A Study To Evaluate The Effectiveness of Strengthening Exercise On Joint Pain Among Osteoarthritis Patients in Selected Hospitals, Bangalore.

“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRENGTHENING
EXERCISE ON JOINT PAIN AMONG OSTEOARTHRITIS PATIENTS IN
SELECTED HOSPITALS, BANGALORE.”
By
Mrs. JANET BABU
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka
In partial fulfillment of the requirements for the degree of
MASTER OF SCIENCE
IN MEDICAL SURGICAL NURSING
Under the Guidance of
Mr.K.Gopalakrishnan , (M.Sc NURSING)
Professor & HOD
Department of Medical Surgical Nursing
GLOBAL COLLEGE OF NURSING
BANGALORE
2018
LIST OF ABREVIATIONS
Expansion
Abbreviation
OA Osteoarthritis
WHO World Health Organization
RR Relative Ration
CI Confidence Interval
KOA Knee Osteoarthritis
SD Standard Deviation
MHAQ Modified Health Assessment Questionnaire
ACR Arthritis Clinical Rating
WOMAC Western Ontario and McMaster Universities Osteoarthritis Index
VAS Visual analog pain scale
RCT Randomized Control Trials
BPAS Behavioral Pain Assessment Scale

LIST OF TABLES
SL. NAME OF THE TABLES PAGE

NO: NO:
1 Frequency and percentage distribution of selected socio-demographic 37
variables of osteoarthritis patients
2 Pre-interventional level of joint pain among osteoarthritis patients in 44
experimental and control group
3 Mean pre-interventional joint pain score among osteoarthritis patients in 46
4 Post-interventional level of joint pain among osteoarthritis patients in 45
5 Mean post-interventional joint pain score among osteoarthritis patients in 47
6 Effectiveness of strengthening exercise on regulating joint pain among 48
osteoarthritis patients
7 Association between pre-interventional level of joint pain among 49
osteoarthritis patients and their selected socio demographic variables in
experimental group
8 Association between pre-interventional level of joint pain among 51
control
LIST OF FIGURES
SL. NAME OF FIGURES PAGE

NO: NO:
1 Schematic Representation Conceptual frame work 11
2 Schematic Representation of Research Design 24
3 Schematic Representation of Research methodology 25
4 Bar diagram shows that percentage distribution of osteoarthritis patients on 40

the basis of age
5 Cylindrical diagram shows that percentage distribution of osteoarthritis 40
patients on the basis of gender
6 Cone diagram shows that percentage distribution of osteoarthritis patients 41
on the basis of religion
7 Bar diagram shows that percentage distribution of osteoarthritis patients on 41
the basis of educational status
patients on the basis of Occupational status
patients on the basis of family monthly income
10 Cone diagram shows that percentage distribution of osteoarthritis patients 43
on the basis of duration of osteoarthritis
patients on the basis of pharmacologic management
12 Cylindrical diagram shows that distribution pre-test level of joint pain 45
among osteoarthritis patients in experimental and control group
13 Cylindrical diagram shows that distribution post-test level of joint pain 46
among osteoarthritis patients in experimental and control group
RESEARCH ABSTRACT
Back ground of the study
Osteoarthritis (OA) is a common joint disease that most often affects the middle age to
elderly people. It is commonly referred to as “wear and tear” of the joints, but we know now that
OA is a disease of the involving cartilage, joint lining, ligaments and bone. Severe joint pain is the
typical symptom associated with OA. Exercise is thought to be the most effective non drug
treatment for the reduction of pain and improving movement for the people with osteoarthritis. For
those with osteoarthritis, the exercises need to be done correctly to avoid causing joint pain.
Specific exercises help to strengthen the muscles around the joints, remove the stress from the
joints, improve joint mobility and reduce joint stiffness and pain.
Aim
The aim of the study was to evaluate the effectiveness of strengthening exercise on joint
pain among osteoarthritis patients in selected hospitals at Bangalore.
Objectives of the study
1. To assess the level of joint pain among osteoarthritis patients in experimental group and control
group, before the administration of strengthening exercise.
2. To evaluate the effectiveness of strengthening exercise on joint pain among osteoarthritis
patients.
3. To determine the association between pre-interventional level of joint pain among
osteoarthritis patients with their selected demographic variables in experimental and control
group.
Methods
The research approach adopted for the study was evaluative research approach. The
research design selected for the study was experimental research design.
Simple random sampling technique was used for the study. 60 osteoarthritis patients (30 in
experimental group and 30 in control group) were selected for this study.
The tool used for the data collection was behavioral pain assessment scale, which has two
sections. Section-A provides about socio-demographic data and Section-B deals with behavioral
pain assessment scale. Collected data was analyzed by using descriptive and inferential statistics
in terms of frequencies, percentage, mean, standard deviation, chi-square values and paired ‘t’ test.
Results
Result showed that, among 30 osteoarthritis patients in experimental group, 17(56.67%) of
them were between 51-60 years of age, 21(70%) of them were female, 19(63.33%) of them were
Hindus, 16(53.33%) of them were undergraduates, 11(36.67%) of them were private employees,
13(43.33%) of them had monthly income of Rs. 20001-30000, 16(53.33%) of them were suffering
osteoarthritis for more than 10 years, 26(86.67%) of osteoarthritis patients were taking medicine.
It was observed that, among 30 osteoarthritis patients in control group, 14(46.67%) of them
were between 40-50 years of age, 8(60%) of them were female, 13(43.33%) of them were Hindus,
11(36.67%) of them were postgraduates, 15(50%) of them were private employees, 12(40%) of
them had monthly income of Rs.10001-20000, 12(40%) of them were suffering osteoarthritis for
5-10 years and 20(66.67%) of them were taking medicine.
The result of this study showed that in pre test of among 30 osteoarthritis patients in
experimental group majority 25(83.33%) of them had severe joint pain and 5(16.67%) of them had
moderate joint pain whereas in control group 19(63.33%) of them had severe joint pain and
11(36.67%) of them had moderate joint pain. In post-test osteoarthritis patients in experimental
group have showed reduction in their level of joint pain due to strengthening exercise but there
was no significant change found in control group. In post test osteoarthritis patients in experimental
group, 16(53.33%) of them had moderate joint pain, 9(30%) of them had mild joint pain and
5(16.67%) of them had no joint pain whereas in control group 16(53.33%) of them had severe joint
pain and 14(46.67%) of them had moderate joint pain. The overall paired ‘t’ test value was 13.75
in experimental group, which is significant in table value 2.6 at p≤0.01 level. paired ‘t’ test value
in control group was 0.56, which is not significant in table value 2.6 at p≤0.01 level. So it is proved
that the strengthening exercise was effective in reducing joint pain among osteoarthritis patients.
The chi-squire value of the pre-test level of joint pain among osteoarthritis patients with their
selected socio demographic variables was significant at P≤0.05 level.
Key words
Effectiveness, Strengthening Exercise, Joint Pain, Osteoarthritis, Patients.
I. INTRODUCTION
======================================================
Osteoarthritis (also known as OA) is a common joint disease that most often affects the
middle age to elderly people. It is commonly referred to as “wear and tear” of the joints, but we
know now that OA is a disease of the involving cartilage, joint lining, ligaments and bone.
Although it is more common in older people, it is not really accurate to say that the joints are just
“wearing out.” It is characterized by breakdown of the cartilage (the tissue that cushions the ends
of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments,
and various degrees of inflammation of the joint lining (called the synovium).1
Osteoarthritis is a frequently slowly progressive joint disease seen in middle aged to elderly
people. In osteoarthritis, the cartilage between the bones in the joints will break down. This causes
the affected bones to slowly get bigger. The joint cartilage often breaks down because of
mechanical stress or biochemical changes within the body, causing the bone underneath to fail.
OA can occur together with other types of arthritis, such as gout or rheumatoid arthritis.1
OA tends to affect commonly used joints such as the hands and spine, and the weight-
bearing joints such as the hips and knees. Symptoms includes joint pain and stiffness, Knobby
swelling at the joint, cracking or grinding noise with joint movement and decreased function of
the joint. OA affects people of all races and both sexes. Most often, it occurs in patients age 40
and above. Risk factors of getting osteoarthritis includes, older age, family history of OA, obesity,
previous traumatic joint injury, over use of joints, deformed legs etc.1
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. 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 in the ageing population
will generate a global burden of costs and 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 worldwide between 1990 and 2020, the global burden of osteoarthritis will increase
drastically.2
Disability due to hip and knee osteoarthritis is as great as that attributes when compared
with 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.3
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, non-steroidal 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.4
Knee pain could reduce exercise tolerance of people with osteoarthritis of knee pain. The
strength of the knee muscle of the patients with OA knee is usually weaker than that in normal
subjects. Muscle weakness may in turn interfere with the normal mechanics around the knee joint,
thus increasing knee pain. Pain can also be decrease temporarily decreasing the compressive force
on the joint, this is accompanied when technique designed to distract the two joint surface are used.
Strengthening exercise can improve the stability to the knee joint. 5
Exercising with osteoarthritis could harm joints and cause more pain, Research shows that people
can and should exercise when they have osteoarthritis. Exercise is considered the most effective
non-drug treatment for reducing pain and improving movement in osteoarthritis. Three kinds of
exercise are important for people with osteoarthritis: exercises involving range of motion, also
called flexibility exercises; endurance or aerobic exercises; and strengthening exercises. Each one
plays a role in maintaining and improving the ability to move and function. 6
Excess body weight is a risk factor for the both the development and progression of
osteoarthritis. For every pound of body weight, you gain, your knees gain three pounds of added
stress; for hips, each pound translates into six times the pressure on the joints. After many years of
carrying extra pounds, the cartilage that cushions the joints tends to break down more quickly than
usual. Conversely, losing weight can reduce additional stress on joints that can cause cartilage to
wear away. Easing the pressure on joints by shedding extra pounds can also reduce pain in
osteoarthritis-affected joints, which will help you feel and move much better.7
NEED FOR THE STUDY
Osteoarthritis (OA) is widely known as the most frequent musculoskeletal disorder,
mainly occurring in the elderly with a radiographic prevalence of nearly 70% in persons over
t he age of 65 years. Disease burden is related to pain occurrence, frequently leading to
functional disability ranging from slight limitation of movements to severe impairment of

