Relaxation and Visual Imagery

Relaxation and Visual Imagery

PEP Topic 
Anxiety
Description 

Visual imagery involves use of mental visualization and imagination to enhance relaxation and alter specific experiences, and may or may not include direct suggestion. It may differ from guided imagery in that the process may not be highly specific and aimed at imagining a relaxed setting or memory. Relaxation may involve breathing exercises, but not the specific process of progressive muscle relaxation.

Effectiveness Not Established

Research Evidence Summaries

León-Pizarro, C., Gich, I., Barther, E., Rovirosa, A., Farrús, B., Casas, F., . . . Arcusa, A. (2007). A randomized trial of the effect of training in relaxation and guided imagery techniques in improving psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-Oncology, 16, 971–979.

doi: 10.1002/pon.1171
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Intervention Characteristics/Basic Study Process:

The intervention consisted of relaxation and guided imagery provided to patients during hospitalization. The intervention group received training in relaxation and guided imagery for 10 minutes and was given an individualized cassette for use at home and at the hospital. The recording on the cassette consisted of instructions on head-to-toe relaxation and breathing techniques. Patients were then given descriptions of pleasing images (mountains, beach, etc.) based on information gathered from the patients prior to recording of the cassette. Patients in both groups received training regarding brachytherapy, but only study group patients received training in relaxation and guided imagery.

Sample Characteristics:

  • The study reported on a sample of 66 patients: 32 in the intervention group and 34 in the control group.
  • Patients had gynecologic and breast cancers and were undergoing brachytherapy during hospitalization.

Setting:

Two hospitals in Spain

Study Design:

A randomized controlled trial design was used.

Measurement Instruments/Methods:

  • Hospital Anxiety and Depression Scale (HADS)
  • Cuestionario de Calidad de Vida (Spanish quality-of-life questionnaire that has been validated in a Spanish population).
  • Pain Visual Analog Scale
  • Measures were administered prior to, during, and after brachytherapy.

Results:

The intervention group demonstrated a statistically significant reduction in anxiety (p = 0.008) compared with the control group.

Limitations:

  • Special training or costs included creation of the training program, cassettes, and guided imagery education.
  • The small sample size limits generalizability.

Serra, D., Parris, C. R., Carper, E., Homel, P., Fleishman, S. B., Harrison, L. B., & Chadha, M. (2012). Outcomes of guided imagery in patients receiving radiation therapy for breast cancer. Clinical Journal of Oncology Nursing, 16, 617–623. 

doi: 10.1188/12.CJON.617-623
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Study Purpose:

To examine the effects of guided imagery on patient distress and symptoms during radiotherapy.

Intervention Characteristics/Basic Study Process:

Patients received instruction on guided imagery during the first few days of radiotherapy treatment and participated in sessions with a nurse immediately prior to radiotherapy treatments. Sessions lasted about 30 minutes and involved relaxation and breathing exercises with visualization of a calming experience and setting. Patients were provided with a CD for home practice. Study measures were performed at baseline and at the end of radiotherapy treatments. Pre- and postsession pulse, blood pressure, and thermal biofeedback measures were obtained.

Sample Characteristics:

  • The study reported a sample of 66 women; only 11 remained for the final measures.
  • Mean age was 57 years (range 28–77).
  • All patients had breast cancer and were undergoing active radiotherapy. Most were also receiving adjuvant chemotherapy and/or hormonal therapy.

Setting:

  • Single site
  • Outpatient

Study Design:

A quasiexperimental design was used.

Measurement Instruments/Methods:

  • Distress thermometer and visual analog scale (VAS) subscales
  • EuroQol EQ-5D questionnaire
  • Thermal biofeedback

Results:

EQ-5D subscale scores for anxiety and depression declined from a mean of 1.42 to 1.26 by the end of treatment (p = 0.01). There was a decline in overall distress scores (p = 0.04), but no significant changes occurred in depression, sleep, or fatigue scores. Patients showed immediate postsession reduction in respiratory rate and blood pressure but no significant differences in thermal biofeedback findings.

Conclusions:

The findings suggest that relaxation and imagery can be helpful to patients during radiotherapy.

Limitations:

  • The study had a small sample size, with less than 100 patients.
  • The study had risks of bias due no control group, no blinding, and no random assignment.
  • Patient withdrawals were 10% or greater.
  • It is not known whether patients used the intervention between sessions.

Nursing Implications:

Findings suggest that relaxation therapy and imagery can be helpful to patients during radiotherapy treatment; however, this study had substantial design limitations that limited the strength of the evidence. Relaxation and imagery, and particularly patients’ use of these techniques on their own, pose no patient risks and can be a practical intervention that is helpful to patients during active treatment.

Systematic Review/Meta-Analysis

Naaman, S.C., Radwan, K., Fergusson, D., & Johnson, S. (2009). Status of psychological trials in breast cancer patients: A report of three meta-analyses. Psychiatry, 72, 50–69.

doi: 10.1521/psyc.2009.72.1.50
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Purpose:

To determine the overall efficacy and magnitude of clinical benefit of psychological interventions in patients with breast cancer, specifically looking at three outcome variables: anxiety, depression, and quality of life (QOL)

Search Strategy:

Databases searched were MEDLINE (1966–January 2004), EMBASE (1980–2004), Cochrane Controlled Trials Register (1985–February 2004), PsycLit (1973–2004), Biological Abstracts (1990–December 2003), CancerLit (1975–October 2002), CINAHL (1982–December 2003), and Health Star (1975–January 2004).

