RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

A STUDY TO ASSESS THE EFFECTIVENESS OF HOT AND COLD APPLICATION ON ARTHRITIC PAIN AND MOBILITY STATUS AMONG CLIENTS WITH OSTEOARTHRITIS IN SELECTED HOSPITALS AT KOLAR DISTRICT.

SYNOPSIS PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MS. J. ROSE JENILA A.E & C.S PAVAN College of Nursing Kolar, Karnataka-563101

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

SYNOPSIS PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1

NAME OF THE CANDIDATE AND ADDRESS

MS.J.ROSE JENILA I year M.Sc (N) PAVAN College of Nursing Bangalore – Chennai Bypass Road Kolar, Karnataka-563101

2

NAME OF THE INSTITUTION

A.E & C.S. PAVAN College of Nursing Kolar. I year M.Sc (N) Medical and Surgical Nursing 31-05-2007

3

COURSE OF THE STUDY AND SUBJECT DATE OF ADMISSION TITLE OF THE TOPIC

4 5

“A STUDY TO ASSESS THE EFFECTIVENESS OF HOT AND COLD APPLICATION ON ARTHRITIC PAIN AND MOBILITY STATUS AMONG CLIENTS WITH OSTEOARTHRITIS IN SELECTED HOSPITALS AT KOLAR DISTRICT.”

6.BRIEF RESUME OF THE INDENDED WORK INTRODUCTION “For all the happiness mankind can gain Is not in pleasure but relief from pain.” Osteoarthritis is primarily a degenerative, non-inflammatory disorder of movable joints characterized by an imbalance between the synthesis and degradation of particular cartilage leading to the classic pathologic changes of wearing away and destruction of cartilages.1 Joint diseases affect millions of people throughout the world, causing pain and disability with great impact on individuals and on society as a whole. Osteoarthritis is the most common joint disease in the near future and is projected to rank second for women and fourth for men in the developed countries in terms of years lived with disability. Men are more often affected than women before the age of 50. Women are affected twice as often as men after the age of 50. Elderly patients are most often affected (joint diseases account for half of all chronic conditions in persons aged 65 years and above) and because the number of individuals over the age of 50 years is expected to double world wide between 1990 and 2020, the global burden of osteoarthritis will increase drastically. Osteoarthritis in the ageing population will generate a global avalanche of costs and disability.2

The prevalence of osteoarthritis varies according to the method used to detect it. Radiographic prevalence showed that 75% of women in the age group of 50 – 70 years had evidence of osteoarthritis of distal inter phalangeal joints of hand prevalence rate of all joint sites study increased markedly with age in both men and women where as osteoarthritis knee is more common in women where as osteoarthritis of hip is more common in men Although osteoarthritis is worldwide problem, geographic and ethnic differences have been reported. The prevalence of hand and knee osteoarthritis is similar among Europeans and Americans. There is a lower rate of hip osteoarthritis in African blacks. Asians, Indians and Hon Kong Chines.3 Most of the population in India is above the age group of 60 years. 95% of them are less than 85 years. In this 87% are having acute illness and 96% are having chronic illness. Hypertension, cataract and osteoarthritis were the 3 most common illnesses among older population in India.4 The pain from osteoarthritis is the first presenting complaint of clients and is localized, deep dull ache. The pain is due to subchondral bone changes, stretching of ligaments or nerve endings in periosteum and inflamed or distended joint capsule. Client also experience pain with activity due to bone on bone contact at the time of weight bearing. 80% of the clients with knee osteoarthritis reported problems related to muscle function i.e., muscle strength, endurance and balance coordination. 5 Disability due to hip and knee osteoarthritis is as great as that attributes heart disease. While osteoarthritis affects many joints of the body, the knee is the most commonly involved joint associated with

