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doi:10.1111/1744-1609.12045

EVIDENCE

Int J Evid Based Healthc 2013; 11: 265–274

SYNTHESIS

Interventions to reduce anxiety, distress and the need for sedation in adult patients undergoing magnetic resonance imaging: a systematic review Zachary Munn PhD and Zoe Jordan PhD The Joanna Briggs Institute, The University of Adelaide, Adelaide, South Australia, Australia

Abstract Purpose Adults undergoing MRI scans can experience anxiety, claustrophobia and fear during the scanning experience and, in some cases, require sedation. The aim of this systematic review was to determine what strategies are effective in reducing fear, anxiety and claustrophobia, and the need for sedation in adults undergoing MRI.

Methods A quantitative systematic review, according to the methodology of the Joanna Briggs Institute, was carried out. A systematic search of a number of databases was performed. Studies were then screened and critically appraised by two independent reviewers before being included in the review.

Results In total, 21 studies met the inclusion criteria for the review, which assessed the following interventions: MRI design features, cognitive–behavioural strategies, prone positioning, information, fragrance administration and team training. All of these had some positive impact on outcomes. Conclusion Healthcare professionals working with adults undergoing MRI may consider some of the strategies included in this review to implement in their practice to reduce anxiety and increase patient comfort while reducing the need for sedation.

Key words: anxiety, magnetic resonance imaging, sedation, systematic review.

Introduction Magnetic resonance imaging (MRI) is an important and increasingly prevalent imaging modality used in healthcare today.1,2 Although hospital staff may view radiological procedures, such as MRI, as routine, patients can find them frightening and confronting. It has been previously shown that patients may experience a wide range of emotions during scanning, ranging from slight nervousness to fear, anxiety and an uncontrollable need to escape.3,4 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.5 High levels of anxiety or claustrophobia regarding imaging may lead to increased movement,6 resulting in motion artefacts and thereby decreasing the value of the resultant images.7,8 In extreme cases, additional sequences may need to be performed, sedation may need to be used, scans may need to be aborted or patients Correspondence: Mr Zachary Munn, The Joanna Briggs Institute, The University of Adelaide, Level 1, 115 Grenfell Street, Adelaide, SA 5005, Australia. Email: [email protected]

may simply refuse to have the scan.9 These missed or increasingly difficult scans have financial implications as valuable staff and equipment time is lost.9,10 There have been many advances in the design of the scanners, particularly MRI scanners, as manufacturers have become aware of the increased costs of claustrophobia and anxiety-related events. Over recent years, MRI designs have become friendlier, with the introduction of shorter bores, open MRI machines and reduced noise.11 However, these technological advancements have not led to a complete reduction of claustrophobic reactions,9,12 and head examinations in particular may still seem daunting for claustrophobic patients, even in more patient-friendly designs.12 To improve the scan experience and reduce feelings of anxiety, claustrophobia and fear prior to scanning, a number of interventions have been developed. These interventions vary significantly in terms of their ease of implementation and the burden they place on staff time and costs.13 Some of these include information/education, different patient positions, manipulation of the environment, prism glasses, lighting levels, movement of air/fans, company, installation of

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panic buttons, music, open MRI design, psychological preparation, hypnosis, aromatherapy, sedation, mock MRI, patient positioning devices and screening of patients for claustrophobia, or a combination of different methods in an anxiety reduction protocol.2,6,14–16 One cross-sectional survey found that despite many MRI departments implementing strategies to reduce anxiety during scanning, high levels of anxiety still prevail.5 A search of MEDLINE, the Joanna Briggs Institute Library of Systematic Reviews and the Cochrane Library of Systematic Reviews did not identify any systematic reviews on this topic. Systematic reviews are more appropriate than standard literature reviews, as they provide a comprehensive and unbiased summary of literature in one area, and include critical appraisal and methods to synthesise data from individual studies.17 Therefore, it was the objective of this review to identify the effectiveness of interventions aiming to reduce anxiety, distress and the need for sedation in adult populations undergoing magnetic resonance imaging.

