Guided Imagery Relaxation Therapy in Malaysian Patients with Knee Osteoarthritis: A Randomized Controlled Trial

Abstract

Introduction: There is limited data regarding the use of relaxation technique in managing knee osteoarthritis in Asian population.

Full text

International Journal of Collaborative Research on Internal Medicine & Public Health
Vol. 7 No. 5 (2015)
92
Guided Imagery Relaxation Therapy in Malaysian Patients
with Knee Osteoarthritis: A Randomized Controlled Trial
Azlina Elias
1
, Lili Husniati Yaacob
1*
,
Azidah Abdul Kadir
1
, Azizah Othman
2
1
Dept of Family Medicine, Universiti Sains Malaysia, Kelantan, Malaysia.
2
Dept of Paediatrics, Universiti Sains Malaysia, Kelantan, Malaysia.
* Corresponding author: Lili Husniati Yaacob,
Department of Family Medicine, Universiti Sains Malaysia, Kelantan, Malaysia.
Telephone number: +6097676613
Email: husniati@usm.my
Abstract
Introduction: There is limited data regarding the use of relaxation technique in managing knee
osteoarthritis in Asian population.
Aims and Objectives: The efficacy and acceptance of relaxation therapy in improving
symptoms, physical functions and quality of life of patients with primary knee osteoarthritis was
examined in this study.
Methods / Study Design: Sixty patients with knee osteoarthritis were randomly assigned to an
intervention group using relaxation therapy (n=30) or to a control group of usual care (n= 30) for
eight weeks. The intervention consisted of listening to 13 minutes of an MP3 player with pre-
recorded Guided Imagery with Relaxation Therapy. Changes from baseline on pain, symptoms,
physical functions and quality of life using the Knee injury and Osteoarthritis Outcome Score
(KOOS) was determined using ANCOVA analysis. The difference of analgesic consumption
using analgesic score was also calculated.
Findings: A total of 60 patients enrolled in the study, however only 59 patients completed the
study (98.3%). The mean age of the patients was 52.2 (SD 7.08). There were significant
improvements in the pain (p<0.004), daily living activities (p<0.02), sports and recreational
activities (p<0.005) and quality of life (p<0.01) scores in the intervention. Overall there was
good acceptance of the therapy among the participants.
Conclusion: Guided Imagery with Relaxation Therapy has significantly reduced pain and
improved daily living activities and health-related quality of life with good acceptance by the
participants. These results justify further investigation into Guided Imagery with Relaxation
Therapy as self-management in patients with knee osteoarthritis in Asian patients.
Key words: Knee osteoarthritis, guided imagery, relaxation therapy, acceptance

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Introduction
Osteoarthritis is one of the most common causes of disability among older patients, especially
those with knee and hip osteoarthritis. A study conducted in the Asian population showed the
estimated prevalence of symptomatic knee arthritis in individuals over 65 years old to be about
30%.
1
The standard management for knee osteoarthritis is symptom control with analgesics.
However, chronic uses of analgesics result in numerous adverse effect namely gastrointestinal
bleeding and renal impairment. Because of this there have been multiple studies which look into
alternative therapy in managing osteoarthritis. One of the emerging alternative treatments is
relaxation therapy with guided imagery.
Progressive muscle relaxation therapy (PMR) was first introduced in 1932 by Jacobsen.
2
It is a
series of technique involving cycles of tension and release in 50 different muscle groups aiming
to increase awareness of muscular tension in the human body and also to learn to release the
tension.
3
This relaxation technique was expanded to address several physical and also
psychobehavioural problems. The original protocol of muscle relaxation therapy was produced
by Bernstein and Borkovec in 1979 and was called Abbreviated Progressive Relaxation
Technique (APRT).
Individualized Guided Imagery (GI) technique is another type of muscle relaxation therapy. The
content of GI usually includes scenery or places using information obtained during the initial
session. Participants are guided to create a place in their mind using their senses of touch, sound,
smell, sight and taste and to use these to transform the pain and tension into other forms of
objects or creative energy and increase their sense of control over the pain.
4
Guided Imagery may
also result in a reduction of autonomic nervous system response.
5
It blocks the transmission of
painful stimuli through higher brain centres and is widely used in managing patients with chronic
pain such as recurrent abdominal pain, cancer, chronic headaches, fibromyalgia, etc.
Even though there have been a few studies which have shown that relaxation therapy with
guided imagery may be beneficial as alternative or adjunct treatment for osteoarthritis, these
studies were mainly done in the western countries and there is insufficient data regarding the use
of the treatment in Asian community.
6-10
This study would provide information about the
acceptance of this treatment in the Malaysian context which might be different due to different
cultural and social values. Therefore this study not only attempt to look into the efficacy of the
treatment in Asian patient but also seek to determine the acceptance of the treatment among this
group of patient.
Materials and Method
Study design and setting
This randomized controlled pilot study sought to compare the efficacy of relaxation therapy
among patients with knee osteoarthritis attending a primary care clinic in north eastern Malaysia.

