Effectiveness of patient empowerment over stress related to knee arthroplasty surgery

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ASA: American Society of Anesthesiologists." ] ] ] "textoCompleto" => "<elsevierMultimedia ident="tb0005"></elsevierMultimedia>IntroductionSurgery is undoubtedly a powerful source of stress for a patient, not only because of the diagnosis itself, but also due to the recommendation for immediate surgery, the time spent in the hospital, and the consequences of further surgery and recovery, which together will significantly influences surgical results in pain, function, and quality of life.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> For patients, surgery and hospitalization may represent insecurity, a fear of not awakening from anesthesia, pain during the procedure and during recovery, the disclosure of personal information during anesthesia, disorientation and the loss of intimacy outside of their familiar environment, among others.<a class="elsevierStyleCrossRef" href="#bib0130">2</a>There is medical evidence supporting the idea that, due to all these factors, surgery affects the mental condition and well-being of patients before surgery and during the recovery process.<a class="elsevierStyleCrossRef" href="#bib0135">3</a> Studies of pre-surgical stress have found two paths to overcome such situations. The psychological path seeks to relate features, strategies of confrontation. The medical path aims to inhibit the functional competence of the immune system in subjects that experience situations of pain of different intensity and duration.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The psychological path aims to improve patient wellness by reducing emotional stress, while the medical path tries to enhance physical stress. The two paths are not entirely different, and are in fact complementary.Patient Empowerment is defined as the act of self-regulation, which may be induced in an educational session to promote individual potential, and maximize patient health and wellness.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> Even though while some studies found not all patients wanted to know everything about a surgical procedure before it occurred,<a class="elsevierStyleCrossRef" href="#bib0150">6</a> it has been demonstrated that in some cases an empowerment session substantially helps to improve the medical procedure, as is the case in arthroplasty surgery,<a class="elsevierStyleCrossRef" href="#bib0155">7</a> diabetes,<a class="elsevierStyleCrossRef" href="#bib0160">8</a> antidrug or smoking treatments.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>This phenomenon can be properly interpreted by the following idea: in each case, the empowerment session provides patients with better knowledge of their condition and teaches them how to deal with a new situation that presents a surmountable challenge. After the session, the patient believes that he/she knows what will happen, what might be expected and that he/she possesses the tools to deal with new challenges. In other words, to use the language of psychiatry: the empowerment session reduces the level of emotional stress related to a new situation.Focused on arthroplasty surgery as the stress stimulus, the experiment described in this paper was planned to objectivize and demonstrate the above-mentioned interpretation. To date, the obtained results have been even better than was initially expected. This paper additionally proposes a measurement methodology based on heart rate variability analysis and psychometric tests. Taking into account the fact that there is no well-defined measurement tool, the methodology proposed in this paper will constitute a measure of the quality of the empowerment session performed by a nurse as well as a measure to improve and to validate its effectivity.<a class="elsevierStyleCrossRef" href="#bib0170">10</a>Physiological and psychological stress responses can be measured or evaluated using different strategies, such as psychometric test and electrophysiological or biochemical measurements. However, there is no medical agreement as to how a mental stress state should be measured or how exactly it should be defined. Indeed, a quantitative measurement is required to improve mental health care. Thus, a framework of interrelated measurements may help to achieve a quantitative level of stress.Psychiatry has established psychometric tests as tools to evaluate emotional stress. For instance, the State-Trait Anxiety Inventory (STAI) and the Stress Visual Analog Scale (VAS) tests. STAI evaluates anxiety and VAS records the patient's self-perceived stress level. Studies also show STAI to be a highly reliable measure of stress situations.<a class="elsevierStyleCrossRef" href="#bib0175">11</a>Emotional state is manifested, among other responses, in the autonomic nervous system (ANS). As the ANS controls the heart, the measurement of cardiac activity seems to be a feasible and non-invasive way to evaluate the state of the ANS.<a class="elsevierStyleCrossRef" href="#bib0180">12</a> Consequently, changes in heart rate, defined as heart rate variability (HRV), indicate the heart's ability to respond to multiple physiological and environmental stimuli. HVR variability is also associated with the balance between the sympathetic nervous system (SNS) and parasympathetic nervous system (PNS). Therefore, it is usually taken as an indicator of a person's emotional state.<a class="elsevierStyleCrossRefs" href="#bib0185">13,14</a> Taking this into account, electrophysiological signals are used in some studies to determine stress levels induced by psychological stress stimuli such as Stroop tests and the Trier Social Stress Test,<a class="elsevierStyleCrossRefs" href="#bib0180">12,13</a> applied in short periods (less than 1h).In HRV analysis, a high oscillation or variation between two consecutive heartbeats is related with a normal state and characterizes a healthy person with effective autonomic mechanisms. Meanwhile constant or low fluctuating consecutive heartbeats are frequently associated to an abnormal response or alert state.<a class="elsevierStyleCrossRef" href="#bib0195">15</a>Nowadays some surgery protocols include Patient Empowerment as a key factor to enhance mental state and thus improve results. Specifically, since 2011 the “Fast Track Prosthetic Knee Project” at the Hospital Clinic of Barcelona has included mandatory educational session prior to knee arthroplasty surgery, in such a way that preoperative information reduces pre-operative stress.<a class="elsevierStyleCrossRef" href="#bib0125">1</a> Therefore, patient Empowerment improves the results and satisfaction of patients with lower limb prosthesis. From an economic point of view, other studies suggest that pre-operative education is a safe and effective method to reduce the length of hospital stays for knee arthroplasty patients.<a class="elsevierStyleCrossRefs" href="#bib0155">7,16,17</a>This study aims to show evidence of the Empowerment Session's effectiveness through measurements of surgery related emotional stress before and after this session, i.e. the empowerment session will decrease stress related to the surgery scheduled to be conducted in the following weeks.MethodA sample size of 32 patients was selected to ensure a power of 80% in order to detect effect size of 0.5. To consider a potential error on measurement on 20% of patients 41 patients were included in this study. Sample size determination was made using the software ENE 3.0.During three months, all patients older than 18 years-old diagnosed with knee arthroplasty surgery prescription at Hospital Clinic of Barcelona as inclusion criteria were asked to participate in the study. Exclusion criteria were: to be a woman during the third trimester of pregnancy and to be a patient with a cardiac disease.This study was approved by Hospital Clinic of Barcelona's Research Ethics Committee (CEIC) and follows the guidelines of the Declaration of Helsinki. All participants provided written informed consent in order to participate in the study.The present study is experimental, prospective and observational. Data was collected by the nurse who leads the empowerment session according to the following protocol: two sets of emotional stress measurements per patient were performed, few minutes before (Pre-session) and after (Post-session) the mandatory empowerment session. Each set consisted of recording an electrocardiogram (ECG) for 10min while the patients were seated and then applying two standard psychometric tests: State-Trait Anxiety Inventory test and Visual Analog Stress test. Additionally, patients were asked whether they felt stressed or not (Non stressed). If they did, they were asked again whether this stress was related to the surgery (Surgery Related Stress) or not (Not Stressed by Surgery).The following general socio-demographic data were also registered for each patient: Age (years-old), Sex (woman or man), Level of education (low, medium, high), Occupation (unemployed, active, retired), Sedentary (yes: does not practice any type of physical activity, or no: practice physical activity). Body Mass Index (BMI), ASA physical status which is the Classification System used by the American Society of Anaesthesiologists (ASA) to estimate the risk posed by anesthesia for the different states of the patient (ASA I: Healthy Patient. ASA II: Patient with a mild, controlled and non-disabling systemic disease. ASA III: Patient with severe, but not incapacitating, systemic disease. ASA IV: Patient with severe and incapacitating systemic disease. ASA V: This is the terminal or dying patient whose life expectancy no more than 24h, with or without surgical treatment), Surgery in the last 6 months (yes or no), Marital status (married, separated, single, widowed).Measurements were not taken on the day of the surgery or after it, because the main interest of this work is the Empowerment Session's effectiveness over emotional stress related to the surgery and not the surgery itself. Due to the empowerment session is mandatory for all patients, this is an observational study because involves repeated observations of the same variables over time.ECG was recorded using the CE marked device Medicom system, ABP-10 module (Medicom MTD Ltd, Russia). Biochemical markers were not used, because this study proposes a non-invasive methodology and most of those markers are mainly related to physical stress rather than emotional stress, which is our aim.The empowerment session takes place 2 or 4 weeks before arthroplasty surgery. 