COMPARISON OF OUTCOME OF WARM HYDROTHERAPY

VS ALTERNATIVE WARM AND COLD HYDROTHERAPY ON

LEVEL OF PAIN AMONG OSTEOARTHRITIS PATIENTS.

DISSERTATION SUBMITTED TO

THE TAMIL NADU DR.M.G.R.MEDICAL UNIVERSITY

CHENNAI

In partial fulfillment of requirement for the award of degree of

MASTER OF SCIENCE IN NURSING
APRIL, 2012
 A COMPARITIVE STUDY TO ASSESS THE OUTCOME OF
WARM HYDROTHERAPY VS ALTERNATIVE WARM AND
COLD HYDROTHERAPY ON LEVEL OF PAIN AMONG
OSTEOARTHRITIS PATIENTS AT SELECTED HOSPITALS,
CHENNAI, 2011-2012.
Certified that this is the bonafide work of

E.ANAND
VEL R.S. MEDICAL COLLEGE – COLLEGE OF NURSING,
NO.42, AVADI - ALAMATHI ROAD,
CHENNAI - 600 062
COLLEGE SEAL

SIGNATURE: _________________
M.ANURADHA
R.N, R.M., M.Sc.(N).,
Principal,
Vel R.S. Medical College - College of Nursing,
No.42, Avadi - Alamathi Road,
Chennai – 600 062, Tamil Nadu.

Dissertation Submitted to
THE TAMIL NADU DR.M.G.R.MEDICALUNIVERSITY
CHENNAI
In partial fulfillment of requirement for the award of degree of
MASTER OF SCIENCE IN NURSING
APRIL, 2012
 A COMPARITIVE STUDY TO ASSESS THE OUTCOME OF
WARM HYDROTHERAPY VS ALTERNATIVE WARM AND
COLD HYDROTHERAPY ON LEVEL OF PAIN AMONG
OSTEOARTHRITIS PATIENTS AT SELECTED HOSPITALS,
CHENNAI, 2011-2012.

Approved by Dissertation Committee in December, 2010

PROFESSOR IN NURSING RESEARCH
M. ANURADHA
R.N, R.M., M.Sc.(N),
Principal,
Vel R.S. Medical College - College of Nursing,
No.42, Avadi - Alamathi Road,
Chennai – 600 062, Tamil Nadu.

CLINICAL SPECIALITY EXPERT

M. K. DHANALAKSHMI
R.N, R.M., M.Sc (N),
Reader,
Medical and Surgical Nursing Department,
Vel R.S. Medical College - College of Nursing,
No.42, Avadi - Alamathi Road,
Chennai – 600 062, Tamil Nadu.
MEDICAL EXPERT
R. M. SIVASUBRAMANIAN ______________________
MBBS, MS (ORTHO), FRCS,
CHIEF ORTHOPEDICIAN, H.O.D.,
Hindu Mission Hospital, Tambaram, Chennai.

Dissertation Submitted to
THE TAMIL NADU DR.M.G.R.MEDICAL UNIVERSITY
CHENNAI
In partial fulfillment of requirement for the award of degree of
MASTER OF SCIENCE IN NURSING
APRIL, 2012
 ACKNOWLEDGMENT

I owe my success to Almighty God who blessed me with the necessary will power,
strength, courage and health throughout this endeavor.

I wish to express my gratitude to the Founder, Chairman, R.Rangarajan, Vice -

Chairman, Sakunthala Rangarajan, Managing Director and Trustees of Vel Group of
Educational Institutions, whose dynamic personality and charisma was an inspiration to many of
us throughout our course in this esteemed institution.

“Behind every author there is a great inspiration”. This Chinese saying is aptly fulfilled by
our Principal, M.Anuradha R.N, R.M., M.Sc (N)., who was a great inspiration for me
throughout my study. Her attention to detail and quest for perfection reflected by her vast
experience and was instrumental in making my study a fine success. I owe my profound
gratitude and sincere thanks to our most respected Principal.

I like to express my heartfelt gratitude to the Vice Principal, HOD of Medical Surgical
Nursing, K. SudhaDevi, R.N, R.M., M.Sc (N)., for her immense support from the initial period
of my study.

I would like to take this opportunity to convey my sincere thanks and heartfelt gratitude
to M. K. Dhanalakshmi R.N, R.M., M.Sc.(N)., Reader of Medical Surgical Nursing who has
guided me as a good mentor and her immense support was instrumental in completion of my
study.

I thank Jannet and Savithri R.N, R.M., M.Sc (N), Lecturers, and all PG faculty
members Vel R.S.Medical College-College of Nursing for her guidance and continuous support
throughout my study.

It gives me immense pleasure to thank HemaSuresh, R.N, R.M., M.Sc (N)., Medical
Surgical Nursing, Vice Principal of Meenakshi College of Nursing, N.Jayasri, R.N, R.M.,
M.Sc (N)., Medical Surgical Nursing, Vice Principal of Miot College of Nursing for their help in
evaluating the tool for my study.

It gives me great pleasure to share my gratitude Selvakani Pandiyan, R.N, R.M., M.Sc
(N)., Medical Surgical Nursing, Vice Principal of SRM College of Nursing, Jolly Ranjith, R.N,
R.M., M.Sc (N) Reader of Medical Surgical Nursing Department, OmayalAachi College of
Nursing, for their help in evaluating the tool for my study.
My immense gratitude to D.K. Srinivasan, Secretary, Hindu Mission Hospital permitting
to conduct study in their setting.

My sincere thanks to R. M. SivaSubramanian, M.B.B.S., MS, (ORTHO), FRCS,

W.Emmanuel D.P.T, Physiotherapist for validating the tool of my study.

I take this opportunity to thank Thenarasu, Biostatistician, Shankara Nethralaya

Hospitals, G.K.Venkataraman, Elite Computers for their assistance in statistical analysis and
presentation of data.

I would like to convey my thanks to P.SylviaGrace, M.A., M.Phil, M.Ed., and

R.AnjelineEzhilarasi, M.A., M.Phil, B.Ed., for their immense help in English and Tamil
editing for my study.

I take this opportunity to thank all my teaching and non-teaching staff members,
librarians and office staff members of Vel R.S Medical College – College of nursing for their
co-operation and help rendered.
It would be a lapse on my part if I fail to thank my brother, E.PremKumar B.E. and my
parents and my friends for their indescribable support in every aspect of this whole study
without whose constant guidance, spiritual support, encouragement and well wishes, the
successful completion of this study would have not been possible.

Last but not the least I would like to express my thanks to the study participants for
their co-operation and participation, without whom this study would have been impossible.

(E.ANAND)
 TABLE OF CONTENTS

Chapter Title Page no

I INTRODUCTION 1

3
Back ground of the study
5
Significant & Need for the study
9
Title
9
Statement of the problem 9
9
Objectives
Variables of the study 10
10
Hypothesis of the study
10
Operational definition
11
Assumptions
11
Delimitations
12
Projected outcome
12
Summary 12
Organization of the report

II REVIEW OF LITERATURE 13

14
Part I-Review of Literature
Part II-Conceptual Framework 22

III RESEARCH METHODOLOGY 25

25
Research Approach
25
Research Design
27
Research Setting
 Variables under study 27
Population 27
Sample 27
Sample size 28
Sampling Technique 28
Criteria for Sample selection 29
Method of developing the Tools 29
Description of Research Tools 30
Validity of the Tool 30
Reliability of the Tool 30
Ethical consideration 30
Pilot study 31
Data Collection Procedure 33
Data Analysis Procedure

IV DATA ANALYSIS AND INTERPRATATION 34

V DISCUSSION 62

VI SUMMARY, RECOMMANDATION & LIMITATION

66

REFERENCES 71

APPENDICES i - xxii
 LIST OF TABLES

Table no. Title Page no

1 Frequency and percentage distribution of demographic 35

variables in the Experimental group I and II

Assessment
2 Frequency and percentage distribution of pretest and post 47
level of pain in the Experimental group I

3 Frequency and percentage distribution of pretest and post 49

test level of pain in the Experimental group II

4 Outcome of pretest and post level of pain in the 51

Experimental group I

5 Outcome of pretest and post level of pain in the 53

Experimental group II

6 Comparison of post test level of pain between Experimental 55

group I and II

7 Association of post test level of pain among patients with 56

osteoarthritis with their demographic variables in
Experimental group I.

8 Association of post test level of pain among patients with 60

osteoarthritis with their demographic variables in
Experimental group II
 LIST OF FIGURES

Figure no. Title Page no

Conceptual Framework (Modified Wiedenbach‟s helping art of

1
Clinical Nursing Theory (1964). 24

Schematic representation of Research Methodology 26

2
Percentage distribution of age in the Experimental 38
3 group I and II.

Percentage distribution of gender in the Experimental groups I 39

4 and II.

Percentage distribution of marital status in the 40

5 Experimental groups I and II.

Percentage distribution of type of family in the Experimental 41

6 group I and II

Percentage distribution of education in the Experimental group I 42

7 and II

Percentage distribution of family income in the Experimental 43

8 group I and II

Percentage distribution of duration of illness in the Experimental 44

9 group I and II

Percentage distribution of duration of medical intervention in the 45

10 Experimental group I and II

Percentage distribution co – morbid illness in the Experimental 46

11 group I and II

Percentage distribution of pre test and post test level of pain in 47

12 the Experimental group I
Percentage distribution of pre test and post test level of pain in 49
13 the Experimental group II
 Mean and Standard deviation distribution of pre test and post 51
14 level of pain in Experimental group I.

Mean and Standard deviation distribution of pre test and post 53

15 level of pain in Experimental group II.
 LIST OF APPENDICES

Appendix no. Title Page no

A List of Experts for content validity of the Tool. i
ii
Letter seeking expert‟s opinion for content validity.
Content validity certificate. iii
B Tool – English Version ix
xiii
Tool – Tamil Version

C Permission Letter xvii

Certificate for English editing
xviii
Certificate for Tamil editing xix
D Photos xx
 ABSTRACT
Arthritis is one of the most common conditions in the population resulting substantial
social and economic costs. Arthritis conditions do not cause death, but they affect quality of life
of a person. Osteoarthritis affects the articular cartilage in a joint. Over time the articular
cartilage can thin or form cracks. Pieces of articular cartilage may come loose and float inside
the joint, further irritating the joint. Osteoarthritis is one of the most frequent causes of physical
disability among adults. It usually comes on slowly and results in joint pain, stiffness and/or
swelling. Sometimes a grating sound can be heard when a joint is moved, such as the knee when
going up or down stairs. It is found that Hydrotherapy is effective in helping those individuals
with osteoarthritis , focusing on relieving pain and discomfort as well as on responding to tension
before it develops into disease, that is, before constrictions and imbalance can do further damage.

Thus the investigator conducted a study to compare the outcome of warm hydrotherapy
versus alternative warm and cold hydrotherapy on level of pain among patients with
osteoarthritis. The objective of the study is to compare the outcome of warm hydrotherapy and
alternative warm and cold hydrotherapy of level of pain among osteoarthritis patients.
The conceptual frame work is based on modified Widenbach‟s helping art of Clinical Nursing
Theory (1964). A quasi experimental study with a evaluative research approach was adopted for
this study was conducted in Hindu Mission Hospital, Tambaram, Chennai, at orthopedic
outpatient department.

