604 Journal of Pain and Symptom Management Vol. 36 No.

6 December 2008

Original Article

Individual Difference Variables and the

Effects of Progressive Muscle Relaxation
and Analgesic Imagery Interventions
on Cancer Pain
Kristine L. Kwekkeboom, PhD, RN, Britt Wanta, MS, RN,
and Molly Bumpus, BS, RN
University of Wisconsin-Madison School of Nursing (K.L.K., B.W.) and University of Wisconsin
Hospital & Clinics (M.B.), Madison, Wisconsin, USA

Abstract
Clinicians in acute care settings are often called upon to manage cancer pain unrelieved by
medications. Cognitive-behavioral strategies, such as relaxation and imagery, are
recommended for cancer pain management; however, there appear to be individual
differences in their effects. This pilot study examined variation in pain outcomes achieved
with progressive muscle relaxation (PMR) and analgesic imagery interventions among
hospitalized patients with cancer pain, and assessed the influence of four individual
difference variables (cognitive ability, outcome expectancy, previous experience, and
concurrent symptoms) on pain relief achieved with each intervention. A crossover design was
used in which 40 hospitalized cancer patients received two trials of PMR, two trials of
analgesic imagery, and two trials of a control condition. In comparing means between
treatment and control conditions, both PMR and analgesic imagery produced greater
improvements in pain intensity, pain-related distress, and perceived control over pain than
the control condition. However, individual responder analysis revealed that only half of the
participants achieved a clinically meaningful improvement in pain with each intervention.
Patients who achieved a meaningful improvement in pain with analgesic imagery reported
greater imaging ability, more positive outcome expectancy, and fewer concurrent symptoms
than those who did not achieve a meaningful reduction in pain. Similar relationships were
not significant for the PMR intervention. Investigators should continue efforts to identify
factors that moderate the effects of cognitive-behavioral pain coping strategies so that
clinicians can identify the most beneficial treatments for individual patients. J Pain
Symptom Manage 2008;36:604e615. Ó 2008 U.S. Cancer Pain Relief Committee.
Published by Elsevier Inc. All rights reserved.

This work was funded in part by research grants of Nursing, K6/336 Clinical Science Center, 600
from the University of Wisconsin Madison Graduate Highland Avenue, Madison, WI 53792, USA.
School and the Center for Patient-Centered Inter- E-mail: kwekkeboom@wisc.edu
ventions (Grant Number P20 NR008987 from the Accepted for publication: December 10, 2007.
NIH [PI: Sandra Ward, UW-Madison School of
Nursing]).
Address correspondence to: Kristine L. Kwekkeboom,
PhD, RN, University of Wisconsin-Madison, School

Ó 2008 U.S. Cancer Pain Relief Committee 0885-3924/08/$esee front matter

Published by Elsevier Inc. All rights reserved. doi:10.1016/j.jpainsymman.2007.12.011
Vol. 36 No. 6 December 2008 Individual Difference Variables 605

