Impact of Laughter Therapy on Anxiety and Pain in Pediatric Dentistry: A Double-Blinded Randomized, Controlled Clinical Trial

Abstract Objective: To evaluate the effect of laughter therapy on reducing anxiety and pain during dental procedures in children 5-7 years of age. Material and Methods: 48 children aged 5-7 years were included in this cross-over double-blinded clinical trial after the parents completed the Screen for Child Anxiety Related Disorder questionnaire (SCARED). After allocation into two groups: laughter intervention (A) and neutral intervention (B), the anxiety as well as pain were determined by Modified Child Dental Anxiety Scale Faces questionnaire (MCDASF) and the Wong-Baker Faces Scale, respectively. Also, the child's behavior during the treatment was recorded using the Sound, Eye, Motor scale (SEM). Data were analyzed by SPSS 21 using Paired t-test, Independent t-test, Chi-square, Mann-Whitney and Wilcoxon's test. Results: The mean score of anxiety in the laughter intervention group (17.42±2.74) was significantly less than (22.06±2.16) in the neutral intervention group (p=0.000) and lower in boys in both groups (p=0.000, p=0.047). The mean pain severity reported by the children in the neutral intervention group (5.33±1.81) was higher than in the laughter intervention group (2.38±1.87; p=0.00) and higher in girls in both groups (p=0.02; p=0.03). Conclusion: The laughter intervention before dental procedures had a significant effect on reducing anxiety and pain during dental treatment (AU).

Percepciones de un equipo de cuidados paliativos pediátricos acerca del clown de hospital / Pediatric palliative care team perceptions' about hospital clowns / Percepções de uma equipe de cuidados paliativos pediátricos sobre o clown de hospital

Resumen La presente es una síntesis de resultados de una investigación mayor, cuyo objetivo principal fue conocer las perspectivas de familias y equipo de salud respecto de la presencia de clowns de hospital trabajando en cuidados paliativos pediátricos en una unidad en Chile. Guiado por un paradigma interpretativo, estrictos criterios de calidad y éticos, la metodología utilizada fue de tipo cualitativo, aplicando las técnicas de recolección de datos de entrevistas en profundidad, análisis de documentos y grupos de discusión. La sección de datos sobre el equipo aquí presentados, se analizó a través de las técnicas análisis de contenido y análisis crítico del discurso. Los resultados indican que la figura del clown es percibida como un mediador y valorada como terapia complementaria, especialmente por las competencias socioemocionales de esos profesionales y el juego que se utiliza como herramienta de intervención. Las conclusiones señalan que las competencias socioemocionales que promueve el clown de hospital son fundamentales para el trabajo en cuidados paliativos.

Abstract This is a synthesis of results of a major research which main objective was to know the perspectives of families and the health team regarding the presence of hospital clowns working in pediatric palliative care in a unit in Chile. Guided by an interpretivist paradigm, strict quality and ethical criteria, the methodology used was qualitative, applying in-depth interviews, document analysis and discussion groups as data collection techniques. The data section presented here about the health team was analyzed through content analysis and critical discourse analysis techniques. The results indicate that the figure of the clown is perceived as a mediator, valued as complementary therapy, especially due to the socio-emotional competences of these professionals and play used as an intervention tool. The conclusions indicate that the socio-emotional competences promoted by the hospital clown are fundamental to work in palliative care.

Resumo A presente é uma síntese de resultados de uma investigação maior, cujo objetivo principal foi conhecer as perspectivas de famílias e equipe de saúde a respeito da presença de clowns de hospital trabalhando em cuidados paliativos pediátricos em uma unidade no Chile. Guiado por um paradigma interpretativo, critérios estritos de qualidade e éticos, a metodologia utilizada foi de tipo qualitativo, aplicando as técnicas de coleta de dados de entrevistas em profundidade, análise de documentos e grupos de discussão. Os dados sobre a equipe aqui apresentados, foram analisados através das técnicas de análise de conteúdo e análise crítica do discurso. Os resultados indicam que a figura do clown é percebida como um mediador e valorizada como terapia complementar, especialmente pelas capacidades sócio-emocionais desses profissionais e o jogo que se utiliza como ferramenta de intervenção. As conclusões apontam que as capacidades sócio-emocionais que promovem o clown de hospital são fundamentais para o trabalho em cuidados paliativos.

A arte do palhaço na educação médica / The art of clowning in medical education

Resumo: Introdução: Em todo o mundo, a arte tem sido utilizada como recurso pedagógico no curso médico. No Brasil, vários grupos de "palhaçoterapia" - projetos que envolvem a atuação de estudantes como palhaços-doutores - foram criados visando promover uma humanização do cuidado nos hospitais. A partir daí, vários estudos começaram a identificar impactos da participação nesses projetos na formação médica. Este estudo investiga a percepção do profissional formado acerca da influência da experiência como palhaço-doutor na sua prática médica. Objetivo: Este estudo tem como objetivo analisar, na graduação de Medicina, a formação na arte do palhaço como estratégia para contribuir para o desenvolvimento de competências na prática médica. Método: Trata-se de uma pesquisa exploratória e descritiva com abordagem qualitativa, por meio de entrevista semiestruturada com 15 participantes, que foram escolhidos pela técnica da bola de neve. O universo da pesquisa consiste em médicos que participaram de projetos de palhaçoterapia durante a graduação, em Recife, Pernambuco. As informações coletadas foram organizadas com o auxílio do software MAXQDA e submetidas à análise textual discursiva proposta por Moraes, que segue três passos de forma cíclica: a desmontagem dos textos em unidades de significado, o estabelecimento de relações e a captação do emergente. Resultado: A partir da análise das transcrições das entrevistas, emergiram diversas categorias de competências relatadas pelos participantes. No processo de construção de um novo significado com base nesses achados, foi necessário selecionar os que tinham relação com o que estava proposto nas Diretrizes Curriculares Nacionais (DCN) de Medicina de 2014. As habilidades percebidas foram agrupadas nas seguintes categorias: sensibilização, ressignificação, lidar com o erro e relação com o paciente. Conclusão: Esta pesquisa procurou explorar o fenômeno translacional, por meio do qual se investigaram quais ensinamentos, na visão de profissionais da medicina, foram apreendidos para sua prática a partir da aprendizagem e do exercício da arte do palhaço. Quando se realizou essa comparação com as DCN, foi possível encontrar interseções entre o que se espera desenvolver durante a formação médica e algumas das competências desenvolvidas com ajuda da arte do palhaço.

