Clinical Feature

Journal of Perioperative Practice

2018, Vol. 28(1 & 2) 7–15
The effect of multimedia-based nursing ! The Author(s) 2018
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DOI: 10.1177/1750458917742045

signs in patients undergoing lumbar journals.sagepub.com/home/jopp

disc herniation surgery: A randomised

clinical trial

Behrooz Zarei1, Sina Valiee2, Bijan Nouri3, Fatemeh Khosravi4

and Mohammad Fathi2

Abstract
This study was a randomised clinical trial on 60 candidates undergoing lumbar disc herniation surgery. Anxiety rate and
vital signs were measured before and after the intervention. There was a statistically significant difference between the
two groups in terms of the preoperative anxiety, systolic and diastolic blood pressure, pulse and respiratory rate
(P ¼ 0.0001). Neurosurgery perioperative nurses can make use of multimedia in preoperative nursing visit based on the
needs of patients.

Keywords
Preoperative anxiety/Lumbar disc herniation/Vital signs/Nursing visit/Multimedia

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication 20 June 2017.

Introduction Papanastassiou et al 2011); anxiety is one of the most

Low back pain is a common problem experienced by
80 to 85 percent of the world's population during
their life time (Hoy et al 2010). Globally between 100
and 200 billion dollars (Duthey 2013) are spent each
year, directly or indirectly, for treatments of back pain
and its complications (Ferreira et al 2002). Around
one-third of the adult population in the UK
experiences low back pain every year (Hong et al
2013). Annual rates of low back pain in the American
population are in the range of 5% to 22% (Ma et al
2014). The prevalence of low back pain in Iran varies
from 14.4% to 84.1% and it is the second largest
cause of a visit to a doctor (Mousavi et al 2011). The
mean overall global prevalence of low back pain is
31% (Hoy et al 2012).
Spinal disc herniation refers to protrusion of an inter-
vertebral disc into the spinal canal which leads to spinal
stenosis in the anteroposterior axis (Tan & Black 2002).
Today, herniated disc surgery is one of the most
common surgeries in the world (Tan & Black 2002,
common problems before surgery (Agarwal et al 2005)
and is present in 11 to 81% of adults undergoing
surgery (Mavridou et al 2013).
Anxiety is a vague feeling of fear, discomfort or
apprehension which is often due to unfamiliar
situations, perception of the risk of death, discomfort,
fear of postoperative pain, change in body shape or
functions and family concerns (Padmanabhan et al
1
Student Research Committee, Kurdistan University of Medical Sciences,
Sanandaj, Iran
2
Assistant Professor, Clinical Care Research Center, Kurdistan University
of Medical Sciences, Sanandaj, Iran
3
Assistant Professor, Social Determinants of Health Research Center,
Kurdistan University of Medical Sciences, Sanandaj, Iran
4
Besat Hospital, Kurdistan University of Medical Sciences, Sanandaj, Iran
Corresponding author:
Mohammad Fathi, BSN, MSN, PhD, Clinical Care Research Center,
School of Nursing and Midwifery, Kurdistan University of Medical
Sciences, Pasdaran St, 66177-13446, Sanandaj, Kurdistan, Iran.
Email: mohammad.fathi@muk.ac.ir
8 Journal of Perioperative Practice 28(1 & 2)
2005, Mavridou et al 2013, Ali et al 2014). Preoperative
anxiety begins when the patient receives notification
that surgery is required, it is increased during the
hospitalization, and reaches its peak prior to anesthesia
(Nourian et al 2014).
High preoperative anxiety could slow down the
postoperative recovery process (Kraskian 2010, Duthey
2013). A high level of anxiety preoperatively is followed
by high incidence of postoperative pain (Laufenberg-
Feldmann et al 2016), reduced ability to resist infection,
increased use of analgesics after surgery, delayed
wound healing (Britteon et al 2017), negative effects on
patient's mood and prolonged hospitalization (Rasouli et
al 2016).
Since nurses spend more time with patients in the
clinical environment than other members of the medical
team, and also have more interaction with patients, they
play a crucial role in relieving anxiety (Zakerimoghadam
et al 2010). Several studies have shown that giving
information and education leads to the increased
understanding of clinical interventions by patients and
thus reduces anxiety (Jlala et al 2010, Parveen et al
2016). A nursing visit includes assessing a patient's
condition, charting the observations, performing
evaluation tasks, listening to the patient and responding
to concerns or requests, and providing care that is
accompanied with patient education (Sadati et al 2013,
Fortacín et al 2015). Studies have found that holding an
education class for patients before spinal surgery
enhances satisfaction and improves control of pain in
these patients (Papanastassiou et al 2011). Also, an
educational program with the use of a compact disc (CD)
which contains video and images about the process of
pre and postoperative care before the spinal surgery can
reduce the state of anxiety, as the experience of
unpleasant feelings when confronted with specific
situations, demands or a particular object or event can
improve self-care (Cho & Chun 2015).
Multimedia education can be defined as using basic
types of media material like text, video, sound, graphics
and animation and incorporating this approach into a
learning environment (Raymond 2016). Multimedia
education provides a relatively cost-effective, time-