disability. Knee arthritis causes many limitations, which include difficulty in floor level activities, ascending and descending stairs, squatting, etc. High impact activities, that include running or jumping can be detrimental and painful. These difficulties or limitations can significantly reduce the quality of life in an active individual.6 No curative treatment has yet been found for knee osteoarthritis and treatment is directed towards symptom relief and preventing of further functional deterioration. Current modes of treatment helps to decrease pain and improve functioning range from information, education, physical therapy and aids, analgesics, nonsteroidal anti-inflammatory drugs, joint injections and knee replacement procedures in which all or part of the joint is replaced with plastic, metal or ceramic implants.7 Thermo therapies have been used in the conservative management of osteoarthritis, the local stimulations of temperature sensitive receptors in the skin, impulses travel from the periphery to the hypothalamus and the cerebral cortex. The hypothalamus then initiates heat producing or heat reducing location of the body. The conscious sensations of temperature are aroused in the cerebral cortex. These interventions are effective by decreasing pain through hot applications and increasing large diameter nerve fibre input to block small diameter pain fibre input to block small diameter pain fibre messages by cold and hot application.8

6.1 NEED FOR THE STUDY “A physically active individual lives much healthier and active life than people who are physically inactive”. This is true for every one but especially for people with osteoarthritis. In America 32.9 million Americans (about 23 % of adult populations) had some type of arthritis. In this 15% of the population experience long term complications due to osteoarthritis related conditions. Pain and stiffness are the main features of osteoarthritis and it may result in deformity and disability. 9 The Health statistics report stated that, osteoarthritis of knee based on racial categories – 27 % of Caucasian population, 2.1% of American population and 1% of people classified in ‘other’ racial categories. It was reported that more than 20 million Americans have symptomatic osteoarthritis. Women had higher rates of incidence than men especially after age of 40 years. In the US, osteo arthritis numbers second to Ischemic heart disease as a cause of work disability in men over the age of 50 years. In UK it affects Approximately 2.5% of the populations. In India primary osteoarthritis was more common than secondary osteoarthritis. 10 Osteoarthritis can have serious effects on a person’s life and well being. Current treatment strategies include pain Relieving drugs, a balanced rest and exercise, cost effective symptomatic management interventions, client educations and support programs allow more people with this disorder to lead an active and productive life.11 Pain and stiffness are the main features of Osteoarthritis and it may results in deformity and disability if proper care is not taken. Because of the chronic and progressive nature of the disease, hot and cold application may be required periodically for weeks or even years

depending upon the course of the disease and the individual patient. Therapy has a great influence on the knowledge of rehabilitation, which helps in reducing disability or deformity thus improving the quality of life. Pain particularly experienced by orthopaedic patient is one of the most common clinical stimulation encountered by health professionals especially by nurses. The nurse is most effective in providing comfort by understanding the nature of pain and client’s perception and working closely with the clients to find out the best relief measures. Hot or cold applications may relieve pain through a counterirritant effect as well as by direct effect on peripherals and free encoding. Hot applications promote muscle relaxation and decrease pain from spasm or stiffness where as cold application decreases nerve conduction velocity, induce numbness or paresthesia. Before applying hot and cold therapies, the nurse has to asses the physical condition for signs of potential intolerance to heat and cold. The nurse is legally responsible for safe administration of hot and cold application. 12 During the investigator’s clinical practice in the field of nursing, the investigator found that many clients attending orthopedic out patient department and inpatient department clients undergoing total knee replacement had various degrees of osteoarthritis with severe pain and limitations in mobility. The clients expressed that they need an intervention to relieve pain and improve their mobility status. Based on the review of literature various therapies like hot and cold applications have beneficial effect in reducing joint pain and improving the mobility status. Pain is subjective feeling and so it is extremely important for the nurse to assess, intervene and evaluate each clients discomfort on an individual basis. So the investigator would like to conduct such a study on osteoarthritis.