Key Words
Cancer, oncology, pain, relaxation, imagery, individual differences

Introduction may help to identify subgroups of patients

most likely to benefit from the intervention.
The prevalence of cancer pain is high in the
Individual variability in response to
inpatient setting. Up to 46% of hospitalized
cognitive-behavioral pain strategies may be
cancer patients experience moderate to severe
explained, in part, by characteristics of study
pain,1e5 and nearly 51% experience episodes
participants. Pain researchers have identified
of breakthrough pain despite the use of anal-
a number of demographic (age, gender),
gesics.6 Although clinicians are available to
personality (extroversion, neuroticism) and
help manage symptoms around the clock,
psychological factors (expectancy, catastrophiz-
quality improvement research indicates that
ing) that influence pain processing and subse-
pain management in the hospital setting re-
quent experiences of chronic pain.27e29 Less
mains ‘‘inadequate and ineffective.’’7 (p.126)
attention has been paid to factors that influ-
Cancer pain management guidelines recom-
ence responses to specific cognitive-behavioral
mend cognitive-behavioral coping strategies as
coping strategies (e.g., relaxation or imagery),
adjuvants to analgesic medications.8,9 Clini-
particularly for acute pain episodes. Kwekke-
cians often have a variety of such coping strat-
boom and colleagues24,30 suggested that the
egies in their repertoire including relaxation,
effects of cognitive-behavioral pain coping
distraction, imagery, and music interventions,
strategies may be moderated by individual
among others. Cognitive-behavioral coping
differences in cognitive ability, outcome expec-
strategies may reduce pain by interrupting
tancy, previous experience, and concurrent
the transmission of pain signals, limiting the
symptoms (Fig. 1). Cognitive ability, in this
cognitive capacity to pay attention to pain,
use, refers to one’s aptitude or capacity to en-
stimulating the release of endorphins, or by
gage in the activities of the strategy. For exam-
helping patients diminish pain-exacerbating
ple, the cognitive ability to create and
thoughts.10e13
experience vivid mental images facilitates
Relaxation and guided imagery are two
symptom relief with guided imagery.24,31 Out-
cognitive-behavioral strategies that have shown
come expectancy is one’s anticipated response
promise in managing acute nonmalignant
to using the specific cognitive-behavioral strat-
pain,14,15 as well as in controlling various
egy, which may be positive or negative based
cancer-related symptoms.16,17 In studies of
on past experience, and is thought to influence
acute cancer pain, investigators have demon-
one’s commitment or focus in using the
strated beneficial effects of relaxation and
strategy.32e34 Finally, the experience of multi-
guided imagery for treatment-related pain
ple concurrent symptoms when using the
(i.e., surgery, bone marrow transplant)18e20
and disease-related pain in patients with vari-
ous cancer diagnoses.21e24 Individual re- Previous
Experience
sponses to these strategies vary, however, and
a strategy that works for some patients may
Cognitive
not work for others.24,25 Studies of cognitive- Skill /
Outcome
Expectancy
behavioral pain treatments typically report Ability
group mean pain scores, but individual im-
provements are rarely described. Witter Cognitive- Pain
Behavioral Outcomes
et al.26 recommended that individual re- Strategy
sponder analysis (i.e., determination of
whether each study participant met desired Concurrent
Symptoms
endpoints) might better capture important re-
sults of clinical pain management trials than Fig. 1. Factors influencing effects of specific
traditional evaluation of group means, and cognitive-behavioral pain coping strategies.
606 Kwekkeboom et al.
cognitive-behavioral strategy may compromise
one’s focus or concentration and has been
shown to negatively affect pain outcomes.24
Given the general recommendation to use
cognitive-behavioral strategies in managing
cancer pain, it is important not only to docu-
ment whether specific strategies are effective,
but also to determine if individual difference
variables influence which strategies work for
specific patients. Knowledge of such individual
difference factors may provide a better ratio-
nale for selecting a specific cognitive-
behavioral strategy when helping patients
manage episodic flares in pain.
This pilot study assessed variation in re-
sponses to progressive muscle relaxation
(PMR) and analgesic imagery interventions
among hospitalized patients with cancer pain,
and examined the influence of selected indi-
vidual difference variables (ability, outcome
expectancy, previous experience, and concur-
rent symptoms) on pain relief achieved with
each intervention. Responses were evaluated
with respect to one primary pain outcome
(change in pain intensity) and two secondary
pain outcomes (change in pain-related distress
and perceived control over pain). We hypothe-
sized that:
1. Comparison of group means would dem-
onstrate better pain outcomes with the
PMR and analgesic imagery interventions
compared to a control condition.
2. Individual responder analysis would dem-
onstrate variation in response to PMR
and analgesic imagery, with only some
participants achieving a clinically mean-
ingful improvement in pain outcomes
with each intervention.
3. Patients who achieved a clinically meaning-
ful improvement in pain outcomes would
report greater imaging or relaxation ability,
more positive outcome expectancy, more
positive previous experiences with the
interventions, and fewer concurrent symp-
toms than persons who did not achieve
a meaningful improvement in pain.
Methods
Design and Participants
Because our goal was to demonstrate differ-
ences in individual outcomes for specific
Vol. 36 No. 6 December 2008
treatments, we used a crossover design in
which each participant received two trials of
a control condition, two trials of PMR, and
two trials of analgesic imagery. The study was
conducted over a two-day period, with subjects
receiving one control trial and two trials of
PMR or imagery on each day (Fig. 2). Partici-
pants were blocked by average pain severity
(2e4 vs. 5e8), and then randomized to the or-
der of interventions. Pain intensity and pain-
related distress were measured before and af-
ter each trial and perceived control over pain
was measured after each trial.
Participants included 40 patients with
cancer-related pain hospitalized at a Midwest
academic medical center. Criteria for partici-
pation were age $18, average pain in the last
24 hours rated 2e8 on a 0e10 scale, and
anticipated hospitalization for at least two
days. Exclusion criteria were: pain that was
postoperative or neuropathic in etiology, in-
ability to read and understand English, and
cognitive impairment that would prevent com-
pletion of study procedures. Nursing staff
identified 161 potential participants; 112
agreed to talk with the research nurse. Of
those, 44 did not meet eligibility criteria and
28 refused to participate for reasons related
to time (12dtoo busy, 2danticipating early
discharge), physical condition (3dtoo tired,
2dtoo sick), or concerns about study proce-
dures (4dnot interested, 3dskeptical about
intervention effectiveness, 1ddislike of ques-
tionnaires, 1dfear of exacerbating pain). Forty
patients agreed to participate, signed consent
forms, and started baseline questionnaires.
Participants’ demographic characteristics
are described in Table 1. Most were non-
Hispanic Caucasians and about half (55%)
were female. Participants ranged in age from
18 to 75 (mean ¼ 49, SD ¼ 16 years). Fifty-five
percent had hematologic malignancies and
45% had solid tumors. Pain was most com-
monly somatic (62%) and treated using strong
opioids with or without weak or nonopioids
(75%).
Instruments
Demographic Questionnaire. Patients provided
demographic data including age, gender,
race, ethnicity, and education. Cancer
Vol. 36 No. 6 December 2008 Individual Difference Variables 607