Abstract: Introduction: Art has been used as a teaching resource in medical education around the world. In Brazil, several "clown therapy" groups - a common name for projects in which students perform as "clown doctors" in hospitals - have been created with the aim of helping to humanize hospital care. Several studies have identified the impacts on medical training, as perceived by the participants of such projects. This study investigates how trained professionals view the influence of their previous experiences as clown doctors on actual medical practice. Objective: To analyze clown training in medical school as a strategy to contribute to the development of medical practice skills. Method: This is an exploratory and descriptive study with a qualitative approach. Semi-structured interviews were conducted with 15 participants, who were chosen using the snowball technique. The sample consists of doctors who participated in clown therapy projects during their undergraduate training, in Recife, Pernambuco. The collected information was organized with the MAXQDA software and underwent discursive content analysis as proposed by Moraes, which follows a three-step cycle: the deconstruction of text into units of meaning, the establishment of relationships, and the capture of the emerging knowledge. Result: Analysis of the interview transcripts generated several categories of competencies reported by the participants. In the process of constructing new meaning based on these findings, it was necessary to select those that were related to the proposals of the 2014 National Curriculum Guidelines (DCNs) for medicine. The perceived skills were grouped into the following categories: awareness, resignification, dealing with error and physician-patient relationship. Conclusion: This research sought to explore the translational phenomenon, investigating which competencies, in the eyes of medical professionals, were learned from practicing the art of clowning. By drawing comparisons with the National Curriculum Guidelines (DCNs), intersections were found between expected development during medical training and some of the skills developed with the help of the art of clowning.

A terapia do riso como ferramenta de cuidado com a criança hospitalizada: revisão integrativa da literatura / La risoterapia como herramienta de atención para niños hospitalizados: una revisión bibliográfica integradora / Laughter therapy as a care tool for hospitalized children: an integrative literature review

Objetivo: Investigar, na literatura nacional e internacional, o uso da terapia do riso junto às crianças hospitalizadas. Método: Revisão integrativa da literatura. As bases de dados pesquisadas foram MEDLINE®, Cumulative Index to Nursing and Allied Health Literature, PsycINFO®, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Banco de Dados em Enfermagem ­ Bibliografia Brasileira e Índice Bibliográfico Español em Ciencias de la Salud. Os termos utilizados identificados nos Descritores em Ciência da Saúde e nos Medical Subject Headings foram "terapia do riso", "criança", "pré-escolar" e "criança hospitalizada", além das palavras-chave "risoterapia", "riso-terapia" e "riso terapia" em diferentes combinações. O recorte temporal foi de 10 anos, a partir de 2008. Resultados: A amostra final para a análise foi constituída de 17 artigos, que foram organizados em três categorias: Risoterapia como estratégia para a diminuição da dor, do desconforto e do sofrimento; A diminuição do medo, do estresse e da ansiedade com a risoterapia e O Impacto psicossocial da risoterapia na criança hospitalizada. Conclusão: Foi possível perceber benefícios da terapia que incluem diminuição da dor, do estresse e da ansiedade e mudanças emocionais e sociais. Salienta-se a importância da temática, por meio da qual é possível oferecer ao paciente pediátrico um cuidado integral e humanizado.(AU)

Objective: To investigate, in the Brazilian and international literature, the use of laughter therapy with hospitalized children. Methods: An integrative literature review. The databases searched were MEDLINE®, Cumulative Index to Nursing and Allied Health Literature, PsycINFO®, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Banco de Dados em Enfermagem ­ Bibliografia Brasileira and Índice Bibliográfico Español em Ciencias de la Salud. The index terms used on Descritores em Ciência da Saúde and Medical Subject Headings were "laughter therapy", "child", "preschool" and "hospitalized child", and the keywords "risotherapy" in different combinations. The timeframe was 10 years, starting from 2008. Results: The final sample for analysis consisted of 17 papers, organized into three categories: laughter therapy as a strategy to reduce pain, discomfort and suffering; Decreased fear, stress, and anxiety with laughter therapy; and the psychosocial impact of laughter therapy on hospitalized children. Conclusion: Some observed benefits from laughter therapy include decreased levels of pain, stress, and anxiety, as well as emotional and social changes. We emphasize the importance of this theme since it provides pediatric patients with a comprehensive and humanized care(AU)

Objetivo: Investigar en la literatura nacional e internacional el uso de la risoterapia con niños hospitalizados. Metodología: Revisión integrativa de literatura. Las bases de datos establecidas fueron: MEDLINE®, Cumulative Indexto Nursing and Allied Health Literature, PsycINFO®, Literatura Latino-Americana e do Caribe em Ciências da Saúde, Banco de Dados em Enfermagem ­ Bibliografia Brasileira e Índice Bibliográfico Español en Ciencias de la Salud. Los descriptores utilizados identificados en los Descritores em Ciência da Saúde y Medical Subject Headings fueron: "terapia de la risa", "niño", "preescolar" y "hospitalizado", y la palabra clave "risoterapia" en sus diferentes combinaciones. El plazo fue de 10 años, a partir de 2008. Resultados: La muestra final para el análisis consistió en 17 artículos, agrupados en tres categorías: La risoterapia como estrategia para reducir el dolor, las molestias y el sufrimiento; Disminución del miedo, el estrés y la ansiedad con la risoterapia y El impacto psicosocial de la risoterapia en los niños hospitalizados. Conclusión: Fue posible obtener beneficios de la terapia que incluyen disminución del dolor, estrés, ansiedad y cambios emocionales y sociales. Se enfatiza la importancia del tema porque a través de él es posible ofrecer a los pacientes pediátricos una atención integral y humanizada..(AU)

Efectividad de la risaterapia en manejo el dolor en pacientes pediátricos postoperados de apendicetomía / Effectiveness of laughter therapy in pain management in pediatric patients in postoperative appendectomy / Efetividades da risoterapia no manejo da dor em pacientes pediátricos em pósoperatório de apendicectomia

Objetivo: evaluar el efecto de la risaterapia en el manejo del dolor en pacientes pediátricos postoperados de apendicetomía versus pacientes que reciben tratamiento farmacológico. Método: ensayo clínico controlado, prospectivo, de corte longitudinal, en 32 pacientes divididos en 16 por grupo experimental y control, seleccionados aleatoriamente. El dolor fue evaluado en ambos grupos por la Escala Visual Análoga, constantes vitales, antes y después de la intervención de risaterapia y la terapia farmacológica. Resultados: la disminución del dolor mediante la risaterapia es efectiva (t= 4.138, p= .001; t=2.216, p = 0.043; respectivamente) en el grupo experimental versus en el grupo control, donde se aplico la terapia farmacologica (t= 5.436, p= .001; t=4.443, p = .001; respectivamente). Conclusión: la risaterapia tiene un impacto equitativo a la administración del medicamento en los pacientes pediátricos, además disminuye la frecuencia respiratoria y aumenta la saturación de oxígeno de los pacientes, al contrario de lo que sucede con el fármaco.