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Participants and instruments
The participants included those with unilateral or bilateral knee osteoarthritis as diagnosed
according to the American College of Rheumatology .
11
The exclusion criteria included patients
with connective tissue diseases such as rheumatoid arthritis or systemic lupus erythematosus,
patients with active gouty arthritis, patients currently using of guided imagery or acupuncture,
patients with psychiatric illness, patients with grade 4 knee osteoarthritis according to the
radiological criteria by the Kellgren Lawrence Classification and those with a body mass index
(BMI) more than 35 kg/m
2
. A power analysis using standard deviation of 11 and detectable
difference of 13 for guided imagery and knee osteoarthritis symptom score, and considering
10% drop out rate indicated that a total sample size of 60 was needed for power greater than
0.90.
9
The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to assess the patients’
opinions regarding their knee pain and associated problems.
12
It is a valid, reliable, and
responsive self-administered instrument in the follow-up of short-term and long-term
osteoarthritis and knee injuries.
13
The Malay version of KOOS was validated with Cronbach
alpha ranged from 0.94 to 0.96 and factor loading of 0.25 to 0.89 (Maryam, unpublished thesis,
2013)
It comprises 42 items in five separately scored subscales, which include pain, other symptoms,
function in daily living (ADL), function in sports and recreation (Sport/Rec) and knee-related
quality of life (QOL).
12
The last week before the questionnaire was administered was taken into
consideration when answering the questions. Standardized answer options were given (five
Likert boxes), and each question received a score from 0 to 4. A normalized score (100
indicating no symptoms and 0 indicating extreme symptoms) was calculated for each subscale. A
higher normalized score indicated a better outcome for the patient. For patients with bilateral
osteoarthritis, the most compromised knee was used as the reference.
A rescue-analgesic diary was developed to assist the participants in documenting the types,
dosage, and number of analgesia tablets they had been taking during the study period. In this
study, all participants were prescribed either tablets of acetaminophen (1000 mg) or ibuprofen
(400 mg) for rescue analgesia. A 1000mg of Acetaminophen for was scored as 1, and a 400mg of
Ibuprofen was scored as 2.5 (i.e. per tablet consumption) as recommended by the Ibuprofen,
Paracetamol Study in Osteoarthritis (IPSO).
14
Participants were informed that any intake of other
forms of analgesia need to be informed to the investigators and recorded accordingly.
In preparing the GIR audio for patients with OA in Bahasa Malaysia, an imagery-induced
relaxation script was developed by a clinical psychologist based on an extensive review of the
literature
6,8,10,15,16
and thorough analysis of a locally, validated GIR audio developed for
children with chronic illness.
17
The script, narration and recording quality were assessed through
multiple ‘listening sessions’. Listening and evaluation were conducted at different stages by a
panel of experts including a psychiatrist, medical officer, trained nurses and patients. Comments
and suggestions for improvement were taken into consideration and changes were made
accordingly. The scripts was then narrated by a female voice and recorded into audio version.
The whole script runs for approximately 13 minutes, with no background music.

