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10 Articles in Volume 15, Issue #8
A Wake-Up Call From Under Anesthesia
Combined Electrochemical Treatment for Peripheral Neuropathy
Cranial Electrotherapy Stimulation: Treatment of Pain and Headache in Military Population
Guided Imagery, Mindful Meditation, and Hypnosis for Pain Management
Legacy Patients From High-Dose Opioid Era
Letters to the Editors: Prednisone and Microglia Modulators
Percutaneous Electrical Neurostimulation for Detoxification in Opioid-Dependent Chronic Pain Patients
Pulsed Radiofrequency Energy for Treatment of Chronic Pain Syndromes
Steroids for Complex Regional Pain Syndrome?
What You Need to Know About Neurostimulation

Guided Imagery, Mindful Meditation, and Hypnosis for Pain Management

Adopting one of these mindful techniques can help reduce pain, anxiety, and depression among patients with acute and chronic pain.

The practice of pain management has expanded exponentially over the past 150 years—from the introduction of opioids, advances in surgical intervention, and the introduction of electromedical devices,1 to our understanding the psychosocialbiological model of pain management.

However, even with these advances, only 25% of patients with chronic neuropathic pain do better after 1 year of treatment.2

Therefore, pain physicians may have to look beyond the “conventional” medical toolbox to help their patients cope with chronic pain. In this article, I review the rise of one area of alternative treatment—that of guided imagery, mindful meditation, and hypnosis.

History of Hypnosis

The concept of hypnosis and psychophysiology really began with Franz Anton Mesmer (1783-1815), a scientist who theorized that the “tidal” influences of the planets also operate on the human body through a universal force, which he termed “animal magnetism.”3 His work led him to experiment with altering gravitational tides in the body (hypnotic suggestion) to treat painful maladies, but his showmanship led to distain from his medical colleagues.

James Braid (1795-1860) is often credited as being the “Father of Hypnotism” for moving “mesmerism” from the occult into medical practice.4 Despite his excellent work, and considerable additional investigations by numerous other psychologists and physicians, hypnosis was not accepted widely until the mid-20th century.

At the beginning of the 20th century, physicians throughout Europe began seriously investigating hypnosis, but were often rejected by their peers. In 1902, James Esdaile, a British surgeon working in India, performed hundreds of surgical operations on mesmerized patients.5 Despite the success of the operations, most of Esdaile’s peers remained skeptical of mesmerization.

By 1912, a German psychiatrist, Johannes H. Schultz, was quite successful at hypnotherapy. However, he did not like the fact that patients became dependent upon him to go into a trance. Questioning patients as they descended into deeper states of hypnosis, Schultz concluded that patients could self-hypnotize by repeating certain phrases and imagery. His first book on Autogenic Training was published in 19326 and in 1969 the first of 6 volumes on the practice was published with co-author Wolfgang Luthe.7

With 2,600 scientific references, the authors concluded that 80% of stress-related illnesses could be well-controlled with Autogenic Training (Table 1). They reported great success in treating headache, back pain, depression, anxiety, and hypertension. In addition, students, athletes, and even business executives were said to have achieved considerable improvement in their activities.

Despite fairly widespread use of hypnosis by some psychologists and a few psychiatrists, the major impetus for a significant increase in professional interest in the field was the development of biofeedback training by Elmer Green, MD, in the early 1970s. Interestingly, Green initially called the technique autogenic feedback, and he included the imagery associated with the basic autogenic phrases.8 In 1973, after hearing about his 84% success rate in migraine patients, I asked him about its use in back pain. He said: “Buy yourself some equipment and try it.”

Over the next few years, I tried electroencephalography (EEG), temperature, Galvanic Skin Response, and electromyography (EMG)-guided muscle tension biofeedback, always including appropriate guided imagery, and most often accompanied with relaxing background music. Over the next 4 years, 195 patients were treated with a comprehensive 2- or 3-week biofeedback-guided imagery program.

All of the patients were severely disabled with chronic pain, mostly the result of failed back surgeries. Upon completion of the program, 80% of patients were able to discontinue pain medication, with marked increase in physical activity, marked improvement in mood, and pain reduction of 50% to 100%. Follow-ups visits conducted at 1- to 2-years revealed a 60% long-term improvement.9

Meanwhile, Wilbert Fordyce, MD, published his work on Operant Conditioning.10 Over a 5-year period, he had enrolled 100 chronic pain patients, mostly from failed back surgeries, in a 2-month inpatient program. Fordyce’s protocol included:

  • Withdrawal of all pain and mood drugs
  • Pain complaints and behavior were ignored
  • Patients were assigned minor physical activity, such as walking, sitting for specific and increasing periods of time
  • No physical therapy or psychotherapy

The program cost $5,000 and Fordyce stated that a 10% success rate would allow the insurance system to recover their costs because of the high medical costs of these patients. He reported an initial 60% success rate with significant decrease in pain, improvement in activity, and freedom from medications. However, at 6 months, only 40% of the men and 25% of the women maintained this improvement.