Methods A systematic review was conducted according to the methods of the Joanna Briggs Institute, a not-for-profit research institute committed to the translation of evidence into practice.18–22 Prior to conducting the review, a protocol was developed, submitted to the institute and approved. Types of participants This review considered studies that included adults (aged 18 years and over) with any pre-existing condition or disability, undergoing MRI for a wide range of indications. A separate review has been published that considers patients under the age of 18.23 MRI procedures are more complex than other basic procedures (such as X-rays) and can be more difficult to operate, which may have an effect on the holistic care of the patient, as it distances healthcare staff from the patient.4,24 All diagnostic imaging procedures considered for this review were non-invasive or minimally invasive. Types of interventions This review considered studies that evaluated interventions designed to reduce fear, anxiety, or feelings of claustrophobia during scanning, compared with usual care. The review also considered interventions that aimed to improve the satisfaction of persons undergoing imaging. This included a number of interventions delivered individually or in combination. These interventions also may have resulted in changes to outcomes such as throughput, sedation rates, comfort and completion rates, and were also included in the review. Types of studies This review considered 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 and case–control studies were considered for inclusion. Critical appraisal and synthesis Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments. Any disagreements that arose between the reviewers were resolved through discussion, and there was no need for a third reviewer. Data were, where possible, pooled in statistical meta-analysis. Search strategy The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilised in this review during the period of August to October 2011. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the retrieved titles and abstracts and of the index terms used to describe articles. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles were searched for additional studies. Only studies published in English were considered for inclusion in this review, and there was no time limit imposed on the review. The databases searched included CINAHL, Ingenta Connect, Embase, MEDLINE, PsychINFO, Sociological Abstracts, Web of Science, SCOPUS and The Cochrane Library (including CENTRAL).The search for unpublished studies included Mednar, Intute, Google Scholar, Current Contents and Digital Dissertations.

Results Description of studies Twenty-six studies found through the search process were critically appraised by two independent reviewers to assess their methodological quality prior to including or excluding them from this review. No disagreements regarding the critical appraisal process occurred, and both reviewers agreed that five of these studies25–29 were not of satisfactory methodological quality and were therefore excluded (Fig. 1). The reason these studies were not included was the lack of a control or comparison group.25–29 Of the final 21 studies, there were 14 randomised or pseudorandomised controlled trials and controlled cross-over trials, and 7 studies of varying designs with a comparison group. The trials were assessed with the Joanna Briggs Institute MetaAnalysis of Statistics Assessment and Review Instrument (JBI-MAStARI) critical appraisal checklist for randomised controlled trials, while the remaining studies were assessed with the JBI-MAStARI critical appraisal checklist for comparable cohort/case–control studies. The JBI-MAStARI critical appraisal checklist for randomised controlled trials includes the following criteria: 1 Was the assignment to treatment groups truly random? 2 Were participants blinded to treatment allocation?

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7 Were the outcomes of people who withdrew described and included in the analysis? 8 Were outcomes measured in a reliable way? 9 Was appropriate statistical analysis used? Overall, the methodological quality of the randomised controlled trials was high, although for questions 2, 3, 4 and 5 of the quality appraisal checklist (details on allocation blinding, allocation concealment and outcomes of withdrawals from the study) there was no or little compliance (Table 1). For question 2 this is understandable, as it is difficult to blind the patient to the interventions received, and only one study met this criterion; it assessed fragrance delivered via nasal cannula, with one group receiving a fragrance and the other humidified air only.38 In question 5, outcomes were deemed to have been measured with objective criteria if they were not self-reported or able to be influenced by the researcher. As many studies used the Spielberger State-Trait Anxiety Inventory (STAI) or other scales to measure anxiety, these were deemed to be subjective, as they are self-reported. However, it can be argued here that objective measurements of anxiety are not necessarily required, as it is the patient’s subjective anxiety that will impact their ability to tolerate the scanning process. The other studies were all of quite high methodological quality for their design (Table 2). The studies included assessed MRI design features, cognitive–behavioural strategies,

