Complementary Health

Practice Review

A Review of the Effects of 15(2) 98-107

The Author(s) 2010
Reprints and permission:
Guided Imagery on Cancer sagepub.com/journalsPermissions.nav
DOI: 10.1177/1533210110388113
Patients with Pain http://chpr.sagepub.com

Kelly King, RN, MN1

Abstract
Over half of the patients diagnosed with cancer suffer from pain. Often, analgesic medications do not
completely relieve the pain and alternative measures are sought out for relief. Mindbody techniques
such as guided imagery (GI) have been thought to be helpful and used as an adjuvant to pain relief.
This article evaluates and summarizes studies performed from 2001 to 2008, which investigated the
use of GI for relief of cancer pain. Electronic databases were searched with the keywords cancer
pain, visualization, and guided imagery, for any studies utilizing GI with an outcome measure of pain.
Five studies included pain as either a primary or a secondary outcome measure. In three of those,
pain intensity and pain-related distress decreased in the GI intervention versus control. There is incon-
sistency in the methodological qualities of these trials and further research is necessary to provide better
evidence for the use of GI in cancer pain.

Keywords
guided imagery, cancer pain, systematic review

Introduction
It is estimated that one third of all cancer patients suffer from moderate-to-severe pain related to
their cancer and over 50% of patients diagnosed with cancer suffer from some type of pain (Van den
Beuken-van Everdingen et al., 2007). The most common types of pain related to cancer are due to
the cancer tumor and the treatment. Unlike those who suffer from chronic pain, cancer pain sufferers
often experience pain in more than one area; the pain can be both acute and chronic and often varies
in presentation (McGuire, 1989). Pain is associated with changes in psychosocial relationships,
decreased quality of life, and increased rates of depression and anxiety (Godfrey, 2005; Syrjala &
Chapko, 1995).
Unfortunately, patients and providers often find that pharmacologic therapy does not completely
control pain associated with cancer. Pharmacologic management of pain often comes with side
effects such as nausea, constipation, drowsiness, pruritus, sedation, and delirium (National Compre-
hensive Cancer Network [NCCN], 2009). Therefore, complementary and alternative medical

1
University of Washington, Seattle, WA, USA

Corresponding Author:
Kelly King, University of Washington, 7954 20th Ave SW, Seattle, WA 98106, USA
Email: kellking@u.washington.edu
King 99

