Guided Imagery
A Significant Advance in the Care of Patients Undergoing
Elective Colorectal Surgery
Diane L. Tusek, R.N., B.S.N.,* James M. Church, M.D., B.S., F.R.A.C.S.,*
Scott A. Strong, M.D.,* Jeffrey A. Grass, M.D.,~ Victor W. Fazio, M.B.B.S., F.R.A.C.S.*
From the Departments of *Colorectal Surgery and tPain Management, The Cleveland Clinic Foundation,
Cleveland, Ohio
PURPOSE: Guided imagery uses the p o w e r of thought to
influence psychologic and physiologic states. Some studies
have shown that guided imagery can decrease anxiety,
analgesic requirements, and length of stay for surgical pa-
tients. This study was designed to determine whether
guided imagery in the perioperative period could improve
the outcome of colorectal surgery patients. METHODS: We
conducted a prospective, randomized trim of patients un-
dergoing their first elective colorectal surgery at a tertiary
care center. Patients were randomly assigned into one of
two groups. Group 1 received standard perioperative care,
and Group 2 listened to a guided imagery tape three days
preoperatively; a music-only tape d u t ~ g induction, during
surgery, and postoperatively in the recovery room; a guided
imagery tape during each of the first six postoperative days.
Both groups had postoperative patient-controlled analgesia.
All patients rated their levels of pain and anxiety daily, on a
linear analog scale of 0 to 100. Total narcotic consumption,
time to first bowel movement, length of stay, and nnmber of
patients with complications were also recorded. RESULTS:
Groups were similar in age and gender distribution, diag-
noses, and surgery performed. Median baseline anxiety
score was 75 in both groups. Before surgery, anxiety in-
creased in the control group but decreased in the guided
imagery group (median change, 30; P < O.O0O. Postopera-
tively, median increase in the worst pain score was 72.5 for
the control group and 42.5 for the imagery group (P <
0.001). Least pain was also significantly different (P <
0.001), with a median increase of 30 for controls and 12.5
for the imagery group. Total opioid requirements were
significantly lower in the imagery group, with a median of
185 mg vs. 326 mg in the control group (P < 0.001). Time
to first bowel movement was significantly less in the imag-
ery group (median, 58 hours) than in the control group
(median, 92 hours; P < 0.001). The number of patients
experiencing postoperative complications (nausea, vomit-
ing, pruritus, or ileus) did not differ in the two groups.
CONCLUSION: Guided imagery significantly reduces post-
operative anxiety, pain, and narcotic requirements of colo-
rectal surgery and increases patient satisfaction. Guided
imagery is a simple and low-cost adjunct in the care of
patients undergoing elective colorectal surgery. [Key
words: Imagery; Relaxation; Anxiety; Colorectal surgery;
Pain]
Read at the meeting of The American Society of Colon and Rectal
Surgeons, Seattle, Washington, June 9 to 14, 1996.
Address reprint requests to Dr. Fazio: Department of Colorectal
Surgery, The Cleveland Clinic Foundation, Desk Al11, 9500 Euclid
Avenue, Cleveland, Ohio 44195.
172
Tusek DL, Church JM, Strong SA, Grass JA, Fazio VW.
Guided imagery: a significant advance in the care of patients
undergoing elective colorectal surgery. Dis Colon Rectum
1997;40:172-178.
h e n p a t i e n t s u n d e r g o surgery, t h e y o f t e n ex-
w p e r i e n c e a loss o f c o n t r o l a n d feel t h e y b e -
c o m e a victim i n s t e a d o f a participant. Their e m o t i o n s
m a y b e in disarray. Anxiety, fear o f the u n k n o w n , fear
o f pain, d e p e n d e n c y , uncertainty, a n d h e l p l e s s n e s s
are p r o m i n e n t . 1 T h e s e e m o t i o n s c a n intensify the p e r -
c e p t i o n o f p a i n a s s o c i a t e d w i t h invasive m e d i c a l p r o -
c e d u r e s . 2 Physical a n d p s y c h o l o g i c stress c o n t r i b u t e
to p e r c e i v e d surgical pain, p r o l o n g i n g p o s t o p e r a t i v e
r e c o v e r y time, a n d e n h a n c i n g i m m u n o s u p p r e s s i o n . 3
U n f a m i l i a r s u r r o u n d i n g s o f t h e o p e r a t i n g r o o m inten-
sifies p a t i e n t s ' anxieties. 4
Clinical studies h a v e s u g g e s t e d , h o w e v e r , that a
r a n g e o f p o s i t i v e c o p i n g skills i n c l u d i n g i m a g e r y , re-
laxation, self-talk, a n d p o s i t i v e o u t c o m e e x p e c t a t i o n s
a l l o w p a t i e n t s to retain a s e n s e o f c o n t r o l a n d to
i m p r o v e their surgical o u t c o m e . 1 F u r t h e r m o r e , ran-
d o m i z e d s t u d i e s h a v e s h o w n that p s y c h o l o g i c inter-
v e n t i o n s to r e d u c e stress c a n e n h a n c e i m m u n e func-
tion a n d p r o l o n g survival in c a n c e r patients. 5' 6
O n e practical t h e r a p e u t i c t e c h n i q u e that c a n b e
u s e d to e a s e stress a n d to a l l o w r e l a x a t i o n is g u i d e d
imagery. G u i d e d i m a g e r y u s e s a u d i o t a p e s to c r e a t e
m e n t a l i m a g e s that b r i n g a b o u t a state o f f o c u s e d
c o n c e n t r a t i o n . This state, in turn, a l l o w s r e l a x a t i o n
a n d p r o d u c e s a s e n s e o f p h y s i c a l a n d e m o t i o n a l well-
being. T h e ability to relax, to clear t h e mind, a n d to
e n g a g e in h e a l i n g i m a g e s e n h a n c e s b o t h p h y s i o l o g i c
a n d p s y c h o l o g i c w e l l n e s s . 7 In this w a y , g u i d e d imag-
