
It constitutes a basic ingredient in bee’s nutrition used for
current needs or stored for later period [13]. Bee pollen results
from agglutination of flower pollen, nectar or honey, and bee’s
salivary substances [14].
Bee pollen treatment of topical, thermal damage of the
skin was compared with the commonly applied pharmaceu-
tical preparation such as silver sulfadiazine (SSD), which has
many side effects.
AgSD not only may be responsible for the development
of argyria and dysfunctions of liver, spleen, and kidney
due to systemic accumulation of silver or determined by
sulphadiazine presence, dermatitis, erythema multiforme
rashes, and acute hemolytic anemia but also unfortunately
could be responsible for cytotoxic effect on fibroblasts and
keratinocytes [15, 16].
The clinical assessment of the treatment process of burn
wounds was conducted. It concerned wound pathomorphol-
ogy including the extent and depth of the burn, wound
maceration, occurrence, and character of the exudate as well
as the process of scar formation. The histopathological assess-
ment of the burn wound epithelialization of the dynamics was
done together with qualitative and quantitative assessment of
particular microorganisms in tissue samples collected from
beds of experimental burn wounds.
2. Material and Methods
2.1. Therapeutic Agents. The following therapeutic prepara-
tions were used: 1% silver sulfadiazine (SSD) (Lek, Poland),
0.9% NaCl (Polpharma), and bee pollen formulation. The
analyzed bee pollen came from the apiary “Barć” in Kami-
enna. These are clean and ecological regions of Poland. In this
apiary the European Dark Bee also known as Western Honey
Bee is bred. The pollen was a composition of many pollens of
various plants. Taking into account the location of the apiary,
the dominating pollens came from such plants as oilseed
rape (lemon-yellow color), shamrock (brown color), coltsfoot
(bright yellow), common dandelion (bright orange), linden
(bright green), or heather (red-yellow). Macroscopically, it
was a multicolor blend of granules which were ground. 50 g
of the ground pollen was added to 500 mL of 70% ethanol.
The extraction of the solution was conducted for 4 weeks at
room temperature. After that period, the solution underwent
microfiltration. Next, the ethanol was distilled with vacuum
evaporator. The result was dry matter which was used to
prepare the bee pollen formulation (ointment containing
5% bee pollen ethanolic extract and 95% of petroleum jelly
(according to Polish norm PN-R-78893)). The procedure
was performed under general anesthesia according to the
dosage regimen: atropine sulfate, 0.05 mg/kg body weight
(Polfa Warszawa); ketamine hydrochloride, 3 mg/kg body
weight (Biovet, Puławy); xylazine hydrochloride, 1 mg/kg
body weight (Sandoz GMBH). Silver sulfadiazine was used
in order to prolong the analgesic effect, 5 mg/kg body weight
(Polpharma).
2.2. Tissue Material. The study protocol was approved by
the Ethics Committee of the Medical University of Silesia.
Two, 16-week-old, domestic pigs have been chosen as the
useful experimental animals for the evaluation of wound
repair because of many similarities of pig skin to human one.
The usage of the limited number of experimental animals
was consistent with validated animal model developed by
Hoekstra et al. [17] in modification of Brans et al. [18]. The
last mentioned pig model is based on the application of one
experimental animal [18]. Moreover, in accordance with the
guidelines of good laboratory practice for animal testing,
the established principle is to use the minimum number of
animals necessary to arrive at scientifically robust data and to
ensure reliable data. Thus, the animals used in our study were
bred and selected for the highest degree of genetic purity. This
form of breeding purpose prevents genetic contamination
and allows minimizing the number of animals necessary for
the experiment, with very reliable results to be obtained.
Pigs were housed according to G.L.P. standards of Polish
Veterinary Law. Each animal was inflicted with 18 skin burn
wounds with equal gaps (9 wounds on each side along the line
of the backbone). The size of each wound was identical, 1.5 cm
× 3 cm. Totally, the wounds took about 2% of the surface of
each animal’s body subject to the experiment.
Burns were classified as 2nd-degree deep partial thickness
burns. Animals were divided into two groups: control (C) and
experimental ones (E). 36 dermal burns were inflicted. The
wounds of animals in the control group were either untreated
(subgroup C1) or treated with physiologic saline (subgroup
C2).
The postburn wounds of the experimental group were
also treated with SSD (subgroup E1) and with the bee pollen
containing ointment (subgroup E2). The wounds in question
were treated with mentioned substances twice a day, starting
on the first day of the experiment. Three replications of
biopsies were taken from the same wound of each animal,
using surgical knife. Occlusive dressings were applied every
12 hours in all animals of all subgroups.
2.3. Clinical Study. Clinical observation was to assess the
extent and depth of the burn, its maceration, and presence
Evidence-Based Complementary and Alternative Medicine
of necrotic tissue in it. Macroscopic reading of pathomor-
phological picture of the wound considered occurrence and
intensification of typical symptoms of burn wounds: ery-
thema, swelling, exudate, bleeding, and eschar. The process
of granulation tissue formation together with the course of
scar formation, ongoing on the burn wound surface, was also
assessed.
2.4. Histopathological Study. The process of granulation, the
type of the granulation tissue, intensification of swelling
around the burn angiogenesis, and possible scarring of
the wound were assessed. The microscopic picture of skin
preparations included degree of the damage in the area and
near the wound as well as the repair processes in next stages
of the observation. Histopathological studies concerned the
samples which were collected from burn wounds and from
the adjacent, unchanged tissue in general anesthesia on 0, 3rd,
5th, 10th, 15th, and 21st day from the moment of inflicting
the burn. After consolidation, tissues samples were collected
form skin specimen in order to make histopathological
preparations. The basic slides with samples were stained to
achieve optical differentiation and verification of the elements
of cell structure. Two different kinds of dyes were used:
hematoxylin and eosin. Two histopathological preparations,
which resulted from that process, underwent the microscopic
assessment.
2.5. Microbiological Study. Microbiological study was per-
formed from the material collected from the burn wounds
on 0, 3rd, 5th, 10th, 15th, and 21st day of the experiment.
In the case of quantitative study, the material was collected
with a sterile swab stick from the burn wound surface of
1 cm2 and was subsequently put into the 10 cm3 of a sterile
solution of 0.9% NaCl. This suspension of microorganisms
served as the basis for a series of dilutions. Then, a 1 cm3
of the suspension was collected and spilt on the slide and
dissolved in both the Mueller Hinton agar (MH), in order
to assess the amount of bacteria, and Sabouraud agar, in
order to assess the amount of fungi and mould. The material
to microbiological purity test of the skin was simultane-
ously collected from the places where the burns were not
inflicted. In the case of quantitative studies, the material was
collected with AMIES transport medium with active carbon
(HAGAMED, Poland), which was stored at 5∘ C up to the
moment of performing microbiological tests (max. up to
2 hours). Simultaneously, the samples for microbiological
purity test were collected from the skin of animals not
taking part in the experiment. Microbiological diagnosis was
conducted in accordance with the standards of National
Committee for Clinical and Laboratory Standards [19]. The
cultures were conducted on the following enrichment and
differential media such as liquid media (Carbohydrate broth,
an enrichment medium for aerobic bacteria) and solid media
(blood agar, to enrich aerobic microorganisms and charac-
terize the type of hemolysis; Mannitol Salt Agar (Chapman),
to differentiate Staphylococcus spp.; MacConkey Agar, to
differentiate Enterobacteriaceae species; Sabouraud Agar, to
identify fungi; Agar D-Coccosel, to identify Enterococcus
3
faecalis; Cetrimide Agar, to identify Pseudomonas spp.). The
identification of isolated bacteria species was conducted by
microscopic tests, culture tests, and commercial biochemical
test API (bioMerieux, France). The growth promotion test
was carried out with reference strains. The next stage of the
test was to assess the amount of bacteria on 1 cm2 of the burn
wound surface. Therefore, the material was collected from
1 cm2 of the wound which was then shaken in 10 cm3 of the
sterile solution of physiological saline.
2.6. Data Analysis. In addition to the analytical methods
mentioned above, the automatic measurement of the time
constants was proposed. They concern the change rate analy-
sis of the number of bacteria, fungi, or moulds in the wound.
Therefore, the electrical-analog method, the inertial first-
order object with delay, was suggested. For such a proposed
model, the time constants for particular groups C1, C2, E1,
and E2 were measured.
The microbiological data analysis was performed using
Statistica 7.0 package (StatSoft, Cracov, Poland). The normal-
ity of distribution was verified with Kolmogorov-Smirnov
test. Statistical differences between variables were verified by
analysis of variance (ANOVA), followed by post hoc NIR test.
3. Results
3.1. Clinical Test Results. The clinical view of the wounds was
compared on 3rd, 5th, 10th, 15th, and 21st day after burn
infliction.
Differences in the clinical view of healing wounds were
noticed on the 5th day of the observation. In the control
subgroups, untreated wounds (C1), wounds treated with 0.9%
NaCl solution (C2), and the study subgroup (E1) in which the
wounds were treated with silver sulfadiazine, the erythema
was observed to exceed the area of the burn wound. The
skin surrounding the wound was very swollen with visible
exudate. In the case of the wounds treated with the ointment
with a 5% bee pollen, the subgroup (E2), the area of the
wound was covered with a thin, flexible eschar accompanied
by bleeding. On 10th and 15th day of the experiment, the
untreated wound, in the control subgroup (C1), was covered
with a hard, dry, and cracked eschar strongly adhering in the
center. Under the eschar, there was a pink granulation tissue.
During the same days, in the control subgroup, treated with
0.9% NaCl solution (C2), the burn wound was covered with
a softened eschar with a small amount of serosanguineous
exudate. In the experimental subgroup (E1) treated with silver
sulfadiazine, the area of the wound was covered with a hard
eschar and there was an erythema. The burn wounds of
subgroup (E2), treated with the bee pollen ointment on the
10th day, were covered with a thin, flexible eschar with a
visible granulation, while, on the 15th day, there was a clear
epithelium being formed. The area of the wound decreased.
The tissues surrounding the wound were characterized by
a weak, atrophic inflammatory condition. On the 21st day
of the observation, the clinical view was still significantly
differentiated. In subgroup (C1) the untreated wounds were
covered with a dry, cracked eschar. In subgroup (C2),
4 Evidence-Based Complementary and Alternative Medicine

II
I

III
II

III
I

(a) Untreated (C1) (b) NaCl (C2)

I
II

II
III

(c) SSD (E1) (d) Bee pollen (E2)

Figure 1: The picture of microscopic changes of skin samples collected from burn wounds on the 10th day of the experiment: (a) untreated (I:
swollen inflammatory granulation tissue in the area of dermis, II: eschar with a slight bleeding, and III: visible, pink, and swollen granulation
tissue); (b) washed with NaCl (I: petechial hemorrhages, loss of stratified squamous epithelium, II: coagulative necrosis, and III: massive
lymphocytic infiltration); (c) treated with SSD (I: petechial hemorrhages, II: area of aseptic necrosis with many inflammatory infiltrations,
and III: inflammatory infiltrations on the verge of necrosis); (d) treated with bee pollen (I: petechial hemorrhages, II: area of necrosis with
many inflammatory infiltrations).