Objective: to evaluate the effect of laughter therapy on pain management in postoperative pediatric patients of appendectomy versus patients receiving pharmacological treatment. Method: controlled, prospective, longitudinal cut clinical trial, in 32 patients divided into 16 by experimental and control group, randomly selected. Pain was evaluated in both groups by the Visual Analog Scale, vital signs, before and after the intervention of laughter therapy and pharmacological therapy. Results: the decrease in pain through laughter therapy is effective (t = 4,138, p = .001; t = 2,216, p = 0.043; respectively) in the experimental group versus the control group, in which pharmacological therapy was applied (t = 5.436, p = .001; t = 4.443, p = .001; respectively). Conclusion: laughter therapy has an equitable impact on drug administration in pediatric patients, it also decreases respiratory rate and increases patients' oxygen saturation, unlike drug therapy

Objetivo: avaliar o efeito da risoterapia no manejo da dor em pacientes pediátricos em pós-operatório de apendicectomia versus pacientes em tratamento farmacológico. Método: ensaio clínico controlado, prospectivo e longitudinal, em 32 pacientes divididos em 16 por grupo experimental e controle, selecionados aleatoriamente. A dor foi avaliada em ambos os grupos pela Escala Visual Analógica, sinais vitais, antes e após a intervenção da risoterapia e terapia farmacológica. Resultados: a diminuição da dor através da terapia do riso é eficaz (t = 4.138, p = 0,001; t = 2,216, p = 0,043; respectivamente) no grupo experimental versus no grupo controle, onde a terapia farmacológica foi aplicada (t = 5,436, p = 0,001; t = 4,443, p = 0,001, respectivamente). Conclusão: a risoterapia tem um impacto equitativo à administração do medicamento em pacientes pediátricos, ademais diminui a frequência respiratória e aumenta a saturação de oxigênio dos pacientes, ao contrário do que ocorre com o fármaco.

Palhaçoterapia em ambiente hospitalar: uma revisão de literatura / Clown therapy in the hospital setting: A review of the literature

Resumo A inserção do palhaço no hospital é relativamente recente e mais de 700 organizações realizam a palhaçoterapia nessas instituições no Brasil e em outras ao redor do mundo. Dada a ênfase na integralidade do cuidado e humanização da assistência à saúde, torna-se oportuno compreender e analisar a produção nacional e internacional do conhecimento científico sobre esta prática que desafia o modelo hegemônico de cuidado e potencialmente contribui na recuperação da saúde. Foi realizada uma revisão de literatura utilizando análise de conteúdo temática que analisou 18 publicações. As categorias que emergiram foram: respostas fisiológicas, comportamentais e emocionais; ansiedade pré-operatória; e ressignificação das práticas e do ambiente hospitalar. A literatura analisada aponta que a palhaçoterapia provoca diminuição significativa da ansiedade pré-operatória em crianças, comparativamente maior do que a obtida com o uso de um fármaco indutor de anestesia. A maior parte dos estudos investigou o uso da palhaçoterapia na adaptação à hospitalização, auxiliando na atribuição de novos significados. Apesar da baixa representatividade do tema no campo científico e mesmo não sendo amplamente aceita como prática de saúde, os resultados encontrados sugerem benefícios na utilização da palhaçoterapia em ambiente hospitalar.

Abstract The presence of clowns in hospitals is relatively recent and more than 700 organizations now perform clown therapy in hospitals in Brazil and around the world. Considering the emphasis on comprehensive care and the humanization of health, it is timely to understand and analyze the national and international scientific literature on clown therapy. This practice challenges the hegemonic biomedical model and potentially helps in the recuperation of health. A review of the literature was conducted and 18 publications were analyzed using thematic content analysis. The following categories arose from the analysis: physiological, behavioral, and emotional responses; presurgical anxiety and attribution of new meanings to practices and the hospital environment. Results have shown that clown therapy leads to a significant decrease in preoperative anxiety in children, even compared with the results obtained with the use of anesthesia-inducing drugs. Most studies investigated the use of clown therapy during patients' adaptation to hospitalization, helping them to attribute new meanings to this situation. Despite its low representation in the scientific field and the fact that it has not been widely accepted as a health practice, several studies have shown the benefits of using clown therapy in the hospital setting.

Intervenciones no farmacológicas para reducir síntomas depresivos en mujeres con cáncer de mama / Non-pharmacological interventions to reduce depressive symptoms in women with breast cancer

Resumen: Objetivo: Describir y discutir los resultados de las intervenciones no farmacológicas (INF) adyuvantes en el tratamiento de los síntomas depresivos entre mujeres con cáncer de mama (CaMa). Material y métodos: Se realizó una revisión sistemática sobre INF, aplicadas a pacientes con cáncer y síntomas depresivos en siete bases de datos. La revisión se limitó del 1 de enero de 2006 al 31 de diciembre de 2017 y a los idiomas inglés, español y portugués. Los descriptores médicos empleados fueron "breast neoplasm" y "depression". Resultados: Existen diversas INF que pueden estimular principalmente las dimensiones físicas o psicosociales. En este artículo se propone una clasificación basada en nueve estrategias terapéuticas identificadas, entre las que sobresalen el ejercicio, la psicoterapia y el yoga con meditación. Conclusiones: Con base en la evidencia disponible, se concluye que la psicoterapia y yoga con meditación reducen los síntomas depresivos en pacientes con CaMa. Se requiere mayor investigación para determinar la magnitud de la reducción de los síntomas depresivos, de acuerdo con su gravedad, presencia de comorbilidades y diversidad de INF.

