Study on intensity of knee joint pain by 'Application of Moist Heat'

among geriatric population (≥ ≥ 60 years of age)

Parminder Kaur, Indarjit Walia, Sushma Kumari Saini

Abstract : Healthy geriatric population make major contribution to health. Providing nursing
care for geriatric population is a major area of responsibility in all health care settings. Knee joint pain
is the most frequent complaint among the geriatric population. The present study has been undertaken
to study the effect of ‘moist heat application’ on the intensity of knee joint pain among geriatric
population (≥ 60 years of age) residing at Dadu Majra Colony, U.T., Chandigarh. Out of the total
geriatric population surveyed in the present research 48% had knee joint pain. Every 3rd individual
was selected as a study sample by using a systematic random sampling technique .The sample
size consisted of 87 subjects i.e. 43 in the experimental and 44 in the control group. The experimental
and the control groups were similar in respect to age, marital status, intensity of knee joint pain,
intake of pain killer, duration and experience of knee joint pain. Intensity of knee joint pain was
assessed on the 1st and 8th day of intervention among both experimental and control group. ‘Moist
heat’ was applied at the knee joint twice a day for seven days in the experimental group. The results
show that intensity of knee joint pain and intake of painkiller was reduced significantly in the
experimental group as compared to the control group as indicated by chi-square test. Hence, the use
of moist heat application is recommended for home base management of knee joint pain.

Key Words : Introduction

Knee joint pain, Moist heat application Ageing is a natural phenomenon that
is experienced by all living organisms. Healthy
geriatric population makes major contribution
to the health and development of the country.
Live well, eat well and be positive. Those who
Correspondence at : have survived to old age should be well
Sushma Kumari Saini informed about the ways to prevent diseases
Lecturer, and to maintain the quality of life to extend
National Institute of Nursing Education their sur vival. 1 Various diseases that
PGIMER, Chandigarh, India.