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The GIR technique in this present study consists of five major steps started with brief
orientation and induction, deepening, coping strategies, positive suggestions and closure. The
script starts with directing the listener to sit comfortably and to breathe deeply for several times.
The listeners are brought into an induction phase via eye-fixation technique and counting
method. Then, the relaxing experience is deepened through deep breathing instructions and
passive progressive muscle relaxation. The script guides the listeners through a fantasy place
where they would find their peace, relaxation and preferences there. They are encouraged to
experience physical, mental, and emotional relaxation through imagination and utilization of
multiple senses including vision, touch, taste, smell and hearing. Again through deep breathing
instructions, the listeners are assisted to sustain their focus and state of relaxation. Incorporated
in the script are suggestions on coping strategies using modelling technique whereby the listeners
are guided to witness a person having similar problems and pain, however manage to cope
successfully, using GIR techniques. The person is illustrated to be able to function in their life
satisfactorily, and be active. The script convinces the listeners to believe that they could be this
person they witness, or better. It also incorporated suggestion of the power of the creator to
promote the power of healing, feeling of reliant and subsequent perceived strength. Finally,
positive end-state suggestions recommend sustainable relaxation, gradual reduction in pain,
higher self-control and mobility. Through a sequence of deep breathing, the listeners are
gradually brought back to reality. The GIR script is audio-recorded in a MP3 player, which is
given to the participants in the intervention group. Accompanied the player is a notebook for
participants to record their listening session, throughout the study period
Participants’ feedback on the method was assessed through questionnaire developed from
extensive literature review.
16,18,19
The questionnaire consists of three sections. The first section
asked about the quality of the script itself, the voice, narrator and the quality of recording. The
second part of questionnaire asked the appropriateness of the script, and the last part of
questionnaire asked regarding their respond towards the scripts.
Study procedure
The study participants were acquired from the Outpatient and Orthopaedic Clinic at the Hospital
Universiti Sains Malaysia. Informed consent was obtained from participants who agreed to be
involved in the study. Patients were required to complete social demographic data. Patients’
history regarding knee pain and previous treatments received were documented through a
standardized questionnaire.
Basic physical examinations including body weight and height were taken and knee x-rays were
performed. Patients were then required to complete the KOOS and were randomly placed into
two groups using a computer-generated table of random numbers. Subjects in the intervention
group were then taught how to use the guided imagery relaxation (GIR) technique using the MP3
player. They were required to perform the GIR on their own at least once a day at home and to
record this in a book that was provided. Patients were allowed to continue taking pain relief
medication for their symptoms; however, they were allowed to take only 1 gram of
acetaminophen or 400 mg of ibuprofen as rescue analgesia. Patients were required to write the
dose of the analgesia in the diary provided.

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Phone calls were made to the intervention group at Week 2 and Week 4 of the study to
encourage compliance and to record the intervention used. At Week 8, all participants were
asked to complete the KOOS again. The analgesic score was also calculated. The diaries in
which patients recorded the frequency of relaxation therapy use and medication use were also
retrieved by the researchers.
Statistical analysis
Analysis was conducted using SPSS statistics software version 19. Baseline data analysis was
done to compare between intervention and control group to see if there are significant difference.
For age, BMI, duration of symptoms and income, Independent t Test was used. For race, sex,
marital status, osteoarthritis grading and the presence of medical illness, Chi Square Test was
used. If the assumption for Chi Square test is not met i.e. less than 5, Fisher’s exact test was
used. The level of statistical significance was set at 0.05.ANCOVA analysis was used to
compare the mean of the KOOS scores between the control and intervention groups at two
months post-intervention.
Results
Sixty subjects were enrolled in the study; however, only 59 subjects completed the study. One of
the subjects from the intervention group developed a transient ischaemic attack during the
intervention period. Due to this event, the response rate was 98.3%. the baseline data is presented
in table 1. There were no significant differences in term of age, sex, occupation, BMI,
osteoarthritis grading and previous nonsteroidal anti-inflammatory drugs (NSAIDs) usage
between the intervention and control groups. The female gender was prominent in this study,
whereby more than 90% of the participants were female in both the intervention and control
groups. For osteoarthritis grading using Kellgren Lawrence X ray classification, grade 2
represented the majority of participants in both the intervention and control groups. Sixty-seven
percent and 70% of participants in the intervention group and control group, respectively, had
previously taken NSAIDs for their knee pain. There were also no significant differences between
the intervention and control groups in terms of pain, symptoms, sports and recreational activities,
daily living activities and quality of life scores at baseline.
Table 2 shows the comparison of KOOS scores between groups at the completion of the study.
Analysis of covariants (ANCOVA) showed there is significant difference between the
intervention and control groups in terms of the pain, daily living activities, sports and quality of
life scores. Regarding the symptoms score, even though there was a difference between these
two groups, the value did not reach statistical significance. There was no significant difference in
the analgesic score between the groups throughout the study.
There were generally positive feedbacks from the participants regarding the use of the therapy as
shown in table 3. Majority of participants agreed that Imagery Induced Relaxation was
beneficial, the scripts was well written, they would like to hear it again, able to imagine well and

