RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE ANNEXURE – II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. Name of the candidate and JITHIN JOSEPH address I YEAR M. Sc. NURSING (in block letters) LAXMI MEMORIAL COLLEGE OF NURSING BALMATTA MANGALORE
2. Name of the Institution LAXMI MEMORIAL COLLEGE OF NURSING BALMATTA MANGALORE
3. Course of Study and Subject M. Sc. NURSING MEDICAL SURGICAL NURSING
4. Date of Admission to the 12.06.2012 course
5. Title of the Topic
EFFECTIVENESS OF HOME BASED EXERCISE ON PAIN AND FUNCTIONAL PERFORMANCE AMONG ELDERLY WITH KNEE OSTEOARTHRITIS IN SELECTED OLD AGE HOMES AT MANGALORE
6 Brief resume of the intended work
1 6.1 Need for the study
The musculoskeletal system allows human body to maintain its upright posture, to move freely and to function independently. Arthritis (inflammation of a joint) is a common disorder of the musculoskeletal system that causes joint pain and stiffness. Although there are 100 arthritic conditions, osteoarthritis and rheumatoid arthritis are the two main types.1,2
Osteoarthritis (OA) , also known as degenerative joint disease (DJD), hypertrophic arthritis, osteoarthrosis or senescent arthritis, is a condition in which the cartilage that acts as a cushion between bones in joints begins to wear out, causing inflammation and pain in joints, thereby restricting movement.2
Osteoarthritis is the most common form of arthritis. By the age of 55, more than 80% of the population have radiographic evidence of the disease. Osteoarthritis affects an estimated 20 million Americans and account for approximately 3.7 million hospital admissions annually. In India, osteoarthritis affects about 50% of person at age 65 and older and this prevalence increase to 85% in the age group 75 and older. The prevalence of osteoarthritis increases after the age of 40 in women and 50 in men. The article published in times of India “Osteoarthritis is India's No. 1 ailment” has ranked osteoarthritis as number one comparing with diabetes mellitus and hypertension. The high incidence of osteoarthritis in India is the result of its prevalence among women who fall victim to it.1
Patients with chronic conditions of aging such as osteoarthritis are a large and growing portion of the population. Even though regular exercise has proven health and functional benefits, inactivity increases as patient age. Certainly in patients with osteoarthritis, regular exercise can improve pain control, proprioception, strength, stability and endurance, all of which improve functional independence. Treatment guidelines for osteoarthritis knee have included exercise as an important non pharmacological approach. In addition, it directly reduces disability and corrects walking.3
Treatment for arthritis requires a multidisciplinary or team approach. Many types of health professionals care for people with arthritis e.g. Physical
2 therapy, Physicians, Rheumatologists, and Nurse Educator3
Optimal management of patients with osteoarthritis of the knee requires a combination of non pharmacological and pharmacological therapies. Conservative treatment is advocated in patients with mild to moderate osteoarthritis of the knee. Because muscle weakness is associated with pain and physical dysfunction and influences the progression of the disease in patients with osteoarthritis of the knee, muscle strengthening is a key component. Muscle strength can be maintained by engaging in regular exercise. An appropriate warm up and cool down programme is essential to prevent muscle strain and damage. ROM exercises should be performed daily. Isometric and isotonic exercises, which do not stress the joint, are an excellent starting point. As strength and endurance of the joints increases, progressive, resistive exercises can be added to the regimen.1
From the literature review it is quite evident that home based exercises are beneficial to improve the functional mobility of joints in old age people. When the mobility increases, intensity of joint pain decreases. There are different techniques in carrying out the home based exercise and some of the techniques have already been tried out, in other countries. These exercises does not take much time, requires no special equipments, except a comfortable place to do the exercises. It is a simplest technique, which is considered to be appropriate for the low socioeconomic status, and easily applicable for the old age people.
A study was conducted at Rheumatology Unit, City Hospital, Nottingham, to assess the effect of a home based exercise programme, designed to improve quadriceps strength, on knee pain and disability. One ninety one men and women with knee pain aged 40-80 were recruited from the community and randomized to exercise (n=113) or no intervention (n=78). WOMAC pain score reduced by 22.5% in the exercise group and by 6.2% in the control group. VAS scores for pain also reduced in the exercise group compared with the control group (p<0.05).
Physical function scores reduced by 17.4% in the exercise group and were unchanged in controls (p<0.05). The study concluded that a simple programme of home quadriceps exercises can significantly improve self reported knee pain and
3 function4.