saving, user-friendly and easy to reach strategies in
patient and caregiver education (Lam et al 2016). Today,
multimedia sources of information like videos, audio,
and pictures are combined in preoperative education
strategies (Raymond 2016). Using multimedia assists
educators in overcoming linguistic, physical and cultural
barriers and in addressing different learning needs. It
also provides unique experiences in presenting
materials in different formats and from different
perspectives for patients (Wiljer & Catton 2003).
To sum up, as preoperative anxiety can lead to
complications, it is essential to reduce preoperative
anxiety and educate patients. This study was conducted
to determine the effectiveness of a multimedia-based
nursing visit on preoperative anxiety and vital signs in
patients undergoing spinal disc herniation surgery.
Methods
This study was a randomised clinical trial (RCT) with two
groups. The RCT is an experimental study in which
participants are randomly assigned to treatment groups
(intervention and control groups); it aims to determine
whether a clinical intervention is effective under optimal
circumstances (James et al 2015). The study was
approved by the Student Research Committee and
Research Council of Kurdistan University of Medical
Sciences No 1395.132 and has been registered at
Iranian Registry of Clinical Trial
(IRCT2016051627927N1).
Subjects included patients who were candidates for non-
emergency lumbar disc herniation surgery. The inclusion
criteria were:
• voluntary participation in the study
• elective surgery
• surgery under general or spinal anesthesia
• lack of history of diseases such as hypertension, vas-
cular diseases, thyroid diseases, rheumatoid arthritis,
lumbar trauma, fever, lack of history of mental dis-
eases or taking antidepressants
• no previous experience of surgery, and
• 18 to 65 years of age.
The exclusion criteria included:
• patients taking medications affecting anxiety such as
alprazolam, oxazepam, chlordiazepoxide and diaze-
pam (24 hours before the intervention until re-
measurement of anxiety and vital signs) and
• patients withdrawal from continuing to participate in
the study.
The research environment was the neurosurgery ward of
Besat Hospital in Sanandaj, Iran.
Based on the sample size formula as well as previous
studies (Sadati et al 2013, Valiee et al 2012), the
sample size for each group was calculated as n=30 for
each group. Seventy seven patients were assessed for
eligibility and 17 excluded for not meeting the inclusion
Zarei et al.
criteria or for declining to participate. None of subjects
left the study after randomization (Figure 1).
Measuring tools
Data collection tools in this study included a three-part
data recording:
• form containing demographic data
• form including clinical data and
• the Spielberger State Anxiety Inventory (1983).
The Spielberger State Anxiety inventory included 20
likert items. The minimum earned point (20) means the
absence of anxiety and the maximum point (80)
means the highest rate of anxiety. The validity and
reliability of this questionnaire has been examined
in Iran (Mahram 1993). The validity of the test has been
confirmed through concurrent validity (Kraskian 2010).
Analog manometer and stethoscope were used to
measure systolic and diastolic blood pressure, one-
minute radial pulse was used to count the pulse rate,
and counting in a full one minute by the researcher was
used for the respiratory rate and tympanic digital ear
Enrollment
Allocated to intervention (n=30)
♦ Received allocated intervention (n=30)
♦ Did not receive allocated intervention (give
reasons) (n=0)
Lost to follow-up (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Analysed (n=30)
♦ Excluded from analysis (give reasons) (n=0)
Figure 1 CONSORT flow diagram
9
thermometers (Infrared Ear Thermometer, CuraplexV
R)
was used to measure body temperature. All
measurements were performed by one person.
Before the data collections, investigator triangulation
was used to confirm the reliability of measurement of
vital signs and preoperative anxiety by the researcher.
Thus, after the measurement by one of the researchers,
a follow-up measurement was done by a nurse using the
same protocol to be sure of the correct method of
measurements. To determine the validity of the
instrument to measure blood pressure an analog
manometer (ALPK2 model: No 300-VS; Tanaka Sangyo
Co Ltd) was used for all the research units after being
calibrated. Anxiety and vital signs were measured at
7.00pm one day before the surgery; these readings were
the 'before the intervention' score or baseline. Anxiety
and vital signs were measured before the transfer to the
operating room as 'after the intervention' score.
Procedure
The researcher reviewed patients who were referred to
the neurosurgery ward one day before the surgery for
inclusion criteria by using patients' files and doing an
Assessed for eligibility (n=77)
Excluded (n=17)
♦ Not meeting inclusion criteria (n=10)
♦ Declined to participate (n=5)
♦ Other reasons (n=2)
Randomized (n=60)
Allocation
Allocated to intervention (n=30)
♦ Received allocated intervention (n=30)
♦ Did not receive allocated intervention (give
reasons) (n=0)
Follow-Up
Lost to follow-up (give reasons) (n=0)
Discontinued intervention (give reasons) (n=0)
Analysis
Analysed (n=30)
♦ Excluded from analysis (give reasons) (n=0)
10 Journal of Perioperative Practice 28(1 & 2)