the wounds, being constantly washed with 0.9% NaCl, were
covered with an irregular eschar tightly adhering to the
wound in its central part. After the eschar was removed
mechanically, a pink granulation tissue without the features
of epithelialization could be seen. The wound, treated with
silver sulfadiazine (subgroup E1), was covered with a pink
epithelium. The tissues surrounding the wound had no
significant inflammatory features. The wound area did not
decrease. The wounds, treated with the bee pollen ointment,
in subgroup E2, were covered with a thick epithelium. The
features of the healing process were strongly visible. Within
the surrounding tissue there were not any signs of erythema
or the ongoing inflammatory process.
3.2. Histopathological Test Results. The histological view of
wound healing of animals from all groups until the 5th day of
the experiment were identical. Figure 1 shows differentiated
dynamics of repairing processes which occurred on the 10th
day of the experimental healing process for all analyzed
groups. Application of the bee pollen (E2) achieved its ther-
apeutic effect on the 10th day of the experiment. The whole
wound surface was filled with collagen fibers, which affected
scar formation, and the stratified squamous epithelium was
being created.
On the 15th day of the observation, other changes in
the histopathological view were observed. In the control
subgroups C1 and C2 and in the E1 subgroup, a slow wound
healing process in the phase of fibroplasia with the sustaining
inflammation could be observed. In subgroup (E2), in which
the wounds were treated with the ointment with 5% bee
pollen extract, fibroplasia was significantly proceeding, while
the present granulation tissue was covered with a regenerated
epithelium. In the wound area there were no clear signs of
inflammatory reaction. The regenerated stratified squamous
epithelium was appearing on the wound edges together with
existing inflammatory infiltrations in the histopathological
view on the 21st day of the experiment in the case of the
untreated wounds (subgroup C1). In case of wounds washed
with 0.9% of NaCl (subgroup C2) as well as in subgroup (E1),
in which the wounds were treated with silver sulfadiazine, the
developed stratified squamous epithelium was covered with
an eschar, under which there was a visible mature granulation
tissue with a lot of fibers. In subgroup (E2), in which the
wounds were treated with the bee pollen ointment, the whole
wound surface was filled with a scar together with a thick
Evidence-Based Complementary and Alternative Medicine 5

II
I
I
II

III

(a) Untreated (C1) (b) NaCl (C2)

II
II

III

I
(c) SSD (E1) (d) Bee pollen (E2)

Figure 2: The microscopic changes of skin samples collected from burn wounds on the 21st day of the experiment: (a) untreated (I: regenerated
stratified squamous epithelium on the sample edge, II: vessel-rich and cell-rich granulation tissue); (b) washed with NaCl (I: eschar, II:
regenerated stratified squamous epithelium, and III: vessel-rich and cell-rich inflammatory granulation tissue); (c) treated with SSD (I: a
slightly swollen dermis, II: eschar with petechial hemorrhages, and III: regenerated stratified squamous epithelium); (d) treated with bee
pollen (I: connective tissue scar covered with epithelium and II: inflammatory granulation tissue with predominating collagen fibers).

stratified squamous epithelium. There was no granulation
tissue. The E2 subgroup showed a correctly healed burn
wound. The description of histopathological observations on
21st day of the experiment is shown in Figure 2.
3.3. Microbiological Test Results
3.3.1. Quantitative Study. The Logarithmic CFU (colony
forming unit) values of bacteria cultured on particular days
of the burn wound healing are summarized in Table 1.
The result of the quantitative study conducted on the 0
day, immediately after burning, showed no microorganisms
from none of the experimental groups. The effect of thermal
feature made the skin sterilized. On the 3rd day of the study,
the bacteria were isolated only from the tissue specimens
collected from the untreated wounds. On the 5th day, the
microorganisms were present in the tissue material of all
studied groups. Further growth of the average number of
bacteria in 1 cm2 of the wound was found on the 10th day of
the experiment. However, the number of bacteria decreased
in wounds washed with 0.9% of NaCl (C2) and in wound
treated with the bee pollen ointment (E2). A further decrease
of the number of bacteria in most analyzed groups was
observed on the 15th day after burning. However, the wounds
treated with the bee pollen ointment were characterized by
the smallest number of bacteria in relation to the previous
measurement. A systematic decrease of the number of bac-
teria in the wounds classifying to control and experimental
groups was confirmed on the 21st day of the experiment
and; what is more, the beds of thermal damage treated with
silver sulfadiazine and with the bee pollen ointment were
characterized by the biggest decrease of the bacteria number
(Figures 3 and 4).
Logarithmic CFU (colony forming unit) values of fungi
and mould cultured on particular days of the burn wound
healing are summarized in Table 2.
The growth of fungi and mould in the wound area of
animals, evaluated on 0 and 3rd day of the C1, C2, E1, and E2
subgroups, resulted in finding no such microorganisms. The
experimental studies conducted on 5th and 10th day showed
that the number of fungi and moulds increased particularly
in the case of untreated wounds as well as those treated with
silver sulfadiazine. Next days showed a decreased general
number of fungi and mould in untreated wounds and those
treated with SSD. The wounds washed with NaCl and those
exposed to bee pollen ointment were characterized by the
lowest number of fungi and mould on the 21st day of the
experiment (Figures 5 and 6).
Variable number of fungi and moulds in time was
analytically analyzed. This analysis is to approximate the
6 Evidence-Based Complementary and Alternative Medicine

C1 C2
4.00 6.00
a a a, b a

3.00
4.00
a, b a, b

log CFU
log CFU

2.00
2.00

1.00
0.00

0.00

0 3 5 10 15 21 0 3 5 10 15 21
(Day) (Day)

E1 E2
4.00 a
5.00
a, b
4.00
3.00
a, b, c a
3.00
a, b
2.00
log CFU

log CFU

2.00
a, b, c
1.00
1.00

0.00 0.00

−1.00 −1.00

0 3 5 10 15 21 0 3 5 10 15 21
(Day) (Day)

Figure 3: Quantitative study: log CFU value of bacteria cultured on particular days of the burn wound healing: C1: tissue material from
untreated wounds; C2: tissue material collected from wounds washed with NaCl; E1: tissue material from wounds treated with silver
sulfadiazine; E2: tissue material from wounds treated with bee pollen ointment. Results are expressed as mean ± standard error of the mean
(SEM) of the assays performed in triplicate. a 𝑝 < 0.05 compared with value determined on 5th day, b 𝑝 < 0.05 compared with value determined
on 10th day, and c 𝑝 < 0.05 compared with value determined on 15th day.

Table 1: log CFU values of bacteria on the following days of the experiment.

0 day 3rd day 5th day 10th day 15th day 21st day
C1 (untreated) — 1.47 2.78 3.57 3.56 3.54
C2 (NaCl) — — 5.18 5.08 3.48 3.46
E1 (SSD) — — 3.43 3.68 3.57 2.53
E2 (bee pollen) — — 5.23 4.24 3.53 2.48

Table 2: log CFU values of fungi and mould on the following days of the experiment.

0 day 3rd day 5th day 10th day 15th day 21st day
C1 (untreated) — — 1.59 1.47 1.19 0.99
C2 (NaCl) — — 1.01 1.01 1.19 0.18
E1 (SSD) — — 1.68 1.60 1.07 1.00
E2 (bee pollen) — — 0.99 0.88 1.16 0.75
Evidence-Based Complementary and Alternative Medicine 7

6.0 Table 3: The error value of matching the inertial first-order object
model with the experimental data (bacteria, fungi, and mould) for
given time constants 𝑇1 .
4.5
C1 C2 E1 E2
log CFU

3.0 𝛿(𝐵) [%] 3 44 5 58

𝑇1 [day] 20 1 18 1
𝛿(𝑅) [%] 25 17 18 17
1.5
𝑇1 [day] 7 20 6 20

0.0
0 3 5 10 15 21 of the response relationship for the multi-inertial object is as
(Day) follows:
𝑘
C1 E1 𝐺 (𝑠) = , (1)
C2 E2 (1 + 𝑠𝑇1 ) (1 + 𝑠𝑇2 ) ⋅ ⋅ ⋅ (1 + 𝑠𝑇𝑛 )

Figure 4: Dynamics of log CFU value of bacteria cultured on
particular days of the burn wounds treated with NaCl (C2), silver
sulfadiazine (E1), bee pollen ointment (E2), and untreated wounds
(C1).
mode of changes in time with a model. A model, being
the inertial first-order object with delay, has been chosen.
The very choice of the model results from earlier authors’
experiences concerning the analysis of dynamic changes (e.g.,
linked to temperature) occurring in humans and animals.
The model enables parameterization of characteristics linked
to the change rate of the number of fungi and moulds.
These parameters are time constant 𝑇1 and delay. The time
constant enables the determination of the change rate of
the number of fungi and moulds in time. According to the
theory of automatic control (the processes occurring in living
organisms) the steady state takes place after third up to fifth
time constants (95% and 99% of the steady state). For the
cases in question it means that if the obtained results are
approximated with this model (the inertial first-order object
with delay) it will become possible to determine the time
after which the decrease in the number of fungi and moulds
to the values close to 0 (zero) will appear. It will be, for
example, 3 ∗ 𝑇1 for which only 5% of fungi and mould will
remain when related to the maximum value. Similarly for
5 ∗ 𝑇1 only 1% of fungi and mould will remain in relation
to the maximum value. The approximation of changes of the
number of fungi and mould in time with the inertial first-
order object with delay enables obtaining one more error
parameter of matching 𝛿, which gives the information about
the matching compliance of the model with the obtained
experimental data.
The time change of the average number of bacteria, fungi,
and moulds is a nonlinear relationship. Due to the analogy
to the control systems, the response of the system (in this
case it is the number of bacteria, moulds, and fungi) may be
approximated by the inertial first-order object with delay. It
results from the biological and medical rationale concerning
the growth rate (development) of the bacteria, fungi, and
moulds on the healing wound surface (regardless of the fact
if it was C1, C2 or E1, E2). The general transmittance form
where 𝑘 is amplification and 𝑇1 , 𝑇2 , . . . , 𝑇𝑛 is time constant.
This was the basis for formulating the error of matching
the model with the source data, for example, for the bacteria
(superscript) and tissue material from untreated wounds
(subscript) done as follows:
𝐼
100 󵄨 (𝐵) 󵄨
(𝐵)
𝛿C1 = (𝐵)
∑ 󵄨󵄨󵄨󵄨𝑦C1 (𝐵)
(𝑖) − 𝑦SC1 (𝑖)󵄨󵄨󵄨󵄨 [%] , (2)
𝐼 ⋅ max𝑖 𝑦C1 (𝑖) 𝑖=1
where 𝑦C1(𝐵)
(𝑖) is change in the number of bacteria (superscript
(𝐵)
𝐵) in the next 𝑖-measurements, 𝑦SC1 (𝑖) is simulation of
change in the number of bacteria (superscript 𝐵) in the next
𝑖-measurements for the model (unit response) described by
transmittance, and 𝐼 is total number of measurements.
Similarly, the error of experimental data match with the
standard for fungi and mould (superscript 𝑅) and different
materials is calculated. For such a formulated error the
method of a tuned model was applied in order to match the
multi-inertial object with the data and to specify the order of
the model. The smallest values of errors, shown in Table 3,
were obtained for multi-inertial first-order object.
In Table 3 the calculated error values of the match 𝛿(𝐵)
and 𝛿(𝑅) for the materials C1, C2, E1, and E2 were shown. The
calculations were done for the inertial first-order object (with
the time constant 𝑇1 ) with delay (5 days) for which the value
of particular errors is smaller. In the graph in Figure 7 the
(𝑅)
exemplary obtained results are shown, the behaviors of 𝑦C1 (𝑖)
(𝑅)
and 𝑦SC1 (𝑖) for 𝑇1 = 8.
As it can be concluded from Figure 7, the biggest error
values (>44%) occur for materials C2 and E2, which results
from the specification of changes in the number of bacteria
in the wound. Due to individual variation of pigs, this
specification depends on many factors. The smallest error
values and, simultaneously, the best match of the model with
experimental data occur for materials C1 and E1. The time
constants for them are 20 and 18 days. Similar error values
were obtained for fungi and mould which fluctuate around
the value of 18%. The time constants are also different (as in
the case of bacteria) for materials C1 and E1 amounting to 6
and 7 days, while for materials C2 and E2 they are equal to
20 days. Summing up the obtained results, the time constant
average value of the growth of bacteria, mould, and fungi in
the wound is at the level of 18 up to 20 days.
8 Evidence-Based Complementary and Alternative Medicine

C1 C2
2.00 a, b
1.20

1.00
1.50
0.80
log CFU

log CFU
a
1.00 0.60

0.40
0.50
0.20

a, b, c
0.00 0.00

0 3 5 10 15 21 0 3 5 10 15 21
(Day) (Day)

E1 E1
2.00 a, b
1.20

1.00
1.50
0.80 a, b, c
a, b
log CFU
log CFU

a, b
1.00 0.60

0.40
0.50
0.20

0.00 0.00

0 3 5 10 15 21 0 3 5 10 15 21
(Day) (Day)

Figure 5: Quantitative study: log CFU value of fungi and mould cultured on particular days of the burn wound healing: C1: tissue material
from untreated wounds; C2: tissue material collected from wounds washed with NaCl; E1: tissue material from wounds treated with silver
sulfadiazine; E2: tissue material from wounds treated with bee pollen ointment. Results are expressed as mean ± standard error of the mean
(SEM) of the assays performed in triplicate. a 𝑝 < 0.05 compared with value determined on 5th day, b 𝑝 < 0.05 compared with value determined
on 10th day, and c 𝑝 < 0.05 compared with value determined on 15th day.

