Below you will find a proposed/hypothetical pyschobiological study I had written for a psych class, and was a study that I actually wanted to do while working on my bachelor’s in psychology. Unfortunately, in the little area I live in, no medical clinicians were interested. The short of the study is to have postoperative orthopedic patients use guided imagery of some type of exercise to reduce their pain. I came up with the idea for this study after having found that stress headaches I had went away not only after performing exercise but interestingly enough after thinking about doing specific exercises (I had studied/practiced meditation and hypnosis and observed that what the mind says the body to some extent or another will do). Had I gone to graduate school for psychology the study I had hoped to do would have sought to find out if one can use guided exercise imagery to coax the body into making telomerase and extra mitochondria in the cells akin to what actual exercise does. This of course being useful for increasing longevity and immune system function. That grad school study would have been an offshoot of the one below with the following important changes:
Measure for levels of telomerase and mitochondria in the subjects pre and post treatment/guided exercise imagery.
Based on the literature, determine to what intensity level individual exercise sessions must be performed, how long individual exercise sessions must be performed, and over what span of time (days, weeks, months) and frequency within a given span of time individual exercise sessions must be performed before there is a significant increase in both telomerase and mitochondrial levels. Once this information is gathered, word the guided imagery script accordingly.
If anyone is interested in pursuing either or both of these proposed studies you have my permission. I only ask that you give credit where credit is due and list me as a coauthor of the study(ies).
Imagery, Exercise, and Pain Modulation Effects and Relationships:
SUNY Oneonta, State University of New York
Imagery, Exercise, and Pain Modulation Effects and Relationships
Can thinking about exercise reduce pain? It is a fairly simple question, but one with great possibilities. This proposed study seeks to understand the potential mechanisms behind this process and its potential efficacy. It is well known that emotional and/or psychological stress can have ill effects on the body. This stress can range from Post Traumatic Stress Disorder to the stress of everyday modern life, and the ill effects can range from slightly elevated high blood pressure and decreased digestive system function to stroke or heart attack. It is also well established that various emotional and/or psychological stressors can be managed by changing how and what one thinks. This changing of how and what one thinks can also be effective for alleviating physical pain.
There are many different mental techniques one could use to alleviate pain, although the differences appear to be a matter of semantics. One could do meditation, visualization, guided imagery, hypnosis, but for all intents and purposes at their core what matters is how and what one is thinking about, or as Hart (2008) puts it in regards to guided imagery “using the imagination”. To help sort out the differences between two of the techniques used in the cited studies (hypnosis versus guided imagery), clarification comes from a study by Jensen et al. (2012) where it is stated that the difference between mental imagery and hypnosis is that mental imagery lacks the induction phase (relaxing phase) that is used in hypnosis before a “suggestion” is given, and the induction phase itself plays no role in pain reduction. Therefore, it seems that the terms “suggestion”, “guided imagery”, and “mental imagery” can be interchanged with one another. For this proposed study these terms will be defined as what a person is thinking about and to some extent or another is experiencing within their mind as though these experiences were really happening – tastes, smells, touch, temperature, pressure, etc. As it turns out, what people experience in their minds using these various techniques does have a direct impact on their perception of pain.
In a general review of guided imagery and its effects by Hart (2008), individuals in two separate studies – postoperative colorectal surgery patients, and those afflicted with interstitial cystitis, both used guided imagery techniques to decrease pain. Guided imagery recordings (audio tape and CD) were also used to help reduce pain for children post-surgery (Pölkki et al., 2006) and for post-operative seniors (Antall & Kresevic, 2004). Guided or not, a study by Younger, Aron, Parke, Chatterjee, and Mackey (2010) demonstrates that simply thinking about one’s loved ones can also reduce pain. These types of studies involving imagery go on and on. Needless to say, changing what one thinks about can change one’s perception of pain.
Actual physical exercise can also change one’s perception of pain. Naugle, Fillingim, and Riley (2012), looked at three different types of exercise: isometric, aerobic, and dynamic resistance exercises and found that all three reduced the “perception of experimentally induced pain in healthy participants.” This happens, according to Njis, Kosek, Van Oosterwijck, and Meeus (2012), because exercise increases an individual’s pain threshold by turning on “descending nociceptive inhibitory mechanisms”, and releasing neurotransmitters like endorphins (of the beta variety) which activate opioid receptors that cause pain reduction. Along with the release of specific neurotransmitters, from a study by Sheef et al. (2012) the use of fMRI techniques has found the following areas of the brain that correspond to pain reduction are also affected by exercise (running): the periaqueductal gray (PAG), middle insular cortex, and pregenaual anterior cingulate cortex.
