Beneficial Stress Response May Enhance Postsurgical Recovery

Laurie Barclay, MD

December 04, 2009

December 4, 2009 — A beneficial stress response reflected in immune cell redistribution may enhance postsurgical recovery, according to the results of a prospective longitudinal study reported in the December issue of the Journal of Bone and Joint Surgery.

"In nature, wounds and infections often occur during stressful situations, or cause stress soon after they occur," senior author Firdaus S. Dhabhar, PhD, from the Stanford Institute for Immunity, Transplantation and Infection in California, said in a news release. "Therefore, we reasoned that the short-term stress response would prepare organisms for immune challenges, just as it prepares them for fight-or-flight."

The hypothesis tested by this study was that predefined adaptive immune cell redistribution profiles seen during surgery would predict enhanced short- and long-term postoperative recovery. Knee function was tested before surgery in 57 patients undergoing meniscectomy, as well as at 1, 3, 8, 16, 24, and 48 weeks postoperatively, using the clinically validated Lysholm scale to measure mechanical function, pain, mobility, and performance of daily activities. At baseline, before surgery, and after surgery, participants underwent testing of surgery-induced immune cell redistribution in the blood.

"One of the beauties of the tests is that it's so easy," said Esther Sternberg, MD, chief of the section on neuroendocrine immunology and behavior at the National Institute of Mental Health, who was not involved in this study. "The information is completely available to any physician pre- and postsurgery."

Patients with the predefined ''adaptive'' lymphocyte and monocyte redistribution profiles during surgery had better recovery compared with other patients, based on mixed-model repeated-measures analyses. Compared with men, women had less adaptive immune cell redistribution and significantly delayed maximum recovery (48 vs 16 weeks).

"It was slightly surprising to see how much in tandem the immune cell redistribution appeared to be with the overall gender recovery difference," Dr. Dhabhar said.

Across both sexes, interindividual differences in immune cell redistribution predicted recovery rate.

"Immune cell redistribution that is induced by the stress of undergoing surgery can predict (and may partially mediate) postoperative healing and recovery," the study authors write. "These findings may provide the basis for identifying patients (either prospectively or during surgery) who are likely to show good as opposed to poor recovery following surgery and for designing interventions that would maximize protective immune responses and enhance the rate and extent of recovery."

Limitations of this study include a lack of biological measurements at the surgical site, the correlational nature of the findings that are unable to prove causation, and an inability to determine the potential effects of the type of anesthetic agent and the depth of anesthesia on immune cell redistribution.

In an accompanying commentary and perspective, Martin I. Boyer, MD, MSc, FRCS(C), from Barnes-Jewish Hospital at Washington University, St. Louis, Missouri, called this an "important" and well-executed study.

"If the correlation of the rise and fall of circulating blood leukocytes were found to be not only correlative but causative (the temporal rise and fall of these white cells following surgery is the reason that the patient does well), then a more direct manipulation of the circulating white cells might be in order," Dr. Boyer writes.

"Could the preoperative use of relaxation therapy lower circulating leukocytes so that a better response is achieved? This seems far-fetched, although relaxation therapies, biofeedback, soothing music, and other modalities have been suggested as ways of enhancing patients' well-being during both the intraoperative and the healing periods," he added.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases supported this study. The study authors and Dr. Boyer have disclosed no relevant financial relationships.

J Bone Joint Surg Am. 2009;91:2783-2794. Abstract


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