BOX 1. Multimedia based nursing visit steps taken in the intervention group

First step 1 Introducing oneself, steps and goals

2 Providing information on the causes of spinal disc herniation and different ways to treat it
3 Displaying several educational video clips by a tablet including the words of a neurosurgeon about
lumbar disc herniation surgery and words of several recovered patients
4 Distributing educational pamphlets about herniated disc surgery among patients
Second step 1 How to transfer to the operating room
2 Physical space of the waiting room, operating room and recovery room
3 Comments about surgical and anesthesia team, anesthesia process, existing devices in the oper-
ating room, actions that the patient has to do before and while being anesthetized and how the
patient is transferred from the operating room to the ward
4 Displaying some photos that were taken from the operating room space by a tablet
Third step Some training about postoperative care both in the ward and at home such as how to change
dressing and bandages, and how to walk with the display of pamphlet and photograph via a table
Fourth step Answering the questions and uncertainties of the patients in various fields relating to disease and
surgery process that were not referred to by the researcher in the nursing visit

interview. After explaining the purpose of the study and
obtaining their written consent, the patients were
randomly allocated to either the intervention or control
group by tossing a coin; the side of the coin (ie heads -
control, tails - intervention) determined the assignment
of each subject. The tossing a coin is the most common
and basic method of simple randomization. This
randomization method is easy and simple to implement
in clinical research (Suresh 2011).
The anxiety and vital signs (systolic and diastolic blood
pressure, pulse rate, respiratory rate, and body
temperature) of the two groups were measured and
recorded. All patients were admitted to the ward at
5.00pm one day before surgery. The levels of cortisol
increase in evening (Gonzalez et al 2017) and there is a
greater level of cortisol in patients with elevated anxiety
(Yilmaz et al 2012). Thus, to control for the confounding
effect of this change and to have enough time for
intervention and to measure variables at the same time
for all subjects, variables were measured at 7.00pm one
day before the surgery. Afterwards the control group
received the routine care and the intervention group
received multimedia-based nursing visit (Box 1).
The multimedia-based nursing visit in the intervention
group included a 30-to-50 minute visit at the patient's
bedside by the researcher in four steps.
• The first step included providing information about
herniated intervertebral disc, the causes of the dis-
eases, critical preoperative care, removal of accesso-
ries and denture on the operation day before
transferring to the operating room, different ways of
treatment including surgery. Then a video clip was
played on a tablet of the neurosurgeon doctors talk-
ing about lumbar disc herniation surgery, as well as
the three video clips of several patients who had
undergone surgery and had recovered. Finally, a pam-
phlet about lumbar disc herniation surgery was
shown.
• In the second step, some information regarding trans-
fer to the operating theatre, its physical environment
and waiting room, instruments and equipment avail-
able in the operating theatre, and explanations about
the surgical and anesthesia team were provided.
Information regarding what was expected of the
patient before and during general or spinal anesthe-
sia and how to participate, measures taken in the
recovery and how the patient is transferred were pre-
sented; at the same time, ten pictures taken from the
surgery room and the instruments used there were
displayed via the tablet.