6.2 REVIEW OF LITERATURE Review of literature is a systematic search of literature to gain information about a research topic .It helps to gain an insight in to the research. Problem and provides information of what has been done previously. It helps the researcher to be familiar with the existing studies and also provides base for methodology tool for data collection and research design. The literature review is based on an extensive survey of books, journals and articles. The relevant studies are organized in to the following categories based on objectives. It is divided into 5 sections as follows: Section A: Studies related to over view and risk factors of osteoarthritis Section B: Studies related to Pain and mobility status in osteoarthritis of knee Section C: Studies related to conservative therapy for osteoarthritis Section D: Studies related to effectiveness of hot applications for osteoarthritis Section F: Studies related to effectiveness of cold applications for osteoarthritis REVIEW OF RELATED LITERATURE Section A: Studies related to overview and risk factors of osteoarthritis. Review of studies conducted to estimate the lifetime risk of symptomatic knee osteoarthritis overall and stratified by sex, race education, history of knee injury and body mass index (BMI). A longitudinal study of black and white women and men age > or =

45years

living

in

rural

North

Carolina.

Radiographic

and

sociodemographic and symptomatic knee data measured at baseline and first follow-up were analyzed. The result showed lifetime risk rose with increasing BMI with a risk of 75% among those who were obese. Nearly half of the adults will develop symptomatic knee osteoarthritis by age 85 yrs with life time risk highest among obese persons.40 Population based study conducted in North California to estimate the prevalence of knee related osteoarthritis outcomes in African American and Caucasians aged more than 45 years. 3018 participants have been selected. Kellegran and Lawrence radiographic grading was used. 28% had radiographic knee osteoarthritis, 16% had symptomatic knee osteoarthritis and 8% had severe radiographic knee osteoarthritis. Higher prevalence was seen in older individuals especially among women and African Americans than Caucasians.13 Comparative study conducted with the aim of examining the relationship between knee osteoarthritis with body weight in osteoarthritis with body weight in Moroccan sample of clients. Interviews were obtained from 95 cases with knee osteoarthritis and control taken from general population. The risk of knee osteoarthritis increased with higher body mass index, odds ratio=3.12(p<0.001) overweight is risk factor for knee osteoarthritis. 14 Population based survey conducted to document the association of floor activities with pattern and severity of knee osteoarthritis 288 women and 288 men more than 40 years from southern Thailand have been studied. 3 common positions in floor activities squatting side knee bending and kneeling were recorded. Multinomial logistic regression analysis was used. The results showed that squatting and

side knee bending positions had increased the relative risk of moderate to severe knee pain and radio graphic knee osteoarthritis. 15 In order to identify the risk of osteoarthritis associated with occupational factors, four relevant epidemiological studies showed a correlation between osteoarthritis of knee joint and knee flexion under physiological stresses. Mechanical stress leads to degeneration of osteophytes and early onset of tibio femoral osteoarthritis in the elderly.16 Retrospective study conducted to investigate the association between squatting and the prevalence of knee osteoarthritis. A random sample of 72 Beijing residents more than 60 years were enquired about duration of squatting. Knee radiographs were taken. Among the study subjects, 40% of the men and 68% of the women reported squatting one hour per day. Prevalence of tibio - femoral osteoarthritis was found to be increased in both men and women who squatted more than 30 minutes per day compared to subjects who squatted less than 30 minutes per day. 17 Descriptive study conducted to determine the health concerns of men with osteoarthritis from Missouri hospital were selected by convenient sampling technique. Arthritis Impact Measurement Scale 2 was used. The men were more concerned about pain, walking, bending and stairs climbing. They predicted that in the next 10 years arthritis would be a major health problem. So interventions should focus on strategies to deal with pain and decreased mobility. 18