3.3.2. Qualitative Study. In the qualitative study, changes of
microbial species from the swabs of burn wounds treated
with appropriate experimental agents and of the healthy skin
surface were evaluated during next days of the experiment.
On 0 day, the number of microorganisms, which constitute
the physiological flora of the skin and the environment,
increased in healthy skin (Table 4). However, no bacteria were
cultured from none of the samples collected from the burn
wounds immediately after burning.
On the 3rd day of the study, the wounds were colonized
with microorganisms from Micrococcus species only in the
subgroup in which the wounds were untreated (C1). On
the 5th day of the study, the number of isolated microor-
ganisms species significantly increased in the animals of all
subgroups. Besides typical physiological flora of the skin
and the environment (Micrococcus spp., Bacillus spp.) there
were also microorganisms which are characteristic for wound
inflammation. In the subsequent days of the experiment,
all burn wounds were characterized by a lower number of
strains. On the 21st day of the study, in subgroups C2, E1, and
E2, the bacterial flora was reduced to only one environmental
species, such as Bacillus spp., while in the group of untreated
wounds (C1), only Staphylococcus hyicus was found.
4. Discussion
Wound healing is a dynamic and time-synchronized reaction
of the organism connected both with the actions of many
cells, such as inflammatory cells, vascular cells, connective
tissue cells, and epithelial cells, and with accumulating extra-
cellular matrix (ECM) components, which leads to creation
of a new tissue [20]. A significant role in the healing process
is played by ECM components: glycosaminoglycans (GAGs),
fibronectin, proteoglycans, vitronectin, and collagens [21, 22].
Evidence-Based Complementary and Alternative Medicine 9

Table 4: Changing of species of microflora in burn wounds in the following days of the experiment; N: tissue material from healthy skin not
inflicted with a burn; C1: tissue material from untreated wounds; C2: tissue material from places washed with 0.9% NaCl; E1: tissue material
from places treated with silver sulfadiazine salt; E2: tissue material from places treated with the with bee pollen ointment.

0 day 3rd day 5th day 10th day 15th day 21st day
Micrococcus spp.
Micrococcus spp. Micrococcus spp. Micrococcus spp. Bacillus spp.
Micrococcus spp. Micrococcus spp.
N Bacillus spp. Bacillus spp. Bacillus spp. Aerococcus
Bacillus spp. Bacillus spp.
Staphylococcus Staphylococcus Gemella spp. viridans
Aerococcus viridans Aerococcus viridans
lentus lentus Aerococcus viridans Enterococcus
faecalis
Micrococcus spp.
C1 Staphylococcus Staphylococcus
— Micrococcus spp. Micrococcus spp. Candida spp.
hyicus hyicus
Candida spp.
C2 — — Micrococcus spp. Micrococcus spp. Bacillus spp. Bacillus spp.
Bacillus spp.
Staphylococcus
E1 Bacillus spp.
— — hyicus Bacillus spp. Bacillus spp.
Micrococcus spp.
Enterococcus
faecalis
Bacillus spp.
Staphylococcus Bacillus spp.
E2 — — hyicus Pseudomonas Bacillus spp. Bacillus spp.
Pseudomonas aeruginosa
aeruginosa

1.8 40

35

1.35 30

25
log CFU

, ySC1 (i)

0.9
(R) (R)

20
yC1

15
0.45
10

5
0.0
0 3 5 10 15 21
0
(Day) 0 5 10 15 20 25
t (day)
C1 E1
(R)
C2 E2 yC1 (i)
(R)
Figure 6: Dynamics of log CFU value of fungi and mould cultured ySC1 (i)
on particular days of the burn wounds treated NaCl (C2), silver
Figure 7: The graph of changes in the number of fungi and moulds
sulfadiazine (E1), bee pollen ointment (E2), and untreatedwounds
in time for experimental and simulation data of the material C1.
(C1).

a positive influence of the mentioned apitherapeutic agent on

The therapeutic effect of a natural bee preparation, propolis,
in the treatment of experimental burn wounds was the
subject of our previous experimental studies. They showed
that application of propolis modulated the expression of gly-
cosaminoglycans, collagens, noncollagenous glycoproteins,
and free radicals in the burn wound bed, which favors the
intensification of healing process and, therefore, confirmed
the metabolism of ECM components [21–24].
The aim of the present study was to compare the ther-
apeutic efficiency of another natural agent based on bee
pollen extract with a commonly used pharmaceutical silver
sulfadiazine in treatment of thermal burns.
Although silver sulfadiazine is considered as a gold
standard in the topical treatment of burn wounds, this
10
therapeutic agent is characterized by many side effects such as
the risk of crystalluria, methaemoglobinaemia, neutropenia,
erythema multiforme, and prolonged reepithelialization and
the impairment of the mechanical strength of newly created
tissue [25, 26]. Such side effect cannot be found in the case
of bee pollen. This apitherapeutic agent demonstrates strong
immune-modulating properties, which accelerate epithelial-
ization and has bacteriostatic, bactericidal, and anesthetic
properties [9, 27]. Moreover, bee pollen has a strong anti-
inflammatory activity, decreases the healing period, and
reduces the duration and intensity of ailments [9, 28].
The experimental model implemented in the present
study was based on the tissue material collected from the
domestic pig skin. The choice of the animal was made mainly
due to the similarity between pig skin and human one [29].
Clinical and histopathological observation comprising
the assessment of the extent and depth of the burn wounds,
wound maceration, presence of necrotic tissue, granulation
tissue type, and swelling around the burn wound indicated
that, on the first days of the experiment, the pathomorpho-
logical view of the wounds for every group was the same.
It became significantly differentiated on the 5th day of the
observation. In the case of the wounds treated with the
ointment with bee pollen ointment (E2), the wound area was
covered with a thin, flexible eschar with a slight bleeding. In
the wound area there were signs of swelling and reddening.
On the next days of the observation of the wounds
treated with the apitherapeutic agent, a strong granulation
and, subsequently, epithelium formation with clearly visible
fully healed characteristics were noted. The wound surface
decreased and was the size of 1 cm × 1 cm. In the area of
the tissues surrounding the healing wound there were no
signs of swelling or the ongoing inflammatory process. The
clinical and histopathological assessment led to a conclusion
that the applied apitherapeutic agent ointment reduces the
time of burn wound treatment. Similar results were obtained
in our previous studies where the therapeutic usability of
another apitherapeutic agent, propolis, was assessed in the
course of regeneration of experimental thermal skin damage.
Propolis ointments in comparison with SSD preparation
significantly accelerated the regenerative-reparative process
of tissue damage not demonstrating any undesirable effects
at the same time [30]. The beneficial effect of standardized
propolis formulation on the healing process was also proved
in Jastrzębska-Stojko et al. experimental studies [31]. The
healing process of burn wounds treated with Sepropol was
faster as compared to the standard SSD therapy. Moreover,
histopathological tests showed that the process of scar forma-
tion in wounds treated with propolis formulation started con-
siderably earlier as compared to the control group [31]. The
other part of our studies concerning microbiological exami-
nations during experimental burn wound healing proved that
bee pollen ointment had an effective antimicrobial activity,
reducing both the number of microorganisms and presenting
bactericidal activity in isolated strains. The antibacterial
properties of another apitherapeutic agent, propolis, were
already assessed in the study with animal model of burn
wounds. The mentioned study indicated a higher antimicro-
bial effectiveness of propolis ointment as compared to SSD in
Evidence-Based Complementary and Alternative Medicine
the course of burn wounds healing. A more beneficial action
of the first from the mentioned preparations was manifested
by a significant reduction of microorganisms as well as a more
effective bactericidal action of the applied apitherapeutic
agent. A similar trend in the effects of SSD action and a bee
product in the range of antibacterial action were described by
Kabała-Dzik et al. [32].
The therapeutic mechanism of bee natural products
is based, among others, on antimicrobial activity and on
inducing processes of damaged tissues regeneration. These
characteristics proved their usability in wound healing and
ulcerations of different etiology [31, 33].
The results in this study confirmed the beneficial effect of
the bee pollen ointment on the burn wound healing process
which could be seen in the decreased number of bacteria in
the burn wounds during subsequent days of the experiment.
Different mechanisms could be responsible for the
observed antibacterial effects of bee pollen. The first one
results from the presence of active compounds, such as
flavonoids and phenolic acids, whose forming complexes
with bacterial cell walls lead to the disruption of cell wall
integrity, blocking ion channels, and inhibiting electron flow
in the electron transport chain [34].
The second mechanism by which bee pollen exerts
antibacterial activity might be based on the inhibition of
bacterial RNA-polymerase by phenolic compounds such as
flavanone pinocembrin, flavonol galangin, and caffeic acid
phenethyl ester [35].
Besides high antimicrobial activity, bee pollen ointment
was also characterized by a bactericidal effect for isolated
strains.
Moreover, the study also proved that thermal damage and
bacterial infection of the wound favor yeast multiplication
including Candida albicans. The yeast of the Candida species
in proper conditions is saprophytes which live in the natural
environment and colonize mucosa and human skin. How-
ever, they may induce life-threatening candidiases. Burns and
necrotic lesions, which are the gates for fungal infection,
may contribute to sepsis. Bacillus cereus and Bacillus subtilis,
which are usually harmless, may induce infections in the
condition of decreased immunity.
The clinical and histopathological observations per-
formed in our study led to a conclusion that the bee pollen
exerts a beneficial effect on wound healing cellular events
providing reepithelization and wound closure. The micro-
biological studies proved that bee pollen ointment had an
effective antimicrobial activity. The benefits and advantages
of the bee pollen ointment in burn wound treatment imply
the usability of the applied apitherapeutic agent preparation
in topical burns therapy.
Competing Interests
The authors declare that they have no conflict of interests.
Acknowledgments
This work was supported by a grant from the Medical
University of Silesia, Poland (KNW-1-018/K/4/0).
Evidence-Based Complementary and Alternative Medicine
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Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
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Published in final edited form as:

Int J Clin Exp Hypn. 2016 ; 64(1): 75–115. doi:10.1080/00207144.2015.1099405.

HYPNOSIS FOR ACUTE PROCEDURAL PAIN: A Critical Review

Cassie Kendrick, Jim Sliwinski, Yimin Yu, Aimee Johnson, William Fisher, Zoltán Kekecs,
and Gary Elkins
Baylor University, Waco, Texas, USA

Abstract
Clinical evidence for the effectiveness of hypnosis in the treatment of acute, procedural pain was
Author Manuscript

critically evaluated based on reports from randomized controlled clinical trials (RCTs). Results
from the 29 RCTs meeting inclusion criteria suggest that hypnosis decreases pain compared to
standard care and attention control groups and that it is at least as effective as comparable adjunct
psychological or behavioral therapies. In addition, applying hypnosis in multiple sessions prior to
the day of the procedure produced the highest percentage of significant results. Hypnosis was most
effective in minor surgical procedures. However, interpretations are limited by considerable risk of
bias. Further studies using minimally effective control conditions and systematic control of
intervention dose and timing are required to strengthen conclusions.