e r y c a n h e l p p a t i e n t s c o n t r o l their r e a c t i o n s to anxi-
ety, d e p r e s s i o n , a n d stressful situations a n d m a y also
s t r e n g t h e n t h e i m m u n e system, w h i c h p o t e n t i a l l y e n -
a b l e s p a t i e n t s to e n h a n c e their o w n healing. 8' 9 T h e
p u r p o s e o f this s t u d y w a s to d e t e r m i n e w h e t h e r
Vol. 40, No. 2 GUIDED IMAGERY
guided imagery in the perioperative period would
improve the outcome of colorectal surgery.
MATERIALS A N D M E T H O D S
This was a prospective, randomized clinical inves-
tigation involving 130 patients undergoing their first
elective colorectal operation. For sample size calcula-
I
tion, a two-sided Type I error rate (significance level)
of 0.05 and a statistical power of 80 percent were
assumed. Using the sample size formula for compar-
ing two means, 1~ the estimated sample size to detect
a two-day mean difference in hospital length of stay
was 65. The study was approved by the Institutional
Review Board at the Cleveland Clinic Foundation. The
study was initiated March 1995 and completed April
1996. Eligible candidates were male or female En-
glish-speaking patients between the ages of 18 to 75
years, w h o were able to understand simple instruc-
tions. Patients were excluded ff there was a history of
substance abuse, chronic pain lasting more than six
months, narcotic use of more than six months, intol-
erance to morphine, a major psychiatric disorder, or a
contraindication to patient-controlled analgesia
(PCA).
Discussion of study protocol was identical in both
groups of patients and performed before group as-
signment to prevent study bias. Postoperatively, both
groups were given equal amounts of support to as-
sure study objectivity. In addition, patients were nei-
ther told of previous research findings nor given an
expectation of study results. Masking was not possi-
ble in this trial. Quality assurance procedures in-
cluded a visual review of the data forms, ongoing data
processing, rekey verification, and data edit queries
generated through interim summarizations of study
data.
After informed consent had been obtained, patients
were randomly assigned using the uniform random
number generator within SAS11 into one of two
groups. Block randomization was used to help bal-
ance numbers of patients assigned to each group.
Group 1 received the routine postoperative care,
which included intravenous PCA that was monitored
daily by the Pain Management Service for adequacy of
analgesia and changed as necessary to provide ade-
quate pain relief. Group 2 also received intravenous
PCA, but in addition listened to a guided imagery tape
three consecutive days preoperatively. They listened
to a music-only tape during induction of anesthesia,
during the operation, and in the recovery room; they
173
also listened to a guided imagery tape daily for the
first six postoperative days.
The guided imagery tape taught techniques that
allowed them to b e c o m e calm and focused. They
were then brought to a "special place" in their mind
that was safe, secure, protected, supported, and re-
laxed. The imagery story encouraged patients to con-
front and work through any feelings of fear, anxiety,
and negativity. Patients were instructed to listen to the
tape without interruption twice per day, once in the
morning and once in the evening. Tapes were 20
minutes long and had a soft, soothing, musical back-
ground. Music-only tapes were also 20 minutes long
and had the same music that was on the guided imagery
tape. Patients used auto-reverse audio cassette players
to allow for continuous play during surgery and the
immediate postoperative period. Tapes were purchased
from Health Journeys, Cleveland, Ohio.
Pain and suffering are subjective experiences that
are not easy to measure objectively. Assessment of
pain, therefore, usually relies on patient self-report-
ing. A commonly used method to assess pain intensity
is the Numerical Rating Scale.t2 Validity of the Numer-
ical Rating Scale has been well documented, with
good correlations with other measures of pain inten-
sity. Data on pain or anxiety were collected: 1) at the
first meeting with the patient, after surgery had b e e n
scheduled and informed consent for the study had
been obtained (pain and anxiety); 2) shortly before
surgery, as a recall of anxiety of the last three preop-
erative days; 3) before surgery, as the current level of
anxiety; 4) during the morning and evening of each of
the first six postoperative days (pain and anxiety). At
each assessment of pain, patients rated their worst
and least levels of experience. Thus, each patient
provided 1 preoperative and 24 postoperative ratings
of pain (12 worst-pain scores and 12 least-pain
scores) and 3 preoperative and 12 postoperative rat-
ings of anxiety. Mean of the morning and evening
rating during the postoperative period was used as
the raw data for data analysis. Patients were visited or
contacted twice daily (morning and evening) to assess
pain and anxiety. Patients rated their pain and anxiety
twice daily on a linear analog scale from 0 to 100,
where 0 = no pain and 100 = pain as bad as it could
be and 0 = no anxiety and 100 = anxiety as bad as
could be. Narcotic consumption, time to first bowel
movement, side effects, sleep quality, and length of
stay were also recorded. Intravenous PCA narcotic
consumption was recorded as milligrams of morphine
or its equivalent (per a conversion factor); oral nat-
174 TUSEK E T A L Dis Colon Rectum, February 1997