Section B: Studies related to pain and mobility status in osteoarthritis of knee. Comparative study conducted to explore the gender differences in pain experiences, pain control beliefs, pain coping strategies and depressive tendency among Chinese elderly with knee osteoarthritis.199 outpatients with osteoarthritis, in Taiwan were selected. Female elder reported greater pain and depressive tendency was a mediator in predicting overall pain intensity. But there was no significant difference in gender with regard to pain control beliefs.19 An exploratory study conducted to understand the experience of living with knee osteoarthritis in older adults. Nine interviews conducted to participants with physician diagnosed knee osteoarthritis of different ages, sexes, cultural backgrounds and selfperceptions. The results showed living with knee osteoarthritis emerged experiencing knee pain is central to daily living experiencing mobility limitations devalues self-worth, sharing the experience, assessing our own health and managing chronic pain. 41 An experimental study conducted to determine whether knee osteoarthritis reduces ambulatory capacity and impairs quality of life. 56 subjects were selected with and without knee osteoarthritis. A 6 minutes walk test results showed that vital oxygen peak was significantly higher in the controls when compared with clients .The subjects without knee osteoarthritis walked a significantly longer distance than clients with knee osteoarthritis. A significant negative correlation between pain and physical limitation was observed. 20 An article on osteoarthritis states that progresses the knee pain, joint misalignments, restriction in knee mobility and reduced walking occur frequently. Activities such as climbing stairs or sitting

for long periods with bent legs are named as sources of pain for clients with patello femoral osteoarthritis. Medical or lateral osteoarthritis of the knee was very probable. 21 Comparative study conducted at New York to investigate the movement and muscle activation strategies during walking of individuals with medial knee osteoarthritis. 28 cases and 26 controls were participated. Knee instability was assessed with activities of daily living scale and knee motion was assessed by motion analysis. Independent’s test and regression analysis revealed that osteoarthritis group used less knee motion and higher Muscle co-contraction during weight acceptance which was found to be detrimental to joint integrity.22 An experimental study conducted to assess the physical function of older clients with clinical knee osteoarthritis. 106 sedentary subjects more than 60 years (mean 69.4, standard deviation 5.9) with knee osteoarthritis (mean 12.2, standard deviation 11.0) were participated in the study. Mobility, joint flexibility and muscle strength were evaluated by recording time to ascend 8 of descend 4 stairs, rise from sitting or sit down from chair (5 times). Using Spearman correlation walking, stairs climbing, chair rise were significantly correlated with each other and with the pain rating scale index (p<0.001). 23 Descriptive study conducted from 1192 Africans and Caucasians to evaluate pain severity and mobility limitations in osteoarthritis knee clients. Multiple logistic regression analysis showed that 43% reported difficulty in performing 1 task. Mild radiographic knee osteoarthritis was associated with difficulty in mobility like mobility like climbing, taking a tub bath, getting in and out of car. Moderate pain was associated with difficulty in performing 17 out of 20 tasks, except

lifting a cup, opening car door, and turning faucets. Knee pain severity was the strongest risk factor for self reported difficulty in performing upper and lower extremity tasks. 24 Section C: Studies related to conservative therapy for osteoarthritis. Comparative study conducted to investigate the therapeutic effects of physical agents administered before isokinetic exercise in women with knee osteoarthritis. One hundred patients with bilateral knee osteoarthritis were randomized in to five groups of 20 patients each received hot packs and exercise with in addition of. Group 1 received short wave diathermy. The second group received transcutaneous electrical nerve stimulation. Group three received ultrasound. Group four received hot packs and isokinetic exercise and group five served as controls and received only isokinetic exercise. The results showed pain and disability index scores were significantly reduced in each group. Patients in the study groups had significantly greater reductions in their visual analog scale scores and scores on the sequence index than did patients in the controls group. 42 An article on conservative therapy states that highly effective measures as well as orthopedic aids are available for the knee osteoarthritis. Thermotherapy, physiotherapy, Balneo therapy, pulse signal therapy, magnetic field therapy, acupuncture, radiotherapy and drug therapies control symptoms to different extents in osteoarthritis management. 25 An experimental study conducted in Hong Kong to assess the effectiveness of an arthritis self management programme with an added exercise component among osteoarthritis clients. 88 and 94 subjects were assigned to an intervention group and control group