Procedural pain poses a significant and substantial problem. Though it would be impossible
to fully quantify the incidence of painful medical procedures, the scope of the problem is
Author Manuscript

estimable, given the $560–$635 billion in yearly pain-related expenditures in the United
States (Gay, Philippot, & Luminet, 2002). The challenge of achieving adequate pain control
without adverse side effects further compounds the problem and provides rationale for
seeking complementary medicine alternatives (Askay, Patterson, Jensen, & Sharar, 2007;
Fleming, Rabago, Mundt, & Fleming, 2007).

Hypnosis has a long history in the treatment of pain (Elkins, 2014; Gay et al., 2002; Hilgard
& Hilgard, 1994; Liossi & Hatira, 1999; Patterson, 2010; Patterson & Jensen, 2003) and is
one of the most recognized nonpharmacological pain management techniques. Despite the
long legacy of hypnoanalgesia in medicine, mechanisms of hypnotic pain relief are still
debated. One of the two most influential theories proposes dissociational processes and
emphasizes the importance of hypnotic susceptibility and an altered state of consciousness
(Bowers, 1992; Hilgard & Hilgard, 1994), while the other suggests that social and cognitive
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processes are responsible for hypnosis induced analgesia and highlights the significance of
contextual variables, compliance with instructions, expectancies, cognitive strategies and
role enactment (Chaves, 1993).

A number of previous reviews have examined the effectiveness of hypnosis in addressing

pain (Accardi & Milling, 2009; Cyna, McAuliffe, & Andrew, 2004; Elkins, Jensen, &

Address correspondence to: Gary Elkins, Mind-Body Medicine Research Lab, Department of Psychology and Neuroscience, Baylor
University, One Bear Place #97243, Waco, TX 74798-7243, USA. Gary_Elkins@Baylor.edu.
No conflicts of interest exist.
 Kendrick et al. Page 2

Patterson, 2007; Jensen & Patterson, 2005; Montgomery, DuHamel, & Redd, 2000;
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Patterson & Jensen, 2003; Richardson, Smith, McCall, & Pilkington, 2006); however, the
most recent review involving studies with an adult population on procedural pain was
conducted over 10 years ago. The aim of this review is to provide an updated overview of
the literature incorporating studies conducted since the last comprehensive review on acute,
procedural pain for both adults and children in 2003 (Patterson & Jensen, 2003) and to
assess how procedural, interventional, and methodological factors can affect pain related
outcomes based on the results of the included randomized controlled clinical trials.

Method
The following databases were searched from their inception to November, 2013: MEDLINE,
HealthSource: Nursing/Academic Edition, PsycINFO, PsycARTICLES, PsycCRITIQUES
and the Psychological and Behavioral Sciences. Search terms used were (hypnosis AND
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pain AND procedure); (hypnotherapy AND pain AND procedure); (hypnosis AND pain
AND surgery); (hypnotherapy AND pain AND surgery); (hypnosis AND pain AND
operation); and (hypnotherapy AND pain AND operation).

Prospective, randomized, controlled trials of hypnosis for acute, procedural pain were
included. Studies were not excluded based upon specifics of the hypnosis or control
interventions. However, studies were excluded if they were case studies or case series, if
they were not clinical trials, if they were not randomized or controlled, or if hypnosis was
poorly defined or was combined with several other treatments as a part of a larger, complex
intervention (in which the effects of hypnosis intervention would be difficult to identify).
Studies were also considered irrelevant if they were not specifically examining the use of
hypnosis for the treatment of procedural pain. For example, studies of hypnoanalgesia in
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labor were excluded because labor pain cannot be characterized as pain caused by a medical
procedure. Language restrictions were not applied. However, our search resulted only in
English language studies.

All trials meeting the aforementioned criteria were reviewed in full by two independent
reviewers. The reviewers extracted procedure type, study design, whether intention to treat
analysis (ITT) was used, intervention and control regimens (with special attention to timing
and dose of the intervention), sample size by groups, pain related measures used, results on
each measure, methodological quality indicators (randomization, blinding, dropouts),
whether hypnotizability was assessed, used for participant inclusion, or found to be
correlated with any of the outcomes, and the conclusion of the authors on the effectiveness
of hypnosis for acute pain relief. Discrepancies were resolved by discussion between the two
reviewers, ZK and CK, and, if necessary, by seeking guidance from the third reviewer, GE,
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who also reviewed all ratings of the first two reviewers.

Methodological quality was evaluated by way of a modification of the Oxford, 5-point Jadad
score (Jadad et al., 1996). In order to account for the difficulty in blinding of hypnosis
practitioners, a maximum of 4 points were awarded in the following manner: 1 point for a
study description that indicated the study was randomized; 1 point for use of an appropriate
randomization technique as well as a 1 point penalty deduction for inappropriate

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
 Kendrick et al. Page 3

randomization technique; 1 point for providing explanation of withdrawals and dropouts;

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and 1 point if the experimental and hospital staff were blinded to treatment assignment.

The effectiveness of hypnosis for controlling acute pain has been examined in a large variety
of medical procedures in both adult and pediatric populations. We have to acknowledge that
there are great differences in the type, location and level of pain experienced in these
procedures; thus, direct pooling or comparison of effect sizes could be misleading. To
overcome this problem, results were simplified to either being significant or non-significant
by measures used. In the assessment of the effects of moderating factors, we used the
measurements as basic units instead of studies to control for the inflated alpha error
probability originating from multiple testing of the same hypothesis. Thus, the indicator of
effectiveness in a given moderator condition (like interventions consisting of one hypnosis
session instead of many) was the percentage of the number of measurements with significant
effects within the total number of measurements in the study pool. In this assessment of
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moderators, only comparisons of hypnosis vs. attention control, or, if not applicable,
hypnosis vs. usual care were entered.

Results
The initial searches yielded a total of 398 articles. Of these, 155 were duplicates, and of the
remaining 243 articles, 29 randomized, controlled trials (RCTs) met the aforementioned
criteria for inclusion in the review (Enqvist & Fischer, 1997; Everett, Patterson, Burns,
Montgomery, & Heimbach, 1993; Faymonville et al., 1997; Harandi, Esfandani, &
Shakibaei, 2004; Katz, Kellerman, & Ellenberg, 1987; Kuttner, Bowman, & Teasdale, 1988;
Lambert, 1996; Lang et al., 2000; Lang et al., 2006; Lang, Joyce, Spiegel, Hamilton, & Lee,
1996; Liossi & Hatira, 1999, 2003; Liossi, White, & Hatira, 2006, 2009; Mackey, 2009;
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Marc et al., 2008; Marc et al., 2007; Massarini et al., 2005; Montgomery et al., 2007;
Montgomery, Weltz, Seltz, & Bovbjerg, 2002; Patterson, Everett, Burns, & Marvin, 1992;
Patterson & Ptacek, 1997; Smith, Barabasz, & Barabasz, 1996; Snow et al., 2012; Syrjala,
Cummings, & Donaldson, 1992; Wall & Womack, 1989; Weinstein & Au, 1991; Wright &
Drummond, 2000; Zeltzer & LeBaron, 1982). The PRISMA Flow Diagram in Figure 1
provides details on the inclusion and exclusion process.

The methodological quality of studies varied, (Jadad score range 0–4, M = 2.33). Nine RCTs
provided descriptions for randomization methods, and 11 trials provided adequate detail of
dropouts and withdrawals. One study used a crossover design; all other studies applied a
parallel design. Key data are provided in Table 1.

In the majority of the studies reviewed, more than one measure was used to assess pain. The
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most frequently used pain related outcome was subjective pain intensity (used in 27 studies),
followed by analgesic use or pain medication stability (15 studies), behavioral signs of pain
(13 studies), anxiety (five studies), pain unpleasantness or an affective component of pain
(three studies), and cardiovascular measures (two studies). Subjective pain intensity was
measured by visual analog scale (VAS) in most instances (12 studies). However, single item
numeric rating scales (nine studies), pictorial rating scales (e.g., using pictures of emotional
faces, five studies), and pain questionnaires (McGill Pain Questionnaire (MPQ), Children’s

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
 Kendrick et al. Page 4

Global Rating Scale (CGRS), two studies) were also applied. Most of the studies compared
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the effectiveness of hypnosis to standard care (20 studies), while some studies also utilized
attention control (11 studies) or compared the effectiveness of hypnosis to another type of
active treatment, like cognitive behavioral therapy (CBT, three studies), distraction (three
studies), emotional support from the therapist (one study), play therapy (one study) or
relaxing music (one study).

From a total of 45 measurements comparing hypnosis to standard care, the hypnosis group
had significantly lower pain ratings in 28 measurements (62%), while hypnosis decreased
pain compared to attention control in 16 out of 30 measurements (53%). Furthermore, in 16
out of 30 (53%) measurements, hypnosis yielded significantly better results when compared
with other adjunct pain therapies. Specifically, from two measurements, there was no
difference between hypnosis and play therapy; in two out of seven measurements, hypnosis
was significantly better than CBT; in eight out of 15 measurements, hypnosis was superior
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to distraction1; three out of three measurements confirmed the benefits of hypnosis during
surgery over emotional support; and similarly, three out of three measures yielded
significantly better results for hypnosis combined with relaxing music compared to relaxing
music alone.

In the included studies, hypnosis was used for pain management in bone marrow aspiration
(seven studies), lumbar puncture (five studies), burn debridement or other burn care (five
studies), surgical procedures (eight studies), or other medical procedures (abortion,
venipuncture, radiological procedures, angioplasty; seven studies). Only six studies applied
more than one session of hypnosis, and most of the hypnosis sessions were shorter than 30
minute, or they lasted as long as the procedure itself. Interventions were either administered
days before the medical procedure (eight studies), preoperatively on the day of the procedure
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(seven studies), both days before the procedure and preoperatively (two studies), during the
procedure (six studies), or both preoperatively and during the procedure (six studies). Table
2 displays an overview of effectiveness by showing the percentage of measures in which
hypnosis significantly decreased pain as compared to different control conditions by
different intervention characteristics (timing, length, dose), and by medical procedures.
Hypnotizability was assessed in seven studies, four of which reported significant positive
association between the level of hypnotic susceptibility and pain-related outcomes.

Discussion
The evidence for the effectiveness of hypnosis as an adjunct therapy for management of
acute pain was evaluated. Overall, results from RCTs identified in the review process
suggest that hypnosis reduces acute pain associated with medical procedures.
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Pain was most often measured with a single VAS score. Although this scale is easy to
administer and has low time-cost from the respondents, its acceptability and psychometric
properties are questionable when used with in a pediatric or geriatric population (e.g.,

1Although Kuttner, Bowman and Teasdale (1988) showed the superiority of hypnosis compared to distraction in some cases for pain
and anxiety reduction, these results were only significant in a subsample (younger children), thus they were counted as not
significantly better overall.

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
 Kendrick et al. Page 5

Hjermstad et al., 2011; Stinson, Kavanagh, Yamada, Gill, & Stevens, 2006; van Dijk, Koot,
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Saad, Tibboel, and Passchier, 2002). Furthermore, VAS and the simple numerical rating
scales applied in most studies are one-dimensional and usually only evaluate pain intensity,
which might be problematic because the affective component of pain remains unassessed
this way. Specifically, according to dissociation theories, hypnotic analgesia does not result
in a simple reduction of pain sensation. Rather, it induces dissociation from pain and the
decoupling of pain intensity and pain unpleasantness. For example, according to Rainville,
Carrier, Hofbauer, Bushnell, and Duncan (1999), sensory and affective dimensions of pain
are largely independent in a hypnotic state, and these factors could be differentially
modulated with different hypnotic suggestions. Brain imaging studies also support the
notion that hypnosis can affect subjective pain intensity through the somatosensory cortex
(Hofbauer, Rainville, Duncan, & Bushnell, 2001) and pain unpleasantness through the
anterior cingulate cortex (Rainville, Duncan, Price, Carrier, & Bushnell, 1997) differentially.
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Thus, suggestions devised to decrease pain unpleasantness may leave pain intensity ratings
unaffected, meaning that the pain scales should be synchronized with the intervention scripts
in all studies, especially if a one-dimensional scale is to be applied as a pain measure.

