Review title

The effectiveness of interventions to reduce fear, anxiety and claustrophobia

of patients undergoing imaging with high technology modalities: a systematic
review
Reviewers
Zachary Munn BMedRad, GradDip HlthSc1
Zoe Jordan BA (Flin), MA(UniSA), PhD 1
1

Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide, South
Australia 5005

Review objective
The primary objective of this review is to identify the effectiveness of interventions aiming to
improve the patient experience of high technology imaging, by reducing fear, anxiety,
claustrophobia and any other negative emotions that may arise during the scanning process.
Additionally, the effectiveness of interventions which result in improved patient satisfaction of high
technology imaging will also be addressed. By addressing these issues, secondary outcomes, such as
throughput, sedation rates, and radiographer satisfaction, may also be affected, and thus will also be
included in the review.

Background
In modern healthcare, medical imaging plays an irreplaceable role in the patients journey through
illness and disease.1 For many conditions and ailments, medical imaging, whether it is a simple
chest X-ray or a complex scan, plays an essential role in the diagnosis, therapeutic management and
surveillance of illness. Diagnostic imaging may refer to a range of medical procedures, including
radiographic and nuclear medicine procedures, Magnetic Resonance Imaging (MRI), Computed
Tomography (CT), Positron Emission Tomography (PET), Ultrasound (US) and Single Photon Emission
Computed Tomography (SPECT), along with many other imaging investigations. CT produces cross
sectional images via the use of x-rays and computer processing.2 PET and SPECT are nuclear
medicine procedures where radioactive tracers are used to produce an image, and the machines
themselves detect the radiation given off from the radioactive tracer, rather than create it3. MRI
uses a combination of magnetic fields and radio signals to produce images, and does not use ionising
radiation as required by CT, PET, X-rays and SPECT.2
Medical imaging is an ever changing field, and there have been significant advancements in imaging
techniques and technologies over the years2. The amount of imaging and the subsequent costs
associated with it have been rising rapidly in many parts of the world for the last 30 years, 4, 5 leading
to a larger percentage of people being exposed to these different imaging modalities.6

Advanced, high technology imaging in particular, such as CT, MRI, PET and SPECT, have seen
significant increases in their use.4 However, these improvements in imaging technology do not
necessarily guarantee a similar advance in patient care.7 Due to this, the patient and patient care
may often be ignored or overlooked, as the focus of the imaging technician is directed largely
towards the technology and not the patient.8 All the different modalities used in the imaging process
are highly technical in nature, and imaging technicians deal with sophisticated equipment every day.
Healthcare professionals involved in patient care may unwittingly objectify patients, and not
necessarily see them as people in pain or distress, but as problems needing solving.9 This can be
seen in medical imaging as well, as Rhodes (1999)10 highlighted when quoting Coulehan, (1985, p.
371)11, patients can be seen as a translucent screen through which we peer to find a diagnostic
entity within. In no setting is this statement more fitting than within a medical imaging department.
There are studies that provide information on the patient experience in diagnostic imaging, reported
in both quantitative and qualitative methodologies, as well as in articles based on expert opinion.1
It has been shown in a plethora of studies that anxiety and claustrophobia are issues that may arise
during the imaging process, and patients who are to undergo diagnostic imaging procedures may
experience a wide range of emotions.1 In a survey of radiographers, 71.6% of respondents stated
that anxiety was a common issue in their imaging department when patients presented for MRI.12
High levels of anxiety or claustrophobia regarding imaging may lead to increased movement13,
resulting in motion artefacts decreasing the value of the resultant images. 14, 15 In extreme cases,
scans may need to be aborted or patients may refuse to have the scan, sedation may need to be
used, or additional sequences performed.16 These missed or increasingly difficult scans have financial
implications as valuable staff and equipment time is lost.16, 17
To improve the scan experience, and reduce feelings of anxiety, claustrophobia and fear prior to
scanning, a number of interventions have been tested. These interventions vary significantly in
terms of their ease of implementation, and burden on staff time and costs.18 These include
information/education, different positions, manipulation of the environment, prism glasses, lighting
levels, movement of air/fans, company, panic buttons, music, open design of MRI, psychological
preparation, hypnosis, aromatherapy, sedation, and screening of patients for claustrophobia, 18 or a
combination of different methods in an anxiety reduction protocol.13 There is some evidence
showing that claustrophobia is reduced in newer MRI machines with a more patient friendly design,
although it is not eliminated entirely.16 One cross-sectional survey found that although many MRI
departments implement strategies to reduce anxiety during scanning, including information,
pre-scan visits, and music, high levels of anxiety still prevail.12 A search of Medline, Cochrane the JBI
Library of Systematic Reviews did not reveal any recent systematic reviews on this topic. It is
therefore the aim of this review to determine the strategies that are effective in reducing fear,
anxiety and claustrophobia in persons undergoing imaging with high technology.

