A Study on the Effectiveness of Cope Program on the Stress and Coping Ability of Mothers

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE ANNEXURE II PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the candidate and CLEETA ANLINE PINTO address (in block letters) NITTE USHA INSTITUTE OF NURSING SCIENCES, PANEER, DERALAKATTE, MANGALORE – 574 160 KARNATAKA, INDIA.

2. Name of the institution NITTE USHA INSTITUTE OF NURSING SCIENCES, PANEER, DERALAKATTE,

3. Course of study and subject Ist YEAR M.SC. NURSING MEDICAL SURGICAL NURSING

4. Date of admission 02-06-2008

5. Title of the topic A STUDY ON THE EFFECTIVENESS OF ISOMETRIC EXERCISES IN REDUCTION OF PAIN AND IMPROVED FUNCTIONAL PERFORMANCE AMONG THE ELDERLY INMATES OF SELECTED OLD AGE HOMES WITH OSTEOARTHRITIS.

6. BRIEF RESUME OF THE INTENDED WORK: 6.1 Need for the study Osteoarthritis is one of the oldest and most common forms of arthritis known

1 as the “wear and tear” kind of arthritis. Osteoarthritis is a chronic joint disorder in which there is progressive softening and disintegration of articular cartilage accompanied by new growth of cartilage and bone at the joint margin (osteophytes) and capsular fibrosis1.Osteoarthritis is more common in older people, can develop it usually as the result of a joint injury, a joint malformation, or a genetic defect in joint cartilage. Both men and women have the disease. Before age 45, it equalizes in both men and women. At the age of 45 it is more common in women. It is also more likely to occur in people who are overweight and those with jobs that stress particular joints2. The incidence and prevalence of OA (osteoarthritis) at different anatomic region vary depending on whether this condition is defined by clinical symptoms, radiological finding or a combination of the two. Although all peripheral joints may be affected, OA of the knee has been the focus of many epidemiological studies. Age is the most consistent risk factor for both radiographic and symptomatic OA at all articular sites. The prevalence of OA increases after the age of 40 in women and 50 in men. OA affects about 50% of person age 65 and older and this prevalence increase to 85% in the group age 75 and older3. The article published in times of India “Osteoarthritis is India's No. 1 ailment” has ranked OA as number one comparing with diabetes mellitus and hypertension4.The high incidence of osteoarthritis in India is the result of its prevalence among women who fall victim to it. Menopausal women are especially prone to it. The disease is however, not restricted to women, although diabetes and hypertension remain the most prevalent ailments among men3. Most successful treatment programs involve a combination of treatments tailored to the patient needs, lifestyle and health. Most programs include ways to manage pain and improve function. These involve exercise, weight control, rest and relief from stress on joints, pain relief techniques, medication, and surgery, complementary and alternative therapies. Research shows that exercise is one of the best treatments for osteoarthritis. Exercise is also inexpensive and one of the non pharmacological therapy. Finally exercise is often required, in addition to dietary modifications for effective weight loss. For patient with knee osteoarthritis, twice daily set of supine 10 second isometric, quadriceps contractions can improve strength, reduce pain and reduce the risk of falling. This exercise is said to be well tolerated by moderately severe knee pain3.

2 Treatment for arthritis requires a multidisciplinary or team approach. Many types of health professionals care for people with arthritis e.g. Physical therapy, Physicians, Rheumatologists, and Nurse Educator. Various studies revealed that isometric exercise can be effective in reducing pain and improving functional ability of clients with osteoarthritis. 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: 1 A study was conducted by Ray Marks, to asses the effect of quadriceps exercise for osteoarthritis of knee. The study compared the short term (six week) versus a long term (13 months) quadriceps strength training regimen for osteoarthritis of knee. The results indicated that the isometric exercises were associated with a 40% increase in maximal isometric torque at six weeks, a 10% torque decline with detraining, with an additional torque increase of 30% after 13 months of further training5. 2 A study was conducted by Center for Health, Exercise, and Sports Medicine, School of Physiotherapy, The University of Melbourne, Victoria, Australia to examine whether the effects of 12 weeks of quadriceps strengthening on the knee adduction moment, pain, and function in people with medial knee osteoarthritis (OA) differ in those with and without varus malalignment. A single-blind, randomized controlled trial of 107 community volunteers with medial knee OA was conducted. Participants were stratified according to knee malalignment (more varus or more neutral) and then randomized into either a 12-week supervised home-based quadriceps strengthening group or a control group with no intervention. The primary outcome was the knee adduction moment, measured using 3-dimensional gait analysis. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index scores (measuring pain and physical function), step test score, stair climb test score, and maximum quadriceps isometric strength. Analyses of covariance were carried out based on intent-to-treat principles. Quadriceps strengthening did not significantly alter the knee adduction moment in either the more malaligned or the more neutral group. Function did not improve significantly following quadriceps strengthening in either alignment group, but there was a significant improvement in knee pain in the more neutrally aligned group (P

