Guided Imagery/Imagery

Guided Imagery/Imagery

PEP Topic 
Chemotherapy-Induced Nausea and Vomiting
Description 

Imagery involves the use of mental visualization and imagination to enhance relaxation and alter specific experiences. It may include direct suggestion. Individuals may use recorded scripts to guide the creation of mental images. Guided imagery can integrate techniques founded in multiple psychological theories and hypnotherapy, and it is often combined with the technique of progressive muscle relaxation. Imagery alone has been examined for effectiveness in patients with cancer for chemotherapy-induced nausea and vomiting, pain, sleep-wake disturbances, and cognitive impairment. 

Effectiveness Not Established

Research Evidence Summaries

Karagozoglu, S., Tekyasar, F., & Yilmaz, F.A. (2013). Effects of music therapy and guided visual imagery on chemotherapy-induced anxiety and nausea-vomiting. Journal of Clinical Nursing, 22, 39–50.

doi: 10.1111/jocn.12030
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Study Purpose:

To examine effects of music and visual imagery on anxiety and chemotherapy-induced nausea and vomiting (CINV) in patients receiving chemotherapy

Intervention Characteristics/Basic Study Process:

Patients were assigned to the control group during their second cycle of chemotherapy and to the experimental condition during the third cycle of chemotherapy. Anxiety and CINV were measured before and after chemotherapy administration. Nature paintings were used for visual imagery, and instrumental Turkish music was selected for each image. Patients selected the image that was most appealing to them and were told to imagine being in the location of the painting. Patients were given the related music CD to listen to during chemotherapy with headphones.

Sample Characteristics:

  • The study reported on a sample of 40 patients.
  • Mean patient age was 59.65 ± 9.67 years.
  • The sample was 77.5% male and 22.5% female.
  • Of the sample, 80% had lung cancer, and all were receiving highly emetogenic chemotherapy.

Setting:

The study was conducted at a single site, outpatient setting in Turkey.

Phase of Care and Clinical Applications:

Patients were undergoing active antitumor treatment.

Study Design:

A pre- and post-test repeated measures, single-group design was used.

Measurement Instruments/Methods:

  • The Spielberger State-Trait Anxiety Inventory was used.
  • Nausea was rated on a 100-mm visual analog scale (VAS).
  • The Morrow Assessment of Nausea and Vomiting was used.

Results:

Anxiety declined from prechemotherapy to postchemotherapy administration in both conditions. Both pre- and postchemotherapy state anxiety levels were lower during the intervention course of treatment. CINV declined over time for both pre- and postchemotherapy administration. Both pre- and postchemotherapy CINV levels were significantly lower during the intervention condition.

Conclusions:

This study does not provide any clear conclusions about the effects of music and visual imagery.

Limitations:

  • The study had a small sample, with less than 100 participants.
  • The study had risk of bias due to lack of a control group, blinding, random assignment, and an appropriate attentional control condition.
  • The authors stated use of a 100-mm VAS but then stated that they grouped scores into 1 cm intervals. It is not clear if actual score differences were maintained, as this was not well described.
  • The authors concluded that the intervention was effective based on analysis of differences before and after chemotherapy between the two study conditions; however, they did not show analysis of the change between pre- and postscores in each condition. This does not make sense as an approach to evaluate the effects.
  • The study design had multiple risks of bias and threats to internal validity. Patients were assigned to the experimental condition in the third cycle—it is possible that anxiety and CINV simply declined over time, unrelated to the intervention.

Nursing Implications:

Findings are inconclusive regarding the efficacy of music and visual imagery for anxiety and CINV during chemotherapy administration because of numerous study design and analysis limitations.

Sahler, O.J.Z., Hunter, B.C., & Liesveld, J.L. (2003). The effect of using music therapy with relaxation imagery in the management of patients undergoing bone marrow transplantation: A pilot feasibility study. Alternative Therapies, 9(6), 70–74.

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Intervention Characteristics/Basic Study Process:

A 45-minute music-assisted intervention with relaxation imagery sessions was provided twice a week by a trained therapist from the date of enrollment in the study to discharge.

Sample Characteristics:

  • The sample consisted of 19 patients aged 5–65 years old.
  • Sample criteria were bone marrow transplant recipients older than four years of age undergoing active treatment.

Setting:

The study was conducted at a university bone marrow transplant center.

Phase of Care and Clinical Applications:

Patients were undergoing the active treatment phase of care.

Study Design:

The study had a case-controlled, nonrandomized convenience sample design.

Measurement Instruments/Methods:

Patient self-reported pre- and postintervention nausea and pain on a 0–10 scale. Time to engraftment also was measured.

