Tammy Hardison Murphy, BS, LRT/CTRS III, Recreational Therapist, Pitt County Memorial Hospital of University Health Systems Kristen Murtha, MS CCC-SLP, Program Manager for General Rehabilitation Teams, Pitt County Memorial Hospital of University Health Systems Dennis Sinar, M.D., Professor of Medicine, Gastroenterology, Brody School of Medicine, Greenville, NC 27834 (retired)
This work has not been presented in any form There were no funding sources for this work
Abstract: An acrylic finger labyrinth was used to assist in stress reduction in thirty-one inpatients seen on the Recreational Therapy consultation service. Adult patients on inpatient medical/surgical services reported that the use of the finger labyrinth at their bedside significantly reduced their stress scores on a pre and post treatment survey. In addition, anxiety scores were also significantly reduced, but scores of pain and depression were not significantly changed by the use of the labyrinth. A discussion is presented of possible applications of the portable acrylic finger labyrinth in inpatients.
Introduction: A labyrinth is an ancient symbol commonly used as an aid in problem solving and achieving mental clarity. More recently, walking the path of a labyrinth in cathedrals and outdoor sites across the United States has helped many people achieve relaxation and peace through meditation. Healthcare facilities have incorporated labyrinths as adjuncts to traditional medical therapy to promote mental well-being among patients during chronic illness. Holistic and Complementary Centers may offer a walking labyrinth as a tool to promote patient wellness and reduce stress. Patients and staff have found that walking a labyrinth helps them cope with the multiple stresses of a modern healthcare facility. (1) There has been research on the therapeutic effect of a walking labyrinth on health and wellness, and some work on the use of labyrinth in easing the stress of cancer care. (2) An area that has not been explored is whether a labyrinth may be a useful component of recreational therapy services to reduce stress in patients who are unable to walk a labyrinth. This study is the first to examine the use of a portable labyrinth in a diverse medical and surgical inpatient population who are not mobile enough to safely navigate a walking labyrinth. Our goal was to determine if using a finger labyrinth in an acute recreational therapy program could be an effective tool for reducing stress in these hospitalized patients.
Methods: Thirty one patients referred to the inpatient Acute Recreational Therapy service of a large academic medical center were the study participants. Successive patients on a busy Recreational Therapy consultation service were offered the bedside use of an acrylic labyrinth under the guidance of a recreational therapist as part of their regular care delivery. In all patients, the reason for the Recreational Therapy consultation was stress reduction or coping skills. Demographics of the study participants included a variety of medical and surgical diagnoses as well as women with pre eclampsia who were required to be at bed rest (table 1). The labyrinths in this study were carved on 0.375 inch clear acrylic on a Shopbot computerized router using the well-known labyrinth pattern from the Chartres Cathedral. The labyrinth was 21 x 21 inches, a size to promote ease of use by most patients in a hospital bed with normal upper body movement. A 1 inch textured grooved surface was cut into the acrylic as the labyrinth path the patient was to follow with their index or middle finger. The depth and texture gave the patient positive feedback and helped visually impaired patients follow the path by tactile cues. Patients had little difficulty tracing the path after initial guidance by the therapist. Acrylic was used as the material of choice for ease of cleaning between patients with compliance with standard infection control practices for multi patient use equipment. Between patients, the labyrinths were disinfected with Cavi-Wipe solution. In the initial consultation the therapist described the labyrinth and utilization as an aid to meditation and relaxation. The patient was asked if they wished to participate in using the labyrinth. If they gave verbal consent, they were given a baseline DAPS (Depression, Anxiety, Pain, Stress) survey. This is a ten point ordinal survey used in our institution to assess interventions by Recreational Therapy staff. On the survey the patient circles a number corresponding with their feeling from a ten point high (maximum feeling) to 1 point low (minimum feeling) for