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Effect of deep pressure input on parasympathetic system in patients with wisdom tooth surgery

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Background/purpose: Deep pressure input is used to normalize physiological arousal due to stress. Wisdom tooth surgery is an invasive dental procedure with high stress levels, and an alleviation strategy is rarely applied during extraction. In this study, we investigated the effects of deep pressure input on autonomic responses to wisdom tooth extraction in healthy adults. Methods: A randomized, controlled, crossover design was used for dental patients who were allocated to experimental and control groups that received treatment with or without deep pressure input, respectively. Autonomic indicators, namely the heart rate (HR), percentage of low-frequency (LF) HR variability (LF-HRV), percentage of high-frequency (HF) HRV (HF-HRV), and LF/HF HRV ratio (LF/HF-HRV), were assessed at the baseline, during wisdom tooth extraction, and in the posttreatment phase. Results: Wisdom tooth extraction caused significant autonomic parameter changes in both groups; however, differential response patterns were observed between the two groups. In particular, deep pressure input in the experimental group was associated with higher HF-HRV and lower LF/HF-HRV during extraction compared with those in the control group. Conclusion: LF/HF-HRV measurement revealed balanced sympathovagal activation in response to deep pressure application. The results suggest that the application of deep pressure alters the response of HF-HRV and facilitates maintaining sympathovagal balance during wisdom tooth extraction.
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ORIGINAL ARTICLE
Effect of deep pressure input on
parasympathetic system in patients with
wisdom tooth surgery
Hsin-Yung Chen
a,b
, Hsiang Yang
c
, Ling-Fu Meng
a,d
,
Pei-Ying Sarah Chan
a,e
, Chia-Yen Yang
f
, Hsin-Ming Chen
c,g,h,i,
*
a
Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of
Medicine, Chang Gung University, Taoyuan, Taiwan
b
Department of Neurology and Dementia Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
c
Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
d
Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, Chang Gung
Memorial Hospital, Chiayi, Taiwan
e
Department of Psychiatry, Chang Gung Memorial Hospital, Taoyuan, Taiwan
f
Department of Biomedical Engineering, Ming-Chuan University, Taoyuan, Taiwan
g
Department of Dentistry, National Taiwan University, Taipei, Taiwan
h
Graduate Institute of Clinical Dentistry, National Taiwan University, Taipei, Taiwan
i
Graduate Institute of Oral Biology, National Taiwan University, Taipei, Taiwan
Received 16 June 2016; received in revised form 7 July 2016; accepted 20 July 2016
KEYWORDS
anxiety;
dental fear;
stress;
supportive care
Background/Purpose: Deep pressure input is used to normalize physiological arousal due to
stress. Wisdom tooth surgery is an invasive dental procedure with high stress levels, and an
alleviation strategy is rarely applied during extraction. In this study, we investigated the ef-
fects of deep pressure input on autonomic responses to wisdom tooth extraction in healthy
adults.
Methods: A randomized, controlled, crossover design was used for dental patients who were
allocated to experimental and control groups that received treatment with or without deep
pressure input, respectively. Autonomic indicators, namely the heart rate (HR), percentage
of low-frequency (LF) HR variability (LF-HRV), percentage of high-frequency (HF) HRV (HF-
HRV), and LF/HF HRV ratio (LF/HF-HRV), were assessed at the baseline, during wisdom tooth
extraction, and in the posttreatment phase.
Results: Wisdom tooth extraction caused significant autonomic parameter changes in both
groups; however, differential response patterns were observed between the two groups. In
particular, deep pressure input in the experimental group was associated with higher HF-
Conflicts of interest: The authors have no conflicts of interest relevant to this article.
* Corresponding author. Department of Dentistry, National Taiwan University Hospital, Number 1, Changde Street, Zhongzheng District,
Taipei City 10048, Taiwan.
E-mail address: hmchen51@ntuh.gov.tw (H.-M. Chen).
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Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
http://dx.doi.org/10.1016/j.jfma.2016.07.008
0929-6646/Copyright ª2016, Formosan Medical Association. Published by ElsevierTaiwanLLC.Thisisanopenaccessarticleunderthe
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Available online at www.sciencedirect.com
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Journal of the Formosan Medical Association (2016) xx,1e7
HRV and lower LF/HF-HRV during extraction compared with those in the control group.
Conclusion: LF/HF-HRV measurement revealed balanced sympathovagal activation in response
to deep pressure application. The results suggest that the application of deep pressure alters
the response of HF-HRV and facilitates maintaining sympathovagal balance during wisdom
tooth extraction.
Copyright ª2016, Formosan Medical Association. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Introduction
Wisdom tooth extraction is one of the most common pro-
cedures associated with a high pain level, high stress, and
anxiety regarding applying local anesthesia, and using
invasive instruments.
1,2
These extraction procedures
commonly lead to unpleasant sensory experiences that may
complicate dental procedures,
1,3,4
resulting in inferior
postoperative recovery.
5
The sensory dimension of pain is
markedly suppressed by local anesthesia; however, reports
on anxiety have revealed that a complex combination of
cognitive, emotional, and affective factors causes wisdom
tooth extraction per se to be unique to the individual.
1,2
Therefore, stress and anxiety management during tooth
extraction is crucial for reducing risks and treating patients
with high anxiety, particularly those with special needs.
6,7
The autonomic nervous system (ANS) is crucial for the
adaptation to anxiety.
8,9
Heart rate variability (HRV) is typi-
cally used as an index to investigatethe central regulation and
modulation of autonomic functions.
10,11
The ANS, comprising
the sympathetic nervous system and parasympathetic ner-
vous system, conveys information regarding autonomic in-
fluences on the rate and rhythm of the heart.
8
Although the
HR levels are influenced by both sympathetic and para-
sympathetic activity, parasympathetic influences are perva-
sive over the frequency range of the HR frequency spectrum,
whereas sympathetic influences “roll-off” at approximately
0.15 Hz.
12,13
Therefore, the high-frequency (HF) component
(0.15e0.4 Hz) represents a marker primarily para-
sympathetic; influences with a low-frequency (LF) compo-
nent (0.04e0.15 Hz) represent a mixture of sympathetic and
parasympathetic autonomic influences;
11,13
and the LF/HF
HRV ratio (LF/HF-HRV) reflects a predominance of sympa-
thetic over parasympathetic balance.
10,11
The parameters of HF-HRV have been hypothesized to be
crucial in behavioral regulation and emotional adaptation
theoretically and empirically.
14e16
Increased HF-HRV
(vagally mediated) is associated with enhanced cognitive
performance, particularly with the capacity for self-
regulation, working memory, and psychological
flexibility,
17e19
whereas the relative reduction in HF-HRV is
associated with alterations in autonomic control over the
cardiac function of behavioral and emotional dysregula-
tion,
20,21
cognitive and behavioral inhibitory deficit,
15,20
and cognitive disorder.
20,22,23
Moreover, neuroimaging
studies have indicated positive correlations between HF-
HRV and the large number of cortical, subcortical, and
brainstem structures that coordinate autonomic func-
tion.