CONSENT

Demographic questionnaire, measures of

individual difference variables
BLOCK by pain level, then RANDOMIZE

ORDER 1 ORDER 2
Day 1 Day 1
Control Trial Control Trial
PMR Trial 1 Imagery Trial 1
PMR Trial 2 Imagery Trial 2

Day 2 Day 2
Control Trial Control Trial
Imagery Trial 1 PMR Trial 1
Imagery Trial 2 PMR Trial 2

Pre-trial measures: Pain intensity, Pain-related distress

Post-trial measures: Pain intensity, Pain-related distress
Perceived control over pain
Concurrent symptoms

Fig. 2. Study design schema.

diagnosis, treatment, type of pain, and analge-
sic orders were obtained from their medical
records.
Individual Difference Variables. Imaging Ability.
Imaging ability was measured with the Imaging
Ability Questionnaire.35 The 32-item Imaging
Ability Questionnaire assesses the tendency to
become engaged in fantasy and imaginative
experiences and the ability to generate vivid
mental images. Items were scored from 0 to 4
and summed with higher scores indicating
better imaging ability. Internal consistency reli-
ability (a ¼ 0.93) test-retest reliability (r ¼ 0.92),
and construct validity of the Imaging Ability
Questionnaire have been previously demon-
strated in healthy adults and persons with
cancer.35 Internal consistency reliability in the
current sample was a ¼ 0.92.
Relaxation Ability. The Relaxation Ability
Questionnaire, adapted from the relaxation
subscale of the Wisconsin Experience Ques-
tionnaire,36 was used to assess the partici-
pants’ perceptions of their ability to
become relaxed. Nine statements regarding
the process of becoming relaxed were rated
using a five-point scale. Mean score was
calculated across items, with higher scores
indicating greater perceived relaxation ability.
Internal consistency reliability in a sample of
healthy adults was a ¼ 0.85e0.87 and teste
retest reliability was r ¼ 0.81.37 In the current
sample, internal consistency reliability was
a ¼ 0.91.
Outcome Expectancy. The Outcome Expec-
tancy Scale was used to assess anticipated
outcomes of using guided imagery and relaxa-
tion interventions, that is, the specific expecta-
tion that guided imagery or relaxation could
relieve the individual’s pain. Beliefs that
one’s pain can be controlled with guided imag-
ery and relaxation were assessed with six items
for each strategy and rated on a seven-point
scale. Means were calculated across the six
items, with higher scores indicating more pos-
itive outcome expectancy. Internal consistency
reliability (a ¼ 0.75e0.89) and construct valid-
ity of the Outcome Expectancy Scale have
been demonstrated in previous work with can-
cer patients and healthy adults (unpublished
data).33 In the current sample, internal consis-
tency reliability was a ¼ 0.90 for the guided im-
agery version and a ¼ 0.91 for the relaxation
version.
Previous Experience with the Interventions. Previ-
ous experiences with relaxation and guided
608 Kwekkeboom et al. Vol. 36 No. 6 December 2008

Table 1
Demographic Characteristics
Order 1: PMRdImagery Order 2: ImagerydPMR Total (n ¼ 40)
Characteristic (n ¼ 24) Mean (SD) (n ¼ 16) Mean (SD) Mean (SD)

Age (years) 52.38 (13.77) 43.75 (18.76) 48.93 (16.29)

Time since diagnosis (months) 21.36 (41.25) 13.70 (16.07) 18.26 (33.28)

Characteristic n (%) n (%) n (%)