3 <0.001).The study concluded that Quadriceps strengthening did not have any significant effect on the knee adduction moment in participants either more varus or more neutral alignment. The benefits of quadriceps strengthening on pain were more evident in those with more neutral alignment6. 3 A study was conducted by Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R to asses the efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. Forty-six community dwelling patients, aged 55 years or older with knee pain and radiographic evidence of knee OA, were randomized to a 4 month home based progressive strength training program or a nutrition education program (attention control). Thirty-eight patients completed the trial with an adherence of 84% to the intervention and 65% to the attention control. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index pain and physical function subscales. Secondary outcomes included clinical knee examination, muscle strength, physical performance measures, and questionnaires to measure quality of life variables. Patients in the strength training group who completed the trial had a 71% improvement in knee extension strength in the leg reported as most painful versus a 3% improvement in the control group (p < 0.01). The study concluded that High intensity home based strength training can produce substantial improvements in strength, pain, physical function and quality of life in patients with knee OA7 4 A study was conducted by Sheila C O'Reilly, Ken R Muir, Michael Doherty 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.191 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). The exercise group performed strengthening exercises daily for six months. The primary outcome measure was change in knee pain (Western Ontario McMaster Osteoarthritis index (WOMAC)). Secondary measures included visual analogue scales (VAS) for pain on stairs and walking and WOMAC physical function scores. 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

4 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 function8. 6.3 Problem statement A STUDY ON THE EFFECTIVENESS OF ISOMETRIC EXERCISES IN REDUCTION OF PAIN AND IMPROVED FUNCTIONAL PERFORMANCE AMONG THE ELDERLY INMATES OF SELECTED OLD AGE HOMES WITH OSTEOARTHRITIS. 6.4 Objectives of the study 1 To identify the prevalence of knee osteoarthritis among the elderly people. 2 To identify the effectiveness of isometric exercises in reduction of pain and improved functional performance among the inmates of old age home with knee osteoarthritis. 3 To compare the experimental group and the control group in terms of reduction of pain and improved functional performance. 6.5 Operational definitions Effectiveness - In this study effectiveness refers to the extent to which the isometric exercises has achieved the desired effect as measured by the subject’s expression in reduction of pain and improved functional performance. Isometric exercises - In this study, it refers to the exercise which consists of statics quadriceps contraction and strengthening exercise carried out twice daily for a period of ten minutes continuously for four weeks. Reduction of pain: - it refers to the decrease in pain as measured by visual analogue scale. Functional performance – it refers to subject’s response to the items of WOMAC scale in terms of reduction in pain and improvement in physical function.

Elderly inmates: it refers to inmates of old age homes in the age group of 50 to 80 years, diagnosed with acute, sub acute and chronic osteoarthritis. 6.6 Assumptions The study assumes that 1. The inmates with acute, sub acute and chronic knee osteoarthritis experience pain and decreased functional performance.

5 2. Isometric exercises are effective in reducing pain and improving the functional performance among the knee osteoarthritis inmates. 6.7 Delimitations The study is limited to 1. The elderly inmates with knee osteoarthritis in selected old age homes. 2. The inmates in the group of 50 to 80 years. 3. To the inmates who are willing to participate. 6.8 Projected outcome (Hypothesis) To achieve the selected objective the following hypothesis were formulated and will be tested at 5% level of significance. H1: There will be a significant reduction in pain after regular performance of exercise among the osteoarthritis inmates. H2: There will be significant improvement in functional performance after regular performance of exercise among the osteoarthritis inmates.

7. MATERIALS AND METHOD: 7.1 SOURCE OF DATA: Elderly Inmates with acute, sub acute and chronic knee osteoarthritis of selected old age homes of Mangalore. 7.1.1 Research design Research design used for the present study is before and after with control design which is a true experimental design used to measure the effectiveness of the exercise program in reducing pain and improved functional performance.

Test Area: Level of Isometric exercise Level of phenomenon after Phenomenon treatment (Y) Before treatment (X) Control area: Level of phenomenon Level of phenomenon Without treatment (A) on without treatment (Z) Treatment (exercise) effect = (Y-X) – (Z-A) 7.1.2 Setting

6 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 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 Sampling size The sample consists of 20 osteoarthritis inmates in control and 20 in experimental group.