Evidence supporting the effectiveness of hypnosis is strongest when compared to standard

care control, and beneficial effects are still apparent when hypnosis is contrasted to attention
control. However, the strength of evidence of clinical trials using these two control
conditions have been challenged (Jensen & Patterson, 2005; Patterson & Jensen, 2003). In
spite of the recommendation of Jensen and Patterson (2005), eight out of nine studies
published after this insightful paper still use standard care control or attention control instead
of a “minimally effective treatment.” This makes it more difficult to fully establish the real
efficacy of hypnosis, because of the possible ‘contamination’ by non-specific treatment
effects (i.e. expectancy). It also makes it difficult for researchers to compare the
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effectiveness of hypnosis to other medical treatments that are usually evaluated with placebo
control. Nevertheless, there are some studies directly contrasting the effectiveness of
hypnosis and other adjunct therapies for pain; expectancy bias is less likely in such
comparisons. Based on the studies in this review, hypnosis seems to be at least as effective as
cognitive behavioral approaches and play therapy, while hypnosis with relaxing music was
more effective than relaxing music alone, intraoperative hypnosis was also more effective
than intraoperative emotional support, and in most instances hypnosis produced better
results than distraction.

Included studies evaluated the effectiveness of hypnosis for pain control during bone marrow
aspiration, lumbar puncture, burn care, surgical procedures and other potentially painful
medical procedures like radiological procedures, abortion, and venipuncture. While there
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were reports of some beneficial effect for all of these procedures, the highest success rate
was demonstrated in hypnosis for surgical procedures, with 75% of measures showing
significantly beneficial results. This finding is in line with numerous previous reviews
showing that hypnosis is a successful adjunctive treatment for the prevention of surgical
side-effects (Flammer & Bongartz, 2003; Flory, Martinez Salazar, & Lang, 2007; Kekecs,
Nagy, & Varga, in press; Montgomery, David, Winkel, Silverstein, & Bovbjerg, 2002;
Schnur, Kafer, Marcus, & Montgomery, 2008; Tefikow et al., 2013; Wobst, 2007). We have
to note here that most of the studies included in this review assess hypnoanalgesia for minor

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 Kendrick et al. Page 6

surgical procedures. A recent meta-analysis (Kekecs et al., in press) also showed that
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hypnosis is likely to reduce postoperative pain for minor procedures, but it failed to find
conclusive evidence to support the effectiveness of postoperative hypnotic analgesia in major
surgeries. The authors of that meta-analysis speculate that hypnoanalgesic effects might not
be sufficient for controlling pain in major surgeries, or, that they may be masked by rigorous
pharmacological pain control regimes used after major procedures. Whichever is the case,
our present review provides additional support for the benefits of perioperative hypnosis in
minor surgeries. On the other hand, our review showed that studies on bone marrow
aspiration and burn care reported the lowest percentage of significant effects from all the
procedure types. Patterson and Jensen (2003) also found inconsistent results on the effects of
hypnosis for burn care. Results of Patterson, Adcock and Bombardier (1997) suggest that
initial levels of burn pain might be a moderator of effectiveness. Specifically, patients with
higher baseline pain levels might be more motivated and more compliant, and additionally
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more able to dissociate, than patients with low burn pain.

Interventions with more than one hypnosis session reported more significant effects than did
studies involving only one session; studies in which hypnosis was applied at least in part
before the day of the procedure seemed to be more successful than those applying the
intervention on the day of the procedure (either before or during procedure), and hypnosis
interventions shorter than 30 minutes produced the best results. The concordance between
the effectiveness of multiple intervention sessions and presentation before the day of the
procedure is not surprising as, in multi-session interventions, sessions are usually not
administered on the same day. Consequently, starting the preparation of patients early with
several hypnosis sessions seems to be the best approach. However, at this point, we cannot
tell if the earliness of the preparation or the multitude of sessions is the effective component
here. Interpretations are also limited by the fact that most studies did not systematically vary
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moderating factors like number of hypnosis sessions, intervention length, and intervention
timing. Thus, we can only draw indirect inferences. Systematic contrast of these intervention
characteristics is needed. Future studies should also investigate whether the possibility of
practice at home plays a role in the efficacy of ‘early starting’ interventions.

Several previous studies evaluated the economical properties of hypnosis as an adjunct

treatment for medical procedures (e.g., Disbrow, Bennett, & Owings, 1993; Lang et al.,
2006; Lang & Rosen, 2002; Montgomery et al., 2007). These studies demonstrated that
hypnosis results in a significant cost-offsetting even when the cost of the intervention is
accounted for, mainly due to decreased procedure times, fewer complications, lower chance
of over-sedation, and shorter hospital stay after the procedures. The fact that most of the
studies in the present review achieved beneficial effects with using merely one hypnosis
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session also suggests cost-effectiveness. However, as stated before, it seems that multiple
sessions may enhance effectiveness. Future studies should evaluate the added benefits of
multiple hypnosis sessions in lite of the increased intervention costs. Our results also showed
that hypnosis sessions were usually shorter than 30 minutes, and that these short
interventions produced the highest percentage of beneficial results.

It is also a question of economic value whether hypnoanalgesia is beneficial only for patients
with high hypnotic susceptibility, or if it can be used with every patient. Earlier studies

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 Kendrick et al. Page 7

advocated the importance of hypnotizability as a determinant of hypnotically achievable

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analgesia (e.g., Freeman, Barabasz, Barabasz, & Warner, 2000; Montgomery, DuHamel, &
Redd, 2000). Although this might be true in laboratory settings, a recent meta-analysis
argues that the variance in outcome explained by hypnotic susceptibility is so small (6%)
that it is of little to no clinical importance (Montgomery, Schnur, & David, 2011). In the vast
majority of the studies included in our review, participants were not screened for hypnotic
susceptibility, and none of the seven studies measuring hypnotizability selected participants
based on this score. Four of these seven studies reported significant associations between
outcomes and hypnotizability. However, in spite of the lack of selection for high
hypnotizables during patient enrollment, most of the studies in our review yielded a
significant beneficial effect, which corresponds with the conclusions of previous reviews
indicating that most patients are “hypnotizable enough” to benefit from hypnotic
interventions (Montgomery, David, et al., 2002; Montgomery et al., 2011). Based on our
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review, we argue that hypnoanalgesia is an effective and treatment for acute procedural pain
which can be applied in a large variety of medical areas and patient populations. Thus
detailed guides of application incorporating recent research findings are needed to make the
technique more generally accessible for clinicians (e.g., Patterson, 2010).

Hypnosis has been defined as a state of consciousness involving focused attention and
reduced peripheral awareness characterized by an enhanced capacity for response to
suggestion (Elkins, Barabasz, Council, & Spiegel, 2015). All of the included studies used
hypnosis in which focused attention, guided imagery and analgesic suggestion are coupled
with relaxation. Relaxational hypnosis is convenient because in most medical procedures
patients are required to lie or sit still and thus relaxation and hypnosis can be continued
during the procedure as well. However according to laboratory studies, hypnoanalgesia can
also be achieved by active alert hypnosis in which hypnosis is performed during intense
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physical exercise of the subject (Bányai & Hilgard, 1976; Miller, Barabasz, & Barabasz,
1991). This is a feature that is yet to be utilized in medical hypnoanalgesia studies. Good
candidates for using this technique might be radiological procedures requiring physical
exercise as a stress test (e.g., some of the coronary artery imaging techniques).

Limitations
Although 75% of the studies had a methodological quality score of two or higher, only five
papers got the maximal score of four during methodological evaluation. This shows that
although methodological quality of the study pool is not poor, there is still a considerable
chance that results are biased. Even more so, as the Jadad score itself is only sensitive to a
limited set of possible methodological biases (Berger & Alperson, 2009), one of which
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(blinding of participants) was already ruled out of scoring because of the nature of hypnosis
interventions. Furthermore, the presence of publication bias is also a common risk in the
evaluation of clinical research, although according to Easterbrook, Gopalan, Berlin, and
Matthews (1991), randomized controlled trials are less prone to it. Thus, simple pooling of
effects of trials found during the literature search is likely to result in overestimation of the
real effects. Further bias can be introduced by the pooling of measurements across different
studies, as certain studies with a higher number of measurements can have a greater

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 Kendrick et al. Page 8

influence on the data. We also have to note that there is a chance that some relevant papers
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may have been missed during our literature search.

Conclusions
Results from randomized controlled clinical trials suggest that hypnosis decreases acute
procedural pain, and is at least as effective as other complementary therapies. Hypnotic
analgesia seems to be especially effective in minor surgical procedures. Furthermore,
interventions started earlier than the day of the procedure and using more than one hypnosis
sessions were most effective. However, further methodologically rigorous studies applying
minimally effective control conditions and systematic control of intervention dose and
timing are required to decrease risk of bias. Hypnosis interventions may affect subjective
pain intensity and pain unpleasantness differentially. Thus, hypnotic suggestions and pain
measures should be carefully matched. Also, additional research is needed to more fully
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evaluate the effectiveness of hypnotic interventions in contrast to non-hypnotic therapies,

devise credible placebo control conditions, and determine the effect of potential moderators
such as dose (i.e., number of sessions) and hypnotizability.

Acknowledgments
We would like to acknowledge Vicki Patterson, Savannah Gosnell, Luzie Fofonka-Cunha and Peter Jiang for their
assistance in obtaining articles, preparation of tables and editing references.

Funding

Dr. Elkins was supported by grant # U01AT004634 from the National Center for Complementary and Alternative
Medicine, National Institutes of Health.
Author Manuscript

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Figure 1.
PRISMA Flow Diagram
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Table 1

Key Data Controlled Trials of Hypnosis for Acute and Procedural Pain

First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Kendrick et al.

Treat Analysis
Zeltner, 1982 Parallel design Bone marrow aspirations Patients were helped to Distraction. This 1) pain self-report and 1) Pain self- ‘(…) hypnosis was
1 or lumbar puncture become increasingly involved asking the observer rating aggregated ratings shown to be more
Not reported 33/33 involved in interesting child to focus on (1–5) decreased in effective than non-
and pleasant images. (n objects in the room 2) anxiety self-report and both groups hypnotic techniques
= 16) rather than on fantasy. observer rating aggregated significantly, for reducing
(n = 17) (1–5) but hypnosis procedural distress in
* Both measures collected at was children and
baseline and 1–3 BMAs post- significantly adolescents with
baseline better in pain cancer.’
reduction for
bone marrow
aspiration (p
< .03) and
lumbar
puncture (p<.
02).
2) Anxiety was
also
significantly
more reduced
by hypnosis for
bone marrow
aspiration (p
< .05).

Katz, 1987 Parallel design Bone marrow aspirations Training in hypnosis Play matched for time 1) Pain self-report (0–100 1) Pain self- ‘It appears that
2 or lumbar puncture (in and self-hypnosis (two, and attention to scale) patterned after report scores hypnosis and play are
Not reported some cases) 30 min. interventions hypnosis group thermometer. decreased equally effective in
36/36 prior to each BMA + 20 (n=19) 2) PBRS during procedure significantly reducing subjective
min session preceding * Both measures collected at from baseline pain for BMAs.
each of three BMAs. baseline and 3 BMAs post- at each
(n= 17) baseline subsequent
BMA in both

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
groups (p<.05).
There were no
significant
intergroup
differences in
self-reported
pain.
2) No
significant
intergroup
differences in
observational
ratings.
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 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
Kuttner, 1988 Parallel design Bone marrow aspiration 5–20 minute 1) standard care (n = 1) PBRS during procedure by 1) no ‘(…) distress of
2 48/48 preparation just before 16) 2 observers difference in younger children, 3–6
Not reported procedure and hypnosis 2) 5–20 minute 2) observed anxiety rating the whole years old was best
Kendrick et al.

and guided imagery preparation and scale (1–5), 3) observed pain sample, but alleviated by
facilitating the training in breathing rating scale (1–5) younger hypnotic therapy,
involvement in an technique, and 2) and 3) were the aggregated patients had a imaginative
interesting story during distraction with toys score of physician, nurse, lower PBRS in involvement, whereas
procedure. Additionally during procedure. (n = parent, 2 observers the hypnosis older children’s
participants could turn 16) 4) anxiety self-report group than observed pain and
pain off with a ‘pain (pictorial scale) both other anxiety was reduced
switch’. (n = 16) 5) pain self-report (pictorial groups (ps < . by both distraction
scale) 05). and imaginative
2) observed involvement
anxiety was techniques.’
lower for older
children in the
hypnosis group
and the
distraction
group
compared to
the control (p<.
05), but not
hypnosis vs.
distraction.
While hypnosis
was better at
anxiety
reduction than
distraction for
younger
patients (p<.
05),.
3) no
difference in
the whole
sample,

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
observed pain
was lower in in
older patients
in the hypnosis
group
compared to
the standard
care group.(p<.
05). While for
younger
patients,
hypnosis was
better for pain
reduction.(p<.
05).
Page 14
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
4) no effect on
anxiety self-
report
Kendrick et al.

