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5.3Rest, relaxation, and pacing

REST: In adults with OA, what are the benefits and harms of rest and relaxation/application of pacing techniques versus no treatment or other interventions with respect to symptoms, function and quality of life?
Bibliographic referenceM. C. Gay, P. Philippot, and O. Luminet. Differential effectiveness of psychological interventions for reducing osteoarthritis pain: a comparison of Erikson [correction of Erickson] hypnosis and Jacobson relaxation. European Journal of Pain 6 (1):1–16, 2002.
Study type & evidence levelRCT: 1+
AimTo assess the efficacy of Erikson hypnosis versus relaxation (Jacobson’s technique) versus control (no treatment) in adults with knee and/or hip OA.
Number of patientsTotal N=41; N=14 (Erikson Hypnosis), N=14 (Relaxation – Jacobson technique), N=13 (Control – no treatment)
Single centre trial: Belgium
Patient characteristicsBaseline characteristicsErikson Hypnosis (N=13)Relaxation – Jacobson technique (N=13)Control - no treatment (N=10)
Age, years, mean (SD)64.2 (5.8)63.9 (6.1)66.3 (4.6)
Female, N (%)13 (100)11 (85)9 (90)
OA duration, years, mean (SD)10.7 (8.8)12.4 (9.3)19.3 (13.9)
OA site, N (%)
 Hip8 (62)8 (73)8 (80)
 Knee9 (69)9 (82)7 (70)
Pain Intensity, VAS, mean (SD)4.2 (1.9)3.7 (1.6)4.4 (1.6)
• All participants had knee and/or hip OA (radiological and/or clinical diagnosis) and had at least moderate levels of pain of at least 2.5 on rating scale of 1–10 on average over the last month).
• Patients were excluded if they had a prosthesis on the target joint, other rheumatological disorders, major medical problems, requiring ongoing treatment, psychological, neurological or CNS disorders, changes in treatment (medication, physiotherapy) in the 3 months prior to the sessions.
• Patients were asked to continue their usual treatment (medication, physiotherapy).
• There were NS differences between the groups for any of the baseline characteristics.
InterventionErikson Hypnosis technique. − 30 minute session

Relaxation – Jacobson technique − 30 minute session
ComparisonControl – no treatment
Length of follow-up2 months (end of treatment); follow-up at 3 months and 6 months post-treatment
Outcome measuresPain Intensity (VAS).
Effect size
ERIKSON HYPNOSIS vs CONTROL
• Erikson Hypnosis was significantly better than control for:
 ○ Pain (VAS) at 4 weeks (mid-treatment), at 8 weeks (end of treatment) and at 3 months post-treatment (all: p<0.05).

• There was NS difference between Erikson Hypnosis and control for:
 ○ Pain (VAS) at 6 months post-treatment (all: p<0.05).

JACOBSON RELAXATION vs CONTROL
• Jacobson relaxation was significantly better than control for:
 ○ Pain (VAS) at 8 weeks, end of treatment (p<0.05).

• There was NS difference between Jacobson relaxation and control for:
 ○ Pain (VAS) at 4 weeks (mid-treatment), 3 months post-treatment and at 6 months post-treatment (all: p<0.05).

ERIKSON HYPNOSIS vs JACOBSON RELAXATION
• Erikson Hypnosis was significantly better than Jacobson relaxation for:
 ○ Pain (VAS) at 4 weeks, mid-treatment (p<0.05).

• There was NS difference between Erikson Hypnosis and control for:
 ○ Pain (VAS) at 8 weeks (end of treatment), 3 months post-treatment and at 6 months post-treatment.