17,24,25
In the dental environment, reduced HF-HRV in
an attentional task indicates that the cognitive and
behavioral regulation function might not provide an
appropriate endogenous coping effect to alleviate anxiety
in people with dental anxiety.
3
Therefore, exogenous stress
management should be considered to be a supplement for
stress and anxiety management in tooth extraction.
Deep pressure input is a type of tactile pressure stimu-
lation exerted by firm touching, holding, stroking, hugging,
swaddling, and squeezing, and it is carried by the dorsal
column-medial lemniscal system to the somatosensory
cortex.
26e28
Various modes of deep pressure strategies
(e.g., weight blanket, weight vest, and papoose board)
have been reported to alleviate feelings of anxiety and
produce a calming effect.
28e30
Although physiological evi-
dence is relatively scarce, the application of deep pressure
input plays a role in ANS modulation under dental condi-
tions. A few studies have reported a positive increase in HF-
HRV, an indicator of emotion regulation, in dental prophy-
lactic treatment with sustained deep pressure input in
healthy individuals and patients with special needs;
31,32
however, the participants in these studies underwent
dental treatment without anesthetic procedures. Although
parasympathetic activity is increased, dental procedure-
induced pain is still confounded by deep pressure input in
psychological stress alleviation. Because local anesthesia is
essential for pain suppression, in vivo exposure to deep
pressure input during wisdom tooth extraction provides an
opportunity for clarifying the contribution of deep pressure
input through ANS response in behavioral adaptation for
stress management and a calming effect.
The aim of the present study was to evaluate theeffects of
deep pressure input exerted by a weight blanket during wis-
dom tooth extraction in healthy adults under local anes-
thesia. Frequency domain HRVanalysis in a relatively painless
dental procedure potentially leads to sympathetic and para-
sympathetic responses during the treatment. We hypothe-
sized that deep pressure input is an effective intervention
strategy for altering the parasympathetic response in tooth
extraction. In addition, the ANS modulation pattern during
tooth extraction was investigated based on the basis of the
LF/HF-HRV to verify the effect of deep pressure input.
Methods
Participants
Patients requiring wisdom tooth extraction were eligible to
be recruited in this single-blind, randomized, crossover
2 H.-Y. Chen et al.
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Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
control group investigation in the Division of Oral and
Maxillofacial Surgery, Department of Dentistry, National
Taiwan University Hospital (NTUH), Taipei, Taiwan. Patients
with any one of the following criteria were not included in
the study: (1) a history of systemic diseases that would
contraindicate surgical treatment; (2) being pregnant or
lactating, (3) smoking more than 10 cigarettes/d; (4) poor
overnight sleep quality; and (5) refusal to sign the informed
consent agreement. The participants signed the informed
consent forms and all the procedures were approved by the
Human Research Ethics Committee of NTUH. All surgeries
were performed under local anesthesia (4% articaine with
1:100,000 epinephrine) by the same oral surgeon using
similar techniques and sterilized surgical material. A buccal
mucoperiosteal flap was raised and protected using a Min-
nesota retractor (Hu-Friedy Co., Chicago, Illinois, USA).
Lingual flap retraction was performed only if necessary.
Sterile low-speed hand pieces and sterile distilled water
were used for osteotomy and crown sectioning. The wound
was closed with 3e0 silk postoperation.
Deep pressure apparatus
The deep pressure apparatus, a weighted blanket (WB),
was fabricated using smooth cotton fabric, 70 cm 150 cm,
to prevent annoying skin sensations (e.g., scratchy or
rough) as described previously.
31
The appropriate weight
load for participants was approximately 10% of the body
weight,
29,33
and it was adjusted to be distributed evenly
over the body of the participant from the axillaries to an-
kles. Only those in the experimental group received deep
pressure input during wisdom tooth extraction.
Experimental design and procedures
The testing was performed in the morning to prevent
physiological and physical fatigue in the participants. The
temperature of the recording environment was controlled
at 22 2.0C, and the relative humidity was maintained at
w40e50% to prevent artifacts in data acquisition.
Physiological measurements were acquired continually
with the participants in identical supine positions to reduce
posture effects throughout the treatment periods. Wisdom
tooth extraction was divided into two phases. First, data
acquisition in the baseline phase (T0) was performed with
the individual lying on the dental chair before the dental
treatment. Next, the treatment phase (Tx) of wisdom tooth
extraction began following local anesthesia administration,
and it proceeded with several pauses for rest if required.
Two equal treatment time slots for tooth extraction were
defined. In the treatment time slot (Tx1), both the control
and experimental participants received regular wisdom
tooth extraction. In the treatment time slot (Tx2), different
treatment conditions were designed for the control and
experimental groups. In Tx2, the control group underwent
sustained regular tooth extraction as in Tx1. Conversely,
the experimental group underwent sustained regular wis-
dom tooth extraction; however, an adjusted load of deep
pressure input was applied simultaneously in Tx2. In the
experimental group, Tx1 and Tx2 were sequenced randomly
to avoid the order effects of physiological measurement.
The shifting point between Tx1 and Tx2 was on a short
pause during the entire period of wisdom tooth extraction,
depending on the clinical estimation of its requirement.
Following wisdom tooth extraction, the individual remained
lying on the dental chair for data acquisition in the post-
treatment (PTx) phase.
HRV analysis
HR and HRV were determined using a monitor based on
photoplethysmography connected to a Bluetooth-based
telemetric bioamplifier (Nexus-10; Mind Media B.V.,
Roermond-Herten, The Netherlands) with a sampling rate
of 128 Hz and the Biotrace
þ
software (Mind Media B. V.,
Roermond-Herten, The Netherlands) for frequency domain
processing. The percentages of specific frequencies
comprised LF (0.04e0.15 Hz) and HF (0.15e0.4 Hz) com-
ponents of HRV across the entire spectrum, which were
used to indicate sympathetic nervous system and para-
sympathetic nervous system activation, respectively. The
LF/HF-HRV was calculated to yield a measure of sympa-
thetic/parasympathetic balance during tooth extraction.
Statistical analysis
The mean and standard deviation of the data from a de-
mographic survey were analyzed for all participants, and
the results were presented as descriptive statistics. Two-
way repeated measure analysis of variance (ANOVA) was
used to investigate the distinct phases and main effects of
HRV. All statistical tests were two-tailed, with the signifi-
cance level (a) being set at 0.05, and they were performed
using SPSS version 18.0 (SPSS Inc., Chicago, IL, USA).
Results
During recruitment, 60 participants were randomized to the
experimental and control groups. There was no significant
difference between the groups regarding personal charac-
teristics. The demographic characteristics are presented in
Table 1. The groups were similar at the baseline.
Results from two-way repeated measure ANOVA
revealed a significant effect and interaction effect
involving participant groups and treatment phases on HRV
indices. For HR, a significant effect was observed only
during tooth extraction (p<0.001, h
2
Z0.499). In HRV,
significant effects were observed for response in group (LF-
HRV: pZ0.005, h
2
Z0.127; HF-HRV: pZ0.01,
h
2
Z0.108; LF/HF-HRV: pZ0.002, h
2
Z0.152), phase
(LF-HRV: pZ0.030, h
2
Z0.056; HF-HRV: p<0.001,
h
2
Z0.143; LF/HF-HRV: p<0.001, h
2
Z0.154), and the
phase versus participant interaction (LF-HRV: pZ0.002,
h
2
Z0.094; HF-HRV: p<0.001, h
2
Z0.262; LF/HF-HRV:
p<0.001, h
2
Z0.339).