3 Was allocation to treatment groups concealed from the allocator? 4 Were the outcomes of people who withdrew described and included in the analysis? 5 Were those assessing outcomes blind to the treatment allocation? 6 Were the control and treatment groups comparable at entry? 7 Were groups treated identically other than for the named interventions? 8 Were outcomes measured in the same way for all groups? 9 Were outcomes measured in a reliable way? 10 Was appropriate statistical analysis used? The JBI-MAStARI critical appraisal checklist for comparable cohort/case-control studies includes the following criteria: 1 Is sample representative of patients in the population as a whole? 2 Are the patients at a similar point in the course of their condition/illness? 3 Has bias been minimised in relation to selection of cases and of controls? 4 Are confounding factors identified and strategies to deal with them stated? 5 Are outcomes assessed using objective criteria? 6 Was follow-up carried out over a sufficient time period?

Table 1 Results of critical appraisal of included randomised and pseudorandomised controlled trials Reference 30

Argue 1995 Caruso et al. 200631 Grey et al. 200032 Lukins et al. 199733 McCauley et al. 199234 Michel et al. 200235 O’Halloran 199336 Quirk et al. 198937 Redd et al. 199438 Selim 200139 Thompson et al. 199440 Tornqvist et al. 200641 Verhoek et al. 199842 Youssefzadeh et al. 199743

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Y Y Y Y Y N Y Y Y Y Y N N Y

N N N N N N N N Y N N N N N

U U N U U N N N U U N U N U

N N/A N N Y N/A U N N U N N N N/A

N N N U U N N U U N Y N N U

Y Y Y Y Y Y Y Y Y Y N Y Y U

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y Y Y Y Y Y

N, no; N/A, not applicable; U, unclear; Y, yes.

Table 2 Results of critical appraisal of comparable cohort/case–control studies Reference Bangard et al. 200744 Dewey et al. 20079 Eshed et al. 200745 Hunt et al. 201112 Lang et al. 201046 McNulty and McNulty 200947 Spouse and Gedroyc 200048

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Y Y Y Y Y Y Y

Y Y Y Y Y Y Y

Y Y N N/A Y U Y

N Y N N N Y N

Y Y Y Y Y N N

Y Y Y Y Y Y Y

Y N/A Y N/A N/A N/A N/A

Y Y Y Y Y Y N

Y Y Y Y Y Y Y

N, no; N/A, not applicable; U, unclear; Y, yes.

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prone positioning, information, fragrance administration and team training (Table 3). Figure 1 shows a summary of the studies by type of intervention. Data have been synthesised where possible.

Design features Open MRI Three studies specifically looked at the impact of having an open MRI in terms of claustrophobic events, anxiety and acceptability. Due to heterogeneity in populations and the outcome measured, no meta-analysis could be performed. In the three studies assessing open35,44 or interventionally48 configured MRI scanners, all studies showed evidence of benefit. Completion rates were increased, claustrophobia decreased and overall satisfaction improved. However, these studies were performed in specific populations (women undergoing pelvimetry and already known claustrophobic patients), and it is unclear how these findings may carry over to the general population. MRI with shorter/wider bore Two9,12 studies specifically looked at the impact of having a newer MRI unit with a shorter, wider bore in terms of the number of claustrophobic events, the need for patient sedation and the number of successful scan completions. Due to the heterogeneity in populations (as one study specifically focused on claustrophobic patients) and variability of outcomes measured, meta-analysis was not appropriate. In the two studies9,12 assessing shorter- and wider-bore MRI scanners, both showed evidence of benefit. Completion rates increased, sedation rates decreased and claustrophobic reactions decreased. The large study by Dewey et al.9 showed that this held true across the general population, and not only in claustrophobic patients, as shown in the study by Hunt et al.12 Dedicated low-field MR scanner Verhoek et al.42 found that whole-body systems are preferred by patients and produce better images.