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follow the thoughts, the description given was clear and they were able to focus until the end of
the session. Majority of them also felt relaxed after hearing the audio and enjoyed it.
Discussion
It has been proven that there is a vicious cycle between pain and emotion. Stress and anxiety
might decrease the pain threshold and make subjects more aware of and more sensitive to pain.
20
Relaxation therapy is effective in breaking this cycle and will reduce feelings of anxiety, hence
making the subjects experience less pain.
20
According to the evidence above, the use of
relaxation therapy has an advantage in clinical practice in managing patients with chronic pain,
particularly those with knee osteoarthritis.
Our results also showed there was improvement in KOOS scoring in terms of the pain score,
daily living activities score, sport and recreational score and also quality of life score in the
patients using GIR. There are many studies which have reported the use of relaxation therapy in
reducing pain, particularly in musculoskeletal pain such as osteoarthritis, anterior cruciate
ligament reconstructions and others.
6-10,20
The result of our study is supported by the finding in a study by Baird and Sands.
8
Their study
compared intervention using GI with sham intervention (an audio without GI). The length of
their study was up to 12 weeks of intervention, and most of the participants used GI at least once
a day – some of them listened to GI up to four times per day. The study showed that pain and
mobility problems improved significantly after 12 weeks of intervention compared with the
control group. They concluded that guided imagery is easy to teach, even in elderly patients, and
is an inexpensive option for self-management of knee problems due to osteoarthritis. However
the majority of the studies done including ours were only short duration. This is an important
issue in management of knee osteoarthritis which is a chronic, lifelong condition. Further studies
need to be done on the acceptability and effectiveness of the therapy for long term.
The results from the quality of life score also indicated improvement in the intervention group. In
contrast, the results for the control group were more variable but did show deterioration at the
end of intervention. These results are also consistent with earlier research showing similar
improvements in the quality of life score after intervention using progressive relaxation therapy
such as in patients with knee osteoarthritis, cancer pain, chronic headaches and also after
operations for ligament reconstruction.
8,10, 21
A review of previous studies using GIR revealed that they were mainly carried out in western
countries namely United States, Norway and Australia.
22
It is important to see the effect and
acceptance of relaxation therapy in Asian patients since this technique is not as well known in
the region. There are two studies done recently using relaxation technique in Taiwan and Turkey
with positive outcome.
23,24
However they were carried out among post knee arthroplasty patients.
Our participants generally showed good acceptance of the therapy. This can promote compliance
and patient’s self management of their illness.

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One of the strength of our study was the incorporation of local belief and custom in the guided
imagery script. The participants were guided to feel and sense the power of the creator in helping
them heal and having the strength to manage the symptoms. None of the previous studies have
used the same technique in their therapy.
6-10,20
It is arguable that this technique may not work
for everyone and may only be beneficial in the settings where such belief is held and practiced.
One of the main concerns regarding the treatment of knee osteoarthritis is the reliance on over
the counter pain medication which can have deleterious health effect. Any adjunct or alternative
treatment which can result in the decrease in the consumption of pain medication would be very
valuable for the long term care of patients. Previous study by Baird et al did not find any
significant reduction in the medication intake.
9
Even though our study showed a lower analgesic
consumption in the intervention group, the result was also not statistically significant. This result
might be due to the fact that analgesic consumption was too small for statistical significance.
Furthermore, the severity of knee pain in our participants ranged from mild to moderate pain,
and most of them did not take medication for pain relief. On the other hand, it can also be
concluded that the improvement in the KOOS score in the intervention group was not influenced
by difference in analgesic use.
There are several limitations in this study. The results of this study cannot be generalized to
patients with grade 4 osteoarthritis and those with a BMI of more than 35 kg/m
2
as both of these
groups of patients were excluded from this study. The results from this study also might have
information bias due to self-reporting, which is common when using questionnaires to measure
results. Even though most of the participants were compliant with the intervention lasting over
eight-week duration, it is important to determine whether it is reasonable to expect patients with
knee osteoarthritis to use this therapy for extended periods of time. Therefore, studies of longer
duration should be carried out to evaluate the long-term efficacy of GIR in the management of
knee osteoarthritis.
Conclusion
In conclusion, Guided Imagery with Relaxation Therapy is feasible, is easy to use, is cost–
effective, has minimal side effects and is significantly proven to improve pain, daily living
activities, sports and recreational activities and quality of life in patients with knee osteoarthritis.
Medication intake was also lower in the intervention group as compared to control group even
though it was not statically significant. The results from this study justify further investigation of
the effectiveness of GIR as a self management technique to reduce the pain and mobility
difficulties that are commonly encountered by patients with knee osteoarthritis.
Conflict of interest statement
The author(s) declare that they have no competing interests.
Authors contributions:
AE, AAK ,LHY, AO participated in the design of the study.
AO prepared the script for the GIR

