Guided Imagery: A Therapeutic Intervention for Clients with Chronic Lower Back Pain.
For the person living with chronic pain, unfortunately, the pain becomes the focus of their lives (Turk, Wilson & Swanson, 2012). As pain is the focus of a person's life, a sense of loss of control is to be expected. As McCracken and Eccelston (2003) stated, a person diagnosed with chronic pain has to decide to learn to live with the pain, or to learn to manage pain, rather than constantly seek a cure. It is this struggle to find a cure that affects the person's perception of control as that person feels as though he or she no longer has the control to alleviate the pain. This lack of pain control can lead to frustration and depression, as well as feelings of helplessness and hopelessness ultimately impacting physical, psychological and social functioning (Fuss, Angst, Lehmann, Michel, & Aeschlimann, 2014). This then can lead to a diminished overall quality of life with the individual neglecting his or her needs, including the goal of controlling the pain (Fuss et al., 2014). While chronic pain is not curable, it can be controlled with a variety of non-pharmacological treatments such as guided imagery.
Guided imagery has been indicated in the literature as an innovative and positive intervention for pain management among adults experiencing chronic back pain (Achenbach, 2000; Lewandowski, 2004; Lewandowski, Jacobson, Palmieri, Alexander & Zeller, 2011). Guided imagery can be defined as a dynamic, psychophysiological process, in which a person imagines, and experiences, an internal reality in the absence of external stimuli (Menzies, Taylor-Gill, & Bourguignon, 2006). As a cognitive-behavioral therapy (CBT) technique, guided imagery allows the client the opportunity to use non-pharmacological alternatives to cope with pain severity. Guided imagery also provides a sensory component including olfactory, visual, and auditory senses. There are numerous studies on the effects of guided imagery (Baird & Sands, 2004; Csaszar, Bagdi, Stoll & Szoke, 2014; Kwekkeboom, Abbott-Anderson, & Wanta, 2010; Menzies et al., 2006; Lewandowski, 2004; Lewandowski et al., 2011). However, there is very little information related to the field of recreational therapy (RT) using this particular intervention; specifically with adults experiencing chronic back pain.
As noted, guided imagery is typically categorized as a CBT technique. The premise of CBT is that people create their psychological problems because of how they think about events and feelings experienced in daily life. Treatment includes restructuring thoughts and reengaging behaviors using new cognitions (Sylvester, Voelkl, & Ellis, 2001). CBT provides the rationale for using relaxation, imagery, and distraction as treatment strategies. Interventions are believed to affect symptoms by changing symptom-related thoughts, diminishing those beliefs that exacerbate symptoms, and increasing personal perceptions of control over symptoms (Kwekkeboom et al., 2010). Further, previous studies have indicated that "CBT combined with guided imagery has a significant impact on functional status, self-efficacy as well as a reduction in emotional distress and pain" (Menzies et al., 2006, p.24).
In addition to guided imagery being utilized within CBT, prior studies have shown that guided imagery can be used as a treatment modality within other therapeutic interventions. Specifically in the field of RT, Bonadies (2009) provided evidence of the success of guided imagery with his case study. After completing four guided imagery sessions (length of sessions were based on the guided imagery script used), "... the client began to become more involved in his daily routine as he was able to manage his pain.the client's quality of life began to improve with the use ofguided imagery and other medical and non-pharmacological interventions" (Bonadies, 2009, p.49). Achenbach (2000) also completed a case study examining the use of guided imagery as a relaxation technique with a client experiencing chronic pain. Five sessions were completed with the client during which the client experienced a decrease in pulse and breathing rates indicating that guided imagery had an effect on the client's physiological reaction to stress associated with pain (Achenbach, 2000). Additional positive outcomes included improvements in relationships between the client and family and perceived control over the client's pain severity. Another example of the successful use of guided imagery is provided by Lewandowski (2004) who completed a study using a quasi-experimental design on the effects of guided imagery on participants living with chronic pain. These participants used audiotaped guided imagery scripts over a four day period, resulting in a significant reduction of pain (Lewandowski, 2004).