Due to the similarity in the intervention and population studied, a meta-analysis was conducted between two studies, despite the differences in study design.39,41 As there was statistically significant statistical heterogeneity when using a fixed-effects model (χ2 = 33.44, P = 0.0), a randomeffects model was used. As one of the studies41 only reported standard errors, standard deviations were calculated to allow meta-analysis to be conducted. This was done following the guidance of the Cochrane handbook.49 Only a subgroup of patients from Tornqvist et al.41 who had not had an MRI previously was included, even though there were data for those who had, as Selim39 only included those who had not had an MRI previously (Fig. 2). As can be seen from the forest plot, there is statistically significant heterogeneity between the included studies (χ2 = 33.44, P = 0.0). There was no statistically significant effect when the studies were combined (weighted mean difference = −8.6, confidence interval −25.82 to 8.62), and there was a wide variance in the magnitude of the effect size between the upper and lower confidence intervals. This may be due to the population and settings of the studies, as well as differences in the actual intervention compared with standard or routine care. Another contributing reason may be the fact that Tornqvist41 only scanned heads/spines, while Selim39 did not disclose the scan type. Also, one of these studies was a randomised controlled trial,39 while the other did not use randomisation.41 In summary, in the five studies assessing information with or without additional strategies, the results were somewhat mixed. In the studies that assessed provision of additional information along with a psychological intervention31 or an anxiety reduction protocol,32 there were positive results. In studies assessing additional information alone, two found positive benefits in terms of anxiety39,43 while one did not.41 This may be due to a wide range of reasons, including how the information was delivered, what the other aspects of the intervention included, and the standard of care given in the control or routine group.

Quieter machine McNulty and McNulty47 found that patients were much more accepting of a system with improved gradient technology (2.45 overall mean acceptability), which was quieter than the comparison machine (3.71 overall mean acceptability).

Team training (including hypnosis) One study46 specifically looked at the impact of a team training exercise to improve MRI completion rates, with the authors concluding that team training in advanced rapport skills and hypnosis can improve completion rates, and also noted the change in outcomes due to organisational disruptions.

Detailed information and additional strategies Five studies31,32,39,41,43 specifically looked at the impact of providing additional information for MRI, which could be verbal or written and delivered with or without additional strategies, in terms of anxiety, depression and ability of patients to complete the scan. Although four of the studies31,32,39,41 utilised the self-reported STAI measure to measure anxiety in their studies, due to heterogeneity in populations, the intervention and the timing of when the outcome was measured, a meta-analysis was only appropriate for combining data from two of these studies.39,41

Prone positioning Although three studies27,34,44 were identified that specifically looked at the impact of prone positioning compared with supine positioning in terms of claustrophobia and scan termination, only two of these studies were deemed of high enough quality to be included in this review.34,44 Due to heterogeneity in populations and the outcome measured, no meta-analysis could be performed. Both studies showed evidence of benefit from prone scanning, and claustrophobia appeared to be reduced when patients were scanned in the prone position in one study.45

© 2013 The Authors International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute

Quasi-experimental before-and-after study Quasi-experimental study with a historical control group

Randomised controlled trial

Lukins et al. 199733

Lang et al. 201046

Perth, Australia

USA

USA

London, UK

Outpatients (between the ages of 17 and 76 years) undergoing MRI for the first time

Claustrophobic patients (age 7–88 years) unable to previously complete MRI Patients attending for an MRI scan

Patients (age range 5–99 years) undergoing MRI Neurology and neuropsychiatry patients (over 16 years of age) undergoing brain or spinal MRI scans

Germany

Germany

Adult women with either suspect or manifest breast cancer Adults undergoing MRI

Hunt et al. 201112

Eshed et al. 200745 Grey et al. 200032

Caruso et al. 200631 Dewey et al. 20079

Adult patients (18–75 years of age), some of whom had reported claustrophobia

Adult outpatients undergoing MRI (aged 18–82 years)

Participants

Rome, Italy

Germany

Quasi-experimental before-and-after study with a control group Randomised controlled trial Quasi-experimental study with a historical control group Comparable cohort study A pseudorandomised controlled trial