Exercise increase the functional ability of joints and thereby reduce the pain perception. But many are ignorant about the positive effects of exercises on osteoarthritis. People have a notion that physical activities may worsen the pain and functional disability in osteoarthritis patients. So the patients usually hesitate to perform on exercise in the home setting. Hence the researcher felt the importance of these exercise in a view to meet the needs of clients suffering from osteoarthritis and thus improve their quality of life.
6.2 Review of literature
A comparative study was conducted at Mexico to find the effectiveness of isokinetic versus isometric therapeutic exercise in patients with osteoarthritis knee. It was a quasi experimental study in a population of 45 to 75-year-old patients with a diagnosis of knee osteoarthritis. Group 1 (experimental) was put under isokinetic exercises and group 2 (control) under isometric exercises. The sample size was of 33 patients per group; the allocation to the experimentation or control group was non-random, but stratified by degrees of knee osteoarthritis. The effectiveness of the exercise was measured in three dimensions: muscle strength, joint range and pain. The intervention lasted eight weeks and the physical activity was carried out every third day. The analysis of muscle strength comparing the categories independently demonstrates differences at 8 weeks; 33.3% of the isokinetic exercise is in the normal category and 15.2% in the isometric exercise (P=.04). There was no difference of joint range between groups, despite finding a stage I range in 100.0% of the isokinetic group and 97.0% in the isometric (P>.05) group. Pain was milder in the isokinetic exercise group at 8 weeks (P=.01). Hence they proved that Isokinetic exercises have a greater effectiveness than isometric exercises for muscle strength and pain in patients with knee osteoarthritis5.
A prospective randomized clinical trial was conducted on activity modification in 162 patients with osteoarthritis knee at Chittagong Medical College, Bangladesh. Out of them, 96(59.3%) were male and 66 (40.7%) were female and male: female ratio was 1: 0.68. The mean age of the patients was
4 53.7±11.3 years. The patients were divided into two groups. The Group A was treated with shortwave diathermy, exercise, naproxen and activity modification and the Group B was treated with shortwave diathermy, exercise and naproxen. Improvement was found more in Group A than Group B after 4th week (95 % CI was -2.59 to 6.56). Then it was found that the improvement was gradually increased in Group A than Group B and finally, it was found that there was highly significant improvement in Group A than Group B after 6th week (95 % CI was -3.45 to -0.70).6
A comparative study was conducted to evaluate the effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee using a randomized clinical trial approach. The intention of the study was to compare 16 weeks of isometric versus dynamic resistance training on the control on knee pain and functioning among patients with knee osteoarthritis (OA). Hundred and two volunteer subjects selected from outpatient settings with OA of the knee were randomized to isometric (n=32) and dynamic (n=35) resistance training groups or a control (n=35).As intervention, strength exercises for the legs, 3 times weekly for 16 weeks were provided. The main outcome measure used was the time to descend and ascend flight of 27 stairs and to get down and up off of the floor. In the isometric group, time to perform all 4 functional tasks decreased (P<.05) by 16% to 23%. In the dynamic group, time to descend and ascend stairs decreased by 13% to 17%. Both groups decreased knee pain while performing the functional tasks by 28% to 58 The control group did not change over the duration of the study.7
Another comparative study was done in physical therapy clinics at 3 military hospitals: Brooke Army Medical Centre in Texas, Madigan Army Medical Centre in Washington, and Martin Army Community Hospital in Georgia to assess the effectiveness of supervised clinical exercise and manual therapy procedures versus a home exercise programme on knee osteoarthritis. One hundred thirty-four subjects with osteoarthritis of the knee were randomly assigned to a clinic treatment group (n=66; 61% female, 39% male; mean age [±SD]=64±10 years) or a home exercise group (n=68, 71% female, 29% male; mean age [±SD]=62±9 years). Subjects in the clinic treatment group received
5 supervised exercise, individualized manual therapy, and a home exercise program over a 4-week period. Subjects in the home exercise group received the same home exercise program initially, reinforced at a clinic visit 2 weeks later. Measured outcomes were the distance walked in 6 minutes and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). . Both groups showed clinically and statistically significant improvements in 6-minute walk distances and WOMAC scores at 4 weeks; improvements were still evident in both groups at 8 weeks. By 4 weeks, WOMAC scores had improved by 52% in the clinic treatment group and by 26% in the home exercise group. Average 6- minute walk distances had improved about 10% in both groups.8
An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip was conducted using randomized controlled trial approach at TNO Prevention and health, Netherlands. Three types of primary health-care providers (n = 18) delivered the OA Knee programme (n = 20) and the OA Hip programme (n = 20), supported by programme manuals and implementation guidelines, in four regions. The outcome measures were pain and mobility. The Knee programme had OA knowledge and self-efficacy as additional outcome measures. Differences in outcome measures and background variables of participants were assessed between the RCTs and the implementation study. Positive effects (P < 0.05) were found for OA knowledge, pain and self-efficacy in the Knee programme (n=157), and for pain in the Hip programme (n =132). No effect was found for mobility. Effect sizes of the RCTs and the present study were comparable. Background variables did not explain the variance in the outcome measures.9
6.3 Statement of the problem
Effectiveness of home based exercise on pain and functional performance among elderly with knee osteoarthritis in selected old age homes at Mangalore.