respectively. Mann Whitney U-test and Friedman test revealed that there was a significant difference in reduction of pain (p=0.001), fatigue (p=0.008), Increase duration of weekly light exercise practice (p=0.001) and knee flexion (p=0.004) in between groups. Intervention group had a positive effect in pain reduction and improvement of functional status. 26 Studies on various modifiable risk factors for osteoarthritis include obesity, occupational factors, sports, sports participation, muscle weakness, nutritional factors and hormonal influence. Drug therapies may reduce pain joint damage. For severely damaged joints, partial or total replacement of the joint is performed. Rehabilitative interventions are joint specific exercises, physical fitness, physical modalities, education and self management. 27 The group randomized pattern controlled study conducted to 38 participants were recruited from the community sources and randomly assigned to 12 weeks aquatic programme of a non exercise control condition. Data were collected at baseline, week 6 and week 12. Goniometry, 6 minutes walk test, health assessment questionnaire and visual analog scale for pain used. Repeated measure analysis of variance showed that aquatic exercise had a statistically significant improvement in knee flexion, strength and aerobic fitness. 28 To explored the wide spectrum of treatment modality including education, exercise, pharmacological agents and surgery. The evidence for these treatments needs to be examined so that nurses can have an evidence based practice. The importance of individual characteristics and available resources need to be considered on treatment selection. 29

Descriptive study conducted to explore the perceived importance of symptoms and treatment preferences of people with osteoarthritis. 112 knee osteoarthritis clients were interviewed. The results showed that pain, instability and disability in the joint were the common symptoms. Oral drugs (90%), physical therapy (62%) and aids (56%) were the common medical treatment. Surgery and intraarticular injections were the most efficacious options. 30 Section D: Studies related to effectiveness of hot application for osteoarthritis. An experimental study conducted to reveal the efficacy of heated mud pack treatment in patients with knee osteoarthritis and to find the contribution of chemical factors to the build up of these effects. 60 clients were randomly allocated in to 2 groups. The intervention and followed up for 24 weeks at 4 weeks intervals. A significant number of patients in the study group showed minimal clinically important improvement as compared to the control group. The result showed heat mud pack treatment significantly improved the pain and functional status of patients with knee osteoarthritis. 43 A prospective randomized study conducted to evaluate the effectiveness of the dry heat sheet. 37 patients using the heat steam generating sheet and 17 using the dry heat generating sheets, who used the sheets continuously for 4 weeks, were studied. The pain rating scale score was used. The result showed significant improvement of the total pain rating scores with heat generating steam group, but no significant change was observed in the dry heat generating sheet group.44 Comparative study conducted to assess the therapeutic benefits of thermo care heat wrap combined with and education programme to

an education – only programme on reducing pain and disability in osteoarthritis clients. 43 clients at US have been randomly assigned to two groups. One group received education alone and the other group received education and topical heat application 400C for 87 hours. The results evaluated on day 4, 7 and 14 and it showed a significant reduction in pain intensity, increased pain relief and improved disability scores after treatment with heat therapy. 31 A research on prospective, researcher blinded, repeated measures, and randomized complete block design. The researcher compared the effects of moist heat pack and control treatment on hamstring muscle strength. Participants received a 3 treatment sequence to the posterior thigh. A mixed model analysis of variance with 3 pretest and 3 posttest measures showed a significant difference between posttest scores of the moist heat group and the control group. The heat therapy helps in gaining flexibility of the hamstring musculature. 32 An experimental study conducted to assess the effectiveness of transcutaneous nerve stimulation for managing osteoarthritis knee pain, 24 subjects were randomly allocated in to 2 groups receiving transcutaneous nerve stimulation (TENS) at 100 Hertz or a placebo. Repeated measure analysis of variance and Pearson correlation were used. By day 10, Transcutaneous nerve stimulation produced a significantly increased maximum knee range of motion (p=0.067) than placebo group (p=0.033). So transcutaneous nerve stimulation has proved to improve knee function and knee range of motion. 33 An experimental study conducted to assess the effectiveness of superficial heat 400C on quantifiable pain behaviors in osteoarthritis of knee. Spontaneous pain behaviors, degree of weight bearing and joint circumference were assessed. Heat treatment produced a small but

significant decrease in pain behavior (p=0.05). Acute arthritic pain can be treated with superficial heat for reducing pain and guarding. 34