An additional study using guided imagery in conjunction with supplementary cognitive behavioral interventions has shown positive results in decreasing participants' pain severity. Baird and Sands (2004) used guided imagery scripts that focus on progressive muscle relaxation to study the effects of this intervention with women diagnosed with osteoarthritis. Results revealed that the participants receiving guided imagery treatments experienced a reduction in pain and mobility difficulties.
Due to the minimal information available on guided imagery within the field of RT, the purpose of this paper is to introduce a guided imagery protocol using process imagery as a non-pharmacological alternative method of pain management implemented with one client who has experienced chronic lower back pain for over 30 years.
Intervention Protocol Implementation
This guided imagery protocol was facilitated as a case study with one client currently participating in a community-based RT program. The overarching goal of the case study was to examine the effectiveness of a guided imagery program using process imagery on a client with chronic pain.
For the purpose of this paper, the pseudonym "Lewis" is used when referring to the client. Lewis had experienced chronic lower back pain for over 30 years and left upper extremity pain for the past eight years.
The guided imagery protocol was facilitated with Lewis, a 62-year old male living at home with a history of cerebral vascular accident (right side), diabetes, and lower back pain. Lewis has had lower back pain for 35 years as a result of a work place injury and left upper extremity pain since his stroke in 2005. Lewis has used many narcotic medications (e.g., Percocet, Hydro Morphine, Oxycontin, and Fentanyl) as the primary form of pain management. Gabapentin was used as a nerve blocker in conjunction with the narcotic medications, as well. According to Lewis, these medications proved to be ineffective in providing pain relief. Lewis continued to experience pain severity that was not tolerable, as well as numerous side effects (nausea, loss of appetite, dry mouth, dizziness, weakness, constipation, and hallucinations) associated with these medications. Within the past eight years Lewis utilized a variety of non-pharmacological interventions as part of his pain management including: acupuncture, reflexology, chiropractic services, and energy therapy. While he has experienced temporary relief through energy therapy, none of the alternative therapies provided the results that Lewis was trying to achieve to control his pain.
As a result of ineffective pain management, Lewis indicated that he no longer had any leisure interests. His relationships with family and friends had been affected and he felt "alienated from his family." He stated that if he can find a cure for the pain then he can return to his normal life. Lewis has a prior history of using forms of meditation and guided imagery as a preoperative relaxation technique and as a general relaxation technique. Based on his history, and his openness to alternative therapies, Lewis appeared to be a good candidate for guided imagery.
Guided Imagery Criteria
The guided imagery intervention is recommended for clients who exhibit signs of pain and stress. Clients must be able to follow directions and be receptive to visualization. Further, Dossey (1995) suggests assessing clients'
(a) understanding of the imagery process,
(b) anxiety and tension levels,
(c) knowledge of relaxation skills,
(d) ability to work with their eyes closed, and
(e) primary sensory modalities (p.42).
Clients are able to end a guided imagery session or terminate treatment if they feel uncomfortable or unsafe at any time. Exit requirements from the intervention include when the client has achieved his/her goals and is able to use guided imagery as a self-management coping strategy. Client outcomes developed for the guided imagery protocol include:
(a) to reduce pain severity,
(b) to reduce stress levels, and
(c) to reduce anxiety (refer to table 1 for guided imagery protocol).
A recreational therapist completed the assessment phase with Lewis at his home with his spouse present. Lewis was able to articulate his answers and follow the instructions to complete the assessment. The recreational therapist used the Leisure Diagnostic Battery (LDB) (Witt & Ellis, 1989), an Initial Pain Assessment (Pasero & McCaffery, 2011), and the Numeric Pain Rating Scale (NRS) (McCaffery & Beebe, 1989) as assessment tools. The initial pain assessment tool was used to gather information on Lewis's pain and was completed during the initial assessment. The NRS was used as a tool to allow Lewis to better understand how his activities affect his pain levels. The NRS was used pre- and post- each guided imagery session. The LDB was used as the tool to assess Lewis's perceived freedom, perceived barriers and activity preferences.