cotic consumption was also noted. Follow-up contin- tient in the imagery group had postoperative compli-
ued for a full six days postoperatively, even if the cations requiring heavy sedation, preventing her from
patient was discharged. In this case, contact was listening to the tapes and giving subjective assess-
made by telephone. ments. Her preoperative data were evaluated but her
An intent to treat philosophy was followed for the postoperative data were not available for analyses.
analysis of all outcome data. Outcome measures were Total analgesic requirements were significantly
summarized using median and interquartile ranges. lower in the imagery group (median, 185 (range,
Confidence intervals (95 percent) for median differ- 55-908) mg) compared with control group (median,
ences in outcome measures were generated using 326 (range, 63-1,108) mg; P < 0.001). Time to first
methods described by Conover. 13 Statistical compar- bowel movement was also significantly less in the
isons for categoric data were performed with chi- imagery group (median, 58 (range, 16-288) hours)
squared tests. Within-group comparisons of controls than in the control group (median, 92 (range, 8-264)
and imagery patients for changes in pain (postoper- hours; P = 0.003). Median length of stay for imagery
ative day 1-preoperative) and anxiety (preoperative- patients was 6.2 (range, 4-31) days and was not sig-
baseline) scores were done with the Wilcoxon's nificantly different from that of the control group (6.4
signed-rank test and between-group comparisons (range, 2.9-30.1) days).
(control v s . imagery) with the Wilcoxon's rank-sum The difference between the worst pain on postop-
test. To compare the decline in the postoperative erative day 1 and the worst pain experienced before
period for pain and anxiety between groups, a sepa- surgery (before tapes were given to the imagery
rate linear regression (least-squares) intercept and group) was significantly different between the two
slope were calculated for each patient. Mean slope for groups. Median increase in the worst pain score was
each outcome was compared between groups using a 72.5 (range, -30-100) for the control group v s . a
t-test. Data were analyzed with the SAS statistical median increase of 42.5 (range, -60-90) for the im-
software system. agery group ( P < 0.001). Least pain (using the same
comparisons) was also significantly different ( P >
RESULTS 0.001), with a median increase of 30 (range, - 4 0 -
92.5) for controls and 12.5 (range, -70-82.5) for the
One hundred thirty patients were enrolled. Of the
imagery group. Anxiety decreased for those listening
65 assigned to the imagery group, two did not listen to
to the tapes (median change, - 3 0 (range, -95-50),
the tapes consistently b e y o n d the initial preoperative
but median change was 0 in the control group. The
day; however, they were still included in data analy-
difference between the two groups in those changes
sis. Median age of all patients was 40 (range, 17-78)
in anxiety scores was significant ( P < 0.001).
years. Median age for control group was 39 years;
The proportion of patients experiencing complica-
median age for imagery group was 40 years. Groups
tions, such as nausea, vomiting, pruritus, and ileus,
were similar in age distribution, diagnoses, and sur-
did not differ significantly between the two groups
gery performed. Data for diagnosis and surgical pro-
(13.8 percent for controls v s . 7.9 percent for the im-
cedures are summarized in Tables 1 and 2.
agery group. Clinical results for narcotic consump-
No statistically significant differences were found
tion, time to first bowel movement, length of stay, and
between patient groups for these variables. One pa-
postoperative complications are described in Table 3.
Worst pain, least pain, and presurgical and postsurgi-
Table 1. cal anxiety were rated by patients on a linear analog
Diagnosis
scale of 0 to 100 during the first six postoperative
Control Imagery Total days. Median scores are displayed in Figures 1
Diagnosis Group Group
n (%) through 3. There are clear advantages for the guided
n (%) n (%)
imagery group, with less pain and anxiety on each
Primary cancer 17 (26) 18 (28) 35 (27) day. However, the rate of decline during the postop-
Mucosal ulcerative 29 (45) 32 (49) 61 (47)
erative period did not differ between groups.
colitis
Crohn's disease 15 (23) 10 (15) 25 (t9) A completion questionnaire was given to the imag-
Undetermined 0 1 (2) 1 (1) ery patients on postoperative day 6. All 64 patients
Other 4 (6) 4 (6) 8 (6) stated that the tapes helped them preoperatively.
Total 65 (100) 65 (100) 130 (100) Only 3.2 percent (2/62) believed that guided imagery
Vol. 40, No. 2 GUIDED IMAGERY 175