(CAM) therapies, including mindbody techniques, are often sought out (Barnes, Bloom, & Nahin,
2008). Mindbody therapies are recommended in addition to pharmacologic approaches for cancer
patients experiencing pain (American Cancer Society [ACS], 2009; NCCN, 2009).
The American Cancer Society issued a report in 2008 revealing the percentage of use of CAM
therapies obtained from over 4,000 cancer survivors 1024 months after their diagnosis. The CAM
therapies most frequently reported were prayer/spiritual practice (61.4%), relaxation (44.3%), faith/
spiritual healing (42.4%), nutritional supplements/vitamins (40.1%), meditation (15%), religious
counseling (11.3%), massage (11.2%), support groups (9.7%), and guided imagery ([GI] 9.1%;
Gansler, Kaw, Crammer, & Smith, 2008).
GI is a technique that dates back to ancient times. Dr. Rossman, a cofounder of the Academy for
Guided Imagery, describes in his book Guided Imagery for Self-Healing, practices and rituals aimed
at both spiritual and physical healing within many different cultures and religious practices dating
back to the time of Hippocrates in ancient Greece when the imagination was considered an organ
(2000, p. 210). Examples of other traditions that utilized a type of GI include Shamanic Healers,
Native American medicine men, Hindu sages, traditional Chinese medicine practitioners, Tibetan
healers, Judaism teachings, and Egyptian medicine. In the 19th century, as techniques later named
as hypnosis became more widely known, imagery came to the forefront as Sigmund Freud developed
psychoanalysis and Carl Jung later described using a method he developed, active imagination
(Rossman, 2000, p. 212).
Theories behind the process of how GI affects healing and pain include (but are not limited to) the
psychoneurological theory and the gate control theory. The psychoneurological theory developed by
Green and Green (Vines, 1988) proposes that when a person creates an image the cerebral cortex is
in turn activated. As that image is held, the limbic system is activated; subsequently, the hypotha-
lamus is activated to create changes in the autonomic nervous system (Vines, 1988). The basis for
how GI works to control pain according to the gate control theory is that when sensory stimuli and
images stimulate the cerebral cortex, they may compete with the pain stimuli and in turn help to
close the pain gate; neurotransmitters are then secreted (e.g., serotonin), which further suppress
pain transmission and allow the inhibitory neurons to secrete natural opioids (Godfrey, 2005;
Melzack & Wall, 1965).
A common theme in the use of GI is that the patient is led or guided verbally through a series of
descriptive images, using visual, auditory, olfactory, and other sensory-related verbal triggers, in an
effort to more fully engage the imagination, to obtain the desired outcome (Ackerman & Turkoski,
2000; Kwekkeboom, Huseby-Moore, & Ward, 1998; Tusek & Cwynar, 2000). Research suggests
that a brief introduction to relaxation may help the participant be more engaged while beginning
a session (Ackerman & Turkoski, 2000; Arathuzik, 1994; Eller, 1999). A GI session can take place
through a prerecorded audiotape or with a practitioner who leads either an individual or a group
through the imagery.
Lewandowski (2004) discusses the potential increase in benefits of an individualized versus
group GI session, in which the recipient can determine what scene or image they feel most
drawn to/compelled to use. However, there may be benefit to prerecorded audiotapes because
of their ability to be used in private settings and at a patients convenience (Tusek & Cwynar,
2000).
GI has been shown to have a positive impact on quality of life, depression, anxiety, and overall
well-being (Apostolo & Kolcaba, 2009; Arathuzik, 1994; Devine, 2003; Eller, 1999; Freeman et al.,
2008; Lewandowski, 2004; Morone, Lynch, Greco, Tindle, & Wiener, 2008). However, there still is
some question as to whether GI is useful in the treatment of pain, especially in the long term. Results
have been mixed; many of the studies are designed differently so that it is difficult to compare
results. Some of the differences in design include patient population, type of pain, the different
scripts for GI, and different measurement tools (Eller, 1999).
100 Complementary Health Practice Review 15(2)

Method
An initial literature search was performed using the electronic databases PUB MED, CINHAL,
PSYINFO, and the COCHRANE library to identify any studies related to the use of GI for cancer
pain. The search included review articles and was not limited to randomized controlled trials (RCTs)
due to the limited amount of research available to review. The search was limited to those published
in English and to those published since 1985. The keywords utilized in the search were cancer pain,
visualization, and GI. A total of 58 articles describing clinical studies were found in the search.
Articles were then reviewed for their relevance to the aim of this review and their reference lists
were scanned for additional relevant studies cited. Of these, 53 were eliminated because they were
either systematic reviews or clinical trials that did not utilize GI as an intervention, did not
specifically investigate cancer pain, were not actually a clinical study but a summary of GI, utilized
a qualitative design, and were not within the time frame that was later decided to be inclusion
criteria, (description to follow).
Six systematic reviews were found that focused on the use of GI; none of the six reviews focused
solely on the role of GI for cancer pain management. Instead, the focus of these reviews was on
practice outcomes (Van Kuiken, 2004), its use as a sole adjuvant therapy for cancer patients (Roffe,
Schmidt, & Ernst, 2004), and its role combined with psychoeducational interventions on cancer pain
(Devine, 2003). The systematic review that is most similar to the aims of this review was completed
by Devine and published in 2003; in Devines review, 25 studies published from 1978 to 2001 were
examined to determine the effects of psychoeducational interventions (education, music therapy, GI,
and progressive muscle relaxation) on cancer pain. Five of the 25 articles reviewed included some
type of GI in the treatment group (Devine, 2003).
In order to focus on the most current research, this review targeted articles published during
20012008. Within the time frame of 20012008, five clinical trials were identified.

