Megan Tersteeg

Dr. Schur
Honors 205
March 6, 2018
Laughter as a Recovery Tool
Introduction
In the United States alone, 48 million surgical inpatient procedures are performed each year.
These procedures fix internal problems directly by repairing anatomy, but leave the patient with
many painful side effects that linger after the procedure. Depending on the type of surgical
intervention, the recovery time may extend much longer than desired and cause months of
painful episodes. Pain is managed in the hospitals using medications and sedatives, which mask
the sensations. Unfortunately, these medications can only be prescribed in small amounts
because they are costly and highly addictive. In recent years, laughter and humor have been
studied as an alternative to pain management in patients. These studies vary in the type of pain
they examine such as cold water induced pain or natural pain (arthritis), but most of these studies
have started to draw similar conclusions: laughter and humor can be used to decrease the
experience of pain.

Research Proposal
A wide variety of humor techniques have been tested in studies within the past decade.
Some hospitals and clinics use clown therapy to help pediatric patients, while others utilize
comedy movies or television shows to provoke humor. Although there have been numerous
studies performed, researchers are still trying determine if humor can really reduce pain and
healing time in patients. The limited research available on the topic shows that humor can be
used to reduce stress levels in patients. This benefit improves many physiological systems,
including the immune system and cardiovascular system. One study examined the effect of
humor on pain by having the participants watch a comedy video while enduring painful
transcutaneous end nerve stimulation. Those participants who watched the humorous video
reported less pain than those who watched a non-humorous video. Additionally, those
participants who watched the unhumorous video, but scored high on a measure of sense of
humor, shows just as much pain resistance as those who watched the funny video. These studies
show that there is some benefit to humor in health settings, but doctors are still unsure about the
science behind it or how far this concept can extend.
Due to the lack of previous research on the effect of humor on post-operative recoveries,
the present study aims to observe the impact of humor induced by viewing a comedy show or
unhumouros movie on the pain experience and healing time of patients after a knee replacement
surgery. This surgery leaves patients with extreme pain and is known to prescribe large amounts
of opitates. A better understanding of the effects humor can have as a pain management
alternative after surgery will not only provide additional knowledge of the interactions of humor
on the body but it can also allow doctors to utilize our natural endorphins to lower pain levels
rather than relying on addictive medications to lower pain.
 This study will take place at Barnes Jewish Hospital in St. Louis, MO in order to ensure
the patients’ medical treatment is the same. Volunteer participants will be randomly assigned to a
comedy show experimental group, unhumorous movie experimental group, or control group
(CG) using a computerized database to select for the variance of age and socioeconomic status.
The control group will not view any form of comedy during their post-operative stay and will be
used to compare the results from the experimental groups. The experimental participants will not
be informed on which group they are assigned to in order to the placebo effect in the
experimental groups. Participants in the comedy show experimental group will watch a 2-hour
standup comedy show the three consecutive days following their procedure. Tim Hawkins, Kevin
Hart, and Amy Schumer will perform the shows. The movie experimental group will watch three
documentaries that are 2 hours in length and watch them the three days following their surgery.
All three groups will receive these experimental procedures along with normal amounts of post-
surgical pain medication.
Two types of data will be collected from this study. The first will use hospital data to
determine clinical progress in the participants particularly the duration of the stay in the hospital
(in days) after the surgery as well as determining how long it takes to start rehab. The study will
also take ask the participants to complete a survey that rates their hospital experience to see if
there are improvements with the use of humor. The second set of data will be collected from
three different pain-rating scales to determine the effect of the humor on pain sensations. This
study will use the Wong/Baker pain rating scale, a self-evaluation numeric scale, and the
patient’s nurse evaluation of a pain rating scale. Once the data is successfully collected, the study
will compare the results between all three groups to determine if humor had any additional
benefits to healing time and pain reduction after knee replacement surgery.