Inclusion criteria
Types of participants

This review will consider studies that include patients of any age who have undergone high
technology imaging in a medical imaging department. The participants may be receiving imaging for
a wide range of indications, and may have any pre-existing condition or disability. For the purposes
of this review, MRI, CT, PET and SPECT will be considered to be high technology medical imaging, 1, 4,
6, 19
and will be searched for specifically. Advanced, high technology imaging procedures are
increasingly prevalent and there is rapid growth in these imaging modalities.6 These scans are more
complex than other basic procedures, and can be more difficult to operate, which may have an
effect on the holistic care of the patient, as it distances the imaging technologist from the patient.1, 20
All diagnostic imaging procedures considered for this review are non-invasive or minimally invasive.
Interventional diagnostic procedures were not included.

Types of interventions

This review will consider studies that evaluate interventions designed to reduce fear, anxiety, or
feelings of claustrophobia during scanning compared to usual care. The review will also consider
interventions that aim to improve the satisfaction of persons undergoing imaging. These may include
a number of interventions delivered individually or in combination, including but not limited to
information/education, different positions, manipulation of the environment, prism glasses, lighting
levels, movement of air/fans, company, panic buttons, music, open design of MRI, psychological
preparation, hypnosis, aromatherapy, sedation, and screening of patients for claustrophobia. These
interventions may result in changes of secondary outcomes such as throughput, sedation rates, and
radiographer satisfaction, which may be affected and reported, and thus will also be included in the
review.
Types of outcomes

This review will consider studies that include measurement of the outcomes through reporting using
scales, validated tools, or other means.
Primary outcomes:

Patient anxiety
Patient fear
Patient claustrophobia
Patient satisfaction

Secondary outcome measures include:

Sedation rates
Patient throughput
Radiographer satisfaction

Types of studies

This review will consider both experimental and epidemiological study designs including randomised
controlled trials and non-randomised controlled trials. In the absence of these trials, other study
designs, such as quasi-experimental, before and after studies, prospective and retrospective cohort
studies, case control studies and analytical cross sectional studies will be considered for inclusion. If
there is a significant lack of analytical literature on this topic, than this review will also consider
descriptive epidemiological study designs including case series, individual case reports and
descriptive cross sectional studies for inclusion.

Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search
strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be
undertaken followed by analysis of the text words contained in the title and abstract, and of the
index terms used to describe article. A second search using all identified keywords and index terms
will then be undertaken across all included databases. Thirdly, the reference list of all identified
reports and articles will be searched for additional studies. Studies published in English will be
considered for inclusion in this review, and there will be no time limit imposed on the review.
The databases to be searched include:

CINHAL
Ingenta Connect
Embase
Medline
PsychINFO
Sociological Abstracts
Web of Science
SCOPUS
The Cochrane Library (including CENTRAL)

The search for unpublished studies will include:

Mednar (including Google Scholar)
Intute
Current Contents
Digital dissertations

Initial keywords to be used will be:

Magnetic resonance imaging, positron emission tomography, Computed tomography, Nuclear
Medicine, fear, anxiety, claustrophobia
A detailed search strategy is presented in Appendix I.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological
validity prior to inclusion in the review using standardised critical appraisal instruments from the
Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI)
(Appendix II). Any disagreements that arise between the reviewers will be resolved through
discussion, or with a third reviewer.

Data collection
Data will be extracted from papers included in the review using the standardised data extraction tool
from JBI-MAStARI (Appendix III). The data extracted will include specific details about the
interventions, populations, study methods and outcomes of significance to the review question and
specific objectives.

Data synthesis
Quantitative data will, where possible be pooled in statistical meta-analysis using JBI-MAStARI. All
results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data)
and weighted mean differences (for continuous data) and their 95% confidence intervals will be
calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and
also explored using subgroup analyses based on the different study designs included in this review.
Where statistical pooling is not possible the findings will be presented in narrative form including
tables and figures to aid in data presentation where appropriate.

Conflicts of interest
None noted.

Acknowledgements
This systematic review is to be conducted during enrolment in postgraduate studies. The author would
like to thank Professor Alan Pearson AM, Dr Zoe Jordan and Dr Frederick Murphy for their assistance
and feedback during the development of this protocol.