5 patients participate in each session. All patients are accompanied by a relative or caregiver. The session is run by a physiotherapist and a nurse on Wednesday mornings. During the session frequently asked questions by the patient, family and caregiver are answered. For example: what should they bring to hospital? What should they do at home before surgery? Which physiotherapy exercises will they do after surgery? And how should they use crutches properly? After that, patients are informed of the type of anesthesia, surgery and daily mobilization targets during and after hospitalization. The family, patients or caregivers may ask any questions during the session in order to resolve all doubts related to the surgery. During the session, participants meet a patient whose surgery was performed a few days before. This patient explains his/her experience with the surgery. At the end, they receive a brochure with information about how they should perform physical therapy exercises at home and what they should bring on the day of surgery.After the empowerment session, the patients are optimally prepared, informed and involved throughout the process, thus minimizing their stress, motivating them and giving them clear expectations about their surgery. Following the surgery protocol at the Hospital Clinic of Barcelona, the empowerment session is mandatory for all patients, even in case that patient is reluctant to receive detailed information about surgery. In this case, care personnel will give more general information about the surgery itself but emphasizing the details that will allow him/her to deal with the new situation and to facilitate his recovery.The VAS and the Spanish version of STAI<a class="elsevierStyleCrossRef" href="#bib0210">18</a> tests were applied before and after the empowerment session. The VAS test measures the stress level that is subjectively perceived by a patient. Furthermore, the STAI test evaluates anxiety from two different points of view. As a state (STAI-s) at a given time, and as a trait (STAI-t) or stable trend of the individual to respond by increasing the level of anxiety in stressful situations.<a class="elsevierStyleCrossRef" href="#bib0215">19</a> Later studies<a class="elsevierStyleCrossRefs" href="#bib0220">20,21</a> showed that the STAI is sensitive to the stress of caregivers and can therefore be used as an indicator of stress. In this study, the STAI-t test was not taken into account, because we assumed that the patient's traits will not change in the Empowerment session. These psychometric test were used based on the selection done at ES3 Project.<a class="elsevierStyleCrossRef" href="#bib0230">22</a>For the physiological measurement, we computed the Pre-session and Post-session HRV-index from the ECG measurements. Time domain analysis was performed by calculating the average heart rate as beats per minute (Mean HR), the standard deviation of all inter-beats intervals (SDNN) and the root mean square of successive differences (RMSSD) and finally the percentage of pairs of adjacent inter-beats intervals differing by more than 50ms (PPNN) were computed from the fixed R-peak series.Frequency domain analysis includes low frequency power (LF) and high frequency power (HF), which were computed from the spectral density of the HRV signal and calculated using the Fourier transform. HRV signal is obtained by subtracting from the instantaneous HR signal, a low pass filtered HR signal (cut-off frequency of 0.03Hz), which mainly accounts for changes in mean HR. The LF/HF ratio was computed as well. Power in the very low frequency (VLF) band ranged from 0 to 0.03Hz and was computed from the power spectral density of the low pass filtered HR signal. Normalized LF Power (PLF) is the LF divided by the sum of LF and HF.The mean Pre-session and Post-session scores for the psychometric tests were compared by the Student T test for paired samples. The median HRV Indices were compared by the Wilcoxon signed rank test. In addition, the same analysis was performed by dividing patients into those who self-perceived as: not stressed, stressed but not related to the surgery and stressed concerning the surgery by Analyses of Variance (ANOVAs) for paired samples. Pearson's correlation was computed between physiological and psychometric measurements. All data analysis was performed by using MATLAB R2015b.ResultsForty-one patients diagnosed with knee osteoarthritis and undergoing arthroplasty at Hospital Clinic of Barcelona were taken. The final sample consisted of 30 women and 11 men with an average age of 72.9 (range 64–90). Most of them are not active workers (95.1%) and are married or widows/widowers (90.2%). On average, all patients are overweight according to their BMI and 14 of them are considered obese. Indeed, this group is socio-demographically homogeneous and a coherent sample, as shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>. For the further Heart Rate Variability analysis, 9 patients were excluded: 4 heart disease patients, 1 patient with a chronic renal condition and 4 patients with errors in their measurement records.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The first analysis of the applied psychometric test was performed by comparing the Pre-session and Post-session values. Mean values and their standard deviations for each test are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Pre-session test results have higher mean and range values, so after the empowerment session, test result values decrease, indicating lower mean patient stress.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The difference between Pre-session and Post-session total test results is 24.91 points, which represents a 17.79% reduction in stress for the total value of the stress scale. Mean value test results after the empowerment session decrease by 41.91%, taking the Pre-session values as a reference. So, there is a 41.91% decrease in stress state after the empowerment session measured by the Psychometric Test. These changes are statistically significant according to the paired samples T-student test. The evidence that the values from both sessions are different implies that patients have a better stress state before and after the empowerment session.When dividing patients by their self-perceived stress before the empowerment session (Stressed), the scores of subjects after the empowerment session are lower than the scores before the empowerment session, <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. It also shows a significant difference in VAS scores among self-perceived stress groups. It suggests that patients with surgery related stress have the highest reduction compared to others. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows that only the patients with Surgery Related Stress have significantly different results for psychometric tests before and after the empowerment session.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The results in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> suggest a significant change in Mean HR, RMSSD, VLF and Total power after the empowerment session, which is also supported by the Wilcoxon signed rank test that compares the Pre and Post Session states. Changes in HRV-index are associated with an adaptation of the autonomic nervous system, as well as a different wellness state.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Conversely, the HF and LF components have no statistically significant differences. Therefore, it is not possible to determine changes in parasympathetic or sympathetic activity or in a wellness state.HRV-index values dividing patients according to their self-perceived stress is also shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. Patients with no self-perception of stress and patients that are not stressed by surgery do not show any significant change in HRV-index. Moreover, patients with surgery related stress have lower HRV-index values after the empowerment session. These differences between the self-stress perception groups indicate a specific effect of the empowerment session on surgery-related stress. These results are consistent with the results of psychometric tests.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Psychometric and physiological measurement results suggest a greater decrease in surgery related emotional stress state after the empowerment session. Other analyses performed to establish the relationship between physiological and psychological measurements by Pearson's correlation coefficient shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Correlation was computed between each psychometric test and each HR-index. Some HR-indices, such as LF, HF, Power HF and LF/HF ratio, do not have significant linear correlation with psychometric tests but they correspond with those that do not have significant changes in value after the session. Those values that change after the empowerment session are related to psychometric tests. Especially in this study, VAS proves more sensitive than STAI.DiscussionPsychometric stress measurement shows a reduction in stress between test results before and after the empowerment session. In this study, the VAS test proves to be more sensitive than the STAI-state test probably because the patient's mental state is influenced by other factors in addition to anxiety.Mean HR, RMSSD, VLF power and total power change in value (p-value<0.001) suggesting more sympathetic and less parasympathetic activity. HRV is associated with the patients’ wellness state, so both results corroborate the evidence of emotional stress state change after the empowerment session.The relationship between physiological and psychological measurements is analyzed by Pearson's correlation and the results suggest a relation between patient stress state and cardiac responses, confirming that a stressed state provokes variations HRV indices. Both physiological and psychological measurements may help to the preoperative stress characterization, that would permit a referral of the patient to an appropriate counseling service until the surgery until take place as was suggested in Ref. <a class="elsevierStyleCrossRef" href="#bib0125">1</a>.The psychometric State-Trait Anxiety Inventory test administered before and after the empowerment session shows a substantial decrease in surgery related stress due to the session, while stress related to other sources does not change.The same behavior and results can be seen in the Visual Analog Scale. Although the VAS basis is purely subjective, when it is applied to patients who are aware of what they are asked to do, the results fitted with the other measurements.The conducted experiment demonstrates that, in the case of emotional stress, there is a significant correlation between stress level and HRV index (Mean HR, RMSSD, VLF power and total power). This is an evidence for future studies on emotional stress based on HRV analysis, due to psychometric tests and heart rate variability analysis could be interchangeable as measurement tools of emotional stress.Both psychological and physiological measurements give support to the effectiveness of the empowerment session because of the significant increase in the wellness state of patients. The main limitations of the study are: the small size of sample limits the power of the statistical analysis and the probability of finding a wider range of biomarker levels. The intrinsic relation between the empowerment session and the nurse makes it difficult to evaluate the effect of the contents of the session from how the nurse performs the session.Differences in emotional stress before and after an empowerment session using psychometric tests and heart rate variability analysis could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes due to the role that the nurses play before the surgery. Therefore, psychometric tests and heart rate variability analysis can be used as an objective measurement for the patient centered care with a focus on patient education and rehabilitation proposed by Akhtaar and Houlihan-Burne.