normal daily living activities Therefore, pain relief plays an important role in the treatment of
OA.8
Osteoarthritis is the second common rheumatologic problem and it is the most frequent
joint diseases with a prevalence of 39% in India. Osteoarthritis is more common in women than
men, but the prevalence increases dramatically with age. In India, approximately 40% of
population more than 70years shows Osteoarthritis in which nearly 2% have severe knee pain and
disability. The incidence of knee Osteoarthritis increase 10 folds amongst the ages of 30 and 65
years.9
According to the United Nations by 2050 people aged over 60 years will account for more
than 20 %of the world population.in this 20%population 15% will have symptomatic Osteoarthritis
and one third of these people will be never disabled. This means that by 2050,130 million people
will suffer from Osteoarthritis worldwide, of whom 40 million will be severely disabled by the
disease.10
Cartilage destruction actually begins between the age of 20-30 years and majority of adults
affected by age 40 years. Many patient experience symptoms until after age 50 or 60 years, but
more than half of those who over 50 year of age have x-ray evidence of the disease in at least one
joint. Hip osteoarthritis is more common in men after the age of 55 years. Osteoarthritis in
interphalangeal joints and thumb base is more common in women after the age of 55 years. Knee
osteoarthritis is more common in men before the age of 45 year but in women after the age of 45
years. 11
Based on the article “Chronic disease and health promotion” by WHO in 2016,
osteoarthritis is considered as one of the ten most degenerative disabling diseases in developed
countries. The worldwide estimation says that 9.6% of men and 18% of women aged above 60
years have the symptoms of osteoarthritis.80% of those have limitations in movement and 25%
cannot perform their major daily living activities.12
A cross sectional study has been done in Bangalore urban district to measure the prevalence
of knee osteoarthritis among adults. The study was done on 342 subjects across seven villages
coming under a sub center from December 2011 – January 2012 by stratified random sampling.
The interviewer administered questionnaire was used to estimate the prevalence and associated
risk factors of osteoarthritis based on EULAR 2009, ACR criteria, anthropometry and clinical
examination of knee. The study resulted that the prevalence of osteoarthritis was found to 8.9%
and 3.2% in adult population and 54.1% and 16.4% in the elderly. Prevalence of Osteoarthritis was
found to bev17 % in the total population with a prevalence of 15.5 % in males and 18.8% in female
by the modified ACR criteria and 5.6 % in the total population,4.2% in males and 6.8% in females
by EULAR criteria.As per modified ACR and the EULAR 2009 criteria ,the prevalence in the
elderly population was 54.1 % and 16.4% respectively..13
Exercise is thought to be the most effective non drug treatment for the reduction of pain
and improving movement for the people with osteoarthritis. For those with osteoarthritis, the
exercises need to be done correctly to avoid causing joint pain. Specific exercises help to
strengthen the muscles around the joints, remove the stress from the joints, improve joint mobility
and reduce joint stiffness and pain.14
Evidence shows that being overweight increases the strain on your joints – especially your
knees. Being overweight not only increases your risk of developing osteoarthritis but also makes
it more likely that your arthritis will get worse over time. Because of the way your joints work, the
force put through your knees when you walk, especially on stairs and slopes, can be several times
your actual body weight. Losing even a small amount of weight can make a big difference to the
strain on your weight-bearing joints. No special diet has been shown to help with osteoarthritis,
but if you need to lose some weight we would recommend a balanced, reduced-calorie diet
combined with regular exercise.15
A Quasi experimental study was conducted at the physiotherapy department of general
Hospital at Ahmedabad.21% males and females in the age range of 60-75 years,diagnosed with
case of osteoarthritis was selected in experimental and control group.Pain intensity at rest and
during activity was assessed using Visual analog scale and physical function was assessed by
Western Ontario McMasters Arthritic Index (WOMAC ).The result of the study showed that
resistance exercises were better than walking in reducing pain and improving physical function in
older adults with knee Osteoarthritis. 16
From the above facts and by the researcher's own observation, the researcher found that
the strengthening exercise is very effective in relieving pain in the joints of osteoarthritis patients.
In this study the investigator plans to conduct the study to evaluate the effectiveness of
strengthening exercise for joint pain among osteoarthritis patients.

II.OBJECTIVES
===============================================================
This chapter deals with main objectives of the study, the concepts involved and the
conceptual framework on which the study is based.
STATEMENT OF THE PROBLEM
“A study to evaluate the effectiveness of strengthening exercise on joint pain among
osteoarthritis patients in selected hospitals at Bangalore.”
OBJECTIVES OF THE STUDY
1. To assess the level of joint pain among osteoarthritis patients in experimental group
and control group, before the administration of strengthening exercise.
2. To evaluate the effectiveness of strengthening exercise on joint pain among
osteoarthritis patients.
osteoarthritis patients with their selected demographic variables in experimental and
control group.
HYPOTHESIS
H1: There will be significant difference in level of joint pain among osteoarthritis patients
before and after administration of strengthening exercise.
H2: There will be significant association between pre-interventional level of joint pain
among osteoarthritis patients with their selected socio demographic variables in
experimental and control group.
1
OPERATIONAL DEFINITIONS
1. Evaluate: In this study, it refers to measure the effectiveness of strengthening exercise
in terms of reduction of joint pain among osteoarthritis patients in experimental and
control group.
2. Effectiveness: In this study, it refers to the extent to which the outcome measure of
difference between pre interventional and post interventional pain scores after the
administration of strengthening exercises.
3. Strengthening exercise: In this study it refers to the exercises which will improve and
maintain the muscle strength. It includes standing calf stretch, seated hip march, seated
leg raise, quadriceps stretch, step up, and hamstring stretch. The exercise duration is
about 30 -40 minutes per day.
4. Osteoarthritis patients: In this study it refers to those patients who are diagnosed with
osteoarthritis of knee and hip with joint pain aged between 40-70 years.
ASSUMPTION
This study assumes that,
1. the administration of strengthening exercise may helps to reduce joint pain among
DELIMITATIONS
This study is delimited to:
 the collection of data is only from osteoarthritis patients in selected hospitals,
Bangalore.
2
 60 osteoarthritis patients.
 4 weeks of data collection.
CONCEPTUAL FRAMEWORK
Conceptual frame work is an organized phenomenon which deals with concepts
that are assembled by virtue of their relevance to a common theme. Conceptual frame work
can severe to guide research which will further support theory development. The
conceptual models attempt to represent reality with its minimal use of words.17
Here the conceptual frame work was based on CIPP model, which included content
evaluation input evaluation, process evaluation and product evaluation.
Context Evaluation
It highlights the environment, surrounding from where the individual engages and
interact. In this study it included selected factors such as age, sex, religion, educational
status, occupational status, family monthly income, duration of suffering osteoarthritis and
pharmacologic management of joint pain.
Input Evaluation
It specifies the resources used in the process such as men, money and material. In
this study, input evaluation includes measuring pre-interventional level of joint pain and
administration of strengthening exercise.
Process
The process could include the phases of problem resolution and conflict resolution.
In this study different type of strengthening exercise would be demonstrated to practice.
Product
3
This information refers to the output as a result of the intervention. It includes
evaluating the effectiveness of strengthening exercise on joint pain among osteoarthritis
patients.
Feed back
Refers to the information sent backward from the product evaluation to the input
and the process in order to gain understanding and modify or accept the strategies.
4
Figure 1: CONCEPTUAL FRAME WORK BASED ON CIPP MODEL
Context Input Process Product
Selected factors of Pre-test Implementation of Post-test

Osteoarthritis patients strengthening
Assessment of level exercise for 3 weeks. Assessment of level
Age, sex, religion, of joint pain before of joint pain after
educational status, administering the administration of
occupational status, family intervention. intervention.
monthly income, duration
of suffering osteoarthritis
and pharmacologic
Preparation and
management of joint pain.
demonstration of
strengthening Mild or Moderate Severe
exercise. no joint joint pain joint pain
pain
Setting
Nursing Agent
Sagar hospitals, Bangalore.
Investigator
Feedback
Not in per-view of study
5
I. REVIEW OF LITERATURE
=============================================================
The literature review is an essential component of the research as it aids researcher in
formulating the research plan. By definition, the review of literature is broad, comprehensive, in-
depth, systematic and critical, audio-visual material and personal communication. The primary
purpose of the literature review is to give broad background knowledge or understanding of
limitation that is available related to research problem of interest. It is also helping the researcher
to conduct his or her actual study. The literature review includes both research and non- research
literature.18
The review of literature can be classified under the following headings.
1) Risk factors and prevalence of osteoarthritis
2) Osteoarthritis and its associated complications.
3) Effectiveness of strengthening exercises in reduction of joint pain.
Risk factors and prevalence of osteoarthritis
A population based study was conducted to assess the risk factors and prevalence of
osteoarthritis in USA. Population based survey was used to collect the information . The result
showed that, approximately 12% of the overall prevalence of symptomatic OA is attributable to
posttraumatic OA of the hip, knee, or ankle. This corresponds to approximately 5.6 million
individuals in the United States being affected by posttraumatic OA. Thus the study concluded
that, there is a need for adequate treatment after a traumatic injury to prevent future complication
like posttraumatic osteoarthritis.19

A met a-analytical study was conducted in US to assess the sex differences prevalence,
incidence and severity of osteoarthritis. Random sampling techniques was used on scientific
studies over a period of 1966-2003.Males had a significantly reduced risk for prevalent OA in the
knee [Risk Ratio (RR) 0.63, 95% CI 0.53–0.75] and hand [RR 0.81, 95% CI 0.73–0.90] but not
for other sites. Males aged <55 years had a greater risk of prevalent cervical spine OA [RR 1.29,
95% CI 1.18–1.41]. Males also had significantly reduced rates of incident OA in the knee
[Incidence Rate Ratio (IRR) 0.55, 95% CI 0.32–0.94] and hip [IRR 0.64, 95% CI 0.48–0.86], with
a trend for hand [IRR 0.65, 95% confidence interval (CI) 0.35–1.20]. Females, particularly those
≥55 years, tended to have more severe OA in the knee but no other sites. Thus, the study concluded
that, the presence of sex differences in OA prevalence and incidence, with females generally at a
higher risk. Females also tend to have more severe knee OA, particularly after menopausal age.20
A cross sectional study was conducted to assess the incidence of symptomatic hand, hip,
and knee osteoarthritis among patients in a health maintenance organization in antral
Massachusetts and consecutive sampling technique was used. OA was confirmed by radiography
(grade ≥2 on the Kallgren‐Lawrence scale of 0–4) plus joint symptoms at the time the radiograph
was obtained or up to 1 year before the radiograph was obtained. Result showed that, The age‐ and
sex‐standardized incidence rate for hand OA was 100/100,000 person‐years (95% confidence
interval [95% CI] 86, 115), for hip OA 88/100,000 person‐years (95% CI 75, 101), and for knee
OA 240/100,000 person‐years (95% CI 218, 262). The incidence of hand, hip, and knee OA
increased with age, and women had higher rates than men, especially after age 50. A leveling off
or decline occurred for both groups around the age of 80. Thus the study concluded that, OA
observed incidence rates was increased with age. In women ages 70‐89, the incidence of knee OA
approached 1% per year.and women had higher rates than men, especially after age 50.21
A Community based cross section study on morbidity pattern of elderly, Raniblock,
kamrup (rural) district, Assam was done in 2014.The cluster sampling technique was used to
collect 390 subjects. The results show that 43 % morbidity of Osteoarthritis, which has 54.1%
female and 26.8% male elderly person.22
A Cross sectional study was conducted to assess the prevalence of knee osteoarthritis and
its determinants in 30-60 years old women of Gurdaspur, Punjab done in 2017.Systematic random
sampling was used.422 women were selected for the study. A semi structured interview schedule
was used to collect the data. The result of the study showed that the prevalence of knee
Osteoarthritis was 21.6 %. Most of the respondents (54.9%) were from the age group of 50-60
years.The prevalence of knee Osteoarthritis was reported high in this age group. Sedentary life
style and greater BMI were associated with Knee Osteoarthritis. 23
A study was conducted to assess prevalence, incidence and progression of knee
osteoarthritis. The prevalence was age-standardized (US 2000 Population 40–84 years). Result
showed that, Mean (SD) baseline age was 58.9 (9.9) years (56.5% women). The age-standardized
prevalence of KOA was only modestly higher in women (44.2%) than men (37.7%), whereas the
age-standardized prevalence of erosive and symptomatic OA was much higher in women (9.9%
vs 3.3%, and 15.9% vs 8.2%). The crude incidence of KOA over 9-year follow-up was similar in
women (34.6%) and men (33.7%), whereas the majority of those women (96.4%) and men (91.4%)
with KOA at baseline showed progression during follow-up. Thus the study concluded that, the
usual female predominance of prevalent and incident KOA was less clear for radiographic KOA
than for symptomatic and erosive KOA.24

