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Feasibility trial of guided imagery and control interventions in mock subjects
Abstract
This article reports a Phase I feasibility trial of a guided imagery intervention in 20 healthy volunteers. Structural equivalence of a placebo control intervention of listening to audio book segments was evaluated. Content analysis of participant journals and exit interviews suggest suitability and acceptability of both the guided imagery and control interventions. Suggestions for their use in future clinical trials are discussed.
... The GI exercises included relaxation techniques, music, positive imagery, and components specifically designed for pain management, i.e., "now imagine that you leave all the pain you have experienced at the beach post." Jacobson et al. [11,12] examined the effects of GI on functional outcomes of a total knee replacement (TKR) in a pilot randomized controlled trial (RCT). The GI intervention was designed to promote functional outcomes after a TKR. ...
Purpose of Review
Guided imagery (GI) is a non-pharmacological method used to reduce pain, stress, and anxiety. No comprehensive review has yet investigated the application of GI in musculoskeletal medicine, its various types, and potential mechanisms. The aim of this comprehensive narrative review was to examine the types of GI used in musculoskeletal medicine and GI effect on pain and health-related quality of life.
Recent Findings
A comprehensive narrative review of the English language scientific literature. PubMed, Google Scholar, ProQuest, and PEDro databases were searched from inception until August 2020 using keywords related to GI, musculoskeletal disorders, pain, and health-related quality of life. The search results generated 133 articles. After a critical analysis, 12 publications were included in this review. GI characteristics and protocols varied significantly between studies.
Summary
Based on the reviewed studies, we advocate GI as a safe, non-invasive technique that can assist in managing pain, depression, stress, fatigue, anxiety, reducing medication use, improving general well-being, wellness, and quality of life in patients with musculoskeletal disorders. We recommend further investigations of GI mechanisms.
... Although persons in the study stopped engaging in the intervention 3 weeks after surgery, participants in the GI group may have gained stress reduction techniques as a result of 5 weeks of GI intervention 6 months earlier. This explanation is compatible with previous reports of a ''carryover'' effect from a brief GI intervention, 97 which may lead to persistent effects of relaxation, enhanced pain management, and improved outlook and mood. 94 Our HCC data are in line with recent research suggesting that hair cortisol analysis is a useful tool to evaluate the effects of a stress-reduction intervention on long-term cortisol secretion. ...
Objectives:
To determine the effect of guided imagery (GI) on functional outcomes of total knee replacement (TKR), explore psychological and neuroimmune mediators, and assess feasibility of study implementation.
Design:
Investigator-blinded, randomized, placebo-controlled pilot study.
Settings:
Hospital, surgeon's office, participant's home.
Participants:
82 persons undergoing TKR.
Interventions:
Audiorecordings of TKR-specific GI scripts or placebo-control audiorecordings of audiobook segments.
Outcome measures:
Gait velocity and Western Ontario and McMaster Universities Arthritis Index (WOMAC) Function scale.
Results:
Outcomes for 58 participants (29 receiving GI and 29 controls) were analyzed at 6 months after surgery. The most frequent reason for noncompletion was protocol-driven exclusion at 6 months for having the contralateral knee replaced before the study endpoint (n = 15). With imaging ability as a moderator, gait velocity, but not WOMAC Function score, was significantly improved at 6 months in the GI group. Participants in the GI group, but not the control group, had lower WOMAC Pain scores at 3 weeks after surgery than at baseline. Hair cortisol concentration was significantly lower at 6 months after surgery than at baseline in the GI group but not the control group. GI group participants had lower treatment adherence but greater treatment credibility than the control group.
Conclusion:
Randomized controlled trials of GI in the TKR population are feasible, but inclusion/exclusion criteria influence attrition. Further studies are needed to elaborate this study's findings, which suggest that guided imagery improves objective, but not patient-reported, outcomes of TKR. Hair cortisol concentration results suggest that engagement in a time-limited guided imagery intervention may contribute to stress reduction even after the intervention is terminated. Further investigation into optimal content and dosing of GI is needed.
... Accompanied the player is a notebook for participants to record their listening session, throughout the study period Participants' feedback on the method was assessed through questionnaire developed from extensive literature review. 16,18,19 The questionnaire consists of three sections. The first section asked about the quality of the script itself, the voice, narrator and the quality of recording. ...
Introduction: There is limited data regarding the use of relaxation technique in managing knee osteoarthritis in Asian population.
The use of a placebo is the gold standard for establishing the efficacy of new treatments in randomized controlled trials (RCTs). Placebo treatments are inert; this allows specific effects of the experimental treatment to be separated from nonspecific physiological, psychological, and social effects. The aim of this study was to scrutinize the workings of an audiobook (AB) placebo treatment, which was used in a placebo-controlled, investigator-blinded, RCT of the effect of guided imagery (GI) to improve pain and function in persons undergoing total knee replacement. A secondary analysis of quantitative and narrative data collected during the RCT was performed. The AB treatment provided attention control. Participants in the AB group identified benefits—pleasant get-away, new knowledge, quiet time-out, and inspiration; however, there was also evidence of resentful demoralization, especially in the postoperative period. The use of ABs as a placebo treatment in GI RCTs should be executed with caution.
Maternal stress during pregnancy has been associated with numerous adverse pregnancy, birth, and health outcomes. Pregnant African American women have been reported to have higher levels of stress compared to other ethnic or racial groups underscoring the need for effective interventions to reduce stress in this population. The purpose of this study was to gain an in-depth understanding of the perceptions of guided imagery (GI) as a technique for stress management in a cohort of pregnant African American women who participated in a GI intervention as part of a larger mixed methods randomized controlled trial. The 12week intervention was a professionally recorded compact disc with four tracks developed and sequenced to reduce stress and associated symptoms. The findings from this descriptive phenomenologic study were derived from daily logs and interviews from 36 participants randomized to the GI group. Participants described the stressful nature of their lives. Results demonstrated pregnant African American women perceived the intervention as beneficial in reducing stress and the associated symptoms. The emergent themes suggested the intervention offered a respite from their stressful lives, reduced the negative emotional responses to stress and enhanced well-being, benefited other areas of their daily life, and provided an opportunity to connect with their baby. The study results support the perceived efficacy of GI as a stress coping intervention. GI is an economic as well as easy to implement, access and use technique that has potential stress coping benefits as perceived by pregnant African American women.