Gender
Male 9 (38) 9 (56) 18 (45)
Female 15 (62) 7 (34) 22 (55)
Ethnicity
Hispanic/Latino 0 (0) 1 (6) 1 (3)
Non-Hispanic/Latino 24 (100) 15 (94) 39 (97)
Race
Caucasian 24 (100) 16 (100) 40 (100)
Education
12th grade or less 5 (21) 4 (25) 9 (23)
College 15 (62) 10 (62) 25 (62)
Graduate school 4 (17) 2 (13) 6 (15)
Diagnosis
Hematologic cancer 12 (50) 10 (63) 22 (55)
Solid tumor 12 (50) 6 (37) 18 (45)
Pain type
Somatic 14 (58) 11 (69) 25 (62)
Visceral 10 (42) 5 (31) 15 (38)
Current treatment
None 9 (38) 5 (31) 14 (35)
Chemotherapy 7 (29) 6 (38) 13 (32.5)
Radiotherapy 3 (12) 2 (12) 5 (12.5)
Combination/other 5 (21) 3 (19) 8 (20)
Current analgesic orders
Nonopioid only 0 (0) 1 (6) 1 (3)
Weak opioid  nonopioid 5 (21) 1 (6) 6 (15)
Strong opioid  weak opioid  nonopioid 18 (75) 13 (81) 31 (78)
Some items do not sum to 100 due to missing data.
No demographic characteristics differed by treatment order.

