Review Article

Relaxation Therapy with

Guided Imagery for
Postoperative Pain
Management: An
Integrative Review
---

M
arcia Marques dos Santos Felix, Candidate, MSc, PhD*
Maria Beatriz Guimar~ aes Ferreira, PhD,*
Luciana Falc~
ao da Cruz, Candidate, MSc, PhD*
and Maria Helena Barbosa, PhD†

- ABSTRACT:
From the *Stricto Sensu Graduate To identify the evidence in the literature about relaxation therapy with
Program in Health Care, guided imagery for postoperative pain management. Integrative re-
Universidade Federal do Tri^ angulo
Mineiro, Uberaba, Minas Gerais,
view. PubMed, Lilacs, Cochrane, Embase, Web of Science, Scopus and
Brazil; †Didactical-Scientific Cinahl, between August 2006 and December 2016. Descriptors: Post-
Department of Hospital Care operative Pain, Imagery (Psychotherapy) and Guided Imagery. Study
Nursing, Stricto Sensu Graduate
selection: original studies published in English, Spanish and Portu-
Program in Health Care,
Universidade Federal do Tri^ angulo guese. 291 studies were identified and eight were selected. Descriptive
Mineiro, Uberaba, Minas Gerais, data analysis, presented in detail, with a summary of the knowledge
Brazil. produced in each study. In the primary studies included, the use of
Address correspondence to Maria guided imagery associated with other complementary therapies was
Helena Barbosa, PhD, Av. Getulio highlighted: hand and foot ‘‘M’’ technique, education on postoperative
Guarit
a, 107, Bairro Abadia, CEP: pain management with analgesic drugs, relaxation exercises, respi-
38025-440, Uberaba, MG, Brasil.
E-mail: mhelena331@hotmail.com
ration exercises, meditation, soothing biorhythmic music combined
with positive and encouraging assertions and music with nature
Received May 1, 2017; sounds. The knowledge synthesis resulting from this study indicates
Revised October 9, 2017;
that evidence could be identified on the use of guided imagery asso-
Accepted October 11, 2017.
ciated with relaxation therapy as a complementary approach to drug
This work was supported by analgesia in postoperative pain control strengthens its indication for
Foundation for Research of the State nursing practice. This evidence, however, demonstrates that the
of Minas Gerais (FAPEMIG) [grant
numbers APQ-01828-15. Universal quality of the use of this therapy is limited, and it is necessary to carry
Demand/FAPEMIG]. out new randomized clinical studies to fill the existing gaps in this
The authors declare no conflicts of topic.
interest related to this article.
Abstract
Ó 2017 by the American Society for Pain Management Nursing

1524-9042/$36.00 Human pain relief is considered an important mission of health professionals.

Ó 2017 by the American Society for
Pain Management Nursing
Despite the advances in the pharmacologic treatment of pain, many of the patients
https://doi.org/10.1016/ admitted for surgeries still do not receive appropriate treatment for postoperative
j.pmn.2017.10.014 pain relief (Rognstad et al., 2012). Reducing the incidence of postoperative pain