Figure 1A shows significant differences in HR among the
treatment phases. Intragroup data revealed that phases
with tooth extraction (Tx1 and Tx2) resulted in higher HR
for both the control (p<0.001) and experimental
(p<0.001) groups than the phases without tooth extraction
(T0 and PTx) did, indicating that wisdom tooth extraction is
the stressor to increase sympathetic activity. Moreover, no
Parasympathetic effect of deep pressure in tooth surgery 3
+MODEL
Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
significant difference was observed between the control
and experimental groups in all phases of the present study.
Intragroup data indicated significantly higher LF-HRV
only for the control group in T0 versus Tx1 (p<0.001) and
Tx1 versus Tx2 comparisons (p<0.001; Figure 1B). Inter-
group data showed significantly higher LF-HRV in the con-
trol group than in the experimental group only in Tx2
(p<0.001), indicating that applying a WB significantly
reduced LF-HRV in the experimental group during wisdom
tooth extraction.
For HF-HRV, Figure 1C illustrates significant intragroup
and intergroup differences in the control and experimental
groups. In the control group, HF-HRV was significantly lower
in Tx2 than in Tx1 (p<0.001). Conversely, HF-HRV was
significantly higher in Tx2 than in Tx1 in the experimental
group (p<0.001). Furthermore, intergroup data revealed
that HF-HRV was significantly higher in Tx2 in the experi-
mental group than in the control groups (p<0.001). The
results indicated that deep pressure input is associated
with higher HF-HRV in wisdom tooth extraction, even over a
sustained tooth extraction period.
In LF/HF-HRV, significant intragroup and intergroup dif-
ferences were observed (Figure 1D). In the control group,
LF/HF-HRV was significantly higher in Tx2 than in Tx1
(p<0.001), indicating that sustained tooth extraction was
accompanied by increasing LF-HRV and decreasing HF-HRV
in the control group. Furthermore, LF/HF-HRV was signifi-
cantly higher in PTx than in T0 (p<0.001), indicating that
the tooth extraction-induced effect on LF-HRV was pro-
longed to the post tooth extraction period in the control
group. In the experimental group, LF/HF-HRV was signifi-
cantly higher in Tx1 than in Tx2 (pZ0.001). The intergroup
data of the experimental group revealed that LF/HF-HRV
was significantly lower than that of the control group only
in Tx2 (p<0.001). The results indicated that the effect of
deep pressure is accompanied by decreasing LF-HRV and
increasing HF-HRV in tooth extraction, even in a phase with
a longer intervention period.
In summary, our data revealed that applying a WB alters
the autonomic response to wisdom tooth extraction by
maintaining LF-HRV, increasing HF-HRV, and reducing LF/
HF-HRV.
Discussion
This study investigated HRV in healthy adults undergoing
wisdom tooth extraction in response to deep pressure
input, to more clearly understand the interrelation of
sympathetic activity, parasympathetic activity, and ANS.
According to our review of relevant literature, this is the
first study investigating the effect of deep pressure stimu-
lation during wisdom tooth extraction. The results from the
present study revealed increased HF-HRV, particularly
during the application of deep pressure during wisdom
tooth extraction. These findings may indicate that deep
pressure input increases flexibility/regulation in para-
sympathetic activity and ANS modulation to alleviate the
stress experienced during tooth extraction.
HRV is a quantitative measure that has been used as a
marker to characterize autonomic influences (particularly
parasympathetic) on the heart, and it has been widely used
in understanding cardiac and emotional regulation and
their relative associations.
20,21,34
Negative emotions, such
as stress and fear, result in parasympathetic withdrawal
and sympathetic activity, as represented by a relative
decrease in HF-HRV associated with an HR increase.
Conversely, positive emotions, such as happiness and calm,
result in altered ANS activity, which is characterized by an
increase in HF-HRV associated with a decreasing HR.
17,35
Therefore, HRV is commonly used in investigating physio-
logical responses to stress and threats. The results of our
cardiac autonomic measurement are consistent with the
typical physiological response associated with negative
emotions experienced in wisdom tooth extraction (Tx1),
namely an increase in HR and a decrease in HF-HRV re-
sponses compared with the baseline phase,
21,35
in both the
control and experimental groups. Our results indicated that
tooth extraction induced psychological stress in the pa-
tients, even if local anesthesia was administered. By
contrast, alternative, typical, and physiological responses
associated with positive emotion significantly reduced HR
and increased HF-HRV, demonstrating the effect of
Table 1 Characteristics and autonomic response of the
study population.
Characteristics &
measures
Control
(nZ30)
Experimental
(nZ30)
p
Gender
(male/female)
15/15 12/18 0.60
Age 24.83 4.62 23.60 4.03 0.28
T0
HR 74.95 7.07 74.67 12.58 0.92
LF-HRV 43.53 8.74 43.89 13.33 0.90
HF-HRV 41.90 10.67 38.89 13.38 0.34
LF/HF-HRV 1.15 0.51 1.38 0.90 0.22
Tx1
HR 81.63 8.14 84.16 11.68 0.34
LF-HRV 46.21 7.72 45.41 7.16 0.68
HF-HRV 35.28 10.96 36.83 8.05 0.54
LF/HF-HRV 1.55 0.88 1.28 0.34 0.12
Tx2
HR 81.22 4.00 74.57 7.65 0.25
LF-HRV 54.20 4.47 48.40 11.86 <0.001
HF-HRV 23.44 3.92 35.07 12.16 <0.001
LF/HF-HRV 2.42 0.62 1.60 0.83 <0.001
PTx
HR 83.36 9.37 74.68 9.73 0.96
LF-HRV 42.90 6.22 43.96 9.04 0.11
HF-HRV 41.89 7.50 39.11 12.26 0.21
LF/HF-HRV 1.07 0.25 1.29 0.59 0.09
Data are presented as mean standard deviation.
HF-HRV Zpercentage of the high-frequency component of
heart rate variability; HR Zheart rate; LF/HF-HRV Zlow-
frequency to high-frequency heart rate variability ratio; LF-
HRV Zpercentage of the low-frequency component of heart
rate variability; PTx Zpost wisdom tooth extraction treatment
condition; T0 Zbaseline condition; Tx1 Zfirst treatment
phase, regular wisdom tooth extraction without deep pressure
input in both the experimental and control groups;
Tx2 Zsecond treatment phase, regular wisdom tooth extrac-
tion with deep pressure input in the experimental group and
without deep pressure input in the control group.
4 H.-Y. Chen et al.
+MODEL
Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
parasympathetic modulation in the patients in the experi-
mental group. The present findings provide some of the first
data clarifying the HF-HRV differences in dental procedure-
induced stress between patients receiving and those not
receiving deep pressure input.