Copyright © 2015 Elsevier Inc. All rights reserved.
The concept of therapeutic landscape, as introduced to geographers by Gesler, has had a significant impact on what has become a reformed geography (or geographies) of health. Burgeoning research in this field has developed the number and type of sites that have been characterised as therapeutic landscapes. It is notable, however, that in this expansion, little focus has been given to imagined therapeutic landscapes, perhaps indicating a dominance of positivist, masculinist approaches. Although several researchers provide suggestions as to what these mindscapes might depict, little more than anecdotes currently exist. This research explores the imagined therapeutic landscapes of 80 trainee social care professionals, based on thematic analysis influenced by Heideggerian hermeneutic phenomenological approaches. Findings indicate that although there may be widespread unity in the mindscapes of many, the diversity within each field is notable. This study also notes that, although primacy is routinely given to the visual landscape, the impact of the other senses in moulding therapeutic mindscapes must not be underestimated. Cultural and gender relationships are explored and suggestions for further research are made.
To measure the effectiveness of customized guided imagery for increasing comfort in women with early stage breast cancer.
Experimental longitudinal, random assignment to groups.
Two urban radiation oncology departments.
53 women (26 in the experimental group, 27 in the control group) aged 37-81; 80% European and 10% African American with stage I or II breast cancer about to begin radiation therapy.
The experimental group was to listen to a guided imagery audiotape once a day for the duration of the study. The Radiation Therapy Comfort Questionnaire was self-administered at three time points: prior to the introduction of intervention and the beginning of radiation therapy (Time 1), three weeks later (Time 2), and three weeks after completing radiation therapy (Time 3). The State Anxiety Inventory was administered at Time 1 only.
The effect of use of guided imagery on comfort with anxiety as a control variable.
Pooled data indicated a significant overall increase in differences in comfort between the treatment and control group, with the treatment group having higher comfort over time. The data also revealed a significant linear trend in differences between groups. No significant interaction of group and time existed.
Guided imagery is an effective intervention for enhancing comfort of women undergoing radiation therapy for early stage breast cancer. The intervention was especially salient in the first three weeks of therapy.
Guided imagery audiotapes specifically designed for this population were resource effective in terms of cost, personnel, and time.
The diagnosis and treatment of breast cancer are stressful, and stress may be associated with a poorer response to chemotherapy. There is a need, therefore, to develop and evaluate interventions that might enhance quality of life and, possibly, improve treatment response. The effects of relaxation combined with guided imagery (visualizing host defences destroying tumour cells) on quality of life and response to primary chemotherapy, to date, have not been adequately evaluated. Ninety-six women with newly diagnosed large or locally advanced breast cancer (T2 > 4 cm, T3, T4, or TxN2 and M0) took part in a prospective, randomized controlled trial. Patients were randomized following diagnosis to a control condition (standard care) or to the experimental condition (standard care plus relaxation training and imagery). Psychometric tests to evaluate mood and quality of life were carried out before each of the six cycles of chemotherapy and 3 weeks after cycle 6: tests of personality and coping strategy were carried out prior to cycles one and six. Clinical response to chemotherapy was evaluated after six cycles of chemotherapy using standard UICC criteria and pathological response was assessed from the tissue removed at surgery. As hypothesized, patients in the experimental group were more relaxed and easy going during the study (Mood Rating Scale). Quality of life was better in the experimental group (Global Self-assessment and Rotterdam Symptom Checklist). The intervention also reduced emotional suppression (Courtauld Emotional Control Scale). The incidence of clinically significant mood disturbance was very low and the incidence in the two groups was similar. Finally, although the groups did not differ for clinical or pathological response to chemotherapy, imagery ratings were correlated with clinical response. These simple, inexpensive and beneficial interventions should be offered to patients wishing to improve quality of life during primary chemotherapy.
Clinical research has demonstrated that guided imagery, a simple form of relaxation, can reduce preoperative anxiety and postoperative pain among patients undergoing surgical procedures. In 1998, the cardiac surgery team implemented a guided imagery program to compare cardiac surgical outcomes between two groups of patients: with and without guided imagery. Data from the hospital financial cost/accounting database and patient satisfaction data were collected and matched to the two groups of patients. A questionnaire was developed to assess the benefits of the guided imagery program to those who elected to participate in it. Patients who completed the guided imagery program had a shorter average length of stay, a decrease in average direct pharmacy costs, and a decrease in average direct pain medication costs while maintaining high overall patient satisfaction with the care and treatment provided. Guided imagery is now considered a complementary means to reduce anxiety, pain, and length of stay among our cardiac surgery patients.
This review considers psychological interventions involving relaxation and guided imagery targeting immune functions. The review provides evidence of immune control accompanied by reports of enhanced mood and well-being. Three recent investigations of the author and his colleagues with self-hypnosis training incorporating imagery of the immune system are outlined. In two studies, hypnosis buffered the effects of stress on immune functions in medical students at exam time, and the comparison of self-hypnosis with and without immune imagery confirmed advantages to targeted imagery for both immune function and mood, and importantly, fewer winter viral infections. The implications for health were investigated in a third study in patients with virulent and chronic herpes simplex virus-2 HSV-2). Six weeks of training almost halved recurrence, improved mood and reduced levels of clinical depression and anxiety. Immune functions were up-regulated, notably functional natural killer cell activity to HSV-1. Individual differences in hypnotic susceptibility and absorption have typically been found to predict efficacy. New replicable evidence is reviewed of the importance of cognitive activation, a personality difference whose neurophysiological underpinning is consistent with left hemispheric preferential influences over the immune system. Now that the validation of psychological interventions includes advantages for health, this field of enquiry, which has been characterised by modest, small scale, largely preliminary studies, warrants a greater investment in research.