30 osteoarthritis patients for each group who fulfilled the inclusive criteria were
selected by non - probability purposive sampling method. 30 samples were assigned to each
group for experimental group I and II. The variables selected for this study were Age in years,
gender, marital status, type of family, education, type of work, family income, duration of
illness, duration of medical interventions, co-morbid illness. The tool used for the assessment of
level of pain was Modified Numerical categorical pain scale. The pre test was done by using the
same tool. The osteoarthritis patients in experimental group I and II were exercised with warm
hydrotherapy and alternative warm and cold hydrotherapy. Post test was done by using the same
scale for both the group. Descriptive and inferential statistics were used to analyze the data.
 In the experimental group, the pre-test and post-test mean score with standard
deviation of experimental group I pre-test=6.13±1.17, post-test=3.37±1.43, calculated„t‟ value is
23.084*** which was statically highly significant p=0.000(S). The pre-test and post-test mean
score with standard deviation of experimental group II pre-test=6.13±1.50, post-test=3.33±1.60,
calculated „t‟ value is 21.468*** which was statically highly significant p=0.000(S).Finally
comparison post-test level of pain of experimental group I and II using unpaired t test; t=0.085
which is not significant with p value=0.933,(N.S).

So from the statistical data analysis the research hypothesis has been proved non-
significant, therefore both warm hydrotherapy and alternative warm and cold hydrotherapy is
effective towards level of pain among osteoarthritis patients.
 1

CHAPTER-I

INTRODUCTION

Health is the greatest gift, contentment the greatest wealth, faithfulness the

best relationship. – Gautama Buddha.

Arthritis is one of the most common chronic conditions in the population resulting
insubstantial social and economic costs. Due to aging of the population prevalence and the
impact of this disease is projected to greatly increase. Osteoarthritis is the most common form of
arthritis.

Arthritis condition does not usually cause death but they affect quality of life of a
person. It limits the ability of the people to work and care for themselves and their families. It
costs nearly 86.2 billion annually to the national economy.

Osteoarthritis affects the articular cartilage in a joint. Articular cartilage is the smooth
coating that covers the surface of the bones inside a joint. Articular cartilage also cushions and
helps lubricate the joint surfaces. In osteoarthritis the articular cartilage is damaged. Over time
the articular cartilage can thin or form cracks. Pieces of articular cartilage may come loose and
float inside the joint, further irritating the joint. After a long period of time the articular cartilage
can become completely "worn away" and the bones can rub together.

Osteoarthritis is one of the most frequent causes of physical disability among adults.
More than 40 million people in the United States have the disease. By 2030, an estimated 20
percent of Americans -- about 70 million people -- will have passed their 65th birthday and will
be at risk of developing osteoarthritis.
 2

Pain is the multidimensional phenomenon that varies with each individual and each
painful experience. It is now accepted that pain should be anticipated and be safely and
effectively controlled in all patients, whatever is their age, maturity or severity of illness.

Osteoarthritis usually comes on slowly and results in joint pain, stiffness and/or swelling.
Sometimes a grating sound can be heard when a joint is moved, such as the knee when going up
or down stairs. Bumps may also appear around the joint. Sometimes a joint can have a mild
amount of osteoarthritis and feel perfectly fine.

By the early 1900s, hydrotherapy was a common treatment employed by naturopathic

physicians. Benedict Lust, Henry Lindlahr, and O.G. Carroll were three of the most famous
naturopathic physicians who have ever lived. They combined hydrotherapy with other treatments
such as herbal medicine, homeopathy, and diet therapy to help heal literally thousands of people
whose conditions were originally considered incurable. Hydrotherapy was the center-point of
their practices and many of the treatments that they used are still being used today.

Hydrotherapy can also be effective in helping those individuals with osteoarthritis (OA).
Several studies have shown that strength training and aerobic exercise can reduce pain and
improve the physical function and general health of people with osteoarthritis in their knees.
Water's buoyancy offers an alternative method for getting exercise by allowing easier joint
movement and being virtually impact-free, making it an excellent choice for people with painful
joints.

Hydrotherapy focuses on relieving pain and discomfort as well as on responding to

tension before it develops into disease, that is, before constrictions and imbalance can do further
damage. Hydrotherapy offers considerable benefits for the disabled. These patients benefit
specifically from increased blood flow to skeletal muscles, which can help prevent atrophy.
Hydrotherapy can also assist in recovery from stroke, brain injury, and orthopedic surgery; it can
benefit women before and after giving birth. By relieving stress, it strengthens resistance to
disease and promotes wellness.
 3

BACKGROUND OF THE STUDY:

According to the Global Statistics (2007) 100 million people suffer from the
osteoarthritis. According to the National Arthritis Data Group Statistics (2005) osteoarthritis is
the common type of arthritis. Nearly 27 million people have osteoarthritis.

It is estimated that approximately four per cent of the world's current populace is
affected by osteoarthritis. According to the US-based Arthritis Foundation, one-sixth of the total
US populace, or 40 million Americans are victims of arthritis, of which osteoarthritis is the most
common. The Foundation also estimates that 80 per cent of the 50-plus people in the world will
experience arthritis in one of its many hundred forms.

Centers for Disease Control and Prevention (CDC) estimate 27 million Americans suffer
from OA with more women than men affected by the disease. Forecasts indicate that by the year
2030, 25% of the adult U.S. population, or nearly 67 million people, will have physician-
diagnosed arthritis. OA is a major debilitating disease causing gradual loss of cartilage, primarily
affecting the knees, hips, hands, feet, and spine.

William C. Shiel.Jr., MD, FACP, FACR osteoarthritis is caused by breakdown of

cartilage, with eventual loss of the cartilages of the joints. When the cartilages deteriorates, the
bone next to it becomes inflamed and can be stimulated to produce new bone in the form of a
local bony protrusion, called the “spur.” A very common early sign of osteoarthritis is a knobby
bony deformity at the smallest joint of the end of the fingers. This is referred to as a Heberden's
node, named after a very famous British doctor. The bony deformity is a result of the bone spurs
from the osteoarthritis in that joint. Another common bony knob (node) occurs at the middle
joint of the fingers in many patients with osteoarthritis and is called a Bouchard's node. Dr.
Bouchard was a famous French doctor who also studied arthritis patients at the turn of the last
century. The Heberden's and Bouchard's nodes may not be painful, but they are often associated
with limitation of motion of the joint. The characteristic appearances of these finger nodes can be
helpful in diagnosing osteoarthritis.
 4

According to Knee Replacement Organization, India osteoarthritis usually occurs after the
age of 50 and affects one in five people. It is twice as common in women, and most often
damages the knee joint. Overweight people, those with previous injury to the joint, overuse or
incorrect alignment between the bones (e.g., bow legs) are more commonly affected.
Rheumatoid Arthritis strikes 3% of women and 1% of men, usually between the ages of 20 and
55 years. Gout affects 3-4 persons per 1000. It is mostly seen in men over 35 years. Ankylosing
spondylitis also mainly affects men, usually between the ages of 20 and 30 years.

Alan Silman Prof., Medical Director (Arthritis Research UK) when your knee has
osteoarthritis its surfaces become damaged and it doesn’t move as well as it should do. The
cartilage becomes rough and thin – this can happen over the main surface of your knee joint and
in the cartilage underneath your kneecap. The bone underneath the cartilage reacts by growing
thicker and becoming broader. All the tissues in your joint become more active than normal, as if
your body is trying to repair the damage. The bone at the edge of your joint grows outwards,
forming bony spurs called osteophytes. The synovium may swell and produce extra fluid,
causing the joint to swell – this is called an effusion or sometimes water on the knee. The capsule
and ligaments slowly thicken and contract.

Stephen Messier of Wake Forest University found that a program of diet and exercise
reduced pain and improved mobility by as much as 50 percent in those with knee arthritis. He
assigned adults with knee OA and pain to one of three groups for the 18-month program. One
group dieted only, one group exercised only and one group did both. In all, 399 overweight or
obese men and women, average age 66, completed the study. The diet and exercise group lost the
most weight, averaging 11.4 percent of their body weight. The diet-only group lost 9.5 percent;
the exercise-only group lost 2.2 percent. When they compared pain and mobility, the diet and
exercise group reported much less pain and had greater walking speed than the other groups.

Jeffrey Driban, assistant professor of rheumatology at Tufts Medical Center in Boston.

He reviewed studies that looked at a link between sports participation and knee OA. He focused
on 16 studies, and then honed in on 10 that looked at athletes and nonathletic. While there were
not great differences later in the amount of knee OA for former sports players and nonathletic,
 5

he did find a risk linked with the type of sport and level of participation. Soccer players, whether
elite level or not, had a greater risk of knee OA, he found. So did elite long-distance runners,
competitive weight lifters and wrestlers. The increased risk of arthritis in these participants
varied from about threefold to more than six fold compared to nonathletic, he said.

SIGNIFICANCE AND NEED FOR STUDY:

The Centre for Disease Control estimated that arthritis affected 43 million people in
1998 and thus figure would increase to 60 million by the year 2020 (Klippel 2001)

International Research agencies conducted a study on social impact of arthritis in

Australia in the year 2004. The different areas studies were life style relationship, employment
and treatment. They found that women are more dissatisfied in the lifestyle activities of those
men (Felson, 1996)

Once patient develop OA, they suffer from the disease for the remainder of their lives and
the severity of pain and disability generally increases. The frequency and chronicity of OA and
the lack of effective preventive measures or cures make this disease a substantial economic
burden for patient’s health care system business and nations. (Charles Saltzman MD, October
2004)

Reilly.S (2006) done a postal survey wit the aim to assess the prevalence of knee pain
among 4057 men and women aged between 40 – 80 years. The study was conducted at the
department of Rheumatology unit, City hospital, Nothingham. The subjects were asked about
chronic knee pain question was concerning job titles and industry was included. The prevalence
of knee pain was assessed. This result explored high prevalence of knee pain among knee
bending and heavy lifting

San Dieg Calif (2004) has done a survey with the aim to determine the prevalence of
knee osteoarthritis. The study was conducted at Korea, among 258 women. According to
multivariate analysis, the prevalence of knee osteoarthritis increased with age and household
 6

industry. The result suggests that there was a relationship with significant family history of
injury and high body mass index

David T. Felson MD (2005) has done a study with the aim to investigate the prevalence of
osteoarthritis (OA) of the knee in elderly subjects. The study was conducted at the Framingham
Heart Study cohort, a population based group 1,805 subjects with the age group between 63-94
years participated in this study. The subjects were graded 0-4 according to the scales described
by Kellgren and Lawrence. The result suggests that there is a marked age – associated increase in
the incidence of osteoarthritis.