It is axiomatic by biomedical definition that the ANS
contributes to maintenance of homeostasis and proper
functioning of the body. Significant correlations were
observed between the neural activity of brain regions, such
as the anterior cingulate cortex (ACC), insula, amygdala,
and hippocampus, and the parasympathetically linked HF-
HRV.
13,15,36
According to neuroimaging observations, the
areas of the ACC are involved predominantly in cognitive
and emotional processes.
36
Dorsal ACC activation is related
to cognitive interference tasks, and a study emphasized its
role in mediating cognitive processes such as error pro-
cessing and response inhibition.
24
Therefore, increased
dorsal ACC activation is related to response inhibition,
affirming its role in processing cognitive information.
Contrary to the dorsal ACC, neuroimaging studies have
indicated a positive correlation between HF-HRV and
ventral ACC activation, which provides evidence of the role
of the ventral ACC in parasympathetic nervous system
modulation.
13,24
In association with neural modulation, this
suggests that enhanced AAC activity may be associated with
a reduction in stress-related responses and increased car-
diovagal activity under stress. In the present study, deep
pressure input resulted in increasing HF-HRV during wisdom
tooth extraction, which might reflect the contributions of
specific brain regions in stress modulation.
The WB is an apparatus that provides deep pressure
input by evenly distributing the load on the torso of the
individual. Our results demonstrated significantly higher
HF-HRV in the experimental group than in the control
group. This result is consistent with previous deep pressure
studies, which have reported that deep pressure input al-
leviates feelings of anxiety and produces a calming effect
through the influence of parasympathetic activity in clinical
Figure 1 Comparison of heart rate variability parameters between the control and experimental groups during wisdom tooth
extraction at the baseline (T0), in the first treatment phase (Tx1) for both the control and experimental groups, in the second
treatment phase (Tx2) with deep pressure input in the experimental group and without deep pressure input in the control group,
and during posttreatment (PTx). Error bars depict the standard deviation of the mean. Significance according to two-way repeated
measurement ANOVA with group and phase entered as within-individual variables and phase and group entered as between-
individual variables. bpm Zbeats per minute; Ctrl Zcontrol; Exp Zexperimental; HF-HRV Zpercentage of high-frequency
component; HR Zheart rate; LF/HF-HRV Zlow-frequency component to high-frequency heart rate; LF-HRV Zpercentage of
low-frequency component.
Parasympathetic effect of deep pressure in tooth surgery 5
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Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
practice.
31,32,37
The use of a WB, having the same con-
duction pathways as deep pressure massage does, may
provide its benefits by shifting the ANS from a state of
sympathetic response to a state of parasympathetic
response.
29,38
Studies have postulated that, when the
pressure receptors beneath the skin are stimulated, the
vagal tone increases and the cortisol and skin conductance
level decrease.
29,37,39
Therefore, deep pressure input is
suggested to lead to homeostasis, which results in
improving arousal modulation that is consistent with a state
of calmness.
38
In the present study, we observed that
higher HF-HRV, the index of inhibitory function, resulting
from deep pressure input, is associated with enhanced
behavioral regulation and modulation of calming processes,
inducing stress management in wisdom tooth extraction.
17
When accompanied by increased HF-HRV, ascending in-
puts from deep pressure input might function in association
with the brain areas having functional neurovisceral activ-
ity. Although the mechanism of deep pressure input in
increasing HF-HRV is still unclear, cortical interaction be-
tween deep pressure input and brain areas with neuro-
visceral activity is believed to be critical in the processes of
ANS modulation in wisdom tooth extraction.
In conclusion, this study investigated the physiological
correlations of HF-HRV with the application of deep pres-
sure input under stress during wisdom tooth extraction. We
observed substantial consistence between the main effect
of deep pressure input and its correlation with ANS modu-
lation, particularly in HF-HRV. The type of physiological
measures in HRV is a feasible strategy for objectively
assessing ANS responses. Our findings provide empirical
evidence that deep pressure input can influence autonomic
arousal through enhancement of parasympathetic activa-
tion during stress, such as that induced by wisdom tooth
extraction. Our results further suggest that deep pressure
input may be an appropriate therapeutic modality for use in
people with special needs with arousal regulation during or
in preparation for stress conditions, such as wisdom tooth
extraction and regular dental procedures. Future studies
are necessary to further investigate its underlying mecha-
nism and correlation with ANS modulation for application in
clinical practice.
Acknowledgments
The authors acknowledge the support provided by grants
from the Ministry of Science and Technology (NSC 102-2320-
B-182-032) and Chang Gung Memorial Hospital (BMRPA70,
CMRPD1B0332, and CMRPD1A0023), Taiwan. Moreover, the
authors thank the dental patients who participated in this
study.
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Parasympathetic effect of deep pressure in tooth surgery 7
+MODEL
Please cite this article in press as: Chen H-Y, et al., Effect of deep pressure input on parasympathetic system in patients with wisdom
tooth surgery, Journal of the Formosan Medical Association (2016), http://dx.doi.org/10.1016/j.jfma.2016.07.008
... Mullen et al. had found no notable link between EDA and weighted blanket use; however, Champagne et al. determined the use of weighted blankets to be 33% more effective in lowering EDA. Chen et al. (2016) examined the use of weighted blankets for anxiety in 60 healthy adults undergoing wisdom tooth surgery. Blanket weights were calculated at 10% of participants' weight. ...
... Results of this study showed an increase in HF HRV, demonstrating activated balanced sympathovagal responses, with weighted blanket use during wisdom tooth surgery. This finding indicates that DPS can increase the flexibility in and regulation of parasympathetic activity and autonomic nervous system modulation, which are associated with enhanced behavioral regulation and calming processes (Chen et al., 2013(Chen et al., , 2016. Losinski et al. (2017) compared the effects of two types of DPS (compression vest and 6-lb weighted blanket) with that of antecedent exercise (riding a stationary bike) on stereotypical behaviors (e.g., hand flapping, echolalia, blinking, moving fingers in front of the eyes, and rocking) of 3 students with autism spectrum disorder because stereotypical behaviors are thought to be a result of increased arousal or anxiety. ...
... Limitations of these studies include narrow sampling methodology and small sample sizes, with the largest study having only 60 participants (Chen et al., 2016). One study was limited to only women (Chen et al., 2013) and 1 study to only boys (Losinski et al., 2017). ...
Article
Importance: Sensory integration modalities, such as weighted blankets, are used in occupational therapy practice to assist with emotional and physical regulation. However, the research related to the use and effectiveness of weighted blankets is sparse. Objective: To identify, evaluate, and synthesize the current literature to help develop the impetus needed to launch a research study into the effectiveness of using weighted blankets to decrease anxiety and insomnia. Data sources: A literature search was conducted between January 23, 2018, and March 1, 2018. Databases and sites included the Cochrane Library, PubMed, PsycINFO, CINAHL, OTseeker, Web of Science, and Nursing Reference Center Plus. Search terms included weighted blanket, deep pressure, and occupational therapy as well as combinations of these terms. Study selection and data collection: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were included if the study used weighted blankets as the modality of deep pressure stimulation. Data from presentations, conference proceedings, non-peer-reviewed literature, dissertations, and theses were excluded. Findings: Only 8 studies were included: 4 Level I, 2 Level III, and 2 Level IV studies. The outcomes of these studies suggest that weighted blankets have the potential to be beneficial in limited settings and populations. Conclusion and relevance: Weighted blankets may be an appropriate therapeutic tool in reducing anxiety; however, there is not enough evidence to suggest they are helpful with insomnia. What this article adds: Evidence-based research on the effectiveness of weighted blankets in reducing anxiety and insomnia is sparse. More research is needed to define guidelines for the use of weighted blankets in clinical practice and to investigate the underlying mechanism of action. This systematic review can be used to begin an investigation of the use of weighted blankets for larger and more diverse populations.