Section E: Studies related to effectiveness of cold application for osteoarthritis. Review of studies conducted to evaluated the physiological responses to cold therapy Cryotherapy (ice pack) is prescribed for reduction of pain, swelling and discomfort in osteoarthritis. Cryotherapy inhibits signs of inflammation and skin temperature decreases from 330C to 100C within 10 to 20 minutes. Cryotherapy leads to vasoconstriction, reduction of edema, and diminished pain perception, Ice packs are efficient techniques to cool tissues. 35 An experimental study conducted at Bangkok to compare the skin surface temperature during cryotherapies. A repeated measures design was used. 50 women receive each of the 4 cryotherapies (ice pack, gel pack, frozen peas, mixture of alcohol and water). The mean skin temperature for the above therapies was 10.2, 13.9, 14.4 and 10 0C respectively. The ice pack and mixture of alcohol and water significantly reduces the skin temperature (p<0.001) than the gel pack and frozen peas. 36 Randomized controlled trial conducted at New York to determine the effectiveness of cryotherapy in the treatment of knee osteoarthritis. 179 clients receive 20 minutes of ice massage for 3 weeks compared to controls with a placebo treatment. Mean difference results showed increase in quadriceps strength (29% relative difference), improves knee flexion (8% relative difference) and functional status (11% relative difference). 37

An experimental study conducted at Chicago to test whether significant pain relief could be achieved by whole body cold therapy. 120 consecutive clients with rheumatoid arthritis. Osteoarthritis, low back pain, primary and secondary fibro myalgia were treated 2.5 minutes in the main chamber at -105 degrees C.ANOVA and paired ttests results showed that pain level decreases significantly and lasts for about 90 minutes. 38 An experimental study conducted at Netherlands to evaluate and compare the effects of locally applied cold treatments on skin and intra articular temperature of osteoarthritis clients. 42 clients were divided randomly into two treatment groups (ice chips and nitrogen cold air). The results showed that the mean temperature of the surface skin after 3 hours dropped from 32.2 – 160C after application of the ice chips and from 32.6 – 9.80C after nitrogen cold air; the mean intra articular temperature decreased from 35.50C – 29.10C and from 35.80 C – 32.50C respectively after the therapies. 39

STATEMENT OF THE PROBLEM A study to assess the effectiveness of hot and cold application on arthritic pain and mobility status among clients with Osteoarthritis in selected hospitals at Kolar district. 6.3 OBJECTIVES OF THE STUDY 1. To compare the pretest level of pain and mobility status between hot and cold application groups clients with osteoarthritis. 2. To compare the posttest level of pain and mobility status between hot and cold application groups clients with osteoarthritis. 3. To associate the posttest level of pain and mobility status with their selected demographic variables of hot application group clients with osteoarthritis. 4. To associate the posttest level of pain and mobility status with their selected demographic variables of cold application group clients with osteoarthritis. 6.4 OPERATIONAL DEFINITIONS: Effectiveness: It refers to the reduction of pain level and improvement of mobility status after the application of hot and cold therapy over the painful joint area. Hot application: It refers to the application of moist heat therapy over the painful joint surface in the form of wringer rods wrung out of hot water

(450C) and allowed to remain for 15 minutes for 3 times a day with the interval of 3hrs for 3 days

