Laura Scheufele, PT, DPT, WCS
August 5, 2015
Pelvic PT Distance Journal Club
Aim: Study the effect of
guided affective imagery on the irritable bowel symptom severity and quality of
life when combined with lifestyle modifcations in patients with IBS.
“Guided affective
imagery (GAI) is a form of psychotherapy, which involves focusing on the mental
images to induce relaxation. The principle behind GAI is the interruption of
stress-provoking thoughts with a relaxing image, thereby inducing relaxation. “
Study Design: Prospective, randomized,
controlled pilot study.
Materials and Methods:
Subject
enrollment: All subjects 18 or older and recruited from neurogastroenterology
clinic after being screened by one of the study physicians. Inclusion criteria: All participants met the Rome III diagnostic criteria for IBS.
All subjects had negative celiac serology, normal stool microscopy and culture, and negative stool C difficile antigen and toxin assay. Any subject over 50 or anyone with iron deficiency anemia underwent colonoscopy to exclude malignancy or inflammatory bowel disease.
Taking antidiarrheal and antispasmodic medications, as well as over the counter fiber supplements permitted; as was anxiolytic or antidepressant medications at a stable dose for more than 3 months.
Exclusion criteria: Patients with DSM IV/V diagnosed with schizophrenia or other psychotic disorders; untreated, unstable, or recent onset (< 3 months) of anxiety or depression; patients receiving ongoing psychiatric care; participation in any form of psychotherapy; prior gastrointestinal surgery; and having a major concomitant disease
Data collection: Gathered at enrollment
(pre-treatment) following 8 weeks (post-treatment). Randomized after initial
visit with dietician. Randomly assigned in parallel by using concealed blocks
of four, obtained from computer-generated sequence to be in psychotherapy with
GAI group or no intervention (controls). The study physician and dietician
blinded.
A
total of 56 subjects were assessed for eligibility, of which 21 were excluded
(9 because they did not meet inclusion criteria, 10 declined to participate, 1
in renal failure and one in ongoing psychotherapy for depression). This left 35
to be randomized.
Symptom
assessment: utilizing
self-administered questionnaire that included: VAS evaluating the following
parameters over the previous 7 days: bloating, satisfaction with stool
frequency, satisfaction with stool form, distress caused by diarrhea, distress
caused by hard stools, straining, stool urgency, completeness of evacuation,
and impairment in activities of daily living due to bowel dysfunction.
IBS-Quality
of Life Questionnaire (IBS-QoL): Highly validated tool consisting of 34 items with 5 point Likert
response scale (1-5) for 8 subcategories
to assess how much the statement described the feelings of the respondent. Ranging from 1= not at all to 5= extremely. Dysphoria, interference with
activity, body image, health worry, food avoidance, health worry, food
avoidance, social reaction sexual concerns, and relationships. Higher value
indicates better QoL. 0-100 scale after conversion.
Intervention:
All subjects had a one-hour session with a dietician
specializing in IBS who offered personalized dietary and lifestyle recommendations.
Eight
weekly sessions provided, lasting 3 hours each.
Session one: Education regarding the
physiological and psychological basis of IBS. Set expectations of reasonable
expectation for “homework” between sessions and agreed on treatment goals.
Session
two: Education regarding theoretical basis of GAI and application in IBS.
Stressors identified.
Session
three to eight: Relaxation training using guided imagery exercises performed
and instructed to perform at least one exercise daily for 30 minutes.
Statistical analysis: See details in article.
Results: A total of 16 subjects were randomized
into intervention group but one chose to withdraw consent, leaving 15 to
complete to intervention. A total of 19 subjects randomized into control group,
all of which completed the study.
Comparison between the 2 groups revealed the treatment group
participants were significantly
younger, more often single, and less likely to be
retired. No difference in baseline
scores with symptom severity scores or IBS-QoL scores. See Table 1.
Symptom
severity: See Table 2. In the treatment group the MEAN
Symptom severity score significantly reduced (p < 0.01)
as compared to controls. (treatment MEAN scores
: 6.1 +/- 1.4 to 4.6 +/- 1.7 vs no
significant change with controls: 5.8 to 5.9).