... Research demonstrates that broad, deep pressure touch stimulation increases the arousal of the parasympathetic nervous system, while also reducing sympathetic arousal (Chen et al., 2016;Reynolds et al., 2015). The increase in parasympathetic arousal is hypothesized to have a calming effect, while the decrease in sympathetic arousal is associated with changes in physiological processes that dampen the body's physiologic stress response (Chen et al., 2016;Mullen et al., 2008;Reynolds et al., 2015). ...
... Research demonstrates that broad, deep pressure touch stimulation increases the arousal of the parasympathetic nervous system, while also reducing sympathetic arousal (Chen et al., 2016;Reynolds et al., 2015). The increase in parasympathetic arousal is hypothesized to have a calming effect, while the decrease in sympathetic arousal is associated with changes in physiological processes that dampen the body's physiologic stress response (Chen et al., 2016;Mullen et al., 2008;Reynolds et al., 2015). Daily use of weighted blankets has shown reductions in stress-related psychologic and physiologic symptoms among non-cognitively impaired older adults with mental health conditions (Champagne et al., 2015;Mullen et al., 2008). ...
... Stress induced chronic inflammation is proposed to play an important role in the development of depression, anxiety and ADRD (Bisht et al., 2018;Dafsari & Jessen, 2020;Hermida et al., 2012;Salim et al., 2012), which explains the association between physiologic stress-related chronic inflammatory diseases, such as cardiovascular diseases with ADRD (Cunningham & Hennessy, 2015;Newman et al., 2005). Prior research supports that acutherapy and deep pressure therapies have anti-inflammatory effects at the cellular level (Chen et al., 2016;Kavoussi & Ross, 2007;McDonald et al., 2015), which is the hypothesized mechanism by which sensory stimulation therapies affects symptoms experienced by non-cognitively impaired individuals with depression and anxiety (Lu et al., 2016;Pilkington, 2013;Sun et al., 2010). ...
Thesis
People living with dementia (PLWD) often experience behavioral and psychological symptoms of dementia (BPSD) which are burdensome to those diagnosed, their families, and society. Many non-pharmacologic interventions have demonstrated efficacy in reducing BPSD in research but have had limited uptake in the community, possibly due to lack of feasibility and limited acceptance by PLWD and their family caregivers. Acutherapy and weighted blankets are non-pharmacologic interventions that have improved outcomes among older adults, but few studies have focused on PLWD and BPSD. The purpose of this research was to explore the potential of acutherapy and weighted blankets as non-pharmacologic interventions to reduce BPSD in PLWD. The research presented in this 3-paper dissertation was guided by 6 specific aims: 1. Identify, examine, and synthesize the state of the science relating to the effects of acutherapy on BPSD. (Paper 1) 2. Explore perspectives of family caregivers of community dwelling older adults with Alzheimer’s disease or related dementias (ADRD) regarding BPSD and use of non-pharmacologic interventions for BPSD management. (Paper 2) 3. Explore perspectives of family caregivers of community dwelling older adult family members with ADRD regarding changes in their caregiving experiences, BPSD displayed by their relatives with ADRD and BPSD management strategies used during the COVID-19 pandemic. (Paper 2) 4. Explore initial perceptions of family caregivers regarding weighted blankets as an in-home care strategy for community dwelling PLWD following a brief description and visual presentation of weighted blankets. (Paper 3) 5. Examine feasibility and acceptability of a virtually delivered, in-home weighted blanket intervention for older adults with ADRD living in the community as perceived by the family caregiver and the person with ADRD. (Paper 3) 6. Examine feasibility of collecting outcome measures of BPSD, cognitive function, and quality of life of care recipients with ADRD, and well-being and self-reported health status of family caregivers. (Paper 3) Aims were addressed using: a scoping review methodology (Aim 1); a qualitative approach using semi-structured interviews with 21 family caregivers living with community dwelling PLWD (Aims 2, 3, and 4); a prospective, within subjects, pre-post design study with 21 community dwelling PLWD and their family caregivers (Aims 5 and 6). This dissertation research had 6 key findings: 1) Acutherapy is a safe non-pharmacologic care strategy for PLWD and a potential treatment for BPSD, but additional research is needed to determine efficacy; 2) The caregiving experience of family caregivers of community dwelling PLWD was described as an interdependent partnership between the caregiver and the PLWD; 3) Family caregivers and PLWD experienced challenges to in-home care prior to the COVID-19 pandemic, many of which were compounded by it; 4) The virtually delivered, in-home weighted blanket intervention was feasible and acceptable to PLWD and their family caregivers; 5) Collecting outcome measures of care recipient cognitive function, caregiver well-being and caregiver self-reported health was feasible; 6) Collecting outcome measures of care recipient BPSD and quality of life was feasible through measures completed by caregiver report, but not by care recipient self-report. The efficacy of feasible and acceptable care strategies for community dwelling PLWD must be determined to promote broader uptake by clinicians, support service providers, and families. As BPSD are overwhelming for PLWD, their families, and society, we are in dire need of evidence-based non-pharmacological interventions to reduce the burden and improve the quality of life of PLWD and their families.
... The results of these treatments showed that the use of a pressure vest can affect the activity of the autonomic system and provide a calming effect on the participants [32]. The calming effect and anxiety reduction were shown in the provision of deep pressure treatment in the form of a weighted blanket under wisdom tooth extraction [33] and third molar extraction conditions [34]. ...
... The comfort obtained in group I was provided by a wider pressure surface using the AHMPS inflatable wrap than the manual pull model [35,36]. This supports the findings from the previous study regarding the use of the deep pressure method for the treatment of children with ASD that yielded positive results from its application [28][29][30][31][32][33][34], especially in the context of traveling purposes [35,36]. ...