• In the third phase, pamphlets and photographs were
used to educate patients about postoperative care,
both in the ward and at home, such as how to
change dressing and bandages and how to walk.
• In the fourth step, any questions and uncertainties of
the patients in various fields relating to disease and
surgery process that were not referred to by the
researcher in nursing visit, were answered.
Patients in the control group received only the
routine preoperative information given by the ward
nurses (removal of hair from the wound site by
electric clippers (National Collaborating Centre for
Women's and Children's Health 2008), eating nothing by
mouth before surgery (Brown and Heuberger 2014), and
specific information regarding postoperative
complications such as bleeding, pain and drains at
Zarei et al. 11

Table1 Demographic data of groups

Intervention Control

Variables Number (percentage) Number (percentage) p

Sex Female 8 (26.7) 8 (26.7) 1

Male 22 (73.3) 22 (73.3)
Marriage Married 28 (93.3) 23 (76.7) 0.073
Single 2 (6.7) 7 (23.3)
Age (MSD) 40.0210.51 4316.51 0. 647
Education Illiterate 5 (16.7) 6 (20) 0.842
Primary 10 (33.3) 10 (33.3)
Diploma 15 (50) 13 (43.3)
Student 0 (0) 1 (3.3)
Job Employee 1 (3.3) 1 (3.3) 0.242
Tradesman 19 (63.3) 14 (46.7)
Retired 1 (3.3) 4 (13.3)
Housekeeper 8 (26.7) 7 (23.3)
Unemployed 0 (0) 2 (6.7)
Student 1 (3.3) 2 (6.7)
Smoking Yes 4 (13.3) 6 (20) 0.492
No 26 (86.7) 24 (80)
Anesthesia General 10 (33.33) 13 (43.33) 0.43
Spinal 20 (66.66) 17 (56.66)

the incision site, time of dressing change and time to to the participants that they could leave the study
walk after surgery. whenever they wanted to.

Statistical methods
The demographic characteristics of the two groups were
compared using statistical chi-square test, and the
independent t-test was used for the age. The
Kolmogorov-Smirnov test was used to determine the
normal distribution of variables and to decide whether to
use a parametric or nonparametric test. To compare the
rate of anxiety and vital signs in the two groups at
different times Mann-Whitney test was used (Corder and
Foreman 2011).
Ethical considerations
This study is the result of a master’s degree dissertation
funded by the Council of Kurdistan University of Medical
Sciences. The study was approved by the Ethics
Committee of Kurdistan University of Medical Sciences
IR.MUK.REC.1395.132. Ethical considerations in the
research included getting permission from the subjects,
explaining the objectives and nature of the research,
getting written consent and inviting them to participate
in the research, and ensuring them that obtained
information would remain confidential. It was explained
Results
The information obtained from the 60 patients was
analysed. Statistical tests showed that there was no
significant relationship between the intervention (n=30)
and control groups (n=30) in terms of demographic
variables; the two groups were homogeneous in this
respect (Table 1).
The results showed that before the intervention, the
mean anxiety in patients in the intervention group was
50.93  10.41 and in the control group it was 48.06
 10.95 (p ¼ 0.4). After the intervention, the mean
anxiety for the intervention group and control group was
37.83  7.20 and 53  10.29 respectively (p ¼ 0.0001)
which indicated a significant statistical difference after
intervention in the intervention group. Moreover, there
was a significant difference in the anxiety rate before
and after intervention in the control group (p ¼ 0.0001).
There was a significant difference in the systolic and
diastolic blood pressure rate in the intervention group
before and after intervention (p ¼ 0.0001). Moreover,
there was a significant difference in the systolic and
diastolic blood pressure rate before and after intervention
12 Journal of Perioperative Practice 28(1 & 2)