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AE and AAK performed the data collection and the statistical analysis.
LHY, AE, AAK and AO drafted the manuscript.
All authors read and approved the final manuscript.
Approval by the research and ethics committee
This study was approved and accepted by the Universiti Sains, Malaysia, Human Ethics
Committee (Ref: USM/PPP/JEPeM [241.3[2]])
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Table 1: Baseline clinical and sociodemographic data
Variables Intervention group Control group p value
n(%) n(%)
Age 52.8(7.16)
‡
51.6 (7.05) 0.516
*
Sex
Female 27(90.0) 28(93.3) 0.313
§
Male 3(10.0) 2(6.7)
Body Mass Index (BMI) 25.8(3.11)
‡
25.8(1.99) 0.953
*
Duration of OA 3.6(2.51)
‡
3.2(2.12) 0.544
*
OA severity
║
Grade 1 5(16.7) 6(20.0) 0.939
†
Grade 2 15(50.0) 14(46.7)
Grade 3 10(33.3) 10(33.3)
KOOS Domain
Pain 73.6 (10.57) 75.1 (7.49) 0.485
Symptom 67.7 (9.66) 66.8 (9.71) 0.574
Sport 54.1 (15.12) 47.7 (11.12) 0.085
ADL 77.8 (10.49) 76.2 (8.45) 0.472
Quality of life 55.6 (14.71) 49.2(12.79) 0.075
Using NSAIDs for knee pain
Yes 20(66.7) 21(70.0) 0.781
†
No 10(33.3) 9(30.0)
*
Independent T test
†
Chi square Test
§
Fisher’s Exact Test
‡
Mean (±SD)
║
(Based on Kellgren Lawrence X ray classification)

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Table 2: Between group comparisons of the KOOS score at the post intervention.
KOOS domain Intervention Control F stat p value
Adjusted mean 95% CI Adjusted mean 95% CI
Pain 78.8 76.6, 81.0 74.2 72.0, 76.3 9.198 0.004
Symptoms 70.2 68.1, 72.2 68.9 66.9, 71.0 0.728 0.397
Activity daily living 80.7 80.0, 82.4 77.8 6.1, 79.5 5.567 0.022
Sport 57.1 53.6, 60.7 49.6 46.1, 53.1 8.782 0.005
Quality of life 55.8 52.8, 58.8 50.0 45.9, 52.0 7.220 0.01
*ANCOVA analysis with age, OA severity, body mass index, duration of the illness and baseline KOOS score as covariates.

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Table 3: Participants’ responses regarding mp3 use
Item Disagree Neutral
Agree
n(%)
Hearing this mp3 gives advantages to me 0(0) 9(30) 21(70)
I like to hear the words 0(0) 11(36.7) 19(63.3)
I will listen again in the future 2(6.7) 11(36.7) 17(56.7)
I will suggest this mp3 to my friends and 4(13.3) 11(36.7) 15(50)
relatives
I can imagine picture illustrated in the mp3 3(10) 13(43.3) 14(46.7)
My thought wanders during listening to this mp3 6(20) 11(36.7) 13(43.3)
The description said in this mp3 was real/clear 2(6.7) 11(36.7) 17(56.7)
I feel relax after listening to this mp3 0(0) 4(13.3) 26(86.7)
I can concentrate during listening to this mp3 0(0) 9(30) 21(70)
I enjoyed listening to this mp3 0(0) 13(43.3) 17(56.7)