Article
Full-text available
Traveling with children with autism can be very challenging for parents due to their reactions to sensory stimuli resulting in behavioral problems, which lead to self-injury and danger for themselves and others. Deep pressure was reported to have a calming effect on people with autism. This study was designed to investigate the physiological effect of deep pressure, which is an autism hug machine portable seat (AHMPS) in children with autism spectrum disorders (ASD) in public transportation settings. The study was conducted with 20 children with ASD (16 boys and 4 girls) at the Semarang Public Special School with an age ranging from 4 to 13 years (mean 10.9 ± 2.26 years), who were randomly assigned into two groups. The experiment consisted of group I who used the AHMPS inflatable wraps model and group II who used the AHMPS manual pull model. Heart rate (HR) and skin conductance (SC) were analyzed to measure the physiological calming effect using pulse oximeter oximetry and a galvanic skin response (GSR) sensor. Heart rate was significantly decreased during the treatment compared to the baseline (pre-test) session in group I (inflating wrap model) with p = 0.019, while no change of heart rate variability (HRV) was found in group II (manual pull model) with p = 0.111. There was no remaining effect of deep pressure using the HRV indicator after the treatment in both groups (group I with p = 0.159 and group II with p = 0.566). GSR captured the significant decrease in skin conductance during the treatment with p < 0.0001 in group I, but no significant decrease was recorded in group II with p = 0.062. A skin conductance indicator captured the remaining effect of deep pressure (after the treatment); it was better in group I (p = 0.003) than in group II (p = 0.773). In conclusion, the deep pressure of the AHMPS inflating wrap decreases physiological arousal in children with ASD during traveling.
... A weighted blanket can also affect depressive symptoms, which are alleviated in connection with sleep problems and vice versa [17]. The weighted blanket is considered to dampen the nervous system's stress system via its deep pressure, which may be the reason for the calming effect that improves sleep for older people [35,72,73]. However, some studies do not support this finding regarding improved sleep. ...
Article
Full-text available
Background: An increasingly aging population is a global phenomenon. While considered a positive step forward, vulnerability to age-related health problems increases along with the ageing population. The aim of the study was to investigate weighted blankets' effect on health regarding quality of life (QoL), sleep, nutrition, cognition, activities of daily living ADL and medication in older people living in nursing homes. Methods: In total, 110 older people were involved in an intervention with weighted blankets, and 68 older people completed the intervention. Measures before and after were performed regarding quality of life; QoL-AD, EQ-VAS, sleep; MISS, nutrition; MNA, cognition; S -MMSE (ADL) and medication. Comparative statistical analyses were applied. Results: After intervention with weighted blankets, health in general, such as QoL, improved. Sleep also improved significantly, especially with respect to waking up during the night. Nutrition was enhanced, health as a cognitive ability improved, and medication in the psychoanaleptic group decreased. The effect size varied between small and large. Conclusions: A weighted blanket seems to be an effective and safe intervention for older people in nursing homes, as several improvements were made regarding the health of older people.
... The utilization of other sensory-based interventions during dental care has been investigated, with most reporting preliminary success. For example, aromatherapy was found to have a calming effect for children during dental care and adults in the dental office waiting room [271][272][273][274][275]. Heart rate and physiological anxiety were reduced during dental treatments when using a weighted blanket for deep pressure sensations [276][277][278]. Lastly, a sensory adapted dental environment, designed to decrease noxious stimuli and increase calming stimuli, decreased physiological and behavioral distress in typically developing children and those with disabilities [44, [279][280][281][282][283]; this intervention is now included in the American Academy of Pediatric Dentistry's [284] list of best practices as a potential basic behavior guidance technique for use with dental patients with anxiety or special healthcare needs. ...
Article
Full-text available
Dental fear and anxiety (DFA) is common across the lifespan and represents a barrier to proper oral health behaviors and outcomes. The aim of this study is to present a conceptual model of the relationships between DFA, general anxiety/fear, sensory over-responsivity (SOR), and/or oral health behaviors and outcomes. Two rounds of literature searches were performed using the PubMed database. Included articles examined DFA, general anxiety/fear, SOR, catastrophizing, and/or oral health behaviors and outcomes in typically developing populations across the lifespan. The relationships between the constructs were recorded and organized into a conceptual model. A total of 188 articles were included. The results provided supporting evidence for relationships between DFA and all other constructs included in the model (general anxiety/fear, SOR, poor oral health, irregular dental attendance, dental behavior management problems [DBMP], and need for treatment with pharmacological methods). Additionally, SOR was associated with general anxiety/fear and DBMP; general anxiety/fear was linked to poor oral health, irregular attendance, and DBMP. This model provides a comprehensive view of the relationships between person factors (e.g., general anxiety/fear, SOR, and DFA) and oral health behaviors and outcomes. This is valuable in order to highlight connections between constructs that may be targeted in the development of new interventions to improve oral health behaviors and outcomes as well as the experience of DFA.
... Furthermore, a case series of 30 psychiatric in-patients using a similar experimental setup, showed comparable results with no adverse physiological responses and no increase in anxiety, albeit, when comparing WB to no blanket, both reduced anxiety to a similar degree [5]. A more acute stress response during tooth extraction may be ameliorated by WB as shown by more stable heart rate variability in a randomized-controlled trial [7]. ...
Article
Full-text available
Objective To measure rate of subscription of common sleep medication and diagnoses of substance use disorder (SUD) before and after receiving a prescribed weighted blanket (WB) among patients with psychiatric diagnoses. Materials and methods Using register-based data of health-related factors in a Swedish region, a total of 1785 adult individuals with a psychiatric diagnosis, received a WB and resided in the region during the study period were identified. Using each individual as their own control, the rate of one-year prior prescription of WB or diagnosed SUD was compared to rate after a half year wash-out after prescription of WB for a full year. Results The number of patients without prescription of sleep medication increased by 3.3% (95% confidence interval (95%CI): 0.2–6.4, p=.04). Furthermore, the proportion without a prescription of benzodiazepine receptor agonist/antihistamines sleep medication increased by 5.5% (95%CI: 2.2–8.8, p=.001). Melatonin prescription increased after WB by 3.6% (95%CI: 1.1–6.2, p=.006). Younger age and unipolar-, anxiety-, attention-deficit/hyperactivity-, and post-traumatic stress disorder was associated with decreased use while psychotic-/bipolar- and personality disorder was not associated with a decrease in the use of sleep medication. The number of alcohol SUD diagnoses did not increase while sedative SUD rate increased statistically significantly by 0.7% (odds ratio = 1.63, p=.02). In a multivariate model, only younger age predicted discontinuation of sleep medication while psychotic-/bipolar- and personality disorder had statistically less decrease. Conclusion This observational register study found a statistically significant association between WB use and decreased use of common sleep medication except melatonin that increased slightly.
... There is evidence suggesting that deep pressure stimulation increases parasympathetic arousal of the autonomic nervous system at the same time reducing sympathetic arousal, which is considered to be the cause of the calming effect. 20,21 Also, the deep pressure on the body increases levels of oxytocin, which has a central role in relaxation and sleep. Oxytocin may produce anxiolytic-like or sedative effects and an increased pain threshold. ...