Results:

Nausea, pain, and time to engraftment decreased from pre- to postintervention.

Conclusions:

The intervention was implemented successfully with a very ill population (i.e., transplant environment).

Limitations:

  • Subjects were not randomized; the study did not inventory personality and other factors that influence bone marrow transplant outcomes.
  • The intervention was delayed until after transplantation.
  • The frequency of the intervention was lower than planned because of staff perceptions that patients were too sick to participate.
  • Time and attention control condition was not provided to the control subjects.

Troesch, L.M., Rodehaver, C.B., Delaney, E.A., & Yanes, B. (1993). The influence of guided imagery on chemotherapy-related nausea and vomiting. Oncology Nursing Forum, 20, 1179-1185.

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Intervention Characteristics/Basic Study Process:

Guided imagery was added to a standard antiemetic regimen; subjects in the experimental group listened to a 20-minute audiotape during chemotherapy administration, and the control group received standard antiemetic regimen alone. The intervention was done over three cycles of chemotherapy. The 20-minute tape was listened to 60 minutes prior to cisplatin, the following morning before breakfast, and the following evening at bedtime.

Sample Characteristics:

  • The study consisted of 28 newly diagnosed chemotherapy-naive patients with cancer who were receiving cisplatin.
  • Ages ranged from 33–80 years, and the mean age was 63 years for the control and experimental groups.
  • Patients with gastric cancer, malignancies in the upper gastrointestinal (GI) system, or pre-existing disease states of GI tract were excluded.

Setting:

Subjects were recruited from one oncologist’s practice (inpatients and outpatients) in a large, Midwestern teaching center.

Study Design:

The study included a convenience sample and was nonrandomized.

Measurement Instruments/Methods:

  • The Rhodes Index of Nausea and Vomiting, form 2 (eight-item, five-point, Likert-type, self-report tool) was used to determine each patient's total experiences score.
  • The Chemotherapy Experience Survey, which was designed by the researchers, was used to evaluate overall perceptions of the chemotherapy experience. It consists of two parts. The first is a five-point, Likert-type tool with eight word pairs ranging from negative to positive; the second is a rating of overall chemotherapy experience (10 = most negative, 100 = most positive).

Results:

  • No statistical significance was demonstrated with symptom occurrence and distress.
  • Guided imagery did not have a statistically significant effect on patients’ perceptions of the frequency of nausea, vomiting, and retching, as well as associated distress.
  • Patients who participated in the guided imagery felt significantly more in control, powerful, relaxed, and prepared than the control group.
  • The guided imagery group described their overall experience more positively than the control group.

Limitations:

  • Only adult patients receiving cisplatin were included.
  • Only one physician's office was used for recruiting the sample (could control antiemetic regimen).
  • The scope of the study was limited.
  • The study had a small sample size.
  • Other limitations include complex monitoring required over three cycles of chemotherapy, communication difficulties, and inability to control hospital setting and activities.

Systematic Review/Meta-Analysis

Miller, M., & Kearney, N. (2004). Chemotherapy-related nausea and vomiting—Past reflections, present practice and future management. European Journal of Cancer Care, 13(1), 71-81.

doi: 10.1111/j.1365-2354.2004.00446.x
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Search Strategy:

  • Databases searched were MEDLINE and CINAHL (1990-2002).
  • Search keywords were nausea, vomiting, chemotherapy and neoplasm, assessment, management, complementary therapies, pharmacological, and nonpharmacological.
  • Studies were included in the review if they included primary research, literature reviews, opinion articles, and information leaflets/booklets.
  • Studies were excluded if they involved anticipatory nausea and vomiting associated with chemotherapy, because the authors felt that symptoms with a psychological basis should be addressed in a separate paper.

Literature Evaluated:

  • Nonpharmacologic management interventions were reviewed with the intention that they do not replace standard antiemetic therapies but, rather, are adjuncts to improve quality of life (QOL).
  • Intervention articles were reviewed for progressive muscle relaxation, guided imagery, self-hypnosis, acupressure/acupuncture, transcutaneous electrical nerve stimulation, biofeedback, cognitive distraction, and music therapy.

Conclusions:

Support for the use of nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV) was weak.

Limitations:

Many studies were flawed because of small sample sizes and confounding variables (e.g., stage of disease, various chemotherapy regimens, culture, patient compliance).

Nursing Implications:

Preliminary available evidence suggests positive benefits through nonpharmacologic techniques; however, larger randomized trials are needed to demonstrate the exact benefits, including economic.


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