John Rizzo, Ph.D., and colleagues used data from the 1996-2005 Medical Expenditure
Panel Survey (MEPS) to determine the overall annual expected medical care expenditures for
OA in the U.S. The sample included 84,647 women and 70,590 men aged 18 years and older
who had health insurance. Expenditures for physician, hospital, and outpatient services, as well
expenditures for drugs, diagnostic testing, and related medical services were included.
Healthcare expenses were expressed in 2007 dollars using the Medical Care

Arthritis & rheumatism, a peer-reviewed journal of the American college of

rheumatology (ACR). Close to 27 million Americans age 25 and older have OA and this
disabling condition accounts for 25% of all arthritis-related healthcare visits. OA is the most
common form of arthritis and is traditionally considered a disease affecting older individuals,
with incidence rates increasing with age. However, recent reports suggest the majority of adults
with OA are younger than 65. Prior studies have shown that occupational physical demands,
traumatic joint injury, and activities involving repetitive joint movement all contribute to OA
development.

Center for disease control and prevention: (CDC)

Prevalence:
Overall OA affects 13.9% of adults aged 25 and older and 33.6 %( 12.4 million) of
those 65 years and above; an estimated26.9 million US adults in 2005 up from 21 million in
1990(believed to be conservative estimate)
Radiographic OA (moderate to severe) - prevalence per 100 population
 7

Hand = 7.3 (9.5 female ; 4.8 male)

Feet = 2.3 (2.7 female ; 1.5 male)
Knee = 0.9 (1.2 female ; 0.4 male)
Hip = 1.5 (1.4 female ; 1.4 male)
Symptomatic OA – prevalence per 100
Hand = 8% (8.9% female; 6.7% male) 2.9 million adults aged 60+ years.
Feet = 2.0 % (3.6 % female; 1.6% male) aged 15 – 74 years.
Knee = 12.1% (13.6% female; 10.0% male) 4.3 million adults aged 60+ years.
Knee = 16% (18.7% female; 13.5% male) adults aged 45+ years.
Hip = 4.4% (3.6% female; 5.5% male) adults ≥ 55 years of age.

Incidence:
Age and sex-standardized incidence rates of symptomatic OA:
Hand OA = 100 per 100,000 person years.
Hip OA = 88 per 100,000 person years.
Knee OA = 240 per 100,000 person years.
Among women:
i. Incident radiographic knee OA 2% per year.
ii. Incident symptomatic knee OA 1% per year.
iii. Progressive knee OA 4% per year.

Mortality:
About 0.2 to 0.3 deaths per 100,000 populations due to OA (1979–1988).
OA accounts for ~6% of all arthritis-related deaths.
~ 500 deaths per year attributed to OA; numbers increased during the past 10 years.
OA deaths are likely highly underestimated. For example, gastrointestinal bleeding due to
treatment with NSAIDs is not counted.

Hospitalizations:
OA accounts for 55% of all arthritis-related hospitalizations; 409,000 hospitalizations for
OA as principal diagnosis in 1997.
 8

Knee and hip joint replacement procedures accounted for 35% of total arthritis-related
procedures during hospitalization.
From 1990 to 2000 the age-adjusted rate of total knee replacements in Wisconsin
increased 81.5% (162 to 294 per 100,000).

NATIONAL STATISTICS:
'TNS Arogya 2006-07 The Health Monitor' - conducted by TNS, an ISO-
accredited market research agency in Delhi, in October 2007, was carried out across a swathe of
15 cities - Delhi, Lucknow, Ludhiana, Jaipur, Varanasi, Chennai, Bangalore, Hyderabad, Cochin,
Kolkata, Patna, Mumbai, Ahmedabad, Nagpur and Indore. According to the study, in the age
band of 25 to 35 years, osteoarthritis is the second most prevalent disease in India after diabetes.
Despite this, reports the study, awareness amongst Indians about the bone ailment is almost nil as
compared to high profile diseases like cancer, AIDS and diabetes.

Osteoarthritis - or degenerative joint disease (DJD) - is a common rheumatologic

disorder. The World Health Organization (WHO) estimates that 70 million Indians are its
victims, nearly 80 per cent of them above 75 years. Although the symptoms occur earlier in
women, the prevalence of osteoarthritis among men and women is at par, say experts.

According to state statistics (2009) 50% of adults 65years or older reported an arthritis
diagnosis. 28.3 million Women and 18.2 million men reported doctor diagnosed arthritis.
According to the age group 18-44 years -8.7 million, 45-64years-20.5million 65years and
above.
 9

TITLE

Comparison of outcome of warm hydrotherapy Vs alternative warm and cold

hydrotherapy on level of pain among osteoarthritis patients.

STATEMENT OF PROBLEM

A comparative study to assess outcome of warm hydrotherapy Vs alternative warm

and cold hydrotherapy on level of pain among osteoarthritis patients at selected hospital,
Chennai, 2011- 2012.

OBJECTIVES

1. To assess the pre-test level of pain among osteoarthritis patients of warm hydrotherapy
(Group I) and alternative warm and cold hydrotherapy (Group II).

2. To assess the post test level of pain among osteoarthritis patients warm hydrotherapy
(Group I) and alternative warm and cold hydrotherapy (Group II).

3. To determine the outcome of warm hydrotherapy on level of pain.

4. To determine the outcome of alternative warm and cold hydrotherapy on level of pain.

5. To compare the outcome between warm hydrotherapy and alternative warm and cold
hydrotherapy.

6. To associate post test level of pain intensity among warm hydrotherapy group with their
demographic variables.

7. To associate post test level of pain intensity among alternate warm and cold hydrotherapy
group with their demographic variables
 10

VARIABLES:

The variables under the study were independent and dependent variable.

Independent variables

Hydrotherapy – 1. Warm hydrotherapy

2. Alternative warm and cold hydrotherapy.

Dependent variable

Level of pain.

EXTRENEOUS VARIABLES

Age in years , gender , marital status ,type of family, education, type of work, family
income, duration of illness, duration of medical interventions, co-morbid illness (if any)

RESEARCH HYPOTHESIS

H1 -There is significant difference between pre-test and post-test level of pain among
osteoarthritis patients in Group 1 and Group II.

H2 - There is significant difference between post-test level of pain between Group 1 and
Group II.

OPERATIONAL DEFINITION
Outcome:

Refers to impact of warm hydrotherapy and alternative warm and cold hydrotherapy on
level of pain among osteoarthritis patients.
 11

Warm hydrotherapy:

Refers to immersing of the lower extremities up to the calf muscle region of patients
with arthritic pain in warm water at 98°F-103°F for 15 minutes for 3 days.

Alternative warm and cold hydrotherapy:

Refers to immersing the lower extremities up to the calf muscle region of the patients
with arthritic pain alternatively first in warm water for 15 minutes followed by cold water (68-
72˚F) for 60 seconds for 3 days.

Clients with osteoarthritis:

Refers to individuals diagnosed by orthophysician as having degenerative inflammation

of the joints and joint ligaments. (Osteoarthritis)

Level of pain:

Refers to pain intensity experienced by osteoarthritis patients, can be measured with

modified numerical pain rating scale with coding from 1 to 10.

ASSUMPTIONS

1. Warm hydrotherapy may have some effects on pain management in osteoarthritis

patients.
2. Alternative warm and cold hydrotherapy may have some effects on pain management in
osteoarthritis patients.

DELIMITATION

1. The duration of the study was delimited to one month of data collection.
2. The study was delimited to Hindu Mission Hospital, Tambaram.
 12

PROJECTED OUTCOME
1. The study would help to determine the need for usage of warm hydrotherapy and
alternative warm and cold hydrotherapy to reduce level of pain among osteoarthritis
patients.
2. The study would enhance the patients to experience comfort without pain.
3. The study findings would help the investigator to implement the effective method of
hydrotherapy in reducing the level of pain.

SUMMARY

This chapter dealt with introduction, background of the study, need for the study, and
statement of the problem, objectives, operational definitions, assumptions, hypotheses,
delimitations and projected outcome.

ORGANIZATION OF THE REPORT

The following chapter contains,

Chapter II: Review of literature

Chapter III: Methodology

Chapter IV: Analysis and interpretation of data

Chapter V: Discussion

Chapter VI: Summary and conclusion

(This is followed by reference and appendices)

 13

CHAPTER – II
REVIEW OF LITERATURE

Review of literature is a written summary of the state of existing knowledge on a research

problem. The task of reviewing research literature involves the identification, selection of a
critical analysis and written description of existing information on a topic.

Review of literature is an essential step in the research project. It provides basis for future
investigations justifies the need for study, throws light on the feasibility of the study.

Review of literature for the present study is classified under the following headings,

PART – I: Literature review

Section A: Literature related to osteoarthritis and its prevalence.

Section B: Study related to osteoarthritis and its prevalence.

Section C: Study related to outcome hydrotherapy on osteoarthritis.

Section D: Study related to outcome of warm hydrotherapy on level of pain among

osteoarthritis patients.

Section E: Study related to outcome of alternative warm and cold hydrotherapy on

level of pain among osteoarthritis patients.

Section F: Study related to outcome of hydrotherapy on other conditions.

PART – II: Conceptual framework

 14

PART – I
SECTION- A
Literature related to osteoarthritis and its prevalence:

David T. Felson MD (2005) has done a study with the aim to investigate the prevalence
of osteoarthritis (OA) of the knee in elderly subjects. The study was conducted at the
Framingham Heart Study cohort, a population based group 1,805 subjects with the age group
between 63-94 years participated in this study. The subjects were graded 0-4 according to the
scales described by Kellgren and Lawrence. The result suggests that there is a marked age –
associated increase in the incidence of osteoarthritis.

Joseph A.Buckwalter, MD (2004) conducted a study with the aim to assess the
prevalence and cost expenditure for osteoarthritis per year. Osteoarthritis the clinical syndrome
of joint pain and dysfunction caused by joint degeneration affects more people than any other
joint disease. There are no consistently effective methods of preventing osteoarthritis (or)
slowing its progression and symptomatic treatments provide limited benefits for many patients.
Osteoarthritis disables about 10% of people who are older than 60years, compromises the quality
of life of more than 20 billion Americans and costs the United States economy more than $60
billion per year.

San Dieg Calif (2004) has done a survey with the aim to determine the prevalence of knee
osteoarthritis. The study was conducted at Korea, among 258 women. According to multivariate
analysis, the prevalence of knee osteoarthritis increased with age and household industry. The
result suggests that there was a relationship with significant family history of injury and high
body mass index.

SECTION- B
Studies related to osteoarthritis and its prevalence

Francisco J.Blanco, Ramon Guitan (2008) conducted a study with the aim to determine
which kind of cell death occurs in cartilage from patients with osteoarthritis. The study consists
of 7 normal and 16 OA cartilage sample collected at autopsy or during joint replacement surgery.
The result shows that OA chondrocytes displayed nuclear and cytoplasmic changes consistent
with apoptotic cells FACS analysis showed that the OA cartilage had a higher proportion of
 15

apoptotic chondrocytes than did normal tissue. This mechanism of cell death plays a important
role in the pathogenesis of OA and could be targeted for new treatment strategies

Reilly.S (2006) done a postal survey wit the aim to assess the prevalence of knee pain
among 4057 men and women aged between 40 – 80 years. The study was conducted at the
department of Rheumatology unit, City hospital, Nothingham. The subjects were asked about
chronic knee pain question was concerning job titles and industry was included. The prevalence
of knee pain was assessed. This result explored high prevalence of knee pain among knee
bending and heavy lifting jobs.