5) no effect on
pain self-report

Wall, 1989 Parallel design Bone marrow aspirations Hypnosis (two group Active cognitive 1) 10cm VAS2 (procedural 1) Self- ‘(…) both strategies
3 or lumbar puncture training sessions during strategy (two group pain, behavioral observation reported pain were effective in
Not reported 20/201 the week prior to the training sessions and self-reports, three times) decreased in providing pain
procedure, n= 11) during the week prior both groups (p reduction.’
to the procedure, n= 2) MPQ3 (affective and = .003) with no
9) procedural components of significant
pain, one time, subjects above between group
12yo) differences.
3) independent observer blind 2) MPQ
to treatment assignment – present pain
rated procedural pain via 10 index (p<.02)
cm VAS and pain
ratings index
(p<.01)
significantly
decreased in
both groups
with no
significant
between group
differences.
3)
Observational
pain ratings
reflected
decrease in
procedural pain
(p<.009).
Between group
differences
were
insignificant.

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
Weinstein, 1991 Parallel design Angioplasty (by Hypnosis (30 min) Standard care (n = 16) 1) Pulse 1) No ‘(…) reduction [of
0 inflating balloons in before the day of the 2) Blood pressure difference in analgesic use] was
Not reported occluded coronary procedure, with 3) Pain medication used pulse significant, and in
arteries) posthypnotic 4) balloon inflation time 2) No line with reports of
32/32 suggestions for difference in less pain medication
relaxation during blood pressure required by burn
angioplasty. (n = 16) 3) Fewer victims who have
patients needed mad hypnotic
additional pain therapy’
medication in
the hypnosis
group (p = .05)
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
4) Balloon
could remain
inflated 25%
Kendrick et al.

longer in the
hypnosis group
(not significant,
p = .10)

Patterson, 1992 Parallel design 33/30 Hypnosis (25 min) prior 1) Standard care 1) 10 cm VAS self-report 1a) significant ‘Hypnosis is a viable
3 to debridement + 2) Attention and 2) 10 cm nurse administered within group adjunct treatment for
Not reported standard care information control + VAS difference in burn pain.’
standard care 3) pain medication stability hypnosis group
(p=.0001) not
seen in
controls.
1b) Hypnosis
participants
had
significantly
less post-
treatment pain
than attention
(p=.03) and
standard care
control (p=.01).
2a) significant
within group
pre-post
reduction in
pain among
hypnosis
participants not
seen in
controls.
2b) no
significant
intergroup
differences

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
3) no
significant
intergroup
differences

Syrjala, 1992 Parallel design Bone marrow aspiration 1) Hypnosis (2 pre- 1) Therapist contact 1) VAS self-report of oral 1) Hypnosis ‘Hypnosis was
2 67/45 transplant sessions +10 control (2 pre- pain participants effective in reducing
Not reported booster sessions)+ transplant sessions 2) opioid medication use experienced oral pain for patients
standard medical care +10 booster sessions) less pain than undergoing marrow
2) Cognitive behavioral + standard medical therapist transplantation. The
coping skills training (2 care contact or CBT CBT intervention was
pre-transplant sessions 2) Treatment as usual participants not effective in
+10 booster sessions) + (standard medical (p= .033). reducing symptoms
standard medical care care measured.’
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
2) no
significant
differences
Kendrick et al.

between groups

Everett, 1993 Parallel Burn debridement 1) Hypnosis (25 min) 1) standard care 1) VAS self-report 1) No ‘The results are
2 32/32 before debridement 2) hypnosis attention 2) VAS nurse observation significant argued to support the
Not reported +standard care control: time and 3) pain medication stability intergroup or analgesic advantages
2) Hypnosis (25 min) attention (25 min) + within group of early, aggressive
intervention prior to standard care differences opioid use via PCA
debridement + 2) No [patient-controlled
Lorazepam + standard significant analgesia apparatus]
care intergroup or or through careful
within group staff monitoring and
differences titration of pain
3) Pain drugs.’
medication was
equivalent
across four
groups.

Lambert, 1996 Parallel design Variety of elective 1 training session (30 Attention control: 1) pain reported each hour 1) lower pain ‘This study
2 surgical procedures min) 1 week before Equal amount of time after surgery on a numerical ratings in the demonstrates the
Not reported 52/50 surgery, where children spent with a research rating scale (0–10) hypnosis group positive effects of
were taught guided assistant discussing 2) total analgesics used (p<.01) hypnosis/guided
imagery. Posthypnotic surgery and other postoperatively 2) no imagery for the
suggestions for better topics of interest. 3) self-report anxiety significant pediatric surgical
surgical outcome. (n (n=26) (STAIC) difference in patient.’
=26) analgesic use
between groups
3) no
significant
difference in
anxiety
between groups

Lang, 1996 Parallel design Radiological procedures Instruction in self Standard care (n=14) 1) 0–10 numeric rating scale 1) Hypnosis ‘Self-hypnotic
3 30/30 Hypnosis to be used at baseline, at ‘20 min into participants relaxation can reduce

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
Not reported during operation + every 40-min interval, and reported drug use and improve
standard care (n=16) before leaving the significantly procedural safety’
intervention table’ less pain than
2) Blood pressure controls (p<.
3) Intravenous PCA4 01)
2) No
significant
intergroup
differences
with regard to
increases in
blood pressure.
3) Controls
self-
administered
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
significantly
more
medication
Kendrick et al.

than hypnosis
participants
(p<.01).

Smith, 1996 Crossover-design venipuncture or Training for the child Training for the child 1) Children’s Global Rating 1) CGRS pain ‘Hypnosis was
2 infusaport access and parent to use a and parent to apply Scale (CGRS) of pain by the rating was significantly more
Not reported 36/27 favorite place hypnotic distraction technique patient lower in the effective than
induction where the using a toy during the 2) Children’s Global Rating hypnosis distraction in
parent and child go on medical procedure. Scale (CGRS) of anxiety by condition (p<. reducing perceptions
an imaginary journey to Daily practice for 1 the patient 001), of behavioral distress,
a location of the child’s week before the 3) pain Likert scale by the especially in pain, and anxiety in
choosing during the procedure. (n = 36) parent high hypnotizable
medical procedure. 4) anxiety Likert scale by the hypnotizables. children.’
Daily practice for 1 parent 2) CGRS
week before the 5) Independent observer- anxiety rating
procedure. (n = 36) reported anxiety was lower in
6) Observational Scale of the hypnosis
Behavioral Distress-Revised condition (p<.
(OSBD-R) 001),
especially in
high
hypnotizables.
3), 4) and 5)
parent reported
pain and
anxiety, and
observer
reported
anxiety showed
the same
pattern (ps<.
001).
6) no
significant
main effect of

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
condition
reported for
OSBD-R
scores.

Enqvist, 1997 Parallel design Surgical removal of third 20 min Hypnosis via Standard care (n= 36) postoperative analgesic use Of participants ‘The preoperative use
3 mandibular molars audiotape one week randomized to of a carefully
Not reported 72/69 prior to surgery with hypnosis, 3% designed audiotape is
recommendations for consumed three an economical
daily listening + or more intervention, in this
standard care (n= 33) equipotent instance with the aim
doses of to give the patient
postoperative better control over
analgesics in anxiety and pain. A
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
comparison to patient-centered
28% of approach, together
controls. with the use of
Kendrick et al.

hypnotherapeutic
principles, can be a
useful addition to
drug therapy. A
preoperative hypnotic
technique audiotape
can be additionally
helpful because it
also gives the patient
a tool for use in
future stressful
situations.’
Faymonville, 1997 Parallel design Plastic surgery Hypnosis (just Emotional support 1) Intraoperative pain VAS 1) ‘(…) hypnosis
2 60/56 proceeding and during (during surgery) + 2) postoperative pain VAS Intraoperative provides better
Yes surgery) + standard care standard care (n=25) (self-report) was perioperative pain
(n=31) 3) intraoperative pain significantly and anxiety relief,
medication requirements lower among allows for significant
hypnosis reduction in
participants alfentanil and
than controls midazolam
(p<.02). requirements, and
2) Hypnosis improves patient
participants satisfaction and
reported surgical conditions as
significantly compared with
less conventional stress
postoperative reducing strategies
pain than support in patients
controls (p<. receiving conscious
01) sedation for plastic
3) Hypnosis surgery.’
participants
required
significantly

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
less
intraoperative
midazolam
(p<.001) and
alfentanil (p<.
001) than
controls.

Patterson, 1997 Parallel Design Burn debridement 1) hypnosis (25 min) 1) attention and 1) 100 mm VAS self-report 1a) No ‘The findings
4 63/57 prior to debridement information control + 2) 100 VAS nurse observation significant provided further
Not reported +standard care standard care 3) pain medication stability intergroup evidence that
differences in hypnosis can be a
the total useful psychological
sample. intervention for
reducing pain in
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
1b) Hypnosis patients who are
participants being treated for a
experienced major burn injury.
Kendrick et al.

less pain (p<. However, the findings

05) among also indicate that this
patients with technique is likely
high baseline more useful for
pain levels patients who are
2a) observer experiencing high
ratings levels of pain.’
indicated less
pain among
hypnosis
participants
than controls
(p<.05)
2b) no
intergroup
differences
among patients
with high
baseline pain
according to
nurses
3) no
significant
intergroup
differences
(comparing all
patients or high
pain patients)

Liossi, 1999 Parallel design Bone marrow aspirations Hypnosis (3, 30 min 1) Standard care (n = 1) PBCL5 (behavioral 1) PBCL ‘Hypnosis and CB
3 30/30 sessions prior to 10) observation, pain, during one indicated were similarly
Not reported procedure, n= 10) 2) Cognitive hypnosis (p=. effective in the relief
behavioral (CB) BMA6 at baseline and during 001) and CB of pain….It is
coping skills (3, 30 BMA after interventions) patients (p = . concluded that
min sessions prior to 2) 6-point faces rating scale 003) were less hypnosis and CB

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
procedure, n= 10) (self-report, pain, during one distressed than coping skills are
BMA at baseline and during controls. effective in preparing
BMA after interventions) Hypnosis pediatric oncology
participants patients for bone
also had less marrow aspiration.’
distress than
CB (p = .025)
participants.
2) Hypnosis
participants (p
= .005) or CB
(p = .008)
reported
decreased pain
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
in comparison
to baseline that
was not
Kendrick et al.

observed in
controls. In
addition, self-
reported pain
was less among
hypnosis
participants
(p=.001) and
CB participants
(p=.002) than
controls. There
were no
significant
group
differences of
self-reported
pain between
hypnosis and
CB
participants.

Lang, 2000 Parallel design Percutaneous vascular Guided self- hypnotic 1) Standard care 1) 0–10 verbal scales (pain, 1) Participants ‘Structured attention
3 and renal procedures relaxation during (n=79) before surgery and every 15 experienced a and self-hypnotic
Not reported 241/241 surgery + standard 2) structured attention min during it) linear increase relaxation proved
medical care (n=82) during surgery + 2) Amount of medication in pain beneficial during
standard medical requested during procedure throughout the invasive medical
care(n=80) operation if procedures. Hypnosis
randomized to had more pronounced
attention (p= . effects on pain and
0425) or anxiety reduction,
standard care and is superior, in
(p<.0001). that it also improves
However, hemodynamic
hypnosis stability.’
participants did

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
not experience
a significant
pain increase.
2) Medication
usage was
significantly
greater among
participants
randomized to
standard care
(1.9 units) in
comparison to
hypnosis (0.9
units) or
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
structured
attention
participants
Kendrick et al.