Table 2.
Surgical Procedures
Control Imagery Total
Surgical Procedures Group Group
n (%) n (%)
n (%)
Colectomy 18 (28) 18 (26) 36 (28)
Colectomy with coloanal anastomosis 4 (6) 3 (4) 7 (5)
Anterior proctocolectomy 9 (14) 5 (7) 14 (11)
with colorectal anastomosis
Small-bowel resection 8 (12) 11 (17) 19 (15)
Ileal pouch-anal anastomosis 23 (35) 26 (40) 49 (38)
Other 3 (5) 2 (3) 5 (4)
Total 65 (100) 65 (100) 130 (100)

Table 3.
Clinical Results of 130 Patients Undergoing First Elective Colorectal Surgery With or Without Guided Imagery
Control Imagery Median
Response Variable Group Group Difference P
(n = 65) (n = 65) (95% CI)
Median (IQR) narcotic 326 185 115 <0.001
Consumption (mg/patient) (218-432) (123-287) (72-162)
Median (IQR) time to first 92 58 23 <0.001
Bowel Movement (hr) (54-120) (43-90) (7-37)
Median (IQR) hospital 6.4 6.2 0.3 NS
Length of stay (days) (5.3-8.0) (5.1-7.1) (-.1-1)
Percent of patients with 13.8 7.9 5.9 NS
complications*
IQR = interquartile range; CI = confidence interval; NS = not significant.
* Nausea, vomiting, pruritus, or ileus.

