The
Use of Guided Imagery in Pain Management
Abstract
According to recent statistics,
treatment plans in the field of pain management that rely solely on pain
suppression are inadequate. Because the
pain experience is multidimensional, it is important to address the
psychological component in addition to the physiological mechanism of
pain. The use of guided imagery is
proven to provide many benefits in a wide range of pain patients. This includes decreased pain levels, enhanced
psychological functioning, and a sense of control. Guided imagery can easily be incorporated
into various existing psychological techniques or used alone as an inexpensive
adjunct to traditional treatment methods.
Because the efficacy of guided imagery techniques depends on having the
flexibility to adapt to individual preferences, attempts at standardization can
diminish results.
Keywords:
guided imagery, pain management, alternative medicine, visualization
As
the cost of pain management in healthcare continues to skyrocket, simple and
inexpensive alternative methods of pain control prove to be a worthwhile tool
to use in order to decrease the length of hospital stays and reduce medical
costs. Medical intervention, such as
surgery or prescription medication, is heavily relied upon to treat pain
patients. However, according to recent
statistics, drugs only reduce chronic pain by 30-40 percent in fewer than 50
percent of patients, and more than 40 percent of patients who are implanted
with pain relieving devices will experience significant adverse effects (Turk, Swanson,
& Tunks, 2008). In addition to this,
certain types of pain, such as chronic neuropathic and radicular pain, are of
special importance because they are often unaffected by pharmaceutical methods
of pain relief or anti-inflammatory drugs (DeLeo, 2006). Patients afflicted by this category of pain
are in dire need of functioning treatment programs to provide some sense of
relief.
The
downfall of traditional medical techniques for treating pain is that they often
focus solely on pain suppression (McCracken, 1999). Pain affects an individual
on multiple levels, and cognition can play a large role in the experience of
pain. Any negative cognitions that
become associated with pain, along with the individual's emotional state of
mind, can contribute greatly to its overall effects (Turk et al., 2008). Often,
psychological intervention is not part of the treatment plan until clinical
levels of accompanying psychological dysfunction have been recorded or the pain
has reached an elevated level of severity for extended periods of time. Because the experience of pain is now
commonly viewed as a multidimensional psychophysiological occurrence, this
oversight makes little sense (Barber, 1996).
The failure of medical and pharmaceutical treatment in pain management
suggests that a comprehensive treatment plan, which includes coping methods to
deal with acute and chronic pain, should be included prior to the onset of
severe dysfunction, instead of later.
The use of guided imagery (GI) is a simple, yet effective, technique
which can be incorporated into any treatment program to assist in addressing
many of these overlooked aspects of the pain experience.
Guided
Imagery in Pain Management
Since
the focus of traditional biomedicine remains grounded in treating the
physiological symptoms of pain, while largely ignoring its social and
psychological components, the experience of pain as a whole is often not
addressed in Western medicine (Kleinman, Brodwin, Good, & DelVicchio-Good,
1992, as cited in Pincus & Sheikh, 2009).
Western culture and scientific study has firmly distanced itself from
the traditional shamanic ways of seeing and evaluating the human
experience. According to Pincus and
Sheikh, conceptual boundaries in the field of scientific study have been
created which limit complementary dualities, such as body/mind,
reality/imaginary, and spirituality/science in order to disconnect each pair
into a distinctly separate category of its own.
Western models of thinking have been struggling to overcome this
self-imposed restriction on conceptualization, and this limitation of thought
also extends into the role of biomedical theory as it relates to the psychology
of pain management.
Historically,
imagery and the imagination have always been a part of the healing process
(Lewandowski, Good, & Draucker, 2005).
As science and medicine have evolved, ancient methods of folk healing
have become abandoned and thought of as primitive quackery. According to Eliade (1964), the shamanic
healing system is based on techniques of entering into altered states of
consciousness in order to engage and interpret the realm of the imagination (as
cited in Achterberg, 1985). The
subconscious imagination, along with cultural beliefs and general expectations,
helps to shape cognitions surrounding health and healing. This becomes apparent upon examining the
potent role of the placebo effect as a meaning response in healthcare (Moerman,
2002). The powerful use of imagery that
is the foundation of the shamanic tradition is now the inspiration of the modern
use of imagination in some practices of psychology and healthcare today
(Achterberg). The use of guided imagery
(GI) in pain management is one way to engage the creative psychological
processes in order to create a substantial effect that has been proven to
enhance medical and pharmaceutical treatment or can be used on its own.