imagery were measured using five questions
that assessed the quality of personal or vicarious
experiences with each strategy. Items were
answered ‘‘yes,’’ (þ1) ‘‘no,’’ (1) or ‘‘not sure’’
(0), and summed across items with higher
scores indicating more positive previous experi-
ence. Internal consistency reliability in the cur-
rent sample was a ¼ 0.85 for both the guided
imagery and relaxation versions.
Concurrent Symptoms. The Edmonton Symp-
tom Assessment System38 was used to measure
concurrent symptoms experienced while lis-
tening to control or cognitive-behavioral inter-
ventions. Severity of tiredness, nausea,
depression, anxiety, drowsiness, lack of appe-
tite, sense of well-being, shortness of breath,
and other (fill in the blank) symptoms were
scored on a 0e10 numeric rating scale and
a sum calculated across all items. Internal
consistency reliability in this use ranged from
a ¼ 0.62 to 0.81.
Primary Pain Outcome. Change in Pain Intensity.
Current pain intensity was measured using
a 0 (no pain) to 10 (worst pain imaginable)
numeric rating scale. Percent change in pain
intensity was calculated from pre- to post-trial
for each trial (control and interventions). Per-
centage change in pain scores have been shown
to be less biased by pretreatment pain than ab-
solute (raw) change scores39 and correlate well
with patient reports of perceived pain reduc-
tion.40 A reduction of $30% has been identi-
fied as a clinically meaningful change in pain.41
Secondary Pain Outcomes. Change in Pain-
Related Distress. Participants were asked to rate
their pain-related distress (i.e., How distressing
Vol. 36 No. 6 December 2008 Individual Difference Variables
is your pain right now?) using a 0 (no distress)
to 10 (unbearable distress) numeric rating
scale. Percent change in pain-related distress
was calculated from pre- to post-trial for each
trial (control and interventions).
Perceived Control Over Pain. The Control sub-
scale from the Survey of Pain Attitudes42 was
used to measure perceived control over pain.
Five statements about personal control over
pain were rated on a five-point scale. Mean
score was calculated across items with higher
scores indicating greater perceived control
over pain. Internal consistency reliability in
the current sample ranged from a ¼ 0.77 to
0.90.
Equipment and Interventions
The control condition, guided imagery, and
PMR interventions were recorded on CD using
a male voice with no musical background. A
portable CD player with large (3.500  2.7500 )
over-the-ear style headphones was used to
play the recordings.
Control Condition. Information recordings
were used to control for the effects of attention
from the research nurse, use of the CD player
and headphones, and the distraction of receiv-
ing a recorded message. The recording used
on Day 1 identified members of the health
care team, explained patients’ rights, and de-
scribed various hospital services (time ¼ 14:09).
The recording used on Day 2 described exer-
cises and activities to maintain strength while
hospitalized and identified issues in thinking
ahead toward discharge (time ¼ 13:17).
Progressive Muscle Relaxation. Listeners were
guided through instructions to tense and relax
muscles in a series of 12 major muscle groups
from head to feet (time ¼ 13:36). Instructions
encouraged participants to focus on sensations
associated with release of muscle tension and
feelings of comfort. Patients were advised not
to tense muscle groups that felt strained or
that aggravated pain.
Analgesic Imagery. A glove anesthesia tech-
nique43,44 was used in which listeners were first
asked to scan their bodies to identify areas of
pain and to imagine replacing pain with com-
forting sensations (e.g., heat or cold). Next
they were asked to imagine soaking a hand in
609
anesthetic fluid, feeling it go numb, and trans-
ferring the numbness to painful areas of the
body (time ¼ 14:29).
Procedure
All study procedures were approved by the
Institutional Review Board (IRB) and patients
were recruited from June 2005 to September
2006. Staff nurses identified patients who met
criteria. A research nurse met with willing pa-
tients, confirmed eligibility criteria, and ex-
plained study purposes and procedures. The
research nurse provided a brief (two to three)
sentence description of each intervention in-
cluding how it was thought to impact pain. Af-
ter written consent was obtained, participants
completed measures of demographic vari-
ables, imaging ability, relaxation ability, out-
come expectancy, previous experience, and
baseline perceived control over pain. Subjects
were then randomized to the order of inter-
ventions by selecting a preprepared randomi-
zation envelope from the appropriate pain
strata (2e4 or 5e8).
Control and intervention trials were con-
ducted when current pain (pain now) was
rated 2e8 on the 0e10 scale. Trials were de-
layed if patients had received an oral analgesic
within the last 60 minutes or an IV analgesic
within the last 30 minutes to prevent con-
founding the effect of the study intervention
with any new onset of analgesic action. Patients
on patient-controlled analgesia (PCA) pumps
received their basal continuous infusions, but
were asked to refrain from patient-initiated
doses during the 15-minute trials. The first
trial of each day was always the control trial
to prevent any potential carryover from the ac-
tive treatments into the control condition. If
pain persisted at the end of the control trial
(rated 2e8), the research nurse continued
with the first of two trials of the assigned
day’s cognitive-behavioral strategy. Two trials
of each cognitive-behavioral strategy were con-
ducted per day to allow participants more than
just one single assessment while also attempt-
ing to limit subject burden. The second trial
was conducted at least one hour after the first
trial.
The following procedures were used for
each control or intervention trial. First, the pa-
tient completed pre-trial ratings of pain
610 Kwekkeboom et al.
intensity and pain-related distress. The patient
was then given the appropriate CD loaded in
a CD player. The research nurse helped the pa-
tient start the recording, then stepped out of
the room and posted a ‘‘Do Not Disturb’’
sign on the patient’s door. The research nurse
waited outside the door and re-entered at the
end of the recording time to administer post-
trial measures of pain intensity and pain-
related distress, perceived control over pain,
and concurrent symptoms. The CD player
and CDs were taken out of the patient’s
room between trials. Participants were reim-
bursed $30/day for their time and effort.
Data Analyses
For each outcome (change in pain intensity,
change in pain-related distress, perceived con-
trol over pain), scores were averaged across the
two control, PMR, or analgesic imagery trials.
For example, change in pain intensity from
the first PMR trial was averaged with change
in pain intensity from the second PMR trial
to form the score used in data analyses. In
cases where participants completed only one
trial, the score from that single trial was used
in analyses. Summary statistics were used to de-
scribe the sample with respect to demographic
