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Guided imagery

An effective pain management tool for total joint replacement?

Quinn, Catherine MSN, RN

doi: 10.1097/

Guided imagery after total joint replacement

Catherine Quinn is an RN at Good Samaritan Hospital in Suffern, N.Y.

The author has disclosed no financial relationships related to this article.

GUIDED IMAGERY is an increasingly popular pain management option within the scientific and healthcare communities as opioid-related deaths continue to rise. A psychological relaxation technique, guided imagery utilizes mental images of pleasant sights, smells, sounds, tastes, or somatic sensations (touch, movements, or positions) to create a positive cognitive and emotional state that can prevent or ameliorate pain or other sources of distress.1 (See Types of guided imagery.) It may be used as an adjunct modality to help alleviate pain and anxiety in patients who have undergone a total joint replacement (TJR) of the knee or hip. Implementing guided imagery has been shown to decrease pain and anxiety levels, improving patient satisfaction scores.3 Although more evidence is needed to help support their effectiveness for postoperative pain and anxiety, complementary therapies such as guided imagery have the potential to increase self-efficacy of patients in many surgical situations. Elective TJR is a painful procedure, and acute postoperative pain after the procedure can be intense. This article explores the potential effectiveness of using guided imagery for patients recovering from TJR.

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The case for nonopioid alternatives

Pharmacologic modalities during the immediate postoperative period are often needed and may be used to effectively manage a patient's pain; however, incorporating complementary therapies allows the patient to take control of his or her pain and recovery. Using a multimodal approach to pain management during the postoperative period may decrease the amount of pain experienced by the patient. A multimodal approach uses various analgesics, such as opioids, acetaminophen, gabapentin, and nonsteroidal anti-inflammatory drugs, in addition to nonpharmacologic modalities such as ice or cognitive therapies (for example, guided imagery) to help decrease pain.4 When a patient's pain is well managed, he or she is better able to participate in physical therapy, cough, take deep breaths, and concentrate on healing and regaining independence.

From 1999 to 2017, approximately 218,000 people died from overdoses associated with opioid prescriptions.5 Lack of pain control in surgical patients can contribute to longer hospital stays, prolonged use of opioids while in the hospital and at home, a decrease in quality of life, and difficulty with mobility.6 Goesling and colleagues found that patients who reported using opioids before surgery had a higher rate of opioid use 6 months post-op. Patients who take higher amounts of opioids preoperatively as well as postoperatively are more likely to have a difficult time weaning off them once their postoperative pain improves.7 Opioid use can cause sedation and respiratory depression, two adverse reactions that may impede early ambulation and lead to poor patient outcomes.8 Pain medication may also hamper a patient's self-efficacy.9

Data from National Health Statistics Reports show that 41.6% of adults used some type of complementary medicine in 2012. The report highlights the evidence of complementary techniques being used to manage pain in adults with musculoskeletal issues.10 The National Center for Complementary and Integrative Health has listed advancing the understanding of the effect that the mind and body have on health as part of its 2016 Strategic Plan.11 Guided imagery focuses on positive or pleasant imagery to allow the mind to move away from physical and psychological pain, which may lead to a decrease in anxiety, stress, and/or pain.12

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How can guided imagery help?

Guided imagery is a relaxation technique that can help reduce stress and anxiety as patients are guided to imagine themselves healing.13 (See Using guided imagery: An example.) Guided imagery uses all the senses to connect the mind and body. Patients should be encouraged to envision themselves with decreased pain and to adopt a positive outlook on their expected outcomes and health processing. In a double-blind randomized study on same-day surgical patients, guided imagery was found to decrease pain and anxiety in patients 2 hours after surgery.14 It also has the potential to enhance patient outcomes and psychological well-being.13 During a meta-analysis by Fernandez and Turk, which explored six different cognitive therapies to control pain instead of using no treatment, imagery therapies were found to have the most positive effect on reducing pain.15

Guided imagery may be used by all members of the interdisciplinary team. It has been studied by researchers including, but not limited to, professionals in the psychology, nursing, and rehabilitation fields.16

Appropriate pain management after any surgery is important in optimizing a patient's recovery. TJR (knee or hip) is a painful procedure, and opioid use in the immediate postoperative period is often needed. Incorporating nonpharmacologic methods may contribute to an overall decrease in anxiety and allow patients to better manage their pain.12

Uncontrolled pain following TJR often delays recovery because patients are less willing to participate in therapy. Poorly managed pain also can increase length of stay and decrease patient satisfaction. Implementing guided imagery has been shown to decrease pain and improve patient satisfaction scores.3 Therefore, more research is needed to incorporate guided imagery into practice for patients who have undergone TJR.