The
terms guided imagery and hypnosis are often interchangeable and involve many
similar and overlapping features. They
are generally defined as "states of highly focused attention during which
alteration of sensations, awareness, and perceptions can occur" (Syrjala
& Abrams, 1996, p. 231). There are
several other psychological techniques that fall into this categorical definition
which also includes progressive muscle relaxation, breathing exercises,
mindfulness training, and meditation.
Due to similarities between these treatments, protocols which involve
guided imagery can often incorporate multiple methods (Syrjala & Abrams, 1996). For example, most studies of progressive
muscle relaxation (PMR) have incorporated some form of guided imagery (GI) into
their protocols used (Baider et. al., 2001, as cited in Chen & Francis,
2010). According to Syrjala and Abrams,
"an individualized approach with labels and language that fit the
patient's request and personal style" is the most effective in regards to
pain management (p. 233). An analysis of
the efficacy of cognitive-behavioral methods for pain control reported that the
most efficient component among the various techniques was the use of imagery
(Fernandez & Turk, 1989, as cited in Syrjala & Abrams). According to Eller's (1999) review of 46
guided imagery intervention studies, 87 percent of these studies found that
guided imagery resulted in improvements in the psychological or physiological
outcomes that were examined (as cited in Carrico, Peters, & Diokno,
2008).
The
gate control theory of pain examines the role of the central nervous system and
states that the pain experience consists of three dimensions that interact with
one another to ultimately regulate the flow of sensory information between the
body and the brain (Melzack & Wall, 1965, 1996, as cited in Pincus &
Sheikh, 2009). According to Pincus and
Sheikh, the "sensory-discriminative dimension," which involves nerve
receptors at the actual site of pain can be most affected by transformational
or dissociation imagery. The second
dimension of the experience of pain is called the "motivational-affective
dimension" and refers to the resulting feelings that motivate behavior as
a result of the pain. This dimension is
most affected by scripts that involve pleasant environmental imagery to produce
a relaxed and positive state of being.
The "cognitive-evaluative dimension" is the third dimension of
the pain experience and refers to the attributions and meanings that are given
by an individual. This dimension can be
most affected by any imagery that redefines the pain in a more positive light
or a different context (Pincus & Sheikh).
Melzack
(2004) has continued his research into the gate control theory of pain which
has now evolved into the neuromatrix theory of pain. It is proposed that the patterns of nerve
impulses which are generated within the brain's neural networks need not
necessarily be triggered by actual sensory experience. Because chronic pain involves cognitive
aspects of the brain in addition to sensory input, the application of
neuromatrix theory indicates that new approaches to treatment are necessary. According to Melzack (2004):
Pain
is not injury; the quality of pain experiences must not be confused with the physical event of breaking skin or bone. Warmth and cold are not "out
there"; temperature changes
occur "out there," but the qualities of experience must be generated by the structures in the brain.
(p. 87)
With this in mind, Melzack (2004)
has illustrated how some forms of chronic pain with no apparent physical cause
can be attributed to patterns that have become activated and engrained within
the neuromatrix due to prolonged or repeated low level pain stimuli. Pincus and Shiekh (2009) refer to this as a
"body-memory" which can trigger the body's stress response and
results in an increased level of stress hormones that have a negative effect
over time (p. 15). These neural patterns
become increasingly emphasized as time passes and replay themselves, even in
the absence of true somatic stimuli.
Melzack (1993) has also proposed that the limbic system, which is
related to emotional response, plays a large contributing role to the
neuromatrix.
Benson
and Friedman (1996) use the term, "remembered wellness" to refer to
the placebo effect (as cited in Pincus & Sheikh, 2009). This refers to the power of self-healing that
resides within an individual to aid in recovery. The use of imagery in pain management causes
an inward shift in orientation that helps to direct the patient towards their
own remembered wellness and unconscious healing abilities (Baer, Hoffman, &
Sheikh, 2003, as cited in Pincus & Sheikh).