Results
When only those research studies published from 2001 to 2008 were included, a total of five studies
were found that included pain as either a primary or a secondary outcome measure. The samples
ranged from 40 to 66 patients. Table 1 describes each studys sample, intervention, pain measurement
tool, outcomes measured, duration, and findings.
Two studies included hospitalized patients with cancer pain; one article focused on patients
undergoing colorectal resection; one focused on outpatients receiving brachytherapy; and another
focused on ambulatory patients with cancer pain. As previously noted, the nature and cause of cancer
pain is complex and includes pain related not only to the tumor itself but to the treatment as well.
Therefore, it was felt to be within the scope of the aim of this article to include the study by Haase,
Schwenk, Hermann, and Muller (2005), which investigated the use of GI in the postoperative colorectal
surgery patient population.
Three of the studies were randomized controlled trials, one was a crossover design and one was a
one-group prepost test design. All of the studies utilized audiotapes for the GI intervention.
However, the GI intervention in each study was different. Interventions ranged from the glove
anesthesia technique to 10- to 20-min GI audiotapes. One study utilized a 45- to 50-min informa-
tion session for both the control and experimental group and an additional 10-min training regarding
imagery and relaxation for the experimental group; members of the latter were then given an
audiotape to listen to on their own time. All but one study described in detail the script of the tapes.
The studies ranged in length from 1 intervention and measurement per participant (this was a pilot
study) to up to 4 measurements lasting until 89 weeks after baseline.
 Table 1. Studies Reviewed on the Effects of GI on Cancer Patients With Pain: Description of Methods and Outcomes
Author Type of Study Sample Intervention Outcomes Measured Pain Measurement Tool Duration Findings

Kwekkeboom, Wanta, &
Bumpus 2008b
Kwekkeboom, Kneip, &
Pearson, 2003
Haase, Schwenk, Hermann, &
Muller, 2005
Leon-Pizarro, et al., 2007 RCT
RCT crossover 40 hospitalized Glove anesthesia technique Pain intensity and pain-
design patients with of GI, PMR, and control;
cancer pain. using a 14- to 29-s
audiotape/CD; 2 trials of
each per participant over
a 2-day period.
One group 62 hospitalized 12-min imagery tape; one
pre- and cancer intervention per
posttest patients. participant.
design
RCT 60 inpatients with 12 min of GI, PMR, or con- Pain medication use:
colorectal car- trol started 2 days prior
cinoma espe- to surgery and
cially recommended to listen
colorectal to tapes 3 a day. From
resection. induction of anesthesia
until fully awake, listened
to tapes containing only
background music.
66 patients Training in relaxation and Pain; body discomfort;
undergoing GI10 min and given an depression; anxiety.
brachytherapy. audiotape for use while
at home and in the hos-
pital. All participants
experimental/control
received 45- to 50-min
session of information
about the brachytherapy.
010 NRS 2 days. Percentage change in pain
related distress; Imaging intensity GI 31% versus
ability, outcome control 8%, percentage
expectancy. change in pain-related
distress 37% GI versus
16% in control.
Mean pain intensity; mean 010 NRS One intervention Average pain intensity
pain-related distress; per participant. score decreased in 90%
perceived control over of participants.
pain; outcome
expectancy, previous
history of use, preferred
coping style, perceived
credibility of the
provider.
100 mm VAS 6 day: 2 days No statistically significant
Analgesic consumption, preoperative difference for any of
number of analgesic until 4th day primary or secondary
requests or number of postoperative. measured outcomes.
rejected analgesic Patient response to
requests on PCA. Forced psychological
vital capacity, forced intervention was posi-
expiratory volume, time tive, 79% thought they
to first flatus & bowel had benefited from
movement, reinsertion listening to tape, 98%
of nasogastric tube, liked listening to intrao-
fatigue, patient response. perative music. 90% said
that they would recom-
mend to others.
010 pain inventory 12 weeks Statistically significant
prior to reduction of anxiety,
hospitalization depression, body dis-
up until 3 weeks comfort in study group.
after treatment. Pain analogue scale has
similar ratings across
both groups. Psychoso-
cial Disorder scale with
reduced level of altera-
tion in experimental
group, not statistically
significant.