served no benefit postoperatively. In addition, 81 per-
cent (50/62) believed that it improved their quality of
sleep, 91 percent (56/60) stated that it helped speed
their recovery, and 100 percent (62/62) stated that
guided imagery reduced their anxiety after surgery.
Ninety-eight percent responded that the guided im-
agery program reduced their pain after surgery (61/
62), and 94 percent (58/62) believed that all patients
having major abdominal surgery should have the op-
portunity to use the guided imagery tapes.
DISCUSSION
The therapeutic use of relaxation and imagery is
centuries old. Only recently, however, has medical
research supported its use. Investigators from health
psychology, behavioral medicine, and the relatively
new field of psychoneuroimmunology have begun to
provide data that explain how the mind and body
interact as a whole to influence healing and the im-
mune system. 2 Guided imagery can empower the
patient by allowing them to actively participate in
their recovery. 14
Music affects human physiology through electric
conduction, heart rhythm, circulation, and respira-
tion. It may relieve stress by diverting attention away
from, or by masking, annoying noises. 4 Allowing pa-
tients to listen to music during anesthesia induction
and surgical procedures has been shown to decrease
anxiety and stress levels. 4 Guided imagery also pro-
vides a means for patients to directly focus on positive
images and thoughts, thus allowing a "mental tempo-
rary escape." Our study did not evaluate the patient's
responses using a music-only tape during induction
and during the surgical procedure. However, overall
patient satisfaction and comments regarding the mu-
sic-only tape were high.
Through guided imagery, patients have been
shown to relax, clear the mind, and engage in images
that can support them physiologically and psycholog-
ically. 15 This study shows that guided imagery bene-
fits patients undergoing colorectal surgery. In addi-
tion to significantly reducing pain and anxiety, guided
imagery improved patients' assessment of their well-
being. Baseline levels (pre-tape) of anxiety and pain
for both control and imagery patients were similar,
suggesting that all patients began the study experi-
176 TUSEK E T A L Dis Colon Rectum, February 1997

100 m

= Control

80 .--<>-- Imagery
I.g
n-
O
0 60
\
k-
w
X 40
Z

20

0 I I I I I p
Baseline Preop 1 2 3 4 5 6

POST OP DAY
Figure 1. Plot of anxiety scores for control and imagery groups at baseline, immediately before the operation, and on
each of the six postoperative days. Data are given as median interquartile ranges.