Pain Management Nursing, Vol -, No - (--), 2017: pp 1-10

2 Felix et al.

represents a challenge for the multidisciplinary team 2014). These images are usually visualized within a
(Matkap, Bedirli, Akkaya, & G€ um€us, 2011; Rico et al., state of relaxation, possibly with a specific goal in
2013). mind, such as pain relief (Posadzki & Ernst, 2011).
Postoperative pain is classified as acute pain re- Relaxation therapy can be understood as a psy-
sulting from the combination of anxiety, tissue injury, chological intervention method that aims to assist the
and pain. Its occurrence depends on the influence of patient to achieve a state of rest (physical relaxation)
cultural and psychological factors, previous illnesses, and inner calm (mental relaxation) (Willhelm,
place and type of incision, extent of the trauma during Andretta, & Ungaretti, 2015). The use of relaxation
the surgical intervention, and technical aptitude of the techniques such as diaphragmatic breathing or pro-
surgeon (Darnall, 2016; Miranda, Silva, Caetano, Sousa, gressive muscle relaxation is incorporated into the
& Almeida, 2011). The lack of appropriate pain relief in guided imagery strategy to help the patient stay
the perioperative context entails negative effects for focused. Consequently it will help the patient reduce
the results of the surgery and the patient’s the stress response and promote relaxation. Physical
satisfaction. If left unsolved, these can cause and mental relaxation facilitates visualization and re-
physiologic changes that can result in chronic pain, duces reactivity to stress as it reshapes stressful situa-
entailing losses for the health and quality of life tions from negative responses of fear and anxiety to
(Miranda et al., 2011; Rico et al., 2013). positive images of healing and well-being (Fitzgerald
Brazilian and international studies have found that & Langevin 2014; Kosslyn, Ganis, & Thompson, 2001).
a significant number of patients continue to report mod- Guided imagery can be receptive, when the individ-
erate to severe postoperative pain, signaling one of the ual perceives messages issued by the body, or active,
most important problems in surgery, with significant when the individual evokes thoughts or ideas. It can be
impact on the health system (Boezaart, Munro, & done through audio recordings, videos, or therapists
Tighe, 2013; Robleda, Sillero-Sillero, Puig, Gich, & themselves. Normally the sessions starts with a relaxation
Ba~nos, 2014; Sanansilp, Dejarkom, & Deetayart, 2016; exercise, such as diaphragmatic breathing or progressive
Serrano & Oliveira J unior, 2016; Suksompong, muscle relaxation, to help the participant to focus. After
Chaikittisilpa, Rutchadawong, Chankaew, & Von the participant is relaxed, the therapist suggests an image
Bormann, 2016). of a relaxing, calm, or comforting place. Scenes
The appropriate treatment of postoperative pain commonly used to induce relaxation include watching
should be emphasized because it is fundamental for a sunset or moonlight, sitting on a hot or warm beach,
the patient’s comfort and for the optimization of the or floating on the water or through space (Fitzgerald &
surgery results (Rico et al., 2013). The pharmacologic Langevin, 2014). The therapist can also guide the imag-
approach seems to be the best way to control and fight ery, using positive suggestions to relieve the symptoms
this pain, but there are nonpharmacologic interven- of specific conditions, such as pain (Foji, Tadayonfar,
tions that grant the patient a greater feeling of pain Mohsenpour, & Rakhshani, 2015; Nelson et al., 2013).
and anxiety control, interfering positively in the con- This therapy helps to deviate the attention from
trol of postoperative painful stimuli (Lin, 2012). the physical and psychological discomfort by staying
In a review, the authors discussed medical practice concentrated on pleasant imagery, which can decrease
in response to acute pain and acknowledge that health anxiety and pain, reduce analgesic intake, and bring
professionals should see acute pain as a disease process, down tension, anguish, fear, heart frequency, and
as well as minimizing the use of opioids and promoting blood pressure, besides promoting psychological
alternative pain management strategies (Boezaart et al., well-being, energy, and sleep (Costa & Reis, 2014;
2013). Complementary therapies, such as relaxation, Polomano et al., 2017; Salvador, Rodrigues, &
massage, guided imagery, and acupuncture, have been Carvalho, 2008; Williams, Davies, & Griffiths, 2009).
found to have benefits for patients admitted for different The body-mind strategies encourage self-efficacy
types of surgeries (Hansen, 2015). and active participation in the cure process (Alam
Among the complementary intervention thera- et al., 2016; Glickman-Simon & Tessier, 2014).
pies for pain, guided imagery is highlighted; it is an Relaxation therapy with guided imagery is a widely
integrative body-mind intervention to relieve the used intervention that can be effective to promote
stress, reduce the anxiety, and promote a feeling of clinical results, including surgical outcomes
peace and calmness (Nelson et al., 2013). This inter- (Jacobson et al., 2016). Therefore, it is fundamental
vention is a cognitive-behavioral strategy that uses to investigate health interventions that complement
the patient’s own imagination to form a mental repre- traditional medicine.
sentation of an object, place, event, or situation, In view of these aspects of guided imagery, the
perceived through the senses (Fitzgerald & Langevin, objective in this study was to identify the evidence
 Guided Imagery for Postoperative Pain Management 3