Peebles, McWilliams, Herchuk Norris, & Park (1999) studied the consistency of the LDB Long Form C and gathered data for adults with chronic pain related to physical injuries. The LDB is based on the model of perception and the assessment measured the person's perception of leisure. Chronic pain has shown to affect a person's perception of self. The results of the study show a high degree of internal consistency for the five scales and was comparable to reliability estimates reported (Cronbach's alpha coefficients of 0.90 to 0.92 for the five scores and 0.96 for the total score) in the test manual for Form A, suggesting that the LDB Form C is consistent, as well. The study concluded that the LDB has acceptable consistencies and is appropriate for individuals with chronic pain (Peebles et al., 1999). Consequently, the LDB was deemed appropriate for this case study as it allowed Lewis to recognize how his leisure functioning has been affected by his pain.
During the initial assessment, Lewis indicated that his goal was to find a cure for his pain. Chronic pain is a diagnosis that cannot be cured; however, pain management interventions can be effective coping strategies in controlling pain severity. Lewis's goal of finding a cure for his pain was unrealistic; therefore, the recreational therapist and Lewis worked on developing achievable goals. The finalized goals included:
(a) identify the correlation between activities (whether physical activity or recreational and leisure activity) and pain intensity levels,
(b) identify alternative coping strategies that are effective in decreasing pain intensity, and
(c) decrease pain intensity levels to a tolerable level as identified by Lewis.
The recreational therapist and Lewis discussed alternative interventions for pain management (yoga, physical exercise, tai chi, and guided imagery) and Lewis agreed to trial guided imagery. Lewis had used guided imagery in preoperative settings but he had previously not considered it as a pain management strategy. According to the agreed upon treatment plan, guided imagery would be provided twice a week for three weeks by the recreational therapist for a total of six sessions. Additionally, the recreational therapist would provide guidance on how to self-administer the guided imagery scripts used. Guided imagery can be self-administered or facilitated by a therapist. By teaching Lewis how to self-administer the pain scripts and concentrating on his pain symptoms, Lewis would have the opportunity to feel empowered and increase his control over his pain symptoms. The length of each session varied and was dependent on:
(a) how long the client used deep breathing to achieve a relaxed state, and
(b) how long it would take the client to achieve the lowest possible level on his visual pain scale.
Lewis was also encouraged to use guided imagery as a self-management tool to relieve his pain throughout the day.
During the implementation phase of the RT process, the guided imagery protocol was facilitated. Sessions occurred in the client's home. Lewis was given the choice of location to facilitate the guided imagery sessions and he chose the living room. Lewis was instructed to find a comfortable position for the sessions, either sitting or lying down. Lewis chose to lay on his couch as he indicated sitting up for long periods of time contributed to his pain intensity. The sessions included the following format:
(a) rating and discussing the client's pain severity for the day of treatment, the client's use of guided imagery independently since the last session and the effectiveness of the independent guided imagery session;
(b) implement the guided imagery session beginning with deep breathing exercises;
(c) complete the guided imagery script; and
(d) debriefing after the session, rating, and discussing the client's pain severity post session.
Three guided imagery scripts suggested by Bonadies (2009, p.51) and Dossey (1995) for pain relief were used with Lewis (refer to figure 1). The scripts included:
1. The Pain Intensity Scale--the client imagines an intensity scale from zero to ten. The client focuses on his/her current pain intensity level on the numeric scale and then proceeds to lower the number until it becomes a tolerable pain level (Bonadies, 2009).
2. The Red Ball of Pain script--the client gathers pain into a red ball and changes the size and shape of the ball. Gradually the ball is made smaller until it can pass through the body.
3. The Dimensions of Pain script--the client focuses on the pain and its dimensions. The client then makes a cup with his/her hands to hold the pain and decides what to do with the pain.
Lewis was given the option of which script he wanted to use. The following outlines what occurred during each session.
Session One: For the first session, the goal of the session was to identify which guided imagery script would be used. Two guided imagery scripts were attempted with Lewis, the Red Ball of Pain and the Dimensions of Pain scripts. The first guided imagery script used was the Dimensions of Pain script. Lewis indicated to the recreational therapist that this image was not effective as he felt an increase of pain in his left arm when cupping his hands. The Red Ball of Pain was then attempted and Lewis believed the red ball of pain could be effective and asked for a written copy of the script for his own use. During the first session the recreational therapist provided Lewis with copies of the guided imagery scripts that were attempted and provided the education on how to use guided imagery as a self-management tool. The session time was 25 minutes.