<a class="elsevierStyleCrossRef" href="#bib0135">3</a>Following this line, the proposed measurements could be used to compare among empowerment sessions that have been included in different surgeries or medical procedures for diabetes,<a class="elsevierStyleCrossRef" href="#bib0160">8</a> antidrug or smoking treatments.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>According a recent publication,<a class="elsevierStyleCrossRef" href="#bib0235">23</a> negative preoperative emotions were related to poorer quality of recovery whilst greater satisfaction with care could be associated with better quality of recovery. Then, if the psychometric tests and HRV could be assess through wearables technologies and smartphones, a personalized and continuous measurement of the emotional stress level or the wellness state of the patient could constitute a valuable guide to apply personalized interventions before the surgery.The presented methodology sets a precedent for the study of stress factors in humans, such as surgery in the case of this study, and behavioral changes that appear in response to adaptation to an external stimulus. As suggested in the Roadmap for mental health research in Europe (ROAMER) in order to enhance the diagnosis of mental disorders, follow-up and treatment using objective measurements are required.<a class="elsevierStyleCrossRef" href="#bib0240">24</a>Conflict of interestThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1031988" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec989031" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1031987" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec989032" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0020" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack348522" "titulo" => "Acknowledgments" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-21" "fechaAceptado" => "2017-09-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec989031" "palabras" => array:6 [ 0 => "Stress" 1 => "Electrocardiography" 2 => "Biomarkers" 3 => "Arthroplasty" 4 => "Replacement" 5 => "Knee" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec989032" "palabras" => array:6 [ 0 => "Estrés" 1 => "Electrocardiografía" 2 => "Biomarcadores" 3 => "Artroplastia" 4 => "Reemplazo" 5 => "Rodilla" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveThis study aims to show evidence of the Empowerment Session's effectiveness through measurements of surgery related emotional stress before and after this session. MethodThe study was performed on 41 patients with knee arthroplasty surgery prescription by measuring the evolution of their emotional stress generated by surgery expectative, during the empowerment session. Two sets of measurements per patient were performed, before and after the empowerment session. Each set consisted of recording an electrocardiogram for 10min while the patients were seated and then applying two standard psychometric tests: State-Trait Anxiety Inventory test and Visual Analog Stress test. Differences in emotional stress were analyzed using psychometric tests and heart rate variability (HRV) analysis as stress biomarkers. ResultsPsychometric stress measurement shows a 17.8% reduction in stress according to the total stress scale value, and a 41.9% reduction in stress between test results before and after the session. Mean heart rate values increased by 7.4% with respect to the initial values, very low frequency power and total power also change in value suggesting more sympathetic and less parasympathetic activity. ConclusionsBoth psychological and physiological measurements suggest the effectiveness of the empowerment session due to a significant increase in the wellness state of patients. Additionally, the correlation between psychometric tests and HRV indices demonstrates that both emotional stress indicators could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEste estudio tiene como objetivo dar evidencias de la eficacia de la sesión de empoderamiento a través de mediciones del estrés emocional relacionado con la cirugía antes y después de esta sesión. MétodoEl estudio se realizó en 41 pacientes con prescripción de cirugía de artroplastia de rodilla durante la sesión de empoderamiento. Se realizaron 2 conjuntos de medidas por paciente, antes y después de la sesión. Cada conjunto consistió en registrar el electrocardiograma durante 10min mientras los pacientes estaban sentados y luego aplicando 2 test psicométricos estándar: test State-Trait Anxiety Inventory y escala análoga visual. Las diferencias en el estrés emocional se analizaron mediante test psicométricos y el análisis de la variabilidad del ritmo cardíaco (HRV) como biomarcadores de estrés. ResultadosLos puntajes en los test psicométricos muestran una reducción del 17,8% en el estrés según el valor de la escala de estrés total, y una reducción del 41,9% en el estrés entre los resultados de las pruebas antes y después de la sesión. Los valores medios de ritmo cardíaco aumentaron un 7,4%. Las variaciones en la potencia ultra baja frecuencia y la potencia total sugieren una mayor actividad simpática y menor parasimpática. ConclusionesTanto las mediciones psicológicas como fisiológicas sugieren la efectividad de la sesión de empoderamiento debido a un aumento significativo en el estado de bienestar de los pacientes. Además, la correlación entre las pruebas psicométricas y los índices de HRV demuestra que ambos indicadores de estrés emocional podrían utilizarse como retroalimentación en las sesiones de empoderamiento o como una referencia para mejorar los resultados quirúrgicos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 934 "Ancho" => 2329 "Tamanyo" => 137068 ] ] "descripcion" => array:1 [ "en" => "Quantitative socio-demographic data." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 3061 "Ancho" => 2333 "Tamanyo" => 511543 ] ] "descripcion" => array:1 [ "en" => "Qualitative socio-demographic data. ASA: American Society of Anesthesiologists." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Values are: mean (standard deviation). STAI: State-Trait Anxiety Inventory. VAS: Stress Visual Analog Scale." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STAI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.88 (12.91) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.73 (10.95)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.83 (24.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.07 (18.27)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59.71 (34.37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.8 (27.5)<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757147.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "p-value <0.001, t-test for paired samples." ] ] ] "descripcion" => array:1 [ "en" => "Psychometric test results." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Values are: mean (standard deviation). STAI: State-Trait Anxiety Inventory. VAS: Stress Visual Analog Scale." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non stressed</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Not stressed by surgery</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery related stress</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">STAI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.25 (2.44) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.37 (2.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.42 (3.69) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.420 (2.18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.72 (2.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.76 (2.49)<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VAS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.46 (4.42) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.87 (3.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.71 (5.66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.14 (3.78) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.44 (5.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.88 (3.55)<a class="elsevierStyleCrossRef" href="#tblfn0010">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757148.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "*" "nota" => "p-value <0.05, Wilcoxon signed rank test. This work is supported by Universidad Autónoma de Barcelona project PI12/00514 funded by MINECO and by the Biomedical Research Networking Center on Bioengineering, Biomaterials and Nanomedicine (CIBER-bbn) at the Carlos III Institute of Health (ISCIII)." ] ] ] "descripcion" => array:1 [ "en" => "Psychometrics tests dividing patients according to their self-perceived stress." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Values are: mean (standard deviation)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Wilcoxon \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean HR (bpm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.93 (6.43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.01 (8.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDNN (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.054 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RMSSD (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.88 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81 (0.08) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPNN (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.64 (1.64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34 (1.34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.094 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power VLF (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.71 (0.30) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.99 (0.