available in the literature on the use of guided imagery relaxation therapy with guided imagery for postopera-
associated with relaxation therapy for postoperative tive pain management?
pain management. The search for the primary studies was undertaken
in the following databases: PubMed, LILACS, Cochrane,
Embase, Web of Science, Scopus, and CINAHL. The de-
scriptors were selected according to each search tool in
METHOD the respective primary databases, using DeCS terms for
To achieve the proposed objective, the review method LILACS; MeSH terms to search the databases PubMed,
called integrative review was chosen and conducted Cochrane, Embase, Web of Science, and Scopus; and CI-
through the following steps: establishment of the hy- NAHL Headings for CINAHL. Two of the researchers
pothesis and objectives of the integrative review; elab- independently searched the databases and read the ab-
oration of the research question; sampling or literature stracts to select the articles included in the review in
search for primary studies; extraction of data from pri- January 2017. The following controlled descriptors
mary studies; assessment of primary studies included were used: Postoperative Pain, Imagery (Psychother-
in the integrative review; analysis and synthesis of re- apy), and Guided Imagery. To guarantee a broad search,
view results and presentation of review (Galv~ao, various combinations of descriptors were made,
Mendes, & Silveira, 2010). including their respective synonyms.
The following guiding question was used: What The inclusion criteria of the primary studies
scientific evidence is available in the literature about selected for this integrative review were studies on

FIGURE 1. - Information flow with different phases of the integrative review. Adapted from Moher et al., 2009.
4 Felix et al.

TABLE 1.
Characterization of Studies Included in the Integrative Review

Title Authors/Year Type of Study

1. Effect of structured touch and guided imagery for pain Forward, Greuter, Randomized clinical trial
and anxiety in elective joint replacement patients: A Crisall and Lester (2015)
randomized controlled trial: M-TIJRP
2. Guided imagery for adolescent post-spinal fusion pain Charette et al. (2015) Randomized clinical trial
management: A pilot study
3. Efficacy of relaxation intervention on pain, self-efficacy, Lim, Yobas, and Chen (2014) Quasiexperimental
and stress-related variables in patients following total
knee replacement surgery
4. An evaluation of the effectiveness of relaxation therapy Lin (2012) Quasiexperimental
for patients receiving joint replacement surgery
5. Effects of guided imagery on postoperative outcomes Gonzales et al. (2010) Quasiexperimental
in patients undergoing same-day surgical procedures:
A randomized, single blind study
6. Is guided imagery effective in reducing pain and anxiety Thomas and Sethares (2010) Quasiexperimental
in the postoperative total joint arthroplasty patient?
7. Evaluation of the magic island: Relaxation for kids Huth, Daraiseh, Henson, Quasiexperimental
compact disc and McLeod (2009)
8. Imagery-induced relaxation in children’s postoperative € lkki, Pietila
Po €, Vehvila
€inen-Julkunen, Randomized clinical trial
pain relief: A randomized pilot study Laukkala, and Kiviluoma (2008)