Although an assumption of consistency in intervention delivery is key to the conclusion that the findings are valid, attention to both interventionist adherence and competence has not become a standard in nursing intervention research.
The purpose of this article is to describe the technology model of intervention fidelity as it applies to psychosocial interventions, and to propose its application in nursing intervention research as a way to support accurate conclusions about validity.
The features and methods of the Technology Model of intervention fidelity were reviewed. The review included development of a manual, training and supervision of interventionists, measurement of intervention fidelity, and inclusion of intervention fidelity as an independent variable in the analysis.
The Technology Model and the associated methodologies that have been used to monitor psychosocial intervention fidelity in psychiatry can be adapted and applied by nursing. Monitoring costs can be managed through use of a general system that can be applied across programmatic or related studies.
Application of the Technology Model of intervention fidelity could advance the maturation of nursing intervention research and evidence-based clinical practice.
The aim of this study was to investigate whether brief psychologic interventions to reduce perioperative stress may improve the postoperative course of patients undergoing abdominal surgery.
We used a randomized, controlled, partially blinded trial to evaluate the differential effectiveness of two brief psychologic interventions (guided imagery and progressive muscle relaxation) on analgesic requirement, pain perception, pulmonary function, duration of postoperative ileus, and fatigue after conventional resection of colorectal carcinoma in elderly cancer patients.
Sixty patients (20 guided imagery, 22 relaxation, 18 control) were evaluated. Acceptance of the brief psychologic interventions was high and 90 percent of the patients indicated that they would recommend it to other patients. Analgesic consumption (P = 0.6) and subjective pain intensity at rest (P = 0.3) and while coughing (P = 0.3) were not different between groups. Recovery of pulmonary function, duration of postoperative ileus, and subjective postoperative fatigue were also not influenced. When the data from intervention groups were pooled, again no benefits were detected compared with the control group.
Brief psychologic interventions such as guided imagery and relaxation yielded a very positive patient response but did not show a clinically relevant influence on the postoperative physiologic course of elderly patients undergoing conventional resections of colorectal cancer.
The purpose of the present study was to examine the effectiveness of imagery on muscular endurance, dynamic balance, and functional stability in athletes who sustained a grade II ankle sprain. The sample consisted of 20 active athletes (aged from 18 to 30 years) with a grade II ankle sprain, as confirmed by ultrasound testing. The participants were randomly divided into two groups of 10 participants each; one experimental and one control group. The experimental group received 12 individual sessions of imagery rehearsal in addition to a normal course of physical therapy, while the control group followed only the physical therapy treatment. Results revealed significant differences only in the variable of muscular endurance. This study partly supports the contribution of imagery to the functional rehabilitation of grade II ankle sprain. Further research should be conducted to examine the effect of imagery on the functional rehabilitation of sport injuries using other tests of functional rehabilitation along with larger sample sizes.
The general view of descriptive research as a lower level form of inquiry has influenced some researchers conducting qualitative research to claim methods they are really not using and not to claim the method they are using: namely, qualitative description. Qualitative descriptive studies have as their goal a comprehensive summary of events in the everyday terms of those events. Researchers conducting qualitative descriptive studies stay close to their data and to the surface of words and events. Qualitative descriptive designs typically are an eclectic but reasonable combination of sampling, and data collection, analysis, and re-presentation techniques. Qualitative descriptive study is the method of choice when straight descriptions of phenomena are desired. © 2000 John Wiley & Sons, Res Nurs Health 23:334–340, 2000.
The general view of descriptive research as a lower level form of inquiry has influenced some researchers conducting qualitative research to claim methods they are really not using and not to claim the method they are using: namely, qualitative description. Qualitative descriptive studies have as their goal a comprehensive summary of events in the everyday terms of those events. Researchers conducting qualitative descriptive studies stay close to their data and to the surface of words and events. Qualitative descriptive designs typically are an eclectic but reasonable combination of sampling, and data collection, analysis, and re-presentation techniques. Qualitative descriptive study is the method of choice when straight descriptions of phenomena are desired.
The purpose of this experiment was to determine the effects of an audiotape series employing Relaxation with Guided Imagery (RGI) on the psychophysiologic stress response and wound healing in surgical patients. Twenty-four patients undergoing cholecystectomy were randomly assigned to either RGI or control (quiet period) conditions and measured against three indexes of recovery: state anxiety, urinary cortisol levels, and wound inflammatory responses. An analysis of variance for repeated measures revealed that the RGI group demonstrated significantly less state anxiety, lower cortisol levels one day following surgery, and less surgical wound erythema than the control group. Thus, the RGI tapes demonstrated stress-relieving outcomes closely associated with healing.
This study compares the effectiveness of guided imagery and progressive muscle relaxation in reducing pain and distress. Thirty adult oncologic patients in a large military hospital listened to two taped transcripts in random order; one used guided imagery and the other progressive muscle relaxation. Patients rated their pain and distress on a 10 cm analog scale before and after listening to each tape. The results indicated that both strategies were equally effective in reducing pain and distress in this small sample. The majority of patients expressed a preference for the progressive muscle relaxation technique. Nurses are encouraged to use these strategies in helping oncologic patients reduce pain and distress.