Neugebaver V.etal (2006) conducted a study to assess the techniques of knee point pain
among arthritis patient at the Medical University of Texas. 50 samples were included in the
study. The measurement to assess knee joint arthritis were knee extension angle struggle
threshold hind limb withdrawal reflex threshold of knee compressing force and vocalization in
response to stimulation of the knee. The result of the study showed the knee extension angle
struggle threshold and vocalization in response to stimulation of the knee was affective in
assessing knee join pain.

SECTION- C
Studies related to outcome of hydrotherapy on osteoarthritis

Marlene Fransen, Lillias Nair(August 2010) conducted a study with the aim to determine
whether Tai Chi or hydrotherapy classes for individuals with chronic symptomatic hip (or) knee
osteoarthritis (OA) result in measurable clinical benefits. A randomized controlled trial was
conducted among 152 older persons with chronic symptomatic hip (or) knee OA. Participants
were randomly allocated for 12 week to hydrotherapy classes (n=55), Tai Chi classes (n=56), or
waiting list control group (n=41). Outcomes were assessed 12 and 24weeks after randomization
and included pain and physical function. The result states that access to either hydrotherapy or
Tai Chi classes can provide large and sustained improvement in physical function for many
older, sedentary individuals with chronic hip (or) knee OA.

Jenny Geytenbeek(March 2002) study with the aim to search for appraise the quality of
and collate the research evidence supporting the clinical effectiveness of hydrotherapy.A
systematic search of literature was performed using ten medical and allied health databases from
 16

which studies relevant to hydrotherapy practice were retrieved.17 randomized control trials two -
case control studies, 12 cohort studies and two-case report were included in the appraisal. Fifteen
studies were deemed to provide moderate quality evidence for the effectiveness of hydrotherapy.
The balance of high to moderate quality evidence supported benefited from hydrotherapy in pain,
function, self-efficacy and affect, joint mobility, strength and balance, particularly among older
adults, subjects with rheumatic condition and chronic low back pain.

Van Bannetal (1999) conducted a study to assess the effectiveness of hydrotherapy on the
range of motion among osteoarthritis clients. Non probability convenient sampling technique
was used, 429 subjects were randomly assigned to both experimental and control group. The
result showed that there was significant effect in hydrotherapy (experimental group) in terms of
improvement in flextion, extension, increased left quadriceps muscles among osteoarthritis
client.

SECTION- D
Studies related to outcome of warm hydrotherapy on level of pain among osteoarthritis
patients

JaneHall, Suzanne M. Skevington, Peter J.Maddisson, (2007) conducted a study with the
aim to evaluate the therapeutic effects of hydrotherapy which combines elements of warm water
immersion and exercise. It was predicted that hydrotherapy would result in a greater therapeutic
benefit than either of these components separately. One hundred thirty-nine patients with chronic
rheumatoid arthritis were randomly assigned to hydrotherapy, seated immersion, land exercise,
or progressive relaxation. Patients attended 30-minute sessions twice weekly for 4 weeks.
Physical and psychological measures were completed before and after intervention, and at a 3-
month follow up. The result states that all patients improved physically and emotionally, as
assessed by the Arthritis Impact Measurement Scales 2 questionnaire. In addition, hydrotherapy
patients showed significantly greater improvement in joint tenderness and in knee range of
movement (women only). At follow up, hydrotherapy patients maintained the improvement in
emotional and psychological state.

Stener-Victorian E, Kruse-Smidjie C,(2004) conducted a study with the aim to compare

the effectiveness of hydrotherapy and electro-acupuncture, both in combination with patient
education and patient education alone, on the symptomatic treatment of osteoarthritis of the hip. :
 17

Forty-five patients, aged 42-86 years, pain related to motion, pain on load, and aches were
chosen. They were randomly allocated to EA, hydrotherapy, both in combination with patient
education, or patient education alone. Outcome measures were the disability rating index (DRI),
global self-rating index (GSI), and visual analogue scale (VAS). The result states that pain
related to motion and pain on load was reduced up to 3 months after last the treatment in the
hydrotherapy group and up to 6 months in the EA group. Ache during the day was significantly
improved in both the EA and hydrotherapy group up to 3 months after the last treatment. Ache
during the night was reduced in the hydrotherapy group up to 3 months after the last treatment
and in the EA group up to 6 months after.

Brosseau L, Yonge KA, Robinson V, Marchand S, Judd M, Wells G, Tugwell P(1998)

conducted a study with the aim to determine the effectiveness of thermotherapy in the treatment
of OA of the knee. The outcomes of interest were relief of pain, reduction of edema, and
improvement of flexion or range of motion (ROM) and function. Three randomized controlled
trials, involving 179 patients, were included in this review. The included trials varied in terms of
design, outcomes measured, cryotherapy or thermotherapy treatments and overall
methodological quality. In one trial, administration of 20 minutes of ice massage, 5 days per
week, for 3 weeks, compared to control demonstrated a clinically important benefit for knee OA
on increasing quadriceps strength (29% relative difference). There was also a statistically
significant improvement, but no clinical benefit in improving knee flexion ROM (8% relative
difference) and functional status (11% relative difference). Another trial showed that cold packs
decreased knee edema.

SECTION- E
Studies related to outcome of alternative warm and cold hydrotherapy on level of pain
among osteoarthritis patients

Devon R.Dougherty, Jacob E Friedman, Maween E.Schimizzi (July 2010) conducted a

study with the aim to assess the preferences for an effect of 5days of twice daily superficial heat,
cold (or) contrast therapy applied with a commercially available system permitting the
circulation available system permitting the circulation of water through a wrap-around garment,
use of an electric heating pad, or rest for patients with level II–IV osteoarthritis (OA) of the knee.
Randomized order design to study 34 patients receiving each treatment in 1-week blocks. A knee
 18

injury and osteoarthritis outcome score (KOOS) questionnaire and visual analog pain scale was
completed at baseline, and twice each week. Pain reduction and improvements in KOOS
subscale measures were demonstrated for each treatment but responses were (P < 0.05) greater
with preferred treatments. The result recommends that when superficial heat or cold is
considered in the management of knee OA that patients experiment to identify the intervention
that offers them the greatest relief and that contrast is a treatment option

Schencking M, Otto A, Duetsch T, Sandholzer H (August 2009) conducted a study with

the aim to compare the Kniepp Hydrotherapy with conventional Physiotherapy in the treatment
of osteoarthritis of hip or knee. One hundred and eighty patients diagnosed with osteoarthritis of
hip or knee will be randomly assigned to one of three intervention groups: hydrotherapy,
physiotherapy, and both physiotherapy and hydrotherapy of the affected joint. In the first group,
patients will receive Kneipp hydrotherapy daily, with water applied in the form of alternate cold
and warm thigh affusions (alternating cold and warm water stimulation is particularly relevant to
the knee and hip regions).Patients in the second group will receive physiotherapy of the hip or
knee joint three times a week. This study methodology has been conceived according to the
standards of the CONSORT recommendations. The results will contribute to establishing
hydrotherapy as a non-invasive, non-interventional, reasonably priced, therapeutic option with
few side effects, in the concomitant treatment of osteoarthritis of the hip or knee.

Darryl J Cochrane (2009) conducted a study to investigate whether alternating hot-cold

water treatment is a legitimate training tool for enhancing athlete recovery. Alternating hot–cold
water treatment has been used in the clinical setting to assist in acute sporting injuries and
rehabilitation purposes. However, there is overwhelming anecdotal evidence for it's inclusion as
a method for post exercise recovery. The result states that hot–cold water immersion helps to
reduce injury in the acute stages of injury, through vasodilatation and vasoconstriction thereby
stimulating blood flow thus reducing swelling. This shunting action of the blood caused by
vasodilatation and vasoconstriction may be one of the mechanisms to removing metabolites,
repairing the exercised muscle and slowing the metabolic process down. More research is needed
before conclusions can be drawn on whether alternating hot–cold water immersion improves
recuperation and influences the physiological changes that characterize post exercise recovery.
 19

SECTION- F
Studies related to outcome of hydrotherapy on other conditions

Cina Tschumi B, (2007) conducted a study to assess the evidence base impact of
hydrotherapy on postoperative pain, swelling, drainage and tolerance after orthopedic surgery.
The sample size was 30 patients, convenient sampling was used, the application of hydrotherapy
above degree was considered comfortable by the clients, where as reducing effects on swelling
drainage could not been found. The study concluded that effect of hydrotherapy is effective on
post operative and no effect on swelling, drainage and tolerance after orthopedic surgery.

Eversden L, Maggs F, Nightingale P (2007) conducted a study with the aim to compare
the effectiveness of land exercise and hydrotherapy on overall wellbeing and quality of life in
rheumatoid arthritis. One hundred and fifteen patients with RA were randomized to receive a
weekly 30-minute session of hydrotherapy or similar exercises on land for 6 weeks. Our primary
outcome was a self-rated on a 7-point scale ranging from 1(very much worse) to 7 (very much
better) assessed immediately on completion of treatment. Secondary outcomes including
EuroQol health related quality of life, EuroQol health status valuation, HAQ, 10 meters walk
time and pain scores were collected at baseline, after treatment and 3 months later. Binary
outcomes were analyzed by Fisher's exact test and continuous variables by Wilcoxon or Mann-
Whitney tests. Baseline characteristics of the two groups were comparable. Patients with RA
treated with hydrotherapy are more likely to report feeling much better or very much better than
those treated with land exercises immediately on completion of the treatment program.

Kullenberg B, ylip et al (2006) conducted a prospective study to assess the effectiveness

of post-operative hydrotherapy after total knee-arthroplasty. The sample size was 86 patients and
the patients were treated wit cold compression (or) epidural analgesia for 3days after total knee
arthroplasty pain was measured on a visual analogue scale and total consumption of analgesics
was recorded. The range of movement at discharge was 75 degree in cold compression group Vs
degrees in control group. The study shows that hydrotherapy reduces the pain for who had
undergone total knee arthroplasty.

Huiling Lai (2006) conducted a study to compare the effects of a hydrotherapy resistance
programme with gym based resistance exercise program on strength and function in the
treatment of osteoarthritis was conducted at Brazil. The study used for the study was
 20

osteoarthritis clients. The study concluded that the hydrotherapy group increased left quadriceps
strength in 35 subjects and the gym group both left and right quadriceps significantly increased
in 35 patients.

Dongeuibogam (2002) conducted a study to assess the effectiveness of hydrotherapy on

the foot to determine the influence of cardiovascular system affected physiological parameters
inherent, to thermal stimulation at the temperature at 43°C. The relevant physiological
parameters, blood flow, heart rate, blood pressure, O2 saturation and leg temperature, associated
with cardiovascular system, were selected for analysis. Pre and post experimental condition, at a
temperature of 43°C, were assessed for 10 healthy volunteers over 10 days. Pre and post
measurements were obtained at 5, 10, and 15 an 20 minutes. The study concluded that,
hydrotherapy applied to the foot does appear to exert an influence on the cardiovascular system,
and also appears to generally improve human metabolism.