guided imagery for postoperative pain management, concepts described by Polit and Beck (2016). The au-
research developed on human beings, and studies pub- thors classify the studies quantitative in experimental,
lished in English, Spanish, and Portuguese between quasiexperimental, and nonexperimental. For the ran-
August 2006 and December 2016. Narrative reviews domized clinical trials, the methodologic quality of the
of literature, dissertations, theses, and editorials or study was analyzed using Jadad’s Quality Scale, which
response letters were excluded from the sample. consists of a quality scale to measure the probable
In total, 291 articles were identified in the 7 data- bias in the study. The Jadad score is a 5-point scale
bases investigated: 92 in PubMed, 19 in Cochrane, 30 including three criteria: randomization, level of blind-
in Embase, 40 in Web of Science, 68 in Scopus, 42 in ing, and mention of dropouts and withdrawals. One
CINAHL, and none in LILACS. After reading the titles point is attributed for the presence of each criterion.
and abstracts, 18 studies were selected, considering Points are added if randomization and double blinding
the inclusion and exclusion criteria, which were evalu- are described and appropriate (1 point each) or de-
ated for eligibility, with full text. ducted if inappropriate. Out of the 5 potential points,
Among the 18 primary studies selected, 8 were high-quality protocols are scored $3 and low-quality
excluded because they did not assess postoperative <3 (Jadad et al., 1996).
pain and 1 because other types of complementary ther- The data were analyzed descriptively and pre-
apies were used, not guided imagery. Hence, the integra- sented in detail, including a summary of the knowl-
tive review sample consisted of eight primary studies: edge produced in each study (objective, intervention,
seven in PubMed and one in CINAHL. The selection sample, method, main results, and conclusions).
process of the studies has been illustrated in Figure 1
by means of the PRISMA flowchart (Moher, Liberati,
Tetzlaff, Altman, & the PRISMA Group, 2009) (Fig. 1).
RESULTS
To extract the data from the articles included in Among the eight studies included in this integrative re-
the integrative review, a data collection tool was used view, seven were developed by nurses and one by phy-
that was submitted to face and content validation sicians. As for the language, all studies were published
(Ursi & Gav~ao, 2006), which consists of five items: in English and, regarding the research design and meth-
identification of the study, host institution, type of jour- odologic quality, we found five studies with quasiex-
nal, methodologic characteristics of the study, and perimental designs and three randomized clinical
assessment of methodologic rigor. trials (Table 1). Among the clinical trials, one scored
The analysis of the research design of the studies 3 on the Jadad Quality Scale (maximum total score of
included in the integrative review was based on the 5), indicating that the study was described as
 Guided Imagery for Postoperative Pain Management 5

randomized, the method to produce the randomization explanations on how to turn in the bed after the sur-
sequence was appropriate, and the losses and exclu- gery, including various exercises to address the phys-
sions were reported, but without masking. One study ical and pulmonary functions. In addition, relaxation
received a score of 2 because it was described as ran- exercises (Jacobson method) were provided with
domized but the method to produce the randomization guided imagery, culminating in a state of tranquility
sequence was inappropriate; losses and exclusions and calmness. The control group only received (stan-
were reported, but without masking. And another dard) habitual care. The Brief Pain Inventory, State-
study received a 0 score because it was described as Trait Anxiety Inventory, and Pediatric Pain Coping
randomized but the randomized method was inappro- Inventory were used to measure the pain, anxiety,
priate and there was no masking, nor was there a and coping. The authors noted that adding a DVD
description of losses and exclusions. with guided imagery and relaxation exercises for use
Forward et al. (2015) aimed to investigate the effi- at home was more effective than standard treatment