(0.8 units).

Wright, 2000 Parallel design Burn debridement Hypnosis (15 min) prior Standard care 1) Self report of sensory and 1a) Significant Hypnosis is ‘a viable
1 30/30 to debridement affective pain during burn pre-post adjunct to narcotic
Not reported procedures + standard care decreases of treatment for pain
care 2) retrospective self-report of sensory (p<. control during burn
pain ratings after burn care 001) and care.’
3) medication consumption affective (p<.
001) pain were
seen among
hypnosis
participants by
end of first
procedure.
1b) Self report
of sensory (p<.
05) and
affective (p<.
05) pain were
lower among
hypnosis
participants
than controls
after the
second
debridement.
3) In the
hypnosis
group,
consumption of
paracetamol
(p<.01) and
codeine (p.=.
01) decreased
but remained

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
unchanged in
controls.

Montgomery, 2002 Parallel design Excisional breast biopsy Hypnosis (10 min Standard-care (n=20) 10cm VAS (pain). Hypnosis ‘The results of the
1 20/20; + 20 healthy hypnotic induction Healthy group (n=20) group present study
Not reported controls before the procedure, demonstrated revealed that a brief
n=20) decreased post- hypnosis intervention
surgery pain in can be an effective
comparison to means to reduce
control (p<. postsurgical pain and
001) distress in women
undergoing
excisional breast
biopsy. Postsurgical
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
pain was reduced in
patients receiving
hypnosis relative to a
Kendrick et al.

standard care control

group.’

Liossi, 2003 Parallel design Lumbar punctures (LP) 1) Direct hypnosis (1, 1) Standard care (n= 1) PBCL (behavioral 1) Observed ‘(…) Hypnosis is
2 80/80 40 minute session + 20) observation, pain, at baseline distress in effective in preparing
Not reported administration directly 2) ) Attention control and during 2 LP with hypnosis group pediatric oncology
before and during 2LP (40 minutes session + therapist directed decreased patients for lumbar
+ self-hypnosis standard care, n=20) interventions + 3 LP with significantly puncture, but the
instruction + standard self-hypnosis interventions) during presence of the
care, n=20) 2) 6-point faces rating scale intervention (p therapist may be
2) Indirect hypnosis (1, (self-report, pain, during <.001) and was critical.’
40 minutes session + baseline, 2 consecutive LPs significantly
administration directly with therapist interventions lower than that
before and during 2LP + 3 LPs with self-hypnosis of controls (p<.
+ self- hypnosis only) 001). In
instruction + standard addition,
care, n=20) behavioral
distress was
lower among
treatment
groups during
1st and 3rd LPs
using self-
hypnosis than
among controls
(p<.001 for all
comparisons
between
groups).
However,
distress
increased to
baseline levels
at 6th LP using
self-hypnosis.

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
There were no
significant
intragroup
differences
between the
treatment or
control groups.
2) During the
intervention
phase,
hypnosis
participants
experienced
significantly
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
less pain than
attention (p<.
02) and
Kendrick et al.

standard care
(p<.001)
controls. Pain
decreases
continued
during 1st and
3rd LPs using
self-hypnosis
but increased to
levels baseline
levels by the
6th LP with
self-hypnosis.
No significant
intragroup
differences
between the
treatment or
control groups.

Harandi, 2004 Parallel design Physiotherapy for burns Hypnosis once a day Standard-care (n=22) 100mm VAS7 (pain) Hypnosis ‘Hypnosis is
0 44/44 for a period of 4 days, participants recommended as a
Not reported n=22) experienced complementary
less pain method in burns
physiotherapy - physiotherapy.’
related pain in
comparison to
controls (p<.
001)

Massarini, 2005 Parallel design Surgical operation 15 – 30 min of Standard care (n=20) 0–10 numeric rating scale 1a) Hypnosis ‘This controlled
1 42/42 Hypnosis 24 hours prior combined with a scale of participants study showed that
Not reported to operation (n=20) facial expressions (Faces Pain reported less brief hypnotic
Rating Scale) recorded each pain intensity treatment carried out
day postoperatively for 4 on day 1(p = . in the preoperative

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
days to assess affective and 006) and 2 period leads to good
sensory pain (p= .003) results with surgery
following their patients in terms of
operation in reducing anxiety
comparison to levels and pain
controls. perception.’
However, pain
intensity in the
hypnosis group
was
comparable to
that of controls
on day 3 and 4.
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
1b) Affective
pain was also
less among
Kendrick et al.

hypnosis
participants in
comparison to
controls on day
1 (p=.010) and
2 (p=.010)
postoperatively,
but was
equivocal on
day 3 (p=.204)
and 4 (p=.702)

Lang, 2006 Parallel design Breast biopsy Hypnosis during 1) Standard care (n = 1) Verbal 0–10 analog scale Intraoperative ‘(…) while both
3 240/236 procedure + empathetic 76) (intraoperative every 10 min) pain increased structured empathy
Not reported attention (n= 78) 2) Structured significantly and hypnosis
emphatic attention for all groups decrease procedural
during procedure (n= (p<.001). pain and anxiety,
82) However, the hypnosis provides
pain increase more powerful
among anxiety relief without
hypnosis undue cost and thus
participants appears attractive for
was less steep outpatient pain
than that of management.’
empathy (p = .
024) or
standard care
(p = .018)
participants.

Liossi, 2006 Parallel design Lumbar punctures 1) EMLA +Hypnosis 1) EMLA =15 1) The Wong–Baker FACES 1) During all 3 ‘(…) self-hypnosis
4 45/45 (approximately 40 min 2) EMLA + Attention Pain Rating Scale (self- measurement might be a time- and
Yes session + self- hypnosis (approximately 40 report) times, hypnosis cost-effective method
training, n= 15) minute session, n= 2) PBCL participants that nevertheless
15) * Measures were collected 3 were found to extends the benefits

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
times - during therapist led report less pain of traditional hetero-
intervention (time 2) – - that the hypnosis.’
during self-hypnosis attention
intervention (time 3 and 4) controls: (p<.
001) for times
2 and 3; (p<.
002) for time 4.
In addition,
hypnosis
participants
experienced
less pain than
EMLA only
controls: (p<.
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
001) for times
2, 3, and 4
2) At times 2,
Kendrick et al.

3, and 4,
participants
randomized to
EMLA +
hypnosis
appeared
significantly
less distressed
than those of
the EMLA
group (p<.001)
or the EMLA +
attention group
(p<.001). There
were no
significant
intergroup
differences
between
controls.

Marc, 2007 Parallel design Abortion Hypnosis (20 min Standard-care (n=15) 1) Request for N2O sedation. 1) 36% of ‘(…) hypnosis can be
3 30/29 before and during 2) 11-point verbal numerical hypnosis integrated into
Not reported procedure, n=14) scale used during operation participant standard care and
needed N2O reduces the need for
sedation N2O in patients
compared to undergoing first-
87% of trimester surgical
controls (p<. abortion.’
01).
2) No
significant
differences.
Montgomery, 2007 Parallel design Breast cancer surgery Hypnosis (15 minute, Attention control (15 1) Intraoperative medication 1) Patients ‘Overall, the present

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
4 200/200 pre-surgical minute pre- surgical use randomized to data support the use
Not reported intervention, n= 105) intervention, n= 95) 2) 0–100 VAS pain intensity receive of hypnosis with
and unpleasantness hypnosis breast cancer surgery
required less patients.’
Lidocaine (p<.
001) and
Propofol (p<.
001)
interoperatively
than controls.
Utilization of
Fentanyl and
Midazlam was
not statistically
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
different
between
groups, nor
Kendrick et al.

was use of
postoperative
analgesics.
2) Hypnosis
participants
reported also
reported
significantly
less pain
intensity (p<.
001) and pain
unpleasantness
(p<.001) than
controls.

Marc, 2008 Parallel design Abortion Hypnotic analgesia (20 Standard-care (n=175) 1) Use of sedation. 1) Hypnosis ‘Hypnotic
3 350/347 min before and during 2) 0–100 visual numeric participants interventions can be
Not reported procedure, n=172) scales (two separate ratings required less effective as an
during operation) IV analgesia adjunct to
than controls (p pharmacologic
<.0001) 2) management of acute
Hypnosis pain during abortion.’
participants did
not report
significant pain
increase during
suction
evaluation.

Liossi, 2009 Parallel design Venipuncture EMLA8 + hypnosis (15 1) EMLA (n=15) 1) 100 mm VAS 1a) ‘(…) the use of self-
4 45/45 min) prior to first 2) EMLA + attention 2) PBCL (three times Venipuncture hypnosis prior to
Yes venipuncture + self- (15 minutes) prior to following baseline - during 1:Self-reported venipuncture can be
hypnosis instruction first venipuncture (n= preparation, needle insertion, pain was considered a brief,
(n= 15) 15) and post procedure) significantly easily implemented
less in and an effective

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
hypnosis intervention in
participants reducing
than in venipuncture-related
attention pain.’
controls (p<.
001) who
reported
significantly
less pain than
EMLA only
controls (p<.
04)
1b)
Venipuncture
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
2&
Venipuncture
3: Self-reported
Kendrick et al.

pain was
significantly
lower among
hypnosis
participants
than attention
(p<.001) or
EMLA only
controls (p<.
001). There
were no
significant
intergroup
differences
between
controls.
2a)
Venipuncture
1: Hypnosis
participants
displayed less
observable
distress than
attention (p<.
001) controls,
who appeared
less distressed
than EMLA
only (p<.001)
controls.
2b)
Venipuncture
2& 3:
Hypnosis
participants

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
again displayed
significantly
less observable
distress than
attention
controls (p <.
001) in both
venipunctures.
Attention
controls also
appeared less
distressed than
EMLA only
controls during
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First Author, Year Study Design Condition Sample Size Intervention (regimen) Control (regimen) Pain Measurement Methods Main Result Authors’ Conclusion
Quality Score (Randomized/
Intention-to- Analyzed)
Treat Analysis
both
venipuncture 2
(p=.025) and 3
Kendrick et al.

(p = .008).

Mackey, 2010 Parallel design Molar extraction Hypnosis + relaxing Relaxing background 1) postoperative pain - 10cm 1) ‘(…) the use of
4 91/91 background music music during surgery VAS Postoperative hypnosis and
Not reported during surgery + + standard care (n= 2) intraoperative medication pain was therapeutic
standard care (n=46) 54) use significantly suggestion as an
3) postoperative prescription less among adjunct to
analgesic used hypnosis intravenous sedation
participants assists patients
than controls having third molar
(p<.001). removal in an
2) Control outpatient surgical
participants setting.’
required
significantly
more
intraoperative
medication
than hypnosis
participants
(p<.01).
3) The use of
postoperative
analgesics was
significantly
less among
hypnosis
participants
than controls
(p<.01).

Snow, 2012 Parallel design Bone marrow aspirates Hypnosis (15 min Standard-care (n=39) 100mm VAS (pain, anxiety) No significant ‘(…) brief hypnosis
1 and biopsies before and during the between group concurrently
Not reported 80/80 procedure) + standard differences in administered reduces
care (n= 41) pain ratings. patient anxiety during

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
bone marrow
aspirates and biopsies
but may not
Adequately control
pain.’

1
‘Due to changes in medical treatment protocols which eliminated or significantly reduced the number of BMA/LP’s done with patients, only 20 of the original group of 42 subjects who initially
volunteered completed the study.’ Page 183
2
VAS, visual analog scale
3
MPQ, McGill Pain Questionnaire
Page 29
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript
4
PCA, Intravenous patient-controlled analgesia
5
PBCL, Procedure Behavior Checklist
6
BMA, Bone marrow aspiration
7
VAS, visual analog scale
8
Kendrick et al.

