Guided Imagery/Imagery

Guided Imagery/Imagery

PEP Topic 
Chronic Pain

Imagery involves use of mental visualization and imagination to enhance relaxation and alter specific experiences and may or may not 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 is often combined with the technique of progressive muscle relaxation. Imagery alone has been examined for its effectiveness in patients with cancer experiencing chemotherapy-induced nausea and vomiting, pain, sleep-wake disturbances, and cognitive impairment.

Effectiveness Not Established

Systematic Review/Meta-Analysis

King, K. (2010). A review of the effects of guided imagery on cancer patients with pain. Complementary Health Practice Review, 15, 98–107.

doi: 10.1177/1533210110388113


To review the effects of guided imagery on patients with cancer experiencing pain

The type of report was systematic review.

Search Strategy:

Databases searched were PubMed, CINAHL, PsycINFO, and Cochrane Library.

Search keywords were guided imagery, cancer pain, and systematic review.

Studies were included if they were review articles published in English since 1985; the search was not limited to randomized controlled trials (RCTs).

Studies were excluded if they were clinical trials or systematic reviews that did not utilize guided imagery as an intervention, did not specifically investigate cancer pain, were not a clinical study but rather a summary of guided imagery, had a qualitative design, and were not conducted within the study time frame.

Literature Evaluated:

In order to focus on the most current research, this review targeted articles published during 2001–2008.

Sample Characteristics:

  • A final number of five clinical trials were identified that included pain as either a primary or secondary outcome measure.
  • Sample range across studies was 40–66 patients.
  • The sample included three RCTs, one group pre/post-test design, and one RCT crossover design.


Five studies included pain as either a primary or secondary outcome measure. In three of those, pain intensity and pain-related distress decreased in the guided imagery intervention versus control for pain intensity and pain-related distress, average pain score decreased, and there was a decrease in body discomfort.


It is difficult to give concrete recommendations that guided imagery will work for all patients who suffer from cancer pain. However, based on the information from these reviews, guided imagery can be recommended as a potential aid in the relief of pain associated with cancer.


Inconsistencies and limitations included the small sample size, different patient populations, different scripts, and frequency of medication administration.

Nursing Implications:

There is inconsistency in the methodological qualities of these trials. Further research is necessary to provide better evidence for the use of guided imagery in cancer pain.

Kwekkeboom, K. L., Cherwin, C. H., Lee, J. W., & Wanta, B. (2010). Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. Journal of Pain and Symptom Management, 39, 126–138.

doi: 10.1016/j.jpainsymman.2009.05.022


To identify and synthesize the evidence for mind-body interventions for which the evidence suggests benefit for at least two of the three cluster symptoms of pain, fatigue, and sleep disturbance.

Search Strategy:

Databases searched were CINAHL, MEDLINE, and PsycINFO through March 2009.

Search keywords were guided imagery, hypnosis, relaxation, biofeedback, cognitive behavioral therapy, coping skills training, meditation, virtual reality, music AND cancer AND fatigue, sleep disturbance, sleep difficulty, insomnia, and pain.

Studies were included in the review if they

  • Were limited to research
  • Included adults aged 18 years and older
  • Included mind-body activities that involved primarily mental activity that could be performed by almost all patients
  • Included pain, fatigue, or sleep among study dependent variables.

Studies were excluded if they

  • Involved the use of yoga
  • Involved patients in whom a diagnosis of cancer was not yet established
  • Had a sample that included people without cancer.

Literature Evaluated:

A total of 47 studies were identified. In four of those, all testing virtual reality, only the symptom of fatigue was measured, so these were eliminated.

Sample Characteristics:

The final sample included 43 studies. Study sample sizes and total patients involved across studies were not reported.



Six studies examined relaxation interventions in hospitalized patients, outpatients with chronic pain, and women with early-stage breast cancer.

  • Significantly greater pain relief was obtained with progressive muscle relaxation compared to massage, usual treatment, mood manipulation, distraction, and controls.
  • One study found no difference in pain between a daily relaxation exercise and distraction.
  • Training in muscle relaxation did not improve fatigue in one study compared to provision of information.
  • In one study, muscle relaxation improved sleep compared to usual treatment controls.

Imagery and Hypnosis

Six studies examined imagery and hypnosis.

  • In four studies, imagery was used in hospitalized patients with cancer pain, and beneficial effects were reported.
  • One study found no differences in pain or fatigue between patients with an imagery intervention and those receiving standard care.
  • Four studies used imagery in comparison to cognitive-behavioral therapy (CBT) and combined imagery with relaxation. Of those, one study reported no significant effect, two reported significant pain reduction, and one reported significant reduction in fatigue and sleep disturbance.