100
--- Control
LLI
Iz: 80
,--o---Imagery
0
r
og
z
~ 6O
I--

0 4O
I;,
20

I I I i I I I
Preop 1 2 3 4 5 6

POST OP DAY
Figure 2. Plot of worst pain scores for control and imagery groups at baseline, immediately before the operation, and
on each of the six postoperative days. Data are given as median interquartile ranges.

encing the same discomfort levels. After surgery, pa-
tients receiving guided imagery rated their pain and
anxiety considerably lower than controls did on each
of the first six postoperative days.
Psychologic and behavioral preparation for surgery
can affect the body's recovery. A controlled study
conducted by McLintock, e t al. 16 at The Royal Infir-
mary in Glasgow was conducted to determine if pos-
itive suggestions given to a patient under general
anesthetic would reduce postoperative pain and an-
algesic requirements. The audio tape containing pos-
itive suggestions did not have a musical background.
Sixty-three w o m e n undergoing elective abdominal
hysterectomy were randomized to listen to either a
Vol. 40, No. 2 GUIDED IMAGERY
100
Lla
,,,,- 8O
0
0
t~
~ 60
!--
O3
'~ 4 0
W
,_1
20
0 I
Preop 1 2
POST OP DAY
Figure 3. Plot of least pain scores for control and imagery groups at baseline, immediately before operation, and on
each of the six postoperative days. Data are given as median interquartile ranges.
blank tape or a tape of positive suggestions during the
operation. Pain scores and narcotic consumption was
recorded for the first 24 hours postoperatively. Mean
morphine requirements were 51 mg for the w o m e n
w h o listened to the positive suggestions vs. 66 mg in
those w h o listened to a blank tape. Difference be-
tween the means was 14.6 mg ( P = 0.028). Pain
scores were similar in the two groups.
Anxiety increases oxygen consumption, cardiac
output, and blood pressure. The combination of anx-
iety and stress may produce a need for higher dosages
of anesthetics and sedatives during procedures that
may have a negative impact on patients' recoveries. 4
Gastrointestinal surgery and postoperative pain are
associated with adverse physiologic stress responses.
Medications used to treat pain postoperatively can
also lead to several postoperative side effects, includ-
ing nausea, pruritus, and paralytic ileus. Disbrow and
Bennett 17 compared the return of intestinal function
after intra-abdominal surgery in a control group with
that of patients w h o received positive suggestions v i a
audio tape. The study group had earlier return of
bowel function (2.6 vs. 4.1 days) than the control
group. Patients w h o received guided imagery left the
hospital on an average of 1.5 days before those in the
control group.
Our results for bowel function are similar to those
of Disbrow and Bennett, 17 although this earlier return
did not decrease the median length of hospital stay.
177
= Control
,--<>---Imagery
I
3 4 5 6
Similarly, an effect on hospital stay may have b e e n
masked by the generally short stay that is n o w routine
for colorectal surgery patients (6 days) and by low
patient numbers. Sample size calculation for this
study was based on data available on 362 patients
having colorectal surgery at The Cleveland Clinic in
1994 w h e n mean length of stay was 8.2 (standard
deviation = 4) days, which is almost one day longer
than that observed for this study (mean, 7.4; standard
deviation, 4.3). To detect a difference of one day in
the mean length of stay between the two groups in a
new study with 80 percent power and an alpha level
of 0.05, the sample size would need to be approxi-
mately 600 (300 in each group). The observed power
for this study was 75 percent to detect a two-day
difference in mean length of stay. Although there was
no significant difference in our study between con-
trois and imagery patients for complications and
length of stay, the imagery group used significantly
less narcotic and had their first bowel movement
earlier. Our study required listening to the guided
imagery tape more frequently than previous studies,
including preoperative, operative, and postoperative
listening.
CONCLUSION
Results of this study suggest that the use of guided
imagery has a significant impact on preoperative and
178 TUSEK E T A L
postoperative anxiety, pain, narcotic consumption,
and patient satisfaction. Guided imagery is a simple,
low-cost adjunct in the care of patients undergoing 7.
elective colorectal surgery.
8.
ACKNOWLEDGMENTS
9.
The authors thank Kirk Easley, Geri Locker, and Lin
Williams for statistical assistance with this manuscript, 10.
Hayley H e c k m a n for assistance with data collection
and patient assessment, and Dr. Michael McKee and
Jerry Kiffer from the Department of Psychology for 11.
assistance with protocol development.
12.
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