each of the four dimensions: depression, anxiety, pain or stress. As the therapist introduced the use of the labyrinth, they guided the patient’s index finger along the path of the labyrinth and encouraged them to self-lead and explore the piece at their own pace. After the introduction, the patient was asked to take several deep breathes and mentally visualize a pleasant place or scene such as a family member’s smiling face. The patient then moved their finger along the grooved path with their index finger until they reached the center. At the center, they were again asked to take several deep breaths and visualize their pleasant scene before reversing the path to the starting point. At the completion of the circuit, they were again asked to repeat several deep breaths, visualize their pleasant scene a last time and to rest quietly for several minutes. After the patient completed one circuit of the labyrinth, the therapist answered questions. They stressed that there was no time limit to the use, no recommended speed, and that the use was entirely at the patient’s discretion. The patient could use the piece on several occasions if they found it helpful by letting the therapist know and a labyrinth would be provided for their use. In subsequent consultations, the therapist followed the same procedure until the final consultation visit, when they again completed using the labyrinth and completed a DAPS survey. The final consultation generally corresponded with discharge or move to a different level of care. No patients stopped using the labyrinth because of discomfort or adverse emotional changes. Each of the thirty-one patients completed between two and five sessions using the labyrinth. Observations by the therapist were that patients traced the path at their own pace and tended to take more time tracing the path with more uses of the labyrinth. The amount of time each patient used the labyrinth was not captured in this study. Patients were encouraged to voice their comments about the experience and those comments are presented in table 2. Each set of surveys (pre-labyrinth use and post-labyrinth use) was used for analysis. A numeric difference was calculated between the pre and post survey for each of the four dimensions and descriptive statistics were tallied from completed surveys and presented graphically. For the statistical comparison of pre and post scores for the four dimensions (depression, anxiety, pain, stress) a Wilcoxon Signed-Rank test was used.
Results: All 31 patients completed a pre and post treatment survey. There were 8 males and 23 females ranging in age from 22 to 72. Patient location was throughout the hospital: ten patients with cancer, five patients from the Obstetric Service, nine from General Medical Services and seven from Surgical Services. Seven patients used the labyrinth two times, nine used it three times, nine used it four times, and six patients used it five times. Three patients (ages 22-36, diagnosis preeclampsia, who each used the labyrinth two times) listed their feelings as either worse or the same on all dimensions after using the labyrinth. These three patients were excluded from further analysis and the remaining twenty eight patient survey sets were used. On the survey tool 10 is the highest choice in each of the four categories and 1 is the lowest. Figure 1 shows the mean and standard deviation for the 28 patients for each dimension before and after use of the labyrinth. The greatest improvement after using the labyrinth was in the Stress Dimension. The patients’ perception of their stress dropped from 8.75 +/- 0.8 before using the labyrinth to 2.79 +/- 1.26 after using the labyrinth. This was significant at p < 0.001. All twenty-eight patients recorded a lessening of their stress after using the labyrinth, shown graphically in figure 1. Sub grouping patients by age, sex, diagnosis, or number of times the labyrinth was used did not show a pattern of response. There was a strong positive response in 84% of the patients (26/31) who felt their feelings of stress improved by more than 4 gradations and 35% of patients (11/31) who felt their feeling of stress improved by more than 7 gradations.. There were less consistent improvement scores for the patients’ Anxiety Dimension as seen in figure 1. As in the scores for the stress dimension there was no consistent pattern by age, sex, diagnosis or number of times using the labyrinth. There was no consistent change in the patients’ recorded feeling in the dimensions of pain or depression in any diagnosis group by age, sex or number of times the labyrinth was used.