A study was conducted to assess Knee pain and osteoarthritis in older adults in UK. During
a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom
about one in six in the UK and the Netherlands consult their general practitioner about it in the
same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years
is 10%, of whom one quarter are severely disabled. Thus the study concluded that, Knee
osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee
pain and disability suffered by older people. Healthcare provision in primary care needs to focus
on this broader group to impact on community levels of pain and disability.25
A study was conducted by Brenda good man of medical editor arthritis today in 2008 with
an aim to find out the incidence and prevalence of higher risk of osteoarthritis in North Carolina.
The sample selected was 3000 people and has undergone x ray of hip, knee, spine and hands. Later
after 5-7 years they passed through the same process. The results showed that 1 in 2 people got
arthritis in knee before 85 years. Risk is there for 2 in 3 people with overweight. Those who
maintain the body weight have low risk for osteoarthritis about 30%.26
A cross sectional study was conducted to assess the association of age and BMI with knee
Osteoarthritis among female in age group of 40 to 60 years in Urban population of Kadapa town,
in 2011.Random sampling technique was used .150 participated enrolled in the study. Total 63
(42%) participants were affected with knee osteoarthritis. Among them 25 (32.89%) were in the
age group of 40 to 50 years and 38 (51.35%) in the age group of 50 to 60 years which is
significantly more. As per BMI, Participants with BMI > 25 were significantly more affected 29
(63.04 %) compared with participants with Normal BMI 17(33.33 %)27
A descriptive study was conducted to assess the problems of the aged above 60years in a
selected low income urban community in Hyderabad, India (2005). A house to house survey
revealed that there were 186 people aged above 60years in the 2 communities.60 of them were
selected as the sample with the help of simple random sampling technique. 40 of them were
females and 20 were males. 80% of them were unemployed. The instruments of data collection
were validated by clinical nurses, old age care providers and managers of old age homes. A scoring
system was devised to categorise people in to those having severe, moderate and mild problems.
The results showed that 51 out of 60 had perceptual problems, 50 had functional problems, 50
persons had mobility problems and 31 had structural problems, 21.6% had severe structural
problems. The musculoskeletal assessment revealed that there are only 16.67% of the elderly
without any problem, 66.67% had mild problems related to joints and 13.33% had moderate joint
and mobility problems.28
Osteoarthritis and its associated complications
An experimental study was conducted to determine whether knee osteoarthritis reduces
ambulatory capacity and impairs quality of life in UK. 56 subjects were selected using consecutive
sampling technique 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. 29
A comparative study was 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.30
An experimental study was conducted to assess the physical function of older clients with
clinical knee osteoarthritis in UK. Random sampling technique was used for the study. 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). 31
A descriptive study was conducted in 1192 Africans and Caucasians to evaluate pain
severity and mobility limitations in osteoarthritis knee clients. Stratified sampling technique was
used to select the samples. 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. 32
Effectiveness of strengthening exercises in reduction of joint pain
A meta-analysis study was conducted to assess the efficacy of strengthening exercises for
osteoarthritis in US. Only randomized controlled trials using strengthening exercises as an
intervention and treating clients with OA were eligible. Twenty-two trials were included with 2325
patients undergoing various forms strengthening exercises (e.g. isometric, isotonic, isokinetic,
concentric, concentric/eccentric, dynamic). Result showed that, evidence is provided for the
inclusion of strengthening exercises in the rehabilitation programmed for the patient with OA.
Improvements were found for strength, pain, function and quality of life (QOL). Thus, the study
concluded that, strengthening exercises alone have some effects on improving pain and functional
outcomes in clients with OA. However, in order to maximize the effectiveness of strengthening
exercise for these clients, it is necessary to combine strengthening exercises with a more complete
exercise programmed including ROM, stretching, functional balance and aerobic exercises.33
A study was conducted to assess the effectiveness of an exercise programmed in patients
with osteoarthritis of hip or knee are sustained at six and nine months' follow up in Netherlands.
Patients with osteoarthritis of hip or knee (ACR criteria) were selected. 201 patients were randomly
allocated to the exercise or control group, and 183 patients completed the trial. At 24 weeks
exercise treatment was associated with a small to moderate effect on pain during the past week
(difference in change between the two groups −11.5 (95% CI −19.7 to −3.3). At 36 weeks no
differences were found between the groups. Thus, the study concluded that, beneficial effects of
exercise decline over time and finally disappear.34
A Meta study was conducted in UK to assess the effectiveness of aerobic walking and
strengthening exercises in OA. Comparison of aerobic walking or home based quadriceps
strengthening exercise with a non-exercise control group. Simple Random sampling technique
were used.13 studies were included. One study provided a direct comparison between aerobic
walking and home-based strengthening exercises and control. Nine randomized control trails
evaluated quadriceps strengthening exercises, and in three studies the exercise intervention was
predominantly aerobic walking. Control interventions included education and lifestyle advice,
support by telephone calls, and no intervention. When comparing aerobic walking with no exercise
interventions, the pooled effect sizes for pain and disability were 0.52 (95% CI 0.34 to 0.70) and
0.46 (95% CI 0.25 to 0.67) respectively. Corresponding effect size for quadriceps strengthening
was 0.32 (95% CI 0.23 to 0.42) for both pain and disability. Thus the study concluded that, both
aerobic walking and home based quadriceps strengthening exercises are effective at reducing pain
and disability in subjects with knee osteoarthritis.35
A Comparative study was conducted to evaluate the effectiveness of three modes of
kinetic-chain exercises on quadriceps muscle strength and thigh girth among individuals with knee
osteoarthritis. Consecutive sampling technique was used in Nigeria. The study was designed to
evaluate and compare the effectiveness of 12-week open, closed and combined kinetic-chain
exercises (OKCE, CKCE and CCE) on quadriceps muscle strength and thigh girth of patients with
knee osteoarthritis (OA). Result showed that, The three groups were comparable regarding their
demographic and dependent variables at baseline; there was significant time effect (p < 0.001each)
as all three measures significantly increased over time from baseline to week 12 [mean difference:
SQS: 3.30 (95% CI: 2.52–4.08) N; DQS: 0.74 (95% CI: 0.45–1.02) N; TG: 1.32 (95% CI: 0.93–
1.71) cm]. Thus, the study concluded that, all three exercise regimens are effective and
demonstrate similar effects on quadriceps muscle strength and muscular trophism.36
A Experimental study was conducted to evaluate the effectiveness of manual physical
therapy and exercise in osteoarthritis of the knee in UK. Around 83 patients with osteoarthritis of
the knee who were randomly selected to receive treatment (n = 42; 15 men and 27 women [mean
age, 60 ± 11 years]) or placebo (n = 41; 19 men and 22 women [mean age, 62 ± 10 years]).
Clinically and statistically significant improvements in 6-minute walk distance and Western
Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 4 weeks and 8 weeks
were seen in the treatment group but not the placebo group. By 8 weeks, average 6-minute walk
distances had improved by 13.1% and WOMAC scores had improved by 55.8% over baseline
values in the treatment group (P < 0.05). After controlling for potential confounding variables, the
average distance walked in 6 minutes at 8 weeks among patients in the treatment group was 170
m (95% CI, 71 to 270 m) more than that in the placebo group and the average WOMAC scores
were 599 mm higher (95% CI, 197 to 1002 mm). At 1 year, patients in the treatment group had
clinically and statistically significant gains over baseline WOMAC scores and walking distance;
20% of patients in the placebo group and 5% of patients in the treatment group had undergone
knee arthroplasty. Thus the study concluded that, a combination of manual physical therapy and
supervised exercise yields functional benefits for patients with osteoarthritis of the knee.37
A randomized controlled trial was done in US to determine the effect of different exercises
on quadriceps muscle strength and structure in persons with knee osteoarthritis. Sixty-one patients
with knee osteoarthritis were randomly assigned into 6 exercise groups. Patients were evaluated
for pain and functional status with use of the Visual analog pain scale (VAS), Western Ontario and
McMaster Universities Arthritis Index (WOMAC), 50 – step walking, and single leg stance tests
before and after 15 sessions of physical therapy. Isokinetic tests were performed at 60 degree per
second. Results showed increased knee extensor strength was observed bilaterally in the isometric
group (p < .01). In the isotonic group, muscle thickness increased bilaterally (p < .05). These
findings conclude that exercise may influence the muscle architecture in patients with knee
osteoarthritis.38
A study has been done in City Hospital, Nottingham, UK to compare the efficacy of
aerobic walking and home-based quadriceps strengthening exercise in patients with knee
osteoarthritis was conducted. The Medline, PubMed , EMBASE , CINAHL , and Pedro database
and the Cochrane controlled trials register were searched for randomizes control trials (RCTs) of
patients with knee osteoarthritis comparing aerobic walking or home based quadriceps
strengthening exercise with a non-exercise control group. Randomized control trials were grouped
according to exercise mode and the data pooled using both fixed and random effects models. In
result, 35 RCTs were identified, 13 of which met inclusion criteria and provided data suitable for
further analysis. Pooled effect sizes for pain were 0.52 for aerobic walking and 0.39 for quadriceps
strengthening. For self-reported disability, pooled effect sizes were 0.46 for aerobic walking and
0.32 for quadriceps strengthening. Conclusion was that both aerobic walking and home-based
quadriceps strengthening exercise reduce pain and disability from knee osteoarthritis but no
significant difference between them was found on indirect comparison.39
A study was done in University of Nebraska Medical Center, Omaha, USA, to determine
whether an 8 – week isokinetic muscle – strength – training program improved the functional
health status of patients with osteoarthritis of the knee joint. Twenty volunteers with osteoarthritis
of the knee joint were randomly assigned to either an experimental (n = 10) group or control (n =
10) group. The experimental group completed six sets of five maximal contractions three times
per week for 8 weeks on a Cybex 2 dynamometer at 90 degree per second. Both groups were pre-
and post tested for extension and flexion strength of the right and legs, the 50 – foot walk time,
range of motion at the knee joint, the Osteoarthritis Screening Index (OASI), and the Arthritis
Impact Measurement Scale (AIMS). The study resulted that there was a significant decrease in
pain and stiffness and a significant increase in mobility. There was also significant decline in
arthritis activity in the experimental group as measures, while the control group increased in only
right leg flexion and left leg extension across the training period.40
A randomized controlled trial was conducted in US with an aim to assess the effectiveness
of interventions on knee pain. The second aim was to assess the effects on additional clinical
measures on severity of the disease such as function and mobility. The samples consists of 372
people above the age of 55 who were ambulatory, community dwelling person with mild to
moderate tibiofemoral OA and has no other participation in any exercise programs. The
participants are randomized into 3 groups, such as high intensity training (75 – 90 % repetition
maximum (1 RM)); low intensity strength training (30 – 40 % 1 RM); or healthy living education.
The training was done for 30 minutes for 6 months; it includes hip abductor strength, quadriceps
strength and power training. The study resulted that the strength training exercise has shown a high
impact on the improvement in the mobility and function of the participants.41

I. RESEARCH METHODOLOGY
=============================================================
Research methodology is a way to solve the problem systematically. It is a procedure in
which the researcher starts from initial identification of the problem to final conclusion.
Methodology of research organizes all the component of the study in a way that is most likely to
lead to valid answer to the problems that have been posed.42
This chapter deals with the methodology adopted for the present study such as research
approach, research design, setting, variables, population, sample, sampling technique, sampling
criteria, development of tool, content validity, reliability, pilot study, method of data collection,
plan for data analysis and protection of human rights. The present study is aimed to evaluate the
effectiveness of strengthening exercise on joint pain among osteoarthritis patients in
selected hospitals at Bangalore.
RESEARCH APPROACH
The research approach explains the researcher regarding the data collection that is, what to
collect, how to collect, and how to analyze. It also suggests possible conclusions to be drawn from
the available data.38 In the present study, evaluative research approach was adapted.
RESEARCH DESIGN
The research design refers to the researcher’s overall plan for obtaining answer to the
research questions and it spells out strategies that, the researcher adapted to develop information
that is accurate, objective and interpretable.42 The research design provides an overall or blue print
to carry out the study. The research design used for the present study is evaluative type of
experiment.
EXPERIMENTAL PRE POST
TREATMENT
GROUP (G1) TEST TEST
Group-1(Experimental)
CONTROL PRE POST

NO TREATMENT
GROUP (G2) TEST TEST
Group-2(Control)
Figure2. Schematic Representation of Research Design

PURPOSE: - Evaluating effectiveness of strengthening exercise on joint pain among
osteoarthritis patients in selected hospitals at Bangalore.
RESEARCH APPROACH: - Evaluative research approach
RESEARCH DESIGN: - Experimental research design
SETTING: - Sagar hospitals, Bangalore
TARGET POPULATION: - Osteoarthritis patients.

ACCESSIBLE POPULATION:- Osteoarthritis patients in selected hospitals, Bangalore
SAMPLE: - 60 osteoarthritis patients (30 in experimental group and 30 in control group)
SAMPLING TECHNIQUE: - Simple random sampling technique.
TOOL: - Behavioral pain assessment scale
INTERVENTION: - Strengthening exercise
METHOD: - Pre-test- intervention- post-test. (O1- X -O2)
DATA ANALYSIS: - Descriptive and Inferential Statistics.