Bertini, Mario, et al. “Clowns Benefit Children Hospitalized for Respiratory

Pathologies.”Evidence-Based Complementary and Alternative Medicine, Hindawi, 15 Mar. 2011,
www.hindawi.com/journals/ecam/2011/879125/.
The goal of this study was to determine the impact of humor on the health of hospitalized
children in the pediatrics respiratory department. They were interested in analyzing two main
goals: (i) observing the benefits on the patient's clinical progress caused by the clown therapy (ii)
determine the direct effect of the clown interaction on certain physiological and pain parameters
of the child. The study began by utilizing a computerized generator to randomly assign the 44
participants into the experimental (EG) and control (CG) groups accounting for participant’s age
and socio-economic and cultural background. Each group had 22 participants originally (due to
data loss of one patient the experimental group ended with 21 patients) and equal proportions of
identified pathogens. During the study, the control group did not have contact with any clowns
during their stay. The children in the experimental group attended a session with the clowns,
designed for seven to eight children at a time that lasted almost 3 hours (2 p.m. to 5 p.m.). These
sessions consisted of various activities such as magic tricks, gags, puppets, soap bubbles, games,
and word games. The children's parents were not present in the session. Due to the short
hospitalization stay, all of the EG participants only met with the clowns once.
 The many forms of data were collected from the study to examine different hypotheses.
In order to examine clinical progress the researchers collected data on the duration of hospital
stay, duration of fever period, and time taken to achieve clinical recovery. Medical tests such as
chest reports were performed to confirm the release of the patient. Physiological data (blood
pressure, heart rate, respiratory frequency, and axillary temperature) was drawn the the day
before, during, and after the interaction with the clowns. The same method was applied to the CG
excluding the interaction with the clowns. Finally, pain was evaluated utilizing the same
schedule as the physiological data. The researchers used three different pain scales (Wong/Baker,
self-evaluation numeric scale, and CHEOPS scale) to compare the experience of pain between
the CG and EG.
The results showed that there was a slight decrease of the duration of hospitalization stay
and fever duration in the EG, but it was not statistically significant. However, the data did show
that the EG experienced clinical improvement with a shorter healing time than the CG. As for
physiological factors, they were statistically insignificant differences between the CG and EG
although the EG did display a slight improvement on all categories. On the other hand, there was
a dramatic difference of pain levels between the two groups demonstrated in all three-pain scales.
The EG experienced a decrease of pain sensation after the therapy session compared to the CG.
The researchers concluded that the hypotheses “clown intervention in a pediatric
respiratory pathology ward could facilitate the healing process of the juvenile patients” and
“promote beneficial effects on some physiological and pain parameters of a child” were
supported by the data.
This study was extremely through in the explanations and reasonings behind their
methods. The researchers explained the background knowledge, reason for the study, exact
procedure they followed, and provided all the data obtained. Because of all of the detail and
guidelines followed by this study, it proves to be a strong source to examine. The only visible
weakness, which is stated within the article, is that humor has a wide range of effects on each
individual making it hard to objectify in similar studies. Additionally, clowns may be scary to
many of these children, which would affect their experience of humor during their session.
This source is important for my research because it shows that humor can have a positive
effect of pain levels and can improve physical symptoms of diseases. It can be used as a base to
build a similar study that examine pain levels before and after surgery rather than a pediatric
respiratory department to see if the same results appear.

Bell, Jean-Paul. “Laughter Is the Best Medicine.” The Art of Healing, Sept. 2010, pp. 42–
43.EBSCO, web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=7&sid=568d1b7d-9288-4510-
8a17-5ee2c43b379b%40sessionmgr120.
This article was an overview job description of the fifty-five therapy clowns in Australian
hospitals. The clown doctors are part of a non-profit organization called The Humor Foundation
which was created by the author of this article, Jean-Paul Bell, along with a five other
individuals. These individuals were interested on how to incorporate art into the medical field.
Because they were actors, they decided to take their passion offstage into the clinics and
hospitals as therapy clowns. They first started at the Royal Hobart Hospital in Tasmania as a pilot
program. Their main goal was to the boost morale of everyone they met in the hospital including
staff, patients, and families. The author explained how their main focus was to reduce patient
anxiety and help them endure their painful treatments. One important factor that they explained
in the article was that they never forced anyone to talk with them, but they were a support for
those that needed it. I find this beneficial because some people are afraid of clowns and others do
not enjoy talking during stressful situations. Giving the patients the option to participate
encourages an open relationship with the clowns making them feel more comfortable around
them. They described how they were able to help change the mindset of patients that were
struggling through procedures as well as family members that just needed a listening ear. They
describe multiple instances where they were able to lighten a tense environment with one simple
comment helping families laugh during difficult situations.
“Laughter is the Best Medicine” tends to have more weaknesses than strengths, but is still
useful when examining humor in medicine. This article is more of a summary of the
organizations experiences in the Australian hospitals rather than a study, so there are no
conclusions that can be drawn. Additionally, it mostly describes the goals and actions of the
therapy clowns rather than focusing on the effects they had on the patients and staff. However,
this article articulates these goals is such detail that it helps researchers to understand the steps or
mindset of the clowns. This is vital to understand when setting up studies and experiments.
This article is important to my research because it demonstrates that laughter and humor
can be a critical tool in medicine and patient care. Although this is only one form of humor that
can be used, it is important to understand that these “clowns” can be beneficial for more than just
patients. From the study, it is easy to see that humor can be used to “break the ice” or release
tension in hospitals.