cacy of the hand and foot ‘‘M’’ technique, which is a alone for postoperative pain. The coping strategies
hand and foot massage for 18-20 minutes, compared did not produce significant differences. The authors
with guided imagery and habitual care in the reduction concluded that, although the intervention was based
of pain and anxiety in patients admitted for elective on spinal fusion for scoliosis, the results may be gener-
surgery. The sample consisted of 225 patients, adults alizable to include an intervention with a similar design
older than age 18 years, 76 men and 148 women, for any painful procedure in this age range.
admitted for elective hip or knee replacement surgery, Lim et al. (2014) investigated whether a relaxation
randomly distributed in one of the three groups (75 pa- intervention helped to reduce pain, stress, and anxiety
tients in each): group A received the ‘‘M’’ technique, and verified whether it contributed to increase the
group B guided imagery, and group C habitual care. perceived relaxation and self-efficacy. Eighteen partici-
The interventions took place in the immediate preop- pants completed the relaxation intervention. Most par-
erative phase, in the immediate postoperative phase, ticipants were women (n ¼ 13; 72.22%), married
and on the first and second postoperative days. The (n ¼ 17; 94.44%), Chinese (n ¼ 12; 66.67%), and be-
methods employed to measure the interventions tween ages 65 and 69 years (n ¼ 6; 33.33%). The par-
were the Visual Numerical Anxiety Scale, the Numeri- ticipants were admitted for full knee replacement
cal Pain Assessment Scale, and the Hamilton Anxiety surgery and received routine care associated with
Scale. The results evidenced a drop in anxiety and relaxation, an intervention containing three daily
pain using the hand and foot ‘‘M’’ technique and guided 1-hour sessions. The intervention comprised theoret-
imagery in patients admitted for elective full knee or ical and practical components. The theoretical compo-
hip replacement surgery. It was concluded that the un- nent included general information on the negative
derlying reason for the impressive benefit of the ‘‘M’’ effects of emotional tension and physical pain on post-
technique was the use of a specifically structured operative recovery, the benefits of practicing the relax-
touch sequence during the intervention process, ation techniques, and the way these techniques are
through the hands of competent and trained incorporated in daily activities. The practical compo-
professionals. nent, in turn, involved practical experience with two
Charette et al. (2015) assessed an intervention relaxation techniques, including breathing exercises
combining guided imagery, relaxation, and education and guided imagery, using a 20-minute audio instruc-
to reduce the postoperative pain and anxiety in adoles- tion. The dependent variables were assessed using a
cents and young adults between 11 and 20 years of age, Numerical Pain Assessment Scale, Numerical Stress
admitted for spinal fusion for scoliosis, seeking to Assessment Scale, Perceived Relaxation Scale, Ex-
relieve pain intensity, reduce anxiety, and improve pected Self-Efficacy Scale, and State-Trait Anxiety In-
coping. The participants were randomly assigned to ventory. After the intervention, the participants
one of the two groups (20 in the experimental group reported significantly less pain, stress, and anxiety
and 20 in the control group); average age was and greater perceived relaxation and self-efficacy. It
15
2.1 years and 7 were male. was concluded that the use of relaxation techniques
On the day of the discharge, 14 days after the can be an alternative or adjuvant strategy to help pa-
discharge, and 1 month after the discharge, the exper- tients admitted for full knee replacement surgery to
imental group received (standard) habitual care associ- mitigate postoperative pain and relieve the emotional
ated with watching a 30-minute audiovisual tension, thus improving their self-efficacy and
presentation (DVD), which provided information on enhancing their recovery.
the surgery, postoperative care, and postoperative Lin (2012) examined the effect of a relaxation
pain management with analgesic drugs and therapy on the reduction of anxiety and pain before
6 Felix et al.