FIGURE 1 GUIDED IMAGERY SCRIPTS PAIN INTENSITY SCALE Have the client get into a comfortable position and close his eyes. Ask the client to use deep breathing techniques to relax and to focus on his breathing. Begin the pain intensity scale technique by asking the client to visualize a scale from 0-10. Next have the client focus on the number on the scale that is relevant to his pain level at that moment. Then have the client decrease that number and continue to lower the number as his pain decreases. Continue to guide the client to a lower number to a tolerable level or the pain is gone. Have the client lock that number in. Once the client is ready he can open his eyes. RED BALL OF PAIN Have the client scan their body, gathering any aches and pains up into a red ball. Begin changing the size of the ball, let it get bigger; imagine how big you can make it. Now, make it smaller, see how small you can make it. Is it possible to make it the size of a grain of sand? Now allow it to move slowly out of your body, moving further away each time you exhale. Notice the experience with each outward breath as the pain moves away. Suggest to your client to change the ball's size several times in both directions and imagine different ways to dispose of the ball. THE DIMENSIONS OF PAIN Have the client close their eyes and relax. Ask the client to describe their pain to themselves in silence. Be present with the pain. Let the pain take a shape, any shape that comes to your mind. Become aware of the dimensions of your pain (height, width, depth of the pain). Where in the body is it located? Give it a color. Feel the texture of the pain. Now with your eyes still closed, let your hands come together palms turned upward and in the formation of a cup. Put your pain into your hands. Ask the client how they would change the pain's shape, height, width, depth etc. Let yourself decide what you would do with the pain. You can throw the pain away, or out it back where you found it or somewhere else. Let yourself become aware of how pain can be changed. REFERENCES: Modified from: Bonadies, V. (2009). Guided imagery as a therapeutic recreation modality to reduce pain and anxiety. Therapeutic Recreation Journal, 43(2), 43-55. Dossey, B. (1995). Complementary modalities/Part 3: Using imagery to help your patient heal. The American Journal of Nursing, 95(6), 40-47.
Session Two: During the second session, Lewis compared the Pain Intensity Scale script and the Red Ball of Pain script, choosing to use the zero to ten Pain Intensity Scale guided imagery script, because he could relate to the scale. Thereafter, Lewis and the recreational therapist used the pain intensity scale script. Lewis's pain level prior to the guided imagery session was a seven on the NRS. After completion of the second session he indicated that his pain level was three and a half on the NRS. Lewis indicated during this session that he used the guided imagery as a self-management tool when he experienced severe pain, and when he was not in session with the recreational therapist. The total treatment time for session two was 20 minutes.
Session Three: During the third session, Lewis indicated that when he used guided imagery as a coping technique he felt that it eased the pressure of the pain. When the recreational therapist questioned further, Lewis stated that he was feeling relaxed and the pain areas were relaxed, but the pain was still there. His pain level prior to the third session was at a level of eight. Lewis believed the high level of pain severity was a result of completing exercises earlier in the day. After completing the third guided imagery session his pain level was at five and a half on the NRS. The total treatment time for session three was 15 minutes.
Session Four: At the beginning of the fourth session, Lewis indicated his pain level prior to the guided imagery session was 9.5 out of 10. After the completion of the fourth guided imagery session his pain level decreased to eight. Lewis indicated that while he had been trying to lower his pain level through guided imagery throughout the day, he was not successful. During the debriefing segment of the intervention, Lewis and the recreational therapist discussed the effectiveness of guided imagery and why his pain level decreased by 1.5 points on the NRS. Lewis indicated that he did not do anything different during his daily routine. While this session did not lower Lewis's pain severity, he felt that the intervention helped him achieve temporary relief. The total treatment time for session four was 10 minutes.