Figure 3: Schematic representation of research methodology
VARIABLES UNDER STUDY
Variables are concepts at various levels of abstraction that are measured, manipulated or
controlled in the study.42 The variables mainly included in this study are independent variable,
dependent variable and demographic variables.
Independent variable
An independent variable is that which is believed to cause or influence the dependent variable
in experimental research by the manipulated (intervention) variable.42
In the present study the independent variable refers to administration of strengthening
exercise on joint pain among osteoarthritis patients.
Dependent Variable
Dependent Variable is a response, behavior or outcome that the researcher wants to predict.
Changes in the dependent variable are presumed to be caused by the independent variable. It is
otherwise called as effect variable or a criterion measure.42
In the present study dependent variable refers to level of joint pain among osteoarthritis
patients.
Demographic variables
An uncontrolled variable that greatly influences the result of the study is called as attributed
variable.43
Characteristics of osteoarthritis patients such as age, sex, religion, educational status,
occupational status, family monthly income, duration of suffering osteoarthritis and
SETTING
Setting is the physical location and condition in which data collection takes place.43
The study was conducted in Sagar hospitals, Bangalore. The criterion for selecting the
setting was feasibility for conducting the study, availability of the samples and familiarity of the
investigator with the setting. Therefore, the investigator felt that there would be rich opportunity
to evaluate the effectiveness of strengthening exercise on joint pain among osteoarthritis patients
in this setting.
TARGET POPULATION
The target population referred to as population, which represents the entire group or all the
elements like individuals or objects that meet certain criteria for inclusion in the study.43 The target
population for the study was osteoarthritis patients.
ACCESSIBLE POPULATION
The accessible population for this study was osteoarthritis patients those who are meeting
the inclusion criteria in selected hospitals, Bangalore.

SAMPLE AND SAMPLE SIZE
Sample refers to the subset of a population that is selected to participate in a particular
study.42 The sample size of the present study consists of 30 osteoarthritis patients in experimental
group and 30 osteoarthritis patients in control group therefore the total number of samples are 60
osteoarthritis patients in selected hospitals, Bangalore.
SAMPLING TECHNIQUE
Sampling techniques refers to the process of selecting a portion of the population to
represent the entire population.42
Simple random sampling technique was used to select the samples of this study. A total of
60 osteoarthritis patients in selected hospitals, Bangalore were selected. In the first day
osteoarthritis patients who met the inclusive criteria were selected and their names were recorded.
Samples were selected in consecutive days until the sample size reached 60.
CRITERIA FOR SAMPLE SELECTION
a) Inclusion criteria
The study includes osteoarthritis patients, who are
 Attending OPD in selected hospitals Bangalore.
 willing to participate in the study.
 able to communicate in English or Kannada
b) Exclusion criteria
The study excludes osteoarthritis patients, who are,
 participated in pilot study
 not available during data collection.
 on control of joint pain

DEVELOPMENT OF THE TOOL
Selection of the tool:
Behavioral pain assessment scale was selected to assess the joint pain among osteoarthritis
patients.
Development of the Tool:
After an extensive ROL and discussion with experts, Behavioral pain assessment scale was
prepared to assess the pain level of osteoarthritis patients. The Data collection tool was divided in
to two sections.
Section A-Socio-demographic data
It consists of characteristics of osteoarthritis patients such as age, sex, religion, educational
status, occupational status, family monthly income, duration of suffering osteoarthritis and
Section B: Behavioral pain assessment scale (BPAS)
The BPAS was prepared after going through an intensive review of literature including
research articles and personal discussions with the experts.
It consists of 5 pain symptoms such as facial expression, restlessness, muscle tone,
vocalization and consolability.
SCORING
The behavioral pain assessment scale was measured in terms of pain scores, The maximum
score of the scale was 10. For the purpose of the study the pain scores were categorized as follows;
Score Level of Pain
0 No Pain
1-3 Mild Pain
4-6 Moderate Pain
7-10 Severe Pain
INTERVENTION (Treatment)
Strengthening exercise was demonstrated to the osteoarthritis patents. They were instructed
to do the strengthening exercise daily for 30 minutes. The duration of intervention was 3 weeks.
RESULTS
=============================================================
This chapter deals with results of data collected to evaluate the effectiveness of
strengthening exercise on joint pain among osteoarthritis patients, by using a behavioral
pain assessment scale.
The data, which are necessary for the study, were collected through behavioral
pain assessment scale and analyzed by using relevant descriptive and inferential
statistics.
The data were analyzed on the basis of objectives of the study
1. To assess the level of joint pain among osteoarthritis patients in experimental group
and control group, before the administration of strengthening exercise.
2. To evaluate the effectiveness of strengthening exercise on joint pain among
osteoarthritis patients with their selected demographic variables in experimental and
control group.
Hypothesis
H1: There will be significant difference in level of joint pain among osteoarthritis
patients before and after administration of strengthening exercise.
H2: There will be significant association between pre-interventional level of joint pain
among osteoarthritis patients with their selected socio demographic variables in
12
The data organized and presented in four sections
Section- I
Description of selected socio-demographic variables of osteoarthritis patients in
Section-II
Assessment of pre-interventional and post-interventional level of joint pain
among osteoarthritis patients in experimental and control group.
Section-III
Evaluation of effectiveness of strengthening exercise on joint pain among
osteoarthritis patients in experimental and control group .
Section-IV
Association between pre-test level of joint pain among osteoarthritis patients
and their selected socio demographic variables in experimental and control group.
13
SECTION-I
FREQUENCY AND PERCENTAGE DISTRIBUTION OF SELECTED SOCIO
DEMOGRAPHIC VARIABLES OF OSTEOARTHRITIS PATIENTS IN
EXPERIMENTAL AND CONTROL GROUP
Table-1: Frequency and percentage distribution of selected socio-demographic

variables of osteoarthritis patients.
N=30
Respondents
Experimental Group Control Group
Characteristics Category N % N %
40-50 years 8 26.67 14 46.67
Age 51-60 years 17 56.67 9 30
61-70 years 5 16.66 7 23.33
Male 9 30 12 40
Gender
Female 21 70 18 60
Hindu 19 63.33 13 43.33
Christian 5 16.67 11 36.67
Religion
Muslims 6 20 6 20
Others 0 0 0 0
Primary education 0 0 3 10
Educational Secondary education 6 20 9 30
status Undergraduate 16 53.33 7 23.33
Postgraduate or above 8 26.67 11 36.67
Private employee 11 36.67 15 50
Government employee 5 16.67 9 30
Occupational
Self employee 6 20 4 13.33
status
Daily wages 0 0 0 0
Nil 8 26.66 2 6.67
Below Rs. 10000 0 0 0 0
Rs.10001-20000 10 33.33 12 40
Family monthly Rs. 20001-30000 13 43.33 8 26.67
income Rs. 30001 or above 7 23.34 10 33.33
Less than 1 year 0 0 5 16.67
Duration of 1-5 years 9 30 9 30
suffering 5-10 years 5 16.67 12 40
osteoarthritis Above 10 years 16 53.33 4 13.33
Pharmacologic Yes 26 86.67 20 66.67
management No 4 13.33 10 33.33
14
Table-1 shows that, among 30 osteoarthritis patients in experimental group,
17(56.67%) of them were between 51-60 years of age, 8(26.67%) of them were between
40-50 years of age and 5(16.66%) of them were between 61-70 years of age whereas in
control group 14(46.67%) of them were between 40-50 years of age, 9(30%) of them
were between 51-60 years of age and 7(23.33%) of them were between 61-70 years of
age.
In concern with gender of the osteoarthritis patients in experimental group,
21(70%) of them were female and 9(30%) of them were male whereas in control group
18(60%) of them were female and 12(40%) of them were male.
In the area of religion, of osteoarthritis patients in experimental group
19(63.33%) of them were Hindus, 6(20%) of them were Muslims and 5(16.67%) of
them were Christians whereas in control group, 13(43.33%) of them were Hindus,
11(36.67%) of them were Christians and remaining 6(20%) of them were Muslims.
It was observed that, educational status of osteoarthritis patients in experimental
group, 16(53.33%) of them were undergraduates, 8(26.67%) of them were
postgraduates and 6(20%) of them had secondary education whereas in control group,
11(36.67%) of them were postgraduates, 9(30%) of them had secondary education
7(23.33%) of them were undergraduates and 3(10%) of them had primary education.
In relation to the occupation of osteoarthritis patients in experimental group,
11(36.67%) of them were private employees, 8(26.66%) of them were unemployees,
6(20%) of them were self employees and 15(16.67%) of them were Government
employees whereas in control group, 15(50%) of them were private employees, 9(30%)
of them were Government employees, 4(13.33%) of them were self employees and
2(6.67%) of them were unemployees.
15
It was observed that, the family monthly income of osteoarthritis patients in
experimental group, 13(43.33%) of them had monthly income of Rs. 20001-30000,
10(33.33%) of them had monthly income of Rs.10001-20000 and 7(23.34%) of them
had Rs. 30001 or above family monthly income whereas in control group, 12(40%) of
them had monthly income of Rs.10001-20000, 10(33.33%) of them had monthly
income of Rs. 30001 or above and 8(26.67%) of them had family monthly income of
Rs. 20001-30000.
Among 30 osteoarthritis patients in experimental group, 16(53.33%) of them
were suffering osteoarthritis for more than 10 years, 9(30%) of them were suffering
osteoarthritis for 1-5 years and 5(16.67%) of them were suffering osteoarthritis for 5-
10 years whereas in control group, 12(40%) of them were suffering osteoarthritis for 5-
10 years, 9(30%) of them were suffering osteoarthritis for 1-5 years, 5(16.67%) of them
were suffering osteoarthritis for less than 1 year and 4(13.33%) of them were suffering
osteoarthritis for more than 10 years.
It was observed that, in experimental group 26(86.67%) of osteoarthritis
patients were taking medicine and 4(13.33%) of them were not taking any medication
for osteoarthritis whereas in control group, 20(66.67%) of them were taking medicine
and remaining 10(33.33%) of them were not taking any medication.
16
Age in Year
60.00% 56.67%
50.00% 46.67%
Percentage
40.00%
30%
30.00% 26.67%
23.33%
20.00% 16.66%
10.00%
0.00%
40-50 years 51-60 years 61-70 years
Experimental group Age in Year
Control group
Figure 4: Bar diagram shows that percentage distribution of osteoarthritis
patients on the basis of age.
Gender
70%
70%
60%
60%
50%
Percentage
40%
40%
30%
30%
20%
10%
0%
Male Female
Experimental group Gender
Control group
Figure-5: Cylindrical diagram shows that percentage distribution of
osteoarthritis patients on the basis of gender
17
Religion
70.00%
63.33%
60.00%
Percentage
50.00% 43.33%
40.00% 36.67%
30.00%
20% 20%
16.67%
20.00%
10.00%
0% 0%
0.00%
Hindu Christian Muslims Others
Experimental group Religion
Control group
Figure- 6: Cone diagram shows that percentage distribution of osteoarthritis
patients on the basis of religion.
Educational Status
60%
53.33%
50%
40% 36.67%
Percentage
30%
30% 26.67%
23.33%
20%
20%
10%
10%
0%
0%
Primary education Secondary education Undergraduate Postgraduate or
above
Experimental group Control group Educational status
Figure-7: Bar diagram shows that percentage distribution of osteoarthritis
patients on the basis of educational status
18
Occupational Status
50%
50.00%
40.00% 36.67%
30%
Percentage
30.00% 26.66%
20%
20.00% 16.67%
13.33%
10.00% 6.67%
0% 0%
0.00%
Private Government Self employee Daily wages Nil
employee employee
Occupational status
Experimental group Control group
Figure- 8: Cylindrical diagram shows that percentage distribution of

osteoarthritis patients on the basis of Occupational status
Family Monthly Income

45% 43.33%
40%
40%
35% 33.33% 33.33%
Percentage
30% 26.67%
23.34%
25%
20%
15%
10%
5% 0% 0%
0%
Below Rs. 10000 Rs.10001-20000 Rs. 20001-30000 Rs. 30001 or
above
Family monthly income
Figure- 9: Cylindrical diagram shows that percentage distribution of

osteoarthritis patients on the basis of family monthly income
19
Duration of Osteoarthritis
60%
53.33%
50%
40%
Percentage
40%
30% 30%
30%
20% 16.67% 16.67%

