Research Article

A Randomized Controlled Trial of Multisensory Stimulation and Family-Involved Rehabilitation in Elderly Thoracic Surgery Patients

DOI:

10.3791/70305

⸱

June 5th, 2026

 ,  ,  , 
1The Affiliated Hospital of Southwest Medical University, Southwest Medical University

In This Article

Summary

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This randomized controlled trial found that combining multisensory stimulation with family-involved rehabilitation was associated with reduced pain and anxiety, as well as improved physical recovery in elderly patients following thoracic surgery.

Abstract

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Elderly patients undergoing thoracic surgery often experience postoperative pain, anxiety, and delayed functional recovery. Multisensory stimulation nursing (MSSN) and family-participatory rehabilitation training (FPRT) are recognized non-pharmacological approaches; however, evidence for their combined use in this population remains limited. This study evaluated the effects of MSSN combined with FPRT on pain, anxiety, sleep quality, and physical function in elderly patients after thoracic surgery. In this randomized controlled trial, patients aged ≥65 years undergoing elective thoracic surgery were assigned to a control group (routine care, n = 38) or an intervention group (routine care plus MSSN and FPRT, n = 39). MSSN involved 20-min multisensory sessions five times per week for 4 weeks, while FPRT included structured family-assisted respiratory and mobility exercises. Outcomes included pain (NRS), anxiety (HADS-A), sleep quality (PSQI), grip strength, and 6-minute walking distance (6MWD), assessed at baseline, 2 weeks, and 4 weeks. The intervention group demonstrated significantly greater reductions in pain (group × time interaction, P = 0.01; week 2: B = 0.21, P = 0.007; week 4: B = 0.23, P = 0.004) and anxiety (B = -3.42, P = 0.002) compared to the control group. Significant improvements were also observed in sleep quality (PSQI change: -2.71 ± 1.13 vs. -0.94 ± 1.25, P = 0.004), grip strength (week 4: B = -0.31, P = 0.008), and 6MWD (54 m vs. 27 m improvement, P < 0.01), with the 54 m improvement exceeding the estimated minimal clinically important difference (30 m). Postoperative pulmonary complications were lower in the intervention group (7.5% vs. 22.5%), and no adverse events were reported. Combined MSSN and FPRT may safely reduce pain and anxiety while improving sleep and functional recovery in elderly thoracic surgery patients.

Introduction

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The aging global population has led to a rapid increase in elderly patients undergoing major thoracic surgery1. These individuals face heightened risks of postoperative complications, pain, anxiety, and functional decline due to age-related physiological changes and reduced resilience2. Traditional postoperative care primarily focuses on analgesic control and early ambulation. However, this biomedical model often overlooks the psychological and sensory dimensions of recovery, which are critical for elderly patients3. Fortunately, recent research highlights the efficacy of non-pharmacological interventions that integrate sensory and psychosocial stimulation in enhancing rehabilitation quality and patient well-being4.

Among these, multisensory stimulation (MSS) has emerged as an innovative, holistic approach5. By providing targeted visual, auditory, tactile, and olfactory stimulation, MSS promotes neurosensory integration and emotional regulation6. Originating from Snoezelen rooms, this therapy is widely used in geriatric care and has demonstrated benefits including reduced pain, blood pressure, and anxiety, as well as improved mood and quality of life7. However, these findings derive primarily from nursing home or dementia care populations, and their extrapolation to postoperative surgical contexts requires empirical validation. Physiologically, sensory interventions may modulate the autonomic nervous system and influence endorphin release8. Psychologically, they create a relaxing environment that reduces postoperative stress and improves engagement in rehabilitation9.

Similarly, family-participatory rehabilitation training (FPRT) leverages family bonds and motivational support to facilitate recovery10. Research confirms that with active family involvement, such as providing encouragement and assisting with breathing or limb exercises, patients show better adherence, self-efficacy, and satisfaction11. This support is especially vital for elderly thoracic surgery patients, as it alleviates postoperative emotional isolation and ensures smoother continuity of care after discharge.

A conceptual framework underpinning the combined approach posits that sensory stimulation and family engagement operate through complementary pathways. Sensory input (auditory, tactile, visual, olfactory) may directly influence neurophysiological arousal and emotional regulation, while family involvement provides contextual safety, motivation, and continuity. Their interaction may create a reinforcing cycle: reduced sensory discomfort enhances receptivity to family support, and family presence potentiates the calming effects of sensory stimuli by reducing stress-related vigilance. This biopsychosocial synergy aligns with models of environmental enrichment and social buffering of stress.