6.4 Objectives of the study
6 1. To determine the level of pain among elderly with knee osteoarthritis.
2. To determine the level of functional performance among elderly with knee osteoarthritis.
3. To evaluate the effectiveness of home based exercise in reduction of pain and increased functional performance among elderly with knee osteoarthritis.
4. To find the relationship between pain and functional performance among elderly.
6.5 Operational definitions
1. Effectiveness: In this study effectiveness refers to the extent to which the home based exercise achieves the desired result among elderly with osteoarthritis in reducing pain perception and improving functional mobility.
2. Home based exercise: Home based exercises are planned, structured and repetitive physical activities that are done in the home for the purpose of conditioning any part of the body. Home based exercise which are to be administered include:
Isometric Quadriceps Exercises(Quad Sets)
Knee Extension
Straight Leg raise
Knee Flexion
3. Pain: Pain is an unpleasant sensory and emotional experience associated with the actual or potential tissue damage. It is measured by numerical
7 pain scale.
4. Functional performance: Functional performance refers to the ability of an individual to carry out the activities of daily living like sitting, standing and walking. It is measured using KOOS (The Knee Injury and Osteoarthritis Outcome Score).
5. Elderly inmates: it refers to inmates of old age homes in the age group of 50 to 80 years, who are diagnosed to have osteoarthritis.
6. Osteoarthritis: Osteoarthritis is a degenerative disease, involving all the joints in old age carrying joint pain and swelling which restricts the joint movements.
6.6 Assumptions
The study assumes that;
osteoarthritis is common among old age people.
pain has effect on functional performance of patients with knee osteoarthritis
6.7 Delimitations
The study is delimited to:
1. The elderly inmates with knee osteoarthritis in selected old age homes.
2. The elderly in the age group of 50 to 80 years.
3. 3 The elderly who are willing to participate.
6.8 Hypotheses
The hypotheses will be tested at 0.05 level of significance.
H1: There is a significant reduction in pain scores after home based exercise among the elderly.
8 H2: There is a significant improvement in functional performance after home based exercise among the elderly.
H3: There is significant relationship between pain and functional performance among elderly osteoarthritis inmates.
7. Material and Methods
7.1 Source of data
Elderly with knee osteoarthritis of selected old age homes of Mangalore.
7.1.1 Research design
Research design used for the present study is time series design, which is used to measure the effectiveness of the exercise program in reducing pain and improved functional performance.
O1 X O2 O3
O1= Assessment of pain and functional performance of patients having knee
osteoarthritis before administration of treatment (home based exercise )
O2= Assessment of pain and functional performance of patients having knee osteoarthritis after administration of treatment on the 14th day.
O3= Assessment of pain and functional performance of patients having knee
th osteoarthritis after administration of treatment on the 28 day.
X= Treatment (home based exercise).
` 7.1.2 Setting
Study will be conducted in selected old age homes of Mangalore.
7.1.3 Population
In this study, population comprised of inmates diagnosed and those
9 fulfilling the diagnostic criteria of knee osteoarthritis.
7.2 Method of data collection
7.2.1 Sampling procedure
The subjects will be selected by using simple random sampling method.
7.2.2 Sample size
The sample consists of 30 osteoarthritis elderly.
7.2.3 Inclusion criteria
Inmates who are,
1. willing to participate in the study.
2. clients in the age group of 50 to 80 years.
7.2.4 Exclusion criteria
Bed ridden persons.