Article
Study objectives: This study aimed to evaluate the effect of weighted chain blankets on insomnia and sleep-related daytime symptoms for patients with major depressive disorder, bipolar disorder, generalized anxiety disorder (GAD) and attention deficit hyperactivity disorder (ADHD). Methods: One hundred twenty patients were randomized (1:1) to either a weighted metal chain blanket or a light plastic chain blanket for four weeks. The outcome was evaluated using the Insomnia Severity Index (ISI) as primary outcome measure and the Day and Night Diaries (DND), Fatigue Symptom Inventory (FSI), and Hospital Anxiety and Depression Scale (HADS) as secondary outcome measures. Sleep and daytime activity levels were evaluated by wrist actigraphy. Results: At four weeks, there was a significant advantage in ISI-ratings of the weighted blanket intervention over the light blanket (p<0.001) with a large effect size (Cohen´s d 1.90). The intervention by the weighted blanket resulted in a significantly better sleep-maintenance, a higher daytime activity level and reduced daytime symptoms of fatigue, depression and anxiety. No serious adverse events occurred. During a 12 months open follow up phase of the study, participants continuing using weighted blankets maintained the effect on sleep, while patients switching from a light to a weighted blanket got a similar effect on ISI-ratings as participants using the weighted blanket from the beginning. Conclusions: We conclude that weighted chain blankets are an effective and safe intervention for insomnia in patients with Major depressive disorder, Bipolar disorder, Generalized Anxiety Disorder, or ADHD, also improving daytime symptoms and levels of activity.
... ohkushi et al. 20 evaluated differences between propofol and sevoflurane, they showed how propofol may be more suitable for dental treatment. chen et al. 21 evaluated the use of a deep pressure dispositive on parasympathetic system on patients undergoing dental surgery. results of this study suggested that the application of deep pressure facilitates maintaining of sympathovagal balance during surgery. ...
Article
Introduction: The management of anxiety and fear of patients experiencing medical treatment is always a major issue. Dentistry is a branch of medicine that is daily in managing these problems, especially in the case of pediatric patients. Odontophobia can be managed in different ways, and the purpose of this study is to eventually review which methods are currently accepted and which are the most effective. Evidence acquisition: The literature analysis was conducted on a number of articles, suitably skimmed, after a first research, obtained from the most common scientific databases. The number of works included in the review is 28. Evidence synthesis: From the RCTs evaluated we could highlight that there are different methods in the literature, equally effective and certainly conditioned by the systemic condition of the patient. Another chapter instead turns out to be that linked to the management of the syndromic patient. Conclusions: It is clear that there are different methods and equally different ways to manage our patients in the event of non-cooperation in the case of dental care. In addition to proper management by the clinician, in the literature methods linked to audiovisual distractions, hypnosis or pharmacological methods that produce conscious sedation are effectively reported.
Article
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Accumulating evidence linking pain with both attachment and sensory processing variables introduces the possibility that attachment- and sensory-informed strategies may modify pain experiences. The aim of this study was to investigate this proposition using an experimentally induced pain procedure. Pain perceptions of individuals using either a sensory-informed (weighted modality) or an attachment-informed (secure base priming) coping strategy were compared with those of individuals using no designated coping strategy. An independent measures experimental study design was used with a convenience sample of 272 pain-free adults. Experimental participants (n = 156) were randomly allocated to either an attachment (n = 75) or a sensory (n = 81) intervention group. Data from these participants were compared to those of 116 participants involved in an earlier cold pressor study in which no coping strategy was used. All participants completed the same sensory, attachment, and distress questionnaires and participated in the same cold pressor pain test. ANCOVAs revealed that participants in the sensory- and attachment-informed intervention groups reported significantly higher pain thresholds than the control group. Participants allocated to the sensory group also reported higher pain intensity scores than the control group. There were no significant differences in pain tolerance between the three groups after controlling for covariates. While further research is required, findings encourage further consideration of sensory- and attachment-informed strategies for people anticipating a painful experience.
Article
Background: Weighted blankets have been used as a deep touch pressure (DTP) tool to alleviate anxiety in many patient populations. Patients with cancer can experience anxiety related to diagnosis and treatments, such as chemotherapy infusions. Research on the effectiveness of weighted blankets as a DTP tool to alleviate anxiety in patients receiving chemotherapy is limited. Objectives: This study assessed the effectiveness of a medical-grade therapeutic weighted blanket on anxiety in patients receiving their first and second chemotherapy infusions at an outpatient infusion center. Methods: A randomized controlled trial with a crossover design was performed with new patients in the outpatient chemotherapy infusion center. Patients were randomized to one of two study arms (given the weighted blanket during their first infusion or given the weighted blanket during their second infusion). Anxiety was measured using an anxiety inventory and a visual analog scale. Findings: Anxiety was reduced among patients receiving chemotherapy when the weighted blanket was used. Based on the results, a standard-weight, medical-grade therapeutic weighted blanket can be safely used to reduce anxiety in patients of various weights, and a visual analog scale can be a reliable indicator of patients' state anxiety.
Article
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Heart rate variability (HRV) refers to various methods of assessing the beat-to-beat variation in the heart over time, in order to draw inference on the outflow of the autonomic nervous system. Easy access to measuring HRV has led to a plethora of studies within emotion science and psychology assessing autonomic regulation, but significant caveats exist due to the complicated nature of HRV. Firstly, both breathing and blood pressure regulation have their own relationship to social, emotional, and cognitive experiments – if this is the case are we observing heart rate (HR) changes as a consequence of breathing changes? Secondly, experiments often have poor internal and external controls. In this review we highlight the interrelationships between HR and respiration, as well as presenting recommendations for researchers to use when collecting data for HRV assessment. Namely, we highlight the superior utility of within-subjects designs along with the importance of establishing an appropriate baseline and monitoring respiration.
Article
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Background/Purpose Anxiety induced by dental treatment can become a serious problem, especially for patients with special needs. Application of deep touch pressure, which is a sensory adaptation technique, may ameliorate anxiety in disabled patients. However, few empiric studies have investigated the possible links between the clinical effects of deep touch pressure and its behavioral and physiologic aspects. Equally little progress has been made concerning theoretical development. The current study is a crossover intervention trial to investigate the behavioral and physiological effects of deep touch pressure for participants receiving dental treatment. Methods Nineteen disabled participants, who were retrospectively subclassified for positive trend or negative trend, were recruited to receive the papoose board as an application of deep touch pressure. Quantitative analyses of behavioral assessments and physiological measurements, including electrodermal activity and heart rate variability, were conducted. We sought to understand the modulation of the autonomic nervous system and the orchestration of sympathetic and parasympathetic (PsNS) nervous systems. Results Behavioral assessments reported that higher levels of anxiety were induced by the dental treatment for participants with both groups of positive and negative trends. Although no significant differences were found in the SNS activity, physiologic responses indicated that significantly changes of PsNS activity were observed under the stress condition (dental treatment) when deep touch pressure intervention was applied, especially for participants in the group of positive trend. Conclusion Our results suggest that the PsNS activation plays a critical role in the process of ANS modulation. This study provides not only physiologic evidence for the modulation effects of deep touch pressure on stressful conditions in dental environments but also the evidence that the application of papoose board, as a sensory adaptation technique, is not harmful for dental patients with special needs.
Article
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This paper presents the results of a concurrent, nested, mixed methods exploratory study on the safety and effectiveness of the use of a 30 lb weighted blanket with a convenience sample of 32 adults. Safety is investigated measuring blood pressure, pulse rate, and pulse oximetry, and effectiveness by electrodermal activity (EDA), the State Trait Anxiety Inventory-10 and an exit survey. The results reveal that the use of the 30 lb weighted blanket, in the lying down position, is safe as evidenced by the vital sign metrics. Data obtained on effectiveness reveal 33% demonstrated lowering in EDA when using the weighted blanket, 63% reported lower anxiety after use, and 78% preferred the weighted blanket as a calming modality. The results of this study will be used to form the basis for subsequent research on the therapeutic influence of the weighted blanket with adults during an acute inpatient mental health admission.