"Imagery allows for integration and adaptation in the flows of
information within the consciousness of the body-mind" (Pincus &
Sheikh, p. 81). This allows an
individual to tap into their own natural ability to heal and regain a sense of
control in life. This sense of control
is paramount in pain management because previous research indicates that an
expectation of uncontrollable pain often affects the perception of future pain
stimuli and can result in an increased level of pain actually occurring (Turk,
1996).
The
use of guided imagery is considered to be a part of cognitive behavioral
therapy and can be used to alter the perception of pain because it is a
"dynamic, psycho-physiological process" which helps to manipulate the
experience of pain by shaping the inner reality of the subjective experience
which is occurring (Menzies, Taylor, & Bourguignon, 2006, p. 24). Techniques that teach self-management are an
important means to regain a sense of self-control over pain (Turk et. al.,
2008). Often, when a pain patient
experiences a loss of control, it can lead to catastrophic thinking,
depression, and hopelessness (Vowles, McCracken, & Eccleston, 2008). According to McCracken (1999), attitude is
closely related to a person's ability to cope with chronic pain, and acceptance
also plays a large role. For example, a
study on rheumatoid arthritis and chronic lower back pain revealed that
feelings of uncontrollability and helplessness were more highly related to pain
and disability than variables related to disease or pathology (Flor & Turk,
1988, as cited in Turk, 1996). In
addition to this, the degree of psychological flexibility which is possessed by
the patient may have an even greater impact on the experience of pain. It is proposed that this is an active process
in which patients can adapt themselves to the pain experience (Vowles &
McCracken, 2010). The use of imagery in
pain management has been shown to provide many benefits that decrease the
patients subjective pain experience, increase life functioning, and provide a
sense of control (Pincus & Sheikh, 2009).
According
to the cognitive-behavioral approach to chronic pain, cognitive appraisal and
interpretation of painful events affect the emotions and behavior surrounding
the pain. Pincus and Morley (2001)
examined the role of cognitive bias in chronic pain by reviewing previous
findings in regards to attention, interpretation, and memory biases in order to
evaluate their effects on cognitive pain schemas. It was proposed that there are three
interrelated schemas (pain, illness, and self) that act together to produce
these biases. When a person's self
related schema is interrupted by pain, the particular portion that is disturbed
will direct the schema enmeshment and determine any cognitive and emotional
biases that result (Pincus & Morley, 2001).
According to Pincus and Sheikh (2009), imagery can help to modulate
emotional states, provide distraction, and direct attention in order to modify
the pain related schemata.
Early Research on Imagery
Early
investigation into the therapeutic use of imagery revealed its ability to
contribute to the regulation of the autonomic processes of the body including
blood pressure, oxygen consumption, heart rate, and body temperature (Sheikh et
al., 1979, as cited in Sheikh & Jordan, 1983). Autogenic training, which emerged in the
1950s, was a method that was developed in order to induce a state of relaxation
by using visual imagery cues to engage
the autonomic nervous system (Sheikh & Jordan). This technique later began to be used
effectively as a method of treatment in pain management (Pincus & Sheikh,
2009). Imagery was often paired with
meditation, biofeedback, and hypnosis in these early studies, and results were
measured in terms of physiological changes that occurred as a result of somatic
stimuli induced in a laboratory setting (Sheikh & Jordan, 1983).