Table 2 Comparison of preoperative anxiety and vital signs intra and between groups

Group
Variable Intervention Control p

Anxiety Before 50.9310.41 48.0610.95 0.407

MSD After 37.837.20 5310.29 0.0001
p 0.0001 0.0001
Systolic blood pressure Before 12714.35 118.7325.24 0.104
(mmHg) MSD After 111.6616.04 133.5315.93 0.0001
P 0.0001 0.0001
Diastolic blood pressure Before 81.2611.88 77.109.51 0.143
(mmHg) MSD After 70.7310.69 83.3310.04 0.0001
P 0.001 0.0001
Pulse Before 77.334.64 74.605.28 0.028
(per minute) MSD After 70.735.31 79.134.89 0.0001
p 0.0001 0.0001
Respiratory rate Before 16.731.33 16.331.97 0.31
(per minute) MSD After 15.461.56 17.401.83 0.0001
p 0.002 0.003
Temperature Before 37.050.21 370.24 0.33
(centigrade) MSD After 37.080.25 37.090.027 0.307
p 0.627 0.055

in the control group (p ¼ 0.0001). There was not a
statistically significant difference in the systolic (p ¼ 0.1)
and diastolic blood pressure (p ¼ 0.14) rate before the
intervention between the two groups. But there was a
statistically significant difference in the systolic
(p ¼ 0.0001) and diastolic blood pressure (p ¼ 0.0001)
rate after the intervention between the two groups.
There was a significant difference between the pulse
rate (p ¼ 0.0001) and respiratory rate (p ¼ 0.002)
before and after intervention in the intervention group.
Also, there was significant difference between pulse rate
(p ¼ 0.001) and respiratory rate (p ¼ 0.003) before and
after intervention in the control group. Body temperature
before and after intervention in the intervention group
(p ¼ 0.62) and control group (p ¼ 0.055) did not show a
significant difference (Table 2) (Figure 2).
Discussion
The results of this study showed that anxiety of patients
before lumbar disc herniation surgery was reduced after
the multimedia-based nursing visit. The results of
previous studies have shown that a nursing visit reduces
preoperative anxiety and postoperative complications
(Fortacín et al 2015, Sadati et al 2013). In another
research study, preoperative anxiety reduced after a
photographic display with music (Gómez-Urquiza et al
2016), a nursing visit (Sadati et al 2013) and a
preoperative visit and face to face education (Fortacín et
al 2015). A preoperative visit by an anesthesiologist, a
recovery nurse or a theatre nurse can reduce
preoperative anxiety in patients (Sadati et al 2013). In
the present study, a multimedia-based nursing visit
reduced preoperative anxiety. This reduction in anxiety
could result from the nurse interacting directly with the
patient, giving information, creating a secure
environment, providing an opportunity to express
uncertainties, and responding to the patient.
According to the obtained results, the rate of anxiety
before and after intervention was significantly different
in the control group, but the rate of anxiety had
increased on the operation day. An increase in anxiety in
the patients of the control group has been reported in
other studies (Fortacín et al 2015, Mousavi et al 2011,
Valiee et al 2012, Sadati et al 2013). In the present
study the increase could be due to different reasons
such as the lack of receiving adequate education and
awareness on the process of surgery and anesthesia as
well as patients having various questions and
uncertainties about postoperative steps and expected
surgery complications.
According to the existing difference in anxiety scores
after intervention, in both intervention and control
groups, and the increase of anxiety rate in the control
group, it can be said that in the present study, the
multimedia-based nursing visit to patients before lumbar
disc herniation surgery has led to a reduction of
Zarei et al.
Figure 2 Changes of variables before and after intervention in intervention and control groups
preoperative anxiety. A multimedia-based nursing visit
provides the opportunity for the patients to raise any
questions and disturbing subjects that the researcher
has not properly referred to during the nursing visit. On
the other hand, through face to face contact with
patients, nurses can also ensure patients'