13.33%
10%
0%
0%
Less than 1 year 1-5 years 5-10 years Above 10 years
Duration of Osteoarthritis
Figure-10: Cone diagram shows that percentage distribution of osteoarthritis

patients on the basis of duration of osteoarthritis
Pharmacologic management
90.00% 86.67%
80.00%
70.00% 66.67%
Percentage
60.00%
50.00%
40.00% 33.33%
30.00%
20.00% 13.33%
10.00%
0.00%
Yes No
Experimental group Pharmacologic management

Control group
Figure-11: Cylindrical diagram shows that percentage distribution of

osteoarthritis patients on the basis of pharmacologic management
20
SECTION- II(A)
PRE-INTERVENTIONAL LEVEL OF JOINT PAIN AMONG
OSTEOARTHRITIS PATIENTS
Table-2: Pre-interventional level of joint pain among osteoarthritis patients in

N=30
Respondents
Level of joint pain Score Experimental Group Control Group
N % N %
No pain 0 0 0 0 0
Mild pain 1-3 0 0 0 0
Moderate pain 4-6 5 16.67 11 36.67
Severe pain 7-10 25 83.33 19 63.33
Total 30 100 30 100
Table-2 and figure-12 depicts that pre interventional level of joint pain among
osteoarthritis patients in experimental and control group. Among 30 osteoarthritis
patients in experimental group majority 25(83.33%) of them had severe joint pain and
5(16.67%) of them had moderate joint pain whereas in control group 19(63.33%) of
them had severe joint pain and 11(36.67%) of them had moderate joint pain.
21
Pre-interventional level of pain
90% 83.33%
80%
70% 63.33%
Percentage
60%
50%
36.67%
40%
30%
16.67%
20%
10% 0% 0% 0% 0%
0%
No pain Mild pain Moderate pain Severe pain
Level of pain
Figure-12: Cylindrical diagram shows that distribution pre-test level of joint
pain among osteoarthritis patients in experimental and control group
22
MEAN PRE-INTERVENTIONAL JOINT PAIN SCORE AMONG
Table-3: Mean pre-interventional joint pain score among osteoarthritis patients

in experimental and control group
N=30
SL: Respondents
No: Experimental Group Control Group
Item Range Mean SD Range Mean SD
1 Pain score 5-10 8.17 1.46 4-10 7.47 1.92
Table: 3 describe mean pre-interventional joint pain score among osteoarthritis
patients in experimental and control group. It was observed that, osteoarthritis patients
in experimental group had mean joint pain score of 8.17 with SD 1.46 whereas in
control group mean joint pain score and SD were 7.47 and 1.92 respectively.
44
SECTION-II(B)
POST-INTERVENTIONAL LEVEL OF JOINT PAIN AMONG

Table- 4: Post-interventional level of joint pain among osteoarthritis patients in

.
N=30
Respondents
N % N %
No pain 0 5 16.67 0 0
Mild pain 1-3 9 30 0 0
Moderate pain 4-6 16 53.33 14 46.67
Severe pain 7-10 0 0 16 53.33
Total 30 100 30 100
Table: 4 illustrate post-interventional level of joint pain among osteoarthritis
patients in experimental and control group. Among 30 osteoarthritis patients in
experimental group 16(53.33%) of them had moderate joint pain, 9(30%) of them had
mild joint pain and 5(16.67%) of them had no joint pain whereas in control group
16(53.33%) of them had severe joint pain and 14(46.67%) of them had moderate joint
pain.
45
Post-interventional level of pain
60.00%
53.33% 53.33%
50.00% 46.67%
Percentage
40.00%
30%
30.00%
20.00% 16.67%
10.00%
0% 0% 0%
0.00%
No pain Mild pain Moderate pain Severe pain
Level of pain
Figure-13: Cylindrical diagram shows that distribution post-test level of
joint pain among osteoarthritis patients in experimental and control group
46
MEAN POST-INTERVENTIONAL JOINT PAIN SCORE AMONG
Table-5: Mean post-interventional joint pain score among osteoarthritis patients

in experimental and control group
N=30
SL: Respondents
1 Pain score 0-6 2.7 1.69 4-10 7.3 2.03
Table: 5 describes mean post-interventional joint pain score among
osteoarthritis patients in experimental and control group. It was observed that,
osteoarthritis patients in experimental group had mean joint pain score of 2.7 with SD
1.69 whereas in control group mean joint pain score and SD were 7.3 and 2.03
respectively.
47
SECTION-III
EFFECTIVENESS OF STRENGTHENING EXERCISE ON JOINT
PAIN AMONG OSTEOARTHRITIS PATIENTS
Table-6: Effectiveness of strengthening exercise on regulating joint pain among

osteoarthritis patients
Group Aspect Knowledge of Paired ‘t’
Respondents test
Mean SD
Experimental Pre-test 8.17 1.46 13.75*

Group
Post-test 2.7 1.69
Control Group Pre-test 7.47 1.92 0.56
Post-test 7.3 2.03
**Significant at p≤0.01 level, df 29, t-value 2.6
Table 6 depicts the effectiveness of strengthening exercise on joint pain among
osteoarthritis patients. It is inferred that in experimental group the overall paired ‘t’ test
value was 13.75, it is significant in table value 2.6 at p≤0.01 level. So it is proved that
the strengthening exercise was effective in reducing joint pain among osteoarthritis
patients. Whereas in control group, the overall paired ‘t’ test value was 0.56, it is not
significant in table value 2.6 at p≤0.01 level. So it is indicated that there is no change
joint pain among osteoarthritis patients.
The obtained ‘t’ value 13.75 in experimental group was higher than table value
2.6 at p≤0.01 level, hence the hypothesis H1 is accepted.
48
SECTION-IV(A)
ASSOCIATION BETWEEN PRE-INTERVENTIONAL LEVEL OF JOINT
PAIN AMONG OSTEOARTHRITIS PATIENTS AND THEIR SELECTED
SOCIO DEMOGRAPHIC VARIABLES IN EXPERIMENTAL GROUP
Table-7: Association between pre-interventional level of joint pain among

experimental group
(Experimental Group) N=30
N Level of joint pain Chi square
Characteristics Category Severe Moderate
40-50 years 8 7 1 1.67
Age 51-60 years 17 13 4 NS
61-70 years 5 5 0
Male 9 7 2 0.28
Gender NS
Female 21 18 3
Hindu 19 15 4 1.50
Christian 5 4 1 NS
Religion
Muslims 6 6 0
Others 0 0 0
Primary education 0 0 0 8.85
Educational Secondary education 6 6 0 S*
status Undergraduate 16 15 1
Postgraduate or above 8 4 4
Private employee 11 9 2 1.41
Government employee 5 5 0 NS
Occupation Self employee 6 5 1
Daily wages 0 0 0
Nil 8 6 2
Below Rs. 10000 0 0 0 11.01
Rs.10001-20000 10 10 0 S*
Family monthly Rs. 20001-30000 13 12 1
income Rs. 30001 or above 7 3 4
Duration of 1-5 years 9 9 0 NS
suffering 5-10 years 5 5 0
osteoarthritis Above 10 years 16 11 5
Pharmacologic Yes 26 22 4 0.23
management No 4 3 1 NS
**Significant at P≤0.05 level, S: Significant, NS; Non significant
49
Table-7 describes the association between pre-interventional level of joint pain
among osteoarthritis patients and their selected socio demographic variables in
experimental group. The obtained chi square values for educational status and family
monthly income were higher values (8.85 and 11.01 respectively) when compared to
the table value at P≤0.05 level of significance. So there is a significant association
between pre-interventional level of joint pain among osteoarthritis patients with their
demographic variables of educational status and family monthly income in
experimental group. Hence research hypothesis H2 is accepted.
50
Table-8: Association between pre-interventional level of joint pain among
osteoarthritis patients and their selected socio demographic variables in control
group
(Control group) N=30

40-50 years 14 8 6 1.15
Age 51-60 years 9 7 2 NS
61-70 years 7 4 3
Male 12 3 9 12.65
Gender S*
Female 18 16 2
Hindu 13 7 6 1.53
Christian 11 7 4 NS
Religion
Muslims 6 5 1
Others 0 0 0
Daily wages 0 0 0
Nil 2 1 1
Below Rs. 10000 0 0 0 0.10
Rs.10001-20000 12 8 4 NS
51
Table-8 describes the association between pre-interventional level of joint pain among
osteoarthritis patients and their selected socio demographic variables in control group. The
obtained chi square values for gender and educational status were higher values (12.65 and 16.80
respectively) when compared to the table value at P≤0.05 level of significance. So there is a
significant association between pre-test level of joint pain among osteoarthritis patients with their
demographic variables like gender and educational status in control group. Hence research
hypothesis H2 is accepted
52
VI. DISCUSSION
====================================================
This chapter discusses the major findings of the study with reference to the objectives and
hypothesis stated and reviews in relation to findings from the results of other studies.
The aim of this study was to evaluate the effectiveness of strengthening exercise on joint
pain among osteoarthritis patients in selected hospitals at Bangalore.
patients.
group.
Hypothesis
H1: There will be significant difference in level of joint pain among osteoarthritis patients before
and after administration of strengthening exercise.
H2: There will be significant association between pre-interventional level of joint pain among
osteoarthritis patients with their selected socio demographic variables in experimental and control
group.
1. The first objective was to assess the level of joint pain among osteoarthritis patients
before implementing strengthening exercise

Among 30 osteoarthritis patients in experimental group majority 25(83.33%) of them had
severe joint pain and 5(16.67%) of them had moderate joint pain whereas in control group
19(63.33%) of them had severe joint pain and 11(36.67%) of them had moderate joint pain.
The finding of the present study is supported by the findings of the following studies.
A study was conducted to assess Knee pain and osteoarthritis in older adults. During a one
year period 25% of people over 55 years have a persistent episode of knee pain, of whom about
one in six in the UK and the Netherlands consult their general practitioner about it in the same
time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%,
of whom one quarter are severely disabled. Thus the study concluded that, Knee osteoarthritis
sufficiently severe to consider joint replacement represents a minority of all knee pain and
disability suffered by older people. Healthcare provision in primary care needs to focus on this
broader group to impact on community levels of pain and disability.24
The findings of the present study as well as previous studies showed that the osteoarthritis
patients had severe joint pain and measures have to be undertaken to reduce joint pain.
2. The second objective was to evaluate the effectiveness of strengthening exercise on joint
pain among osteoarthritis patients.
In this study a comparison was done between the pre-test and post-test mean scores in order to
evaluate the effectiveness of strengthening exercise on joint pain among osteoarthritis patients. It
was observed that, the overall pre-interventional and post-interventional mean joint pain score in
experimental group was 8.17 and 2.7 respectively with paired ‘t’ value of 13.75, which was above
the table value 2.6 at P≤0.01 level of significance. Hence the research hypothesis H1 is accepted.
In control group, pre-interventional and post-interventional mean joint pain scores were 7.47 and
7.3 respectively with paired ‘t’ value of 0.56 which is not significant with table value 2.6 at p≤0.01
level.
A study was conducted to assess the effectiveness of an exercise programme in patients
with osteoarthritis of hip or knee are sustained at six and nine months' follow up. Patients with
osteoarthritis of hip or knee (ACR criteria) were selected. 201 patients were randomly allocated to
the exercise or control group, and 183 patients completed the trial. At 24 weeks exercise treatment
was associated with a small to moderate effect on pain during the past week (difference in change
between the two groups −11.5 (95% CI −19.7 to −3.3). At 36 weeks no differences were found
between the groups. Thus the study concluded that, beneficial effects of exercise decline over time
and finally disappear.34
The present study and previous studies clearly showed that strengthening exercise was
effective on joint pain among osteoarthritis patients.
3. The third objective was to find out the association between pre interventional level of
joint pain among osteoarthritis patients with their selected socio demographic variables
in experimental and control group.
The chi-squire value of the pre-interventional level of joint pain of osteoarthritis patients and
their selected socio demographic variables was significant at P≤0.05 level. It showed that, in
experimental group, obtained chi square values for educational status and family monthly income
were higher values (8.85 and 11.01 respectively) when compared to the table value at P≤0.05 level
of significance whereas in control group, the chi square values for gender and educational status
were higher values (12.65 and 16.80 respectively) when compared to the table value at P≤0.05
level of significance. Hence research hypothesis H2 is accepted.