Abstract: Objective: To describe and discuss the results of non-pharmacological interventions (NPI) adjuvants in the treatment of depressive symptoms among women with breast cancer (BC). Materials and methods: A systematic review on NPI was performed, which was applied to patients with cancer and depressive symptoms in seven databases. The review was limited from January 1, 2006 to December 31, 2017 and to English, Spanish and Portuguese languages. The medical descriptors used were "breast neoplasm" and "depression". Results: There are several NPI that are able stimulate the physical or psychosocial dimensions. In this article we propose a classification based on nine identified therapeutic strategies, among which exercise, psychotherapy and yoga with meditation stand out. Conclusions: Based on the available evidence, we concluded that psychotherapy and yoga with meditation reduce depressive symptoms in patients with CaMa. More research is needed to determine the magnitude of the reduction of depressive symptoms, according to their severity, presence of comorbidities and diversity of INF.

Effects of a Laughter Therapy on Depression, Anxiety, Fatigue and Quality of Sleep in Gastrointestinal Cancer Patients Post-Treatment: a Randomized Controlled Trial

PURPOSE: The purpose of this study was to examine the effect of laughter therapy on depression, anxiety, fatigue, and quality of sleep in gastrointestinal cancer survivors. METHODS: This study was a randomized controlled trial. We compared the effect of laughter therapy with usual care only in post chemotherapy gastrointestinal patients. Outcomes included changes in depression and anxiety (according to the Hospital Anxiety and Depression Scale), fatigue (according to the Fatigue Severity Scale), and quality of sleep (according to the Verran & Synder-Halpern Sleep Scale). Data was collected July 2015 through January 2016. Seventy nine participants who agreed to participate in this study were randomized to either the experimental group (n=40) or the control group (n=39). Therapy included eight sessions (60 minutes each, once weekly). Data were analyzed using the Windows SPSS 22.0 program. RESULTS: Laughter therapy was effective in reducing fatigue (p=.019) and increasing satisfaction of sleep (p=.030). There were no differences between the groups after therapy for depression (p=.129) and anxiety (p=.200). CONCLUSION: Results of this study indicate that laughter therapy may be an effective nursing intervention for improving the health status of gastrointestinal cancer survivors after chemotherapy.

Risoterapia: una terapia complementaria a la medicina occidental / Laughter therapy: a complementary therapy to western medicine / Risoterapia: uma terapia complementar à medicina ocidental

Resumen La enfermedad y la hospitalización son factores estresantes, las instituciones tienen el deber de manejar de forma integral la salud de los pacientes. Para esto existen múltiples terapias complementarias como la risoterapia. Estas se basan en el humor para la promoción de la salud y se encargan de divertir a las personas, llevando sonrisas donde predominan los descontentos. Sus beneficios son múltiples y sus contraindicaciones son pocas, lo que la convierte en una estrategia costo-efectiva para mejorar la calidad de vida durante la hospitalización. Con este artículo, se pretende, no solo mostrar los asuntos más relevantes en la risoterapia, sino también motivar a investigar, así como concientizar al lector de la importancia de apoyar este nuevo boom.

Abstract Disease and hospitalization are stressful factors, institutions have a duty to comprehensively manage patients' health. For this there are multiple complementary therapies such as laughter therapy. These are based on humor for health promotion and are responsible for entertaining people, bringing smiles where usually there is discontent. Its benefits are multiple and its contraindications are few, which makes it a cost-effective strategy to improve life quality during hospitalization. This article, aims not only to show the most relevant issues in laughter therapy, but also to motivate research, as well as to create awareness among readers of the importance of supporting this new boom.

Resumo A doença e a hospitalização são fatores estressantes; nesse sentido, as instituições têm o dever de lidar de forma integral com a saúde dos pacientes. Para isso, existem múltiplas terapias complementares como a risoterapia. Esta se baseia no humor para a promoção da saúde e encarrega-se de divertir as pessoas, levando sorrisos aonde predominam os descontentamentos. Seus benefícios são múltiplos e seus contraindicações são poucas, o que a torna uma estratégia custo-efetiva para melhorar a qualidade de vida durante a hospitalização. Com este artigo, pretende-se não só mostrar os assuntos mais relevantes na risoterapia, mas também motivar a pesquisar, bem como conscientizar o leitor da importância de apoiar esse novo boom.

The Effects of Laughter Therapy Program on Perceived Stress, and Psycho-Neuro-Endocrino-Immuno Responses in Obese Women

PURPOSE: The purpose of this study was to examine the effects of the laughter therapy program on perceived stress and psycho-neuro-endocrine-immune responses in obese women. METHODS: A nonequivalent control group with a pretest-posttest design was used. The participants (n=60), whose age ranged from 30 to 50 years (pre-menopausal and body mass index of over 25 kg/m2), were assigned to the experimental group (n=24) or control group (n=26). The experimental group was provided with the laughter therapy program (12 sessions) for 6 weeks. RESULTS: There were significant differences in perceived stress, psychological stress response, fasting blood sugar, interleukin-6, and tumor necrosis factor alpha between the two groups after the program. However, there were no significant differences in normalized low frequency (norm LF), normalized high frequency (norm HF), LF/HF ratio, and cortisol between the two groups after the program. CONCLUSION: It was found that the laughter therapy program had positive effects on some variables in terms of perceived stress and psycho-neuro-endocrine-immuno responses. It is suggested that the laughter therapy in this study can provide the direction for developing a program for obese women.