101
(continued)
102
Table 1 (continued)
Author Type of Study Sample Intervention Outcomes Measured Pain Measurement Tool Duration Findings
Anderson et al., 2006 RCT 59 cancer Positive mood group: 20- Pain intensity before and Included VAS in larger Baseline Immediate rating of pain
patients with min audiotape that after practice. Mood, QOL-indicator measurement at after listening to relaxa-
pain. includes positive mood quality of life, and questionnaire for 23 weeks (time tion and distraction
statements and positive self-efficacy for pain Body Discomfort. of second clinic tapes significantly
imagery suggestions; control. Measured VAS one visit), at 45 decreased. No change in
relaxation group: 20-min time. (Calidad de vida weeks, and at positive mood group.
audiotape containing QL-CA-AFex [CCV]). 89 weeks after No significant differ-
standard PMR instruc- baseline. ences in pain intensity
tions. Distraction group: over the course of the
selected an audiotape on 89 weeks in treatment/
a topic such as foreign control groups.
language, geography, or
vocabulary. Waiting list
group: patients told they
would be offered a
choice of the audiotapes
at the third assessment.
45 weeks after
baseline.

Note. GI guided imagery; NRS numeric rating scale; PCA patient controlled analgesia; PMR, progressive muscle relaxation; RCT randomized controlled trial; VAS Visual Analog scale.
King 103

Of the three studies that gave patients audiotapes to listen to while at home or in the hospital, two
included in the results a summary of the mean amount of time the audiotapes were listened to. One
did not address consistency of use or monitor for compliance at all. Also, the time elapsed from when
the tape was listened to until the questionnaire was given/taken was not consistent from study to
study. It is possible that the perception of pain relief would be dependent upon the amount of time
that had elapsed from when the tape was listened to. For example, if pain had returned, it might be
rated as less helpful.
The type of pain measurement for 3 of the studies was on a numeric rating scale (NRS) of 010.
One study used a 100-mm Visual Analog scale (VAS) and one a 27-question body discomfort
questionnaire which included a one-time VAS for pain measurement; more specific details of the
questionnaire are not given. Three of the studies assessed pain levels immediately before and after
the interventions. In the postoperative patients, pain was assessed between 0600 and 0800 daily.
In the brachytherapy patient population, pain was assessed on the 2nd day and then 23 weeks
afterward.
In three of the five studies, there was a short-term decrease in pain in the GI intervention versus
control group for pain intensity and pain-related distress, average pain intensity scores decreased and
there was a decrease in body discomfort. The control groups included receiving an audiotape record-
ing of information regarding their health care team and hospital services (Kwekkeboom, Wanta, &
Bumpus, 2008b), a 45- to 50-min session of information about the brachytherapy that the experimental
groups received (Haase, Schwenk, Hermann, & Muller, 2005) and being told that they would be
offered a choice of audiotapes for GI or progressive muscle relaxation at 45 weeks after baseline
(Anderson et al., 2006).
In the postoperative colorectal resection patients, there was no statistically significant difference
in analgesic consumption or number of requests for and/or rejections of medication (indicator of
pain level). However, the majority of patients reported that they liked listening to the tapes and that
they would recommend it to others.
Anderson et al. (2006) found that the patients listening to positive mood statements and positive
imagery suggestions did not have a change in pain intensity. However, a statistically significant
decrease in pain was seen immediately following listening to the relaxation and distraction tapes.
The description of the positive mood statement/positive imagery tape intervention is limited and its
approach to GI was different than other GI described in previous studies. No other studies were
found that described using positive statements about mood or imagery to bring patients to relaxation.
It is possible that those suffering from pain may need to first be brought into a state of relaxation or
distraction from pain before being presented with positive statements that they are not prepared for
or open to hear.
The aim of a study by Leon-Pizarro et al. (2007) was to investigate the effect of training in
relaxation and GI techniques on quality of life and body discomfort (i.e., nausea/difficulty with
movement). Pain was found not to have a significant decrease across groups in this study. However,
it was measured only once during the hospitalization. In this study, it may be more beneficial to
review pain in a broader context, realizing that the body discomfort scale could be thought of as
a measure of pain.
Only one study in this review (Anderson et al., 2006) assessed pain levels at a longer term interval
(89 weeks), and they did not see any statistically significant reduction in pain and body discomfort
over this longer time. Another study (Leon-Pizarro et al., 2007) assessed pain 23 weeks after the
initial assessment and did not see a significant difference in pain scores but did see a decrease in
body discomfort. Short-term effects may be extended by teaching patients to practice on their own,
after a session is over. Freeman et al. (2008), taught patients to practice short, 60-s doses of
imagery throughout their day (p. 69). These short vignettes were built into the GI program as
conditioning reminders to make it automatic and easy to practice as the need arises (p. 73).
104 Complementary Health Practice Review 15(2)