A
more comprehensive technique that involves guided imagery, called stress
inoculation training (SIT), became popular in the 1970s. SIT is a therapeutic method that focuses on
gaining control over a stressful situation by learning coping skills (Pincus
& Sheikh, 2009). Imagery, along with
educational rationales and self-instruction, has been used in the field of
psychology during SIT for controlling anger, anxiety, and pain (Worthington &
Shumate, 1981). Each component was
incorporated specifically to treat each of the different components of the gate
control theory of pain. For instance,
the sensory-discriminative pain component benefits from relaxation training,
the motivational-affective component can be influenced by directing the
subjects to use imagery to counteract the effects of pain, and the
cognitive-evaluative aspect is influenced by restructuring the subjects’
cognitive processes. Results from Worthington
The Use of Recorded Scripts for Acute and
Chronic Pain
In
recent years, research has indicated that GI scripts on CD can be used before
surgery to reduce anxiety, postoperative pain, pain medication, overall hospital
costs, and length of the hospital stay (Gonzales et al., 2010). According to a new study, even same-day use of guided imagery CD
treatment for outpatient surgery still has the some of the same benefits as
treatments involving the use of CD's for weeks prior to the surgery (Gonzales
et al., 2010). The main target in this
study focuses on relieving pre-operative anxiety in patients who have been
identified as highly susceptible to developing post-operative pain. High levels of anxiety interfere with coping
methods for pain control and contribute to a greater susceptibility toward pain
because of the close relationship between pain and the emotions and the role of
the limbic system in the pain experience (Gonzales et al.).
As
an alternative to standardized guided imagery scripts on CD, it may be more
effective to provide personalized recordings to patients for use at home. Customized treatments have been proven most
effective for guided imagery use in pain management (Syrjala & Abrams,
1996). A recent study on patients with
chronic pain that involved a combined use of guided imagery and progressive
muscle relaxation used information gathered during each patient's initial
session in order to personalize the imagery script used in the individualized
recording (Chen & Francis, 2010). In
contrast to the Gonzales et al. (2010) study, results from this particular
study indicated on the mental health scale that guided imagery may be more
suitable for relieving depression than anxiety.
Chen and Francis (2010) also reported results that support other guided
imagery studies showing a general upward trend in quality of life and decreased
daily pain ratings.
Guided Imagery for Children
There
is an especially high need for non-pharmacological methods to use in conjunction
with medication for the relief of post-surgical pain in children.
Huth, Henson, Daraiseh, and McLeod
(2009) evaluated the efficacy of a guided imagery CD for the use on
post-operative pain in children seven to twelve years of age. Results of the study showed a statistically
significant reduction in pain scores after listening to the recording but
non-significant changes in relaxation scores.
Upon further investigation, it was found that over 50 percent of the
children in the study did not understand the term "relaxation" as
used in the recording. It was also noted
that the small percentage of participants involved who reported the inability
to imagine the particular scenarios also reported a general dislike for the
particular dialogue used, calling it "annoying" or
"weird." These data support
previous research that indicates how personalized imagery scripts have greater
positive results (Syrjala & Abrams, 1996).
In addition, the results demonstrate that the use of words and terms
contained in the imagery scripts must be carefully selected to suit the
particular audience it is intended for.
A
similar study, performed in Finland
Guided Imagery for the Relief of Cancer
Related Pain
Previous
GI research has been highly inconclusive for the treatment of cancer related
pain (Kwekkeboom, Kneip, & Pearson, 2003).
Kwekkeboom et al. performed a study to evaluate possible methods to
predict success with GI audio CD therapy for cancer patients. The use of GI therapy decreased pain for 90
percent of the sample population in this study.
It was found that proficiency in imaging ability was directly related to
the amount of decrease in pain intensity scores, an increased positive affect,
and a heightened perception of control over the pain. However, in contrast to previous research,
outcome expectancy was not a significant predictor in this study. It was suggested that patients be evaluated
on their ability to focus on creating mental images and any previous positive
experience with GI therapy before deciding to include imagery in the treatment
plan.
A
separate study by Kwekkeboom, Wanta, and Bumpus (2008) addressed how individual
difference variables affect the outcome of GI therapy as part of a progressive
muscle relaxation treatment for cancer pain and had similar results to the
Kwekkeboom et al. (2003) study. Results
also revealed methodological problems related to the extremely diminished
functioning of the sample population.
Many patients were too ill or exhausted to initially commit to the
study, and a large portion of subjects became so sick that they could not
complete their obligations regarding this study. Even though previous research indicates that
lengthy cognitive behavioral treatment works best for chronic cancer pain, this
study implies that complicated and extensive therapeutic practice may not be
suitable depending on the severity of co-occurring cancer symptoms (Kwekkeboom,
Wanta, & Bumpus). Secondary analysis
on this data focused on evaluating the perceptions of the participants
regarding the efficacy of the GI techniques (Kwekkeboom, Hau, Wanta, &
Bumpus, 2008). The most common response
for perceived success was that the imagery provided some sort of distraction
from the pain which helped to focus attention elsewhere. The common response for those who reported
that GI therapy was ineffective was that they preferred a different type of
imagery than what was provided on the audio tape or that they had trouble
visualizing the imagery used
(Kwekkeboom, Hau et al.).