Cold application: It refers to the application of moist cold therapy over the painful joint surface in the form of gauze wrung out of cold water (160 -180C) and allowed to remain for 15 minutes for three times a day with the interval of three hours for three days. Arthritic Pain: It is a subjective expression of discomfort perceived by the patient as a result of deterioration of the involved joint as measured by Cincinnati knee rating scale for pain. Mobility status: It refers to the ability of the client to move the joint in its full range of motion as elicited by WOMAC mobility assessment scale. Clients: It refers to those persons who have been admitted for Osteoarthritis. Osteoarthritis: It refers to a slow progressive non-inflammatory disorder of the diarthroidal (synovial) joints. 6.5 HYPOTHESIS: H0: There will be no significant difference in the posttest level of pain and mobility status between hot and cold application group clients with osteoarthritis. 6.6 VARIABLES UNDER STUDY

Independent variable: o Application of hot therapy for 25clients. • Application of cold therapy for 25 clients. Dependent Variable: Pain and Mobility status of hot and cold application group clients with osteoarthritis. Attributed Variables: Age, Sex, education, work status, family income, dietary pattern, duration of illness and previous mode of therapy. 7. MATERIALS AND METHODS:7.1 Source of data Patients admitted in SNR and Devaraj hospitals. 7.2 Methods of data collection: 7.2.1 Research design: The research design in this study is true experimental design and the approach used is comparative approach. R R R – Randomization O1 -- Pretest level of pain and mobility status. O2 -X1 X2 -Post test of pain and mobility status. Application of hot therapy Application of cold therapy O1 O1 X1 X2 O2 O2

7.2.2 Setting of the study:

The study will be conducted in Sri Narasimha Raja (SNR) and Devaraj hospitals; Kolar district. SNR hospital which is a 400 bedded hospital situated 2km away from Pavan College of Nursing from Pavan College of nursing . 7.2.3 Population: Clients with osteoarthritis of both sex. 7.2.4 Sample: Clients with osteoarthritis of both sex the age group between 30 - 60yrs in SNR and Devaraj hospitals at Kolar district. 7.2.5 Sample size: 50 . 7.2.6 Sampling technique: The clients who satisfied the inclusive criteria will be included in sampling framework and 50 samples will be selected by simple random sampling technique (lottery method), out of which 25 samples will be allotted to hot application group and 25 samples will be allotted to cold application group. 7.2.7 Sampling criteria: 1.Inclusion Criteria:  Clients who have been diagnosed to have Osteoarthritis of knee.  Clients who are admitted for a period of at least 3 days.  Clients who are willing to participate in the study.
 Clients who can understand Kannada and English.

and

Devaraj hospital which is a 600 bedded hospital situated 4km away

2. Exclusion Criteria:

 Clients with neurological disorders, who is not able to perceive pain.  Clients with other joint inflammatory disorders or bone disorders.
 Clients who have undergone any ortho - surgical procedures.

 Clients who are under going physiotherapy.
 Clients who are on pain medications like morphine.

 Clients who are having contraindications for heat and cold application 7.2.8 Tools of data collection: The tool comprises of three sections. Section – A: Demographic variables are age, sex, weight, education, work status, family income, dietary pattern, duration of illness and previous mode of therapy. Section – B: Modified Cincinnati knee rating scale for pre and post test level of pain assessment. Section – c: Modified WOMAC Mobility assessment scale for pre and posttest level of mobility assessment on activities like standing, bending to floor, sitting, walking on flat surface, rising from sitting, getting on or off toilet and stairs climbing. Scoring Key; For pain scale:

0, 2 – Mild pain. 4, 6 – Moderate pain. 8, 10 – Severe pain. For mobility scale >7 - 10 Mild difficulty. >3 - 7 Moderate difficulty.

0 - 3 Severe difficulty. 7.2.9 Methods of data collection: Data pertaining to the demographic variables will be collected by interview method. Prior to the study the purpose of the study will be explained and consent of the participants will be obtained to involve in the study. Before the original study a pilot study will be conducted and then necessary modifications and further refinement of the tools will be done. Researcher herself will collect the data. 7.2.10 Data analysis and interpretation: Descriptive and inferential statistical techniques such as frequency distribution, central tendency measures (mean, median, and mode), standard deviation, chi square and co-relation coefficient will be used for data analysis and presented in the form of tables, graphs and diagrams. 7.3 Does the study require any investigation or interventions to be conducted on patients / sample populations / other humans or animals? The study will be conducted on clients of age between 30 and 60 years, admitted in the SNR and Devaraj hospitals, Kolar. Since the study is the pre and post experimental study. 7.4 Has ethical clearance been obtained from your institutes?