understanding and perceive the reflection of their
preoperative education.
Blood pressure
In the present study, as in other studies (Valiee et al
2012, Gómez-Urquiza et al 2016), after the intervention
the rate of systolic and diastolic blood pressure
significantly decreased in the intervention group and
increased in the control group. The effect of anxiety on
the sympathetic nervous system and the ensuing
changes in vital signs can be referred to as the reasons
for systolic decrease in the intervention group and its
increase in the control group. Following the emergence
of anxiety, the rate of blood catecholamine and
consequently the body's need for oxygen will increase,
and this will affect and increase the rate of the cardiac
output and blood pressure (McRee et al 2003).
Anxiety stimulates the sympathetic system response and
thus causes tachycardia, hypertension, and
vasoconstriction (Barker et al 2006). In the present
study, the intervention led to reduction of preoperative
13
anxiety in the intervention group, it can ultimately lead to
the reduction of vital signs such as blood pressure in
this group of patients by reducing the stimulation of the
sympathetic system. However, since there was no
intervention in the control group and the rate of
preoperative anxiety had increased, it could increase
systolic blood pressure in patients by stimulating the
sympathetic system.
Respiratory rate
Considering the respiratory rate, the results showed that
after intervention the respiratory rate significantly
decreased from16.73  1.33 to 15.46  1.56 in the
intervention group, while it significantly increased in the
control group from 16.33  1.97 to 17.40  1.83. In
another study, the patients' respiratory rate had
decreased significantly in the intervention group after
intervention (Gómez-Urquiza et al 2016).
The increase of respiratory rate after intervention in the
control group can be due to the effect of preoperative
anxiety on the increase of adrenocorticoids and
epinephrine and consequently, the increase in
respiratory rate (McRee et al 2003). The reduction of
anxiety in the intervention group due to the nursing visit
is one of the reasons for the reduction of respiratory rate
in patients.
14
Pulse rate
The pulse rate decreased significantly from 77.33
 4.64 to 70.73  5.31 in the intervention group after
intervention, while it increased significantly from 74.60
 5.28 to 79.13  4.89 in the control group, as the
other studies have reported similar results in this regard
(Valiee et al 2012, Gómez-Urquiza et al 2016). A
preoperative nursing visit by an anesthesiologist or a
perioperative nurse leads to the reduction of
preoperative anxiety in patients (Sadati et al 2013).
Moreover, the increase of anxiety can lead to the
increase of pulse rate by influencing the sympathetic
nervous system (McRee et al 2003). In the present
study the reduction of anxiety by intervention in the
intervention group could be the reason for the reduction
of pulse rate in patients before surgery.
Body temperature
In some of the previous studies the effect of
interventions influencing preoperative anxiety on body
temperature has not been reported (Valiee et al 2012,
Gómez-Urquiza et al 2016). The results of this study
showed that preoperative anxiety did not have a
significant effect on body temperature in patients.
Limitations and recommendation
Anxiety is an abstract and mental concept and its
determination by the Spielberger's State-Trait Anxiety
(1983) questionnaire (Spielberger et al 1983) depends
on the individuals' perception of questions and patients'
confidence in expressing their real rates of anxiety. The
state anxiety inventory of Spielberger's questionnaire
was used.
State anxiety is immediately created in temporary
situations, such as impending surgery, that are
perceived as dangerous. Trait anxiety is the results of a
relatively enduring disposition to feel stress, fears, and
worries. So it's recommended to use the Spielberger
State-Trait Anxiety Inventory simultaneously to determine
if patients are naturally anxious.