characteristics, scores on individual difference
variables, and pain outcomes. Nonparametric
statistics (Wilcoxon Signed Rank and Mann-
Whitney U ) were used in comparing paired
data and in making comparisons between
treatment and control conditions and between
treatment responders and nonresponders.
One-tailed tests were used for directional
hypotheses. Because our intent was to demon-
strate individual variation in responses to both
PMR and analgesic imagery interventions, not
to demonstrate that one intervention was
more effective than the other, no statistical
tests were carried out comparing PMR to anal-
gesic imagery.
Results
Twenty-four participants were allocated to in-
tervention Order 1 (PMReImagery) and six-
teen were allocated to intervention Order 2
(ImageryePMR). The number of persons as-
signed to each order was not equal because
our randomization scheme was not set up in
Vol. 36 No. 6 December 2008
small blocks to balance group assignment
throughout recruitment and we had a lower
than anticipated participation rate during the
funding period. Among the 40 participants
who started the study, eight did not receive
any relaxation trials, and nine did not receive
any guided imagery trials because they were
too tired, too busy, felt too ill, were discharged
earlier than anticipated, or their pain resolved.
Thus, data regarding PMR were available from
32 participants and data regarding guided imag-
ery were available from 31 participants. Persons
who completed no trials were older (mean
rank ¼ 28.86, M ¼ 60.57, SD ¼ 9.61) than per-
sons who completed trials (mean rank ¼ 18.73,
M ¼ 46.45, SD ¼ 16.44), Mann-Whitney U ¼ 57,
nnot completed ¼ 7, ncompleted ¼ 33, P < 0.05.
A greater proportion of males (34%) com-
pleted no trials compared to females (5%),
c2(1) ¼ 5.68, P < 0.05. No other demographic
or disease-related variables differed between
persons who completed trials and those who
did not.
Carryover Effects
Neither pretrial pain intensity ratings nor
pretrial pain-related distress ratings differed
significantly across trials, suggesting that any
pain relieving effects of the previous control
or treatment conditions had dissipated before
starting the next trial. Repeated measures anal-
ysis of variance found no significant period
(Day 1 vs. Day 2) by sequence (Order 1 vs. Or-
der 2) interactions, suggesting that responses
on Day 2 were not affected by the treatments
received on Day 1.
Hypothesis 1dComparison of Group Means
(Treatment vs. Control)
Pain outcomes achieved with the PMR and
analgesic imagery interventions were com-
pared to those obtained with the control con-
dition from the same day using the Wilcoxon
Signed Rank test. Greater change in pain in-
tensity (Z ¼ 2.15, P < 0.05), greater change
in pain-related distress (Z ¼ 1.82, P < 0.05),
and greater perceived control over pain (Z ¼
3.02, P < 0.01) were reported with PMR com-
pared to control. Similarly, greater change in
pain intensity (Z ¼ 2.70, P < 0.01), greater
change in pain-related distress (Z ¼ 2.11,
P < 0.05), and greater perceived control over
pain (Z ¼ 2.40, P < 0.01) were reported
Vol. 36 No. 6 December 2008
with analgesic imagery compared to control.
Mean scores for these pain outcomes are re-
ported in Table 2.
Hypothesis 2dIndividual Responder Analysis
Participants were categorized as having
a meaningful improvement in pain with each
cognitive-behavioral treatment (i.e., re-
sponders) if they achieved $30% reduction
in pain intensity and also reported improve-
ment in either pain-related distress, perceived
control over pain, or both. Thirteen of the
32 participants who provided PMR data
(41%) had a meaningful improvement in
pain. Sixteen of 31 participants who provided
analgesic imagery data (52%) had a meaning-
ful improvement in pain. Thirty participants
provided data for both relaxation and analge-
sic imagery trials. Of those 30, eight obtained
meaningful improvement in pain with both
cognitive-behavioral strategies and 13 reported
meaningful improvement in pain with only
one strategy (five with PMR only, eight with
analgesic imagery only).
Hypothesis 3dInfluence of Individual
Difference Variables
Scores on the individual difference variables
were compared between subjects who achieved
a meaningful improvement in pain and those-
who did not (Table 3). There were no signifi-
cant differences in perceived relaxation
ability, outcome expectancy for relaxation, pre-
vious experience with relaxation or concurrent
symptoms between persons who experienced
a meaningful improvement in pain with PMR
and those who did not. With respect to ana-
lgesic imagery, persons who demonstrated a
meaningful improvement in pain had greater
Mean (SD) Pain Outcomes with PMR and Guided Imagery Compared to Control
Pain Outcome
a
Percent change in pain intensity
Percent change in pain-related distressa
Perceived control over painb
Pain Outcome
b
Percent change in pain intensity
Percent change in pain-related distressa
Perceived control over painb
Control scores are from the trial conducted on the same day as the specified cognitive-behavioral strategy.
a
P < 0.05, Wilcoxon Signed Rank test.
b
P < 0.01, Wilcoxon Signed Rank test.
Individual Difference Variables 611
imaging ability (Mann-Whitney U ¼ 71.00,
P < 0.05), more positive outcome expectancy
(Mann-Whitney U ¼ 69.5, P < 0.05), and fewer
concurrent symptoms (Mann-Whitney U ¼ 76.00,
P < 0.05) than persons who did not report
a meaningful improvement in pain. Previous
experiences with imagery interventions did
not differ between groups.
Discussion
The PMR and analgesic imagery interven-
tions appeared to be helpful to some partici-
pants. Group means suggested that both
cognitive-behavioral strategies were signifi-
cantly more effective in improving pain out-
comes than the control condition. These
findings are consistent with those of other in-
vestigators who demonstrated beneficial ef-
fects of PMR and imagery interventions
among hospitalized patients with cancer
pain.22e24 After the intervention trials were
completed, more than three-fourths of partici-
pants told us that they enjoyed using PMR and
found it to be helpful. More than half reported
that they enjoyed the analgesic imagery inter-
vention and found it to be helpful.45
As anticipated, there were considerable
variations in the individual responses to PMR
and analgesic imagery with only about half
of the participants achieving a meaningful im-
provement in pain. The simple distraction of
the control condition also produced varying
results, with seven of the 32 participants
reporting meaningful improvement in pain.
Reports of such variation in response to cogni-
tive-behavioral strategies are limited. Donovan
and Laack25 reported that 31% of chronic pain
outpatients were unable to achieve pain relief
with relaxation and imagery interventions.
Table 2
PMR Mean (SD) Control Mean (SD) Possible Score Range
31 (32) 18 (27) 100e100
26 (61) 19 (38) 100e100
2.37 (0.90) 1.98 (0.91) 0e4
Guided Imagery Mean (SD) Control Mean (SD) Possible Score Range
31 (36) 8 (34) 100e100
37 (43) 16 (40) 100e100
2.51 (0.80) 2.26 (0.78) 0e4
612 Kwekkeboom et al. Vol. 36 No. 6 December 2008