Guided Imagery For Special Populations
GI
therapy has also been found to benefit patients who experience chronic pain due
to fibromyalgia. Although the
participants' reported measures of pain did not show significant changes, other
improvements were noted such as an improvement in overall functioning, a
greater sense of control over the symptoms of pain, and an improvement in
activity levels (Menzies et al., 2006).
In a study on interstitial cystitis, Carrico et. al. (2008) found that
GI therapy reduced both pelvic pain and urinary frequency in over 45 percent of
the sample population.
A
small study was also conducted to test the efficacy of GI therapy on women with
osteoarthritis pain which showed a clinically significant decrease in pain
ratings for all 17 participants in the treatment group (Baird & Sands,
2004). It was proposed by Baird and
Sands (2004) that GI practice may create opportunities for the mental rehearsal
of motor actions with an expectation of a more positive and less painful
experience. This expectation could then
carry over into the actual experience itself.
However,
a study conducted by Gustin et al. (2008) on the effect of motor imagery on
sensations of neuropathic pain in patients with complete spinal cord injury
showed just the opposite. Although it
was hypothesized that pain symptoms would diminish, this study showed that
motor imagery involving regions without sensation actually caused an increase
in neuropathic pain and other non-painful symptoms. These results conflicted with findings from
studies conducted on amputees with phantom limb pain. Gustin, Wrigley, Henderson, and Siddall
(2010) continued their exploration of motor imagery and spinal cord injury in
order to demonstrate that motor imagery has the ability to activate the sensory
and motor cortices in patients who lack any sensation at all in the area.
Cupal
and Brewer (2001) examined the efficacy of GI when used on subjects undergoing
physical therapy after reconstruction of the anterior cruciate ligament of the
knee. Because previous research has
indicated that there is a correlation between psychological factors and
rehabilitation from injury and recovery time, it was proposed that GI could
have substantial effects on the healing process, not limited to only the
management of pain. Not only did
subjects report less pain at the end of the study, but they also demonstrated
greater knee strength and less reinjury anxiety when compared to the control
group. This study further expands the
usefulness of psychological treatments that include GI to include sports
rehabilitation therapy (Cupal & Brewer).
Guided Imagery for Phantom Limb Pain in
Amputees
Phantom
limb pain (PLP) is often attributed as a type of body memory that is shown to
be accompanied by activity in the corresponding areas of the brain (Oakley,
Whitman, & Halligan, 2002). Previous
research has proven that PLP is influenced by emotional states, suggestion, and
expectation (Soloman & Schmidt, 1978, as cited in Oakley et al.,
2002). MacIver, Lloyd, Kelly, Roberts,
and Nurmikko (2008) found that mental motor imagery provided significant pain
relief for phantom limb pain. It was proposed
that these imaginary movements helped provide a sense of control over the
phantom limb. In Oakley et al’s (2002)
review of various case studies, some cases reported using a combination of
mental visualization and hypnosis while other cases used only proprioceptive
imagery with no co-occurring visual images.
It was noted that both treatment protocols, as well as measures of pain,
needed to be standardized in order to make comparisons accurate (Oakley et al.).
Hugdahl
et al. (2001) used functional magnetic resonance to demonstrate how motor
imagery can activate the same motor areas in the brain as that of real
movements. This supports current trends
in GI theory that show a connection between actual and perceived sensation and
shows that imagined movements can have a real effect on the discomfort which is
experienced in this population of patients.
It was also shown that pure motor imagery was able to engage areas of
the brain related to motor activity while the somatosensory areas were
activated by imagery of painful sensations in the associated area (Hugdahl et
al.).