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 162
commonly affect geriatric population are
musculoskeletal pain, hear t diseases,
hyper tension, diabetes, asthma and skin
diseases.2
Musculoskeletal pain is a major health
problem among geriatric population according
to the surveys undertaken in both developed
and developing countries. Knee and low back
pain are the most frequent complaints among
this population.3 Knee pain is more common
than back pain among this population and
with increase in life expectancy in developed
and developing countries, this is an epidemic
which is destined to grow.4 Most of geriatric
population is troubled by chronic knee pain
that has a major effect on their quality of life.5
It accounts for approximately one-third of
musculoskeletal problems in this population.
High prevalence of knee joint pain was
reported by various authors i.e. 46.7% among
60 years and above population and 40.7%
among 65 years and above.7, 8 Under treated
or poorly managed knee joint pain can affect
their physical, psychological, social, and
emotional life.6
These real life consequences of knee
joint pain need to be given adequate attention
in the home care settings. So, there is a need
to have home based management. Many
researchers have studied and recommended
the moist heat application for helping the
people suffering from knee joint pain.9,10,11
Moist heat application is non pharmacological,
inexpensive and simplest approach which has
Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007
a beneficial effect on knee joint pain.12 It causes
vasodilatation and it penetrates deeper into
the muscle and hence reduces the muscle
spasm and pain.9, 13
It prevents the perception of the pain
through its effect on sensory nociceptors by
decreasing the conduction time and synaptic
activity. Moist heat is more effective than dry
heat as it penetrates more than dry heat with
the same temperature. It has additional
capacity to change the tissue temperature
rapidly and more vigorous response from
temperature receptors. It increases the
extensibility of collagen tissues. It decreases
joint stiffness in tendons and ligaments.9,13
Studies show that topical heat
application is more easily accepted while cold
application is less favorably accepted. 12 A
study on the use of moist heat application
revealed that 20-30 minutes of topical applied
heat produce a marked increase in local
circulation, with all structure contributing to
the response including tissues located three
or more centimeters below the surface of the
skin.14 While working in the community the
investigator has observed that majority of
population is suffering from knee joint pain.
No standard protocol is being practiced in
community for moist heat application. Hence
the investigator is motivated to conduct this
study on management of knee joint pain
following application of moist heat among
geriatric population. So, this comprehensive
study is designed to find out the change in
163
intensity of pain at knee joint by moist heat
application.
Main Objective
To evaluate the change in the intensity
of pain by application of moist heat on the
knee joint among geriatric population.
Materials and Methods
A quasi-experimental study was
conducted during the months of January and
February 2007 in Daddu Majra Colony, U.T.,
Chandigarh. Daddu Majra Colony is a
resettlement Colony, chosen purposively for
the study because of familiarity with the area.
It is situated on the Nor thwest corner of
Chandigarh and is at a distance of 5 km from
National Institute of Nursing Education (NINE)
PGIMER, Chandigarh and 6 km from the
Interstate Bus Terminus sector 17 of
Chandigarh. The investigator developed a
procedure for ‘Moist Heat Application’ on knee
joint pain, Sur vey Per forma, Inter view
Schedule and Pain Assessment Scale
according to the objectives.
Nine experts from the field of Nursing,
one from Community Medicine and one from
Physiotherapy validated the tool. The experts'
suggestions were incorporated into the final
draft of the tool. The survey Per forma,
interview schedule and pain assessment scale
were translated into Hindi and again
retranslated into English to check the validity
of translated tools. The tools were assessed
for their completeness, contents and language
Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007
clarity during pilot study. Tools were found
complete in terms of contents and clarity of
language. For checking the reliability of the
tools test retest method was used and value
of Spearman's rank correlation was found to
be 0.90 and hence significant and tool was
reliable.
Survey was done to enlist the total
geriatric population of the DMC U.T.,
Chandigarh. Total 612 (3.73%) of total
population approximately subjects were
enlisted during the survey. Every 3rd individual
was selected as a study sample by using a
systematic random sampling technique i.e. 89
subjects were selected as a study sample and
2 subjects were not available. Hence, 43
subjects were in experimental and 44 in control
group. First day data was collected through
interviewing and pain assessment performa.
As part of the experiment in the study, moist
heat was applied at the knee joint for 20
minutes twice daily for 7 days in the
experimental group. No intervention was
given among the control group. The knee joint
pain was assessed in both experimental and
control group on 1st and 8th day of
intervention. The data was analyzed as per
objectives by applying both descriptive and
inferential statistics.
Results
Mean age ± SD of the subjects was
66.65±6.86 years and 66.19±17.24 years
in experimental and control groups, ranging
between 60-83 and 60-95 years respectively.
164
Table - 1 : Socio demographic characteristics of the study subjects N=87
Characteristics Expt. Group Control Group
n=43 n=44
f (%) f (%)
Age (years)
60-65 21 (48.8) Mean 66.65±6.86 27 (61.4) Mean 66.19±7.24 χ2 =2.04
66-70 12 (27.9) Range Rs. 60-83 07 (15.9) Range Rs. 60-95 d. f. =2**
71-75 03 (07.0) 05 (11.3)
NS*
≥76 07 (16.3) 05(11.4)
Gender
χ2 =0.04
Male 08 (18.6) 10 (22.7)
d. f. =1
Female 35 (81.4) 34 (77.3)
NS*
Marital status
Married 18 (41.9) 24 (54.5) χ2 =0.93
Widow/widower 25 (58.1) 20 (45.5) d. f. =1
Educational status NS*
Illiterate 36 (83.8) 34 (77.3)
Can read or write 03 (07.0) 01 (02.3) χ2 =0.23
Primary 02 (04.6) 05 (11.4) d. f. =1***
Middle 01 (02.3) 03 (06.7) NS*
Matric 01 (02.3) 01(02 .3)
Occupation
Working --- 06 (13.6)
Retired 09 (20.9) 07 (15 .9)
House Wife 34 (79.1) 31 (70.5)
Religion
Hindu 33 (76.7) 42 (95.4)
Sikh 09 (21.0) 01 (02.3)
Muslim 01 (02.3) 01 (02.3)
Type of Family
Nuclear 10 (23.3) 01 (02.3)
Joint 33 (76.7) 43 (97.7)
Monthly Per Capita
Income (Rs.)
<500 07 (16.2) 10 (22.7)
501 -1000 26 (60.5) Mean 1016+846 19 (43.1) Mean 858+393 χ2 =2.60
1001-1500 06 (14.0) Range Rs. 250-4287 12 (27.2) Range Rs. 250-1957 d. f. =2***
≥1501 04 (09.3) 03 (07.0) NS*
* NS - Not significant
** While applying chi-square test the frequencies in the age group 71-75 and ≥76 were merged
*** While applying the chi-square test the frequencies in the education status of can read, primary, middle and matric were merged
**** While applying the chi-square test the frequencies in the Rs.1001- 1500 and Rs. <1501 were merged