7.2.3 Inclusion criteria for sampling Inmates who are, 1. Willing to participate in the study. 2. With acute, sub acute, chronic knee osteoarthritis only. 3. Present at the time of data collection. 4. Clients in the age group of 50 to 80 years.

7.2.4 Exclusion criteria for sampling  Inmates unwilling to participate.  Age below 50 years and above 80 years.  Other than knee osteoarthritis  Those with other forms of treatment modalities.

7.2.5 Instrument 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.  Demographic proforma including Diagnostic checklist.  Visual analogue scale.  WOMAC osteoarthritis index

7 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 are selected using simple random sampling technique. The prevalence is assessed using the diagnostic checklist developed by the researcher. To the control group and the experimental group the visual analogue scale is administered to asses the level of pain and WOMAC scale for the functional performance prior to the intervention. For the experimental group 4 weeks of isometric exercises is administered twice daily for duration of ten minutes and on the 6th week the pain and the functional performance is assessed for both the experimental group and the control group using visual analogue scale and WOMAC scale respectively. The level of pain and the functional performance expressed by both experimental and the control group will be analyzed to find the effectiveness of the isometric exercises. 7.2.7 Data Analysis Plan Data will be analyzed using descriptive and inferential statistics.  Prevalence of osteoarthritis is computed using frequency and percentage.  Effectiveness of isometric exercises on the experimental group is computed by paired‘t’ test.  The comparison of the experimental group and the control group in terms of reduction of pain and improved functional performance is computed using independent sample‘t’ test. 7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so describe briefly. This study needs to administer the diagnostic checklist to identify the cases of knee osteoarthritis and perform the isometric exercises to the inmates diagnosed with knee osteoarthritis and assessing their pain level and functional performance using the visual analogue scale and WOMAC index scale respectively. 7.4 Has the ethical clearance been obtained? Yes , ethical clearance has been obtained from the ethics committee KSHEMA LIST OF REFERENCES 1. Solomon Louis, Warweck David, Nayagam Selvadurai. Apleys system of

8 Orthopedics and Fracture. 8th edition. Hodder Headline Group; 2001. 2. Maheswari .J. Essential Orthopaedics. 3rd edition. Metha Publishers; 2007. 3. American geriatrics society panel on exercise and osteoarthritis. Exercise prescription for older adults with osteoarthritis pain, consensus practice recommendations. Journal of American geriatric society.2001 June; 49: 808 4. Osteoarthritis is India's No. 1 ailment ... and cancer in India, a recent study suggests that osteoarthritis beats them all to claim the No1. Sep 2007. available from: URL: http:// www.timesofindia.indiatimes.com. Access date 11/8/08 5. Ray marks et al. quadriceps exercise for osteoarthritis of the knee a single case study comparing short term versus long term training effects. Physiotherapy, 1994 April; 80: 195-199 6. Boon-Whatt Lim , Rana S. Hinman , Tim V. Wrigley , Leena Sharma , Kim L. Bennell *The University of Melbourne, Victoria, Australia. The effects of 12 weeks of quadriceps strengthening on the knee adduction moment, pain, and function in people with medial knee osteoarthritis (OA). Arthritis Rheum. 2008 Jun; 15:59(7):943-51. 7. Baker KR, Nelson ME, Felson DT, Layne JE, Sarno R, Roubenoff R. The efficacy of home based progressive strength training in older adults with knee osteoarthritis: a randomized controlled trial. J Rheumatol. 2001 Jul; 28(7):1655-65 8. O'Reilly SC, Muir KR, Doherty M. To assess the effect of a home based exercise programme, designed to improve quadriceps strength, on knee pain and disability. Ann Rheum Dis.1999 Jan;58(1):15-19

8. SIGNATURE OF CANDIDATES

9 REMARK OF THE GUIDE

10 NAME AND DISSERTATION OF MRS. MOLLY. PINTO 10.1 GUIDE PROFESSOR

9 MEDICAL SURGICAL NURSING NITTE USHA INSTITUTE OF NURSING SCIENCES,

10.2 SIGNATURE

10.3 CO-GUIDE Nil

10.4 SIGNATURE

11. 11.1 HEAD OF THE MRS. FATIMA D’SILVA DEPARTMENT H.O.D, DEPARTMENT OF MEDICAL – SURGICAL NURSING NITTE USHA INSTITUTE OF NURSING SCIENCES,

11.2 SIGNATURE

12. 12.1 REMARK OF THE CHAIRMAN AND THE PRINCIPAL

12.2 SIGNATURE