In
order to test earlier theories indicating that various therapies for pain
management may have cumulative effects when used together, Bamford (2006)
tested a four part approach to PLP which included self hypnosis, visualization
of movement, psychological treatment, and hypnotic analgesia. This approach to pain relief proved to be
effective at both reducing pain and providing subjects a sense of control over
the pain and self-efficacy in life.
However, this particular study did not account for whether or not any of
the effects were cumulative with regard to the multifaceted approach in
comparison to a single course of treatment because it neglected to include a
control group (Bamford).
Additional Research
It
may be a general misconception that the analgesic effects caused by positive
imagery are linked to its role as a method of distraction. McCaul, Monson, and Maki (1992) found that as
tasks of distraction got increasingly more difficult, they began to fail in
their pain reducing efficacy. Other
research has indicated that distraction in pain management only works because
of its use of positive emotions (McCaul et al.). If this is true, then guided imagery is more
beneficial because of its beneficial emotional aspect than its ability to
merely distract from the situation at hand.
McCaul et al. proposed that distraction, as a technique in itself,
actually fails to work, and it is the other involved therapeutic components
that contribute to its perceived success.
Alden,
Dale, and DeGood (2001) performed a study to test the hypothesis that it is the
qualitative component of the pain distracter that affects the analgesic
outcome. In this study, the effects of
both positive and negative imagery were examined instead of only the typical
positive imagery. A second factor which
was studied was whether or not the imagery had an internal or an external
focus. In addition to self-report
measures, physiological measurements were also collected, such as skin
potential frequency and heart rate. It
was found that positive imagery with an external focus had the greatest
effects. However, physiological measures
did not correspond with any of the associated differences in pain measures
between the experimental groups (Alden et al., 2001).
Common Methodological Problems
Due
to both the subjective nature of pain and the ascribed personal meaning which
is often a large portion of the pain experience, adequate measures for
assessment are an important aspect of any research performed in this field
(Turk & Melzack, 1992). Even though
substantial effort has been given towards providing a reliable and valid
multidimensional measure for use in pain assessment, such as the McGill Pain
Questionnaire, the benefits of having a descriptive diary giving an overview of
all aspects of pain and its effect on psychological and life functioning cannot
be denied (Melzack & Katz, 1992).
Many studies employed the use of various visual analogue scales for ease
in comparing assessment scores (Jenson & Karoly, 1992). However, the use of standardized scales
limits the type of data which can be obtained from the research. On the other hand, descriptive journals when
used as a form of assessment can only be compared in terms of similar
reoccurring themes. At the very least,
it is of utmost importance that assessment measures are comprehensive enough to
cover the full experience of pain on a multidimensional level (Dworkin &
Whitney, 1992).
Another
methodological problem lies in the fact that GI is most effective when its
aspects of use are custom tailored to each individual. Attempts at standardization of GI treatment
must remain flexible enough to suit the needs of each individual. The overall trend is that GI treatments which
are most flexible are also more successful (Syrjala & Abrams, 1996). In most GI studies, physiological measures
are most widely used only during research which is performed in a laboratory
setting. Perhaps these measures could
also be used in clinical research to add an additional psychophysiological
dimension such as those employed in other areas of pain research (Flor,
Miltner, & Birbaumer, 1992).
Although it should be noted that this effort can produce more questions
than answers as reflected in past inconclusive results (Flor et al., 1992).
Conclusion
Modern
explorations into the effects of GI in pain management have shifted their focus
towards actual clinical research and away from the analogue laboratory
setting. This has yielded results that
are more relevant towards real life application. Past research proves that GI
is beneficial in the field of pain management as a valuable component of
psychological treatment whether used alone or used as part of a more
comprehensive healing program. Because
pain is affected by cognition, psychological state, and expectations, the use
of GI can have positive effects that work on many levels of the
multidimensional experience of pain.
Many patients who find that their current course of pain management
treatment is insufficient may benefit from adding this technique. Because of the rising costs of healthcare and
the current state of the economy, future research should focus on implementing
the use of GI as an effective low-cost way to augment current trends in pain
management. Although research has
demonstrated that alternative methods, such as GI, should be implemented more
often in the field of pain management, these techniques have still not gained
sufficient popularity for widespread use.
Future attention should be directed at ways of implementing the use of
GI in clinical practice.
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