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 165
 Out of the total subjects 81.4% in
experimental and 77.3% in control group were
female subjects. Total 41.9% in experimental
and 54.5% in control group were married and
reaming were widow/widower. Nearly three-
fourth of subjects (76.7%) in the experimental
and most of subjects (95.4%) in the control
group belonged to Hindu religion. Per capita
monthly income of the subjects ranged
between Rs. 250/- to Rs. 4287/- with mean
per capita income ± SD as Rs. 1016±846 in
the experimental group and Rs. 858±393 in
the control group. Variables such as age,
gender, marital status, educational and per
capita income of the experimental and control
group were similar as no statistical difference
was observed amongst the experimental and
control group (Table 1).
Two third of the subjects (62.8%) in
the experimental and control group were
experiencing knee joint pain all the time. In
the experimental group, the range of duration
of knee joint pain was between 0.6-30 years
with mean ± SD as 5.73±6.38 years. In the
control group the range of the duration of
the knee joint pain was between 0.6-22.5
years with Mean ± SD as 5.71±6.04 years.
Both the groups were comparable as per
experience and duration of knee joint pain as
indicated by chi-square test (p>0.05)
(Table 2)

Table - 2 : Distribution of subjects as per their experience and duration of knee joint
pain N=87

Variables Expt. Group Control Group

n=43 f (%) n=44 f (%)

Experience of Knee Joint Pain

All the time 27 (62.8) 27 (61.4) χ2 =0.01
While Standing 02 (04.7) 01 (02.2) d. f. =1*
On Sitting 01 (02.3) 03 (06.8) p>0.005
On walking 13 (30.2) 13 (29.6)
Duration of Knee Joint Pain
<1 Year 01 (02.3) Mean±SD 03 (06.8) Mean±SD χ2 =0.1
1-5 year 29 (67.5) 5.73±6.38 27 (61.4) 5.71±6.04 d. f. =1**
6-10 year 05 (11.6) Range 0.6 - 03 (06.8) Range p>0.005
11-15year 05 (11.6) 30years 06 (13.6) 0.6 - 22.50 years
>16 year 03 (07.0) 05 (11.4)
* The frequency in while sitting, on standing and on walking were merged while calculating chi-square test
** The frequency upto 10 year and from>10 were merged while calculating chi-square test

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 166
 Nearly two-third of the subjects i.e.
69.8% in experimental group and 63.6% in
the control group were taking pain killer. Only
8 subjects in experimental and 6 subjects in
control group were taking both calcium as well
as painkillers. Nearly half of the subjects i.e.
43.4% in experimental and 42.8% in control
Table - 3 : Management of knee joint pain by study subjects
group were taking pain killer once a day.
About 30% of subjects in experimental and
35.8% in control group were taking pain killer
twice a day. Only 26.6% and 21.4% of subjects
in experimental and control group respectively
were taking painkiller occasionally (Table 3).
N=87

Variables Expt. Group Control Group

n=43 n=44
f (%) f (%)

Pain Killer 30 (69.8) 28 (63.6)

Calcium (Supplements) 09 (20.4)* 06 (13.6)*
Not Using Any Drugs** 12 (27.9) 16 (36.4)
Frequency of taking Pain Killer n=30 n=28
f(%) f(%)
Once a day 13(43.4) 12 (42.8)
Twice a day 09 (30.0) 10 (35.8)
Occasionally 08 (26.6) 06 (21.4)
*Eight subjects in experimental and Six subjects in control group were taking both calcium & pain killer
*One subject was taking calcium only
**Painkiller + calcium only