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power LF (10−3s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 (0.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 (0.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.525 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power HF (10−3s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.210 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PLF (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.35 (0.10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.33 (0.11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.926 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total power (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.71 (0.29) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.99 (0.41) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001<a class="elsevierStyleCrossRef" href="#tblfn0015">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LF/HF ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.56 (0.34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 (0.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757150.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "*" "nota" => "p-value <0.05, Wilcoxon signed rank test. HR: heart rate. SDNN: standard deviation of all inter-beats intervals. RMSSD: root mean square of successive differences. PPNN: percentage of pairs of adjacent inter-beats intervals differing by more than 50ms. VLF: very low frequency power. LF: low frequency power. HF: high frequency power. PLF: normalized LF power." ] ] ] "descripcion" => array:1 [ "en" => "Heart rate variability indices for all patients." ] ] 5 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Values are: mean (standard deviation). HR: heart rate. SDNN: standard deviation of all inter-beats intervals. RMSSD: root mean square of successive differences. PPNN: percentage of pairs of adjacent inter-beats intervals differing by more than 50ms. VLF: very low frequency power. LF: low frequency power. HF: high frequency power. PLF: normalized LF power." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non stressed</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Not stressed by surgery</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery related stress</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean HR (bpm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60.62 (1.63) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.22 (2.66) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.52 (0.51) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73.93 (3.28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.63 (7.96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.37 (6.57)<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDNN (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.00) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RMSSD (s) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.94 (0.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.81 (0.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.83 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.77 (0.07)<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPNN (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.42 (1.25) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.13 (5.84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.2 (0.76) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26 (0.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.74 (2.74) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.81 (1.81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power VLF (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34 (0.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.49 (0.11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.84 (0.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.98 (0.17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 (0.45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.23 (0.44)<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power LF (10−3s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.03) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 (0.04) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.09 (0.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.08 (0.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.07 (0.05) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power HF (10−3s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 (0.02) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.31 (0.17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 (0.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.15 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.19 (0.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.14 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PLF (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 (0.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.33 (0.06) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.38 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.36 (0.09) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total power (s−2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.34 (0.07) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.49 (0.11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.84 (0.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.98 (0.17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 (0.45) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.23 (0.44)<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LF/HF ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.12 (0.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.04 (0.01) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 (0.24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51 (0.12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.63 (0.26) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.64 (0.27) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757146.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "*" "nota" => "p-value <0.05, Wilcoxon signed rank test." ] ] ] "descripcion" => array:1 [ "en" => "Heart rate variability indices dividing patients according to their self-perceived stress." ] ] 6 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "HR: heart rate. SDNN: standard deviation of all inter-beats intervals. RMSSD: root mean square of successive differences. PPNN: percentage of pairs of adjacent inter-beats intervals differing by more than 50ms. VLF: very low frequency power. LF: low frequency power. HF: high frequency power. PLF: normalized LF power." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">STAI-s \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">VAS \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean HR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.28<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDNN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.17<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.26<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RMSSD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.30<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPNN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.02<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power VLF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.27<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power LF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.01<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.16<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power HF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.05<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.02<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PLF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PHF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.03<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.06<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total power \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.27<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LF/HF ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.02<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.06<a class="elsevierStyleCrossRef" href="#tblfn0025">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.03 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1757149.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "*" "nota" => "Significant values p<0.05." ] ] ] "descripcion" => array:1 [ "en" => "Pearson's correlation and p-value of psychometric tests and heart rate variability indices." ] ] 7 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "What is known?Modern-day surgery protocols include Patient Empowerment as a key factor to improve surgical recovery processes by enhancing the patient's mental state. Since 2011, the “Fast Track Prosthetic Knee Project” at the Hospital Clinic of Barcelona (Spain) has included a patient empowerment session prior to knee arthroplasty surgery. This session is designed to reduce emotional stress by providing information and tools helping patient to better face surgery and recovery.What it contributes?Differences in emotional stress before and after an empowerment session were analyzed using psychometric tests and Heart rate variability analysis as stress biomarkers. Both psychological and physiological measurements give support to the effectiveness of the empowerment session because the significant increase in the wellness state of patients. Additionally, the correlation found between psychometric tests and HRV indices demonstrates that, as is frequently assumed, HRV is associated with emotional stress state. Both emotional stress indicators could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does preoperative psychologic distress influence pain, function, and quality of life after TKA?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Utrillas-Compaired" 1 => "B.J. De La Torre-Escuredo" 2 => "A.J. Tebar-Martínez" 3 => "Á. 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24451479/0000002800000003/v1_201805300410/S2445147918300596/v1_201805300410/en/main.assets" "Apartado" => array:4 [ "identificador" => "63169" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24451479/0000002800000003/v1_201805300410/S2445147918300596/v1_201805300410/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2445147918300596?idApp=UINPBA00004N"]

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Original Article

Effectiveness of patient empowerment over stress related to knee arthroplasty surgery

Efectividad del empoderamiento del paciente sobre el estrés relacionado con la cirugía de artroplastia de rodilla

Jorge Mario Garzón-Reya,b,

Corresponding author

jorgmario.garzon@uab.cat

Corresponding author.