Despite the individual benefits of MSS and FPRT, their potential synergy in the context of thoracic surgery remains largely unexamined. A combined model, rather than a factorial design, was chosen for two reasons. First, in this initial efficacy trial, pragmatic feasibility and minimization of patient burden in a vulnerable postoperative population were prioritized. Second, the intervention was conceptualized as a holistic care package wherein sensory and family components were hypothesized to function synergistically rather than additively. Future factorial designs may usefully disentangle their relative contributions once preliminary efficacy is established. It was hypothesized that integrating these approaches could offer a comprehensive framework, engaging sensory pathways, emotional support, and physical activity simultaneously, to optimize recovery. This combined model aligns with the shift toward patient-centered, holistic perioperative care that prioritizes non-pharmacological interventions.

To bridge this evidence gap, the present study evaluated the combined application of MSS and FPRT in elderly patients after thoracic surgery. The primary hypothesis tested was that this integrated intervention would outperform routine care by more effectively reducing postoperative pain and anxiety and enhancing sleep quality, muscle strength, and functional mobility. Ultimately, this research aims to provide empirical support for a novel, low-risk, and patient-centered strategy to improve postoperative recovery and quality of life.

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Protocol

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This study was approved by the Ethics Committee of The Affiliated Hospital of Southwest Medical University. All participants and their designated family caregivers provided written informed consent prior to participation. The study was registered in the Chinese Clinical Trial Registry. All procedures adhered to the Declaration of Helsinki principles, and participants retained the right to withdraw at any stage without affecting their clinical care. The equipment and the software used are listed in the Table of Materials.

1. Study design
A prospective randomized controlled trial was conducted from March 2024 to March 2025 to evaluate the combined effects of multisensory stimulation nursing (MSSN) and FPRT on postoperative recovery in elderly patients undergoing thoracic surgery. Participants were randomly assigned in a 1:1 ratio to either a control group, which received routine postoperative care, or an intervention group, which received routine care plus MSSN and FPRT.

The randomization sequence was generated by an independent statistician using a computer‑generated random number system. Stratified randomization was performed by age group (65–74 vs. ≥75 years) and surgical type (lobectomy, wedge resection, VATS), with permuted block randomization (varying block sizes of 2, 4, and 6) within each stratum to ensure balance across groups. Allocation concealment was ensured using sequentially numbered, opaque, sealed envelopes. After participants completed baseline assessments and provided written informed consent, the enrolling nurse opened the next envelope in sequence to reveal group assignment.

All outcome assessments were performed by research staff who were blinded to group allocation. Participants were instructed not to discuss their group assignment with the assessors. The study adhered to the CONSORT 2010 guidelines for randomized clinical trials. A schematic overview of the study design is provided in Figure 1.

2. Participants and sampling
Eighty elderly patients (≥65 years) who underwent elective thoracic surgery at the Department of Thoracic Surgery, The Affiliated Hospital of Southwest Medical University, were enrolled. Patients were recruited consecutively after meeting eligibility criteria.

The inclusion criteria were: (1) age ≥65 years; (2) scheduled for or having undergone thoracic surgery (e.g., lobectomy, wedge resection, or thoracoscopic procedure); (3) hemodynamically stable within 24 h postoperatively, defined as systolic blood pressure ≥90 mmHg and ≤160 mmHg, heart rate between 50–100 beats/min, and no requirement for continuous vasopressor infusion or escalating inotropic support; (4) adequate ability to communicate and cooperate with assessments; and (5) provision of informed consent by both the patient and a family caregiver. Key exclusion criteria included: (1) a history of severe cognitive impairment or psychiatric illness; (2) postoperative delirium or mechanical ventilation for >48 h; (3) unstable cardiovascular conditions or severe infection; (4) significant visual, hearing, or communication disorders; and (5) refusal to participate in the rehabilitation activities.

A sample size of 80 was determined through power analysis. The calculation was based on the expected between-group difference in the primary outcome of pain intensity (NRS score) at 4 weeks post-intervention. Based on prior studies of non-pharmacological interventions in postoperative elderly populations, a moderate effect size (Cohen's d = 0.40) was anticipated, corresponding to a mean difference of approximately 1.0 point on the NRS (assuming a common standard deviation of 2.5). Using a two-sided significance level of α = 0.025 (adjusted for two primary outcomes using Bonferroni correction) and power of 0.80, the required sample size was calculated as 35 participants per group using the standard formula for two independent means. To account for an anticipated 15% dropout rate, the target was to recruit 40 participants per group (total N = 80). Sample size calculations were performed using G*Power software (version 3.1). Allocation was managed by an independent researcher not involved in data collection.