Cognitive Behavioral Therapy (CBT)/Coping Skills Training (CST)

Twenty-one studies tested CBT/CST.

  • In three studies, fatigue was the primary focus. Significantly more improvement in fatigue was reported with a six- to 12-week CBT/CST intervention compared to usual treatment and controls.
  • Three studies evaluated CST effects on the combination of pain and fatigue. In all of these, a one-session CST intervention resulted in no difference in symptoms compared to controls.
  • Seven studies evaluated the effects of CBT/CST on fatigue and sleep disturbance. One study reported a decreased incidence of fatigue and sleep disturbance using an audio recording for coping skills training prior to chemotherapy. Two studies reported improvement in sleep with a four- to eight-week CBT intervention, but only one of these also reported improvement in fatigue. One study reported improvement in sleep and fatigue with a five-session CBT intervention, two other studies showed improvement in sleep but no change in fatigue, and one study reported no improvement in either of these two symptoms.
  • Four studies reported effects of CBT/CST on all three symptoms concurrently. One showed improvement in fatigue and sleep but no impact on pain. One study reported less sleep disturbance but no difference in pain or fatigue. One reported lower ratings of worst pain immediately after the CBT program and greater reduction in pain and fatigue six months after the intervention compared to controls. One study found no differences in any of the three symptoms with a CST intervention.


Four studies were included.

  • Three of these studies used mindfulness-based interventions. One study reported significant improvements in both fatigue and sleep among outpatients who participated in an eight-week intervention.


  • Four studies looked at the effect of music on pain. Two studies found significant improvements in a pre-/posttest design using 30 minutes of preferred music among hospitalized patients. Two other studies found no difference in pain with listening to music compared to control groups.
  • Two studies tested a music intervention on fatigue. One found a significant effect, and one found no difference in fatigue between intervention and control groups.


Findings of this review were equivocal.


  • Although the authors stated a criterion for inclusion of examination of at least two of the three symptoms of interest, the review appeared to include studies in which only one of these symptoms was reported.
  • Few investigators used multisymptom interventions and evaluations.
  • Measures of symptom clusters were not been well identified.
  • Some instruments were stated to potentially be more sensitive; however, the scales and individual items that were most useful to measure this symptom cluster were not determined.
  • Timing, dosage, and frequency of interventions varied among studies, making it difficult to draw systematic conclusions. Most music interventions were very brief.
  • This review did not provide study details, such as clear sample descriptions, sample sizes, or actual statistical results, and no effect sizes were calculated, although some studies used the same outcome measures.

Nursing Implications:

Although the findings did not clearly demonstrate the effects of these interventions across studies, the authors concluded that these interventions hold promise. Although such interventions carry minimal risk to patients, some interventions would require substantial time and resource commitment to provide.

Guideline/Expert Opinion

National Comprehensive Cancer Network. (2011). NCCN Clinical Practice Guidelines in Oncology: Adult cancer pain [v. 2.2011]. Retrieved from

Type of Resource/Evidence-Based Process:

These guidelines do not provide any information about search strategy or any specific evaluation of evidence. Notes state that most direct evidence is of low quality, but recommendations do result from unanimous consensus.

Guidelines & Recommendations:

The guidelines provide detailed recommendations regarding:

  • Screening and assessment
  • Management of pain in opioid-naive as well as opioid-tolerant patients
  • Ongoing care of adult patients with cancer and related pain management
  • Comprehensive pain assessment and use of pain ratings
  • Interventions for specific types of pain syndromes
  • Opioid prescribing, titration, and ongoing management
  • Management of adverse effects related to opioids
  • Psychosocial support and patient and family education
  • Nonpharmacologic interventions.


In general, opioids are first-line interventions. The NCCN guidelines suggest that antidepressants and anticonvulsants can be first-line treatments for adjuvant pain, although the recommendation for using them as such is still based on anecdotal experience or guidelines relating to patients who do not have cancer.

Nursing Implications:

The NCCN guidelines provide comprehensive algorithms for pain management, from screening to ongoing maintenance. The guidelines recommend considering a variety of nonpharmacologic interventions. Psychosocial support, including coping-skills training, is recommended, as is comprehensive patient and family education. The guidelines provide useful information and an overview of the full range of pain management. The work points to the ongoing need to consider multiple adjuvant and supportive interventions to achieve pain relief that works for the individual patient.