Interestingly, hypnosis also affects some of the same and neighboring brain regions as exercise in regards to pain reduction, such as the right posterior insula cortex (Abrahamsen et al., 2010) and the anterior cingulate cortex (Knudsen et al., 2011). Furthermore, for the purpose of this proposed investigation, there is evidence that simply thinking about exercise can actually cause a physiological response.
In a study from the Cleveland Clinic Foundation, Vinoth, Vlodek, Jing, Vinod, and Guang (n.d), found that participants in either of the mental practice groups (contracting one’s fifth finger; flexing one’s elbow) had increased their strength over a twelve-week period, as well as increases in cortical activity that itself caused the increases in strength. Gallego, Denot-Ledunois, Vardon, and Perruchet (1996) reported an increase of approximately 32% in average breaths per minute for 29 athletes that imagined themselves in a past sporting event. Erlacher and Schredl (2008) found increases in heart rates when lucid dream participants imagined doing squats (while lucid dreaming), and another study by Erlacher and Schredl (2010) found that lucid dream participants were able to increase their actual performance of tossing a coin into a cup by practicing the task while dreaming. Some of the results from these studies are reasonable to expect, some are simply interesting. However, for this proposal, the most useful findings come from a study that had results that one could reasonably expect and were interesting.
In a study by Cobb, Ripley, and Jones (1973) looking at physiological effects of hypnotic suggestion versus pharmaceuticals, they found a seemingly novel effect of the mind-body connection. Their study consisted of six medical students between the ages of 23 to 26, all of whom had some previous experience with hypnosis. The week before the experiment the participants were tested doing strenuous exercise on a bike ergometer. The day of the experiment the first 45 minutes was used as a period of quiet relaxation, then the hypnotic induction was given with 10 minutes more of relaxation suggestions. Next came 20 minutes of suggestions of bicycle exercise with increasing intensity, another 10 minutes of relaxation suggestions, followed by 15- 25 minutes of the reliving of a life event that could call up feelings of anxiety, anger, depression, or frustration. A final short relaxation period was given, then the hypnotic session was ended. In another session, this series of events was repeated, but with the administration of sodium amytal to cause relaxation and peaceful feelings. Nethalide (used to impede free fatty acid levels) was given to three of the participants in another session of hypnosis. The researchers found that using hypnosis with the exercise suggestion caused an increase in free fatty acid mobilization/arterial concentration in all six participants, and all six participants experienced some level of negative feelings from the reliving of a past troubling event.
Guided imagery can reduce pain. Exercise can reduce pain. Guided imagery can affect the anterior cingulate cortex. Exercise can affect the anterior cingulate cortex. Exercise imagery can produce physiological responses akin to what actual exercise produces. Therefore, it seems reasonable that guided exercise imagery may also reduce pain. If this is the case, then for later analysis to determine the physiological mechanisms causing this reduction in pain (which may or may not be those that actual exercise induces) these three areas should be looked at: the release of neurotransmitters that reduce pain; a decrease in those neurotransmitters that increase pain; activity level of those areas of the brain that may contribute to overall pain reduction.
Can thinking about exercise reduce pain? This question has significant potential utility. If this hypothesis is valid, a person, anywhere, for free, could simply think about exercising and any pain they have could be reduced. No pills, no copays, no side effects short-term or long, no interactions with any other medications. However, this leads to a final question to consider – why think about exercise to reduce pain when there are other imagery techniques to use? A valid question with a simple answer – different individuals will find some techniques more acceptable than others, both logically and emotionally/ideologically. Some individuals may find guided imagery too fanciful. Depending on one’s religious background, meditation and hypnosis may have connotations that are in conflict with one’s beliefs. But exercise is utilitarian, and therefore not fanciful, or having conflicting metaphysical ideas within it. This hypothesis of thinking about exercise to reduce pain may simply add another tool to the toolbox that an individual can use to potentially make their life a little bit easier.
A final caveat which goes to the design of this study is if an individual exercises on a regular basis (at least twice a week, a half hour per session) or not. As mentioned from the previous studies, exercise in and of itself is enough to cause a reduction in pain. To be on the conservative side, the hypothesis for this proposed study is that those individuals who do exercise on a regular basis will derive a greater reduction in pain from the use of exercise-related imagery than those individuals that do not exercise on a regular basis. The rationale being that those who do exercise on a regular basis have experienced positive physical and emotional feelings from exercise, so there may already be an established expectation that some positive will come from exercise, or exercise-related activities.