Existing evidence suggests that preoperative psychological preparation that is designed to reduce anxiety may sensitize cortisol and adrenaline responses to surgery. In a controlled trial of abdominal surgery patients, we therefore tested the effects of a preoperative preparation that used guided imagery, not to reduce anxiety, but to increase patients' feelings of being able to cope with surgical stress; 26 imagery patients were compared with 25 controls who received, instead, background information about the hospital. State-anxiety was similar in each group, but imagery patients experienced less postoperative pain than did the controls, were less distressed by it, felt that they coped with it better, and requested less analgesia. Hormone levels measured in peripheral venous blood did not differ on the afternoon of admission, before preparation. Cortisol levels were, however, lower in imagery patients than in controls immediately before and after surgery. Noradrenaline levels were greater on these occasions in imagery patients than controls. The results are interpreted in relation to two theories. One states that preoperative "worry" reduces surgical stress. The other concerns the influence of active and passive coping on endocrine responses to stress.
The purpose of this study was to determine if the addition of guided imagery to a standard antiemetic regimen decreased nausea, vomiting, and retching occurrence and distress in patients receiving cisplatin-based chemotherapy. A convenience sample of patients (N = 28) was selected from an oncologist's patient population and randomized into two groups. Both groups received the same standard antiemetic regimen, while the experimental group additionally used a chemotherapy-specific guided-imagery audiotape. The Rhodes Index of Nausea and Vomiting Form 2 was used to measure the nausea and vomiting experience. Findings revealed no statistically significant difference in this measurement between the two groups when measured at five different times during chemotherapy administration. The Chemotherapy Experience Survey was used to evaluate the participants' overall perceptions of the chemotherapy experience. The guided-imagery group expressed a significantly more positive experience (p = 0.0001) with chemotherapy. These findings have definite implications for developing effective nursing interventions to promote patient involvement in self-care practices and to increase patient coping abilities during symptom occurrence.
To examine the effects of progressive muscle relaxation and guided imagery on psychological and physiologic outcomes in adults with cardiovascular disease who were participating in a phase II cardiac rehabilitation program. To examine tension levels, practice patterns, and perceived helpfulness of the intervention reported by subjects.
Prospective, quasi-experimental, with random group assignment within sites. Independent replication and extension of a study by Bohachik (1984).
Four midwestern hospital-based phase II cardiac rehabilitation programs.
Fifty patients who within the preceding 12 weeks had had acute myocardial infarction or coronary artery bypass surgery or both, studied during 6 weeks of participation in a phase II cardiac rehabilitation program.
Psychological measures included state and trait anxiety scores on the State-Trait Anxiety Inventory and reported symptoms on the Symptom Checklist-90-Revised. Physiologic measures were resting heart rate and blood pressure. Subjective tension levels before and after home practice, practice patterns, and perceived helpfulness of the intervention were examined.
Individual instruction session in progressive muscle relaxation and guided imagery at the phase II cardiac rehabilitation program, followed by daily home practice with audiotape instructions over a 6-week period.
No statistical differences at the p < or = 0.05 level were found in state anxiety scores or reported symptoms at study exit. However, reductions in mean subscale scores for interpersonal sensitivity (t [19] = 2.11, p < or = 0.05) and depression (t [19] = 2.07, p < or = 0.05) by paired t tests were found for the relaxation group (RG). The two groups differed at study exit in resting heart rate (t [42] = -2.02, p < or = 0.05) by independent t tests and in systolic blood pressure (F [1,42] = 5.13, p < or = 0.05) by analysis of covariance. The RG had a mean resting heart rate 8.6 beats/min lower than that of the control group (CG) and also had within-group reductions in mean heart rate (t [19] = 2.09, p < or = 0.05) by paired t tests. Contrary to expectation, the CG had a 3.5 mm Hg lower mean systolic blood pressure and within-group reductions in systolic (t [22] = 3.02, p < 0.01) and diastolic (t [22] = 3.83, p < 0.01) blood pressure by paired t tests. CG subjects had a greater number of dose increases in cardiac medications and fewer dose reductions than did RG subjects, who also had a higher number of dose reductions. RG subjects reported frequent practice of the technique, rated it as helpful, and reported lower subjective tension levels after practice.
Findings in this study did not support those of Bohachik (who reported lowered state anxiety and fewer somatization, interpersonal sensitivity, and depression symptoms). More instruction sessions on the relaxation method may have resulted in more positive outcomes. However, the within-group scores for interpersonal sensitivity and depression, the reduction in heart rate, and the receptivity of subjects to this intervention suggest that it may be a feasible and helpful adjunctive therapy for participants in a phase II cardiac rehabilitation program.
A review of literature concerning relaxation and imagery interventions for cancer pain is necessary because major review articles have excluded nursing research or were written prior to the publication of controlled studies in cancer pain conducted by nurses. This review of published nursing/medical/psychological literature of adults with cancer pain conducted over the past 14 years (1982-95) revealed few controlled studies, weak theoretical frameworks, few complete descriptions of the nature of the pain problem, and lack of control over the interventions. Most had very small sizes and could not demonstrate significant effects. Additionally, the intervention methods and length of the interventions were highly variable. Despite these design shortcomings, relaxation and imagery appear to reduce the sensory experience of pain, have equivocal effects on affective measures, and appear to have no effect on functional status. Suggestions for improvement include the need for more experimental studies, more complete descriptions of pain, improved statistical reporting, controls over adequacy of and compliance to the interventions, use of single interventions, and use of more complex measures of affective outcomes. Additionally, the paper contains a discussion of the problems of measuring selected outcome variables in this type of research.
Guided imagery is an independent nursing intervention that uses psychoneuroimmunology (PNI) principles to assist an individual in the management of distressing symptoms. The purpose of this article is to discuss the use of guided imagery in holistic nursing practice. The concepts of PNI are described and the basic steps of guided imagery are presented. PNI research and nursing research on guided imagery as an intervention are reviewed. The principles of guided imagery and PNI are applied to holistic nursing practice. Suggestions for future research methodologies, including psychological, neuroendocrine, and immunological measurements to evaluate the effectiveness of guided imagery, are offered. Rationale for using human immunodeficiency virus infection as a disease model to study the effectiveness of guided imagery is provided.