Neuroimmunoendocrine trajectories and the response to stress and fatigue in pediatric cancer patients under chemotherapy submitted to clown intervention / Trajetórias neuroimunoendócrinas e resposta ao estresse e à fadiga em pacientes oncológicos pediátricos em tratamento quimioterápico submetidos à intervenção do palhaço

Cancer and the hospitalization process often have a psychological impact on the children and adolescents, usually leading to intense stress as well as fatigue. This especially applies to children and adolescents who have been submitted to chemotherapy, since it still constitutes a stressful and threatening experience for them and may exacerbate cancer symptom burden clusters, leading to a decrease in their health related quality of life (QoL). In addition, stress associated with cancer development leads to disturbances/disruption in the hypothalamicpituitary-adrenal (HPA) axis and suppresses important neuroimmunoendocrine pathways. Hence, interventions aimed at attenuating the physiological changes related to stress favor the recovery of the immune system and, consequently, induce alterations in neuroimmunoendocrine factors that increase immunological surveillance during cancer treatment. With the increase in cancer rates, it is crucial that healthcare professionals develop effective interventions to support pediatric cancer patients during the hospitalization process in order to relieve the burden of cancer treatment, which may contribute to a better prognosis of the disease. In an attempt to alleviate some of the cancer-related symptoms, pediatric oncology patients can take advantage of non-pharmacological interventions, including clown intervention, which can be a very advantageous approach to reduce unpleasant symptoms in pediatric cancer patients. However, few studies have investigated the molecular mechanisms that mediate health outcomes of clown intervention. The main purpose of this study was to investigate the effects of the clown intervention on psychological stress and cancer-related fatigue (CRF) in pediatric cancer inpatients undergoing chemotherapy. Also, we aimed to investigate whether changes in the levels of biomarkers, including cortisol, ?-amylase (sAA), cytokines, and matrix metalloproteinase-9 (MMP-9) are associated with psychological stress and CRF levels in pediatric osteosarcoma inpatients following clown intervention. A pretestposttest quasi-experimental study was undertaken with pediatric cancer inpatients. Eight nonfasting saliva samples were collected at identical times upon clown intervention, i.e., at baseline (pre-intervention) and post-intervention (+ 1h, + 4h, + 9h, and + 13h post awakening). Salivary cortisol, sAA, cytokines and MMP-9 concentrations were measured using high sensitivity Enzyme-Linked Immuno Sorbent Assay. Sociodemographic and clinical data, and Child Stress Scale-ESI(TM) and PedsQL(TM) Multidimensional Fatigue Scale were applied and the results were compared at baseline and after the clown intervention, and also correlated with biomarker trajectories. Data analysis was performed using nonparametric statistical tests. In comparison with baseline measurements, the overall psychological stress for pediatric cancer inpatients as well as their perception of fatigue improved upon clown intervention (p= 0.003; p= 0.049, respectively). There were no significant correlations between sAA and cortisol for both Areas Under Curve (AUC) at baseline or at post-intervention. Also, clown intervention reduced IL1? and salivary cortisol levels in pediatric osteosarcoma inpatients. Additionally, AUC for IL1? positively correlated with AUC for cortisol as well as with AUC for sAA at postintervention. In contrast, levels of IL-6, TNF-?, IL-12p70, IL-10, TGF-? and MMP-9 did not show significant differences upon clown intervention. Overall, our results suggest that clown intervention is a good non-pharmacological intervention to reduce psychological stress and CRF in pediatric cancer inpatients undergoing chemotherapy

O câncer e o processo de hospitalização comumente cursam com forte impacto psicológico sobre as crianças e adolescentes, gerando estresse e fadiga. Isto aplica-se especialmente, para àqueles sob quimioterapia, pois esta, constitui-se em uma das experiências mais estressantes e ameaçadoras que pode exacerbar os sintomas relacionados ao câncer e levar a uma diminuição da qualidade de vida (QV). O estresse associado ao desenvolvimento do câncer pode causar disrupturas no eixo hipotálamo-hipófise-adrenal, e suprimir importantes vias neuroimunoendócrinas. Assim, intervenções destinadas a atenuar as alterações fisiológicas relacionadas ao estresse podem favorecer a recuperação do sistema imune e induzir alterações neuroimunoendócrinas para potencializar a vigilância imunológica durante o tratamento oncológico. Com o aumento da incidência de câncer, é crucial que os profissionais de saúde desenvolvam intervenções eficazes para o manejo dos sintomas oncológicos, de modo a aliviar a sobrecarga do tratamento nesses pacientes durante o processo de hospitalização, de modo a contribuir para um melhor prognóstico da doença. Ademais, pacientes pediátricos oncológicos podem se beneficiar de intervenções não-farmacológicas, por exemplo, a intervenção dos clowns, para aliviar os sintomas relacionados ao câncer. Contudo, poucos estudos têm investigado os mecanismos moleculares envolvendo a intervenção dos clowns. Nosso objetivo principal foi investigar os efeitos da intervenção dos clowns sobre o estresse psicológico e a fadiga-relacionada ao câncer (FRC) em pacientes pediátricos oncológicos sob quimioterapia. Além disso, nós investigamos se alterações nos níveis de cortisol, ?-amilase (sAA), citocinas e metaloproteinases de matriz (MMP-9) estão associadas com estresse psicológico e com FRC de pacientes pediátricos com osteossarcoma submetidos à intervenção dos clowns. Trata-se de um estudo quase-experimental pré-teste/pós-teste. Foram colhidas oito amostras de saliva em momentos idênticos, isto é, no baseline (pré-intervenção) e no pós-intervenção (+ 1h, + 4h, + 9h e + 13h após o despertar). As concentrações de cortisol salivar, sAA, citocinas e MMP-9 foram mensuradas por ELISA. Dados sociodemográficos e clínicos foram coletados via prontuários médicos, além disso, foram aplicadas a Escala de Estresse Infantil-ESI(TM) e a Escala Multidimensional de Fadiga-PedsQL(TM). Os escores das escalas foram comparados entre o baseline e o pós-intervenção, e também, foram correlacionados com os níveis dos biomarcadores. Para análise dos dados, utilizou-se da estatística descritiva e estatística não paramétrica. Em comparação com as medidas do baseline, observamos que os níveis de estresse psicológico total, bem como os de fadiga geral dos pacientes pediátricos oncológicos, melhoraram significativamente após a intervenção dos clowns ( p= 0.003; p= 0.049, respectivamente). Não houve correlações significativas entre as Áreas sob Curva (AUC) da sAA e do cortisol no baseline e nem no pós-intervenção. Além disso, a intervenção dos clowns reduziu os níveis de IL-1? e de cortisol nos pacientes pediátricos com osteossarcoma. A AUC da IL-1? correlacionou-se positivamente com AUC do cortisol e com a AUC da sAA no pósintervenção. Inversamente, os níveis de IL-6, TNF-?, IL-12p70, IL-10, TGF-? e MMP-9 não mostraram diferenças significativas no pós-intervenção. Em síntese, nossos resultados sugerem que a intervenção dos clowns é uma boa intervenção não-farmacológica para reduzir o estresse psicológico e a FRC em pacientes pediátricos oncológicos sob quimioterapia