Table 3
Scores (Mean Rank, Mean, SD) on Individual Difference Variables Among Persons Who Achieved
Meaningful Reduction in Pain and Those Who Did Not
Meaningful Improvement No Meaningful Improvement

Mean Mean Mean Mean Observed Possible

Individual Difference Variable Rank (SD) Rank (SD) Range Range

PMR (n¼13) (n ¼ 19)

Relaxation ability 14.83 1.69 (0.80) 16.74 1.73 (0.89) 0e3.67 0e4
Outcome expectancy 17.85 4.78 (0.77) 15.58 4.43 (0.91) 2e6 0e6
for relaxation
Previous experience 16.25 1.92 (2.19) 15.84 1.74 (2.02) 2e5 5e5
with relaxation
Concurrent symptoms 17.12 21.85 (8.60) 16.08 21.03 (10.82) 6e40.50 0e90
Analgesic imagery (n ¼ 16) (n ¼ 15)
Imaging abilitya 19.06 76.88 (17.44) 12.73 63.40 (20.86) 27e108 0e128
Outcome expectancy 19.16 4.60 (0.87) 12.63 3.77 (1.16) 1.67e6 0e6
for imagerya
Previous experience 15.36 1.29 (2.13) 13.64 0.86 (1.61) 1e5 5e5
with imagery
Concurrent symptomsa 13.25 17.75 (10.58) 18.93 25.03 (12.39) 0e41.50 0e90
Significant differences using Mann-Whitney U test.
a
P < 0.05.

