Running head: THE EFFECT OF RELAXATION AND GUIDED IMAGERY 1

The Effect of Relaxation and Guided Imagery Techniques on Cancer Patients Pain
Evonne Piazza
University of South Florida
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Abstract
Clinical Problem: Cancer patients experience pain from either their medical treatment or their

disease process itself, which decreases their overall quality of life.

Objective: Determine if relaxation and guided imagery techniques lower adult cancer patients

pain levels. PubMed and CINAHL were accessed to gather clinical trials and the guidelines

about using relaxation and guided imagery techniques to help reduce pain in cancer patients. The

key search terms used were relaxation and guided imagery techniques for pain, reducing pain in

cancer patients, and guided imagery and relaxation techniques for cancer patients pain.

Results: Research supports the use of guided imagery and relaxation techniques to reduce pain in

cancer patients.

Conclusion: Cancer patients that received relaxation and guided imagery techniques had a

reduced rate of pain. Participants overall quality of life increased in conjunction with guided

imagery and relaxation training. Further research is needed to determine which guided imagery

and relaxation techniques work best to decrease pain in cancer patients.

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Effect of Relaxation and Guided Imagery on Cancer Patients Pain

According to Baker, OConnor, and Krok (2014) about 30% to 85% of premature and

progressive phase cancer patients experience chronic pain. Due to the high prevalence of pain in

the cancer patient community, it is imperative to address their pain for the best recovery possible.

Prompt pain assessment and interventions are necessary to recognize and prevent pain during the

course of cancer treatment (Coyle 2006). In addition, a decreased quality of life has been

associated with pain in cancer patients (Niegisch, Retz, Siener, Albers 2016). Currently, there are

many different types of complementary and alternative medicine (CAM) interventions like

relaxation and guided imagery that have been established to decrease cancer patients pain. The

effectiveness of guided imagery and relaxation techniques will be evaluated by the effect it has

on the cancer patients pain level . In adult cancer patients, does relaxation and guided imagery

compared to standard treatment decrease the patients pain over the course of cancer treatment?

Literature Search

PubMed and CINAHL were reviewed to gather guidelines and clinical trials about the

effects of relaxation and guided imagery techniques on adult cancer patients pain. The key

search terms used were relaxation and guided imagery techniques, decreasing pain in cancer

patients, and guided imagery and relaxation for cancer patients.

Literature Review
Chen, Whang, Yang, and Chung (2015) designed a randomized control trial to determine

the effects of guided imagery and relaxation on breast cancer patients. This study measured the

level of pain, insomnia, and depression in breast cancer patients. The hospital anxiety and

depression scale (HADS) and self-rating depression scale (SDS) were used in this study to gather

data. Sixty-five adult breast cancer patients from Taiwan participated in this study. Thirty-three
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of these patients were placed in the control group and the other 32 were placed in the

intervention group where they received guided imagery and relaxation training in addition to

their chemotherapy self-care education. Upon comparing both groups, statistically significant

differences were found in the overall symptom distress (B = 0.11,d P < 0.05), insomnia (B =

0.50, P < 0.05), depression (B = 0.38, P < 0.05), pain (B = 0.38, P < 0.05), and anxiety (B = 3.08,

P < 0.00). Strengths of this trial consisted of randomization of all subjects in either the control or

intervention group, details explaining why participants failed to finish the trial were given, a

suitable control group, the SDS was reliable and valid, and participants in both groups were

comparable on demographic and baseline clinical variables. One weakness of the study was that

the researchers were not blind to the control group. Another limitation was the study consisted of

only females. In addition, the HADS was proven to be valid but not reliable.

Syrjala, Donaldson, David, Kippes, and Carr (1995) designed a randomized control trial

to assess whether relaxation and guided imagery could minimize nausea, stress, and pain

associated with oral mucositis in cancer patients attaining bone marrow transplants. The visual

analog scale (VAS) was used to help gather data from the participants. Ninety-four patients

completed the study and were separated into 4 groups of treatment: traditional control, counselor

support, guided imagery and relaxation preparation, and education in a bundle of cognitive-

behavioral managing aids that encompassed guided imagery and relaxation. Participants within

the experimental groups indicated they experienced a considerably larger effectiveness of their

interventions for managing pain (t=3.18, P-0.002) and stress (t=3.3, P=0.001) when compared to

perceived effectiveness for coping with nausea. Patients addressed that these interventions did

provide helpfulness for managing pain which correlated with the VAS reports. Strengths of this

trial consisted of randomization of all subjects in either the control or intervention group,
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participants and researchers were blind to the experimental group, the control group was suitable,

and details explaining why participants failed to finish the trial were given. One limitation for

this trial was that the randomization of participants was not withheld from the personnel

initiating participants into the study.

Leon-Pizarro et al (2007) designed a study to assess whether guided imagery and

relaxation could be used to decrease pain in breast and gynecologic cancer patients who were in

the hospital receiving brachytherapy. The study measured the level of anxiety, depression, and

pain the cancer patients experienced while they were undergoing treatment in the hospital.

