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Study Appraisal of an Experimental Study

Info: 4116 words (16 pages) Nursing Essay
Published: 23rd Apr 2021

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The Use of Guided Imagery to Manage Pain in an Elderly Orthopaedic Population

 The purpose of this paper is to evaluate the experimental study “The Use of Guided Imagery to Manage Pain in an Elderly Orthopaedic Population” by Antall and Kresevic (2004). This experimental study explored the effect of a guided imagery intervention in the elderly patients who have received joint replacement surgery and the effect on pain, anxiety and length of hospital stay. Before this pilot study, the researchers evaluated the environment to see how the study would fit into the the current pain controlling drug protocols, the overall goal and education of the unit. The healthcare staffs were educated with an overview of pain, guided imagery, as well as review of journal sheets; they served to eliminate bias of the healthcare staff about pain and relaxation. The purpose was to provide evidence based practice guidelines to nurses managing elderly to reduce pain after joint replacement surgery with the use of guided imagery, a non-pharmacologic relaxation technique.

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All 13 participants, who were waiting for hip or knee replacements in a Veterans’ Hospital in the Midwestern area of the U.S., were recruited. There were two inclusion criteria. The participant was 55 and older. The patient was literate, able to read and write, as well as understand and follow simple instructions in English. The patient was excluded if there was a history of substance abuse 6 months prior to the study and psychiatric impairment. After the inclusion was placed, 13 male patients remained and were randomly assigned to two groups, a control group and intervention group. A power analysis sample was not mentioned in the study, so it is difficult to state if sample size was adequately formed. The data collection included several information. It contained individual surveys and journaling of pain, anxiety and physical functioning ratings throughout the treatment. It also included the diagnosis, type of surgery, frequency of the use of emergency unit, as well as any visits to the clinic. Only one patient declined to be randomized to the groups; therefore, the participant consented to chart review only, which included the demographics, previous medical history along with diagnosis and surgeries, number of visits to the clinic, use of pain medication, as well as pain rating scales.

 The data collection included the surveys, journals, chart review, as well as three standardized instruments. First, the pain was measured by the Visual Analog Scale (VAS), which measures self-reported pain rating, with 0 as no pain and 10 as the worst pain the participant has ever felt. Second, anxiety was measured by Profile of Mood States (POMS), which uses 5 point Likert scale. Scores range from 0 to 4, with total possible point of 20, which indicates highly anxious mood state. Lastly, physical functioning was measured by the SF-12 system. It is a self-rating system, scores from 12 to 43, that assesses physical, emotional and social function. Length of hospitalization was also compared. The sample size was identified from the list of potential joint replacement patients in Veterans’ Hospital in the Midwestern area of the United states. After the inclusion criteria has been applied, 13 patients remained. Power analysis or a desired sample size as not mentioned in the study. Also, those who fit the criteria were given an explanation of the study, as well as a consent form; they were reassured that the participation was voluntary.

 After the two groups were obtained by random assignment, the control group received the usual preoperative and postoperative care, which included nursing assessment, physical therapy, education, and medication management, as well as a tape of relaxing music. The study group received the usual care, as well as a 20-minute guided imagery audio tape by Belleruth Naparstek, which helps to decrease patient’s pain intensity, pain medication use and health services use. The participants were given a journal of their experiences in the study before and after the surgery until the day of discharge, which was aided and reminded by the nurse to promote the use of recording and the cassette tape. The control group was instructed to record pain and feelings before and after therapy. The study group was instructed to record three things: frequency of audio tape use with date and time, VAS pain scale ratings before and after tape and feelings before and after the therapy. There were several different findings in this study.

 The main finding demonstrated the effectiveness of guided imagery as a positive outcome to decrease pain and anxiety in the postoperative elder patients with joint replacements. The control had less nurse-recorded pain rating of 2.35 compared to 5.30 of the control group. It is, however, interesting to see the difference in patient and nurse ratings; it may display the complexity of pain and subjective data, as well as individual tolerance. With the decrease in pain, there was less among to Intravenous (IV) morphine sulfate used within four days. The intervention group used 36.70mg, where as the control group used 84.87mg. It is unclear when the IV morphine sulfate was given before the VAS report. However, it supports the belief of pain control includes multiple modalities.  Despite the initial baseline scores, anxiety levels decreased in the intervention group from 6.57 to 2.80, as well as from 3.25 to 1.67 in the control group. The study does not mention why the baseline anxiety score was doubled of the control group; another study should measure both state and trade anxiety.  The difference in decreased length of stay were obvious in the study group. The study group’s length of stay was 9.29 days, where as the control group had mean of 14.93 days of stay. The researchers postulated that this may be due to existing comorbid conditions, personal and physical therapy progress and availability of social support.