A meta-analytical study was conducted to assess the sex differences prevalence, incidence
and severity of osteoarthritis. Males had a significantly reduced risk for prevalent OA in the knee
[Risk Ratio (RR) 0.63, 95% CI 0.53–0.75] and hand [RR 0.81, 95% CI 0.73–0.90] but not for other
sites. Males aged <55 years had a greater risk of prevalent cervical spine OA [RR 1.29, 95% CI
1.18–1.41]. Males also had significantly reduced rates of incident OA in the knee [Incidence Rate
Ratio (IRR) 0.55, 95% CI 0.32–0.94] and hip [IRR 0.64, 95% CI 0.48–0.86], with a trend for hand
[IRR 0.65, 95% confidence interval (CI) 0.35–1.20]. Females, particularly those ≥55 years, tended
to have more severe OA in the knee but not other sites. Thus the study concluded that, the presence
of sex differences in OA prevalence and incidence, with females generally at a higher risk. Females
also tend to have more severe knee OA, particularly after menopausal age.
The present study and previous studies clearly showed that there was significant
association between level of joint pain among osteoarthritis patients and their selected socio
demographic variables.
VII. CONCLUSION
=============================================================
Osteoarthritis (OA) is a common joint disease that most often affects the middle age to
elderly people. It is commonly referred to as “wear and tear” of the joints, but we know now that
OA is a disease of the involving cartilage, joint lining, ligaments and bone. Severe joint pain is the
typical symptom associated with OA. Exercise is thought to be the most effective non-drug
treatment for the reduction of pain and improving movement for the people with osteoarthritis. For
those with osteoarthritis, the exercises need to be done correctly to avoid causing joint pain.
Specific exercises help to strengthen the muscles around the joints, remove the stress from the
joints, improve joint mobility and reduce joint stiffness and pain.
STATEMENT OF THE PROBLEM
FINDINGS
The result of this study showed that in pre test, among osteoarthritis patients in
experimental and control group. Among 30 osteoarthritis patients in experimental group majority
25(83.33%) of them had severe joint pain and 5(16.67%) of them had moderate joint pain whereas
in control group 19(63.33%) of them had severe joint pain and 11(36.67%) of them had moderate
joint pain. In post-test osteoarthritis patients in experimental group have showed reduction in their
level of joint pain due to strengthening exercise but there was no significant change found in
control group. In post test osteoarthritis patients in experimental group, 16(53.33%) of them had
moderate joint pain, 9(30%) of them had mild joint pain and 5(16.67%) of them had no joint pain
whereas in control group 16(53.33%) of them had severe joint pain and 14(46.67%) of them had
moderate joint pain. The overall paired ‘t’ test value was 13.75 in experimental group, which is
significant in table value 2.6 at p≤0.01 level. paired ‘t’ test value in control group was 0.56, which
is not significant in table value 2.6 at p≤0.01 level. So it is proved that the strengthening exercise
was effective in reducing joint pain among osteoarthritis patients. The chi-squire value of the pre-
test level of joint pain among osteoarthritis patients with their selected socio demographic variables
was significant at P≤0.05 level.
IMPLICATIONS OF THE STUDY
The finding of the study has implications for nursing education, nursing practice, nursing
research and nursing administration.
NURSING EDUCATION
 Imparting the concepts of strengthening exercise for reducing joint pain to nursing students.
 Nursing students can utilize information of strengthening exercise on joint pain helps to give
health education in the hospitals and community.
NURSING PRACTICE
 Osteoarthritis patients must be encouraged to participate in programmes of reducing joint pain.
 Nurse as the change agent, can implement the various new measures to reduce the joint pain
of patients.
NURSING ADMINISTRATION
 Nursing personnel can organize continuing nursing education program on strengthening
exercise for reducing joint pain in all health sectors.

 Public awareness program for the public regarding strengthening exercise on joint pain among
 It also helps the nursing administrators to plan for man power, money, materials, methods and
time to conduct successful in-service and public education programme regarding strengthening
exercise on joint pain.
NURSING RESEARCH
 Research must be carried out on newer practices and innovative methods are in-corporate. The
study will serve as a valuable reference material for future investigations. Further research
studies can be conducted on the basis of this study.
Recommendations for further research
Based on the findings of the present study and keeping in mind the limitations of the study,
the following suggestions are offered:
1. A similar study can be conducted among osteoarthritis patients in different setting.
2. Comparative study can be done between different measures to reduce joint pain among
3. This similar study can be replicated on large sample there by findings can be generalized to a
large population.
Limitation of the study
This study is delimited to:
 the collection of data is only from osteoarthritis patients in selected hospitals, Bangalore.
 60 osteoarthritis patients.
 4 weeks of data collection.

VIII. SUMMARY
=============================================================
This chapter provides the process employed in this study. The primary aim of the study
was to assess the effectiveness of strengthening exercise on joint pain among osteoarthritis patients
and to find association between the level of joint pain of osteoarthritis patients with their selected
socio demographic variables.
patients.
group.
Hypothesis
H1: There will be significant difference in level of joint pain among osteoarthritis patients before
and after administration of strengthening exercise.
H2: There will be significant association between pre-interventional level of joint pain among
osteoarthritis patients with their selected socio demographic variables in experimental and control
group.
The conceptual framework of the present study is based on CIPP model.
A review of literature enables the investigator to develop the conceptual frame work,
methodology for the study and to plan for the data analysis in the most effective and efficient way.
The research approach used for this study was evaluative approach and research design
used for this study was experimental research design.
The setting for the study was Sagar hospital, Bangalore.
The Sample consists of 60 osteoarthritis patients in experimental and control group. Each
sample is selected by using simple random sampling technique.
The variables in the study are as follows;
a) Independent variables: Strengthening exercise on joint pain among osteoarthritis patients.
b) Dependent variables: Level of joint pain among osteoarthritis patients.
c) Demographic variables: Characteristics of osteoarthritis patients such as age, sex, religion,
educational status, occupational status, family monthly income, duration of suffering
osteoarthritis and pharmacologic management of joint pain.
The tool used for the study was behavior pain assessment scale.
Level of joint pain was assessed on the in to 4 levels normal, mild, moderate and severe
joint pain.
The tool was validated by experts and their suggestions were incorporated.
Pilot study was conducted among 6 osteoarthritis patients in experimental and control
group and the pilot study was feasible.
The test re-test method was used for determining the reliability of the tool. The reliability
coefficient (r) was 0.91 for observation schedule which indicates high degree of reliability. Hence
the tool was reliable.

Main study was conducted among 60 osteoarthritis patients in Sagar hospital, Bangalore,
within a time period of 4 weeks.
The collected data was analyzed and interpreted by using descriptive and inferential
statistical method.
Major findings of the study
Result showed that, among 30 osteoarthritis patients in experimental group, 17(56.67%) of
them were between 51-60 years of age, 21(70%) of them were female, 19(63.33%) of them were
Hindus, 16(53.33%) of them were undergraduates, 11(36.67%) of them were private employees,
13(43.33%) of them had monthly income of Rs. 20001-30000, 16(53.33%) of them were suffering
osteoarthritis for more than 10 years, 26(86.67%) of osteoarthritis patients were taking medicine.
It was observed that, among 30 osteoarthritis patients in control group, 14(46.67%) of them
were between 40-50 years of age, 8(60%) of them were female, 13(43.33%) of them were Hindus,
11(36.67%) of them were postgraduates, 15(50%) of them were private employees, 12(40%) of
them had monthly income of Rs.10001-20000, 12(40%) of them were suffering osteoarthritis for
5-10 years and 20(66.67%) of them were taking medicine.
In pre-test, among 30 osteoarthritis patients in experimental group majority 25(83.33%) of
them had severe joint pain and 5(16.67%) of them had moderate joint pain whereas in control
group 19(63.33%) of them had severe joint pain and 11(36.67%) of them had moderate joint pain.
In post-test, osteoarthritis patients in experimental group, 16(53.33%) of them had moderate
joint pain, 9(30%) of them had mild joint pain and 5(16.67%) of them had no joint pain whereas
in control group 16(53.33%) of them had severe joint pain and 14(46.67%) of them had moderate
joint pain.
Comparison was done between the pre-test and post-test mean scores in order to evaluate the
effectiveness of strengthening exercise on joint pain among osteoarthritis patients. It was observed
that, the overall pre-test and post-test mean joint pain score in experimental group was 8.17 and
2.7 respectively with paired ‘t’ value of 13.75, which was above the table value 2.6 at P≤0.01 level
of significance. Hence the research hypothesis H1 is accepted. In control group, mean pre-test and
post-test joint pain score was 7.47 and 7.3 respectively with paired ‘t’ value of 0.56 which is not
significant with table value 2.6 at p≤0.01 level.
The chi-squire value of the pre-interventional level of joint pain of osteoarthritis patients and
their selected socio demographic variables was significant at P≤0.05 level. It showed that, in
experimental group, obtained chi square values for educational status and family monthly income
were higher values (8.85 and 11.01 respectively) when compared to the table value at P≤0.05 level
of significance whereas in control group, the chi square values for gender and educational status
were higher values (12.65 and 16.80 respectively) when compared to the table value at P≤0.05
level of significance. Hence research hypothesis H2 is accepted.

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ANNEXURE -9
LETTER TO THE PARTICIPANTS REQUESTING TO GIVE CONSENT TO
PARTICIPATE IN THE STUDY
Dear Respondent,
I, Mrs. Janet Babu M.Sc. Nursing II year student conducting a research project on
― “A study to evaluate the effectiveness of strengthening exercise on joint pain
among osteoarthritis patients in selected hospitals at Bangalore.”
I request you to participate in the study. The Information obtained will be kept
confidential and anonymity will be maintained throughout and after the study.
Thanking You,
Yours Sincerely
Mrs. Janet Babu

ANNEXURE -10
CONSENT FORM
Dear respondents,
I would like to conduct a research study by using behavioral pain assessment scale. I
request you to respond to the questions without hesitating and the information is kept confidential.
Signature of the Investigator
I _______________ here with consent for the above said study knowing that all the information
provided by me will be treated with at most confidential by the investigator.
Date: Signature of Participant

GLOBAL COLLEGE OF NURSING
(AFFILIATED To RAJrV GANDH UNIVERS ryoF HEALTH SC ENCES)
APPROVED BY ]NDIAN COUNCLL & KARNATAKANURSING COUNC L
CIiRTiFICATE OF [I'HTCAL CLEARAIICE
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fl lu.di.rl Surgic,t ldniry \|r hn\ 5..n rtlnill.(l 1. 1]lii
. .cnd.rnl. t.f 20t5-16 lh. .tbi.rl connnin.. htr: n\tr.n rhr
n,.rnJ lul ..turr.| \ orl, .ii ',\n l\"hrrtne
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th€ crcciir.ntss ol strcngthennrg crercis.tr on ioinl Drin

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I ltu
CIIAIRIIAN
Elhic.l Cl., r{n Q un.ille€
C0
Clobal Coll.!€ r)l Nur\n'9
PROFORMA
VALIDITY OF THE TOOL
It refers to the degree to which an instrument measures what it is intended to measure. 42
The prepared the tool along with the problem statement, objectives and criteria check list were
submitted to 2 physician, and the 6 experts from the field of medical surgical nursing for
establishing content validity. After validation from experts, corrections were made.
Eight experts validated the tool used for the study. The tool was evaluated for
appropriateness, adequacy, relevance, and completeness. Comments and suggestions were invited
and appropriate modifications were made accordingly. The tool was refined and finalized after
establishing the validity. The final draft of the tool contained 10 socio-demographic characteristics
and behavioral pain assessment scale to assess joint pain among osteoarthritis patients.
RELIABILITY OF THE TOOL
Reliability is the degree of consistency or accuracy with which an instrument measures the
attribute it is designed to measure.42
The reliability of the tool was elicited by test-retest method. The tool was administered to
6 osteoarthritis patients who fulfilled the inclusion criteria. The Karl Pearson’s coefficient of
correlation was used for calculating reliability. The reliability coefficient (r) was 0.91 for BPAS
which indicates high degree of reliability. Hence the tool was reliable.
PILOT STUDY
Pilot (1999) states “ Pilot study is a small scale version or trail run done in preparation for
a major study”43
For the present study the investigator selected Fortis hospitals, Bangalore for conducting
pilot study. Formal permission was obtained from the concerned authority to conduct the pilot
study and 6 osteoarthritis patients (3 in experimental group and 3 in control group) were selected
by simple random sampling technique for the same purpose. The investigator gave self
introduction, explained the purpose of study, the respondent’s willingness to participate in the
study was ascertained. The respondents were assumed anonymity and confidentiality of the
information provided by them and written consent was obtained from them. A pre-test was
conducted using BPAS for both group followed by administration of intervention for 21 days in
experimental group. On 21st day post-test was conducted by using the same tool for both the group.
The pilot study samples were excluded from the main study.
The objectives of the pilot study were to:
1. Find out the required time for completing the BPAS.
2. Identify the ambiguity in the wording of the tool.
3. Find out the feasibility of the study.
4. Identify any major flaws in the study design.
ETHICAL CONSIDERATIONS
 The study was accepted by the research committee of Global College of Nursing
 Formal permission was obtained from the concerned authority of Sagar hospitals,
Bangalore.
 Written informed consent was obtained from the study samples. There was no ethical issue
aroused during the study period.
 The subjects were informed that their participation was purely on voluntary basis. They
had the freedom to withdraw from the study if needed at any time and the confidentiality
of the data will be maintained.