Terapia do riso como instrumento para o processo de cuidado na ótica dos acadêmicos de enfermagem / Laughter therapy as a tool for caring process from the viewpoint of nursing students

INTRODUÇÃO: O humor é uma estratégia de enfrentamento do estresse, mostrando sentimentos que geralmente são difíceis de expressar e que ajudam a lidar com o medo e as preocupações, evitando conflitos e aliviando a tensão. A terapia do riso pode ser utilizada como ferramenta terapêutica do humor, enfatizando a humanização do cuidado e promovendo melhora orgânica e emocional. OBJETIVO: Este estudo objetivou verificar a utilização e os benefícios da terapia do riso na ótica dos estudantes de enfermagem da Universidade Estadual de Feira de Santana. MÉTODOS: Trata-se de um estudo transversal analítico descritivo. A amostra foi constituída de 70 estudantes, sendo utilizado questionário individual, autoaplicável e pré-testado, composto de questões fechadas e abertas, que incluem variáveis sociodemográficas e relacionadas à terapia do riso, para que o aluno expresse sua crença sobre a terapia do riso. RESULTADOS: População predominantemente feminina, solteira e sem trabalho formal. Verificou-se que a maioria dos acadêmicos que cursaram a disciplina "Terapêuticas não Convencionais" conhecia e descreveu os benefícios da terapia do riso, sendo que um pequeno percentual dos que cursaram puderam presenciar ou utilizaram essa terapia. Foram observados no cliente benefícios como: elevação da autoestima, melhora da receptividade dos procedimentos, diminuição álgica e melhora do quadro clínico. CONCLUSÃO: Observou-se a necessidade de propagar, principalmente no âmbito acadêmico, a utilização de terapias integrativas como a terapia do riso, enquanto instrumento para o cuidar em enfermagem, visto que essa prática melhora a interação entre o enfermeiro e o cliente, e favorece a humanização do ambiente hospitalar.

INTRODUCTION: Humor is a stress coping strategy, which allows the expression of feelings that are often difficult to express and helps to handle fears and concerns. Thus, conflicts and tensions are relieved. The laughter therapy can use humor as a therapeutic tool, which emphasizes the humanization of care and promotes physical and emotional improvements. OBJECTIVE: This study aimed at verifying the use and benefits of laughter therapy from the viewpoint of nursing students from the State University of Feira de Santana. METHODS: Cross-sectional, analytical and descriptive study. The sample included 70 students and an individual, self-administered, and pre-tested questionnaire was applied. It consisted of closed and open-ended questions, with sociodemographic variables and questions related to laughter therapy, so that the students could express their beliefs about the laughter therapy. RESULTS: Population was predominantly female, single, and with no formal job. It was found that most academics who attended the course "Unconventional Therapies" knew and described the benefits of Laughter Therapy and a small already witnessed or used this therapy. Some benefits to the customers were observed, such as higher self-esteem, improved responsiveness to treatment, pain relief and clinical improvement. CONCLUSION: There is a need to disseminate, especially in the academic field, the use of integrative therapies such as laughter therapy as a tool for nursing care, as this practice improves the interaction between the nurse and the client and favors the humanization of hospital.

Humanização, psicologia e riso: produção de liberdade e processos de subjetivação / Humanization, psychology and laughter: production of freedom and subjectivity processes / Humanización, la psicología y la risa: producción de la libertad y de los procesos de subjetivación

Proponho problematizar a produção de processos de subjetivação por uma análise foucaultiana de racionalidades políticas que programam intervenções em hospitais com palhaços. Discursos que justificam e legitimam estas ações são tomados como fontes e, para analisá-los, dois eixos foram eleitos: a história das políticas e práticas de humanização e a história da relação entre a psicologia e o riso. A relação entre estes eixos evidencia-se na descrição de uma estratégia de poder que busca produzir sua própria crítica, ao incitá-la em suas práticas discursivas, e ao criar intervenções que parodiam suas próprias práticas. Estratégia que visa produzir processos de subjetivação e justifica-se no princípio de liberdade, criando uma razão binária que busca separar e colocar em relação de oposição os elementos poder e liberdade. Questiono, enfim, esta oposição ao eleger nas análises o palhaço como agente tático das políticas de humanização, que faz liberar em suas ações sentimentos e risos.

I propose to discuss the production processes of subjectivity by Foucault's analysis of rationales policies that program interventions in hospitals with clowns. Discourses that justify and legitimize these actions are taken as sources and to analyze them, two axes were elected: the history of political and humanization practices and the history of the relationship between psychology and laughter. The relationship between these axes is evident in the description of a power strategy that seeks to produce their own criticism, to excite it in their discursive practices, and to create interventions parodying their own practices. Strategy to produce subjective processes and is justified on the principle of freedom, creating a binary reason that seeks to separate and put in opposition relationship the elements power and freedom. Question, in short, this opposition to elect the analysis clown as tactical agent of humanization policies, which, in his actions, catalyzing freedom feelings and laughter.

Propongo discutir procesos de subjetivación mediante una análisis foucaultiana de certas razones politicas que fundamentan intervenciones de payasos en hospitales. Discursos que justifican y legitiman estas acciones se toman como fuentes y para analizarlos, se eligieron dos ejes: la historia de las prácticas políticas de la humanización y la historia de la relación entre la psicología y la risa. La relación entre estos ejes es evidente en la descripción de una estrategia de poder que busca producir su propia crítica, para instar a que en sus prácticas discursivas, y crear intervenciones parodiando sus propias prácticas. Estrategia para producir procesos subjetivos y se justifica en el principio de la libertad,em la creación de una razón binaria que busca separar y poner en relación de oposición el poder y la libertad. Pongo en duda,finalmente, tal oposición que elige el payaso como agente táctico de la política de humanización que tiene como objetivo la liveración de sentimientos e la risa.Enfim, esta oposição ao eleger nas análises o palhaço como agente tático das políticas de humanização, que faz liberar em suas ações sentimentos e risos.