In interviews after the study, patients recommended a refresher class which may encourage continued
practice. Having an online training or audiotape or compact disc for patients to access at anytime may
be beneficial to ongoing use and may assist in providing longer term benefits.

Factors Influencing GI
In a secondary analysis of the Kwekkeboom, Wanta, and Bumpus (2008b) study by Kwekkeboom,
Hau, Wanta, and Bumpus (2008a), 26 of the 40 original participants agreed to be interviewed about
their observed pain, the perceived effectiveness of the pain interventions, and the factors that influ-
enced the effectiveness of the interventions. Negative comments in the secondary analysis included
the following: too much pain, past the point of being able to participate, and having trouble creating
the images. Positive statements included themes usefulness of GI in distraction from pain, concentration
on something other than pain and helpfulness of a soothing voice, uninterrupted quiet time and the
stimulation of relaxation. In their original study, Kwekkeboom et al. (2008b) also found that those with
fewer concurrent symptoms had more meaningful improvements in pain.
Imaging ability and outcome expectancy have been shown to have an impact on the effectiveness
of GI (Kwekkeboom et al., 1998; Kwekkeboom et al., 2008b; LeBaron, 1989). The patients level of
motivation and previous experience with GI has also been cited as having an impact on its effectiveness
(Freeman et al., 2008; Kwekkeboom et al., 2008a; LeBaron, 1989). The GI instructors or practitioners
level of comfort, experience, and training all may have an effect on the outcomes (Freeman et al., 2008;
Kwekkeboom et al., 2008a; Rossman, 2004).
Certification in GI can be obtained by health care professionals, educators, or coaches in health
services through the Academy for Guided Imagery (2010). A total of 150 hours is dedicated to the
training, with 52 of those hours in small groups under the supervision of the clinical faculty.
An Internet search also revealed multiple different certification programs available to both lay and
health care providers which vary in their curriculum, length, and cost.
Other considerations that may play a role in the effects of GI include how often it is practiced, the
setting in which it is practiced, the time in relation to analgesic medications, and when the pain level
is measured. Kwekkeboom, Kneip, and Pearson (2003) did not include patients that had received
intravenous doses of analgesic medication within 30 min prior to interventions and oral analgesic
60 min prior. Although patients were included in the study that had basal continuous intravenous
infusions via patient-controlled analgesia (PCA) pumps, they were asked to refrain from using
additional doses during the intervention. The Haase et al. (2005) patient population were all placed
on PCA pumps, having access to intravenous analgesic medication at, essentially, all times.
Arguments can be made as to both the hindering and helpful role of analgesia, in GI success.
On one hand, it could be argued that the effects of the analgesia could have hindered the patients
ability to perform and stay focused in the GI session; on the other hand, analgesia could have helped,
as the patient with more pain relief and access to medication would be in theory more comfortable, in
less pain, and able to participate more fully.