Clinical research on psychosocial and behavioral medicine interventions has burgeoned in the past two decades, so much so that sole reliance on standard no-treatment control conditions may no longer be appropriate or feasible. We discuss the ethical, theoretical, scientific, and statistical considerations that shape current clinical outcomes research for psychosocial and behavioral medicine interventions.
Secondary analysis of a psychosocial randomized trial (N = 127) illustrates some of these points.
A new design for randomized clinical trials is described that does not require a no-treatment control group, and that reveals dose-response relationships between interventions and treatment outcomes.
Patients who undergo surgery usually experience fear and apprehension about their surgical procedures. Guided imagery is a simple, low-cost therapeutic tool that can help counteract surgical patients' fear and anxiety. The authors randomly assigned 130 patients undergoing elective colorectal surgical procedures into two groups. Members of one group received routine perioperative care. Members of the other group listened to guided imagery tapes for three days before their surgical procedures, during anesthesia induction, intraoperatively, in the postanesthesia care unit, and for six days after surgery. The authors measured patients' anxiety levels, pain perceptions, and narcotic medication requirements. The patients in the guided imagery group experienced considerably less preoperative and postoperative anxiety and pain, and they required almost 50% less narcotic medications after their surgical procedures than patients in the control group.
Imaging ability, the ability to generate mental images and become absorbed in them as if they were real, is proposed as a moderator in the relationship between guided imagery and symptom relief. Two existing measures of image generation, Marks's (1973) Vividness of Visual Imagery Questionnaire and Betts's (1909) shortened Questionnaire Upon Mental Imagery (Sheehan, 1967), and one measure of absorption, Tellegen's Absorption scale (1993; TAS) were completed by 60 graduate students prior to listening to a guided imagery intervention to relieve anxiety associated with an upcoming stressful task. Analyses were conducted using data from 30 participants (7 men and 23 women) who reported an increase in anxiety level after learning of the stressful task. Participants were divided into two groups, successful (n=21) and unsuccessful (n=9) users of imagery, based on change in anxiety scores after listening to the guided imagery intervention. Absorption (TAS) scores were significantly higher for persons in the successful group; there were no differences in image generation scores. Two TAS items were identified as potential predictors of success with guided imagery. Findings may be helpful in developing a clinically useful instrument to predict likelihood of success with guided imagery in relieving cancer pain and its distress.
For the past several decades, papers in the nursing literature have advocated the use of cognitive interventions in clinical practice. Increasing consumer use of complementary therapies, a cost-driven health care system, and the need for evidence-based practice all lend urgency to the validation of the efficacy of these interventions. This review focuses specifically on guided imagery intervention studies identified in the nursing, medical and psychological literature published between 1966 and 1998. Included were 46 studies of the use of guided imagery for management of psychological and physiological symptoms. There is preliminary evidence for the effectiveness of guided imagery in the management of stress, anxiety and depression, and for the reduction of blood pressure, pain and the side effects of chemotherapy. Overall, results of this review demonstrated a need for systematic, well-designed studies, which explore several unanswered questions regarding the use of guided imagery. These include the effects of different imagery language, symptoms for which guided imagery is effective, appropriate and sensitive outcome measures, method of delivery of the intervention and optimum dose and duration of the intervention, and individual factors that influence its effectiveness.
To discuss and describe the role of relaxation and imagery in the care of patients with cancer, including suggestions for enhancing assessment and brief instructions for implementing basic interventions.
Relaxation and imagery are commonly used to treat various side effects of cancer and its treatment. The nursing literature often has encouraged nurses to use relaxation and imagery to assist patients in managing pain, nausea, vomiting, and anxiety. Frequently, the literature has presented these techniques as being simple, harmless interventions requiring little assessment, planning, or individualization.
Simplistic, generalized approaches may result in suboptimal treatment or deleterious responses.
Clinicians must assess and collaborate with patients in developing an appropriate strategy that fits the individual's preferences and beliefs.
The impact of guided imagery, a method of visualization and relaxation, on exercise performance and quality of life was studied in 8 patients with severe heart failure. No significant improvement was observed in exercise capacity although some trends for improved quality of life were observed.
The general view of descriptive research as a lower level form of inquiry has influenced some researchers conducting qualitative research to claim methods they are really not using and not to claim the method they are using: namely, qualitative description. Qualitative descriptive studies have as their goal a comprehensive summary of events in the everyday terms of those events. Researchers conducting qualitative descriptive studies stay close to their data and to the surface of words and events. Qualitative descriptive designs typically are an eclectic but reasonable combination of sampling, and data collection, analysis, and re-presentation techniques. Qualitative descriptive study is the method of choice when straight descriptions of phenomena are desired.
The patient in acute care settings can have severe emotional and physical stresses that are also experienced by family and significant others. The experience in a hospital has often been described as overwhelming; it can evoke feelings of fear, anger, helplessness, and isolation. Guided imagery, one of the most well-studied complementary therapies, is used increasingly to improve patients' experiences and healthcare outcomes. More and more, patients are relying on the use of guided imagery to provide a significant source of strength, support, and courage as they prepare for a procedure or manage the stresses of a hospital stay. This article provides a brief review of the research base for guided imagery and broad indications for its use. It describes key elements of the therapy and outlines steps to implement a program of guided imagery that can be used in variety of settings.
To determine the effect of adjuvant guided imagery on patients with chronic tension-type headache.
Management of chronic tension-type headache often requires a combination of pharmacological and nonpharmacological therapies. Guided imagery is a relaxation technique based on visualizing pleasant images and body awareness.