Mc.Dowell. J.H; McFarland E.G, Nalli B.J, (1999) conducted a study to use of
hydrotherapy for orthopedic clients. The sample size was 60 and the hydrotherapy is the use of
cold to decrease swelling and pair when tissue is damaged secondary to trauma (or) surgery,
although hydrotherapy has been used for orthopedic clients. The subjects were assessed by using
numerical categorical pain scale and the result shown that pain was reduced about (56.6%) after
giving intervention. The study concluded that continues use of hydrotherapy proved to be highly
effective in reducing pain and swelling.

Green et al (1999) conducted a study to assess the effectiveness of hydrotherapy and gym
based exercise on the strength and physical function among diabetes clients. A randomized
controlled trail was used, 35 into hydrotherapy and 35 into gym based exercise group. The result
showed that gym based groups left quadriceps muscles was significantly strengthened as
compared to the hydrotherapy group. Both the left and right quadriceps muscle strengthen is
increased in hydrotherapy group.

Daniel D.M, stone M.L Arendi D.L (1995) conducted a study to assess the effectiveness
of hydrotherapy on pain, swelling after anterior cruciate ligament reconstructive surgery. The
study was an experimental clinical trial with random assignment of 2 groups, cooling pads were
incorporated into the dressing in 89 patients and no cooling pads were used in 42 patients. There
were 4 cooling pad temperature groups 40°F, 55°F and 70°F. The cooling pads lowered the skin
 21

temperature. The study concluded the hydrotherapy it reduces the pain, swelling after anterior
cruciate ligament reconstructive surgery.

Leutz. D.W, Harris. H (1995) conducted a study to assess continuous hydrotherapy in

total knee orthroplasty. The sample size was 52patients a retrospective study was use, 33 patients
receive cold therapy pads were used an average of 3-days and removed with the first dressing
change. The study concluded that there was no significant change in continuous hydrotherapy in
total orthroplasty.

Hart. Et al (1994) conducted a study to assess the effectiveness of structure hydrotherapy

program in the management of patients with rheumatoid arthritis. The sampling technique used
was convenience sampling technique and sample size was 23 patients received hydrotherapy and
other group not received hydrotherapy. The study concluded that the hydrotherapy in highly
significant in the management of patients with rheumatoid arthritis.
 22

PART-II

CONCEPTUAL FRAMEWORK

The conceptual frame work and the model for the present study was based on
Wiedenbach’s helping art of clinical nursing theory [1964]. It describes a desired situation and a
way to attain it. It directs action towards the implicit goal. This theory had three factors central
purpose, prescription, and realities. A nurse develops a prescription based on central purpose
and implements it according to the realities of the situation.

1. Central purpose was the model refers to what to accomplish. It was the overall goal towards
which a nurse strives. It transcends the immediate intent of the assignment or basic by
specifically directing towards the patient wellness.

2. Prescription refers to the plan of care for a patient. It specifies the nature of action that will
fulfill the nurse’s central purpose and the rationale of the action.

3. A reality refers to the physical, psychological, emotional, spiritual factors that come into play
in a situation involving nursing action. The five realities are Agent, Recipient, Goal, Means,
Frame work.

The conceptualization of nursing practice according to this theory consists of three steps which
are as follows.

i. Identifying the need for help.

ii. Ministering the need for help.

iii. Validating the need for help.

The model adopted for this study was a modified form of Wiedenbach’s helping art of
clinical nursing theory. The investigator adopted this model and perceived apt in enabling to
assist the outcome of warm hydrotherapy versus alternative warm and cold hydrotherapy. This
model views the level of pain among osteoarthritis patients.
 23

The central purpose of the study was to compare the outcome of warm hydrotherapy versus
alternative warm and cold hydrotherapy among osteoarthritis patients. Thus the investigator
selected two groups where warm hydrotherapy was provided for one group and alternative warm
and cold hydrotherapy for the other group.

The realities identified were

Agent : Investigator.

Recipient : Patients with osteoarthritis pain.

Goal : Reduction of pain.

Means : Warm hydrotherapy and Alternative warm and cold hydrotherapy.

Frame work : Modified numerical pain scale.

 24

CENTRAL
PURPOSE

IDENTIFYING MINISTERING VALIDATING

Follow up

Intervention
Assessment of RECEPIENT AGENT GOAL MEANS FRAME
general information,
WORK
age, gender, marital
status, type of
family, family More
Patients with Investigator Reduction Warm Modified
income, type of Post effective
osteoarthritis of pain Hydrotherapy & numerical
work, education, pain Alternative pain scale assessment
duration of illness, warm and cold on level of
Nursing Intervention 1 - 10
medical intervention Hydrotherapy pain among
and co-morbid osteoarthritis
illness. patients
Pre assessment of level Warm hydrotherapy
Group I and
of pain among Exp. Group I
Group II
osteoarthritis patient
Exp. Group II using
using modified Alternative warm and Less
cold hydrotherapy
modified
numerical pain scale effective
numerical
pain scale
Fig. i. MODIFIED WIEDENBACH’S HELPING ART OF CLINICAL NURSING THEORY
 25

CHAPTER-III

RESEARCH METHODOLOGY

Procedures used in making systematic observations or otherwise obtaining data,

evidence, or information as part of a research project or study.

This study is designed to evaluate the effectiveness of warm hydrotherapy versus

alternative warm and cold hydrotherapy on reducing level of pain among patient with
Osteoarthritis. This chapter includes research design, description of settings, variables,
population, sample, sampling technique, sample size, criteria for sample selection, and
description of tool, validity, reliability, pilot study, data collection procedure and plan for data
analysis.

Research Approach

Quantitative evaluative research approach was adopted for the study.

Research Design

The research design selected for this study is Quasi-experimental pre test – post test
design.
Group I O1 X1 O2

Group II O3 X2 O4

O1 : Pre-Assessment of Level of pain among experimental group - I

X1: Warm hydrotherapy.

O2 : Post-Assessment of Level of pain among experimental group - I

O3 : Pre-Assessment of Level of pain among experimental group - II

X2: Alternative warm and cold hydrotherapy.

O4 : Post-Assessment of Level of pain among experimental group - II

 26

Fig. ii: Schematic representation of research methodology population

Research Approach
Quantitative Evaluative Approach

Research design
Quasi experimental pre test – post test design

Population
The population for this study was patients diagnosed as having osteoarthritis

at Selected Hospital, Chennai.

Setting
Hindu Mission Hospital, Tambaram.

Sample
Patients diagnosed as having osteoarthritis with the complaints of pain at Hindu Mission Hospital, Tambaram.

Data collection

Experimental group-I Experimental group-II

Pre-Assessment of Level of pain among Pre-Assessment of Level of pain among

experimental group I using modified experimental group I using modified
numerical pain scale. numerical pain scale.

Intervention Intervention
Warm hydrotherapy. Alternative warm and cold hydrotherapy.

Post-Assessment of Level of pain among Post-Assessment of Level of pain among

experimental group I using modified pain scale experimental group II using modified pain scale

Data analysis and interpretation by using

hydrotherapy.
descriptive and inferential statistics.
 27

VARIABLES UNDERSTUDY:

Age in years , gender , marital status ,type of family, education, type of work, family
income, duration of illness, duration of medical interventions, co-morbid illness (if any)

RESEARCH SETTING:

The study was carried out in Hindu Mission Hospital (Experimental group-I & II)

Tambaram, Chennai. There were more than 15 Private Multispecialty Hospitals in and around

Chennai city. The investigator had selected Hindu Mission Hospital at GST road Tambaram near

Tambaram Railway Station. The investigator selected this setting for the availability of the

sample and feasibility of the study.

POPULATION:

Population of the present study comprised of osteoarthritis patients (40 – 80 yrs) with the

complaints of pain in Ortho OPD, Hindu Mission Hospital, Tambaram.

Target Population

It comprises of all the patients diagnosed as having arthritis.

Accessible Population

It comprises of all the patients diagnosed as having osteoarthritis with the age group of

40-80 years.

SAMPLE:

The sample of this study comprises of patients diagnosed as having osteoarthritis with

the complaints of pain attending Ortho OPD at Hindu Mission Hospital, Tambaram
 28

SAMPLE SIZE:

The sample size was 60. 30 patients in experimental group I from Hindu Mission

Hospital, Tambaram and 30 patients in experimental group II from the same hospital.

SAMPLING TECHNIQUE:

The investigator selected samples by Non probability purposive sampling technique.

Then the patients were grouped under warm hydrotherapy (Group I) and alternative warm and

cold hydro therapy (Group II) by means of lottery method.

CRITERIA FOR SAMPLE SELECTION:

INCLUSIVE CRITERIA

1. Patient with the age group of 40-80 years with the evidence of osteoarthritis.

2. Patients who were having arthritic pain.

3. Patients who were willing to participate in the study.

4. Patients who were coming to the hospital for osteoarthritis treatment in Ortho OPD.

5. Patients who were able to understand Tamil or English.

EXCLUSIVE CRITERIA

1. Patient who had undergone any surgery in the extremities.

2. Patients with any foot ulcers and injuries in the extremities.

3. Patients with other potential complications (bleeding disorder, blood coagulation

disorder, DVT etc.,).

 29

METHOD OF DEVELOPING THE QUESTIONNAIRE:

The following step were carried out in developing the tool

i) Literature review

ii) Expert opinion

DESCRIPTION OF THE TOOL:

The tool consists of two parts

Section-A: Deals with demographic variables such as Age in years , gender , marital status, type
of family, education, type of work, family income, duration of illness, duration of medical
interventions, co-morbid illness.

Section –B: Tools for assessment of level of pain among osteoarthritis patients.

SCORING KEY

Section-A: Coding system 1 to 10 was used

Section-B:
Modified numerical pain scale with scoring from 1 to 10 used to assess the level of pain
among patients diagnosed as having osteoarthritis.

0 – No pain
1-3 – Mild, annoying pain
4-5– Tolerable pain
6-7 – Miserable pain
8-10- Worst pain
 30

VALIDITY AND RELIABILITY OF THE TOOL

Validity of the tool

The validity was obtained from three nursing experts, one orthoconsultant and from one
physiotherapist. All the valuable suggestions said by the experts were incorporated into the
study.

Reliability of the tool

Inter ratter reliability was the degree of agreement among raters. It gives a score of how
much homogeneity, or consensus, there is in the ratings given by judges. It was useful in refining
the tools given to human judges, for example by determining if a particular scale is appropriate
for measuring a particular variable. If various raters do not agree, either the scale was defective
or the raters need to be re-trained. The investigator used the inter ratter method for this study
along with the help of the physiotherapist in assessing the level of pain and correlated using
Spearman’s rank correlation technique and the r value is r = 0.88.

Ethical consideration

The study was conducted after the approval of dissertation committee. The consent was
taken from chief medical officer, Hindu mission hospital and patients who were fulfilling
inclusive criteria. All information about samples was kept confidential.

PILOT STUDY
Pilot study had been conducted from 11 – 06 -2011 to 15- 06- 2011.6 samples who fulfilled
the inclusive criteria were selected and assigned to two experimental group. Pre-test and post-test
were done by using modified numerical pain rating scale. Patients assigned to group 1 were
initially assessed for pre-test level of pain using modified pain scale and given intervention by
warm hydrotherapy at 95˚F - 98˚F for 15 minutes for 3 days. Later assessed for post test level of
pain. Patients assigned to group 2 were initially assessed for pre-test level of pain using modified
pain scale and given intervention by alternative warm and cold hydrotherapy (68˚F-72˚F) first
with warm hydrotherapy for 15 minutes followed by cold hydrotherapy for 60 seconds for 3
days. Later assessed for post test level of pain. Therefore, the investigator states that the setting,
 31

samples of the study and the intervention given for the samples were found to be feasible to
proceed for further main study.