In the left knee at the time of pre
intervention in the experimental and control
groups 25.6% and 27.3% subjects had worst
pain respectively while 23.3% and 9.1%
subjects had severe pain respectively. Another
one-third subjects in experimental (32.5%)
and (27.3%) in control group had moderate
pain. Only 18.6% subjects in experimental and
36.3% subjects in control group had mild
pain. Experimental and control group were
comparable as indicated by Chi-square test
(p>0.05). Af ter the inter vention pain
decreased significantly in the experimental
group and it was observed that 37.2% had
no pain, 39.5% had mild pain, 16.3% had
moderate pain, 7% subject had severe pain
and no subjects had worst pain in experimental
group. In the control group their was no

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 167
significant change in the pain and it was found significant change in the knee joint pain among
that 34.1% subject had mild pain 25% had subjects in the pre inter vention to post
moderate pain, 27.3% had severe pain and intervention period in the experimental group
25% had the worst pain. Hence there was (p<0.01) (Table 4).
Table - 4 : Intensity of left knee joint pain among experimental and control group before
and after the intervention N=87

Variables Left Knee Left Knee

Before Intervention (1st Day) After Intervention (8th Day)
Expt. Group Control Group Expt. Group Control Group
(n=43) f(%) (n=44)f(%) (n=43) f(%) (n=44)f(%)

No Pain 16 (37.2) -
Mild Pain 08 (18.6) 16 (36.3) 17 (39.5) 15 (34.1)
Mod. Pain 14 (32.5) 12 (27.3) χ2 =5.42 07 (16.3) 11 (25.0) χ2 =18.344
d. f. =3 d. f. =2*
Severe Pain 10 (23.3) 04 (09.1) 03 (07.0) 07 (15.9)
p>0.005 p<0.01
Worst Pain 11 (25.6) 12 (27.3) - 11 (25.0)
* While applying chi- square frequency against no pain and mild pain were merged and similarly severe pain and
worst pain were merged

In the right knee at the time of pre
intervention 23.2% had mild pain, 34.9% had
moderate pain, 18.7% had severe pain and
23.3% had worst pain in experimental group.
In control group 25% had mild pain, 27.3%
had moderate pain, 18.2% had severe pain
and 29.5% had worst pain. There was no
statistically difference in experimental group
as indicated by the chi-square test (p>0.05).
Af ter the inter vention pain decreased
significantly in the experimental group and it
was found that 34.9% had no pain, 46.4%
had mild pain, 16.4% had moderate pain and
2.3% had severe pain. In control group 25%
had mild pain, 29.5% had moderate pain,
18.2% had severe pain and 27.3% had worst
pain. The statistically significant change was
observed in the intensity of knee joint pain
from the intervention to post intervention
period in the experimental group as compared
to control group (p<0.01) (Table 5).

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 168
Table - 5 : Intensity of right knee joint pain among experimental and control group
before and after the intervention N=87
Variables Right Knee Right Knee
Before Intervention (1st Day) After Intervention (8th Day)
Expt. Group Control Group Expt. Group Control Group
(n=43) f(%) (n=44)f(%) (n=43) f(%) (n=44)f(%)
No Pain 15 (34.9) -
Mild Pain 10 (23.2) 11 (25.0) 2 20 (46.4) 11 (25.0)
12 (27.3) χ =0.76 13 (29.5) χ =25.55
2
Mod. Pain 15 (34.9) 07 (16.4)
Severe Pain 08 (18.7) 08 (18.2) d. f. =3 01 (02.3) 08 (18.2) d. f. =1*
Worst Pain 10 (23.2) 13 (29.5) p>0.05 - 12 (27.3) p<0.01

* Subjects having no pain and mild pain were merged together for calculating chi-square test similarly subjects
with moderate, severe and worst pain were merged together for calculating chi-square test

Nearly two-third of the subjects i.e.
69.77% in experimental group and 63.64%
subjects in control group were taking pain
killer. Nearly one-third of the subjects i.e.
30.23% and 36.36% subjects in experimental
and control group were not taking pain killer.
Both the groups were comparable and did not
differ statistically from each other for taking
pain killer before intervention as indicated by
chi-square test (p>0.05). After intervention
in the experimental group only 37.2% of
subjects were taking painkiller whereas in
control group 61.3% taking were pain killer.
Statistically frequency of subjects taking
painkiller in the experimental group was found
to be significantly lesser than control group
during same period as indicated by chi-square
test (p<0.05) (Table 6).