One hundred twenty-nine patients with chronic tension-type headache completed the Headache Disability Inventory and the Medical Outcomes Study Short Form (SF-36) at their initial visit to a specialty headache center and again 1 month after the visit. In addition to individualized headache therapy, patients listened to a guided imagery audiocassette tape daily for the month. One hundred thirty-one control subjects received individualized therapy without guided imagery.
Controls and the patients who listened to the guided imagery tape improved in headache frequency, headache severity, patient global assessment, quality of life, and disability caused by headache. More guided imagery patients (21.7%) than controls (7.6%) reported that their headaches were much better (P = .004). The guided imagery patients had significantly more improvement than the controls in three of the SF-36 domains: bodily pain (95% CI; guided imagery patients 11.0, controls 0.2), vitality (95% CI; guided imagery patients 10.9, controls 1.7), and mental health (95% CI; guided imagery patients 7.8, controls 0.4).
Guided imagery is an effective adjunct therapy for the management of chronic tension-type headache.
We examined the long-term effects of a behavioral intervention on the psychological distress of patients recently diagnosed with localized cancer, who were being treated at Hadassah University Hospital. All 116 patients who met the inclusion criteria (49 men and 67 women) were randomized into an intervention group and a control group on a 3:1 basis. The intervention chosen was Progressive Muscle Relaxation with Guided Imagery, which is intended to decrease psychological distress and increase the patient's sense of internal control. The Brief Symptom Inventory (BSI) and the Impact of Events Scale (IES) were used to assess psychological distress within 1 month of diagnosis, 3 months later (shortly before starting intervention), and 6 months after the end of the intervention. At the final assessment, the effect of the behavioral intervention on psychological distress was positive. The effect was relatively modest but statistically significant when assessed in terms of the Global Severity Index (GSI) (a decrease of 2.3 points in the GSI of the treatment group as compared to an increase of 1.2 points in the GSI of the control group P=.005). Despite these moderately positive findings, we suggest that the results might be more meaningful if cancer patients are first screened for psychological distress to exclude those with a low distress level that does not justify intervention, and only then randomized for participation in the study.
Although emerging evidence during the past several decades suggests that psychosocial factors can directly influence both physiologic function and health outcomes, medicine had failed to move beyond the biomedical model, in part because of lack of exposure to the evidence base supporting the biopsychosocial model. The literature was reviewed to examine the efficacy of representative psychosocial-mind-body interventions, including relaxation, (cognitive) behavioral therapies, meditation, imagery, biofeedback, and hypnosis for several common clinical conditions.
An electronic search was undertaken of the MEDLINE, PsycLIT, and the Cochrane Library databases and a manual search of the reference sections of relevant articles for related clinical trials and reviews of the literature. Studies examining mind-body interventions for psychological disorders were excluded. Owing to space limitations, studies examining more body-based therapies, such as yoga and tai chi chuan, were also not included. Data were extracted from relevant systematic reviews, meta-analyses, and randomized controlled trials.
Drawing principally from systematic reviews and meta-analyses, there is considerable evidence of efficacy for several mind-body therapies in the treatment of coronary artery disease (eg, cardiac rehabilitation), headaches, insomnia, incontinence, chronic low back pain, disease and treatment-related symptoms of cancer, and improving postsurgical outcomes. We found moderate evidence of efficacy for mind-body therapies in the areas of hypertension and arthritis. Additional research is required to clarify the relative efficacy of different mind-body therapies, factors (such as specific patient characteristics) that might predict more or less successful outcomes, and mechanisms of action. Research is also necessary to examine the cost offsets associated with mind-body therapies.
There is now considerable evidence that an array of mind-body therapies can be used as effective adjuncts to conventional medical treatment for a number of common clinical conditions.
Guided imagery is an intervention used by nurses in a variety of settings. It has been suggested that better outcomes will occur with continued practice. No studies were found that examined the relationship between practice duration and strength of outcomes. The focus of this meta-analysis was the effect size of guided imagery intervention studies with different durations. Statistical findings of 10 studies of various durations were converted to d statistics and plotted against the duration of study. The results show an increase in effect size of guided imagery over the first 5 to 7 weeks; however, the effect was decreased at 18 weeks.
This un-blinded experimental study investigated the effectiveness of imagery, in addition to routine analgesics, in reducing tonsillectomy and/or adenoidectomy pain and anxiety after ambulatory surgery (AS) and at home. Seventy-three children, aged 7-12, were recruited from five AS settings. Thirty-six children randomly assigned to the treatment group watched a professionally developed videotape on the use of imagery and then listened to a 30-min audio tape of imagery approximately 1 week prior to surgery (T1). They listened to only the audio tape 1-4 h after surgery (T2), and 22-27 h after discharge from AS (T3). The 37 children in the attention-control group received standard care. Pain and anxiety were measured at each time-point in both groups. Measures of sensory pain were the Oucher and amount of analgesics used in AS and home; affective pain was measured with the Facial Affective Scale (FAS). Anxiety was measured using the State Trait Anxiety Inventory for Children (STAIC). When controlling for trait anxiety and opioid and non-opioid intake 1-4 h before the pain measures, MANCOVA showed significantly lower pain and anxiety in the treatment group at T2, but not at T3. When controlling for trait anxiety, a two-way RM MANCOVA indicated no significant group differences in combined opioid and non-opioid use between the groups, or between times. Appropriately trained health care providers should use imagery to reduce post-operative pain following tonsillectomy and/or adenoidectomy in AS. Teaching parents about adequate home administration of analgesics may increase the effectiveness of imagery at home.
Despite the growing number of studies of imagery and the use of complementary and alternative modalities as treatments for asthma, research on mental imagery in adults with asthma is practically, nonexistent. The purpose of this feasibility study was to lay groundwork for a larger follow-up clinical trial.
To determine whether pulmonary function, asthma symptoms, quality of life, depression, anxiety, and power differ over time in adults with asthma who do and do not practice mental imagery (MI). (Power is the ability to make aware choices with the intention of freely involving oneself in creating desired change.)