, Adriana Arza-Valdésa,b, Montserrat Nuevo-Gayosoc, Jordi Aguilóa,b,d

a Department of Microelectronics and Electronic Systems, Universidad Autónoma de Barcelona, Barcelona, Spain

b Biomonitoring Group, Biomedical Research Networking Center (CIBER-bbn), Spain

c Knee Unit, Hospital Clínic of Barcelona, Barcelona, Spain

d Integrated Systems Department, Microelectronics Institute of Barcelona, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0020" class="elsevierStylePara elsevierViewall">Surgery is undoubtedly a powerful source of stress for a patient&#44; not only because of the diagnosis itself&#44; but also due to the recommendation for immediate surgery&#44; the time spent in the hospital&#44; and the consequences of further surgery and recovery&#44; which together will significantly influences surgical results in pain&#44; function&#44; and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> For patients&#44; surgery and hospitalization may represent insecurity&#44; a fear of not awakening from anesthesia&#44; pain during the procedure and during recovery&#44; the disclosure of personal information during anesthesia&#44; disorientation and the loss of intimacy outside of their familiar environment&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">There is medical evidence supporting the idea that&#44; due to all these factors&#44; surgery affects the mental condition and well-being of patients before surgery and during the recovery process&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> Studies of pre-surgical stress have found two paths to overcome such situations&#46; The psychological path seeks to relate features&#44; strategies of confrontation&#46; The medical path aims to inhibit the functional competence of the immune system in subjects that experience situations of pain of different intensity and duration&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The psychological path aims to improve patient wellness by reducing emotional stress&#44; while the medical path tries to enhance physical stress&#46; The two paths are not entirely different&#44; and are in fact complementary&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patient Empowerment is defined as the act of self-regulation&#44; which may be induced in an educational session to promote individual potential&#44; and maximize patient health and wellness&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> Even though while some studies found not all patients wanted to know everything about a surgical procedure before it occurred&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> it has been demonstrated that in some cases an empowerment session substantially helps to improve the medical procedure&#44; as is the case in arthroplasty surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a> diabetes&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> antidrug or smoking treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This phenomenon can be properly interpreted by the following idea&#58; in each case&#44; the empowerment session provides patients with better knowledge of their condition and teaches them how to deal with a new situation that presents a surmountable challenge&#46; After the session&#44; the patient believes that he&#47;she knows what will happen&#44; what might be expected and that he&#47;she possesses the tools to deal with new challenges&#46; In other words&#44; to use the language of psychiatry&#58; the empowerment session reduces the level of emotional stress related to a new situation&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Focused on arthroplasty surgery as the stress stimulus&#44; the experiment described in this paper was planned to objectivize and demonstrate the above-mentioned interpretation&#46; To date&#44; the obtained results have been even better than was initially expected&#46; This paper additionally proposes a measurement methodology based on heart rate variability analysis and psychometric tests&#46; Taking into account the fact that there is no well-defined measurement tool&#44; the methodology proposed in this paper will constitute a measure of the quality of the empowerment session performed by a nurse as well as a measure to improve and to validate its effectivity&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Physiological and psychological stress responses can be measured or evaluated using different strategies&#44; such as psychometric test and electrophysiological or biochemical measurements&#46; However&#44; there is no medical agreement as to how a mental stress state should be measured or how exactly it should be defined&#46; Indeed&#44; a quantitative measurement is required to improve mental health care&#46; Thus&#44; a framework of interrelated measurements may help to achieve a quantitative level of stress&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Psychiatry has established psychometric tests as tools to evaluate emotional stress&#46; For instance&#44; the State-Trait Anxiety Inventory &#40;STAI&#41; and the Stress Visual Analog Scale &#40;VAS&#41; tests&#46; STAI evaluates anxiety and VAS records the patient&#39;s self-perceived stress level&#46; Studies also show STAI to be a highly reliable measure of stress situations&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Emotional state is manifested&#44; among other responses&#44; in the autonomic nervous system &#40;ANS&#41;&#46; As the ANS controls the heart&#44; the measurement of cardiac activity seems to be a feasible and non-invasive way to evaluate the state of the ANS&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a> Consequently&#44; changes in heart rate&#44; defined as heart rate variability &#40;HRV&#41;&#44; indicate the heart&#39;s ability to respond to multiple physiological and environmental stimuli&#46; HVR variability is also associated with the balance between the sympathetic nervous system &#40;SNS&#41; and parasympathetic nervous system &#40;PNS&#41;&#46; Therefore&#44; it is usually taken as an indicator of a person&#39;s emotional state&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">13&#44;14</span></a> Taking this into account&#44; electrophysiological signals are used in some studies to determine stress levels induced by psychological stress stimuli such as Stroop tests and the Trier Social Stress Test&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">12&#44;13</span></a> applied in short periods &#40;less than 1<span class="elsevierStyleHsp" style=""></span>h&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In HRV analysis&#44; a high oscillation or variation between two consecutive heartbeats is related with a normal state and characterizes a healthy person with effective autonomic mechanisms&#46; Meanwhile constant or low fluctuating consecutive heartbeats are frequently associated to an abnormal response or alert state&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Nowadays some surgery protocols include Patient Empowerment as a key factor to enhance mental state and thus improve results&#46; Specifically&#44; since 2011 the &#8220;Fast Track Prosthetic Knee Project&#8221; at the Hospital Clinic of Barcelona has included mandatory educational session prior to knee arthroplasty surgery&#44; in such a way that preoperative information reduces pre-operative stress&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a> Therefore&#44; patient Empowerment improves the results and satisfaction of patients with lower limb prosthesis&#46; From an economic point of view&#44; other studies suggest that pre-operative education is a safe and effective method to reduce the length of hospital stays for knee arthroplasty patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;16&#44;17</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">This study aims to show evidence of the Empowerment Session&#39;s effectiveness through measurements of surgery related emotional stress before and after this session&#44; i&#46;e&#46; the empowerment session will decrease stress related to the surgery scheduled to be conducted in the following weeks&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Method</span><p id="par0075" class="elsevierStylePara elsevierViewall">A sample size of 32 patients was selected to ensure a power of 80&#37; in order to detect effect size of 0&#46;5&#46; To consider a potential error on measurement on 20&#37; of patients 41 patients were included in this study&#46; Sample size determination was made using the software ENE 3&#46;0&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">During three months&#44; all patients older than 18 years-old diagnosed with knee arthroplasty surgery prescription at Hospital Clinic of Barcelona as inclusion criteria were asked to participate in the study&#46; Exclusion criteria were&#58; to be a woman during the third trimester of pregnancy and to be a patient with a cardiac disease&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">This study was approved by Hospital Clinic of Barcelona&#39;s Research Ethics Committee &#40;CEIC&#41; and follows the guidelines of the Declaration of Helsinki&#46; All participants provided written informed consent in order to participate in the study&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The present study is experimental&#44; prospective and observational&#46; Data was collected by the nurse who leads the empowerment session according to the following protocol&#58; two sets of emotional stress measurements per patient were performed&#44; few minutes before &#40;Pre-session&#41; and after &#40;Post-session&#41; the mandatory empowerment session&#46; Each set consisted of recording an electrocardiogram &#40;ECG&#41; for 10<span class="elsevierStyleHsp" style=""></span>min while the patients were seated and then applying two standard psychometric tests&#58; State-Trait Anxiety Inventory test and Visual Analog Stress test&#46; Additionally&#44; patients were asked whether they felt stressed or not &#40;Non stressed&#41;&#46; If they did&#44; they were asked again whether this stress was related to the surgery &#40;Surgery Related Stress&#41; or not &#40;Not Stressed by Surgery&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The following general socio-demographic data were also registered for each patient&#58; Age &#40;years-old&#41;&#44; Sex &#40;woman or man&#41;&#44; Level of education &#40;low&#44; medium&#44; high&#41;&#44; Occupation &#40;unemployed&#44; active&#44; retired&#41;&#44; Sedentary &#40;yes&#58; does not practice any type of physical activity&#44; or no&#58; practice physical activity&#41;&#46; Body Mass Index &#40;BMI&#41;&#44; ASA physical status which is the Classification System used by the American Society of Anaesthesiologists &#40;ASA&#41; to estimate the risk posed by anesthesia for the different