In 1975, Herb Benson’s book Relaxation Response opened the door to a broad variety of alternative approaches.11 Since then, the variety of tools for relieving pain has multiplied exponentially. Options now include guided imagery, biofeedback, self-hypnosis, meditation, music therapy, and yoga.

Evidence for Guided Imagery and Meditation

Since 1980, a number of studies have shown the efficacy of guided imagery and relaxation in a variety of pain conditions. I will present an overview of some of these studies:

Guided Imagery

Acute Pain

Twenty-four patients undergoing cholecystectomy were randomly assigned to receive either guided imagery or a quiet period (controls). The investigators assessed 3 measures of recovery: state anxiety, levels of urinary cortisol, and wound inflammatory responses. The guided imagery group demonstrated significantly less state anxiety, lower cortisol levels 1 day following surgery, and less surgical wound erythema than the control group.12

Cupal et al reported that 10 sessions of relaxation and guided imagery after anterior cruciate ligament (ACL) reconstruction significantly improved knee strength, pain, and anxiety, and decreased reinjury.13 The authors concluded: “Relaxation and imagery may be beneficial to ACL rehabilitation.”

Lambert reported significantly less pain, shorter hospital stays, and decreased anxiety after surgery in 52 children treated with guided imagery.14 The therapy included asking children to visualize a successful procedure.

Guided imagery significantly improved postoperative pain, anxiety, and opioid use in patients after colorectal surgery.15 Although patients entered the study with identical levels of anxiety, those who underwent guided imagery reported less anxiety immediately before the procedure, whereas patients in the control group reported an increase in anxiety (P<0.001). Patients in the imaging group also reported less pain, and required fewer opioids postoperatively, than those in the control group (P<0.001).

Driediger and colleagues found that injured athletes who practiced guided imagery—including cognitive, motivational, visual, and kinesthetic imagery—reported that the approach led to significant improvements in their ability to perform their rehabilitative exercises and their management of pain, and enhanced overall recovery.16

Rheumatoid Conditions

Fibromyalgia is among the most difficult chronic pain problems to treat. A study of 48 patients with fibromyalgia who practiced guided imagery generated mixed results. A 6-week course of imagery led to gains in functional status and self-efficacy regarding the ability of patients to manage pain, but did not appear to reduce pain itself.17

On the other hand, in a study of 28 older women, osteoarthritis pain was found to decrease significantly with guided imagery and progressive muscle relaxation, and mobility improved strikingly.18 Therapy in the randomized trial consisted of listening to a 10 to 15 minute audiotape twice daily for 12 weeks to help the women relax their muscles.

Guided imagery and relaxation also were used in women with osteoarthritis pain. This led initially and in longterm follow-up to significant reduction in pain, as well as improved quality of life.19

Mindfulness meditation, a related technique, also may benefit patients with pain syndromes. In a study of more than 144 adults with rheumatoid arthritis (RA), pain and mood were significantly improved after mindfulness meditation, with the greatest gains observed in those with depression—“indicating that the emotion regulation aspects of that treatment were most beneficial to those with chronic depressive features.”20

In a study of 13 children with juvenile RA, 8 sessions of progressive muscle relaxation, guided imagery, and meditative breathing led to significant reduction in pain. Improvement in both pain and adaptive functioning after these cognitive-behavioral therapies persisted at 6-months and 1-year of follow-up.21

Other Pain Conditions

Paraplegic neuropathic pain is one of the most difficult of all pains to treat. In a pilot study of 5 patients with paraplegia, guided imagery and virtual walking therapy (encouraging patients to imagine themselves walking) led to a significant reduction in pain.22 “Virtual walking may be a viable treatment for pain after spinal cord injury,” the study concluded.

A review of 46 studies from 1966 to 1988 reported positive evidence of guided imagery for management of stress, anxiety, and depression, as well as reduction of blood pressure, pain and even side effects of chemotherapy.23 The results of the meta-analysis “demonstrated a need for systematic, well-designed studies, which explore several unanswered questions regarding the use of guided imagery.” These include the “effects of different imagery language, symptoms for which guided imagery is effective, appropriate, and sensitive outcome measures, method of delivery of the intervention and optimum dose and duration of the intervention, and individual factors that influence its effectiveness,” noted the author.