3. Intervention procedures

  1. Control group (Routine care)
    Patients received standard postoperative care according to hospital protocols, including: (1) Vital sign monitoring: Assessed every 4 h for the first 48 h, then twice daily. (2) Pain management: A standardized analgesic protocol was applied to both groups. Patient-controlled analgesia (PCA) with intravenous opioids was administered for the first 48 h, followed by oral analgesics as needed (acetaminophen or NSAIDs). No additional analgesics were prescribed specifically for the intervention group. (3) Respiratory care: Routine respiratory physiotherapy, including incentive spirometry (10 repetitions every 2 waking hours) and deep breathing exercises. (4) Early ambulation: Patients were encouraged to sit out of bed on postoperative day 1 and begin ambulating with assistance by day 2. (5) Health education: Standardized discharge teaching covering wound care, activity restrictions, and warning signs of complications.
    The analgesic protocol was standardized across both groups, with patient-controlled analgesia (PCA) administered for the first 48 h postoperatively, followed by oral analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs) as needed. No additional analgesics were prescribed specifically for the intervention. Family caregivers were permitted to visit but did not receive any specific training or structured guidance for participation in care.
  2. Intervention group (MSSN + FPRT)
    In addition to routine care, patients in the intervention group received a combined protocol of MSSN and FPRT. The interventions commenced 48 h after surgery and were sustained for 4 weeks.
    1. MSSN
      MSSN was administered in a quiet ward with controlled lighting and temperature. Each 20-min session, supervised by a trained nurse and delivered five times per week, integrated four sensory modalities using a rotating sequential design: auditory (5 min), visual (5 min), tactile (5 min), and olfactory (5 min). The order of modalities was rotated across sessions to prevent habituation. All modalities were delivered sequentially rather than simultaneously to allow patients to focus on and respond to each sensory input individually. Stimulation intensity was individually tailored based on patient tolerance, with adjustments made to volume (auditory), light brightness (visual), massage pressure (tactile), and scent concentration (olfactory) as needed. The specific content included: (1) Auditory: Soothing instrumental or nature sounds (40–50 dB) and recordings of familiar family voices; (2) Visual: Projections of calming natural scenery with slow color transitions; (3) Tactile: Gentle limb massage using warm towels and textured fabrics to stimulate proprioception; (4) Olfactory: Mild aromatherapy with lavender or citrus essential oils to promote relaxation. The stimulation intensity was individually tailored based on patient tolerance.
    2. FPRT
      Family caregivers attended a 30-min training session conducted by the nursing team, which covered postoperative breathing exercises, upper-limb range-of-motion training, and psychological support techniques. The FPRT sessions were structured as follows: (1) Physical support: Caregivers assisted patients with the following exercises for 15 min, twice daily (morning and afternoon): (a) diaphragmatic breathing: 10 repetitions per session, with a 5-s inhalation hold and 5-s exhalation, progressed to 15 repetitions by week 3 if tolerated, (b) shoulder abduction: 8 repetitions per session, progressing from passive to active-assisted to active range of motion based on patient ability, with a target of 15 repetitions by week 4, and (c) hand-grip exercises: Using a soft rubber ball, 10 squeezes per session (5 s/squeeze), progressed to 15 squeezes by week 3 and use of a firmer ball by week 4 if tolerated. All exercises were performed at a low to moderate intensity (rated 3–4 on a 0–10 Borg CR10 scale for perceived exertion), with rest intervals as needed. (2) Emotional support: Caregivers provided encouragement through conversation and gentle touch to bolster patient confidence. (3) Environmental support: Caregivers also helped maintain a calm, safe, and familiar recovery environment. Nursing staff documented daily adherence using a structured checklist.

4. Outcome measures
All outcomes were assessed at three time points: baseline (postoperative day 2), 2 weeks, and 4 weeks after intervention. All assessments were performed by research staff who were blinded to group allocation. The baseline assessment was scheduled for postoperative day 2 (48 h after surgery), coinciding with intervention initiation. By this time, most patients had been transferred to the general ward, had chest tubes removed or stabilized, and were able to cooperate with assessments. While measurements at this early postoperative period may still be influenced by residual anesthesia, analgesics, or surgical stress, this time point represents the earliest feasible and clinically meaningful pre-intervention baseline.

