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Management eBrief no. 153

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Management eBriefs
Issue 153April 2019

The report is a product of the VA/HSR&D Evidence Synthesis Program.

Guided Imagery, Biofeedback, and Hypnosis: A Map of the Evidence

Guided imagery, biofeedback, and hypnosis are complementary treatment modalities that have low risk of harm and potential benefits for patients experiencing a wide range of conditions, including pain, stroke recovery, hypertension, and gastrointestinal conditions, as well as mental health conditions such as anxiety and stress.

Guided imagery or guided meditation is a therapeutic technique that uses focused visualization and imaginative content to evoke sensory perceptions for improving mood and/or physical wellbeing. Biofeedback is a method by which a person receives data on physiological measurements (e.g., heart rate, muscle contractions, and brain wave activity) to help regulate physical and mental processes. Hypnosis or hypnotherapy is the induction of a state of consciousness in which an individual has heightened focus and suggestibility.

The purpose of this report is to provide a broad overview of the effectiveness of guided imagery, biofeedback, and hypnosis — and the health conditions for which these interventions have been examined in systematic reviews, in the form of evidence maps. The evidence maps developed from this systematic review will be used to guide and support decision-making about these treatment modalities in the VA healthcare system.

Investigators with VA's Evidence Synthesis Program in Portland, OR searched Ovid MEDLINE, CINAHL and the Cochrane Database of Systematic Reviews through March 2018 for systematic reviews and meta-analyses of guided imagery, biofeedback, or hypnosis. Investigators abstracted outcomes data in four categories: diagnosis-related outcomes, secondary outcomes, global health outcomes, and harms.

Evidence maps serve to identify current knowledge and future research needs. Although standardized definitions and methodology are still being established, they generally include a systematic search of a broad field of research and a visual representation of the body of literature.

After reviewing 2,533 articles, investigators selected 40 good-quality systematic reviews that represented the most recent and comprehensive evidence available on each intervention, as applied to distinct medical conditions and target populations. Biofeedback interventions were studied in the largest number of health conditions and target populations (N=16), followed by hypnosis (N=14), and guided imagery (N=12). Pain conditions and various forms of anxiety were among the most widely represented. All three interventions were studied in patients with fibromyalgia. For most health conditions, the use of biofeedback, guided imagery, or hypnosis was adjunctive to standard of care.

Summary of Review
Evidence map of the health conditions for which guided imagery, biofeedback, and hypnosis interventions had evidence of a positive effect or evidence of no effect. Each data point – or bubble – represents the evidence for guided imagery, biofeedback, or hypnosis for a distinct health condition.

Evidence map of the health conditions for which guided imagery, biofeedback, and hypnosis interventions had evidence of a positive effect or evidence of no effect. Each data point -- or bubble -- represents the evidence for guided imagery, biofeedback, or hypnosis for a distinct health condition.

Findings
Biofeedback was the best studied intervention both in terms of the absolute size of the literature, and in terms of the overall level of confidence in findings. In particular, there was moderate- to high-level confidence that biofeedback is likely to be effective for urinary incontinence after prostatectomy, fecal incontinence, balance and gait in stroke patients, and headache. Indeed, the finding that biofeedback may improve global health outcomes in headache (migraine and tension-type) and for urinary incontinence after prostatectomy (as an adjunct to pelvic floor muscle training) further underscores these as particularly promising areas for intervention.

There is moderate-level confidence that guided imagery is effective in improving diagnosis-related outcomes in patients with arthritis or other rheumatic diseases. The levels of confidence of guided imagery's effectiveness for other conditions was generally low, due to heterogeneity among the intervention modalities, high risk of bias, lack of blinding, and limited generalizability in some studies.

There is low-confidence evidence that hypnosis provides benefit over comparator interventions for anxiety in patients with cancer, breast cancer care (i.e., pain, distress, fatigue, nausea/vomiting, and hot flashes), and weight loss in obese participants. Limitations to the body of evidence include small combined samples sizes, poor study quality, and inconsistencies among the studies that were included in the systematic reviews.

Future Research
For many of the health conditions studied, the level of confidence was low or insufficient for the majority of outcomes, which suggests that further research in these areas is very likely to change our understanding of the effectiveness of these interventions. The most common limitations were small sample sizes from few trials, and methodologic issues in the included randomized controlled trials. Of note, the reviews included in this report generally provide very little insight into the impact of these interventions on global outcomes, such as quality of life and functional status.

There were a number of interventions and health conditions for which there was evidence of a "potential positive effect," where the findings were mixed across multiple outcomes. Examples of mixed findings include guided imagery for patients with cancer, biofeedback for balance/gait training, and hypnosis for patients with IBS, among others. These are potentially fruitful areas of research.

A cyberseminar on Guided Imagery, Biofeedback, and Hypnosis: A Map of the Evidence will be held on June 4, 2019 from 1:00pm to 2:00pm ET. Register for this session.

Reference
Freeman M, Ayers C, Kondo K, Noonan K, O'Neil M, Morasco B, and Kansagara D. Guided imagery, Biofeedback, and Hypnosis: A Map of the Evidence. VA ESP Project #05-225; 2019.

View the full report — **VA Intranet only**:
http://vaww.hsrd.research.va.gov/publications/esp/guided-imagery.cfm
(copy and paste if you have VA intranet access)

Please feel free to forward this information to others!

Read past HSR&D Management e-Briefs on the HSR&D website.

ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.



This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

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This report is a product of VA/HSR&D's Evidence Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

See all reports online.