states of the patient &#40;ASA I&#58; Healthy Patient&#46; ASA II&#58; Patient with a mild&#44; controlled and non-disabling systemic disease&#46; ASA III&#58; Patient with severe&#44; but not incapacitating&#44; systemic disease&#46; ASA IV&#58; Patient with severe and incapacitating systemic disease&#46; ASA V&#58; This is the terminal or dying patient whose life expectancy no more than 24<span class="elsevierStyleHsp" style=""></span>h&#44; with or without surgical treatment&#41;&#44; Surgery in the last 6 months &#40;yes or no&#41;&#44; Marital status &#40;married&#44; separated&#44; single&#44; widowed&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Measurements were not taken on the day of the surgery or after it&#44; because the main interest of this work is the Empowerment Session&#39;s effectiveness over emotional stress related to the surgery and not the surgery itself&#46; Due to the empowerment session is mandatory for all patients&#44; this is an observational study because involves repeated observations of the same variables over time&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">ECG was recorded using the CE marked device Medicom system&#44; ABP-10 module &#40;Medicom MTD Ltd&#44; Russia&#41;&#46; Biochemical markers were not used&#44; because this study proposes a non-invasive methodology and most of those markers are mainly related to physical stress rather than emotional stress&#44; which is our aim&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The empowerment session takes place 2 or 4 weeks before arthroplasty surgery&#46; 5 patients participate in each session&#46; All patients are accompanied by a relative or caregiver&#46; The session is run by a physiotherapist and a nurse on Wednesday mornings&#46; During the session frequently asked questions by the patient&#44; family and caregiver are answered&#46; For example&#58; what should they bring to hospital&#63; What should they do at home before surgery&#63; Which physiotherapy exercises will they do after surgery&#63; And how should they use crutches properly&#63; After that&#44; patients are informed of the type of anesthesia&#44; surgery and daily mobilization targets during and after hospitalization&#46; The family&#44; patients or caregivers may ask any questions during the session in order to resolve all doubts related to the surgery&#46; During the session&#44; participants meet a patient whose surgery was performed a few days before&#46; This patient explains his&#47;her experience with the surgery&#46; At the end&#44; they receive a brochure with information about how they should perform physical therapy exercises at home and what they should bring on the day of surgery&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">After the empowerment session&#44; the patients are optimally prepared&#44; informed and involved throughout the process&#44; thus minimizing their stress&#44; motivating them and giving them clear expectations about their surgery&#46; Following the surgery protocol at the Hospital Clinic of Barcelona&#44; the empowerment session is mandatory for all patients&#44; even in case that patient is reluctant to receive detailed information about surgery&#46; In this case&#44; care personnel will give more general information about the surgery itself but emphasizing the details that will allow him&#47;her to deal with the new situation and to facilitate his recovery&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The VAS and the Spanish version of STAI<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a> tests were applied before and after the empowerment session&#46; The VAS test measures the stress level that is subjectively perceived by a patient&#46; Furthermore&#44; the STAI test evaluates anxiety from two different points of view&#46; As a state &#40;STAI-s&#41; at a given time&#44; and as a trait &#40;STAI-t&#41; or stable trend of the individual to respond by increasing the level of anxiety in stressful situations&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">19</span></a> Later studies<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">20&#44;21</span></a> showed that the STAI is sensitive to the stress of caregivers and can therefore be used as an indicator of stress&#46; In this study&#44; the STAI-t test was not taken into account&#44; because we assumed that the patient&#39;s traits will not change in the Empowerment session&#46; These psychometric test were used based on the selection done at ES3 Project&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">For the physiological measurement&#44; we computed the Pre-session and Post-session HRV-index from the ECG measurements&#46; Time domain analysis was performed by calculating the average heart rate as beats per minute &#40;Mean HR&#41;&#44; the standard deviation of all inter-beats intervals &#40;SDNN&#41; and the root mean square of successive differences &#40;RMSSD&#41; and finally the percentage of pairs of adjacent inter-beats intervals differing by more than 50<span class="elsevierStyleHsp" style=""></span>ms &#40;PPNN&#41; were computed from the fixed R-peak series&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Frequency domain analysis includes low frequency power &#40;LF&#41; and high frequency power &#40;HF&#41;&#44; which were computed from the spectral density of the HRV signal and calculated using the Fourier transform&#46; HRV signal is obtained by subtracting from the instantaneous HR signal&#44; a low pass filtered HR signal &#40;cut-off frequency of 0&#46;03<span class="elsevierStyleHsp" style=""></span>Hz&#41;&#44; which mainly accounts for changes in mean HR&#46; The LF&#47;HF ratio was computed as well&#46; Power in the very low frequency &#40;VLF&#41; band ranged from 0 to 0&#46;03<span class="elsevierStyleHsp" style=""></span>Hz and was computed from the power spectral density of the low pass filtered HR signal&#46; Normalized LF Power &#40;PLF&#41; is the LF divided by the sum of LF and HF&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The mean Pre-session and Post-session scores for the psychometric tests were compared by the Student <span class="elsevierStyleItalic">T</span> test for paired samples&#46; The median HRV Indices were compared by the Wilcoxon signed rank test&#46; In addition&#44; the same analysis was performed by dividing patients into those who self-perceived as&#58; not stressed&#44; stressed but not related to the surgery and stressed concerning the surgery by Analyses of Variance &#40;ANOVAs&#41; for paired samples&#46; Pearson&#39;s correlation was computed between physiological and psychometric measurements&#46; All data analysis was performed by using MATLAB R2015b&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0140" class="elsevierStylePara elsevierViewall">Forty-one patients diagnosed with knee osteoarthritis and undergoing arthroplasty at Hospital Clinic of Barcelona were taken&#46; The final sample consisted of 30 women and 11 men with an average age of 72&#46;9 &#40;range 64&#8211;90&#41;&#46; Most of them are not active workers &#40;95&#46;1&#37;&#41; and are married or widows&#47;widowers &#40;90&#46;2&#37;&#41;&#46; On average&#44; all patients are overweight according to their BMI and 14 of them are considered obese&#46; Indeed&#44; this group is socio-demographically homogeneous and a coherent sample&#44; as shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46; For the further Heart Rate Variability analysis&#44; 9 patients were excluded&#58; 4 heart disease patients&#44; 1 patient with a chronic renal condition and 4 patients with errors in their measurement records&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The first analysis of the applied psychometric test was performed by comparing the Pre-session and Post-session values&#46; Mean values and their standard deviations for each test are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Pre-session test results have higher mean and range values&#44; so after the empowerment session&#44; test result values decrease&#44; indicating lower mean patient stress&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The difference between Pre-session and Post-session total test results is 24&#46;91 points&#44; which represents a 17&#46;79&#37; reduction in stress for the total value of the stress scale&#46; Mean value test results after the empowerment session decrease by 41&#46;91&#37;&#44; taking the Pre-session values as a reference&#46; So&#44; there is a 41&#46;91&#37; decrease in stress state after the empowerment session measured by the Psychometric Test&#46; These changes are statistically significant according to the paired samples <span class="elsevierStyleItalic">T</span>-student test&#46; The evidence that the values from both sessions are different implies that patients have a better stress state before and after the empowerment session&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">When dividing patients by their self-perceived stress before the empowerment session &#40;Stressed&#41;&#44; the scores of subjects after the empowerment session are lower than the scores before the empowerment session&#44; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; It also shows a significant difference in VAS scores among self-perceived stress groups&#46; It suggests that patients with surgery related stress have the highest reduction compared to others&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows that only the patients with Surgery Related Stress have significantly different results for psychometric tests before and after the empowerment session&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The results in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> suggest a significant change in Mean HR&#44; RMSSD&#44; VLF and Total power after the empowerment session&#44; which is also supported by the Wilcoxon signed rank test that compares the Pre and Post Session states&#46; Changes in HRV-index are associated with an adaptation of the autonomic nervous system&#44; as well as a different wellness state&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Conversely&#44; the HF and LF components have no statistically significant differences&#46; Therefore&#44; it is not possible to determine changes in parasympathetic or sympathetic activity or in a wellness state&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">HRV-index values dividing patients according to their self-perceived stress is also shown in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; Patients with no self-perception of stress and patients that are not stressed by surgery do not show any significant change in HRV-index&#46; Moreover&#44; patients with surgery related stress have lower HRV-index values after the empowerment session&#46; These differences between the self-stress