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 Table of Contents  
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 166-168

Effect of guided imagery as an adjunct to pulmonary rehabilitation on anxiety, quality of life, and quality of sleep in a post COVID-19 patient via telerehabilitation

Department of Musculoskeletal Physiotherapy, KJ Somaiya College of Physiotherapy, Sion, Mumbai, Maharashtra, India

Date of Submission11-Mar-2021
Date of Acceptance10-Jul-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Priyanka Jayesh Shah
KJ Somaiya College of Physiotherapy, Sion, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmhhb.jmhhb_57_21

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The COVID-19 outbreak caused by the novel severe acute respiratory syndrome coronavirus 2 was declared as a global pandemic by the World Health Organization. Patients infected with the disease have to be kept in social isolation in order to limit the spread of infection. This in turn led to anxiety and fear among the general public post isolation related to spread of infection. Furthermore, it was observed that many of them suffered from disturbed sleep which in turn affected the quality of life (QOL) of the patients post COVID-19 infection. The following case report concluded of a positive effect of guided imagery (GI) as an adjunct to pulmonary rehabilitation on anxiety, QOL, and quality of sleep in a post COVID-19 patient via telerehabilitation.

Keywords: Anxiety, guided imagery and pulmonary rehabilitation, quality of life

How to cite this article:
Shah PJ, Ghodge SV. Effect of guided imagery as an adjunct to pulmonary rehabilitation on anxiety, quality of life, and quality of sleep in a post COVID-19 patient via telerehabilitation. J Mental Health Hum Behav 2021;26:166-8

How to cite this URL:
Shah PJ, Ghodge SV. Effect of guided imagery as an adjunct to pulmonary rehabilitation on anxiety, quality of life, and quality of sleep in a post COVID-19 patient via telerehabilitation. J Mental Health Hum Behav [serial online] 2021 [cited 2023 Jun 2];26:166-8. Available from: https://www.jmhhb.org/text.asp?2021/26/2/166/337173

  Introduction Top

COVID-19 pandemic hampered the physical, emotional, and psychological health of the individuals.[1] Due to high contamination rate, patients were kept in isolation, and also, it was observed that patients suffered severe mental distress even after rehabilitation and discharge leading to anxiety- and sleep-related disorders.[2],[3] Due to sudden challenges faced by health-care providers, globally new and innovative methods were deduced for pulmonary rehabilitation (PR) via telemedium. Guided imagery (GI), however, is a novel technique used via telerehabilitation and is effective in improving anxiety and quality of sleep and life post any stressful event. Furthermore, as per studies, it was observed that there were anxiety and reduced quality of life (QOL) and work performance even after rehabilitation.[4] Hence, GI was given as an adjunct to PR via telemedium.

  Case Report Top

A 52 year old male with a prior consent taken and no presenting illness presenting with chief complaints of fever, dry cough, fatigue, and breathlessness on exertion was admitted to a quarantine center after testing positive for COVID-19 on July 24, 2020. He was then shifted to a COVID-dedicated tertiary care hospital in Mumbai. There he had a stay of 10 days and later contracted viral pneumonia. Later, he was shifted to another tertiary care setup. He required an intensive care unit stay of 10 days there and was then shifted to wards and was there for another 8 days and later was discharged on August 20, 2020, on 2 L O2 via nasal prongs. The post discharge chest X-ray revealed ground-glass opacity (patchy consolidation) in both middle and lower zones of the lungs. Due to such a long stay in hospital and isolation, he developed symptoms such as nervousness, fear of something worse happening, and unable to relax completely which affected his sleep and QOL. He was referred to physiotherapy for PR. GI was given as an adjunct to PR for a period of 3 weeks after assessing for anxiety, QOL, and sleep via a telerehabilitation program by a physiotherapist.


Pre and post treatment assessments were done using the Beck Anxiety Inventory for anxiety, Short Form-36 Health Survey for quality of life, and Pittsburgh Sleep Quality Index (PSQI) for quality of sleep, and muscle strength was assessed using single hold breath test, 1-min sit-to-stand test, 1-min squat test, and 1-min repetition maximum with dominant hand. The sessions were conducted via a video call through mobile phone. It started with PR and ended with GI via telerehabilitation. Pulmonary Rehabilitation sessions started with warmup which was followed by strengthening program for upper and lower limbs (starting with half kg and gradually progressing to 2 kgs), aerobic program (including sit to stand,modifed jumping jacks, modified cross jacks etc), spirometer, positioning techniques and ended with breathing exercises. Initially, the exercises were of low intensity and 10–15 reps of each exercise were given and the patient was constantly monitored using pulse oximeter and modified Borg's Rating of Perceived Exertion (RPE) scale. The exercises progressed gradually in the frequency and intensity in the coming weeks. Initially, the patient was on 2 L of O2, and with exercise progression and maintenance of saturation, he was shifted to 1 L O2. GI was given in the form of a 20-min audio prepared in Hindi language. The subject was asked to lie down comfortably in supine position in a room with quiet environment. Before the audio, instructions were given to completely relax the body, with no body movements, and follow the instructions as per the audio. It included imagination of a village scene and the subject was asked to experience as if he is in that scene and make the use of all his senses in order to visualize the scene. The progress for PR and pre and post treatment observations are given in [Table 1] and [Table 2].
Table 1: Pre and post intervention scores of Beck Anxiety Inventory, Pittsburgh Sleep Quality Index, and Short Form-36

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Table 2: Physiotherapy protocol including pulmonary rehabilitation and guided imagery

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The results of our study showed that GI along with PR led to significant change in both physical and mental health. There were reduced anxiety and improved quality of sleep and life, pulmonary functions, and strength of muscles post 3 weeks of protocol.