and after the total joint arthroplasty. Ninety-three par- Thomas and Sethares (2010) assessed the effect of
ticipants were sequentially designated to the control guided imagery as an intervention to reduce pain and
(n ¼ 48) and experimental (n ¼ 45) groups. The anxiety in patients admitted for full joint arthroplasty.
mean age was 71.0
11.1; 33 participants (35.5%) The final sample consisted of 121 participants, who
were men and 60 (64.5%) were women. Using chose to participate in the experimental group
earphones, the experimental group received guided (n ¼ 69) or the control group (n ¼ 52). Of the total,
relaxation therapy with a relaxation audio that con- 84 (69%) were women and 37 (31%) men; the age range
tained deep breathing, guided imagery, and meditation was 43-88 years with a mean age of 67.9
10 years. The
in the preoperative phase and on the first, second, and experimental group received standard care and listened
third postoperative days. No interventions were made to a guided imagery CD intended to develop a feeling of
for the patients in the control group, who were relaxation and harmony in the participants. This CD
encouraged to relax in the bed. The pain and anxiety was heard twice per day for 5 days, before and after
levels were assessed using the visual analogue scale the surgery, while the patients were in hospital. The
(VAS) and the State-Trait Anxiety Inventory, blood pres- control group only received standard care. The pain
sure was verified, and cardiac frequency was verified and anxiety levels in the experimental and control
before and after the intervention. The results indicated groups were self-reported on postoperative days 1, 2,
that the patients admitted for full joint replacement and 3, using the Numerical Pain Scale and the Beck
had significantly lower subjective anxiety and pain Depression Inventory. No significant difference was
rates, as well as lower systolic blood pressure, after found in the pain and anxiety levels between the
receiving relaxation interventions. The relaxation ther- groups. The experimental group obtained lower anxi-
apy could be incorporated into clinical practice as a ety and pain levels at all times though. The authors
routine nursing intervention to help patients in the concluded that additional research, with greater atten-
postoperative phase of full joint arthroplasty to better tion to the implementation of the intervention in a ran-
manage pain and anxiety. domized controlled study, can produce significant
Gonzales et al. (2010) assessed the effects of perceived pain findings.
guided imagery on the postoperative results in patients Huth et al. (2009) checked the efficacy of a CD
admitted for surgical head and neck procedures. The with guided imagery in the reduction of postoperative
convenience sample consisted of 44 participants (con- pain and increased relaxation in children. A conve-
trol group ¼ 22 and experimental group ¼ 22), 26 men nience sample of 17 participants between the ages of
and 18 women, ranging in age from 18-71 years, with 7 and 12 years who had been recently admitted for sur-
mean age 34.6
13 years; 34 were white and 10 Afri- gery was included in the research. These, nine girls and
can American. In the experimental group, the partici- eight boys had a mean age of 9.7
1.9; 11 (65%) were
pants listened to a 28-minute CD that guided the white, 3 (17%) African American, 1 (6%) Asian, and 2
patient through a progressive relaxation exercise and (12%) multiracial. At the surgical service, the partici-
guided imagery in the preoperative phase; a second pants received earphones and a portable CD player to
CD with guided imagery was used during the anes- listen to the audio Magic Island: Relaxation for Kids,
thetic induction, before the incision. This CD con- which is a 52-minute audio with music and storytelling
tained a calm biorhythmic melody, combined with to help the child to relax. The relaxation and pain scores
positive and encouraging assertions. The pain was as- were measured before and after the intervention. An
sessed 1 hour and 2 hours after the end of the proced- eight-question tool was used to collect data on the relax-
ure. Anxiety and pain were measured using the ation and pain levels, as well as details on what the child
Amsterdam Preoperative Anxiety and Information imagined after hearing the CD. To assess the relaxation,
Scale and the VAS in the preoperative phase at the post- a 5-point Likert scale was used (1 ¼ ‘ highly relaxed like
anesthetic recovery service and the outpatient proced- a rag doll’’; 5 ¼ ‘ very tense’’). To assess pain, a modified
ure service. The control group received 28 minutes of version of the OUCHER Scale was used. The results indi-
privacy but no CD. The results evidenced a significant cated that the participants presented reduced pain
reduction in the anxiety levels in the experimental scores before and after the intervention, with a statisti-
group, but no significant difference in the use of opi- cally significant difference. The use of the CD, however,
oids between the two groups. The pain level in the produced no significant increase in the relaxation.
experimental group was also significantly lower than These findings indicate that children of school age can
in the control group at 2 hours after the surgery. It use guided imagery and that relaxation may not be
was concluded that therapy with guided imagery necessary to achieve lower pain levels.
seems promising to reduce preoperative anxiety and P€
olkki et al. (2008) evaluated the efficacy of
postoperative pain. guided imagery and relaxation on postoperative pain
 Guided Imagery for Postoperative Pain Management 7