Withdrawals
• Hypnosis, relaxation and Control were similar for:
 ○ Total number of study withdrawals (N= 3, 21%; N=3, 21%; N=4, 31%)
Outcome, change from baselineErikson HypnosisRelaxation – Jacobson techniqueControl - no treatmentP value Hypnosis vs RelaxationP value Hypnosis vs controlP value Relaxation vs control
Pain Intensity, VAS, mean (SD)
 4 weeks (mid-treatment)1.97 (1.31)3.76 (1.77)5.05 (1.79)<0.05<0.05NS
 8 weeks (end of treatment)1.85 (1.65)2.37 (1.62)4.23 (1.14)NS<0.05<0.05
 3 months post-treatment1.66 (1.49)2.75 (1.91)4.29 (1.31)NS<0.05NS
 6 months post-treatment2.38 (2.47)2.80 (1.63)4.31 (2.38)NSNSNS
Total Withdrawals/lost to follow-up, N (%)3 (21)3 (21)4 (31)
• Randomisation method not mentioned
• No mention of blinding
ITT analysis not mentioned
FundingBelgian Fund for Scientific Research
Ref ID54
Bibliographic referenceR. McCaffrey and E. Freeman. Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing 44 (5):517–524, 2003.
Study type & evidence levelRCT: 1+
AimTo assess the efficacy of rest and relaxation (sitting and listening to music) versus control (sitting quiet and/or reading) in adults with OA.
Number of patientsTotal N=66; N=33 (rest and relaxation – sitting and listening to music), N=33 (control – sitting quiet and/or reading)
Single centre trial: USA.
Patient characteristicsBaseline characteristicsMusic (N=33)Quiet (N=33)
Age, years, mean (SD)76.6 (6.0)75.6 (5.9)
Female, N (%)11 (33.3)11 (33.3)
OA duration, years, mean15.1 (10.9)11.6 (4.9)
• All participants were aged >65 years, had OA (site not specified) and had pain of at least 3 on rating scale of 1–10 on at least 15 days/month).
• Patients were excluded if they had used narcotic analgesics.
InterventionMusic - sitting and listening to 20 mins of music, once/day for 14 days.

Cassette tape player and a cassette prepared with 20 mins of relaxation music (classical) was provide. Music had a tempo between 60 and 80 beats per minute, which is considered relaxing. Participants listened to the entire tape each day for 14 days at approximately 1 hour after completing their morning toilet. Participants were instructed to sit in the same comfortable chair each day and to avoid other distractions such as reading, speaking on the telephone, listening to the radio or watching TV during the 20 mins. Participants completed the SF-MPQ immediately before and after listening to the 20 mins of music.
ComparisonControl – sitting quietly for 20 mins of music, once/day for 14 days.

Participants sat in a comfortable place for 20 mins each day for approximately 1 hour after completing their morning toilet for 14 days. Participants were instructed to sit in the same comfortable chair each day in a relaxed manner and avoid distractions such as speaking on the telephone, listening to the radio or watching TV during the 20 mins. Reading newspapers, books or magazines was permitted in the control group. Participants completed the SF-MPQ immediately before and after the sitting period.
Length of follow-up14 days (end of treatment)
Outcome measuresShort Form McGill Pain Questionnaire, SF-MPQ (Pain, VAS and Pain Rating Index); Withdrawals.
Effect size

Pain
• Rest and relaxation (sitting and listening to music) was significantly better than the control (rest and relaxation sitting quietly and/or reading) for:
 ○ SF-MPQ Pain, VAS (pre-post test changes) at 1 day, beginning of treatment (mean difference 23.4, p=0.001) and at Day 7, mid-treatment (mean difference 18.9, p=0.001) and at 2 weeks, end of treatment (Mean difference 17.3, p=0.001);
 ○ SF-MPQ Pain Rating Index (pre-post test changes) at 1 day, beginning of treatment (mean difference −5.1, p=0.001) and at Day 7, mid-treatment (mean difference +3.8, p=0.001) and at 2 weeks, end of treatment (Mean difference +2.2, p=0.001).