Session Five: During session five, Lewis discussed how his pain severity increased in the afternoon around four o'clock. Lewis continued to use guided imagery as a self-management tool; however, he was unable to get lower than a six on the NRS. Lewis's pain level prior to the fifth guided imagery session was at an eight and half on the NRS and after the session it was at a six. During this session Lewis indicated that his level stayed around seven and that it took a lot of mental energy to focus on lowering the pain before he was able to break through to a level six. The total treatment time for session five was 20 minutes.
Session Six: In the sixth and final session with the recreational therapist, Lewis indicated that he would continue with using guided imagery as a coping strategy for pain management, as it provided temporary pain relief. Prior to starting this session Lewis's pain level was at a seven and after the session he was able to lower his pain level to a five on the NRS. Total treatment time for the last session was 20 minutes.
To evaluate the effectiveness of the guided imagery on pain severity, pain levels were assessed prior to and after each guided imagery session using the NRS. Lewis completed six sessions with the recreational therapist. During each session Lewis was able to decrease his pain level temporarily. Upon completion of the program, Lewis and the recreational therapist evaluated the use of guided imagery as an effective coping strategy for pain relief. Over the duration of six sessions the Lewis averaged a decrease of 2.4 (24%) points on the NRS. The lowest number that Lewis was able to reach in one session was 3.5, indicating a mild pain level. His average pain level after all six treatments was 5.6, which is defined as moderate pain on the NRS.
During debriefing sessions, Lewis indicated that the locations of his pain "relaxed" during the guided imagery sessions. However, on days when his pain level was high, he stated that he had difficulty lowering the pain more than one number on the scale. Even when he was unable to decrease the pain more than one level on the NRS, Lewis indicated that guided imagery relaxed his body, eased the pain and cleared his mind. He continued to self-initiate the guided imagery script up to four times a day and stated that he planned to continue to use guided imagery as a self-management tool for pain relief.
Implications for Practice
There were a number of implications for practice identified from the implementation of this protocol. First, it was discovered that there is the potential for clients to experience pain (whether actual or perceived) with the use of symptom specific scripts. This was evident with Lewis who specified the Dimensions of Pain script caused him pain. As a recreational therapist, this exemplifies the need to develop treatments specific to the client's needs and abilities. One cannot assume that one guided imagery script is better than another. The therapist must have the client try each script and choose the most appropriate script to their need.
Limitations have been identified with the implementation of this program protocol that provide additional practice implications. During the facilitation of the program protocol, Lewis was encouraged to use guided imagery as an independent pain management tool. Lewis was not asked to track his independent sessions through journaling. Journaling and pain tracking is a recommendation for future practice when a client is completing independent sessions. In addition, one of Lewis's goals was to identify non-pharmacological coping strategies. While the client identified guided imagery as a new coping strategy in his pain management regime, it might have been beneficial to have the client track his use of pharmacological treatments when guided imagery was used. As discussed, Lewis was assessed to be a good candidate for guided imagery; however a standardized assessment tool was not used to assess Lewis's suitability for guided imagery. Subjective information through a RT interview was used to assess the client. To further strengthen the program protocol, the use of a standardized imagery scale, such as the Vividness of Imagery Scale (Marks, 1973), could be used to assess the suitability of the client for guided imagery.
Implications for Research
Guided imagery was the only intervention used with Lewis by the recreational therapist. Further study needs to occur to determine the effectiveness of guided imagery as a coping strategy for pain in conjunction with other CBT. Turk, Swanson and Tunks (2008) stated that treatment with CBT alone or within the context of an interdisciplinary pain rehabilitation program has the greatest empirical evidence for success. While this practice protocol was not facilitated in conjunction with CBT, an analysis of the efficacy of this practice protocol, and specifically Lewis's response to guided imagery, and CBT on his short and long-term pain severity levels might have proven beneficial.
Further investigation in relaxation techniques is suggested for clients with chronic lower back pain. Symptom focused guided imagery scripts were used in this protocol as an intervention to reduce pain severity. It would be advantageous to study the effects of pleasant imagery scripts and compare the outcomes among the various guided imagery scripts. Additional studies (Baird Murawski & Wu, 2010; Lewandowski et al., 2011; Menzies et al., 2006) have involved the use of guided imagery audio-tapes as intervention. While this program protocol did not use audio-tapes as an intervention further investigation and comparison between the two methods may provide useful information and evidence about the efficacy of each.