Randomized controlled study using univariate repeated measures analysis of variance (ANOVA) and replacement through block design.
Lenox Hill Hospital, an affiliate of New York University Medical School, New York, NY.
Sixty-eight adults with symptomatic asthma, after 4 weeks of baseline data collection and analysis, met requirements for this randomized controlled study. Thirty-three completed pulmonary function as well as self-report tests at 4 time points over 17 weeks. The 16 experimental participants also completed the 4-session imagery protocol.
Individual imagery instruction (week 1) and follow-up (weeks 4, 9, 15). Participants were given 7 imagery exercises to select from and practice 3 times a day for a total of 15 minutes.
1) Spirometry (FEV1); 2) medication use; 3) Asthma Quality of Life Questionnaire; 4) Beck Depression Inventory; 5) Spielberger Anxiety Scales (A-State and A-Trait); 6) Barrett Power as Knowing Participation in Change Tool, Version II; 7) Epstein Balloon Test of Ability to Image.
There was little evidence of statistical change in this feasibility study; yet, valuable lessons were learned. Paired t-tests indicated there was a significant difference in the total power scores in the imagery group, and in the expected direction (two-tailed, t-statistic = -2.3, P = 0.035) and the choices sub-scale (two-tailed, tstatistic = -2.93, P = 0.01) of the power instrument from weeks one to 16 of the study. Eight of 17 (47%) participants in the MI group reduced or discontinued their medications. Three of 16 (19%) participants in the control group reduced their medications; none discontinued. Chi-square indicated differences between groups (X2 = 4.66, P = 0.05). Persons who reduced or discontinued their medications showed neither an increase in pulmonary function prior to medication discontinuation, nor a fall in these parameters following discontinuation.
Findings related to major outcome measures must be viewed with caution due to the small sample size resulting from attrition related to labor intensiveness and, therefore, low statistical power. However, the study did provide significant data to plan a larger scale study of the use of mental imagery with adult asthmatics. The study also demonstrated that imagery is inexpensive, safe and, with training, can be used as an adjunct therapy by patients themselves. Its efficacy needs additional exploration. Further research for adults with asthma who practice imagery is important, as current treatments are not entirely efficacious. Lessons learned in this study may facilitate improvement in research designs.
The aim of this study was to explore the effects of guided imagery relaxation in people with chronic obstructive pulmonary disease (COPD) using a randomized controlled design. Half of 26 participants were allocated to the treatment group in which six practice sessions on guided imagery were conducted, while the control group was instructed to take rest quietly during the six sessions. At the seventh session, physiological changes: partial percentage of oxygen saturation; heart rate; upper thoracic surface electromyography; skin conductance; and peripheral skin temperature were recorded during a 30-minute session with a sampling frequency of one minute. Repeated measures analysis of variance was used to explore the changes of the parameters between the groups. Mann-Whitney U test was used to compare the change of perceived dyspnoea between the groups. Results showed there was a statistically significant (p < 0.05) increase in partial percentage of oxygen saturation in the treatment group, but no significant effects on the other physiological parameters. Further study exploring the psychological effects of guided imagery is suggested.
Osteoarthritis (OA) is a common, chronic condition that affects most older adults. Adults with OA must deal with pain that leads to limited mobility and may lead to disability and difficulty maintaining independence. A longitudinal, randomized clinical trial pilot study was conducted to determine whether Guided Imagery (GI) with Progressive Muscle Relaxation (PMR) would reduce pain and mobility difficulties of women with OA. Twenty-eight older women with OA were randomly assigned to either the treatment or the control group. The treatment consisted of listening twice a day to a 10-to-15-minute audiotaped script that guided the women in GI with PMR. Repeated-measures ANOVA revealed a significant difference between the two groups in the amount of change in pain and mobility difficulties they experienced over 12 weeks. The treatment group reported a significant reduction in pain and mobility difficulties at week 12 compared to the control group. Members of the control group reported no differences in pain and non-significant increases in mobility difficulties. The results of this pilot study justify further investigation of the effectiveness of GI with PMR as a self-management intervention to reduce pain and mobility difficulties associated with OA.
To describe the importance and process of gathering the perspectives of former patients when designing clinical studies for complementary and alternative medicine (CAM) therapies and to describe how this information was used to guide the planning of a clinical study using complementary modalities to reduce symptom distress and enhance quality of life during the autologous stem cell transplantation (ASCT) process.
Structured interviews with former ASCT patients to identify preferences, opinions, and other issues that may affect a clinical study in this population.
University of Virginia Health System Stem Cell Transplant Clinic.
Ten (10) patients who had undergone ASCT within the previous year.
In general, the 10 study participants interviewed reported that they would have been more receptive to receiving gentle Swedish massage than using guided imagery tapes during the ASCT process, although neither modality would have been particularly welcome during those treatment phases with highest physical or emotional/mental stress. Personal experiences, treatment side-effects, "personality," and life situation all had an influence on not only what was considered most stressful for the patient but also why it was perceived as stressful.
Eliciting the views of persons who have undergone significant medical events is a necessary step in rigorous clinical trial development aimed at testing the efficacy of CAM modalities for symptom management. Consideration of patient preferences and motivations may ensure the best fit between interventions and the desired outcomes.
In the current research environment the design and management of control groups is becoming more complex. The selection of a control group design is dependent on study goals, presence and quality of existing interventions, urgency of the problem or issue being addressed by the intervention, and factors related to the study site. The purpose of the presentation is to identify various approaches to the design of control groups in experimental studies and to identify their strengths, limitations, and applications. A case study exemplifies the issues associated with control group selection and design.