Elmali, Hulya, and Reva Balci. “The Effect of Watching Funny and Unfunny Videos on Post-
Surgical Pain Levels.” Research Gate, 9 Apr. 2017,
www.researchgate.net/publication/307593845_THE_EFFECT_OF_WATCHING_FUNNY_AN
D_UNFUNNY_VIDEOS_ON_POST-SURGICAL_PAIN_LEVELS.

The goal of this study was to determine the effect of watching funny and unfunny videos
on post-surgical pain levels. The study consisted of ninety patients between the ages of 18 and 65
that were staying in a hospital’s Orthopedics and Traumatology Clinic. These volunteers were
split into three groups (each containing thirty individuals). Before the study began, the
researchers surveyed the participants to see what videos prompted laughter as well as what
videos were interesting. From this survey, the participants chose “joke shows” and
“documentaries” respectively. Group A consisted of patients who watched the funny video, group
B were patients that watched the unfunny video, and Group C didn’t watch any videos. The
researchers decided to use the Visual Analogue Scale (VAS) in order to analyze a patient’s pain
intensity at a given time.
 The experiment collected data in the evening hours to avoid conflicts with patient care
priorities. To get the baseline pain level, the participants were asked to rate their pain before
watching the video. Then, the participant would watch a funny, unfunny, or no video for twenty
minutes. The participants again rated their pain intensity using the VAS rating at zero and thirty
minutes after the video ended. The researchers wanted to test whether both videos produced
similar results or if humor was important to reducing pain intensity.
The results showed that all participants had similar pain levels before the twenty minutes;
however, pain intensity levels were significantly different after the videos. Group A and B had
lower pain levels after watching the funny video because laughter lowers the blood pressure and
levels of stress hormones, increases breathing rate, and aids in muscle relaxation. Surprisingly
both of these groups had similar reductions in pain intensity. Contrastingly, Group C’s pain levels
increased after the twenty minutes.
The researchers concluded that the videos provided a mode of distraction that took a
patient’s mind off the pain. The pain level recorded directly after the video ended was
significantly lower than the baseline score for both Group A and B. The data concluded that the
more an individual the finds interest in the video, the lower the pain level becomes.
There are many strengths in this article that make it credible. The researchers provided
detailed descriptions of its methods and procedures that it took to carry out the study.
Additionally, it simplified its variables to test the specific hypothesis and come to an accurate
conclusion. Its only weakness (which it states in the article) is “the absence of any distracting
intervention to control group of patients”.
This study is important for my research because it provides a platform for my study’s
hypothesis. It shows that there is a relationship between videos (funny or unfunny) as a form of
distraction to reduce pain and can be used as a post-surgical pain management tool. My study is
similar to this article, but will be testing a slightly different hypothesis that builds from this
study’s conclusions. It is also important for my research because it shows that this technique can
be successful with post-surgical patients (which I am also testing).

Dunbar, R.I.M, et al. “Social Laughter Is Correlated with an Elevated Pain Threshold.”Research
Gate, 26 Aug. 2011,
www.researchgate.net/publication/51645748_Social_laughter_is_correlated_with_an_elevated_p
ain_threshold.