Article
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Aims: Previous studies have shown that heart rate variability (HRV) measurement is useful in investigating the pathophysiology of various psychiatric disorders. The present study further examined its usefulness in evaluating the mental health of normal subjects with respect to anxiety and depressiveness. Methods: Heart rate (HR) and HRV were measured tonometrically at the wrist in 43 normal subjects not only in the resting condition but also during a task (random number generation) to assess the responsiveness. For HRV measurement, high-frequency (HF; 0.15-0.4 Hz) and low-frequency (LF; 0.04-0.15 Hz) components of HRV were obtained using MemCalc, a time series analysis technique that combines a non-linear least square method with maximum entropy method. For psychological evaluation of anxiety and depressiveness, two self-report questionnaires were used: State-Trait Anxiety Inventory (STAI) and Self-Rating Depression Scale (SDS). Results: No significant relation was observed between HR and HRV indices, and the psychological scores both in the resting and task conditions. By task application, HF decreased, and LF/HF and HR increased, and significant correlation with psychological scores was found in the responsiveness to task measured by the ratio of HRV and HR indices during the task to that at rest (task/rest ratio). A positive relationship was found between task/rest ratio for HF, and STAI and SDS scores. Task/rest ratio of HR was negatively correlated with STAI-state score. Conclusion: Decreased HRV response to task application is related to anxiety and depressiveness. Decreased autonomic responsiveness could serve as a sign of psychological dysfunction.
Article
The application of deep touch pressure (DTP) has been suggested to provide positive effects on anxiety modulation. However, empirical and theoretical evidence linked to the clinical effects of DTP are relatively rare. This study conducts a quantitative analysis of behavioral assessments and performs physiological measurements, including those of electrodermal activity and heart rate variability, to understand the modulation of the autonomic nervous system (ANS), and the orchestration of sympathetic (SNS) and parasympathetic nervous systems (PsNS). The results suggest that the activation of PsNS plays a critical role in ANS modulation. This study provides physiological evidence to support the positive clinical effects of DTP for reducing anxiety in dental environments.
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Deep pressure stimulation has been used in therapeutic practice because of the assumption that it changes physiological arousal. The purpose of this study was to test the effects of deep pressure stimulation, applied with a Vayu Vest (Therapeutic Systems), on both autonomic arousal and performance in a normative adult sample. A repeated-measures, repeated-baseline design was used with participants completing a performance test before and after deep pressure application. A convenience sample of 50 adults participated in the study. Results showed that wearing the Vayu Vest for even short periods of time reduced sympathetic arousal and non-stimulus-driven electrical occurrences. Concomitant increases in parasympathetic arousal were found. Performance improvements were noted after wearing the Vayu Vest, potentially because of changes in arousal. We conclude that deep pressure stimulation is capable of eliciting changes in autonomic arousal and may be a useful modality in diagnostic groups seen by occupational therapy practitioners. Copyright © 2015 by the American Occupational Therapy Association, Inc.
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The anterior cingulate cortex (ACC) has diverse functions and several functional subdivisions. This study implemented a counting Stroop task that presented incongruent (INC) and congruent (CON) stimuli at two speeds to probe dorsal (dACC) and ventral (vACC) using functional magnetic resonance imaging (fMRI). Eighteen healthy subjects completed the task twice: once outside the scanner while heart rate variability (HRV) was recorded and once during fMRI. In both sessions, subjects completed two runs. Stimuli were presented every 2.0 s in one run and every 1.5 s in the other. fMRI data analysis revealed two important findings. First, by computing differential activation between INC and CON stimuli, a cluster of activation related to response inhibition was observed in the left dACC. Additionally, by calculating the interaction of speed with stimulus congruency, a cluster of activation was observed in the left vACC. This activation correlated significantly with high-frequency HRV (P < 0.02 for CON and P < 0.003 for INC) and represents the parasympathetic modulatory role of the vACC. This study supports the notion of functional subdivisions within the ACC and links the processes of cognitive interference and parasympathetic modulation with activation in specific subregions of the ACC, a structure that is critical for the interface between cognition and emotion.
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Encountering patients who are fearful and anxious is common in dental practice and these factors can increase the complexity of dental procedures. A prospective cohort study was performed to assess whether patient anxiety influences the difficulty of impacted lower third molar extraction and to identify other predictive factors of surgical difficulty; 102 extractions done under local anaesthesia were assessed. Several preoperative variables were recorded (demographic, anatomical, and surgical) and patient anxiety was assessed through the use of various questionnaires. Extraction difficulty was measured using the operation time (OT) and a 100-mm visual analogue scale (difficulty VAS) completed by the surgeon. Patients with deep impacted third molars that required bone removal and tooth sectioning showed higher levels of preoperative anxiety. Significant correlations were found between questionnaire scores and the surgical difficulty (OT and difficulty VAS). OT was also related to age, depth of impaction, third molar angulations, proximity of the third molar roots to the mandibular canal, hard and soft tissue coverage, and the need to perform an ostectomy and tooth sectioning. Impacted lower third molar extraction is significantly more difficult in anxious patients. Other demographic, radiological, and surgical factors were also found to be significantly related to the surgical difficulty.
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Here we review our recent body of work on the impact of the mood and comorbid anxiety disorders, alcohol dependence, and their treatments on heart rate variability (HRV), a psychophysiological marker of mental and physical wellbeing. We have shown that otherwise healthy, unmedicated patients with these disorders display reduced resting-state HRV, and that pharmacological treatments do not ameliorate these reductions. Other studies highlight that tricyclic medications and the serotonin and noradrenaline reuptake inhibitors in particular may have adverse cardiovascular consequences. Reduced HRV has important functional significance for motivation to engage social situations, social approach behaviours, self-regulation and psychological flexibility in the face of stressors. Over the longer-term, reduced HRV leads to immune dysfunction and inflammation, cardiovascular disease and mortality, attributable to the downstream effects of a poorly functioning cholinergic anti-inflammatory reflex. We place our research in the context of the broader literature base and propose a working model for the effects of the mood disorders, comorbid conditions, and their treatments to help guide future research activities. Further research is urgently needed on the long-term effects of autonomic dysregulation in otherwise healthy psychiatric patients, and appropriate interventions to halt the progression of a host of conditions associated with morbidity and mortality.
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The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model. Specifically we review recent neuroanatomical studies that implicate inhibitory GABAergic pathways from the prefrontal cortex to the amygdala and additional inhibitory pathways between the amygdala and the sympathetic and parasympathetic medullary output neurons that modulate heart rate and thus heart rate variability. We propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. We next review the evidence on the role of vagally mediated heart rate variability (HRV) in the regulation of physiological, affective, and cognitive processes. Low HRV is a risk factor for pathophysiology and psychopathology. Finally we review recent work on the genetics of HRV and suggest that low HRV may be an endophenotype for a broad range of dysfunctions.