References
1
Munn Z, Jordan Z. The patient experience of high technology medical imaging: a systematic
review of the qualitative evidence. JBI Library of Systematic Reviews. 2011;9(19):631-78.
2
Kevles BH. Naked to the bone: medical Imaging in the twentieth century. Perseus Books
1998.
3
Berneir D, Christian P, Langan J. Nuclear Medicine: Technology and Techniques. 4th ed. St
Louis, Missouri: Mosby 1997.
4
Mitchell JM, LaGalia RR. Controlling the escalating use of advanced imaging: the role of
radiology benefit management programs. Medical Care Research and Review. 2009;66(3):339-51.
5
Hofmann B, Lysdahl KB. Moral principles and medical practice: the role of patient autonomy
in the extensive use of radiological services. Journal of Medical Ethics. 2006;34:446-9.
6
Iglehart JK. The new era of medical imaging progress and pitfalls. The New England Journal
of Medicine. 2006;354(26):2822-8.
7
Crowe J. Radiology: Icon of medicine, avatar of change. American Journal of Roentgenology.
2008;191:1627-30.
8
Adams J, Smith T. Qualitative methods in radiography research: a proposed framework.
Radiography. 2003;9:193-9.
9
Gadow S. Body and self: a dialectic. In: Kestenbaum V, ed. The Humanity of the Ill:
Phenomenological Perspectives. Knoxville: University of Tennessee Press 1982.
10
Rhodes L, McPhillips-Tangum C, Markham C, Klenk. The power of the visible: the meaning of
diagnostic tests in chronic back pain. Social Science and Medicine. 1999;48:1189-203.
11
Coulehan J. Adjustment, the hands and healing. Culture, Medicine and Psychiatry.
1985;9:353-82.
12
Tischler V, Calton T, Williams M, Cheetham A. Patient anxiety in magnetic resonance imaging
centres: is further intervention needed? Radiography. 2008;14(3):265-6.
13
Grey S, Price G, Matthews A. Reduction of anxiety during MR imaging: a controlled trial.
Magnetic Resonance Imaging. 2000;18:351-5.
14
Murphy K, Brunberg J. Adult claustrophobia, anxiety and sedation. . Magnetic Resonance
Imaging. 1997;15:51-4.
15
Harris L, Cumming S, Menzies R. Predictign anxiety in magnetic resonance imaging scans.
International Journal of Behavioural Medicine. 2004;11(1):1-7.
16
Dewey M, Schink T, Dewey CF. Claustrophobia during magnetic resonance imaging: cohort
study in over 55,000 patients. Journal of Magnetic Resonance Imaging. 2007;26(1322-1327).
17
Melendez
J,
McCrank
E.
Anxiety-related
reactions
associated
with
magnetic-resonance-imaging examinations. Journal of the American Medical Association.
1993;270(6):745-7.
18
Phillips S, Deary I. Interventions to alleviate patient anxiety during magnetic resonance
imaging: a review. Radiography. 1995;1:29-34.
19
Murphy FJ. Understanding the humanistic interaction with medical imaging technology.
Radiography. 2001;7:193-201.
20
Adler AMK. High technology: Miracle or malady for patient care. . Radiologic Technology.
1990;61 (6), 478-481.

Appendix I Detailed Search Strategy

The identifiers will be combined with the outcomes and design with and.
Identifiers (combine with or)
Magnetic Resonance Imaging
Nuclear Magnetic Resonance Imaging
Functional Magnetic Resonance Imaging
Magnetic Resonance Tomography
Radionuclide imaging
Radionuclide
Nuclear medicine
Molecular Imaging
Computerised Tomography
Computerized Tomography
Computed Tomography
Tomography
Molecular imaging
Single Photon Emission Computed Tomography
Positron Emission tomography
PET
Computed Axial Tomography
CT
CAT scan
MRI
SPECT
Outcome (combine with or)
Fear
Anxiety
Claustrophobia
anxious
claustrophobic
sedation
Satisfaction
Panic
throughput
Scared
scary
Design (combine with or)
Randomised controlled trial
RCT
Randomized controlled trial
Controlled trial
Clinical controlled trial
Trial
Case control study

Cohort study
Experiment
Case series
Case study
Cross-sectional studies
Survey
Questionnaire

Appendix II Critical Appraisal instruments

MAStARI Appraisal instrument

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this is a test message

Appendix III - Data extraction instruments

MAStARI data extraction instrument

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