relief in hospitalized children (aged 8-12 years) effects to reduce anxiety levels in stressful situations,
admitted for surgery. Sixty participants were randomly like in preoperative period (Foji et al., 2015).
designated to the experimental (n ¼ 30) or control Nelson, Adamek, and Kleiber (2017) evaluated the
group (n ¼ 30). Of the total, 32 were men and 28 effects of introducing music-assisted relaxation
women, with a mean age of 10.5
1.3. The experi- training to adolescents before spinal fusion surgery.
mental group listened to a CD, which included imagery Forty-four participants between the ages of 10 and 19
and relaxation, developed specifically for children of were enrolled. Participants were randomly assigned
this age range in cooperation with a therapist. The to the experimental group that watched the video at
CD allowed for the scope of the child’s own pleasant the preoperative visit or to the control group that did
imagery and offered tranquility and repetitive music not watch the video. On the second postoperative
with nature sounds for the group to reach a profound day all patients received a music therapy session. The
state of relaxation. The control group received stan- video was 12 minutes and showed descriptions of mu-
dard care and was invited to proceed with its normal sic therapy and music-assisted relaxation and demon-
activities, such as reading or watching television. The stration to practice music-assisted relaxation and
child and the nurse assessed pain intensity in three breathing techniques. The session therapy music con-
phases: before the intervention or the standard care sisted of 5 minutes of breathing technique, 10-15 mi-
(phase 1), immediately afterward (phase 2), and nutes of guided autogenic relaxation and safe place
1 hour after (phase 3) the intervention or the standard imagery, and another 10–15 minutes of patients’ favor-
care, using a VAS. It was noted that the children who ite songs sung by music therapy session. Data collec-
heard the CD reported less pain than the children tion included self-reported pain and anxiety before
with received standard care immediately after the and after the music therapy session. A 0–10 numeric
intervention but not 1 hour after the intervention, rating scale was used to measure the variables of
evidencing that the CD did not exert the expected ef- pain and anxiety, with anchors of ‘‘no pain at all (or
fect: to reduce the pain 1 hour after the intervention. no stress at all)’’ and ‘‘pain as bad as it could be (or
The study suggests that the guided imagery and relax- very bad stress).’’ Pain and anxiety scores for both
ation technique for pain relief should be encouraged, groups decreased from pretherapy to posttherapy.
even after a small surgery. Nevertheless, further In a study developed in New Zealand involving 60
evidence-based knowledge is needed on the long- patients admitted for laparoscopic cholecystectomy, it
term effects of these interventions. was evidenced that a 45-minute psychological inter-
vention, based on relaxation and guided imagery, by
means of a CD during 3 days before and 7 days after
DISCUSSION the surgery reduced stress and improved the wound
This research evaluated the available evidence in the healing of surgical patients (Broadbent et al., 2012).
literature on the use of guided imagery associated Proper pain management is still a common prob-
with relaxation therapy for postoperative pain treat- lem that nurses face in the postoperative period. In
ment. Eight studies met the eligibility criteria. Six view of this reality, a Chinese study found statistically
(75%) suggested that the intervention was effective significant differences in the reduction of postoperative
and two (25%) found no significant effects on postop- pain of thoracic surgery with the use of complementary
erative pain, indicating that the evidence is encour- therapy by music. A randomized clinical trial was per-
aging but not conclusive. formed with 112 patients in an experimental (n ¼ 56)
In the primary studies included in this integrative or control (n ¼ 56) group, in which the first group, be-
review, the use of guided imagery associated with sides standard care, received a soft music intervention
other complementary therapies was highlighted: of 30 minutes for 3 days, and the control group received
hand and foot ‘‘M’’ technique, education on postopera- only standard care. In addition to pain, the experimental
tive pain management with analgesic drugs, relaxation group had a statistically significant decrease in levels of
exercises, respiration exercises, meditation, soothing anxiety, systolic blood pressure, and heart rate. Evi-
biorhythmic music combined with positive and dence favors the use of music therapy as a complemen-
encouraging assertions, and music with nature sounds. tary therapy for the management of postoperative pain
Proper postoperative pain treatment is not only a and other alterations (Liu & Petrini, 2015).
physiopathologic but also an ethical and economic The use of complementary therapies for pain after
issue. Besides reducing pain levels, guided imagery orthopedic surgeries is common. A quasiexperimental
and other complementary therapies, such as music, design developed in China aimed to evaluate the effec-
meditation, massages, and biofeedback, can be used tiveness of an intervention in the reduction of postoper-
as inexpensive nondrug interventions with no side ative pain after total knee replacement. Sixty-six
8 Felix et al.