The study (ideally) consisted of at least 40, post-operative orthopedic patients (20 women, 20 men) from A.O. Fox Hospital in Oneonta, NY that had undergone various joint surgeries (hip, knee, elbow, and shoulder). The median age of the participants was 51.5, with the youngest being 18, the oldest being 84. Participants that did some formal exercise for at least a half hour per session, two days a week, were assigned to the “Exerciser” group versus a “NonExerciser” group.
Prior to the start of the experimental treatment a self-report questionnaire regarding the following information was collected: current and past activities – profession and hours of work, physical activities outside of work, history of exercise, involvement in sports; medical history – current state of health, past injuries/accidents, experiences dealing with pain, current pain level, physical therapy use, use of alternative practices (meditation, hypnosis, reiki, “other”); general sleep habits. To quantify pain levels a 7-point Likert scale was used: 1 as the least painful anchor; 7 as the most painful anchor; this numerical scale corresponding to a Visual Analog Scale – happy to progressively unhappy faces (modified from the 10-point VAS from the study by Antall & Kresevic, 2004). A mp3 recording (or other available audio format) for the imagery condition was created using a local voice-over actor to create a scene in which the participant was exercising on a bike ergometer in the participant’s physical therapist’s office. The suggestions start the participant exercising at a comfortable pace, then slowly increase the pace over a fifteen-minute period, prompting the participant to pedal as fast as they comfortably can. The suggestions allow the participant to include the physical therapist in the imagery, as well as a clock or timer, a mirrored wall or windows so the participant can see themselves exercising on the bike, general background noises (phone ringing, cars going by outside), and the physical sensations of exercising on the bike (warming up, muscle ache, breathing faster, faster heart beat, perspiration, etc). A self-report log was given to the participants to track their use of the mp3 recordings and before-and-after mp3 pain levels (if applicable) sleep habits, activity levels, use of pain meds, pain levels before and after physical therapy and/or exercise. A post hoc self-report survey of chronic pain experiences was also issued. The participants were compensated via parking vouchers for visits to their medical provider/researcher dealing directly with this study; compensated at the rate of $10 per hour for their initial 30 minute orientation to the study, follow-up meetings specific to the study, and debriefing meeting (if opted for a meeting); $50 stipend for data entry in their logs.
After the initial self-reports had been submitted by the participants and they had been assigned to either the Exerciser or NonExerciser groups, participants spent 30 minutes with the researcher, nurse, or healthcare staff to have any questions answered and to begin the use and self-reporting of pain levels and other data in their logs. Using random assignment half of the Exerciser and NonExerciser groups (n = 10) were given the mp3 recording of guided exercise imagery (as an addition to their standard care regimens); the other half of the Exerciser and NonExerciser groups received the standard care regimens only – NonImagery Group. The Imagery Group was to record pain levels before and after the use of the mp3, before and after any physical therapy, as well as using this period to make note of any changes in sleep, appetite/diet, pain medicine use, or other information they wished to make note of. The NonImagery group made the same entries, of course with the exception of before and after mp3 session pain levels. At the conclusion of this four-week study the self-report logs were collected and a self-report questionnaire dealing with the presence or absence of chronic pain and its levels were given to the participants as a post hoc measure. The participants were also debriefed to the true goal of the study and it’s findings reported to them within two weeks of the conclusion of the study.
*note: all results and findings are hypothetical
Analyzed effects of activity and imagery presentation using a two-way analysis of variance (ANOVA) found the following (see also Figure 1): main effect for activity was significant, F (1, 36) = 17.45, p < .05, with Exercisers (M = 2.5, SD = 1.8) achieving lower pain rating than NonExercisers (M = 5.125, SD = 2.1); there was also a significant main effect for imagery presentation, F (1, 36) = 16.81, p < .05, with Imagery (M = 3.25, SD = 1.1) achieving lower pain rating than NonImagery (M = 3.75, SD = .86). An interaction between activity and imagery presentation was also significant, F (1, 36) = 25.76, p < .05, with participants in the Exerciser/Imagery condition having the lowest overall pain ratings. A post hoc analysis dealing with suffers of chronic pain found there was a significantly higher rating of pain for participants in the NonExerciser/Imagery condition (M = 5.75, SD = 1.05) versus those participants in Exerciser/Imagery condition (M = 1.2, SD = .97).