Bangard et al. 200744

Argue 1995

California, USA

Setting

Randomised controlled trial

Methods

30

Study

Table 3 Included studies

No relaxation techniques

Standard care pre-training

Standard machine, bore of 60 cm

Supine (all scans aside from breast imaging) Standard information

MRI after receiving routine information Conventional MRI scanner (older)

Scheduled in a closed-bore MRI in the past

Standard (group A)

Control

Clerical personnel and non-licensed healthcare professionals received training in advanced rapport skills only (8 h); licensed healthcare professionals were trained in advanced rapport skills plus rapid hypnotic techniques (17 h) Two intervention groups: (1) relaxation techniques (guided imagery) taught before the scan; (2) relaxation techniques (guided imagery) taught before and during the scan

Standard information in addition to booklet, cognitive strategies, demonstration of MRI noise, a visit to the control room, a device to signal for music volume, timings of the scan and a visible clock Bore of 70 cm, 1.25 m long

Prone (breast imaging)

Three intervention groups: standard plus progressive muscle relaxation, guided imagery (deep slow breathing) (group B); standard plus skills training in cognitive coping strategies (group C); progressive muscle relaxation and cognitive coping strategies (group D) Open MRI system (1.0-T Panorama, Philips, Amsterdam, The Netherlands) with a patient aperture of 160 cm and a horizontal magnetic field MRI after receiving routine information and psychological support Newer MRI, shorter and wider bore

Comparison groups

Reducing anxiety during MRI 269

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USA

Randomised controlled trial Randomised controlled trial Quasi-experimental before-and-after study Randomised controlled trial Non-randomised controlled trial

Controlled crossover trial Randomised controlled trial

Redd et al. 199438 Selim 200139

Spouse and Gedroyc 200048 Thompson et al. 199440 Tornqvist et al. 200641

Verhoek et al. 199842 Youssefzadeh et al. 199743

© 2013 The Authors International Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute Adults (18–80 years of age) undergoing MRI Adult outpatients (over 18 years) undergoing MRI head and/or spine scans Adults (19–74 years of age) referred for MRI of the foot and ankle Patients undergoing standard MRI and breast MRI

Adult outpatients (21–65 years) undergoing MRI Patients (aged 20–69 years) with no previous history of MRI Claustrophobic patients (25–71 years) undergoing MRI

Patients who had not had an MRI before (ages not stated)

Two control groups: (i) standard information; (ii) no breast imaging

1.0-T whole-body scanner

Routine information

No guided imagery

Past experience of closed MRI

Humidified air via nasal cannula Standard care

No cognitive coping treatment or relaxation treatment Standard information

Closed MRI

Older, louder MRI machine

Supine

Control

Detailed information

0.2-T dedicated MRI system

Increased written information

Guided imagery

Open MRI

Two intervention groups: cognitive coping† treatment group and relaxation‡ treatment group Two intervention groups: (1) standard information plus counselling; (2) standard information and a relaxation exercise Fragrance administration via nasal cannula Additional information

Open MRI

Newer, quieter MRI machine

Prone

Comparison groups

† Cognitive coping combats the patient’s negative thoughts with positive coping statements, helping patients recognise anxiety-provoking or non constructive thoughts and replace them with statements that indicate successful coping and control. Patients were encouraged to use this technique during the scan. ‡Relaxation treatment emphasises the release of tension from the body through concentrated focus on particular parts of the anatomy. Patients were taught to recognise tension and then let the tension flow out of the body.

Austria

Switzerland

Sweden

USA

London, UK

Egypt

USA

Randomised controlled trial

Women (25–35 years of age) undergoing pelvimetry Adults (over 18) undergoing head MRI

Switzerland

Quirk et al. 198937

Patients undergoing brain or lumbar MRI scans

Ireland

USA

Women undergoing pelvic MRI

Participants

USA

Setting

Randomised controlled trial

Randomised controlled trial Quasi-experimental, prospectively controlled study Cross-over trial

Methods

McCauley et al. 199234 McNulty and McNulty 200947 Michel et al. 200235 O’Halloran 199336

Study

Table 3 Continued

270 Z Munn and Z Jordan

Reducing anxiety during MRI

Figure 1 The process.

searching

and

271

inclusion

DerSimonian & Laird WMD

Study Tornqvist et al, 2006

Weight WND (95% CI) 49.93% 0.20 (-4.11, 4.51) 50.07% -17.37 (-21.48, -13.26)

Selim 2001 Favours Treatment-22.0

0.0

22.0Favours Control

0.0

22.0Favours Control

Overall

Figure 2 Meta-analysis of anxiety during MRI, as measured retrospectively with Spielberger State-Trait Anxiety Inventory; WMD, weighted mean difference.