METHOD OF DATA COLLECTION
The data was collected from osteoarthritis patients in Sagar hospitals, Bangalore. Written
permission was sought and obtained from the authorities concerned. The period of data collection
was 4 weeks. Around 60 osteoarthritis patients were selected (30 for experimental group and 30
for control group) as per the above mentioned inclusion criteria with prior informed consent to
participate in the study. Initially good rapport was maintained with the patients and the purpose of
the study was explained to them. Patients were made comfortable and the privacy was provided.
Instructions to answer the questionnaire were given. Pretest was conducted through BPAS to
assess the joint pain among osteoarthritis patients. Then the intervention was administered to the
30 patients who were belonging to experimental group, no treatment was given to the control
group. After 21 days of pretest, posttest was conducted to the patients in experimental and control
group with the same BPAS to evaluate their level of joint pain. All the subjects were very
cooperative and investigator expressed her gratitude for their cooperation.
PLAN FOR DATA ANALYSIS
Analysis is the systematic organization and synthesis of research data and the testing of
research hypothesis by using this datas.43
The data obtained was planned to be analyzed based on the objectives and hypothesis of
the study by using descriptive and inferential statistics. To compute the data a master data sheet
was prepared by the investigator.
1. Mean and standard deviation will be used to assess the pre-test and post-test level of joint pain
among osteoarthritis patients.

2. Paired ‘t’ test will be used to evaluate the effectiveness of strengthening exercise on joint pain
among osteoarthritis patients.
3. Chi-square test will be used to associate the pretest level of joint pain among osteoarthritis
patients and their selected socio-demographic variables.

ANNEXURE -5
LETTER REQUESTING OPINION AND SUGGESTIONS OF EXPERTS FOR

ESTABLISHING CONTENT VALIDITY OF RESEARCH TOOL.
From,
Ms. Janet Babu
2nd year M. Sc Nursing
Global College of Nursing
Bangalore
To,
Through,
The Principal
Bangalore
Respected Sir/Madam
Sub:- Request for opinion and suggestions of experts for establishing content validity of the
research tool.
Myself a post graduate student in Medical Surgical Nursing of the Global College of Nursing,
Bangalore have selected the below mentioned topic for my research project to be submitted to
Rajiv Gandhi University of Health Sciences as a partial fulfillment of Masters of Science in
Nursing.
Title :-
With regard to this, I humbly request you to validate my tool for its appropriateness and
relevancy. I am enclosing the objectives of the study, the assessment tool and the criteria rating
scale for your reference. I would be highly obliged for your kindness in validating my tool.
Thanking You, Yours Truly
Enclosures Ms. Janet Babu

Objectives
Assessment tool
Criteria Rating Scale
ANNEXURE -6
EVALUATION CRITERIA CHECKLIST
Respected Madam/ Sir
Kindly go through the content and place right mark against questionnaire in the following
columns ranging from very relevant to not relevant, when found to be not relevant and needs
modification kindly give your opinion in the remarks column.
SECTION A:
SOCIO DEMOGRAPHIC DATA
SL. ITEM RELEVANT NEEDS NOT REMARKS
NO MODIFICATION RELEVANT
7
8
SECTION B
BEHAVIORAL PAIN ASSESSMENT SCALE

5
ANNEXURE -7
CONTENT VALIDITY CERTIFICATE
I, hereby certify that, I have validated the tool of Ms. Janet Babu, II Year M.Sc. Nursing
student who is undertaking a study on “A study to evaluate the effectiveness of strengthening
exercise on joint pain among osteoarthritis patients in selected hospitals at Bangalore.”
Date: Signature of the expert
Place: Name: Designation:

Table-1: Frequency and percentage distribution of selected socio-demographic variables of
N=30
Respondents
Experimental Group Control Group
Characteristics Category N % N %
40-50 years 8 26.67 14 46.67
Age 51-60 years 17 56.67 9 30
61-70 years 5 16.66 7 23.33
Male 9 30 12 40
Gender
Female 21 70 18 60
Hindu 19 63.33 13 43.33
Christian 5 16.67 11 36.67
Religion
Muslims 6 20 6 20
Others 0 0 0 0
Primary education 0 0 3 10
Educational Secondary education 6 20 9 30
status Undergraduate 16 53.33 7 23.33
Postgraduate or above 8 26.67 11 36.67
Private employee 11 36.67 15 50
Government employee 5 16.67 9 30
Occupational
Self employee 6 20 4 13.33
status
Daily wages 0 0 0 0
Nil 8 26.66 2 6.67
Below Rs. 10000 0 0 0 0
Rs.10001-20000 10 33.33 12 40
Family monthly Rs. 20001-30000 13 43.33 8 26.67
income Rs. 30001 or above 7 23.34 10 33.33
Duration of 1-5 years 9 30 9 30
suffering 5-10 years 5 16.67 12 40
osteoarthritis Above 10 years 16 53.33 4 13.33
Pharmacologic Yes 26 86.67 20 66.67
management No 4 13.33 10 33.33
Mean pre-interventional joint pain score among osteoarthritis patients in experimental and
control group
N=30
SL: Respondents
1 Pain score 5-10 8.17 1.46 4-10 7.47 1.92
: Post-interventional level of joint pain among osteoarthritis patients in experimental and

control group
.
N=30
Respondents
N % N %
No pain 0 5 16.67 0 0
Mild pain 1-3 9 30 0 0
Moderate pain 4-6 16 53.33 14 46.67
Severe pain 7-10 0 0 16 53.33
Total 30 100 30 100
Mean post-interventional joint pain score among osteoarthritis patients in experimental
and control group
N=30
SL: Respondents
1 Pain score 0-6 2.7 1.69 4-10 7.3 2.03
Effectiveness of strengthening exercise on regulating joint pain among osteoarthritis

patients
Group Aspect Knowledge of Paired ‘t’
Respondents test
Mean SD
Experimental Pre-test 8.17 1.46 13.75*

Group
Post-test 2.7 1.69
Control Group Pre-test 7.47 1.92 0.56
Post-test 7.3 2.03
**Significant at p≤0.01 level, df 29, t-value 2.6
Association between pre-interventional level of joint pain among osteoarthritis patients and
their selected socio demographic variables in experimental group
(Experimental Group) N=30
40-50 years 8 7 1 1.67
Age NS
51-60 years 17 13 4
61-70 years 5 5 0
Male 9 7 2 0.28
Gender NS
Female 21 18 3
Hindu 19 15 4 1.50
Christian 5 4 1 NS
Religion
Muslims 6 6 0
Others 0 0 0
Daily wages 0 0 0
Nil 8 6 2
Below Rs. 10000 0 0 0 11.01
Rs.10001-20000 10 10 0 S*
Association between pre-interventional level of joint pain among osteoarthritis patients and
their selected socio demographic variables in control group
(Control group) N=30

40-50 years 14 8 6 1.15
Age 51-60 years 9 7 2 NS
61-70 years 7 4 3
Male 12 3 9 12.65
Gender S*
Female 18 16 2
Hindu 13 7 6 1.53
Christian 11 7 4 NS
Religion
Muslims 6 5 1
Others 0 0 0
Daily wages 0 0 0
Nil 2 1 1
Below Rs. 10000 0 0 0 0.10
Rs.10001-20000 12 8 4 NS
ANNEXURE –1
PERMISSION LETTER FOR CONDUCTING PILOT STUDY
ANNEXURE –2
PERMISSION LETTER FOR CONDUCTING MAIN STUDY
ANNEXURE –3
CERTIFICATE OF ETHICAL CLEARANCE
ALREADY ATTACHED
ANNEXURE -4
LETTER REQUESTING OPINION AND SUGGESTIONS OF EXPERTS FOR

ESTABLISHING CONTENT VALIDITY OF RESEARCH TOOL.
From,
Ms. Janet Babu
2nd year M. Sc Nursing
Bangalore
To,
Through,
The Principal
Bangalore
Respected Sir/Madam
Sub:- Request for opinion and suggestions of experts for establishing content validity of the
research tool.
Myself a post graduate student in Medical Surgical Nursing of the Global College of Nursing,
Bangalore have selected the below mentioned topic for my research project to be submitted to
Rajiv Gandhi University of Health Sciences as a partial fulfillment of Masters of Science in
Nursing.
Title :-
With regard to this, I humbly request you to validate my tool for its appropriateness and
relevancy. I am enclosing the objectives of the study, the assessment tool and the criteria rating
scale for your reference. I would be highly obliged for your kindness in validating my tool.
Thanking You, Yours Truly
Enclosures Ms. Janet Babu

Objectives
Assessment tool
Criteria Rating Scale
ANNEXURE -5
EVALUATION CRITERIA CHECKLIST
Respected Madam/ Sir
Kindly go through the content and place right mark against questionnaire in the following
columns ranging from very relevant to not relevant, when found to be not relevant and needs
modification kindly give your opinion in the remarks column.
SECTION A:
SOCIO DEMOGRAPHIC DATA
8
SECTION B
BEHAVIORAL PAIN ASSESSMENT SCALE

5
ANNEXURE -6
CONTENT VALIDITY CERTIFICATE
I, hereby certify that, I have validated the tool of Ms. Janet Babu, II Year M.Sc. Nursing
student who is undertaking a study on “A study to evaluate the effectiveness of strengthening
exercise on joint pain among osteoarthritis patients in selected hospitals at Bangalore.”
Place: Name: Designation:

ANNEXURE -7
LIST OF CONTENT VALIDITY EXPERTS
1. Mr. Deepak Krishna

Assistant Professor, HOD (Medical Surgical Nursing)
Christian college of Nursing
Bangalore
2. Ms. Jency Mathew (Medical Surgical Nursing)
Assistant Professor
Ocean college of nursing
Bangalore
3. Mrs. Reena George (Medical Surgical Nursing)
Principal
Florence college of nursing
Bangalore
4. Mrs. Munmun Mukherjee (Medical surgical Nursing)
Associate Professor, HOD
Indian Academy College of Nursing
Bangalore.
5. Ms. Shalini Devid (Medical Surgical Nursing)
Assistant Professor, HOD
Vijayanagar College of nursing
Bangalore.
6. Prof. Nicolas D’souza