perception groups indicate a specific effect of the empowerment session on surgery-related stress&#46; These results are consistent with the results of psychometric tests&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Psychometric and physiological measurement results suggest a greater decrease in surgery related emotional stress state after the empowerment session&#46; Other analyses performed to establish the relationship between physiological and psychological measurements by Pearson&#39;s correlation coefficient shown in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Correlation was computed between each psychometric test and each HR-index&#46; Some HR-indices&#44; such as LF&#44; HF&#44; Power HF and LF&#47;HF ratio&#44; do not have significant linear correlation with psychometric tests but they correspond with those that do not have significant changes in value after the session&#46; Those values that change after the empowerment session are related to psychometric tests&#46; Especially in this study&#44; VAS proves more sensitive than STAI&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0185" class="elsevierStylePara elsevierViewall">Psychometric stress measurement shows a reduction in stress between test results before and after the empowerment session&#46; In this study&#44; the VAS test proves to be more sensitive than the STAI-state test probably because the patient&#39;s mental state is influenced by other factors in addition to anxiety&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Mean HR&#44; RMSSD&#44; VLF power and total power change in value &#40;<span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; suggesting more sympathetic and less parasympathetic activity&#46; HRV is associated with the patients&#8217; wellness state&#44; so both results corroborate the evidence of emotional stress state change after the empowerment session&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The relationship between physiological and psychological measurements is analyzed by Pearson&#39;s correlation and the results suggest a relation between patient stress state and cardiac responses&#44; confirming that a stressed state provokes variations HRV indices&#46; Both physiological and psychological measurements may help to the preoperative stress characterization&#44; that would permit a referral of the patient to an appropriate counseling service until the surgery until take place as was suggested in Ref&#46; <a class="elsevierStyleCrossRef" href="#bib0125">1</a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The psychometric State-Trait Anxiety Inventory test administered before and after the empowerment session shows a substantial decrease in surgery related stress due to the session&#44; while stress related to other sources does not change&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The same behavior and results can be seen in the Visual Analog Scale&#46; Although the VAS basis is purely subjective&#44; when it is applied to patients who are aware of what they are asked to do&#44; the results fitted with the other measurements&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The conducted experiment demonstrates that&#44; in the case of emotional stress&#44; there is a significant correlation between stress level and HRV index &#40;Mean HR&#44; RMSSD&#44; VLF power and total power&#41;&#46; This is an evidence for future studies on emotional stress based on HRV analysis&#44; due to psychometric tests and heart rate variability analysis could be interchangeable as measurement tools of emotional stress&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Both psychological and physiological measurements give support to the effectiveness of the empowerment session because of the significant increase in the wellness state of patients&#46; The main limitations of the study are&#58; the small size of sample limits the power of the statistical analysis and the probability of finding a wider range of biomarker levels&#46; The intrinsic relation between the empowerment session and the nurse makes it difficult to evaluate the effect of the contents of the session from how the nurse performs the session&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Differences in emotional stress before and after an empowerment session using psychometric tests and heart rate variability analysis could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes due to the role that the nurses play before the surgery&#46; Therefore&#44; psychometric tests and heart rate variability analysis can be used as an objective measurement for the patient centered care with a focus on patient education and rehabilitation proposed by Akhtaar and Houlihan-Burne&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Following this line&#44; the proposed measurements could be used to compare among empowerment sessions that have been included in different surgeries or medical procedures for diabetes&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a> antidrug or smoking treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">According a recent publication&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> negative preoperative emotions were related to poorer quality of recovery whilst greater satisfaction with care could be associated with better quality of recovery&#46; Then&#44; if the psychometric tests and HRV could be assess through wearables technologies and smartphones&#44; a personalized and continuous measurement of the emotional stress level or the wellness state of the patient could constitute a valuable guide to apply personalized interventions before the surgery&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">The presented methodology sets a precedent for the study of stress factors in humans&#44; such as surgery in the case of this study&#44; and behavioral changes that appear in response to adaptation to an external stimulus&#46; As suggested in the Roadmap for mental health research in Europe &#40;ROAMER&#41; in order to enhance the diagnosis of mental disorders&#44; follow-up and treatment using objective measurements are required&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0245" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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          "titulo" => "Acknowledgments"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2017-02-21"
    "fechaAceptado" => "2017-09-04"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec989031"
          "palabras" => array:6 [
            0 => "Stress"
            1 => "Electrocardiography"
            2 => "Biomarkers"
            3 => "Arthroplasty"
            4 => "Replacement"
            5 => "Knee"
          ]
        ]
      ]
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        0 => array:4 [
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          "identificador" => "xpalclavsec989032"
          "palabras" => array:6 [
            0 => "Estr&#233;s"
            1 => "Electrocardiograf&#237;a"
            2 => "Biomarcadores"
            3 => "Artroplastia"
            4 => "Reemplazo"
            5 => "Rodilla"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This study aims to show evidence of the Empowerment Session&#39;s effectiveness through measurements of surgery related emotional stress before and after this session&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The study was performed on 41 patients with knee arthroplasty surgery prescription by measuring the evolution of their emotional stress generated by surgery expectative&#44; during the empowerment session&#46; Two sets of measurements per patient were performed&#44; before and after the empowerment session&#46; Each set consisted of recording an electrocardiogram for 10<span class="elsevierStyleHsp" style=""></span>min while the patients were seated and then applying two standard psychometric tests&#58; State-Trait Anxiety Inventory test and Visual Analog Stress test&#46; Differences in emotional stress were analyzed using psychometric tests and heart rate variability &#40;HRV&#41; analysis as stress biomarkers&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Psychometric stress measurement shows a 17&#46;8&#37; reduction in stress according to the total stress scale value&#44; and a 41&#46;9&#37; reduction in stress between test results before and after the session&#46; Mean heart rate values increased by 7&#46;4&#37; with respect to the initial values&#44; very low frequency power and total power also change in value suggesting more sympathetic and less parasympathetic activity&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Both psychological and physiological measurements suggest the effectiveness of the empowerment session due to a significant increase in the wellness state of patients&#46; Additionally&#44; the correlation between psychometric tests and HRV indices demonstrates that both emotional stress indicators could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este estudio tiene como objetivo dar evidencias de la eficacia de la sesi&#243;n de empoderamiento a trav&#233;s de mediciones del estr&#233;s emocional relacionado con la cirug&#237;a antes y despu&#233;s de esta sesi&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El estudio se realiz&#243; en 41 pacientes con prescripci&#243;n de cirug&#237;a de artroplastia de rodilla durante la sesi&#243;n de empoderamiento&#46; Se realizaron 2 conjuntos de medidas por paciente&#44; antes y despu&#233;s de la sesi&#243;n&#46; Cada conjunto consisti&#243; en registrar el electrocardiograma durante 10<span class="elsevierStyleHsp" style=""></span>min mientras los pacientes estaban sentados y luego aplicando 2 test psicom&#233;tricos est&#225;ndar&#58; test State-Trait Anxiety Inventory y escala an&#225;loga visual&#46; Las diferencias en el estr&#233;s emocional se analizaron mediante test psicom&#233;tricos y el an&#225;lisis de la variabilidad del ritmo card&#237;aco &#40;HRV&#41; como biomarcadores de estr&#233;s&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Los puntajes en los test psicom&#233;tricos muestran una reducci&#243;n del 17&#44;8&#37; en el estr&#233;s seg&#250;n el valor de la escala de estr&#233;s total&#44; y una reducci&#243;n del 41&#44;9&#37; en el estr&#233;s entre los resultados de las pruebas antes y despu&#233;s de la sesi&#243;n&#46; Los valores medios de ritmo card&#237;aco aumentaron un 7&#44;4&#37;&#46; Las variaciones en la potencia ultra baja frecuencia y la potencia total sugieren una mayor actividad simp&#225;tica y menor parasimp&#225;tica&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Tanto las mediciones psicol&#243;gicas como fisiol&#243;gicas sugieren la efectividad de la sesi&#243;n de empoderamiento debido a un aumento significativo en el estado de bienestar