The goal of this study was to determine if the physical action of laughter increases an
individual’s pain tolerance. They discussed other studies that showed positive effects of humor
on a patient’s physical health, but explained that they never tested to see if laughter itself was the
cause of the benefits. The researchers of this study believed that laughter triggers the activation
of the endorphin system, which plays a crucial role in managing pain. The researchers used
evaluated pain thresholds as a signal of an increase of endorphins because they do not cross the
blood-brain barrier. This study consisted of six different experiments to examine the difference
between funny and unfunny videos as well as live performances and their effect of pain
tolerance. Each experiment consisted of about forty participants and their method of “inflecting
pain” was using a frozen vacuum wine cooler sleeve. Data was collected based on how many
times they laughed and how long they could bear the pain.
The data from all six experiments shows that social laughter significantly evaluates pain
tolerance in both the laboratory and naturalistic settings. The laughter rates were highest in the
comedy experiment, however all the experiments had laughter recorded. Surprisingly, females
showed a higher benefit than males in experiments one and two, but the reverse was the case in
experiment three even though all three experiments were examining the effect of funny and
unfunny videos on endorphin activation. In all studies, the experimental groups and had overall
greater pain tolerance than the control, showing that laughter could be the cause of endorphin
activation.
This study was a relatively strong source of evidence. They explained a majority of their
procedure in detail, but some aspects were lacking especially when examining the setup of the
study. Additionally, when discussing the results, the researchers tried to bring in other hypothesis
to explain their findings and it was random in its organization. However, this data on laughter is
important to consider when studying humor’s effect on health. Because no other study has
looked at laughter as the cause of increased pain tolerance, it is important for me to realize that
cause of endorphin release by reside in a participant’s ability to laugh rather than just relying on
their sense of humor. I can use this information to build my study to examine the role of laughter
specifically on post-surgical pain rather than induced pain to see if there can still be a significant
effect.

McGee, Paul. “Humor and Health.” Nurses Learning,

www.nurseslearning.com/courses/nrp/nrpcx-w0009/html/body.humor.htm.
This article contains a collection of multiple different experiments testing humor’s effect
of pain reduction. All of the studies listed in the article came to conclusion that humor/laughter
does lower pain sensation in patients. For example, two individuals suffering each suffering from
a different disease (arthritis or a spinal disease), found that their pain went away after ten minutes
of belly laughter. This idea was tested in studies in Japan and Sweden. The Japanese study
showed that listening to an hour of traditional comic stories reduced the level of pain
experienced by patients with arthritis. It is important to note that the pain level experienced in
conditions like arthritis and multiple sclerosis increases in the presence of negative emotion
states. Furthermore, the Swedish study reported that six women suffering from painful muscle
disorders achieved a significant reduction in pain levels because of a thirteen-week course in
humor therapy. These studies clear show that humor and laughter can be used as a form of pain
management therapy. In a study of “35 patients in a rehabilitation hospital, 74% agreed with the
statement, ‘Sometimes laughing works as well as a pain pill’. These patients were suffering from
conditions such as traumatic brain injury, spinal cord injury, arthritis, limb amputations, and a
range of other neurological or musculoskeletal disorders”. Because of all the evidence
surrounding laughter’s postive effects on pain, it is not surprising that many pain centers around
the country now use medications as well as laughter to manage patient’s pain.
This article’s strengths were giving an overview of the general conclusions drawn from
many different studies on pain. It provided a brief explanation of specific studies that could be
researched individually for their methods and procedures in order to improve my own study.
Because this article was an overview, it lacked the detail that was expressed in the previous
articles I listed. The studies that were described were the conclusions that were drawn and what
disease was being analyzed. It would be important to research the procedure each of these studies
used to determine if they are reliable.
This source is important to my research because it shows that multiple studies have
proven the basis of my hypothesis. Because multiple studies have already concluded humor has a
positive effect on pain, I can expand on this idea and determine the extent to which it can help
patients suffering form post-surgical pain. This article is also useful because it draws evidence
from multiple different studies that I can examine for more information in my own study. This
article proves that doctors and patients believe in the beneficial effects of humor, which I will use
to guide my research on the effect of humor on post-surgical pain.