Overall

100.00% -8.60 (-25.82, 8.62)

Favours Treatment-22.0

Heterogeneity: χ2 = 33.44, P = 0.0

Overall Z = 0.98, P = 0.3320

Cognitive strategies Five studies30,33,36,37,40 specifically looked at the impact of cognitive strategies for MRI in terms of anxiety, distress and sedation. Due to heterogeneity in populations, interventions, the outcome measured and the timing of the outcome, meta-analysis was not appropriate. The majority of the studies reported that techniques such as guided imagery, cognitive coping strategies, and relaxation and breathing techniques were effective for reducing anxiety in adults undergoing MRI, although the size of this effect varied greatly among the studies. This is likely due to the variation in the intervention delivered. None of the studies assessed the effectiveness of the interventions in patient populations who considered themselves claustrophobic.

Fragrance administration Redd et al.38 performed a randomised controlled trial in the USA for adult patients undergoing MRI, comparing fragrance administration via a nasal cannula with humidified air via a nasal cannula to determine whether or not it had an effect on distress and anxiety during imaging. The results of the trial suggest that olfactory stimuli can reduce anxiety for patients undergoing MRI imaging.

Discussion This review sought to synthesise the best available evidence regarding interventions to reduce anxiety, distress and the

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need for sedation in adults undergoing MRI. During the search and retrieval process, 21 studies were identified that met the inclusion criteria and were considered to be of suitable methodological quality. The number of studies identified in this area is promising, as it shows the importance that health professionals and researchers alike are putting on improving the scanning experience for patients undergoing MRI.50 The methodological quality of the studies varied; however, all the studies included had at a minimum a comparative data group. Of the final 21 studies, 14 were randomised controlled trials, while 7 were comparable cohort studies or other observational designs with a control group. As randomised controlled trials are the ideal design to determine effectiveness,18 identifying 14 to include in this review was deemed a good result. Although during critical appraisal none of the included studies scored a perfect result, this is to be expected due to the nature of the interventions studied and the difficulty in blinding patients to these. This review is considered the first of its type in medical imaging. Although there have been other systematic reviews published in the field of medical imaging,4,51–53 none have specifically looked at interventions to reduce anxiety, distress and the need for sedation in adults. During the search process, a literature review13 was identified, but this did not follow a systematic process and the information within it is now quite dated, as it was published in 1995. There are potentially many factors besides the design of the scanner that may affect a person’s anxiety during the scanning process, one of which may be informed by the concept of ‘constructive thinking’.36 When individuals who have high levels of constructive thinking are presented with a stressful situation, they react with ‘automatic thoughts that facilitate situational coping and result in positive affect’ (O’Halloran, p. 9).36 It was shown in one study that those with low constructive thinking, defined as those who ‘experience automatic thoughts which augment their stressful experience’ (O’Halloran, p. 10)36 had higher levels of anxiety initially compared with high constructive thinkers. This finding may help in part to inform why some people suffer anxiety reactions while others do not. This may also partly explain why an intervention can have a range of effects. It may be that in some types of scans, there is increased risk of anxiety-related events, such as in breast MRI.43 This may be due to patients’ having different preconceptions of the scan, perhaps expecting a scan more akin to mammography.43 In these cases, it is reasonable to think that inadequate preparation and information prior to a scan, as well as worrying about the outcome, can lead to anxiety, which can be addressed by providing further information.43 In breast MRI scans, the women undergoing scanning are positioned prone.45 This type of positioning has been found to reduce claustrophobia-related terminations compared with supine positioning.45 In one study included in this review, prone positioning was compared with supine for pelvic examinations.34 However, as shown from another study in this review, pelvic examinations normally have a