Questions related to CREDIBILITY

Yes/No or Not Clear


Is the study published in a source that required peer review?


Orthopaedic Nursing is an international, peer reviewed journal that enhances the education nurses in the healthcare system. It has a wide variety of settings, from hospital unit to client’s home. It is an official Journal of the National Association of Orthopaedic Nurses (NAON).

Was the design used appropriate to the research question?


The experimental research design is stated in this study. It contains an independent and dependent variable, random assignment as well as a control group. There are few aspects of study in this article:

  1. Use of 20-minute guided imagery tape by Belleruth Naparstek in addition to usual preoperative and post operative vs usual preoperative and post operative care with tape of relaxing music
  2. Use of Naparstek’s audio either before or after surgery; at least twice a day.
  3. Intervention’s effect on nurse recorded/patient recorded VAS pain scale, POMS scale physical functioning
  4. Effect on length of hospital stay, as well as use of IV morphine sulfate

 It should be noted that this is a pilot study.

Did the data obtained and the analysis conducted answer the research question?


The data attained and shown in Table 1 is:

  1. Nurse recorded pain rating (0-10)
  2. Patient recorded pain rating (0-10)
  3. Baseline anxiety (0-5)
  4. Anxiety day 3 (0-5)
  5. Intravenous morphine sulfate (mean total of 4 days)
  6. Length of study
  7. Total sample, control group vs intervention group findings

This study examined the effect of guided imagery during preoperative and postoperative period after a joint replacement procedure. The data was obtained by the journals given to the patient, and their written ratings within each criteria. The main intervention was using Naparstek’s audio tape at least twice a day in addition to the usual care. Although most of the questions were answered, and others were not. Table 1 did answer the research question. The results showed that there was a decrease in nurse recorded pain rating, baseline/ anxiety rating, as well as IV morphine sulfate and the length of stay within the intervention group. However, with only 13 participants in the study (insufficient sample size), the patient recorded pain rating could not be recorded. Also, only slightly more than half of the participants competed the journal, which shows the lack of refinement and education. The researchers does cite other studies to support the findings. Although the research question mainly focused on pain relief, decreased anxiety, and decreased length of study, decreased use of IV morphine, provided data that could be used in future studies.

Were the measuring instruments reliable and valid?


The purpose of this study was to examine the effect of guided imagery on pain, anxiety and length of hospital stay of elderly patients undergone joint replacement procedure. To do so, three standardized instruments were used in this study. Pain was measured by VAS scoring system, ranging from 0 to 10 with 0 as no pain and 10 the worst possible pain. Anxiety was measured using the POMS instrument with 5- point Likert scale, with scores ranging from 0 to 4. The maximum point is 20, which indicates highly anxious mood state. Physical functioning was scored using the SF-12 instrument. This measures health status in the general and specific population. For this study, the scores ranged from 12-43. The satisfaction of the guided imagery intervention was measured by a questionnaire designed by the researchers. The length of the stay was measured through the participants’ charts. 

Were important extraneous variables and bias controlled?


This study had specific inclusion and exclusion criteria that prevented possible extraneous variables from influencing the data being collected. The participants had to be able to speak, understand and read English, as well as be able to follow simple instructions. They could not have been diagnosed with major psychiatric illness or have been under substance abuse within the past 6 months. This reduced the number of participants who were not able to self-report while journaling, which could lead to wrong conclusions. Age was controlled by keeping the participants 55 years and older to serve the purpose of studying the elderly orthopaedic population. There is mention of the education of the staff, including the nurses, physical therapy to decrease bias but it is unclear to what extent it affected bias of guided imagery treatments.

Was the study free of extraneous variables introduced by how, when, and where the study was done?