Kwekkeboom et al.24 reported that 10% of hos-
pitalized patients with cancer pain experi-
enced no change or an increase in pain after
using a guided imagery intervention. It is pos-
sible that other investigators obtained similar
results but did not report them as such, focus-
ing only on group means.
Responses to the analgesic imagery interven-
tion, but not the PMR intervention, were re-
lated to proposed individual difference
variables in this sample. Scores on imaging
ability, outcome expectancy, and concurrent
symptoms differed significantly between per-
sons who achieved a meaningful reduction in
pain with guided imagery and those who did
not. Persons with greater imaging ability may
have been better able to create mental images
of changing sensations and numbness com-
pared to persons with lower imaging ability;
while positive expectations for beneficial
effects and fewer concurrent distressing symp-
toms may have allowed greater concentration
and effort toward engaging in the imagery
exercise. Our findings are consistent with pre-
vious research in which imaging ability pre-
dicted relief of cancer-related pain,24 general
anxiety,31 and various other health out-
comes.46 Patients’ expectations for response
to treatment have also been previously shown
to predict health outcomes.34
It is unclear why the individual difference
variables were not related to outcomes of
PMR. Perceived relaxation ability scores
fell near the low-to-mid range (M ¼ 1.73,
SD ¼ 0.82) of possible scores (0e4), suggesting
some restriction in range. Perhaps participants
answered the relaxation ability items based on
their current feelings of relaxation or stress
rather than their ease in becoming relaxed.
An actual test of one’s physiologic response to
relaxation instructions made prior to the PMR
trials may have been a more accurate measure
of relaxation ‘‘ability,’’ but would have intro-
duced additional burden in this ill clinical pop-
ulation. Outcome expectations and previous
experiences with relaxation interventions were
generally positive, and concurrent symptoms
during PMR were only mild to moderate; yet
less than 50% of subjects achieved a meaningful
improvement in pain with PMR. Including
a measure of physiologic or perceived relaxa-
tion after the intervention trials may have
helped us to understand if PMR was ineffective
for these individuals because PMR did not
produce relaxation or because the pain was
not responsive to relaxation.
It is important to note that the interventions
provided only short-term effects. Pain had re-
turned to preintervention levels before the
next trial started, sometimes within one hour.
However, our goal was to treat the acute epi-
sodic pain that commonly occurs in hospital-
ized cancer patients. Pain in the inpatient
setting is often intermittent, fluctuating with
Vol. 36 No. 6 December 2008 Individual Difference Variables
blood levels of analgesics, or flaring with pe-
riods of breakthrough pain. Brief relaxation
and imagery interventions have been less suc-
cessful in treating chronic cancer pain than
lengthy programs of cognitive-behavioral ther-
apy.47,48 We do not know if allowing more prac-
tice or repetitions with each intervention
would have resulted in different outcomes,
however, it may not be feasible for clinicians
to provide extensive practice given the poten-
tially diminished physical and mental reserves
of this acutely ill population.
Recruitment for this study proved challeng-
ing. Thirty percent of potential participants
declined to speak with the research nurse. Fur-
thermore, 41% of patients who met inclusion
criteria declined participation. Most people
who declined participation described concerns
about their ability to meet the demands of the
study (too busy) and lack of interest or skepti-
cism about the interventions. One can under-
stand that the busy pace of the inpatient
setting would prohibit some patients from
agreeing to take on more demands. It may
also be that persons who were particularly ill
felt too overwhelmed or not well enough to fo-
cus on learning the cognitive behavioral inter-
ventions. The IRB did not allow us to collect
demographic or disease-related data about
nonparticipants; thus, we do not know if those
patients had more severe pain or advanced
disease than persons who agreed to partici-
pate. It is unfortunate that those who were
skeptical and uninterested did not participate,
as their cognitive ability, outcome expectancy,
and previous experience scores may have
added greater variability to the results ob-
tained. Investigators must consider methods
to make research participation more desirable
and meaningful for these individuals.
Almost one-quarter of those who agreed to
participate were unable to complete all study
procedures, dropping out or missing a trial.
Persons who did not complete included
more males and were older than persons who
did complete all trials. Previous research has
shown greater interest in complementary ther-
apies among women with cancer than among
men.49 And older patients may have less en-
ergy and endurance for the study procedures.
Our results should be interpreted in light of
limitations. Tests related to individual differ-
ence variables were limited to simple
613
comparisons between responders and nonre-
sponders. We had hoped to recruit a larger
sample that would have allowed us to use mul-
tiple regression to simultaneously explore the
roles of proposed individual difference vari-
ables while controlling for potential covariates,
such as gender and education. Although hav-
ing a control condition was a strength, the con-
trol was run as the first trial of each day to
prevent carryover from the active interven-
tions, and the timing may have introduced
some bias. It is possible that the cognitive-be-
havioral interventions may not have been as ef-
fective if administered without the earlier
control session. It will also be important in fu-
ture research to compare the experimental
treatments with the more realistic control con-
dition of ‘‘treatment as usual,’’ as patients may
independently use other strategies that are
equally effective in controlling pain. Finally, it
was not possible to blind participants to the in-
tervention conditions, and some individuals
may have provided the responses they thought
were expected of them.
Results of this study suggest that PMR and
analgesic imagery interventions may be benefi-
cial in treating acute or episodic pain for some
patients. This pilot study, however, revealed
a number of methodologic issues that need
to be considered in future studies exploring in-
dividual difference variables. Given the diffi-
culty recruiting participants and the frequent
inability of participants to complete all study
procedures, it may be easier to study the indi-
vidual differences in a less ill patient popula-
tion. This might allow inclusion of more
practice sessions and also additional measures
such as physiologic measures of relaxation abil-
ity and relaxation achieved with each interven-
tion. Ability to recruit a larger sample would
also allow randomization to groups that vary
the order of both treatment and control
conditions.
Given the variability we observed in partici-
pants’ responses to each strategy, researchers
need to continue efforts to understand individ-
ual difference variables that moderate effects
of cognitive-behavioral strategies. Studies that
simply compare group means, ignoring indi-
vidual responses and potential moderating
variables, will be plagued by underestimating
actual effects or even failure to demonstrate
significant effects when the interventions
614 Kwekkeboom et al.
were, in fact, helpful to a particular subsample.
Researchers and clinicians alike need to un-
derstand individual difference variables that
moderate effects of cognitive-behavioral strate-
gies if we are to adequately test their efficacy
and identify appropriate treatments for pa-
tients with cancer pain.
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