patients participated in the study, equally divided into Questions are raised regarding why health profes-
the control and intervention groups. The control group sionals do not use nonpharmacologic interventions for
received usual treatment (daily sessions of continuous pain, which tend to be low cost, easy to apply, and free
passive movement therapy and analgesic medications) from adverse effects (Tracy, 2010). Therefore, the
and the intervention group underwent the usual treat- importance of a trained team is highlighted, who can
ment associated with a biofeedback training session, prevent and recognize the pain signs early and who un-
in which they practiced muscle relaxation by observing derstand the benefits of nonpharmacologic measures
how the computerized images showed tension or mus- for acute pain, their mechanisms of action, and how
cle relaxation. The pain was evaluated by a numerical to implement these practices effectively (Polomano
scale. Biofeedback is a monitoring tool that enhances et al., 2017).
awareness of one’s own body functions, in which indi-
viduals can be trained to control body processes and un- Limitations
derstand the power of the mind to influence them as The exclusion of other languages is considered a
well as to have more control. The results indicated research limitation because this review only included
significantly lower pain scores in the intervention group studies in Portuguese, English, and Spanish; other
compared with control, meaning that biofeedback ther- studies have also been excluded because they pre-
apy may be an option for nonpharmacologic comple- sented literature reviews, theses, dissertations, and ed-
mentary treatment for the control of postoperative itorials; because of the time frame to include articles,
pain (Wang et al., 2015). which may have excluded studies published earlier;
In contrast, nurses at a hospital for orthopedics and and because of the impossibility of homogenizing the
traumatology in Turkey developed a study that aimed to research designs to compare the results as a result of
describe the intensity of pain before and after watching inconsistencies in the selection of participants, the
20 minutes of videos. Patients (n ¼ 90) were divided type of protocol used in the intervention with guided
equally into three groups: group A (watched funny imagery, the treatment of variables, the study places
videos), group B (watched dull videos), and group C or contexts, and the quality of the research method.
(did not watch video). The pain was measured by the Also excluded were the articles that dealt with ‘‘guided
VAS. The results indicated a reduction of pain when imagery’’ but adopted another definition for this type
watching both videos, funny or dull; however, the effect of intervention in the study.
lasted for only 30 minutes. Distraction methods are rec-
ommended so that nursing can reduce patients’ postop- Implications for Nursing
erative pain, and future studies are recommended in The use of research results in clinical practice is one of
this context (Elmali & Balci Akpinar, 2017). the most effective actions to avoid or minimize postop-
Another study that did not produce statistically erative complications such as pain. It is up to the
significant results was developed with 105 patients nurses to adequately manage postoperative pain, aim-
admitted for outpatient surgery. A randomized clinical ing to bring comfort and well-being to the patient.
trial was intended to assess the effects of different tech- This research contributes to the construction of
niques—audio relaxation technique, music interven- knowledge within the complementary practices in
tion, nature video application with music, and nature health, besides evidencing the need to carry out
video application without music—on anxiety, studies with greater methodologic rigor, with larger
perceived pain, and self-efficacy in healing. The results samples, standardized control groups, and appropriate
identified no statistically significant difference in the reports of the research methods.
pain scores, measured using the Numerical Assessment There is currently an exponential growth in the
Scale, between the experimental and control groups use of complementary therapies and noninvasive inter-
(Hansen, 2015). vention, and guided imagery has the potential to be
It is important to highlight that pain is a subjective effective in reducing symptoms in various conditions.
measure and that, specifically in surgical situations, It is crucial to conduct evidence-based practices to
other factors, such as anxiety, tension, anguish, fear, familiarize nurses with complementary therapies.
increased perceptions of acute pain, and reduced Nevertheless, it is still important to provide training
self-efficacy in healing, affect the pain level (Hansen, to these professionals for the use of this approach in
2015; Williams et al., 2009). In addition, for ethical the treatment of postoperative pain.
reasons the researcher cannot impede the Nurses should seek training courses and/or post-
administration of anti-inflammatory drugs and/or opi- graduate courses, as well as guidelines for acquiring
oids to better assess pain when applying complemen- the necessary support for the practice and development
tary therapies (Hansen, 2015). of research in this area, thus filling existing gaps in the
 Guided Imagery for Postoperative Pain Management 9

subject. Questions to be developed include which however, suggests that the quality of using this therapy
guided imagery protocols are most appropriate in spe- is limited.
cific conditions, such as postoperative pain (CD use The acknowledged benefits of guided imagery
or session with a professional, duration and number associated with relaxation therapy as a complementary
of sessions); over time, can guided imagery therapy approach to drug analgesia in postoperative pain con-
reduce stress, improve coping, and improve well-being? trol strengthens its indication for nursing practice.
Nevertheless, the scientific community, lacking studies
in a wide range of medical and health specialties, still
CONCLUSIONS underestimates this therapeutic tool.
The knowledge synthesis resulting from this study indi-
cates that evidence could be identified on the use of Acknowledgments
guided imagery associated with relaxation therapy for The authors thank the Foundation for Research of the State of
postoperative pain management. This evidence, Minas Gerais (FAPEMIG) for financial support.

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