Researchers incorporated the HADS and VAS in this study. The sample size of this study

included 64 breast and gynecological cancer patients receiving brachytherapy. Thirty-two adults

participated in the control group and 34 adults were in the intervention group that were taught

relaxation and guided imagery techniques. Strengths in this study comprised of randomization of

all subjects in either the control or intervention group, random placement of participants was

withheld from the personnel initiating participants into the study, details explaining why

participants failed to finish the trial were given, the control group was suitable, and the VAS was

proven to be reliable and valid. One limitation of this study was that the HADS was proven to be

valid but not reliable. Another limitation was only women participated in the study.

Zi-Xuan Wang (2008) designed a randomized control trial to determine whether

psychological intervention, which included guided imagery and relaxation, could reduce post-

embolism pain during hepatic arterial chemoembolization treatment. Researchers used the

symptom chest list-90 (SCL-90) to analyze the mental, emotional, and cognitive state of the

participants prior to surgery. The numeric rating scale (NRS-10) was used to measure the

patients pain before and after surgery. There were a total of 262 patients who participated in this
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trial. Forty-six participants were in the control group who only received analgesic medication

and 216 patients were receiving psychological intervention as well as medication. Results

showed that pain in both groups decreased after receiving analgesic medicine throughout the

surgery (P < 0.01). However, few patients exhibited partial or entire relief of pain after receiving

psychological interventions (29.17% and 2.31%). Results showed that the pain level in the

treatment group was considerably less after drug administration than the control group. Strengths

in this study encompassed randomization of all subjects in either the control or intervention

group and the control group was suitable. One limitation of this study was that no explanations

were given in regards to why some participants were not able to finish the study.

Synthesis

Chen et al. (2015) showed that adult breast cancer patients pain had significantly

decreased after receiving guided imagery and relaxation techniques (-0.28 0.58, P < 0.05). In

addition, Leon-Pizarro et al. (2007) found a reduction in pain in gynecological and breast cancer

patients undergoing brachytherapy who received guided imagery and relaxation training for thier

physical and psychological symptoms of breast cancer (p=0.04). Also, Syrjala et al. (1995)

reported that cancer patients with oral mucositis receiving bone marrow transplants along with

guided imagery and relaxation training reported a significant decrease in pain (t = 3.18, P =

0.002). Finally, Zi-Xuan Wang (2008) found that guided imagery and relaxation therapy was

successful in significantly decreasing pain in cancer patients who were receiving hepatic arterial

chemoembolization treatment.

To conclude, researchers agreed that guided imagery and relaxation techniques decrease

cancer patients level of pain (Chen et al. 2012; Leon-Pizarro et al. 2015; Syrjala et al. 1995; Zi-
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Xuan Wang 2008). This research proves that guided imagery and relaxation techniques can

positively affect cancer patients pain levels, potentially improving their quality of life.

Supplementary exploration is necessary to decide which guided imagery and relaxation

techniques work most efficiently to reduce pain.

Clinical Recommendations

The randomized control trials demonstrated that patients who experience pain during

their cancer treatment should be given the option to participate in guided imagery and relaxation

training to reduce their levels of pain. In addition, guided imagery and relaxation techniques can

be used in combination with analgesic medication and other CAM interventions to potentially

further decrease the patients level of pain. Research confirms that guided imagery and relaxation

techniques have not only partially reduced or completely eradicated pain levels for patients, but

has also decreased other patient subjective symptoms such as: anxiety, insomnia, and depression.

Furthermore, nurses can utilize guided imagery and relaxation techniques to help reduce pain in

addition to other symptoms patients experience throughout their course of cancer. Now that

research has proven guided imagery and relaxation can help decrease pain in cancer patients,

further evidence based practice can use this information and further investigate which kinds of

relaxation and guided imagery works more effectively to decrease the pain.
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References

Baker, T., OConnor, M., Krok, J. (2013). Experience and knowledge of pain management in

patients receiving outpatient cancer treatment: What do older saults really know about

their cancer pain? Pain Med, 15(1), 52-60. doi: 10.1111/pme.12244

Chen, S., Wang, H., Yang, B., Chung. (2015). Effect of relaxation with guided imagery on the

physical and psychological symptoms of breast cancer patients undergoing chemotherapy.

Iran Red Crescent Medical Journal, 17(11), 149-222. doi: 10.5812/ircmj.31277

Coyle, N. (2006) Assessing cancer pain in the adult patient. Oncology, 20(10), 41-9.

Leon-Pizarro, C., Gich I., Barthe E., Rovirosa, A., Farrus, B., Casas, F., Verger, E., Biete, A.,

Craven-Bartle, J., Sierra, J., Arcusa, A. (2007). A randomized trial of the effect of training

in guided imagery techniques in improving psychological and quality-of-life indices for

gynecologic and breast brachytherapy patients. Psycho-oncology, 16(11), 971-979. doi:

10.1002/pon.1171

Niegisch, G., Retz, M., Siener, R., Albers, P. (2016). Quality of life in patients with cisplatin-

resistant urothelial cancer: Typical ailments and effect of paclitaxel-based salvage

therapy. Urol Oncology, 16, 1078-1439. doi: 10.1016/j.urolonc.2016.02.002

Syrjala, K., Donaldson, G., David, M., Kippes, M., Carr. (1995). Relaxation and imagery and

cognitive-behavioral training reduce pain during cancer treatment: A controlled clinical

trial. Pain, (63)2, 189-98. doi: 10.1002/pon.537

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