Guided Imagery/Imagery

To explore research literature related to the use of guided imagery as an intervention for fatigue.

Databases searched were MEDLINE, CINAHL, PsycARTICLES, PsycINFO, and Psychology and Behavioral Sciences Collection from 1980 through 2008, as well as the Cochrane Database of Systematic Reviews and a review of reference lists.

Search keywords were fatigue, tiredness, imagery, guided, and guided imagery.

Inclusion critieria were not specified.

Studies were excluded if they

• Were dissertations
• Used music alone or in combination with guided imagery
• Used hypnosis
• Had relaxation as a keyword.
   

A total of 5,968 references were retrieved. No quality rating was used. A narrative approach was used.

• A total of eight studies were included in the final analysis, with 364 patients (223 in three studies involved patients with cancer).
• The sample range across studies was 8 to 139 patients.
• Of the studies included, two included women with breast cancer, one included patients with colon cancer prior to surgery, one included patients with HIV, one included patients with asthma, one included patients with multiple sclerosis, and one included patients with chronic obstructive pulmonary disease (COPD).
   

Five studies showed no effect, one showed mixed effect, and two demonstrated a statistically significant positive effect in patients with asthma or HIV. Effect sizes from the studies were not reported. Studies varied in measures of fatigue used and intensity of the intervention. The types of images used also varied substantially, which can be expected to influence the results. Study lengths ranged from a single session to multiple daily use for six weeks. The authors noted that the studies that demonstrated significant improvement included the greatest total duration of exposure to guided imagery.

The findings were inconsistent across the studies, and those including patients with cancer did not show a significant effect. Duration of exposure may influence effectiveness. This review did not support the effectiveness of guided imagery alone for fatigue in patients with cancer. 

• The study included a small number of studies with varied sample characteristics, different study measures, and intensity of interventions studied.
• Studies were eliminated that included relaxation because guided imagery and progressive muscle relaxation often are used together.

Insufficient evidence exists from this review to recommend use of guided imagery alone. Additional well-designed research and evidence synthesis encompassing the combination of relaxation and guided imagery are needed.

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

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.

• 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.

• Single site
• Outpatient

A quasiexperimental design was used.

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

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.

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

• 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.

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.