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Reviewing the literature

Spinal and nerve blocks are often used to decrease immediate pain after elective TJR. Feelings of pain slowly return once the anesthesia begins to wear off; anxiety and stress about having to ambulate and move with the pain begins. Patients start to think they will not be able to regain functional mobility due to pain, which leads to stress. When patients are in pain, their BP and heart rate may rise, causing even more stress. Stress due to pain slows down a patient's recovery.17

Guided imagery may help alleviate pain by acting as a neuromodulator, blocking pain by changing the processing in the autonomic nervous system.17 Nurses should educate patients on guided imagery and participate in training. An integrative review of literature conducted by Carpenter and colleagues concluded with recommendations that guided imagery be part of pain management and part of the multimodal plan of care for patients. From their research, the authors recommended deciding on optimal frequency and ensuring patients are using the technique correctly.18

Pain is a subjective measurement; each patient's threshold for pain is different. The same applies for the use of guided imagery, as some patients have a higher imaging ability than others. Guided imagery has been shown to help patients increase their gait speed, especially in those with higher imagery abilities.19 Guided imagery and other relaxation techniques may also help improve sleep and increase feelings of relaxation.20

Patients' perceptions of guided imagery can affect results. Patients who find the technique acceptable and have a positive outlook are more likely to benefit from the therapy. A study exploring the acceptability of the technique by patients showed that many patients felt it helped them relax, reduce pain, and have a more positive outlook.21

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Nursing implications

Nurses are at the forefront of pain management, administering pain medication, using nonpharmacologic methods of pain management such as cold therapy, and assessing and reassessing a patient's clinical status. Guided imagery should be included in training for managing postoperative care of patients undergoing TJR. Taking patients on a visual journey into relieving stress and tension allows them to become more relaxed and better able to perform activities of daily living. It also has the potential to help patients decrease the number of opioids they take both before and after surgery. Nurses must educate patients on the addictiveness of opioids as well as inform them about nonpharmacologic methods that are effective in managing their pain.

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Reducing pain for better outcomes

Evidence suggests that guided imagery is an effective modality for pain management of patients undergoing TJR. However, more research into the topic of guided imagery should be conducted to allow for better patient outcomes and satisfaction in pain management after TJR. Nurses should understand the benefits of guided imagery and know how to implement best practices and assist patients in utilizing it. Guided imagery should be implemented based on the patient's preference.22 Best-practice protocols and proper education need to be fully developed in order to provide the best care with improved outcomes.

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Types of guided imagery2

  • Relaxation imagery involves visualization of relaxing and pleasant images that allow the mind and body to rest. These images may be new or old experiences or memories.
  • Mental rehearsal imagery involves visualizing a positive outcome for an anxiety-producing situation, such as surgery or a job interview. The person imagines him- or herself completing each step of the event, fully recovering from surgery or finishing the interview with success.
  • Pain control imagery involves imagining one's pain as something you can control by being able to switch it off. One method is to take one's pain and transform it into something else. Another way is to imagine the pain disappearing as one becomes pain-free.
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Using guided imagery: An example

A typical guided imagery session consists of verbal prompts to help the patient relax. Here is an example:

Close your eyes and imagine yourself relaxing on a beach somewhere. Focus on your breathing, releasing all the tension in your body as you exhale. Concentrate on the part of your body that has tension or may be in pain. As you feel the air entering and exiting your lungs, allow the stress and pain to leave as you breathe out. Feel yourself relaxing. Listen to the sound of the ocean and imagine yourself walking along the water. Feel the sand under your feet and listen to the waves crashing at the shore. Now, concentrate on your knee or hip and envision yourself walking along the water. Feel the pain and tension releasing, being swept away by the waves.

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