1. Background
Burn is a main reason for acute damages and constitutes more than 1 percent of burden of diseases. Burn damages are important causes of mortality and morbidity. They can also lead to many physical, psychological, social, and economic problems. The prevalence of burn in Iran is high, so that its associated mortality and permanent morbidity are reported frequently. Also, the treatment of burn injuries is a long-term process that requires repeated surgical interventions and ongoing medical treatments by taking a lot of time and imposing heavy cost to community (1-5).
Based on an epidemiological study in Tehran (the capital of Iran) in 2011, burn injury is a major health problem in Iran that involves mainly young people (aged 26 - 35 years) (6).
According to the high prevalence of burn damages, it is necessary to evaluate different treatment methods in order to reduce pain and control its physical/psychological complications.
One of the most stressful complications is pain and pain-related anxiety. Based on an international survey on care of wound and trauma, the highest perceived pain by burn patients is experienced during dressing change (7).
The burn patients experience severe, long-term pain during frequent dressing change that is a necessary measure to prevent infection and promote healing (8).
The process of dressing change increases the underlying pain to some extent depending on burn size (9).
To reduce pain and anxiety of dressing change, different medications such as opioid and non-opioid drugs are used through oral or injection routes that are accompanied with different side effects (10).
It has been indicated that non-medical treatments have similar effects as medical treatments and they can be used in combination with drugs in order to reduce pain and fear in burn patients (11, 12).
One of these non-medical treatments is guided imagery. This method is based on the relationship between mind and body. It means that mind and body are able to cause diseases or improve healing process in a synergistic way. In this way, one can see, hear, or smell the thing that he/she tends to feel it (13).
The effects of this method have been identified in reducing pain and distress induced by various diseases such as different cancers, musculoskeletal complications, etc. (14-18).
In a review of studies on coping strategies for pain management, it was revealed that guided imagery is known as one of the most effective methods that can be used alone or in combination with other interventions such as hypnosis and cognitive-behavioral therapy. Also, the office of research and policy in health research suggests the effects of this method in reduction of pain and distress among cancer patients and management of mild to severe acute pains. Guided imagery acts positively thorough the ways such as: increase of control, decrease of depression, stress and anxiety, reduction of pain, decrease of side effects of treatment, promotion of sleep and quality of life, increase of relaxation, decrease of nausea and blood pressure, increase of healing and immunity, decrease of respiratory problems, decrease of duration of hospitalization and increase of self-esteem (19).
A research on the efficacy of guided imagery in orthopedic operations indicated that patients’ total pain score decreased significantly compared to a control group (20).
2. Objective
Regarding the prevalence of burn injuries, its complications, and lack of research in this field in Iran, this research was conducted to assess the efficacy of guided imagery in reduction of pain and anxiety due to dressing change in burn patients.
3. Materials and Methods
This clinical trial was conducted on patients with the first and second-degree burns (not those with self-Immolation) who admitted to the burn department of Imam Reza hospital (Mashhad, Iran) in 2013. Other inclusion criteria included: elementary education level, absence of psychiatric symptoms or signs, and volunteering for research.
Based on the sample size formula, 40 patients were selected non-randomly through convenience sampling method and divided randomly into two equal groups of intervention and control.
All participants filled out a demographic questionnaire, guided imagery, Beck anxiety, and McGill inventories in pre-test. The intervention group received training on guided imagery technique for 15 minutes a day for 8 days in addition to the routine care (taking drugs and so on).
In the training process, the patients were asked to listen to guided imagery sentences (sentences describing beautiful and sublime views with an emphasis on the release of anxiety and pain) via CD and headphone.
The control group only received the routine care. Finally, at the end of 12th session, two groups completed the mentioned inventories as post-test.
3.1. Beck Anxiety Inventory (BAI)
Aeron Beck and colleagues (1990) introduced this 21-item inventory to measure the severity of clinical anxiety symptoms. BAI is a self-reporting inventory that targets adolescent and adult populations.
Every item in this inventory describes one prevalent symptom of anxiety (mental, physical, and panic symptoms). The 4-point response scale includes: never (0 score), mild discomfort (1 score), moderate discomfort (2 score), and severe discomfort or intolerable (3 score). Therefore, this inventory has a total score in range of 0 to 63.
The internal consistency of this inventory is 92% and its validity in retest with one week interval is 75%. Also, the correlation between its items is various ranging from 30% to 76%. This inventory has been shown to be an applicable instrument for measuring anxiety severity in different types of reality (21, 22).
The assessment of its psychometric characteristics in Iran has indicated that this inventory has satisfactory reliability (72%) and validity (83%) in retest after one month (α = 0.92) (23).
3.2. McGill Pain Questionnaire (MPQ)
This is a most useful standard instrument for evaluation of acute and chronic pains (24).
It includes 78 descriptive sentences in 20 subgroups that form 3 domains: sensation (subgroup 1 - 10), affective (subgroup 11 - 15), cognitive (subgroup 16) and miscellaneous (subgroup 17 - 20). A 5-point scale is used to indicate the severity of current pain (25).
This questionnaire has been used as a standard instrument in many countries and its reliability and validity are reported acceptable (24, 26-29).
The Cronbach’s α and validity in all domains of this questionnaire have been reported above 0.8 in Iran (30).
3.3. Guided Imagery Inventory
This instrument designed by Cristien Qukobom for measuring the imagery ability has been used by different researchers. The designer reviewed the instrument in 2000 and added/deleted several items.