Discussion
There is a consistent theme within research on mindbody therapieslow methodological quality,
small sample sizes, and a limited amount of research available (Bardia, Barton, Prokop, Bauer, &
Moynihan, 2006; Eller, 1999; Roffe et al., 2005). It would be beneficial for future research to repeat
trials with larger sample sizes, incorporating the same type of GI scripts and interventions (number
of times imagery utilized and when), pain measurement times, assessment instruments, and outcome
measurements. It would be difficult, and perhaps unethical, to impose restrictions on study patients
as to timing and amount of analgesic medication; such restrictions may also dissuade patients from
King 105

participating. Also, in order to measure the long-term benefits, studies would need to assess compliance
in the use of audiotapes and measure outcomes on a longer timeline.
Research up to this date regarding the use of GI for cancer pain has been primarily focused on
non-Hispanic Caucasians; therefore, research needs to be carried out with diverse populations.
In conducting such research, cultural sensitivity is important. For example, other cultures may have
different contextual meanings for words described in GI scripts regarding color, places in nature,
sound, and smells. What is viewed as healing or peaceful in one culture may not be useful in another.
Therefore, in conducting future research, it will be important to assess the cultural-based meaning
associated with the images described in the scripts. One way to avoid using inappropriate images is
to utilize a script that allows each patient to create their own place or image of relaxation and
peacefulness.
In conclusion, because of the inconsistencies of measurements such as time of pain measurement,
requirements for when analgesic medications were given in relation to the GI, the different scripts,
different patient populations, and the small sample sizes, it is difficult to give concrete recommen-
dations that GI will work for all patients that suffer from cancer pain. However, based on the
information from these reviews, GI could be recommended as a potential aid in the relief of pain
associated with cancer. Selection of appropriate patients that are motivated and willing to participate
is important. It is possible that a screening tool to assess for imaging ability and coping style
preferences prior to initiation would aid in selecting candidates that would receive the most benefit
from using GI.

Acknowledgment
The author would like to thank Dr. Ardith Doorenbos for her contribution to this article.

Declaration of Conflicting Interests

The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this
article: the National Cancer Institute under grant R42 CA141875.

References
Academy for Guided Imagery. (2010). Certification training. Retrieved from http://www.AcadGI.com
Ackerman, C. J., & Turkoski, B. (2000). Using guided imagery to reduce pain and anxiety. Home Health Care
Nurse, 18, 524-530.
American Cancer Society, Inc. (2009). Non medical treatments for pain. Retrieved October 1, 2009, from
www.cancer.org
Anderson, K., Cohen, M., Mendoza, T., Guo, H., Harle, M., & Cleeland, C. (2006). Brief cognitive-behavioral
audiotape interventions for cancer-related pain. Cancer, 107, 207-214.
Apostolo, J., & Kolcaba, K. (2009). The effects of guided imagery on comfort, depression, anxiety and stress of
psychiatric inpatients with depressive disorders. Archives of Psychiatric Nursing, 23, 403-411.
Arathuzik, D. (1994). Effects of cognitive-behavioral strategies on pain in cancer patients. Cancer Nursing, 17,
207-214.
Bardia, A., Barton, D., Prokop, L., Bauer, B., & Moynihan, T. (2006). Efficacy of complementary and alternative
medicine therapies in relieving cancer pain: A systematic review. Journal of Clinical Oncology, 24,
5457-5463.
Barnes P.M., Bloom B., & Nahin R. (December 10, 2008). CDC National Health Statistics Report, 12.
Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007.
106 Complementary Health Practice Review 15(2)