de los pacientes&#46; Adem&#225;s&#44; la correlaci&#243;n entre las pruebas psicom&#233;tricas y los &#237;ndices de HRV demuestra que ambos indicadores de estr&#233;s emocional podr&#237;an utilizarse como retroalimentaci&#243;n en las sesiones de empoderamiento o como una referencia para mejorar los resultados quir&#250;rgicos&#46;</p></span>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPNN &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;64 &#40;1&#46;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34 &#40;1&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;094&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power VLF &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;71 &#40;0&#46;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;99 &#40;0&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power LF &#40;10<span class="elsevierStyleSup">&#8722;3</span>s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07 &#40;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07 &#40;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;525&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power HF &#40;10<span class="elsevierStyleSup">&#8722;3</span>s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;16 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;210&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PLF &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;35 &#40;0&#46;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;33 &#40;0&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;926&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total power &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;71 &#40;0&#46;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;99 &#40;0&#46;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LF&#47;HF ratio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;56 &#40;0&#46;34&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;53 &#40;0&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020"><span class="elsevierStyleItalic">p</span>-value &#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; Wilcoxon signed rank test&#46; HR&#58; heart rate&#46; SDNN&#58; standard deviation of all inter-beats intervals&#46; RMSSD&#58; root mean square of successive differences&#46; PPNN&#58; percentage of pairs of adjacent inter-beats intervals differing by more than 50<span class="elsevierStyleHsp" style=""></span>ms&#46; VLF&#58; very low frequency power&#46; LF&#58; low frequency power&#46; HF&#58; high frequency power&#46; PLF&#58; normalized LF power&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Values are&#58; mean &#40;standard deviation&#41;&#46; HR&#58; heart rate&#46; SDNN&#58; standard deviation of all inter-beats intervals&#46; RMSSD&#58; root mean square of successive differences&#46; PPNN&#58; percentage of pairs of adjacent inter-beats intervals differing by more than 50<span class="elsevierStyleHsp" style=""></span>ms&#46; VLF&#58; very low frequency power&#46; LF&#58; low frequency power&#46; HF&#58; high frequency power&#46; PLF&#58; normalized LF power&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non stressed</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Not stressed by surgery</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery related stress</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Post-session&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean HR &#40;bpm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60&#46;62 &#40;1&#46;63&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64&#46;22 &#40;2&#46;66&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&#46;52 &#40;0&#46;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&#46;93 &#40;3&#46;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#46;63 &#40;7&#46;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79&#46;37 &#40;6&#46;57&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SDNN &#40;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;00&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RMSSD &#40;s&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;99 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;94 &#40;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;84 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;81 &#40;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;83 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;77 &#40;0&#46;07&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPNN &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;42 &#40;1&#46;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;13 &#40;5&#46;84&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;2 &#40;0&#46;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;26 &#40;0&#46;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;74 &#40;2&#46;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;81 &#40;1&#46;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power VLF &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34 &#40;0&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;49 &#40;0&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;84 &#40;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98 &#40;0&#46;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;9 &#40;0&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;23 &#40;0&#46;44&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power LF &#40;10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;03 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;03&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08 &#40;0&#46;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;09 &#40;0&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;08 &#40;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;07 &#40;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power HF &#40;10<span class="elsevierStyleSup">&#8722;3</span><span class="elsevierStyleHsp" style=""></span>s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14 &#40;0&#46;02&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;31 &#40;0&#46;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11 &#40;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;15 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;19 &#40;0&#46;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;14 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Power PLF &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;11 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;04 &#40;0&#46;01&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;4 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;33 &#40;0&#46;06&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;38 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;36 &#40;0&#46;09&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total power &#40;s<span class="elsevierStyleSup">&#8722;2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;34 &#40;0&#46;07&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;49 &#40;0&#46;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;84 &#40;0&#46;05&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;98 &#40;0&#46;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;9 &#40;0&#46;45&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;23 &#40;0&#46;44&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">LF&#47;HF ratio&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">HR&#58; heart rate&#46; SDNN&#58; standard deviation of all inter-beats intervals&#46; RMSSD&#58; root mean square of successive differences&#46; PPNN&#58; percentage of pairs of adjacent inter-beats intervals differing by more than 50<span class="elsevierStyleHsp" style=""></span>ms&#46; VLF&#58; very low frequency power&#46; LF&#58; low frequency power&#46; HF&#58; high frequency power&#46; PLF&#58; normalized LF power&#46;</p>"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Pearson&#39;s correlation and <span class="elsevierStyleItalic">p</span>-value of psychometric tests and heart rate variability indices&#46;</p>"
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          "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">What is known&#63;</span><p id="par0010" class="elsevierStylePara elsevierViewall">Modern-day surgery protocols include Patient Empowerment as a key factor to improve surgical recovery processes by enhancing the patient&#39;s mental state&#46; Since 2011&#44; the &#8220;Fast Track Prosthetic Knee Project&#8221; at the Hospital Clinic of Barcelona &#40;Spain&#41; has included a patient empowerment session prior to knee arthroplasty surgery&#46; This session is designed to reduce emotional stress by providing information and tools helping patient to better face surgery and recovery&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">What it contributes&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Differences in emotional stress before and after an empowerment session were analyzed using psychometric tests and Heart rate variability analysis as stress biomarkers&#46; Both psychological and physiological measurements give support to the effectiveness of the empowerment session because the significant increase in the wellness state of patients&#46; Additionally&#44; the correlation found between psychometric tests and HRV indices demonstrates that&#44; as is frequently assumed&#44; HRV is associated with emotional stress state&#46; Both emotional stress indicators could be used as feedback on the empowerment sessions or as a reference to enhance surgical outcomes&#46;</p></span></span>"
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                    0 => array:2 [
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                      "doi" => "10.1007/s11999-014-3570-5"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24671514"
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                      ]
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                    0 => array:1 [
                      "LibroEditado" => array:4 [
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                      "titulo" => "Optimization of the patient undergoing total knee arthroplasty-the rapid recovery program"
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                            0 => "K&#46;S&#46;N&#46; Akhtaar"
                            1 => "D&#46;G&#46; Houlihan-Burne"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "B&#46;F&#46; Hudson"
                            1 => "J&#46; Ogden"
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                        "fecha" => "2015"
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                      "titulo" => "Pre-operative patient education reduces length of stay after knee joint arthroplasty"
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