EMLA, eutectic mixture of local anesthetics

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
Page 30
 Kendrick et al. Page 31

Table 2

Effectiveness of hypnosis displayed by various comparison groups and study and intervention characteristics
Author Manuscript

total number of studies total number of measurements sign. effect percentage

control condition
hypnosis is better than standard care control 20 45 62%
hypnosis is better than attention control 11 30 53%
hypnosis is better than other active treatment 9 30 53%
procedure type
bone marrow aspiration 4 10 30%
lumbar puncture 2 5 60%
burn debridement or other burn care 5 12 42%
surgical procedure 6 12 75%
other medical procedures 6 14 69%
Author Manuscript

amount of sessions
more than 1 sessions 3 5 80%
1 sessions 20 50 54%
intervention length
30 minutes or longer 6 16 56%
shorter than 30 minutes 11 25 68%
lasting as long as the procedure 5 14 36%
intervention timing
presentation days before the procedure 6 15 67%
pre-operative presentation 13 34 47%
intra-operative presentation 8 20 45%

Note: sign. effect percentage shows the percentage of measures in which hypnosis groups had significantly lower pain scores than the comparison
Author Manuscript

group in relation to the total number of measures. For the assessment of procedure type, amount of sessions, intervention length and intervention
timing comparison groups were attention control or standard care groups.
Author Manuscript

Int J Clin Exp Hypn. Author manuscript; available in PMC 2017 January 01.
 International Journal of Health Sciences and Research
www.ijhsr.org ISSN: 2249-9571

Review Article

Burns: First Aid

Singh Kuldeep1, Punia Sudhanshu2, Singh Bhupender3, D. Pramod2, Singh Bikramjit2
1
HOD, 2Resident, 3Assistant Professor,
Burns and Plastic Surgery, PGIMS, Rohtak, Haryana, India.
Corresponding Author: Dr. Sudhanshu Punia

ABSTRACT

Burns are common occurrence and often the patient is rushed to a nearby medical practitioner or
hospital for first aid. Some patients may receive first aid from their relatives or friends in correct or
incorrect manner. Most of the time the first respondents in case of burns are family members, friends,
by standers. Properly instituted first aid reduces the morbidity and even mortality in burn patients.
Many simple interventions can make a great difference in the course of burns and improve patient
outcome.
This article is aimed to educate primary health care providers, accident and emergency departments,
paramedicals and even the general public so that treatment for burn patients can start early.

Key Words: First aid, Burns, What to do, Immediate treatments

INTRODUCTION 3. Electrical injuries occur due to

Burns are common occurrence and
often the patient is rushed to a nearby
medical practitioner or hospital for first aid.
Some patients may receive first aid from
their relatives or friends in correct or
incorrect manner. Therefore it is imperative
that the public is made aware of the proper
first aid as it does limit further burn
morbidity. As many of our patients come
from a rural background, so are initially
treated by home remedies, some of which
include ink, ash, mud, turmeric and even
cow-dung. Use of peacock feathers is also
rampant. The scientific base of these
treatments has eluded the authors and has no
place in first aid or treatment.
Most common type of burns in which
properly administered first aid is useful are -
1. Scalds in the pediatric population,
2. Thermal burns in farmers and daily
wage workers, who still utilize kerosene
lamps for illumination or cooking and
accidentally get burnt by it.
inadvertent coming in contact with the
electrical cables, most patients are not
electrical workers hence, do not have
any protective devices for the same.
4. Chemical burns, mostly in factory
workers and as in a case of vitriolage.
Administration of First Aid:
Most of the time the first
respondents in case of burns are family
members, friends, by standers. They have to
be made aware about the proper
administration of first aid, along with, not to
injure themselves while saving the patient.
Thermal burns:
One must always try to put out the
fire first. The stop and drop policy should be
followed. Prevent the victim from running
which would only fan the flames and make
them burn faster. The victim should be
instructed to lie down on the floor
immediately with the burning side

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Vol.7; Issue: 8; August 2017
 Singh, Kuldeep et al. Burns: First Aid
uppermost. As the flames always burn
upwards, lying flat prevents the fire from
going around the body. Rolling should be
avoided as it would burn the previously
unburnt areas and may result in other
injuries. [1]
To stop the victim from burning he/
she may be doused with water or covered
with a heavy cotton cloth. Use of synthetic
textiles should be avoided, as that would
ignite and stick to the victim and do more
harm. Once the fire is extinguished the
garment should promptly be removed, as it
tends to trap heat. If water is not available
any clean, packaged drink can be used eg.
Milk. [2]
Water, which is being used to douse
the patient should be cool (around 15°C)
and not too cold, running and should be
used for at least 10 minutes. This should be
applied as soon as possible after injury. [3]
This can be continued longer till the pain
eases. But, care must be taken to prevent
development of hypothermia, especially in
children and the elderly. [4] Application of a
clean towel dampened with cool tap water
should be done afterwards as it helps in
reducing pain. [5]
In addition to improved healing, cold
water also has an excellent analgesic effect.
Modulation of pain related inflammatory
mediators may be one mechanism by which
properly administered first aid influences
healing afterwards. [5] Use of ice, very cold
water is to be avoided as it may cause
further injury to the already injured tissues,
and if used in large quantities hypothermia
may also occur. Hence, early appropriate
first aid to partial thickness burn wounds
has been shown in an experimental animal
model to be associated with earlier healing
and eventually less scarring. [3,6] The use of
raw eggs and flour has also been mentioned.
The proponents of raw eggs claim that the
proteins in the egg form a layer over the
burnt skin and prevent contamination.
Rings, bracelets, bangles, watches,
jewelry or other tight items should be
removed from the burnt parts. This is to be
done quickly and gently, before the swelling
International Journal of Health Sciences & Research (www.ijhsr.org)
Vol.7; Issue: 8; August 2017
develops in the burnt part. Then removal
becomes difficult, painful and it might even
result in loss of the digit.
Ointments, creams, lotions, powders,
grease, ghee, gentian violet, calamine lotion,
toothpastes, butter, 'local doctor'
formulations etc., should not be applied over
the burn wound. They make the formal
assessment of the nature, depth and extent
of the burn wound difficult. Moreover,
eventual removal of such substances might
also be difficult and painful to the patient.
Furthermore, the potential of these
applicants contaminating the wound always
exists and so, should be avoided. Mud, dirt,
sand should not be applied either for
dousing the flames or afterwards. [2]
For transport, the burnt part should
be covered in a clean dry sheet/ cloth. This
prevents soiling of the wound, reduces pain
caused by the air draft and reduces
infection. Plasticized polyvinyl-chloride
(PVC) film available as a food-wrap is a
good alternative to cover the burned areas.
Being pliable, it molds to the contours of the
wound and forms an impermeable, non-
adherent barrier. Its application and removal
is easy and painless. Moreover, being
transparent, it also permits inspection of the
wound. [7]
Inhalation injury:
If there is a lot of smoke, as in a case
of fire in an enclosed space, the nose and
mouth should be covered with a wet cloth
and the victim should be removed from
those premises by dragging along the floor,
if possible, as smoke tends to rise upwards
and collect towards the ceiling.
Such patients are critical; oxygen
should be administered immediately, if
possible and must be rushed to the nearest
medical facility. These patients may also
need intubation and ventilatory support.
Electrical burns:
The electric current can injure in
several ways – current its self, flame burns,
arc burns, fall resulting in other injuries. [8]
These types of burns tend to injure deeper
structures more than overlying skin. The
injury to deeper structures manifests later as
435
 Singh, Kuldeep et al. Burns: First Aid
necrosis of tissue. When attending to such a
patient make sure the source of current is
off, check that it is off and then help the
patient. Avoid using water to douse flames
at the site of injury as the current can flow
up to the rescuer also. Use a dry wooden
stick/ pole/ wooden chair to remove the
victim from the site. Edema (swelling) sets
in faster in these injuries so limb elevation
should be done immediately and
maintained. Immediate cardiopulmonary
resuscitation may be needed for such
patient; hence, the patient should be rushed
to a tertiary center.
Chemical burns:
In case of chemical burn, which
could be alkali or acid burn, first and
foremost reaction should be to remove all
clothing, ornaments immediately and
rigorous washing continuing for prolonged
time. The time period could be up to an hour
or two. Chemical burns tend to be common
in factory workers, laborers or as in a case
of vitriol age. Acid burns cause less damage
than alkali, which penetrates deeply by
liquifactive necrosis. [9] Common acid burns
are due to sulphuric/ hydrochloric/ nitric
acid. Washing with running water is to be
continued till the pH is neutralized as shown
by litmus paper test. If eyes are involved, as
in facial burns, the eyes should continuously
irrigated with Ringer Lactate/ normal saline
in the hospital and the patient should be
reviewed by an ophthalmologist along with
a burns specialist.
In a few cases, solid particles of
sodium, potassium, calcium may be present,
these should be brushed off or picked off, as
these particles react with water, which, can
cause further damage. Once all the particles
are removed then washing should be
commenced that too with jet/ high flow
systems after taking care of eyes and other
sensitive areas.
Common points in first aid irrespective of
type
 Stop the burning process, ie. remove the
offending agent.
 Be careful not to injure yourself.
International Journal of Health Sciences & Research (www.ijhsr.org)
Vol.7; Issue: 8; August 2017
 Cool the burn area.
 Elevate the burn area.
 Jewelry, including bracelets, rings and
necklaces should be removed.
 Do not try and remove adherent burnt
clothing.
 In hot liquid burns (scalds) all wet
clothes are to be removed.
 Wrapping the burn wounds with a clean
cloth is sufficient during transfer to the
nearest emergency department.
After the first medical attention, the
following information must be provided to
the nearest burn unit/ medical facility before
transfer:
1. Age of the patient
2. Gender
3. The place and means of injury
4. Burning agent
5. Time of injury
6. Width and depth of the burn including
involved body area
7. Associated injuries
8. Co-morbidities if any
9. General medical status of the patient and
any medical interventions performed
CONCLUSION
This article is aimed at health care
providers, especially those who offer their
services at the primary level, accident and
emergency departments, paramedicals and
even the general public, as proper and
timely institution of first aid in burns can
significantly reduce the subsequent
morbidity and even mortality.
BIBLIOGRAPHY
1. Andrew MK. First Aid. In: Settle JA, editor.
Principles and Practice of Burns
Management. Edinburg Churchill
Livingstone. 1996; 199-202.
2. Shrivastava P, Goel A. Pre-hospital care in
burn injury. Indian J Plast Surg 2010; 43,
Suppl S1: 15-22.
3. Australian family physician, Thermal burns,
Assessment and acute management in the
general practice setting. 2012; 41(6): 372-
375.
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 Singh, Kuldeep et al. Burns: First Aid

4. Knacke P., Hennenberger A. The Severely 7. Wilson G, French G. Plasticise polyvinyl

Burned Child and the Rescue Service. 1998;
21: 938-941.
5. Cinat ME, Smith MM. Acute burn
management. In: Sood R, Achauer BM,
editors. Achauer and Sood's Burn Surgery
Reconstruction and rehabilitation. 1 st ed.
Philadelphia Saunders Elsevier; 2006. p. 50-
76.
6. Cuttle L, Kempf M, Liu P-Y, Kravchuk O,
Kimble RM. The optimal duration and delay
of first aid treatment for deep partial
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chloride as a temporary dressing for burns.
Br Med J (Clin Res Ed). 1987; 294 : 556-
557.
8. Metcalf MM. Electrical injuries. In: Wagner
MW, editor. Care of the burn-injured
patient. London: Croom Helm; 1981: 185-
193.
9. Stilwell JH. Chemical burns. In: Settle JA,
editor. Principles and Practice of Burns
Management. Edinburg Churchill
Livingstone; 1996. p. 355-368.

How to cite this article: Kuldeep S, Sudhanshu P, Bhupender S et al. Burns: first aid. Int J Health
Sci Res. 2017; 7(8):434-437.

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