Using a multimedia-based nursing visit recommended in
surgical wards especially before lumbar disc herniation
surgery.
Further research in different surgical populations is
recommended. Moreover, it is recommended to carry out
multimedia-based nursing visit in other surgeries to
investigate the effects of interventions on postoperative
complications This intervention method can be
compared with other methods, particularly various
educational methods in the ward.
Journal of Perioperative Practice 28(1 & 2)
Conclusion
Finally, according to the results of this research it can be
concluded that providing appropriate information and
training with multimedia by the perioperative nurse in
the form of a nursing visit, on the day before lumbar disc
herniation surgery can reduce preoperative anxiety and
vital signs, except for body temperature, in such
patients. Preoperative nurses can use a nursing visit
based on multimedia in customizing information to the
needs of individual patients to reduce their preoperative
anxiety before lumbar disc herniation surgery, in order to
provide nursing care commensurate with the individual
patient's needs.
No competing interests declared
References
Agarwal A, Ranjan R, Dhiraaj S et al 2005 Acupressure for
prevention of pre-operative anxiety: a prospective,
randomised, placebo controlled study Anaesthesia 60
978–81
Ali A, Altun D, Oguz BH et al 2014 The effect of preoperative
anxiety on postoperative analgesia and anesthesia recovery
in patients undergoing laparascopic cholecystectomy
Journal of Anesthesia 28 222–27
Barker R, Kober A, Hoerauf K et al 2006 Out-of-hospital
auricular acupressure in elder patients with hip fracture: A
randomized double-blinded trial Academic Emergency
Medicine 13 19–23
Britteon P, Cullum N, Sutton M 2017 Association between
psychological health and wound complications after surgery
British Journal of Surgery 104 769–76
Brown L, Heuberger R 2014 Nothing by mouth at midnight:
Saving or starving? A literature review Gastroenterology
Nursing 37 14–23
Cho YH, Chun N 2015 Effect of structured information on
immediate preoperative anxiety and uncertainty for women
undergoing laparoscopic hysterectomy Korean Journal of
Women Health Nursing 21 321–31
Corder GW, Foreman DI 2011 Nonparametric statistics for
non-statisticians John Wiley and Sons Inc
Duthey B 2013 Background paper 6.24: low back pain World
Health Organisation (WHO) Priority medicines for Europe
and the world 'A public health approach to innovation'
Geneva, WHO
Ferreira ML, Ferreira PH, Latimer J et al 2002 Does spinal
manipulative therapy help people with chronic low back
pain? Australian Journal of Physiotherapy 48 277–84
Fortacín BC, Fortuño ML, Puig CE et al 2015 Effectiveness of
preoperative visit on anxiety, pain and wellbeing Enfermería
Global 39 41–51
Gómez-Urquiza JL, Hueso-Montoro C, Urquiza-Olmo J et al
2016 A randomized controlled trial of the effect of a
photographic display with and without music on
preoperative anxiety Journal of Advanced Nursing 72
1666–76
Zarei et al.
Gonzalez RE, Lamy O, Stoll D et al 2017 High evening cortisol level
is associated with low Tbs and increased prevalent vertebral
fractures: Osteolaus study Journal Of Clinical Endocrinology
and Metabolism doi: 10.1210/jc.2016-3804
Hong J, Reed C, Novick D, Happich M 2013 Costs associated
with treatment of chronic low back pain: An analysis of the
UK general practice research database Spine 38 75–82
Hoy D, Bain C, Williams G et al 2012 A systematic review of the
global prevalence of low back pain Arthritis and
Rheumatology 64 2028–37
Hoy D, March L, Brooks P et al 2010 Measuring the global
burden of low back pain Best Practice and Research
Clinical Rheumatology 24 155–65
James S, Rao SV, Granger CB 2015 Registry-based randomized
clinical trials: A new clinical trial paradigm Nature Reviews
Cardiology 12 312-16
Jlala H, French J, Foxall G et al 2010 Effect of preoperative
multimedia information on perioperative anxiety in patients
undergoing procedures under regional anaesthesia British
Journal of Anaesthesia 104 369–74