  Discussion Top

The global outbreak of COVID-19 led to significant fear and anxiety related to spread of infection in general public. Studies showed that excessive fear and apprehension about the spread of infection resulted in acute stress, anxiety, and low quality of sleep. It has been studied that there is a relationship between physical illness and mental health and poor mental health can exert a negative effect on an individual's QOL.[5] The above case presents a post COVID-19 patient who developed symptoms of anxiety which affected his quality of sleep and life for which GI was given along with PR. The results of our study are consistent with a study of Nguyen and Brymer which showed that a 2-week nature-based GI intervention was effective in reducing anxiety.[6] GI induces relaxation by regulating respiratory rhythm and refocusing the person's attention from environmental and personal stress to imagined stimuli. It also influences both the systems by improving the motor control skills of the subjects resulting in shift of autonomic nervous system function toward increased parasympathetic nervous system and reduced sympathetic nervous system activity.[7] Lee et al. found the effectiveness of GI on stress reduction in patients with thyroid cancer in 3 weeks with further reduction in the 4th week.[8] Another study showed that 30-min GI performed once daily for 1 week was effective in reducing test anxiety among nursing students.[9] It was also observed that GI had positive effect on improving the quality of sleep.[10] Studies have shown that GI is effective immediately as well as in short and long terms both.[11],[12],[13] PR helps in improving exercise capacity, muscle strength, and health-related QOL leading to improvement in physical and mental health.[14] The patient's oxygen level reduced gradually, and there was improvement in oxygen saturation and RPE score. The post HRCT chest showed improvement with bilateral diffuse subpleural and peri broncho-vesicular interstitial thickening without any areas of honeycombing. An overall improvement in physical and mental health was seen in the post COVID patient after GI and PR. It was also observed that higher exercise frequencies were associated with better mood states.[15] Screening of anxiety and depression symptoms should be done post COVID, and GI along with exercises can be given with other medications to patients diagnosed with COVID during the quarantine period and post isolation for improving physical and mental health. The study can be conducted on a larger population for observing the effects.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit 2020;26:e923549.  Back to cited text no. 1
Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complement Ther Clin Pract 2020;39:101132.  Back to cited text no. 2
Rosen K, Patel M, Lawrence C, Mooney B. Delivering telerehabilitation to COVID-19 inpatients: A retrospective chart review suggests it is a viable option. HSS J 2020;16 Suppl 1:1-7.  Back to cited text no. 3
Bo HX, Li W, Yang Y, Wang Y, Zhang Q, Cheung T, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychol Med 2021;51:1052-3.  Back to cited text no. 4
Patra RC, Kanungo B, Bawa P. Mental health, sleep quality and quality of life in individuals with and without multiple health conditions during home quarantine in India due to the COVID-19 pandemic: A cross-sectional study [version 1; peer review: 1 approved, 1 not approved]. F1000Research 2020;9:718.  Back to cited text no. 5
Nguyen J, Brymer E. Nature-based guided imagery as an intervention for state anxiety. Front Psychol 2018;9:1858.  Back to cited text no. 6
Yijing Z, Xiaoping D, Fang L, Xiaolu J, Bin W. The effects of guided imagery on heart rate variability in simulated spaceflight emergency tasks performers. Biomed Res Int 2015;2015:687020.  Back to cited text no. 7
Lee MH, Kim DH, Yu HS. The effect of guided imagery on stress and fatigue in patients with thyroid cancer undergoing radioactive iodine therapy. Evid Based Complement Alternat Med 2013;2013:130324.  Back to cited text no. 8
Maghaminejad F, Adib-Hajbaghery M, Nematian F, Armaki MA. The effects of guided imagery on test anxiety among the 1st-year nursing students: A randomized clinical trial. Nurs Midwifery Stud 2020;9:130-4.  Back to cited text no. 9
  [Full text]  
Neuendorf R, Wahbeh H, Chamine I, Yu J, Hutchison K, Oken BS. The effects of mind-body interventions on sleep quality: A systematic review. Evid Based Complement Alternat Med 2015;2015:902708.  Back to cited text no. 10
Felix MM, Ferreira MB, Oliveira LF, Barichello E, Pires PD, Barbosa MH. Guided imagery relaxation therapy on preoperative anxiety: A randomized clinical trial. Rev Lat Am Enfermagem 2018;26:e3101.  Back to cited text no. 11
Álvarez-García C, Yaban ZŞ. The effects of preoperative guided imagery interventions on preoperative anxiety and postoperative pain: A meta-analysis. Complement Clin Pract 2020;38:101077.  Back to cited text no. 12
Beizaee Y, Rejeh N, Heravi-Karimooi M, Tadrisi SD, Griffiths P, Vaismoradi M. The effect of guided imagery on anxiety, depression and vital signs in patients on hemodialysis. Complement Ther Clin Pract 2018;33:184-90.  Back to cited text no. 13
Grigoletto I, Cavalheri V, Lima FF, Ramos EM. Recovery after COVID-19: The potential role of pulmonary rehabilitation. Braz J Phys Ther 2020;24:463-4.  Back to cited text no. 14
Chang YK, Hung CL, Timme S, Nosrat S, Chu CH. Exercise behavior and mood during the COVID-19 pandemic in Taiwan: Lessons for the future. Int J Environ Res Public Health 2020;17:E7092.  Back to cited text no. 15


  [Table 1], [Table 2]


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