Prior permission will be obtained from the concerned authorities of SNR and Devaraj hospitals of Kolar district to conduct a study and also from research committee of A.E & C.S Pavan College of nursing, Kolar. The purpose of the study will be explained to the Osteoarthritis patients who are admitted in the SNR hospital. Scientific objectivity of the study will be maintained with honesty and impartiality. 8. LIST OF REFERENCES 1.
2.

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behaviors in osteoarthritis. Journal of Orthopedics. Vol.LXXXVII:No.12. Pp.15 – 18. 35. Greenstein .G (2007). Therapeutic efficacy of cold therapy in osteoarthritis. Journal of Orthopedic Nursing, Vol.XXV: 36. Kanlayanphotporn R. et al. (2005). Comparison of skin surface temperature during cryotherapy. Journal of Orthopedic Nursing. Vol.LXXXVI: No.7. Pp.1411 – 1415. 37. Brosseau. et al.(2003). Cryotherapy for treatment of osteoarthritis. Archieves of Physical Medical Rehabilitation. Vol.LXXXVII:No.6. Pp.749 – 756. 38. Metzger D. et al. (2000). Whole body cryotherapy. Journal of Rehabilitation Nursing. Vol.XXXIX: No.2. Pp.93 – 100. 39. Rasker JJ. (2000). Effect of cryotheraphy on articular temperature. American Journal of Nursing. Vol.XV: No.2. Pp.37 – 40.
40. Murphy L.Schwartz et al (2008). Life time risk of symptomatic

knee osteoarthritis. Journal of Arthritis Rheumatology. Pp. 1207– 13.
41. Maly MR. et al (2007). Personal Experience of living with knee

osteoarthritis in older adults. Journal of Disability Rehabilitation .Pp.1423 - 33.
42. Cetin et al (2008), Comparing hot pack. Journal of Am J Phys

medical Rehabilitation. Pp. 443-451.

43. Odabasi et al (2008). Reveal the efficacy of heated mud pack

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44. Seto H.et al (2008).Evaluate the effectiveness of the dry heat sheet.

Journal of J.Orthopaedic science Pp.187-191.

9

SIGNATURE OF THE CANDIDATE

1 0 1 1

REMAARK OF THE GUIDE

NAME AND DESIGNATION OF (IN BLOCK LETTERS)

11.1 GUIDE 11.2 SIGNATURE

11.3 11.4 11.5 11.6
1 2

CO-GUIDE SIGNATURE HEAD OF THE DEPARTMENT SIGNATURE

REMARKS OF THE CHAIRMAN AND PRINCIPAL 12.1 SIGNATURE

Rajiv Gandhi University of Health Sciences, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

Registration No.
Name of the Candidate Address Name of the Institution Course of Study and Subject Date of Adimission to Course Title of the Topic Brief resume of the intended work Signature of the Student Guide Name Remarks of the Guide Signature of the Guide Co-Guide Name Signature of the Co-Guide HOD Name Signature of the HOD Principal Name Principal Mobile No. Principal E-mail ID Remarks of the Principal

: 05_N006_7165
: J Rose Jenila : #1/253, Mouleeswarar Nager, Moulivakkam, Chennai : AECS Pavan College of Nursing, Kolar : MSc Nursing in Medical Surgical Nursing : 22/05/2008 : A Study to assess the effectiveness of hot and cold application on arthritic pain and mobility status among clients with osteoarthritis in selected hospitals at kolar district. : Attached : : Mrs. Manoranjitham : Good : : Mrs. Shiyamala Rani T : : Mrs. Manoranjitham : : : : :

Principal Signature

:

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