Kraskian A 2010 State-trait anxiety inventory Roshd Moshaver
Madreseh 22 58–59
Lam M, Choi M, Lam HR et al 2016 Use of multimedia in
patient and caregiver education for cancer pain
management: a literature review Annals of Palliative
Medicine 6 66–72
Laufenberg-Feldmann R, Kappis B, Schuster M, Ferner M 2016
Relevance of preoperative anxiety for postoperative
outcome in urological surgery patients: A prospective
observational study Schmerz 30 166–73
Ma VY, Chan L, Carruthers KJ 2014 Incidence, prevalence,
costs and impact on disability of common conditions
requiring rehabilitation in the United States: Stroke, spinal
cord injury, traumatic brain injury, multiple sclerosis,
osteoarthritis, rheumatoid arthritis, limb loss and back pain
Archives of Physical Medicine and Rehabilitation 95
986–95
Mahram B 1993 Manual of Spielberger state-trait anxiety
inventory Master of Science dissertation Ferdowsi
University of Mashhad
Mavridou P, Dimitriou V, Manataki A et al 2013 Patient's
anxiety and fear of anesthesia: Effect of gender, age,
education and previous experience of anesthesia. A survey
of 400 patients Journal of Anesthesia 27 104–08
Mcree LD, Noble S, Pasvogel A 2003 Using massage and
music therapy to improve postoperative outcomes AORN
Journal 78 433–47
Mousavi SJ, Akbari ME, Mehdian H et al 2011 Low back pain in
Iran: a growing need to adapt and implement evidence-
based practice in developing countries Spine 36 E638–46
National Collaborating Centre for Women's and Children's
Health 2008 Surgical site infection: Prevention and
15
treatment of surgical site infection London, National
Institute for Health and Clinical Excellence
Nourian M, Jalaledinee A, Saatchi K et al 2014 Effects of
stroke massage using sesame oil on hospitalization anxiety
in school-age girls Modern Care Journal 10 210–18
Padmanabhan R, Hildreth AJ, Laws D 2005 A prospective,
randomised, controlled study examining binaural beat
audio and preoperative anxiety in patients undergoing
general anaesthesia for day case surgery Anaesthesia 60
874–77
Papanastassiou I, Anderson R, Barber N et al 2011 Effects of
preoperative education on spinal surgery patients SAS
Journal 5 120–24
Parveen A, Ellahi R, Sultana S, Tahir M 2016 Effect of
preoperative education on level of anxiety in patients
undergoing cataract surgery Journal of Islamabad Medical
and Dental College 5 192–94
Rasouli MR, Menendez ME, Sayadipour A 2016 Direct cost and
complications associated with total joint arthroplasty in
patients with preoperative anxiety and depression Journal
of Arthroplasty 31 533–36
Raymond YK 2016 An evidence-based guideline for
preoperative nursing education to alleviate postoperative
pain among patients undergoing video-assisted thoracic
surgery Degree of Master of Nursing, University of Hong
Kong
Sadati L, Pazouki A, Mehdizadeh A et al 2013 Effect of
preoperative nursing visit on preoperative anxiety and
postoperative complications in candidates for laparoscopic
cholecystectomy: a randomized clinical trial Scandinavian
Journal of Caring Sciences 27 994–98
Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA
1983 Manual for the State-Trait Anxiety Inventory Palo Alto
CA Consulting Psychologists Press
Suresh KP 2011 An overview of randomization techniques: An
unbiased assessment of outcome in clinical research
Journal of Human Reproductive Sciences 4 8–11
Tan TC, Black PM 2002 Sir Victor Horsley (1857–1916):
Pioneer of neurological surgery Neurosurgery 50 607–12
Valiee S, Bassampour SS, Nasrabadi AN et al 2012 Effect of
acupressure on preoperative anxiety: a clinical trial Journal
of PeriAnesthesia Nursing 27 259–66
Wiljer D, Catton P 2003 Multimedia formats for patient
education and health communication: Does user
preference matter? Journal of Medical Internet Research 5
e19
Yilmaz M, Sezer H, Gürler H, Bekar M 2012 Predictors of
preoperative anxiety in surgical inpatients Journal of
Clinical Nursing 21 956–64
Zakerimoghadam M, Aliasgharpoor M, Mehran A, Mohammadi
S 2010 Effect of patient education about pain control on
patients' anxiety prior to abdominal surgery Hayat 15
13–22