The Effect of Subjective Xerostomia and Salivary pH in Salivary Glands Stimulated by Laughter Therapy in Frail Elderly Women

PURPOSE: The purpose of this study was to identify the effect of subjective xerostomia and salivary pH in salivary glands stimulated by laughter therapy in frail elderly women. METHODS: The research used a one-group pretest-posttest design. Data were collected from July 2, 2015 to September 30, 2015. A sample of 41 frail female elderly patients was recruited at A Nursing Home in K City, Korea. We measured xerostomia and salivary pH using a questionnaire and BCP test paper (pH 5.6~7.2). Laughter therapy was given once a week for four weeks (3 items). Data were analyzed through descriptive statistics, independent t-test, ANOVA, paired t-test and Cronbach's using the SPSS 18.0 program. RESULTS: There were significant differences in salivary pH according to oral health (t=-2.06, p<.05). There were significant differences in xerostomia (t=4.41, p<.001) and salivary pH (t=-7.94, p<.001) after salivary glands stimulated by laughter therapy. CONCLUSION: Salivary glands stimulated by laughter therapy improved xerostomia and salivary pH of the frail elderly. Therefore, salivary glands stimulated by laughter therapy may be useful in promoting and maintaining oral health among the frail elderly in the rapidly increasing population of old people.

Efeito da intervenção clown no padrão de depressão de idosos em instituição de longa permanência / Effect of clown interventions on depression levels among the geriatric long-term care institutions / Efecto de la intervención del payaso en los niveles de depresión en ancianos en una institución larga estancia

Objetivo: Verificar os efeitos da intervenção clown no padrão de depressão em idosos institucionalizados. Material e método: Estudo quantitativo experimental, realizado numa instituição de longa permanência de Di-vinópolis, Minas Gerais, Brasil. Utilizou-se a Escala de Depressão Geriátrica, Yesavage (GDS-15), aplicada em dois momentos, em dois grupos: intervenção (n=14) e controle (n=10). As intervenções foram visitas onde acadêmicos vestidos de palhaço realizaram atividades lúdicas. A comparação estatística da efetividade das intervenções foi realizada através do método JT. Resultados: Os resultados no primeiro momento demonstraram que no grupo controle 40% apresentavam depressão e após as atividades 50% apresentavam tal quadro. Já no grupo experimental não foram observadas mudanças quanto ao número de indivíduos com transtorno depressivo antes e após as intervenções. Pode-se inferir que a terapia do humor foi benéfica do ponto de vista da não progressão da depressão entre os idosos institucionalizados. Conclusão: Tornam-se necessários novos estudos a cerca da efetividade da animação clown para melhora dos traços de depressão em idosos.

Objective: To evaluate the effects of clown interventions on depression levels along the institutionalized elderly. Method: Quantitative study with an experimental approach, performed in institution geriatric long term Divinópolis, Minas Gerais, Brazil. The Geriatric Depression Scale was used in the reduced version of Yesavage (GDS-15) applied at two points and two elderly groups, having an intervention group (n = 14) and the other control (n = 10). The intervention consisted of visits, where academic gowns clown performed activities in clown mode. The statistical comparison of the effectiveness of interventions was performed using the JT method. Results: Of the 24 elderly participants, 14 (63.6%) were female and 10 (36.4%) were male. The application of the scale in the first time demonstrated that in the control group 40% had depression and after activities 50% had such a framework. You experimental group no changes were observed in the number of individuals with depressive disorder before and after the interventions. Thus, it can be inferred that therapy was beneficial humor point of view of non-progression of depression among institutionalized elderly. Conclusion: Become necessary new studies about the effectiveness of clown animation for improvement of traits of depression in institutionalized elderly.

Objetivo: Evaluar los efectos de las intervenciones de payasos en los niveles de depresión en los ancianos institucionalizados. Material y método: Estudio de abordaje cuantitativo experimental, realizado en institución geriátrica de larga estancia en Divinópolis, Minas Gerais, Brasil. La Escala de Depresión Geriátrica se utilizó en la versión abreviada de la Yesavage (GDS-15), aplicada en dos momentos y en dos grupos de edad avanzada, con un grupo de intervención (n = 14) y control (n = 10). La intervención consistió en visitas de académicos vestidos de payasos, en las cuales se llevaron a cabo actividades lúdicas. La comparación estadística de la eficacia se realizó a través del método de JT. Resultados: De los 24 ancianos, 14 (63,6%) fueron mujeres y 10 (36,4%) eran hombres. La aplicación de la escala, en un primer momento, mostró que en el grupo control, el 40% presentaban depresión y después de las actividades, el 50% presentaban dicho cuadro. En el grupo experimental no hubo cambios en el número de individuos con trastorno depresivo antes y después de las intervenciones. Se puede inferir que la terapia del humor fue beneficiosa desde el punto de vista de la progresión de la depresión entre ancianos institucionalizados. Conclusión: Se necesitan nuevos estudios con respecto a la efectividad de las intervenciones con payasos para la mejora de los rasgos de la depresión en los ancianos institucionalizados.

Cambios en la depresión y el sentimiento de soledad después de la terapia de la risa en adultos mayores internados / Changes in depression and loneliness after laughter therapy in institutionalized elders

Introducción. La vejez es una etapa que está enmarcada por una serie de fenómenos que inciden de forma negativa en la vida de las personas, entre otros, el sentimiento de soledad y la depresión. Objetivo. Evaluar el impacto de la terapia de la risa sobre el grado de depresión y el sentimiento de soledad, en un grupo de adultos mayores internados en centros gerontológicos. Materiales y métodos. Se hizo una investigación exploratoria con diseño cuasiexperimental, en la cual se aplicaron la escala de depresión de Yesavage y la escala ESTE de medición del sentimiento de soledad, ambas validadas para Colombia. La población objeto estuvo conformada por 49 adultos, entre hombres y mujeres de 59 años o más que viven en el hogar gerontológico Colonia de Belencito en el municipio de Medellín, Antioquia, en quienes se aplicó la terapia de la risa entre abril y julio de 2013. Se llevaron a cabo ocho sesiones semanales de terapia de la risa a cargo del grupo "Payasos Hospitalarios" de la Fundación Mediclaun de Medellín. Resultados. Se registró un descenso significativo en el grado de depresión, especialmente en aquellos con depresión inicial establecida (p<0,032). Las personas más receptivas fueron los adultos mayores internados sin pareja, con edades entre 65 y 75 años, pertenecientes al estrato dos y que recibían visitas. No se registraron cambios significativos en el sentimiento de soledad. Conclusión. Se resalta la importancia que tiene la terapia de la risa en la disminución del grado de depresión en adultos mayores. Los resultados concuerdan con la afirmación de que el constructo de soledad es independiente del de depresión.