Discussion: A modern hospital is an efficient delivery system for high technology medical care. In spite of the constant attention of caring staff and ongoing training programs that make staff sensitive to patient issues, hospitalized patients often feel increased stress. Many patients feel overwhelmed by the technology of a modern healthcare facility and by the terminology of the healthcare team. The stereotype of the past of a patient going to the hospital ‘to rest’ has been replaced by the stereotype of a patient going to the hospital ‘for tests’. A considerable amount of patient time in a hospital is either in being tested or in preparing for testing. After tests are completed, the process of treating an illness can further increase a patient’s stress and communication among patients, family and the healthcare team can be an additional cause of stress. In our hospital during the time of this study there were 964 Recreational Therapy consultations during the year and 92% were for assistance with stress-related conditions associated with acute medical processes or adverse changes in chronic medical conditions. In an effort to allow patients to participate in their care and to help them individually reduce stress in ways that work for them, some healthcare facilities have added programs in Complementary Medicine. Our hospital is committed to programs in Complementary Medicine with the availability of Reiki therapy, Yoga, Massage therapy, Animal Assisted Therapy, Music therapy and Art therapy. These programs are regularly available to promote patient wellness and to assist with dealing with life-threatening illnesses. In some facilities, a walking labyrinth has been added to a Complimentary Medicine program and placed in a peaceful indoor or outdoor setting. Patients may be able to leave their room and go to this private space for relaxed thought. A walking labyrinth has also been useful to hospital staff in adapting to the stresses of delivering care to severely ill and dying patients. In addition, Hospice organizations have used labyrinth walking to help patients adjust to the grieving and dying process. (1,3,6) The beneficial effects of walking a labyrinth have been studied in normal people through subjective questionnaires similar to the questionnaire used in this study.(5,6) People report many feelings after walking a labyrinth, and it is not well understood why some people experience relaxation and calming and the effect is not universal. While a walking labyrinth can provide a relaxed and quiet space for stress reduction, unfortunately a large proportion of inpatients may not be able to use a walking labyrinth. Some patients cannot walk a labyrinth because of pending medical procedures or because of changes in the required level of care from intermediate to intensive levels of care. In an attempt to address the needs of this patient group, we developed an acrylic finger labyrinth as a portable alternative that can be utilized at the bedside. In this study, we found this tool to be useful in a variety of adult patients. The patients who participated in this study were able to use the finger labyrinth to assist in reducing their stress and anxiety. The finger labyrinth used in this study is portable, low cost, and can be used in bed ridden and visually impaired patients. Decorative wooden finger labyrinths are commercially available and may be used as individual meditation aides. These wooden products cannot be safely used within the rigid infection control environment of a hospital. The acrylic finger labyrinth is easily disinfected between patients and has proven to be durable in a variety of patient situations. In our observations, the pace our patients used in tracing a finger labyrinth is much faster than they might use walking a large outdoor labyrinth, even with the deep breathing and pleasant scene visualization we asked them to do. Even though we chose not to set time boundaries on the patient’s use of the labyrinth in this study, we found that as a group they tended to take more time to trace the path the more times they used the tool. The patient comments outlined above are helpful in assessing how this group viewed the exercise. They readily accepted the labyrinth and had no problem following the therapists’ general guidance and then using it as they chose. The design of the finger labyrinth is such that patients have considerable flexibility in use yet have self-correcting feedback through their finger on the grooved path. The width and depth of the path carved in the acrylic was acceptable to our patients as reported through their verbal and written feedback. The open approach of introducing the labyrinth helped the therapists provide general guidance, but permitted individual choice in speed, length of time, and the visualization technique that worked best for them. We wonder whether the design of a labyrinth such as the Chartres design is important, or if a more simple design would produce the same effects. An intriguing aspect of this study is that hospitalized patients were able to rapidly adapt to a finger labyrinth and dramatically reduce their self-reported scores in the dimensions of stress and anxiety with only a few uses. The complex hospital setting may be able to be put aside by patients by this type of tool. This study did not address many intriguing features of the patients’ response such as the length of time a relaxing effect may last or whether it is reproducible in other patient populations who may be experienced in meditation. We were encouraged by the strong positive response of 84% of the patients who improved their feelings of stress by greater than 4 gradations after using the labyrinth and a surprising 35% of patients who improved their feelings of stress by more than 7 gradations. Patients reported only minimal improvement in the dimensions of pain and depression after using the labyrinth. This is not unexpected with both pain and depression are more chronic states and unlikely to be materially changed by the short, infrequent use of the labyrinth. We were encouraged by the patient’s positive written comments about their impression of the labyrinth. We plan to continue this approach in a variety of patient settings to determine if this simple and inexpensive technique may have more widespread benefits.
Acknowledgements: The authors would like to thank Noah Rasor and Kayleen Adams of the Fablab for their technical assistance on the finer points of ShopBot programming and Peg Connally, Ph.D. of Western Carolina University for developing the DAPS survey tool
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