Magnitude of change in symptom severity was greater in treatment group.
When
you look at the individual scores of the Symptom Severity Test, the categories
of Impaired ADL, Completeness of evacuation, straining, distress from hard
stools, and bloating all reduced significantly in the intervention group,
whereas none in the control group reduced significantly and bloating actually
significantly worsened.
Multivariate
logistic regression analysis identified GAI as only independent predictor of
symptom improvement.
Quality
of Life: See Table 3.
The IBS-QoL scores were Significantly
improved (increased) in treatment group but not in control group (p<0 .01="" analysis="" as="" change.="" gai="" identified="" improved="" independent="" logistic="" magnitude="" multivariate="" of="" only="" predictor="" qol.="" regression="" span="" the="" treatment="" was="" with="">
High
compliance for completion of treatment program: 94%.
Discussion:
Pilot study
demonstrates dietary modifications with short-term psychotherapy utilizing GAI
improves symptoms and quality of life in IBS patients versus dietary
modifications alone.
No
placebo treatment provided for control group. Omitting a placebo treatment may
lead to overestimation of treatment effects because of greater expectancy of
benefit.
The
small sample size could have led to inflated Odds rations in favor of the
intervention.
Age
disparity between groups, although multivariate logistic regression analysis
did not identify age as a predictor of improvement in symptoms or QoL .
Theoretical
basis for using relaxation techniques in IBS stems from understanding that
visceral pain sensation is heightened by emotional stress.
Active
participation may lead to sense of empowerment and lead to superior results.
GAI is
unique compared to other relaxation techniques because it encourages patients
to invite specific images to enter the mind, allowing patients to gain insight
into their symptoms, and ultimately may lead to solutions.
Conclusion: GAI combined with dietary
modifications may be beneficial in the management of IBS. A larger study
with a longer period of follow-up and defined clinical endpoint is required to
confirm findings.
Weaknesses:
Did not use a validated tool for symptoms.
No measure of compliance with home program or with dietary
recommendations.
Small sample size.
As per Cochrane Review 2009 on Psychological treatments for the
management of IBS, the IBS Severity Scoring System as the preferred instrument
for IBS symptom assessment.
Impact on PT
Practice/Questions:
Would the results be as successful utilizing a standard guided
imagery CD?
What would you recommend to your patient? Frequency/duration?
Do you think it makes a difference to the patient if they know
there is research that demonstrates reduced symptoms with daily use?
Additional Reading:
Aucoin M, Lalonde-Parsi MJ, Cooley K. Mindfulness-based
therapies in the treatment of functional gastrointestinal disorders: a
meta-analysis. Evidence-Based Complimentary and Alternative Medicine. 2014,
September 11: 140724.
Mizrahi MC, Reicher-Atir R, Levy S, et al. Effects of guided
imagery with relaxation training on anxiety and quality of life among patients
with inflammatory bowel disease. Psychology & Health. 2012, December 27(2):
1463-1479.
Saha L. Irritable bowel syndrome: pathogenesis, diagnosis, treatment, and
evidence-based medicine. Journal World
Journal of Gastroenterology. 2014, 20(22): 6759 - 73.
Zijdenbos IL, de Wit NJ, van der
Heijden GJ, Rubin G, Quartero AO. Psychological treatments for the management
of irritable bowel syndrome. Cochrane
Database of Systematic Reviews 2009, Issue 1. Art. No.: CD006442. DOI:10.1002/14651858.CD006442.pub2.
Resources:
A Meditation to Help With Irritable
Bowel Syndrome & Inflammatory Bowel Disease (Health Journeys CD).
Guided imagery-The Forest: http://www.mc.vanderbilt.edu/coe/tfcbt/workbook/Relaxation%20&%20Affective%20Expression/Guided%20Imagery%20Script%20(Forest).pdf
Guided imagery-The Beach:
Scripts for body scan; Go to Record your own section:
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