DATA COLLECTION PROCEDURE

The main study was conducted from 15-6-11 to 15-7-11. Written consent was obtained
from Managing director of Hindu Mission Hospital, Tambaram for proceeding with the study.

Patients who fulfilled the inclusive criteria were categorized under experimental group I and II
by means of non probability sampling and grouping by lottery sampling technique. Consent was
obtained and confidentiality of the response was assured. With the help of screening tool,
samples were selected for the study. Pre-test was done by using modified numerical pain scale.
Patients diagnosed as having osteoarthritis had been exercised warm hydrotherapy (group I) and
alternative warm and cold hydrotherapy (group II) as interventions. The exercises given to
experimental group were as follows,
 32

Date Group I Group II

16.06.2011 2 2

18.06.2011 2 1

20.06.2011 1 1

21.06.2011 1 2

23.06.2011 2 1

27.06.2011 1 1

29.06.2011 1 1

30.06.2011 2 2

01.07.2011 1 2

02.07.2011 1 1

04.07.2011 1 1

05.07.2011 2 2

06.07.2011 1 1

07.07.2011 1 2

08.07.2011 2 1

09.07.2011 2 2

11.07.2011 2 1

12.07.2011 1 2

13.07.2011 2 2

14.07.2011 2 2

Total 30 30
 33

DATA ANALYSIS PROCEDURE

Descriptive and inferential statistics were used to analyze the data analysis of
demographic variables in terms of frequency and percentage distribution, mean and standard
deviation was used to compute the Pre and Post test level of pain among osteoarthritis patients in
experimental group I and II. Paired “t” test was used to evaluate the outcome of warm
hydrotherapy and alternative warm and cold hydrotherapy on level of pain and chi-square test
was used to associate the post test level of pain perception, among patients in experimental group
I and II with their demographic variables. Finally unpaired “t” test used to compare the outcome
of warm hydrotherapy and alternative warm and cold hydrotherapy on level of pain among
osteoarthritis patients.

DESCRIPTIVE STATISTICS

Analysis of demographic data of clients was done in terms of frequency and percentage
distribution. Mean and standard deviation was used to compute the outcome of pre-test and post-
test level of pain in experimental group I and II.

INFERENTIAL STATISTICS

Unpaired T-test was used to study the correlation of post-test level of pain in
experimental group I and II. Chi-square test was used to associate the post level of pain with the
demographic variables.

Analysis and interpretation of data were given in the following chapter.

 34

CHAPTER- IV
DATA ANALYSIS AND INTERPRETATION
This chapter deals with the data analysis and interpretation of data collected to evaluate
the outcome of warm hydrotherapy Vs alternative warm and cold hydrotherapy on level of pain
among osteoarthritis patients.

The collected data was tabulated, organized and analyzed by using descriptive and

inferential statistics as follows,

ORGANISATION OF DATA:

Section-A: i) Distribution of patients according to their demographic variables.

Section-B: i) Assessment of pre test and post level of pain in Experimental group I.

ii) Assessment of pre test and post test level of pain in Experimental group II.

Section-C: i) Outcome of pretest and post test level of pain in Experimental group I.

ii) Outcome of pretest and post test level of pain in Experimental group II.

Section-D: i) Comparison of post test level of pain between Experimental groups I and II.

Section-E: i) Associations on level of pain among patients with osteoarthritis in Experimental

group I and Experimental group II.
 35

SECTION – A

Table I

Frequency and percentage distribution of patients in experimental groups-I and II

according to their demographic variables.

n=60

Exp. Group I Exp. Group II

Demographic Variables
No. % No. %

Age in years

40 - 50 years 7 23.33 9 30.00

51 - 60 years 10 33.33 12 40.00

61 - 70 years 10 33.33 6 20.00

71 - 80 years 3 10.00 3 10.00

Gender

Male 14 46.67 13 43.33

Female 16 53.33 17 56.67

Marital Status

Single - - - -

Married 23 76.67 21 70.00

Widower 4 13.33 8 26.67

Divorcee 3 10.00 1 3.33

Type of Family

Nuclear family 21 70.00 15 50.00

Joint family 9 30.00 15 50.00

Education

Middle School 3 10.00 5 16.67

 36

High School 8 26.67 7 23.33

Higher Secondary 7 23.33 4 13.33

Graduate 11 36.67 7 23.33

None 1 3.33 7 23.33

Type of Work

Sedentary Work 12 40.00 11 36.67

Moderate Work 15 50.00 16 53.33

Heavy Work 3 10.00 3 10.00

Family Income (Rs.)

<5000 3 10.00 6 20.00

5001 - 10000 14 46.67 13 43.33

>10000 13 43.33 11 36.67

Duration of Illness

0 month - 5 years 10 33.33 8 26.67

5year - 10 years 9 30.00 12 40.00

10 years and above 11 36.67 10 33.33

Duration of medical interventions

0 month - 5 years 15 50.00 12 40.00

5year - 10 years 9 30.00 11 36.67

10 years and above 6 20.00 7 23.33

Co-morbid Illness

Diabetes Mellitus 9 30.00 6 20.00

Hypertension 8 26.67 8 26.67

Cardiac Disorders 4 13.33 7 23.33

Others 2 6.67 2 6.67

None 7 23.33 7 23.33

 37

Table I shows the distribution of patients according to their demographic variables.

In Experimental group I, majority 10(33.33%) of them were in the age group of 51- 60
years, 16 (53.33%) were females, 23(76.67%) were married, 21(70%) were living in nuclear
family, 11(36.67%) studied higher secondary education, 14(46.67%) were earning Rs.5001-
10000, 11(36.67%) with 3 years and above duration of illness, 15(50%) taking 0 month to 1 year
duration of medical intervention and 9(30%) were having co-morbid illness of Diabetes.

In Experimental group II, majority 12(40%) of them were in the age group of 51- 60
years, 17 (56.67%) were females, 21(70%) were married, 15(50%) were living in nuclear family,
7(23.33%) studied higher secondary education, 13(43.33%) were earning Rs.5001- 10000,
12(40%) with 1 to 2 years duration of illness, 12(40%) taking 0 month to 1 year duration of
medical intervention and 8(26.67%) were having co-morbid illness of Hypertension.
 38

Fig iii: Percectage distribution of age in experimental group I and II

 39

Fig iv: Percectage distribution of gender in experimental group I and II

 40

Fig v: Percectage distribution of marital status in experimental group I and II

 41

Fig vi: Percectage distribution of type of family in experimental group I and II.
 42

Fig vii: Percectage distribution of education in experimental group I and II

 43

Fig viii: Percectage distribution of family income in experimental group I and II.
 44

Fig. ix: Percectage distribution of duration of illness in experimental group I and II.
 45

Fig. x: Percectage distribution of duration of medical intervention in experimental group I

and II.
 46

Fig. xi: Percectage distribution of co-morbid illness in experimental group I and II.
 47

SECTION-B

Table-II

Assessment of pre test and post level of pain in Experimental group I

n=30.

No Pain Mild Tolerable Miserable Worst

Pain
No. % No. % No. % No. % No. %

Pretest - - - - 10 33.33 16 53.33 4 13.33

Post Test - - 19 63.33 8 26.67 3 10.0 - -

Table II represents assessment of pre test and post level of pain in experimental group I

In Experimental group I majority 16(53.33%) presented with miserable pain at pre test level
and 19(63.33%) reported mild pain at post test level.
 48

Fig. xii: Percentage distribution of pre test and post level of pain in Experimental group I.
 49

Table III

Assessment of pre test and post level of pain in Experimental group II

n=30.

No Pain Mild Tolerable Miserable Worst

Pain
No. % No. % No. % No. % No. %

Pretest - - 1 3.33 8 26.67 16 53.33 5 16.67

Post Test - - 17 56.67 9 30.0 4 13.33 - -

Table III shows assessment of pre test and post level of pain in experimental group II

In Experimental group II majority 16(53.33%) presented with miserable pain at pre test level
and 17(56.67%) reported mild pain at post test level.
 50

Fig. xiii: Percentage distribution of pre test and post level of pain in Experimental group II.
 51

SECTION-C

Table-IV

Outcome of pre test and post level of pain in Experimental group I

n=30

Pain Mean S.D ‘t’ Value

Pretest 6.13 1.17 t = 23.084***

Post Test 3.37 1.43 p = 0.000, (S)

***p<0.001, S – Significant

Table IV shows outcome of pre test and post level of pain in experimental group I

In Experimental group I Mean and Standard Deviation of pre test was 6.13 1.17, Mean
and Standard Deviation of post test was 3.37 1.43 and the t value is t=23.084*** which as
highly significant with the p value of p=0.000, (S). This reveals that warm hydrotherapy was
effective towards the level of pain among osteoarthritis patients.
 52

Fig. xiv: Mean and Standard deviation distribution of pre test and post level of pain in
Experimental group I.
 53

Table V

Outcome of pre test and post level of pain in Experimental group II

n=30

Pain Mean S.D ‘t’ Value

Pretest 6.13 1.50 t = 21.468***

Post Test 3.33 1.60 p = 0.000, (S)

***p<0.001, S – Significant

Table V shows outcome of pre test and post level of pain in experimental group II

In Experimental group II Mean and Standard Deviation of pre test was 6.13 1.50, Mean
and Standard Deviation of post test was 3.33 1.60 and the t value is t=21.468*** which as
highly significant with the p value of p=0.000,(S) . This reveals that alternate warm and cold
hydrotherapy was effective towards the level of pain among osteoarthritis patients.
 54

Fig.xv:Mean and Standard deviation distribution of pre test and post level of pain in
Experimental group II.
 55

SECTION-D

Table VI

Comparison of post test level of pain between Experimental groups I and II

n=60

Post Test Pain Mean S.D Unpaired ‘t’ Value

Experimental Group I 3.37 1.43 t = 0.085

Experimental Group II 3.33 1.60 p = 0.933, (N.S)

N.S – Not Significant

Table VI shows comparison of post test level of pain between experimental groups I and II

In Experimental groups I and II Mean and Standard Deviation of post test of

Experimental group I was 3.37 1.43, Mean and Standard Deviation of post test of Experimental
group II was 3.33 1.60 and the t value is t=0.08 which is not significant with the p value of
p=0.933, (N.S). This reveals that both warm hydrotherapy and alternative warm and cold
hydrotherapy was effective towards the level of pain among osteoarthritis patients.
 56

SECTION-E

Table VII

Association of post test level of pain with the demographic variables in the
Experimental Group I

n=30

Mild Tolerable Miserable Chi-Square

Demographic Variables
No. % No. % No. % Value

Age in years
2
= 6.634
40 - 50 years 6 20.0 1 3.3 - -
d.f = 6
51 - 60 years 6 20.0 4 13.3 - -
p = 0.356
61 - 70 years 6 20.0 2 6.7 2 6.7
N.S
71 - 80 years 1 3.3 1 3.3 1 3.3