reduced rate of claustrophobic terminations,45 and therefore it may not be the most desirable study population in which to determine the effect of prone positioning on claustrophobic events. No studies were located that assessed the option of giving the patient a choice regarding in what position they were to be imaged. However, for many scan types prone scanning may be impractical. It has been stated that patients who are anxious, claustrophobic or panicked may be more likely to move during scans, resulting in motion artefacts.44 It was shown in the review that patients largely prefer open MRI systems to closed ones.35,48 As open MRI configurations increase comfort and reduce anxiety, it is likely that motion artefacts can be reduced with these systems.44 However, examination time can be up to twice as long in open systems,35 and these increased exam times in open MRI may lead to increased examination times,35 which could result in increased restlessness and therefore movement. Interestingly, patient acceptance of open MRI machines was not replicated for a dedicated low-field MRI scanner for the foot and ankle.42 This is likely due to the uncomfortable position required in the foot-and-ankle scanner studied.42 Newer shorter-length, wide-bore MRI scanners also resulted in positive outcomes, with a reduction in claustrophobic reactions that is likely due to their patient-centred design,9 where there is more space between the patient and the bore walls, and a larger proportion of the patient’s body is outside the bore.12 These newer machines are often quieter as well, and one small study noted that quieter machines were better received/accepted by patients.47 Therefore, these new scanners may be more economical than older scanners despite the cost to purchase them, as they reduce sedation rates and non-completions.9,12 However, there is often a trade-off between image quality and patientfriendly (including open) scanner design, which is important to consider when considering the acquisition of a new scanner. A psychological support session lasting for 45 min was found to reduce anxiety after MRI slightly compared with a control group, but more substantial was the difference in depression between the two groups.31 Given that a 45-min psychological support session prior to MRI may not be feasible in many organisations, although it was shown to reduce depression, it may be useful to ensure patients can receive this, but perhaps not during the imaging process. When changing a process in an imaging department, it can be expected that some staff may have concerns regarding new procedures, particularly if additional time is needed.32 However, the addition of an anxiety reduction protocol resulted in delays seldom occurring, and the intervention could be implemented routinely.32 Team training interventions that included rapport skills and hypnotic techniques were found to be effective at reducing non-completion rates, which is likely to have a financial benefit to the department.46 In the one trial assessing fragrance administration for anxiety during MRI, the authors used nasal cannulae and a computerised delivery system to administer the intervention,

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Reducing anxiety during MRI

which may make this anxiety-reducing measure impractical in real-life settings. However, they noted that these measures were put in place to ensure a controlled study design, and that in the non-experimental setting, simpler methods could be employed.38 Limitations of the review There are some potential limitations with this review. Although a thorough systematic search was conducted across multiple databases targeting both published and unpublished literature, it is possible that some articles may have been missed. Also, studies that may have been conducted after the search have not been included. This may mean that as further studies are published in this area, an update of this review will be required. A further limitation is that only articles published in English were included. Finally, many of the studies included were conducted prior to 2000, and as the design of MRI equipment continues to evolve rapidly this may reduce the applicability of these results. Although it was pleasing to identify 21 studies addressing the review question, there is still need for further primary research to provide guidance to health professionals working in this area. Many of these studies had methodological limitations, and future research conducted in this area should ideally employ a randomised controlled trial design. The small sample sizes of many of the included studies also limited the ability of their authors to draw definitive conclusions, and future research into interventions needs to be adequately powered.

Conclusion This review identified 21 studies that assessed interventions to reduce anxiety, distress and the need for sedation in adults undergoing MRI. The studies included assessed MRI design features, cognitive–behavioural strategies, prone positioning, information, fragrance administration and team training. All of the interventions had some positive effect on at least one outcome, except for additional information, where there were mixed findings. Healthcare professionals working with adults undergoing MRI may consider some of the above strategies to implement in their practice.

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