Devine, E. (2003). Meta-analysis of the effect of psychoeducational interventions on pain in adults with cancer.
Oncology Nurse Forum, 30, 75-89.
Eller, L. S. (1999). Guided imagery interventions for symptom management. Annual Review of Nursing
Research, 17, 57-84.
Freeman, L., Cohen, L., Steward, M., White, R., Link, J., Palmer, L., . . . Hild, C. (2008). The experience of
imagery as a post-treatment intervention in patients with breast cancer: Program, process, and patient
recommendations. Oncology Nursing Forum, 35, E116-E121.
Gansler, T., Kaw, C., Crammer, C., & Smith, T. (2008). A population-based study of prevalence of complementary
methods use by cancer survivors: A report from the American Cancer Societys studies of cancer survivors.
Cancer, 113, 1048-1057.
Godfrey, H. (2005). Understanding pain, part 1: Physiology of pain. British Journal of Nursing, 14,
846-852.
Haase, O., Schwenk, W., Hermann, C., & Muller, J. (2005). Guided imagery and relaxation in conventional
colorectal resections: A randomized, controlled, partially blinded trial. Diseases of the Colon and Rectum,
48, 1955-1963.
Kwekkeboom, K., Hau, H., Wanta, B., & Bumpus, M. (2008a). Patients perceptions of the effectiveness of
guided imagery and progressive muscle relaxation interventions used for cancer pain. Complementary
Therapeutics in Clinic Practice, 14, 185-194.
Kwekkeboom, K., Huseby-Moore, K., & Ward, S. (1998). Imaging ability and effective use of guided imagery.
Research in Nursing and Health, 21, 189-198.
Kwekkeboom, K., Kneip, J., & Pearson, L. (2003). A pilot study to predict success with guided imagery for
cancer pain. Pain Management Nursing, 4, 112-123.
Kwekkeboom, K., Wanta, B., & Bumpus, M. (2008b). Individual difference variables and the effects of
progressive muscle relaxation and analgesic imagery interventions on cancer pain. Journal of Pain and
Symptom Management, 36, 604-615.
LeBaron, S. (1989). The role of imagery in the treatment of a patient with malignant melanoma. The Hospice
Journal, 5, 13-23.
Leon-Pizarro, C., Gich, I., Barthe, E., Rovirosa, A., Farrus, B., Casas, F., . . . Arrcusa, A. (2007).
A randomized trial of the effect of training in relaxation and guided imagery techniques in improving
psychological and quality-of-life indices for gynecologic and breast brachytherapy patients. Psycho-
Oncology, 16, 971-979.
Lewandowski, W. (2004). Patterning of pain and power with guided imagery. Nursing Science Quarterly, 17,
233-241.
Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.
McGuire, D. (1989). Cancer pain pathophysiology of pain in cancer. Cancer Nursing, 12, 310-315.
Morone, N., Lynch, L., Greco, C., Tindle, H., & Weiner, D. (2008). I felt like a new person. The effects of
mindfulness meditation on older adults with chronic pain: Qualitative narrative analysis of diary entries. The
Journal of Pain, 9, 841-848.
National Comprehensive Cancer Network. (2009). NCCN Practice Guidelines in Oncology. Adult Cancer Pain.
Retrieved from www.nccn.org
Roffe, L., Schmidt, K., & Ernst, E. (2005). A systematic review of guided imagery as an adjuvant cancer
therapy. Psycho-Oncology, 14, 607-617.
Rossman, M. (2000). Imagery in health care: Past, present and future. In H J Kramer Inc (Ed.), Guided imagery
for self healing (pp. 207224). Tiburon, CA: New World Library.
Rossman, M. (2004). Guided imagery in cancer care. Seminars in Integrative Medicine, 99106.
Syrjala, K., & Chapko, M. (1995). Evidence for a biopsychosocial model of cancer treatment-related pain. Pain,
61, 69-79.
Tusek, D., & Cwynar, R. (2000). Strategies for implementing a guided imagery program to enhance patient
experience. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 11, 68-76.
King 107

Van den Beuken-van Everdingen, M. H., De Rijke, J. M., Kessels, A. G., Schouten, H. C., van Kleef, M., &
Patijn, J. (2007). Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Annals
of Oncology, 18, 1437-1449.
Van Kuiken, D. (2004). A meta-analysis of the effect of guided imagery practice on outcomes. Journal of
Holistic Nursing, 22, 164-179.
Vines, S. (1988). The therapeutics of guided imagery. Holistic Nursing Practice, 2, 34-44.

Bio
Kelly King is a recent graduate from the University of Washington with a Masters in Nursing. She currently
practices in an Intensive Care Unit as an Assistant Nurse Manager in Seattle, WA.