Person who had undergone orthopaedic surgery. (e.g.: amputation, knee replacement).
Those who are already on physiotherapy.
Critically ill patients.
Patients whose score exceeds ‘5’ according to numerical pain scale
7.2.5 Instruments intended to be used
Data collection instruments are the procedures or instruments used by the researcher to observe or measure the key variables in the research problem.
The following tools are used for data collection:
1. Demographic proforma including Diagnostic checklist.
10 2. Numerical pain scale.
3. KOOS (The Knee Injury and Osteoarthritis Outcome Score)
7.2.6 Data collection method
The researcher will obtain a written permission from the old age homes authority and the informed consent will be taken from the sample. The samples will be screened using numerical pain scale. Patients who have pain score less than or equal to five will be selected for the study.
The KOOS scale (The knee Injury and Osteoarthritis Outcome Score) is administered to assess the functional performance prior to the intervention. Home based exercises will be taught to the sample and asked them to do it twice daily for duration of 10 minutes and on the 14th and 28th day, the pain and the functional performance will be assessed using numerical pain scale and KOOS (The knee Injury and Osteoarthritis Outcome Score ) respectively.
The level of pain and the functional performance expressed by the osteoarthritis inmates will be analyzed to find the effectiveness of the home based exercises.
7.2.7 Plan for data analysis
Descriptive and inferential statistics will be used to analyze the data. Demographic Performa will be analyzed by using frequency and percentage. The effectiveness of isometric exercises will be assessed by using paired ‘t’ test. Analyzed data will be presented in the form of tables, graphs and figures
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes, in this study the researcher has to administer a non-invasive intervention-home based exercise. Home based exercises will be taught to the
11 elderly with knee osteoarthritis and the level of pain and functional performance will be assessed before and after giving intervention. The study follows a time series design.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes, ethical clearance has been be obtained from the ethics committee.
12 8. Bibliography
1. Monahan, Sands, Neigbhors, Marek, Greek. Phipps medical surgical nursing. 8th ed. St. Louis: Elsevier; 2008.
2. Black JM, Hawks JH. Medical surgical nursing. Vol. 2. 7th ed. St Louis: Elsevier; 2004.
3. Petrella RJ. Is exercise effective treatment for osteoarthritis of the knee? Br J Sports Med 2000;34:326-31.
4. O'Reilly SC, Muir KR, Doherty M. Annals of rheumatic disease. BMJ 1999;58.
5. Rosa US, Tlapanco JV, Maya CL, Rios EV, Gonzales LM, Rodriguez LG, et al. Reumatol Clin 2012;8.
6. Shakoor MA, Taslim MA, Hosain MS. Effects of activity modification on the patients with osteoarthritis of the knee. Bangladesh Med Res Counc Bull 2007 Aug;33(2):55-9.
7. Topp R, Woolley S, Hornyak J, Khuder S, Kahaleh B. The effect of dynamic versus isometric resistance training on pain and functioning among adults with osteoarthritis of the knee. Arch Phys Med Rehabil 2002 Sep;83(9):1187-95.
8. Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM, Gohdes DD, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Physical Therapy 2005 Dec;85 (12):1301-17.
13 9. De Jong ORW, Hopman-Rock M, Tak ECMP, Klazinga NS. An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip. Health Education Research 2004;19(3):316-325.
10. Sharma SK. Nursing research and statistics. Vol. 1. New Delhi: Elsevier; 2012.
11. http://www.frf.co.in/continrnalofuingEducationProgram.htm.
14 9. Signature of the candidate
10. Remarks of the guide
11. Name and designation of (in block letters) MRS. DIANA LOBO 11.1 Guide ASSOCIATE PROFESSOR DEPT. OF MEDICAL SURGICAL NURSING. LAXMI MEMORIAL COLLEGE OF NURSING, MANGALORE
11.2 Signature
11.3Co-guide (if any) MRS. SHAMBHAVI ASSOCIATE PROFESSOR DEPT. OF MEDICAL SURGICAL NURSING. LAXMI MEMORIAL COLLEGE OF NURSING, MANGALORE
11.4Signature
12 12.1Head of the department DR. LARISSA MARTHA SAMS PRINCIPAL DEPT. OF MEDICAL SURGICAL NURSING. LAXMI MEMORIAL COLLEGE OF NURSING, MANGALORE
12.2 Signature
13. 13.1 Remarks of the Chairman and Principal
13.2 Signature
15