Table - 6 : Comparison of subjects taking pain killer among experimental and control
group before and after the intervention N=87

Variables Before Intervention After Intervention

(1st Day) (8th Day)
Expt. Group Control Group Expt. Group Control Group
(n=43) (n=44) (n=43) (n=44)
f(%) f(%) f(%) f(%)
Taking pain 30 (69.77) 28 (63.64) χ2 =0.143 16 (37.20) 27 (61.36) χ2 =4.155
killer d. f. =1 d. f. =1
Not taking 13 (30.23) 16 (36.36) NS* 27(62.80) 17 (38.64) p<0.05
pain killer

* Not significant

Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007 169
Discussion
High prevalence of knee joint pain was
reported by various authors.7,8 Out of the total
geriatric population surveyed in the present
study 48% had knee joint pain. This is in
agreement with the findings of other studies.7,8
The study was quasi experimental in
which the experimental and the control groups
were similar in respect to age, marital status,
intensity of knee joint pain, intake of pain killer,
duration and experience of knee joint pain. This
shows the similarity between the experimental
and the control group.
Range of the age in the study subjects
between 60-83 years and 60-95 yrs in
experimental and control group respectively.
This group was taken, as the prevalence of
knee joint pain was high in this age group.
The study sample was 43 in
experimental group and 44 in control group.
This size of sample was taken due to limited
study time period. The null hypothesis was
formulated that there is no significant
difference in the intensity of knee joint pain
with or without application of moist heat.
Intensity of knee joint pain was assessed with
the visual analogue scale after modification.
This is a standardized scale.
In the present study, moist heat was
used as an intervention of knee joint pain as
it is safe simple and non-pharmacological
approach. Many authors have recommended
moist heat application for pain relief.9,10,11 At
the time of pre inter vention there was
statistically no difference in the intensity of
knee joint pain in the left and right knee in the
Nursing and Midwifery Research Journal, Vol-3, No. 4, October 2007
experimental and the control group Moist heat
was applied for 20 min twice a day among
experimental group for seven days. No
intervention was given among the control
group. On the 8th day there was significant
reduction in the intensity of pain in the right
as well as the lef t knee (p<0.01) in
experimental group as compared to the
control group as per chi-square test. Time
period for applying heat for 20 min. bid was
recommended by Lehmann 9 and
Tepperman10 Moist heat was applied for
seven days only due to short duration of study
period. Ferrell BA15 applied the moist heat for
6 weeks, the findings of the study revealed
that the application of moist heat led to
significant reduction of intensity of knee joint
pain, when compared to the control group.
In addition, it was observed that moist
heat application had an indirect effect on intake
of painkillers among the experimental group
as compared to control group i.e. the
percentage of subjects taking pain killer
reduced after intervention in the experimental
group which shows that subjects were
benefited from moist heat application.
So while applying chi square test the
null hypothesis was rejected, as there is
significant difference in the reduction of
intensity of knee joint pain after applying moist
application in both knees. This shows that
moist application is effective treatment for
reduction of intensity of knee joint pain.
Findings in current study are almost the same
as Ferrell BA15 He reported that significant
improvement in pain (p<0.05) in
interventional group.
170
 The findings of the study indicated that 7.
moist heat application at knee joint decreases
the intensity of knee joint pain. Results were
statistically significant in favor of the use of 8.
moist heat application while comparing the
pain between experimental and control group
on 1st day and 8th day of intervention in the
current study (p<0.01) as indicated as chi- 9.
square test. Hence the use of moist heat
application can be promoted in community
for home based management of knee joint 10.
pain. Based on present study findings it is
recommended that a similar study may be 11.
conducted on a larger sample to generalize
the findings
12.
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