As mentioned earlier journaling and pain tracking did not occur when Lewis completed the guided imagery scripts independently. By incorporating this practice into the study, more statistical information regarding the effectiveness of guided imagery on pain severity levels could be analyzed.
Studies have shown that guided imagery has provided short-term relief for noncancerous pain (Kwekkeboom et al., 2010) and in fibromyalgia management (Menzies et al., 2006); however, long-term relief was not apparent. Findings from this protocol align with findings from these studies in that Lewis experienced immediate reduction in his pain level, but the effects were not long lasting. Lewis's average reduction in pain severity was 2.4 points (24%) on the NRS; and while this reduction was only temporary, a two point change on the NPR is clinically meaningful (Childs, Piva, & Fritz, 2005). The result of this temporary relief from pain improved Lewis' social interaction, activities of daily living and the pursuit of leisure activities.
In summary, guided imagery is a cognitive behavioral technique that has been shown to provide meaningful temporary reduction in pain levels. It has been suggested that further studies are needed to further analyze the effects of this guided imagery protocol as a cognitive behavioral therapy intervention for pain management.
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Vicki I. Di Giovani, Ph.D., CTRS
Adjunct Faculty * Lambton College * Sarnia, ON
Jennifer A. Piatt, Ph.D., CTRS
Assistant Professor * Indiana University * Bloomington, IN
TABLE 1 GUIDED IMAGERY PROGRAM PROTOCOL TITLE GUIDED IMAGERY Purpose To reduce pain and stress through the use of images and relaxation techniques. Entrance Requirements Clients who exhibits signs of pain and stress. Clients must be able to follow directions and be receptive to visualization. Exit Requirements Client's goals are met, able to use guided imagery independently or the client no longer wishes to participate. Group Size One to One. Duration/Frequency 10-45 minutes dependent on the guided imagery script. Daily or as needed. Safety Considerations The recreational therapist must be aware of the emotional condition of the client and provide a non-threatening, safe environment. Assess clients for organic brain syndrome, psychosis or prepsychosis, use general relaxation techniques rather than imagery techniques. Method 1. Introduce and educate the client to guided imagery. 2. Assess the client's experience with visualization, guided imagery and relaxation techniques. 3. Inform the client that guided imagery is safe and that they are always in control and can stop the session at any time. 4. Receive consent from client to begin guided imagery session. 5. Discuss and agree upon a sign as an indicator to start the session and a signal to stop the session if the client feels unsafe. 6. Ensure the client is comfortable before starting, suggest to the client that they can sit or be lying down. 7. Have the client close their eyes and begin with deep breathing for 5-10 minutes. 8. When the client indicates they have relaxed begin reading the guided imagery script. 9. Use a calming tone of voice and pause frequently when reading the script. 10. When finished reading the guided imagery script, have the client slowly open their eyes when they are ready. 11. Allow the client to re-orientate to their surroundings. 12. Discuss the effect of the session with the client. Ask: How do you feel? What did you learn from the experience? How can you incorporate this technique into your life? Was the session effective? What is your pain severity? 13. Ask the client if they have any questions and if they would like to schedule another session. 14. Conclude the session. Client Outcomes To reduce pain severity through non-pharmaceutical interventions. To develop new coping skills for pain management. To reduce stress levels. To reduce anxiety. REFERENCES: Modified from: Bonadies, V. (2009). Guided imagery as a therapeutic recreation modality to reduce pain and anxiety. Therapeutic Recreation Journal, 43(2), 43-55. Dossey, B. (1995). Complementary modalities/part 3: Using imagery to help your patient heal. The American Journal of Nursing. 95(6), 40-47.
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|Title Annotation:||EVIDENCE-BASED PROTOCOL|
|Author:||Di Giovani, Vicki I.; Piatt, Jennifer A.|
|Publication:||Annual in Therapeutic Recreation|
|Date:||Jan 1, 2016|
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