This inventory has two subscales: The first part is named absorb subscale that includes 21 items and consists of sentences about person’s experiences of images, memory, and events. The subjects are asked to tick a response (never = score 0 to absolutely correct = score 4). The total score of this subscale is in range of 0 - 84.
The second part of this inventory is named image formation that includes 11 items consisting of questions 22 and 23 of the inventory. This part measures the clearness of mental images. The subjects are asked to create one image in his/her mind; then, he/she determines the clearness of the image on a 5-point scale (score 0 - 4) based on the degree of clearness (total score: 0 - 44). The total score of the questionnaire is 0 - 128. The validity and reliability of this questionnaire have been reported as 0.89 and 0.75, respectively (31, 32).
Data were gathered anonymously and patients were participated voluntarily.
The data were analyzed by descriptive statistics such as mean and standard deviation and inferential statistics such as independent t-test.
4. Results
40 patients (equally distributed in intervention and control groups) took part in this research. Demographic characteristics of patients are presented in Table 1.
| Demographic Variable | Intervention Group | Control Group | P Value |
|---|---|---|---|
| Gender | |||
| Male | 11 (55) | 7 (35) | 0.21 |
| Female | 9 (45) | 13 (65) | |
| Age, y | |||
| 20 - 30 | 6 (30) | 6 (30) | 0.91 |
| 31 - 40 | 10 (50) | 11 (55) | |
| 40 ≤ | 4 (20) | 3 (15) | |
| Education | |||
| Elementary | 8 (40) | 6 (30) | 0.62 |
| High school | 8 (40) | 7 (35) | |
| Academic | 4 (20) | 7 (35) | |
| Marital status | |||
| Single | 4 (20) | 9 (45) | 0.09 |
| Married | 16 (80) | 11 (55) |
Demographic Characteristics of Participantsa
The mean score of guided imagery was 69.9 ± 6.9 in the control group and 73.3 ± 6.2 in the experimental group.
The mean scores of anxiety, pain, quality, and severity of pain in the intervention and control groups are presented in Table 2.
| Variable | Intervention Group | Control Group | T | P Value |
|---|---|---|---|---|
| Anxiety | ||||
| Pre-test | 48.4 ± 4.7 | 47.2 ± 5.1 | 0.7 | 0.120 |
| Post-test | 23.1 ± 5.2 | 46.3 ± 6.4 | -11.01 | 0.001 |
| Pain | ||||
| Pre-test | 58.8 ± 5.4 | 56.2 ± 6.1 | -3.14 | 0.310 |
| Post-test | 42.9 ± 5.7 | 54.3 ± 5.6 | 8.51 | 0.001 |
| Quality of pain | ||||
| Pre-test | 59.1 ± 6.2 | 56.8 ± 4.9 | 16.2 | 0.291 |
| Post-test | 40.9 ± 5.6 | 55.7 ± 6.3 | 13.1 | 0.010 |
| Severity of pain | ||||
| Pre-test | 2.9 ± 0.6 | 2.8 ± 0.4 | 10.1 | 0.126 |
| Post-test | 1.8 ± 0.7 | 2.7 ± 0.6 | 8.4 | 0.010 |
The Scores of Anxiety, Pain, Quality, and Severity of Pain Among Participants
Based on the results, there was no significant difference between the two groups in all of the variables in pre-test. However, the post test scores indicated that there were significant between-group differences in all of the variables.
5. Discussion
The results of the present study demonstrated that guided imagery technique can significantly reduce pain and anxiety among burn patients.
We looked for the same studies in this field; but there were no studies focusing on this technique in patients with burn injuries. For example, a systematic review (comprising 8 studies) was conducted to assess the effects of muscle relaxation technique through guided imagery in breast cancer patients' pain and distress. The results of 7 studies indicated that this technique was effective in reduction of pain and distress among the mentioned patients, which was in agreement with our research, although the effect of guided imagery was not evaluated alone but in combination with muscle relaxation (32).
The effectiveness of guided imagery on pain of orthopedic surgeries was assessed in another study. In this research, 74 traumatic patients were divided into control and intervention groups. Based on the scores of research instruments including ability of imagery inventory and McGill pain questionnaire, the total score of pain and the score of quality of pain on 3rd day after operation decreased significantly in the interventional group compared to the control group, although there was not any significant relationship between the scores of imagery ability and the scores of severity and duration of pain (20). Thus, these results are different from those obtained in the present research that indicated the significant effect of guided imagery on pain and anxiety.
Another study assessing the effect of guided imagery on the reduction of pain after arthroplasty operation among elderly patients demonstrated that this method could reduce pain in these patients, which is consistent with our study results (33).
The results of a research conducted to evaluate the effectiveness of guided imagery and mean-therapy in depression, anxiety, and hopefulness among 42 women with cancer indicated that both of the mentioned methods were useful; but mean-therapy was more effective than guided imagery (34).
The lack of evidence regarding the effects of guided imagery on pain and anxiety of dressing change among burn patients indicates the novelty and potential use of this method in reduction of burn-induced consequences, although it made it difficult for us to compare the results of the present study with those of similar researches. It is recommended to conduct further studies to provide sufficient evidence about the efficacy of guided imagery technique especially in acute pains.
5.1. Conclusion
It seems that guided imagery can be effective in the reduction of dressing change-induced anxiety and pain among burn patients.