Gender 2
= 0.254

Male 9 30.0 4 13.3 1 3.3 d.f = 2

Female 10 33.3 4 13.3 2 6.7 p = 0.88(N.S)

Marital Status
2
= 1.427
Single - - - - - -
d.f = 4
Married 15 50.0 6 20.0 2 6.7
p = 0.840
Widower 2 6.7 1 3.3 1 3.3
N.S
Divorcee 2 6.7 1 3.3 - -
2
Type of Family = 1.523

Nuclear family 13 43.3 5 16.7 3 10.0 d.f = 2

Joint family 6 20.0 3 10.0 - - p = 0.467

 57

Mild Tolerable Miserable Chi-Square

Demographic Variables
No. % No. % No. % Value

N.S

Education

Middle School - - 1 3.3 2 6.7 2

= 15.366

High School 5 16.7 2 6.7 1 3.3 d.f = 8

Higher Secondary 6 20.0 1 3.3 - - p = 0.052

Graduate 7 23.3 4 13.3 - - N.S

None 1 3.3 - - - -

Type of Work 2
= 1.079

Sedentary Work 7 23.3 4 13.3 1 3.3 d.f = 4

Moderate Work 10 33.3 3 10.0 2 6.7 p = 0.898

Heavy Work 2 6.7 1 3.3 - - N.S

Family Income (Rs.) 2

= 12.448

<5000 1 3.3 - - 2 6.7 d.f = 4

5001 - 10000 9 30.0 4 13.3 1 3.3 p = 0.014

>10000 9 30.0 4 13.3 - - S*

Duration of Illness 2
= 11.101

0 month - 5 years 9 30.0 1 3.3 - - d.f = 4

5year - 10 years 4 13.3 5 16.7 - - p = 0.025

10 years and above 6 20.0 2 6.7 3 10.0 N.S

2
Duration of medical interventions = 15.138

0 month - 5 years 12 40.0 3 10.0 - - d.f = 2

5year - 10 years 5 16.7 4 13.3 - - p = 0.004

 58

Mild Tolerable Miserable Chi-Square

Demographic Variables
No. % No. % No. % Value

10 years and above 2 6.7 1 3.3 3 10.0 S***

Co-morbid Illness

Diabetes Mellitus 3 10.0 4 13.3 2 6.7 2

= 12.906

Hypertension 8 26.7 - - - - d.f = 8

Cardiac Disorders 1 3.3 2 6.7 1 3.3 p = 0.115

Others 2 6.7 - - - - N.S

None 5 16.7 2 6.7 - -

*p<0.05, ***p<0.001, S – Significant, N.S – Not Significant

Table VII shows association of post test level of pain with the demographic variables in the
experimental group I

The association between the demographic variables with the post test level of pain in
Experimental group I, there is significant association in family income with p value of
p=0.014(S*) and duration of medical intervention with the p value of p=0.004(S***).
 59

Table VIII

Association of post test level of pain with the demographic variables in the
Experimental Group II

n=30

Mild Tolerable Miserable Chi-Square

Demographic Variables Value
No. % No. % No. %

Age in years
2
= 26.833
40 - 50 years 8 26.7 1 3.3 - -
d.f = 6
51 - 60 years 6 20.0 6 20.0 - -
p = 0.000
61 - 70 years 3 10.0 2 6.7 1 3.3
S***
71 - 80 years - - - - 3 10.0
2
Gender = 1.127

Male 7 23.3 5 16.7 1 3.3 d.f = 2

10 33.3 4 13.3 3 10.0 p = 0.569

Female N.S

Marital Status
2
= 13.562
Single - - - - - -
d.f = 4
Married 14 46.7 7 23.3 - -
p = 0.009
Widower 2 6.7 2 6.7 4 13.3
S**
Divorcee 1 3.3 - - - -
2
Type of Family = 3.471

Nuclear family 11 36.7 3 10.0 1 3.3 d.f = 2

6 20.0 6 20.0 3 10.0 p = 0.176

Joint family N.S
2
Education = 10.347

Middle School 2 6.7 2 6.7 1 3.3 d.f = 8

High School 2 6.7 4 13.3 1 3.3 p = 0.241

 60

Mild Tolerable Miserable Chi-Square

Demographic Variables Value
No. % No. % No. %

Higher Secondary 4 13.3 - - - -

Graduate 6 20.0 1 3.3 - - N.S

None 3 10.0 2 6.7 2 6.7

Type of Work 2
= 1.487
Sedentary Work 7 23.3 3 10.0 1 3.3 d.f = 4

Moderate Work 9 30.0 5 16.7 2 6.7 p = 0.829

Heavy Work 1 3.3 1 3.3 1 3.3 N.S

Family Income (Rs.) 2

= 7.222
<5000 2 6.7 3 10.0 1 3.3 d.f = 4

5001 - 10000 9 30.0 1 3.3 3 10.0 p = 0.125

>10000 6 20.0 5 16.7 - - N.S

Duration of Illness 2
= 13.121
0 month - 5 years 7 23.3 1 3.3 - - d.f = 4

5year - 10 years 8 26.7 4 13.3 - - p = 0.011

10 years and above 2 6.7 4 13.3 4 13.3 S*

Duration of medical interventions 2

= 8.369
0 month - 5 years 9 30.0 3 10.0 - - d.f = 4

5year - 10 years 7 23.3 2 6.7 2 6.7 p = 0.079

10 years and above 1 3.3 4 13.3 2 6.7 N.S

Co-morbid Illness

Diabetes Mellitus 3 10.0 2 6.7 1 3.3 2

= 5.510
Hypertension 4 13.3 4 13.3 - - d.f = 8

Cardiac Disorders 4 13.3 1 3.3 2 6.7 p = 0.702

Others 1 3.3 1 3.3 - - N.S

None 5 16.7 1 3.3 1 3.3

 61

*p<0.05, **p<0.01, ***p<0.001, S – Significant, N.S – Not Significant

Table VIII shows association of post test level of pain with the demographic variables in the
experimental group II

The association between the demographic variables and the post test level of pain in
Experimental group II, there is significant association in age with the p value of p=0.000(S***),
marital status p=0.009(S**) and duration of illness p=0.011(S*).
 62

CHAPTER – V

DISCUSSION

This study was conducted to compare the outcome of warm hydrotherapy versus
alternative warm and cold hydrotherapy on level of pain among patients with osteoarthritis with
their selected demographic variables.

Frequency distribution of patients in experimental group I and II according to their

demographic variables

The distribution of variables among patients with osteoarthritis. In Experimental group-I

majority 10(33.33%) of them were in the age group of 51- 60 years, 16 (53.33%) were females,
23(76.67%) were married, 21(70%) were living in nuclear family, 11(36.67%) studied higher
secondary education, 14(46.67%) were earning Rs.5001- 10000, 11(36.67%) with 3 years and
above duration of illness, 15(50%) taking 0 month to 1 year duration of medical intervention
and 9(30%) were having co-morbid illness of Diabetes.

In Experimental group II, majority 12(40%) of them were in the age group of 51- 60 years, 17
(56.67%) were females, 21(70%) were married, 15(50%) were living in nuclear family,
7(23.33%) studied higher secondary education, 13(43.33%) were earning Rs.5001- 10000,
12(40%) with 1 to 2 years duration of illness, 12(40%) taking 0 month to 1 year duration of
medical intervention and 8(26.67%) were having co-morbid illness of Hypertension.

The first objective of study was to assess the pre-test level on pain among osteoarthritis
patients of warm hydrotherapy (Group I) and alternative warm and cold hydrotherapy
(Group II)

Pre test of assessment in experimental group I, 10(33.33%) patients reported tolerable,

16(53.33%) reported miserable pain, 4(13.33%) reported worst pain. In experimental group II,
1(3.33%) patient reported mild pain, 8(26.67%) reported tolerable pain, 16(53.33%) reported
miserable pain, 5(16.67%) reported worst pain. In experimental group II, 1(3.33%) patient
reported mild pain, 8(26.67%) reported tolerable pain, 16(53.33%).
 63

The second objective of study was to assess the post-test level on pain among osteoarthritis
patients of warm hydrotherapy (Group I) and alternative warm and cold hydrotherapy
(Group II)

Post test of assessment in experimental group I, 19(63.33%) patients reported mild

pain, 8(26.67%) reported tolerable pain and 3(10%) reported miserable pain. In experimental
group II 17(56.67%) patients reported mild pain, 9(30%) reported tolerable pain and 4(13.33%)
reported miserable pain.

The third objective of study was to determine the outcome of warm hydrotherapy on level
of pain

In experimental group I majority of 16(53.33%) patients presented with miserable

pain on the first day assessment of their before intervention and 19(63.33%) patients reported
mild pain on third day after intervention. Mean and Standard Deviation of pre test was 6.13
1.17, Mean and Standard Deviation of post test was 3.37 1.43 and the t value is t=23.084***
which us highly significant with the p value of p=0.000, (S). This reveals outcome of warm
hydrotherapy was effective on level of pain among osteoarthritis patients.

The study findings were consistent with the study conducted by Green et al (1999)
conducted a randomized, single blind, controlled trial among patients with osteoarthritis of the
hip. Sixty-three patients were eligible to participate and 47 (74.6%) were randomized. Twenty-
four patients were randomized into hydrotherapy and 23 patients were randomized to home
exercise. The outcome measures included active range of motion, muscle strength, analgesic
requirement, subjective pain score (10 cm visual analog scale), descriptive pain scale and an
overall change score.

The outcomes showed that there was an improvement with regard to both subjective and
objective measurements in both groups. There was no significant difference with regard to these
measurements between the two treatment groups, independent of age, sex and the radiological
level of severity of the osteoarthritis. The authors concluded that, there was beneficial and there
was little benefit in adding hydrotherapy to this regimen.

The Conceptual framework of the study as per Modified Widenbach’s Helping Art clinical
Nursing theory (1964) it is stated that for experimental group I patients were pre assessed with
 64

modified numerical pain scale and warm hydrotherapy was exercised to the patient and post
assessed after three days for effectiveness.

The fourth objective of study was to determine the outcome of alternative warm and cold
hydrotherapy on level of pain

In experimental group II majority of 16(53.33%) patients presented with miserable

pain on the first day assessment of their before intervention and 17(56.67%) patients reported
mild pain on third day after intervention. Mean and Standard Deviation of pre test was 6.13
1.50, Mean and Standard Deviation of post test was 3.33 1.60 and the t value is t=21.468***
which us highly significant with the p value of p=0.000, (S). This reveals outcome of alternative
warm and cold hydrotherapy was effective on level of pain among osteoarthritis patients.

The study findings were consistent with the study conducted by Schenking M, Otto A,
Deutsch T, (2009). Hydrotherapy for osteoarthritis of the hip or knee joint using serial cold and
warm water stimulation not only improves the range of movement but also reduces pain
significantly and increases quality of life over a period. One hundred and eighty patients
diagnosed with osteoarthritis of hip or knee will be randomly assigned to one of three
intervention groups: hydrotherapy, physiotherapy, and both physiotherapy and hydrotherapy of
the affected joint. Kneipp hydrotherapy daily, with water applied in the form of alternate cold
and warm thigh affusions. The results will contribute to establishing hydrotherapy as a non-
invasive, non-interventional, reasonably priced, therapeutic option with few side effects and
statistically significant in the concomitant treatment of osteoarthritis of the hip or knee.