This study was not free of extraneous variables. The participants was selected from a Veterans’ Hospital, and no female participants were included. Patients were directed to record their experiences in a journal but it is unclear if every participant followed the protocol regularly throughout the study at the same time, preoperatively and postoperatively. Comorbidity was not excluded from the study; therefore, it is unsure how much it affects the data. Personal tolerance and weight is also not an inclusion nor an exclusion criterion which could have altered the results. The study does not mention whether the same team or techniques were used for the replacement surgeries; differences in these could have altered the recovery time. Although nurses were instructed to prompt the patients to use the guided imagery recording, it is unclear when or how they assisted the patients. It is also unclear when the scales were given to the patients; was it few hours before and after postoperative stage or was it a day after? How often were the participants supposed to journal? Lastly, there is no mention of monitoring temperature, which could alter the recovery process for each participant has different preferences with hot and cold therapy. Also, the study studies guided imagery’s effect on elder populations with joint replacement surgery, but it is unclear how many of the participants had hip or knee replacements; the different locations of the surgery may affect the outcome of scoring (sample was selected from patients scheduled for hip or knee replacement surgery).

Were participants randomly assigned to groups and were the two groups similar at the start (before the intervention)?


The participants were randomly assigned to the two groups by pre-assigned random numbers. In this way, contamination of data was avoided. However, the researcher mentions that one patient declined to be randomized to the groups; therefore, the patient was asked to consent to chart review only. 

Were the interventions well defined and consistently delivered?

Not clear

Although the interventions were defined, the extent to which they were applied throughout the study is unknown. The control group was given the usual pre-op and post-op care, including assessments, education, pain management, physical therapy and a tape of relaxing music. However, the specific genre is not defined. It is unclear if it’s classical, jazz or other genres; also, the term “relaxing” is a broad term, since everyone has different preferences in defining “relaxing music.” The intervention group was given the usual care above, as well as a 20-minute guided imagery music by Naparstek. They were instructed to use the tape cassette either before or just after the surgery. They were also instructed to use it at least twice a day. However, there is no mention of a specific time frame before or after surgery. Also, there is no mention of how many times the nurse came into their rooms to prompt them in journaling their experiences and opinions throughout the study. The time frame is also unclear. Although the study measured “length of stay,” it is not mentioned as to the parameters of the admission criteria. The parameters of the main interventions studied, the use of guided imagery by Naparstek and the use of standardized instruments were defined.

Were the groups treated equally other than the difference in interventions?

Not clear

The study does not mention in this study if both groups, control and intervention, were treated fairly besides receiving the different interventions. The study does not mention the type of replacement done (either hip or knee) nor if each participants were treated by the same staff and doctor. As mentioned above, the protocols used in hip and knee replacements are different, and doctors have different techniques performing their surgeries. These differences could possibly affect the outcome or extent of the post-op stage. As far as assigning each participants to the group, randomized assignment was used, which decreases contamination.

If no difference was found, was the sample size large enough to detect a difference if one existed?


There was a difference found in this study.

If a difference was found, are you confident it was due to the intervention?


Are the findings consistent with findings from other studies?


The researchers cited several studies that had a similar conclusion that the guided imagery as an effective approach to post-op interventions.

  1. Acute Pain Management Panel (1992)
  2. Deisch et al. (2000)
  3. Dreher (1998)
  4. Devine and Cook (1986)
  5. Daake and Gueldner (1989)
  6. Nilsson, Rawal, Unestahl, Zetterberg and Unosson (2001)
  7. Tusek et al. (1997)
  8. Naparstek (1994)
  9. Thomas (1991)
  10. Bennett, Benson and Kuiken (1986)
  11. Ashton et al. (1997)

The result was also supported by other studies that supports the dissatisfaction of current post-op management protocols practiced by many healthcare facilities.

  1. Watt-Watson et al. (2000) mentions that patients report poorly controlled pain or poor pain management, despite the advances in pain management education and treatment options.
  2. Acute Pain Management Panel (1992) also states that U.S. Public Health Service reported that elders report twice the rate of pain than of the general population.
  3. McCaffery (1999) states that pain management’s goal is to enhance overall functioning and quality of life of each patient.