Meditative techniques also may be effective in reducing pain in children with gastrointestinal illness. A pilot study of 10 children with recurrent abdominal pain found that those who practiced 4 weeks of relaxation and guided imagery reported to a 67% decrease in pain during the 2-month trial (P<0.001).24

Mindfulness Meditation

Low Back Pain

Morone et al demonstrated that regular meditation was associated with improvements in chronic low back pain and overall quality of life in older adults. The study enrolled 37 men and women over age 65 years (mean, 74.9 years). Subjects were randomized to practice meditation multiple times per week for 8 weeks (controls were put on a wait list). Those who meditated reported significantly less low back pain and improved quality of life, including greater overall physical functioning (P=0.03), according to the investigators.25

Similarly, a 10-week program of mindfulness meditation showed significant reductions in pain as well as improvement in mood and psychiatric symptoms, with continuing improvement after longer follow-up.26 The authors reported data on 51 patients with pain affecting a wide variety of locations, including but not limited to the back and neck, fascia, gastrointestinal tract, and chest. At the end of the program, half of patients reported a reduction in pain of at least 50% of the mean total pain rating index. The investigators concluded that “this form of meditation can be used as the basis for an effective behavioral program in self-regulation for chronic pain patients.”

Spiritual Meditation

Spiritual health is improved by guided imagery, meditation, and group support—leading in turn to improved health behavior, diet, and compliance with treatment regimens for existing health problems. Studies suggest that attention to spiritual health can benefit both emotional and physical health, reducing anxiety and improving mood, reversing heart disease, decreasing mortality from cancer, and by other means.27

Frequent migraineurs who received spiritual meditation reported greater decreases in the frequency of migraine headaches, anxiety, and negative affect, as well as greater increases in pain tolerance, headache-related self-efficacy, daily spiritual experiences, and existential well-being.28

Some evidence suggests that adding a spiritual component to meditation is superior to secular meditation and simple relaxation for improving certain health-related outcomes. Wachholtz and Pargament found that spiritual meditation sessions of 20 minutes daily for 2 weeks resulted in greater decreases in anxiety and more positive mood, spiritual health, and spiritual experiences than those in the secular meditation or relaxation groups. Patients who practiced spiritual meditation also tolerated pain in a cold pressor test almost twice as long as those in the other groups.29

Yoga, which carries a spiritual component (and which practitioners consider a holistic discipline) also has been shown to improve symptoms in patients with pain conditions. For example, a study of 80 patients with chronic low back pain found that those who underwent an intensive 7-day yoga program (n=40), including instruction in poses and postures, breathing, meditation, and yogic philosophy, reported significantly greater reductions in pain and gains in flexibility than a control group (n=40). The control group were instructed to perform physical exercises under the guidance of a trained physiatrist who also provided didactic and interactive sessions on lifestyle change.30

Music Therapy

Lewis et al found that patients undergoing bariatric surgery required one-third less anesthetic when listening to hemispheric synchronization (Hemi-Sync) music—tones designed to promote relaxation—compared to those not receiving the intervention (P=0.009).31 However, the same effect was not observed in patients undergoing spinal fusion.


Looking at the rather wide array of non-pharmaceutical cognitive approaches to pain management (Table 2), and having worked with all of these, I am inclined to say that physicians have to make choices.

I list here those options I consider most important:

  • Transcutaneous electrical nerve stimulation (TENS)—properly used, TENS is highly effective in at least 75% of acute pain problems and is of significant benefit in at least 60% of chronic pain problems. It requires far less time and effort to apply than most other tools
  • Pulsed electromagnetic field therapy (PEFT)—requires far more office time than TENS but certainly worth trying in all difficult cases
  • Cranial electrical stimulation (CET)—the best alternative to medications for treating anxiety and depression
  • Autogenic training—worth using as early as possible in all pain and mood problems. Simply providing a compact disk for home use is valuable
  • Vibratory music with guided imagery—an inexpensive adjunct. Sound therapy and guided imagery can significantly improve both mood and pain
  • Hypnotherapy—hypnotherapy can be useful, but requires the right therapist and the right patient. In general, guided imagery with music requires less time and is often as effective
  • Mindfulness and other forms of meditation—excellent long-term, but rarely effective immediately.


The benefits of mindfulness and meditation in reducing pain, anxiety, stress, and improving mood in chronic pain patients cannot be underestimated. I encourage all practitioners to adapt some of these techniques into their practice. By doing so, you will be providing your patients with a method to self-regulate their pain and anxiety.

Last updated on: October 21, 2015
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A Wake-Up Call From Under Anesthesia

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