Introduction: Old age is a stage characterized by a number of factors, such as loneliness and depression, that have a negative effect on people´s lives. Objective: To evaluate the impact of laughter therapy on the level of depression and loneliness in a group of institutionalized elders. Materials and methods: Exploratory research with quasi-experimental design applying Yesavage depression scale and the ESTE scale of loneliness, both validated for Colombia. The target population consisted of 49 men and women who were 59 years old or over, and lived in the Gerontological Home ´´Colonia de Belencito´´ in the city of Medellín (Antioquia); they were contacted between April and July 2013, and they received eight sessions of laughter therapy performed by the group "Hospital Clowns" of the Mediclaun Foundation from Medellín. Results: There was a significant decrease in the level of depression especially in those with initial depression established (p<0,032). The most receptive were institutionalized elders who did not have a couple, they were between 65 and 75 years of age, and they belonged to socioeconomic level 2 and did not receive visits. No significant changes in the level of loneliness were recorded. Conclusion: The importance of laughter therapy in reducing the level of depression in elders is highlighted. These results agree with the statement indicating that the construct of loneliness is independent from depression.

effects of laughter therapy on general health of elderly people referring to Jahandidegan community center in Shiraz, Iran, 2014: a randomized controlled trial

Aging and its social-biological process naturally impair the functions of different body organs and cause progressive disabilities in managing personal affairs and performing social roles. Laughter therapy is an important strategy which has been recommended by experts for increasing health promotion in older adults. Therefore, we aimed to investigate the effect of laughter therapy program on public health of senior citizens. In a randomized controlled trial, we enrolled 72 senior citizens aged 60 and over referring to Jahandidegan [Khold-e-Barin] retirement community center in Shiraz, southwest Iran during January to February 2014. The participants were assigned into experimental [N=36] and control [N=36] groups. Data were collected using General Health Questionnaire [GHQ-28] and demographic questionnaire. The participants of experimental group attended a laughter therapy program consisting of two 90-minute sessions per week lasting for 6 weeks. We found a statistically significant correlation between laughter therapy program and factors such as general health [P=0.001], somatic symptoms [P=0.001], insomnia and anxiety [P=0.001]. However, there was no statistically significant correlation among laughter therapy, social dysfunction [P=0.28] and depression [P=0.069]. We concluded that laughter therapy can improve general health and its subscales in elderly people

The Effect of Laughter Therapy on Arthralgia, Ankylosis, Depression, and Sleep of Elderly Housebound Women with Osteoarthritis

PURPOSE: The purpose of this study was to examine the effect of laughter therapy on arthralgia, ankylosis, depression and sleep of elderly housebound women suffering from osteoarthritis. METHODS: The study used a nonequivalent control group pretest-posttest design. The participants were 48 elderly women: 23 in the experimental group and 25 in the control group. The experimental group received laughter therapy twice a week for 4 weeks. The results were analyzed by using chi2-test, ANCOVA, and t-test with the SPSS/WIN 21.0 program. RESULTS: The results showed that laughter therapy had a significant statistical effective in reducing arthralgia, ankylosis, and depression and improving the quality of sleep as evidenced by the differences between the two groups. CONCLUSION: The results of this study indicated that laughter therapy is an effective nursing intervention reducing arthralgia, ankylosis, and depression and improving the quality of sleep in these women. Therefore, it is necessary to develop laughter therapy as an independent nursing intervention for elderly women with osteoarthritis who are housebound.

Effect and Path Analysis of Laughter Therapy on Serotonin, Depression and Quality of Life in Middle-aged Women

PURPOSE: This study was done to examine how laughter therapy impacts serotonin levels, QOL and depression in middle-aged women and to perform a path analysis for verification of the effects. METHODS: A quasi-experimental study employing a nonequivalent control group and pre-post design was conducted. Participants were 64 middle-aged women (control=14 and experimental=50 in 3 groups according to level of depression). The intervention was conducted five times a week for a period of 2 weeks and the data analysis was conducted using repeated measures ANOVA, ANCOVA and LISREL. RESULTS: Results showed that pre serotonin and QOL in women with severe depression were the lowest. Serotonin in the experimental groups increased after the 10th intervention (p=.006) and the rise was the highest in the group with severe depression (p=.001). Depression in all groups decreased after the 5th intervention (p=.022) and the biggest decline was observed in group with severe depression (p=.007). QOL of the moderate and severe groups increased after the 10th intervention (p=.049), and the increase rate was highest in group with severe depression (p<.006). Path analysis revealed that laughter therapy did not directly affect depression, but its effect was indirectly meditated through serotonin variation (p<.001). CONCLUSION: Results indicate that serotonin activation through laughter therapy can help middle-aged women by lessening depression and providing important grounds for depression control.

The Effects of Laughter Therapy on Anxiety and Depression of Burn Patients

PURPOSE: The study was a non-equivalent control group, quasi-experimental study to find out the effect of the laughter therapy on anxiety and depression of burn patients. METHODS: Study subjects were 60 hospitalized patients with the diagnosis of 2nd degree burn (30 experimental group; 30 control group). Experimental group received laughter therapy by the certificated therapist. STAI questionnaire, blood pressure and pulse were checked before and after the laughter therapy. RESULTS: Before and after the laughter implementation, the experimental group's anxiety decreased, however, the comparison group's anxiety did not show significant difference. Moreover, experimental group's anxiety decreased after the implementation. Experimental group's systolic blood pressure and diastolic blood pressure did not decrease pre/post laughter therapy mediator. The comparison group showed that systolic blood pressure increased, and diastolic blood pressure did not show significant difference. Also, experimental group's systolic blood pressure and diastolic pressure did not show significant difference after the treatment. Pre/post laughter therapy mediation did not decrease the experimental group's pulse and comparison group's pulse. Furthermore, the experimental group's pulse did not show the significant difference after the treatment. In pre/post laughter therapy mediation, the experimental group's depression was decreased, however, the comparison did not how significance difference in pre/post depression score after the treatment. Moreover, the experimental group's depression was decreased after the treatment. CONCLUSION: According the results above, the laughter therapy had effect on decreasing anxiety and depression of the burn patients and it is efficient mediator for the burn patient. Repetitive research was needed to investigate the effect of laughter on cardiovascular system since it did not have decreasing effect on the blood pressure and pulse.