Questions related to CLINICAL SIGNIFICANCE

Yes/No or Not Clear


Note any difference in means, r2s, or measures of clinical effects (ABI, NNT, RR, OR)

Not clear

There were no means, r^2s, or measure of clinical effects. As a pilot study, there were only able to study 13 participants. Because of the small sample size, the researchers did not perform statistical comparison. Therefore, it should be noted that this limited the generalizability. The researchers did not perform inferential statistics due to the small sample size. However, they did perform descriptive statistics to note the trends.

Is the target population clearly described?

Not clear

The study was specific to post-op pain management in the elders. The inclusion criteria were placed to exclude those with psychiatric illness or substance abuse previous 6 months of the study. The purpose of the study was to provide enhanced approach to pain management through evidence based practice guidelines for nurses and patients to decrease pain, anxiety and length of stay at hospitals after surgery. It should be noted that the sample was from a Veterans’ Hospital, in which only 13 male participants were studied. With this small sample, there is a risk that the outcome of the study cannot be generalized across the targeted older adults that have undergone joint replacement surgery. The researchers mention that this is only a pilot study and further research is needed to test this intervention with other surgeries and rehabilitation patients, as well as a larger population.

Is the frequency, association, or treatment effect impressive enough for you to be confident that the finding would make a clinical difference if used as the basis for care?


The result from this study was that the use of guided imagery decreased/reduced the pain, anxiety and length of stay at hospitals for older adults who have undergone joint replacement surgeries. The decreased ratings, use of IV morphine sulfate and days of stay at hospital is a positive sign that guided imagery can be offered as a complementary pain management strategy.

This research classifies under level of evidence of II. It includes a comparison group and an intervention group, as well as a random assignment. However, the intervention could have been more controlled. As a pilot study, there is no mention of power analysis, therefore it is unclear of the needed sample size. Despite the extraneous variables and a need of larger sample size, the study was conducted well. The study had a specific inclusion criterion, which controlled for bias, as well as eliminating the possible effects of psychiatric illness or substance abuse prior to the study. Although it controlled for the older adult population and literacy to understand and record in the journals, it lacked to generalize to both genders; the study only included 13 male participants from a Veterans’ Hospital, which led to lack of statistical comparison. They also cited a variety of other studies that supported their findings, as well as those that supported the overall idea of the positive effects of complementary treatment and guided imagery. There were several parts of this study that could have been improved or should be improved for future studies. Firstly, the population size should be larger. To determine clinical and statistical significance, there should be at least a sample size of 30 in an experimental study; this also could be determined through power analysis. Also, instead of searching in a veterans’ hospital, where there are mainly male, it should be done at an inclusive hospital or postoperative floor to support generalizability of the study. Secondly, possibly the study can be more specific to one type of surgery, since scale of hip and knee replacement is very different. In addition, possibly the surgeon and the surgical team or the technique of the surgery could be limited to one to eliminate procedure bias. Also, the specific time of journaling after procedure could be determined. Pain after post operation is common, however, the more anesthesia wears off of patients, more pain will come forward. Participants may record lower number of pain and anxiety as soon as they wake up from anesthesia rather than few hours after the anesthesia has worn off completely. It is also unclear if all patients received the same Naparstek’s song for this experiment.

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The findings of this research study are credible. Although it is difficult to determine statistical significance due to the small sample size and lack of power analysis, the findings within the 13 participants were consistent. Also, the researchers were able to find several studies that supported their findings of effectiveness of guided imagery; this further supports the credibility but it is still lacking power and generalizability. There was decrease in ratings of pain, anxiety and use of IV morphine sulfate, as well as a decrease in length of stay in the intervention group. This supports the purpose of the study. Clinically, it seems support the idea that guided imagery has a positive outlook from the findings stated above. The use of guided imagery for elders who are expecting to have joint replacement surgeries has numerous advantages. It is patient controlled, accessible to all populations, as well as easy learning directions. Despite the advances in pain research, many patients and clinical staffs choose medication regimens for post operative pain management. With the use of guided imagery and relaxation, patients could lessen their pain and anxiety without the side effects of drug-dependent pain management. Although it is only a pilot, this research could be used as a foundation to perform further studies to explore the use of guided imagery and relaxation techniques for post-operative patients.


  • Antall, F., & Kresevic, D. (2004) The use of guided imagery to manage pain in an elderly orthopaedic population. Orthopaedic Nursing, 23, 5, 335-340. doi: 10.1097/00006416-200409000-00012.


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