The purpose of this study was to examine the potential effect of exercise imagery to reduce pain in post-operative orthopedic patients. The specific hypothesis that those who exercise on a regular basis and used the guided exercise imagery would have lower pain ratings than NonExercisers in both experimental and nonexperimental conditions, as well as Exercisers in the nonexperimental condition, was confirmed by this study. An additional finding from this study was that participants in the NonExerciser/Imagery condition reported the highest pain ratings of any group. One possible explanation stemming from the comments found in the participant logs is that they found the imagery of exercising on the bike ergometer to be boring, monotonous, and laborious. Other comments included how they did not like exercise in general, and having to think about exercise put them in a negative frame of mind. A few participants had not exercised since high school, and this imagery brought up being in gym class and some negative thoughts associated specifically with gym class, and some general negative thoughts about that stage of their lives. Another interesting result from the study was that those in the Exerciser/Imagery condition that were chronic pain suffers reported the lowest ratings for pain. From their logs, we find that the exercise imagery both reminded them of something they liked to do, and helped to remind them that they would be returning to their normal, active lives. Here, we have the reverse of the NonExerciser/Imagery participants, and see that in both conditions emotional frame of mind stimulated by the imagery had some influence on the perception of pain. In a future study, it may be advisable to tailor the imagery to some type of physical activity along a recreational route that the participant enjoys, so long as there is some component of steady physical exertion (e.g. hiking, canoeing, biking outdoors, kicking the ball around with the kids). Also, it may be useful for further comparative purposes to have a “placebo”, such as a guided imagery trip used in the studies cited by Antall & Kresevic (2004), Hart (2008), and Pölkki et al. (2006).
One of many concerns for the actual implementation of this proposed study is the potential harm that could come from the physiological responses to the exercise imagery and here we have some conflicting information. In the study by Cobb et al. (1973), three of the six participants experienced increased heart rates by 19-40 beats per minute, obviously meaning that there was increased blood flow through the body during the imagery session. However, in a study by Wuyam et al. (1995) looking at the cardiovascular response of participants to imagined exercise on a treadmill, non-athlete participants showed no significant changes in breathing patterns, nor was there any significance in heart rate changes for athletes or non-athletes from control activities to imagined exercise. With this in mind, to be on the conservative side, exercise imagery sessions may need to be postponed until such a time as the participant, under their doctor’s orders, would be allowed to do physical therapy and resume somewhat modest exercise/activity levels. This of course means that implementation of exercise imagery sessions must be tailored to an individual’s medical progression timeline, rather than set as an across the board, arbitrary measure.
A final point to consider is an individual’s expectations of any therapy and how those expectations effect outcomes. In a review by Bowering et al. (2013) of studies dealing with the efficacy of the Graded Motor Imagery method for treating chronic pain, the Motor Imagery component (thinking about moving a specific body part suffering with chronic pain) may have no affect on the lessening of pain, and in some studies actually increased pain. The authors of this metastudy did not posit any reason why this was the case. However, from gleaning through this proposed study’s participants’ logs one reasonable explanation is simply that there was the expectation of pain linked to use, even imagined use, of the bike ergometer. Some participants thought that they should have more time to heal and/or were afraid that the peddling would make things worse, which included increased pain, as well as slowing down the healing process, and/or doing further damage to their post-op bodies. More of these negative expectations were seen in the NonExerciser group than the Exerciser group. With all this in mind, it may be advisable that the imagery of the physical activity/exercise/sport be of something that does not primarily engage the afflicted body part, or engage it in a way that the participant (having been asked about their expectations) does not expect any negative outcome from this activity.
Although this study did find evidence to support the efficacy of guided exercise imagery to reduce pain, and some evidence that individuals who exercise on a regular basis and use exercise imagery will have the least pain, this study did not test for the underlying physiological mechanisms that caused said reductions. Further investigation is needed, specifically looking at the saliva/blood chemistry pre and post guided exercise imagery sessions, as well as neuroimaging to determine if those regions of the brain that guided imagery and exercise affect to modulate pain (Abrahamsen et al., 2010; Knudsen et al., 2011; Njis et al., 2012; Sheef et al., 2012) are being activated during these sessions.
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Figure 1. Mean ratings of pain for Exerciser and NonExerciser participants for each condition (Imagery, NonImagery).