Withdrawals
• There were no study withdrawals.
Outcome, pre-post test changesMusic (N=33)Quiet (N=33)Mean difference Music vs QuietP value
SF-MPQ Pain, VAS, mean
 Day 121.7 (20.5)1.7 (3.6)23.40.001
 Day 712.2 (2.1)4.6 (0.8)18.90.001
 Day 1414.1 (2.5)4.3 (0.7)17.30.001
SF-MPQ Pain Rating Index, mean
 Day 15.0 (4.7)0.06 (0.7)−5.10.001
 Day 73.8 (4.2)0.06 (0.9)+3.80.001
 Day 142.2 (0)0.00 (1.1)+2.20.001
• Randomisation by selection of mixed sealed envelopes, stratification according to sex (2:1, women:men)
• No mention of blinding
ITT analysis not mentioned, however no dropouts
FundingNot mentioned
Ref ID42
Bibliographic referenceM. S. Garfinkel, H. R. Schumacher, Jr., A. Husain, M. Levy, and R. A. Reshetar. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. Journal of Rheumatology 21 (12):2341–2343, 1994.
Study type & evidence levelRCT: 1−
AimTo assess the efficacy of rest and relaxation (yoga + relaxation + education) versus no therapy (patient’s usual therapy) in adults with Hand OA.
Number of patientsPhase I - Total N=17; N=9 (yoga + relaxation + education), N=8 (no therapy – patient’s usual therapy)
Phase II - Total N=14; N=10 (yoga + relaxation + education), N=4 (no therapy – patient’s usual therapy)
Single centre trial: USA.
Patient characteristics• All participants had hand OA (distal interphalangeal and/or proximal interphalangeal joints of the fingers) and had pain, aching and/or stiffness in the hands (Altman criteria).
• Patients were instructed not to change any medications or other therapies nor add any new-ones. All patients were on stable OA treatment regimens.
• Phase I of the trial − 17 subjects tested (9 in treatment group; 8 in control group).
• Phase II of the trial − 14 subjects (10 in treatment group − 5 subjects from control group of Phase I + 5 subjects from the treatment group of phase I; 4 in control group – from the treatment group in phase I)
InterventionYoga + relaxation + education − 8 × 60 minute sessions, once a week

Sessions occurred once weekly and included stretching and strengthening exercises emphasising extension and alignment (arms and fingers), emphasis was also given to respiration and upper body alignment. Patients also received written instructions of educational materials.
ComparisonControl – no intervention (patients continued their usual treatment).
Length of follow-up10 weeks (end of treatment)
Outcome measuresPain, VAS (at rest and during activity); Hand function (Stanford Health Assessment Questionnaire); ROM; Hand grip strength; tenderness of finger joints; withdrawals.
Effect size

Withdrawals
• There was one study withdrawal during phase I of the trial in the treatment group.
Outcome, pre-post test changesYoga + relaxation + eductaionControl – usual treatmentP value
Range of motion*, degrees (SD)
 Right hand16.9 (7.8)6.9 (6.7)0.002
 Left hand14.9 (7.9)8.1 (11.1)NS
Hand Grip Strength* (SD)
 Right hand4.2 (4.7)3.4 (5.9)NS
 Left hand6.1 (5.6)2.5 (5.4)NS
Tenderness* (SD)
 Right hand2.2 (1.3)0.4 (0.9)<0.01
 Left hand2.1 (1.6)0.4 (1.4)<0.01
Pain at rest**, mean (SD)−1.9 (5.6)−0.1 (2.9)NS
Pain during activity**, mean (SD)−4.3 (2.1)−1.0 (3.0)0.004
Hand function**, mean (SD)−0.1 (0.2)0.2 (0.8)NS
*positive difference (post-pre) signifies improvement
**negative difference signifies improvement; scores are for both hand combined

• Randomisation method not mentioned
• No mention of blinding
ITT analysis not mentioned
• No details given of baseline characteristics for each group
FundingNot mentioned
Ref ID2498

From: Compiled evidence tables - Chapter 5

Cover of Osteoarthritis
Osteoarthritis: National Clinical Guideline for Care and Management in Adults.
NICE Clinical Guidelines, No. 59.
National Collaborating Centre for Chronic Conditions (UK).
Copyright © 2008, Royal College of Physicians of London.

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