  1. Primary outcomes
    (1) Pain intensity: Pain intensity was assessed using the Numerical Rating Scale (NRS), an 11-point scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’)12. (2) Anxiety level: assessed by the Hospital Anxiety and Depression Scale–Anxiety subscale (HADS-A)13.
  2. Secondary outcomes:
    (1) Sleep quality: evaluated by the Pittsburgh Sleep Quality Index (PSQI)14. (2) Grip strength: measured with a calibrated Jamar hand dynamometer (kg). (3) Functional capacity: assessed using the 6-minute walking distance (6MWD). (4) Postoperative pulmonary complications: recorded according to the standardized Melbourne Group Scale criteria, which define pulmonary complications as the presence of at least four of the following: chest radiograph abnormalities, elevated inflammatory markers, temperature >38°C, positive sputum culture, oxygen saturation <90% on room air, or physician-prescribed antibiotics for respiratory infection. Each assessment was performed by a researcher blinded to group assignment.

5. Quality control and assessor training
To ensure consistency, all four research assessors underwent standardized training prior to study initiation, covering administration of patient-reported outcomes (NRS, HADS-A, PSQI), grip strength measurement technique, and 6MWD protocol per ATS guidelines. Inter-rater reliability was assessed using 10 non-study patients. The intraclass correlation coefficient (ICC) for absolute agreement was 0.94 (95% CI: 0.89–0.97) for grip strength and 0.91 (95% CI: 0.85–0.95) for 6MWD, indicating excellent reliability. For questionnaire-based measures, inter-rater reliability was not applicable as assessors simply recorded patient responses without interpretation. Monthly calibration meetings and a midpoint refresher training were conducted to maintain standardization. All assessments were performed by researchers blinded to group assignment.

6. Data analysis
All statistical analyses were conducted using SPSS version 26.0. Descriptive statistics were presented as mean ± standard deviation (SD) for continuous variables and as frequency (percentage) for categorical variables. Between-group comparisons at baseline were tested using independent t-tests or chi-square tests. Changes over time were analyzed with linear mixed-effects models, incorporating time, group, and their interaction as fixed effects, with an unstructured covariance structure. Post hoc comparisons were adjusted using Tukey correction. For the two primary endpoints (pain and anxiety), statistical significance was set at P < 0.025 after Bonferroni correction; secondary outcomes were interpreted at P < 0.05. Effect sizes were reported as Cohen's d. An unstructured covariance structure was specified for the repeated measures to account for unequal variances and correlations across time points. This structure was selected based on Akaike Information Criterion (AIC) comparisons with alternative covariance structures. Post hoc comparisons were adjusted using the Tukey correction. For the two primary endpoints (pain and anxiety), a P value <0.025 (two-tailed) was considered statistically significant after applying a Bonferroni correction for multiple comparisons. Secondary outcomes were interpreted at P < 0.05 without adjustment, consistent with their exploratory nature. The significance level was set at P .< 0.05 (two-tailed). Effect sizes were reported as Cohen's d for clinical interpretation.

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Results

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Participant characteristics
A total of 126 patients were initially screened for eligibility between March 2024 and March 2025, of whom 80 met the inclusion criteria and were randomized into the control group (n = 40) and the MSSN+FPRT intervention group (n = 40). During follow-up, three participants (two from the control group and one from the intervention group) withdrew due to early discharge or refusal to continue, resulting in a final sample of 77 participants (control group: n = 38; intervention...

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Discussion

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This study demonstrated that MSSN combined with FPRT  was associated with improved postoperative recovery in older thoracic surgery patients. Compared with routine care, the integrated intervention showed greater reduction in postoperative pain and anxiety, as well as enhancements in physical function (grip strength and 6-min walking distance) and sleep quality. These findings suggest that engaging sensory systems and involving family in rehabilitation can accelerate recovery,...

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Disclosures

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The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgements

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The authors sincerely thank all the patients and their family members who participated in this study. The authors also extend their gratitude to the nursing and medical staff of the Department of Thoracic Surgery at The First Affiliated Hospital of Southwest Medical University for their support and collaboration. This study was funded by Southwest University (2025jc167).

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
Hand dynamometer (Jamar Hydraulic Hand Dynamometer)Patterson Medical (Performance Health)5030J1Standard device for grip strength measurement
G*Power software (v3.1)Heinrich Heine University Düsseldorfhttps://www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower
Incentive spirometer (Voldyne 5000)Hudson RCI (Teleflex)Used for respiratory physiotherapy
Statistical software (SPSS v26.0)IBMhttps://www.ibm.com/products/spss-statistics

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Elderly PatientsPostoperative PainAnxiety ReductionSleep QualityFunctional RecoveryRespiratory ExercisesMobility Training

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