The purpose of this article is to address issues in maintaining the integrity of a behavioral intervention. Examples are provided from a recently completed study on how to train research staff and monitor the integrity of the intervention. In this exemplar, the integrity of the behavioral intervention was addressed by the design of the study and research staff training. Throughout the study, the integrity of the behavioral intervention was monitored by delineating a checklist of topics that must be addressed, critiquing audiotapes of the intervention, and discussing incomplete or missing elements with the research staff.
To examine the effectiveness of guided imagery for immediate smoking cessation and long-term abstinence in adult smokers.
A repeated measures design was used with 71 smokers recruited from a hospital outpatient clinic, 38 in the intervention group, and 33 in the control group.
Both study groups received educational and counseling sessions in their homes. The intervention group was provided with additional instruction in the use of guided imagery and was encouraged to practice this imagery at least once per day with a 20-minute audio-taped exercise for reinforcement. The repeated measures included smoking rates (cigarettes per day) that were measured and confirmed through corroborating friends and family.
At 24-months after the intervention, smoking abstinence rates were significantly higher for the guided health imagery intervention group (26% abstinence rate versus 12% abstinence rate for the placebo-control group).
Guided imagery was an effective intervention for long-term smoking cessation and abstinence in adult smokers.
Complementary therapies (touch, music) are used as successful adjuncts in treatment of pain in chronic conditions. Little is known about their effectiveness in care of heart surgery patients. Our objective is to evaluate feasibility, safety, and impact of a complementary alternative medical therapies package for heart surgery patients.
One hundred four patients undergoing open heart surgery were prospectively randomized to receive either complementary therapy (preoperative guided imagery training with gentle touch or light massage and postoperative music with gentle touch or light massage and guided imagery) or standard care. Heart rate, systolic and diastolic blood pressure, and pain and tension were measured preoperatively and as pre-tests and post-tests during the postoperative period. Complications were abstracted from the hospital record.
Virtually all patients in the complementary therapy group (95%) and 86% in standard care completed the study. Heart rate and blood pressure patterns were similar. Decreases in heart rate and systolic blood pressure in the complementary therapies group were judged within the range of normal values. Complication rates were very low and occurred with similar frequency in both groups. Pretreatment and posttreatment pain and tension scores decreased significantly in the complementary alternative medical therapies group on postoperative days 1 (p < 0.01) and 2 (p < 0.038).
The complementary medical therapies protocol was implemented with ease in a busy critical care setting and was acceptable to the vast majority of patients studied. Complementary medical therapy was not associated with safety concerns and appeared to reduce pain and tension during early recovery from open heart surgery.
To evaluate whether the specific techniques of a newly developed behavioral therapy exceed the effects of its common factors (e.g., therapeutic alliance), an ideal comparison control must omit the unique ingredients of the active treatment while possessing the common factors in equal measure. Reviews of the controlled-trial psychotherapy research literature show that such systematic matching is not a common practice. Addressing this gap between theory and practice, we delineate 7 steps for designing a credible control for a recently developed behavioral therapy adapted for binge eating disorder--dialectical behavior therapy (DBT). Our detailed description of matching the common factors to the extent possible and specifically measuring these offers a useful research design template for investigators of controlled behavioral treatment trials.
Although the design of the study we undertook was randomized, the groups were statistically similar, the intervention was based on evidence of previous efficacy, and the treatment was delivered exactly as planned, this pilot study on an intervention to promote motivation for weight loss in new mothers failed to produce an effect. A closer examination using criteria for intervention fidelity revealed a number of weaknesses. Both treatment integrity and differentiation merit careful consideration in intervention design.
It was hypothesized that music or guided imagery versus usual care would result in less anxiety and perceived pain for colposcopy patients.
Patients were randomized to music, guided imagery, or usual care after completing a baseline questionnaire. All patients completed a postprocedure questionnaire.
Study participants (N=170) had a mean age of 28.4 years (SD=9.6; range 18-60) and formed a racially diverse group. Education/income levels were low. No between-group differences were found for postprocedure anxiety or pain rating.
Mind-body interventions had no statistically significant impact on reported anxiety, perceived pain, or satisfaction with care, even for those who anticipated the most pain or started with high anxiety.
Treatment of breast cancer is usually associated with significant psychological stress. In this study, we examined the effects of relaxation and visualization therapy (RVT) on psychological distress, cortisol levels, and immunological parameters of breast cancer patients undergoing radiotherapy.
Participants were randomly assigned to either the experimental (n=20) who underwent group RVT for 24 consecutive days or control group (n=14) who were on radiotherapy only. Psychological scores (stress, anxiety, and depression) were measured by structured clinical interviews. Salivary cortisol was assessed along the day. Lymphocytes were isolated and cultured to measure T-cell proliferation and sensitivity to glucocorticoids (GCs).
RVT was effective to reduce stress, anxiety, and depression scores (all P<.05). However, cortisol levels as well as proliferation remained unchanged following RVT. Although T cells of experimental group were more sensitive to GCs than cells of controls at baseline, no changes were noted following RVT. Cortisol levels were positively correlated to anxiety and depression scores and inversely correlated to T-cell proliferation and sensitivity to GCs.
We conclude that the psychological intervention was capable to attenuate the emotional distress presented during radiotherapy treatment. A longer RVT or worse psychological morbidity at baseline may be necessary to translate psychological into biological changes.
Chapter 6. Categorical-content perspective. Narrative research: Reading, analysis, and interpretation (pp. 112−140)
- A Lieblich
Lieblich, A. (1998). Chapter 6. Categorical-content perspective. Narrative research: Reading, analysis, and interpretation (pp. 112−140). Thousand Oaks, CA: Sage Publications.
The effects of guided imagery relaxation in people with COPD Effect of guided imagery on quality of life for patients with chronic tension-type headache
- S W Louie
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Focus on research methods. Whatever happened to qualitative description? Research in Nursing & Health The control group dilemma in clinical research: Applications for psychosocial and behavioral medicine trials
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