Principal (Medical Surgical Nursing)
Manjushree College of Nursing
Bangalorer
7. Dr. Manjunath S
Physician
Cratis Hospital
Bangalore
8. Dr.Raveender Garshe
Physician
Baptist Hospital
Bangalore
9. Mr. Shobin Joseph
Senior Statistical analyst
Zyme Solutions
Bangalore.
ANNEXURE -8
LETTER TO THE PARTICIPANTS REQUESTING TO GIVE CONSENT TO
PARTICIPATE IN THE STUDY
Dear Respondent,
I, Mrs. Janet Babu M.Sc. Nursing II year student conducting a research project on
― “A study to evaluate the effectiveness of strengthening exercise on joint pain
among osteoarthritis patients in selected hospitals at Bangalore.”
I request you to participate in the study. The Information obtained will be kept
confidential and anonymity will be maintained throughout and after the study.
Thanking You,
Yours Sincerely
Mrs. Janet Babu

ANNEXURE -9
CONSENT FORM
Dear respondents,
I would like to conduct a research study by using behavioral pain assessment scale. I
request you to respond to the questions without hesitating and the information is kept confidential.
Signature of the Investigator
I _______________ here with consent for the above said study knowing that all the information
provided by me will be treated with at most confidential by the investigator.
Date: Signature of Participant

ANNEXURE 10
CERTIFICATE OF ENGLISH EDITING
To whomsoever it may concern
I, hereby certify that the dissertation content of Ms. Janet Babu, II Year M.Sc. Nursing
student of Global college of Nursing who is undertaking a study on “A study to evaluate the
effectiveness of strengthening exercise on joint pain among osteoarthritis patients in
selected hospitals at Bangalore.” is edited by me.
Place: Bangalore
ANNEXURE 11
CERTIFICATE OF STATISTICIAN
To whomever it may concern
I am here by certifying that, the statistical analysis done by Ms. Janet Babu, M. Sc
(Nursing) II year, Global College Of Nursing, Bangalore, for her dissertation on “A study to
evaluate the effectiveness of strengthening exercise on joint pain among osteoarthritis
patients in selected hospitals at Bangalore.” I checked all the calculation and statistical
inferences and found them appropriate.
Date
Place: Bangalore Seal and Signature of the expert

ANNEXURE -12
DESCRIPTION OF THE TOOL
Dear respondents,
This is to bring to your notice that, I am Ms. Janet Babu, a post graduate student of Global
College of Nursing Bangalore, conducting a study “A study to evaluate the effectiveness of
strengthening exercise on joint pain among osteoarthritis patients in selected hospitals at
Bangalore.” I request you to participate in my study by using behavioral pain assessment scale.
Your data will be kept confidential and is only for the purpose of the study.
PART-I
SOCIO-DEMOGRAPHIC DATA
INSTRUCTIONS:
Kindly go through each item and give your responses against the box provided against
each item. Please make sure that you answer all the items.
1. Age in years
a. 40-50 years
b. 51-60 years
c. 61-70 years
2. Gender
a. Male
b. Female
3. Religion
a. Hindu
b. Christian
c. Muslim
d. Others
4. Educational Status
a. Primary education
b. Secondary education
c. Undergraduate
d. Postgraduate or above
5. Occupational status
a. Private employee
b. Government employee
c. Self employee
d. Daily wages
e. Nil
6. Family monthly income
a. Below Rs. 10000
b. Rs.10001-20000
c. Rs. 20001-30000
d. Rs. 30001 or above
7. Duration of suffering osteoarthritis
a. Less than 1 year
b. 1-5 years
c. 5-10 years
d. Above 10 years
8. Pharmacologic management of osteoarthritis
a. Yes
b. No
SECTION-B
BEHAVIOURAL PAIN ASSESSMENT SCALE
ITEMS SCORES
0 1 2
Face Face muscles Facial muscle Frequent to constant

relaxed tension, frown, frown, clenched jaw
grimace
Restlessness Quiet, relaxed Occasional restless Frequent restless
appearance, normal movement, shifting movement may include
movement position extremities or head
Muscle tone Normal muscle tone Increased tone, Rigid tone

flexion of fingers
and toes
Vocalisation No abnormal sounds Occasional moans, Frequent or continuous
cries, whimpers and moans, cries, whimpers
grunts or grunts
Consolability Content, relaxed Reassured by touch, Difficult to comfort by
distractible touch or talk
Behavioural pain assessment scale total (0–10)

ANNEXURE -13
PROCEDURE OF INTERVENTION
PREPARATORY PHASE
1. Explain the procedure to the patient
2. Informed consent to be obtained
3. Level of joint pain to be checked prior to the intervention (both experimental and control
group)
INTERVENTION PHASE (In Experimental group)
Steps;
1. Demonstrate strengthening exercise
2. Encourage patients to do strengthening exercise for 30 minutes every day
3. Continue the intervention for 3 weeks.
At the end of intervention post interventional level of joint pain will be checked in both control
and experimental group
STRENGTHENING EXERCISE
Hamstring Stretch
Stretching keeps you flexible and improves your range of motion, or how far you can move your
joints in certain directions. It also helps you lower your odds of pain and injuries.
Always warm up with a 5-minute walk first. Lie down when you're ready to stretch your hamstring.
Loop a bed sheet around your right foot. Use the sheet to help pull the straight leg up. Hold for 20
seconds, then lower the leg. Repeat twice. Then, switch legs.
Calf Stretch
Hold onto a chair for balance. Bend your right leg. Step back with your left leg, and slowly
straighten it behind you. Press your left heel toward the floor. You should feel the stretch in the
calf of your back leg. Hold for 20 seconds. Repeat twice, then switch legs.
For more of a stretch, lean forward and bend the right knee deeper -- but don’t let it go past your
toes.
Straight Leg Raise
Build muscle strength to help support weak joints.
Lie on the floor, upper body supported by your elbows. Bend your left knee, foot on the floor.
Keep the right leg straight, toes pointed up. Tighten your thigh muscles and raise your right leg.
Pause, as shown, for 3 seconds. Keep your thigh muscles tight and slowly lower your leg to the
ground. Touch and raise again. Do two sets of 10 repetitions. Switch legs after each set.
Quad Set
Is the straight leg raise too tough? Do quad sets instead. With these you don’t raise your leg. Simply
tighten the thigh muscles, also called the quadriceps, of one leg at a time.
Start by lying on the floor. Keep both legs on ground, relaxed (left photo). Flex and hold left leg
tense for 5 seconds (right photo). Relax. Do two sets of 10 repetitions. Switch legs after each set.
Seated Hip March
Strengthen your hips and thigh muscles. It can help with daily activities like walking or standing
up.
Sit up straight in a chair. Kick your left foot back slightly, but keep your toes on the floor. Lift
your right foot off the floor, knee bent. Hold the right leg in the air 3 seconds. Slowly lower your
foot to the ground. Do two sets of 10 repetitions. Switch legs after each set.
Too hard? Use your hands to help lift your leg.

Pillow Squeeze
This move helps strengthen the inside of your legs to help support your knees. Lie on your back,
both knees bent. Place a pillow between the knees.
Squeeze your knees together, squishing the pillow between them. Hold for 5 seconds. Relax.
Do two sets of 10 repetitions. Switch legs after each set.
Too tough? You can also do this exercise while seated.

Heel Raise
Stand tall and hold the back of a chair for support. Lift your heels off the ground and rise up on
the toes of both feet. Hold for 3 seconds. Slowly lower both heels to the ground. Do two sets of 10
repetitions.
Too tricky? Do the same exercise while sitting in a chair.

Side Leg Raise
Stand and hold the back of a chair for balance. Place your weight on your left leg. Stand tall and
lift the right leg out to the side -- keep the right leg straight and outer leg muscles tensed. Hold 3
seconds, then slowly lower the leg. Do two sets of 10 repetitions. Switch legs after each set.
Too hard? Increase leg height over time. After a few workouts, you’ll be able to raise it higher.
Sit to Stand
Practice this move to make standing easier. Place two pillows on a chair. Sit on top, with your
back straight, feet flat on the floor (see left photo). Use your leg muscles to slowly and smoothly
stand up tall. Then lower again to sit. Be sure your bent knees don’t move ahead of your toes. Try
with your arms crossed or loose at your sides.
Too tough to do? Add pillows. Or use a chair with armrests and help push up with your arms.
One Leg Balance
This move helps you bend over or get in and out of cars.
Stand behind your kitchen counter without holding on, and slowly lift one foot off the floor. The
goal is to stay balanced for 20 seconds without grabbing the counter. Do this move twice, then
switch sides.
Too easy? Balance for a longer time. Or try it with your eyes closed.
Step Ups
Do this to strengthen your legs for climbing steps.
Stand in front of stairs, and hold onto the banister for balance. Then place your left foot on a
step. Tighten your left thigh muscle and step up, touching your right foot onto the step. Keep your
muscles tight as you slowly lower your right foot. Touch the floor and lift again. Do two sets of
10 repetitions. Switch legs after each set.

A Study To Evaluate The Effectiveness of Strengthening Exercise On Joint Pain Among Osteoarthritis Patients in Selected Hospitals, Bangalore.

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A Study To Evaluate The Effectiveness of Strengthening Exercise On Joint Pain Among Osteoarthritis Patients in Selected Hospitals, Bangalore.

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“A STUDY TO EVALUATE THE EFFECTIVENESS OF STRENGTHENING

EXERCISE ON JOINT PAIN AMONG OSTEOARTHRITIS PATIENTS IN

SELECTED HOSPITALS, BANGALORE.”

Mrs. JANET BABU

Dissertation Submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

In partial fulfillment of the requirements for the degree of

IN MEDICAL SURGICAL NURSING

Under the Guidance of

Mr.K.Gopalakrishnan , (M.Sc NURSING)

Professor & HOD

Department of Medical Surgical Nursing

GLOBAL COLLEGE OF NURSING

WHO World Health Organization

KOA Knee Osteoarthritis

MHAQ Modified Health Assessment Questionnaire

ACR Arthritis Clinical Rating

WOMAC Western Ontario and McMaster Universities Osteoarthritis Index

VAS Visual analog pain scale

RCT Randomized Control Trials

BPAS Behavioral Pain Assessment Scale

SL. NAME OF THE TABLES PAGE

variables of osteoarthritis patients

2 Pre-interventional level of joint pain among osteoarthritis patients in 44

experimental and control group

3 Mean pre-interventional joint pain score among osteoarthritis patients in 46

experimental and control group

4 Post-interventional level of joint pain among osteoarthritis patients in 45

experimental and control group

5 Mean post-interventional joint pain score among osteoarthritis patients in 47

experimental and control group

6 Effectiveness of strengthening exercise on regulating joint pain among 48

7 Association between pre-interventional level of joint pain among 49

osteoarthritis patients and their selected socio demographic variables in

8 Association between pre-interventional level of joint pain among 51

osteoarthritis patients and their selected socio demographic variables in

SL. NAME OF FIGURES PAGE

2 Schematic Representation of Research Design 24

3 Schematic Representation of Research methodology 25

4 Bar diagram shows that percentage distribution of osteoarthritis patients on 40

Back ground of the study

pain among osteoarthritis patients in selected hospitals at Bangalore.

Objectives of the study

group, before the administration of strengthening exercise.

2. To evaluate the effectiveness of strengthening exercise on joint pain among osteoarthritis

3. To determine the association between pre-interventional level of joint pain among

Result showed that, among 30 osteoarthritis patients in experimental group, 17(56.67%) of

5-10 years and 20(66.67%) of them were taking medicine.

selected socio demographic variables was significant at P≤0.05 level.

or limitations can significantly reduce the quality of life in an active individual.3

Strengthening exercise can improve the stability to the knee joint. 5

NEED FOR THE STUDY

Osteoarthritis (OA) is widely known as the most frequent musculoskeletal disorder,

t he age of 65 years. Disease burden is related to pain occurrence, frequently leading to

functional disability ranging from slight limitation of movements to severe impairment of

cannot perform their major daily living activities.12

elderly population was 54.1 % and 16.4% respectively..13

and reduce joint stiffness and pain.14

combined with regular exercise.15

A Quasi experimental study was conducted at the physiotherapy department of general

older adults with knee Osteoarthritis. 16

strengthening exercise for joint pain among osteoarthritis patients.

conceptual framework on which the study is based.