Search keywords were randomized clinical trial and breast cancer and psychological interventions (cognitive behavioral therapy, group psychotherapy, relaxation, supportive therapy, visual imagery) and psychological adjustment (anxiety, depression, maladjustment, distress, quality of life).

Studies were included in the review if they

  • Were a randomized clinical trial (RCT)
  • Included at least two arms: an intervention arm and a control arm
  • Evaluated the efficacy of a psychological/behavioral intervention
  • Were aimed at alleviating psychiatric/psychological morbidity, as defined by anxiety, depression, and/or QOL
  • Reported on female patients with a histologically confirmed diagnosis of breast carcinoma of any stage who have undergone surgery.

Trials examining efficacy of interventions designed to assuage surgical distress were excluded.

Literature Evaluated:

  • A total of 383 citations were identified, with 36 potentially relevant articles identified and screened for retrieval.
  • The final meta-analysis included 18 RCTs with usable information by outcome.
  • Study quality was evaluated using a framework provided by Cook and Campbell (1979) and a quality assessment scale developed and validated by Jadad and colleagues (1996).

Cook, T.D., & Campbell, D.T. (1979). Quasi-experimentation: Design and analysis issues for field settings. Boston, MA: Houghton Mifflin.

Sample Characteristics:

  • Fourteen trials assessing anxiety were identified, yielding a sample of 1,278 patients.
  • Fourteen trials measuring depression were identified, yielding a sample of 1,324 patients.
  • Seven trials measuring QOL were identified, yielding a sample of 623 patients.
  • Less than half of the trials included were considered to be of high methodological quality.
  • Patients’ ages ranged from 25 to 73 years, and approximately 70% were married or in a committed relationship.
  • Studies were conducted in the United States, Canada, England, Italy, Australia, Japan, and China.

Results:

Anxiety

  • Overall effect size (ES) was -0.40 (95% CI, -0.72 to -0.08) in favor of the treatment condition in comparison to the control.
  • Sensitivity analyses exploring the impact of methodological quality on overall ES found a reduction in ES associated with higher quality studies, -0.26 (95% CI, -0.42 to -0.10).
  • Trials using patients with high morbidity (metastatic breast cancer) yielded a statistically significant overall ES of -0.40.
  • Trials whose treatment extended beyond 20 hours had a statistically significant overall ES of -0.30 in favor of treatment.
  • Treatment orientation showed differential impact on overall ES with cognitive behavioral therapy (CBT), yielding an ES of -0.11, as well as ESs of -0.40 for guided imagery and relaxation, -0.43 for supportive-expressive therapy, and 0.02 for educational interventions.

Depression

  • Overall ES for depression was -1.01 (95% CI, -1.48 to -0.54) in favor of treatment.
  • Trials with higher methodological grade were associated with an overall ES of -0.24 in favor of treatment, while lower quality studies had an overall ES of -1.99.
  • Studies in which patients had lower morbidity yielded an overall ES of -0.45, whereas those with patients with more advanced disease yielded an overall ES of -1.20.
  • Couples and group therapy reached statistical significance with an ES of -1.02 and -1.35, respectively.
  • Treatment orientation showed ESs of -0.85 for CBT, -0.55 for guided imagery, -1.80 for supportive expressive therapy, and -0.45 for educational interventions. With the exception of educational interventions, the other subgroup analyses reached statistical significance.

Quality of Life

  • Overall ES was 0.74 (95% CI, 0.12 to -1.37) in favor of the treatment group, but this was not statistically significant. When lower quality studies were removed, statistical significance was achieved, but ES was reduced (0.35, p=0.04).

Conclusions:

Overall ES trends among the three outcomes show that more reliable studies were associated with smaller gains. Interventions targeted to patients with clinically important levels of anxiety or depression tended to reap the most benefit, compared to patients who undergo treatment on a prophylactic basis. Group psychotherapy appears to be superior to individual therapy in the treatment of both anxiety and depression. However, a direct impact of group therapy on QOL was not supported in this analysis. CBT interventions appeared to be equally as effective as supportive-experiential therapies. Interventions need not span beyond 20 hours to produce statistically significant ES.

Limitations:

The quality of most studies was not high.

Nursing Implications:

Future trials in psychosocial oncology should incorporate methodological features to enhance internal validity. Evaluation of statistically significant findings on psychometric testing may not reflect clinically significant findings and vice versa. This underscores the need for incorporating qualitative analysis in future studies. There is an absence of studies examining the efficacy of short-term interventions on QOL in advanced breast cancer and should be addressed in future research. Short-term, group interventions may provide the best utilization of scarce resources for the most effect; however, they should be targeted to those patients experiencing clinically important levels of distress. Findings point to the need for higher quality research design and reporting in this field.


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