The Conceptual framework of the study as per Modified Widenbach’s Helping Art clinical
Nursing theory (1964) it is stated that for experimental group II patients were pre assessed with
modified numerical pain scale and alternative warm and cold hydrotherapy was exercised to the
patient and post assessed after three days for effectiveness.

The fifth objective of study was to compare the outcome between the warm
hydrotherapy (Group I) and alternative warm and cold hydrotherapy (Group II):

Experimental groups I and II Mean and Standard Deviation of post test of Experimental
group I was 3.37 1.43, Mean and Standard Deviation of post test of Experimental group II was
 65

3.33 1.60 and the t value is t=0.08 which is not significant with the p value of p=0.933, (N.S).
Comparing the outcome with the hypothesis framed and inferential statistics results it is not
significant. So, the research hypothesis (H2) is accepted and it reveals that both warm
hydrotherapy and alternative warm and cold hydrotherapy was effective towards the level of pain
among osteoarthritis patients.

The sixth objective of study was to associate the post test level of pain with the
demographic variables in experimental group I:

The association between the demographic variables with the post test level of pain in
experimental group I, there is significant in family income (Rupees) with the “p” value of
p=0.014 (S*) and the duration of medical intervention with the “p” value of p=0.004 (S***).

The seventh objective of study was to associate the post test level of pain with the
demographic variables in experimental group II:

The association between the demographic variables and the post test level of pain in
experimental group II, there is significant association in age with the “p” value of

p=0.000 (S***), marital status p=0.009 (S**) and the duration of illness p=0.011 (S*).
 66

CHAPTER-VI

SUMMARY, NURSING IMPLICATION, RECOMMENDATION AND

LIMITATION

This chapter presents the summary of the study and conclusion drawn. It clarifies the
Nursing implication, Recommendation and Limitation of the study in different areas of life
Nursing practice, Nursing administration, Nursing education, Nursing research.

A. SUMMARY OF THE STUDY

The statement of the study was

“A comparative study to assess outcome of warm hydrotherapy Vs alternative warm

and cold hydrotherapy on level of pain among osteoarthritis patients at Hindu Mission Hospital,
Tambaram, Chennai.2011-2012.”

The objectives of the study were

1. To assess the pre-test level of pain among osteoarthritis patients of warm

hydrotherapy (Group I) and alternative warm and cold hydrotherapy (Group II).

2. To assess the post test level of pain among osteoarthritis patients warm hydrotherapy
(Group I) and alternative warm and cold hydrotherapy (Group II).

3. To determine the outcome of warm hydrotherapy on level of pain.

4. To determine the outcome of alternative warm and cold hydrotherapy on level of

pain.

5. To compare the outcome between warm hydrotherapy and alternative warm and cold
hydrotherapy.

6. To associate post test level of pain intensity among warm hydrotherapy group with
their demographic variables.

7. To associate post test level of pain intensity among alternate warm and cold
hydrotherapy group with their demographic variables
 67

The assumptions of the study were

1. Warm hydrotherapy may have some effects on pain management in osteoarthritis

patients.

2. Alternative warm and cold hydrotherapy may have some effects on pain management
in osteoarthritis patients.

The following hypothesis were framed for this study

H1 -There is significant difference between pre-test and post-test level of pain among
patients in Group 1 and Group II.

H2 - There is significant difference between post-test level of pain between Group 1 and Group
II.

Review of literature executed studies related to osteoarthritis and its prevalence, outcome of
hydrotherapy on osteoarthritis, outcome of warm hydrotherapy on level of pain among
osteoarthritis patients, outcome of alternative warm and cold hydrotherapy on level of pain
among osteoarthritis patients, outcome hydrotherapy on other conditions.

The conceptual frame work adopted for the study was based on modified Weidenbach’s
helping art of clinical nursing theory. The evaluative approach and a quasi experimental pre test
and post test design were used. The study was conducted in selected hospital, Chennai. Patients
who were diagnosed as having osteoarthritis were selected on the basis of non probability
purposive sampling method. Patients were grouped under warm hydrotherapy (Group I) and
alternative warm and cold hydrotherapy (Group II) by means of lottery sampling method. Pre-
test was done by using by using modified numerical pain scale. Patients in group I exercised
warm hydrotherapy and patients in group II exercised alternative warm and cold hydrotherapy.
The interventions were provided for three consecutive days for patients in group I and II. On the
third day of assessment the post test screening was done by using modified numerical pain scale.
 68

The statistical analysis shows that that in experimental group I the “t” value is t= 23.084***
which has a highly significant “p” value of p= 0.000, (S) and in experimental group II the “t”
value is t= 21.468*** which has a highly significant with the “p” value of p= 0.000(S).

The study findings was concluded analyzing the hypothesis framed with the inferential statistics.
The results show that outcome of warm hydrotherapy and alternative warm and cold
hydrotherapy were effective on level of pain among osteoarthritis patients. Finally, discussions
were made regarding the pre determined objectives with the statistical outcome along with their
supportive studies.

B. NURSING IMPLICATION

The investigator has derived the following implication from the study which is vital concern
in the field of nursing practices, administration, education and research.

Nursing Practice

1. The Nurse need to know about assessing the pain symptoms among osteoarthritis
patients.

2. The Nurse should develop knowledge and skills on practicing warm hydrotherapy
and alternative warm and cold hydrotherapy techniques.

3. The Nurse should advocate the clients regarding physical therapy and help them to
choose appropriate therapy.

4. The Nurse must continue to demonstrate warm hydrotherapy and alternative warm
and cold hydrotherapy techniques to osteoarthritis patients.

5. Both warm hydrotherapy and alternative warm and cold hydrotherapy techniques can
be made to practice as a routine therapy among osteoarthritis patients with pain.
 69

Nursing Administration

1. The Nurse administrator should take an active part in developing cost effective
materials regarding warm hydrotherapy and alternative warm and cold hydrotherapy
techniques.

2. The Nurse administrator should conduct continuing education program and in service
education program on warm hydrotherapy and alternative warm and cold
hydrotherapy techniques and its wide range benefit on management of level of pain
among osteoarthritis patients.

3. The Nurse administrator should organize public awareness program for osteoarthritis
patients on warm hydrotherapy and alternative warm and cold hydrotherapy
techniques.

Nursing Education

1. Provide guidelines for Nurse Educator to plan in service education program.

2. The Nurse Educator should involve the concept of physical therapy and warm
hydrotherapy and alternative warm and cold hydrotherapy techniques in the medical and
nursing profession.

3. Motivate the nursing students to educate warm hydrotherapy and alternative warm and
cold hydrotherapy techniques on management of level of pain among osteoarthritis
patients.

4. Educator can encourage the nurse to bring out innovative and creative ideas pertaining to
management of level of pain among osteoarthritis patients.

5. Educator can encourage the students for effective utilization of research based practice.

Nursing Research

Research findings should be disseminated through conference, seminars, publication in

journals, and World Wide Web.
 70

1. Nurse researcher can provide more research in this evolving discipline.

2. The findings of the study serve as a basic for the student to conduct further studies
regarding management of pain among osteoarthritis patients.

C. RECOMMENDATION

1. A similar study can be conducted with a large sample size and longer duration.

2. Health education program can be organized for older adults and middle age women
regarding management of pain among osteoarthritis patients.

3. The interventions can be applied for other co-morbid illness like Diabetes, Hypertension,
Cardiac disease and others.

4. Study can be done for post operative orthopedic patients for the management of pain and
wound healing also can be used for improving sleep pattern.

5. A similar study can be conducted as structured teaching program.

D. LIMITATIONS

1. The investigator had some difficulties during maintaining the temperature of alternative
warm and cold hydrotherapy intervention.
 71

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Denise S Porit and Cheryl Tatano Beck (2008). Nursing Research. (8th ed). Philadelphia:
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Dieppe PA, Harkness JAL, Higgs ER. Osteoarthritis, In: Wall PD, Melzak R, eds. Textbook of
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NET REFERENCE:

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www.jaaos.org/content/18/7/406.short
 APPENDIX – A
LIST OF EXPERTS FOR CONTENYT VALIDITY
NURSING EXPERTS:
1. Hema Suresh, M.Sc.(N).,
Vice Principal,
Meenakshi College of Nursing,
Mangadu, Chennai-69.

2. Jolly Ranjith, M.Sc.(N).,

Reader,
Omayal Achi College of Nursing,
Avadi, Chennai - 62.

3. Jayasri, M.Sc.(N).,
Vice Principal,
MIOT College of Nursing,
Chennai - 116.

4. Selvakani Pandian, M.Sc.(N).,

Vice Principal,
SRM College of Nursing,
Kattankulathur, Chennai-203.

MEDICAL EXPERT:
1. M.Sivasubramanian, MBBS.,MS(ortho).,
Chief Orthopedician, H.O.D.,
Hindu Mission Hospital, Tambaram, Chennai.

PHYSIOTHERAPIST:
1. W.Emmanuel, DPT.,
Senior Physiotherapist,
Hindu Mission Hospital, Tambaram, Chennai.
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LETTER SEEKING EXPERTS OPINION FOR CONTENT VALIDITY

From
E.Anand
M.Sc. (N) I Year,
Vel R.S Medical College – College of Nursing,
Avadi, Chennai – 600 062.

To

Respected Madam/Sir,
Sub: Requisition for expert opinion on suggestion for content validity of the tools.

I am E.Anand, a student of M.Sc.(Nursing)- II year at Vel R.S Medical College - College

of Nursing, Avadi, Chennai – 62, affiliated to Dr.M.G.R.Medical University, Chennai.

As a partial fulfillment of the requirement in the M.Sc. Nursing Programme, I have to

complete a dissertation the topic I have selected is “A comparative study to assess the outcome
of warm hydrotherapy Vs alternative warm and cold hydrotherapy among osteoarthritis
patients in selected setting”

Herewith I am sending the developed tools for content validity and for your expert opinion
& valuable suggestions.

Thanking you,

Yours sincerely,

(ANAND.E)
Enclosures:
1. Statement and objectives of the study
2. Blue print of the tools
3. Content validity certificate
 iii

CERTIFICATE FOR CONTENT VALIDITY

This is to certify that the tools developed by Mr.E.ANAND, M.Sc.Nursing, IInd year
student, Vel.R.S. Medical College - College of Nursing, Chennai on the topic “A comparative
study to assess effectiveness of warm hydrotherapy Vs alternative warm and cold
hydrotherapy on level of pain among osteoarthritis patients.” is validated by the undersigned
and he can proceed with this tool to conduct the main study.

SIGNATURE:

Place:

Date:
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APPENDIX – B

INTRODUCTION

Good Morning!
I am a student of Vel R.S.Medical College – College of Nursing, conducting a study to
assess the outcome of warm hydrotherapy Vs alternative warm and cold hydrotherapy among
osteoarthritis patients in selected setting.

I request you to permit me to include you as my study participant for interventions such
as warm hydrotherapy and alternative warm and cold hydrotherapy. This will reduce the level of
pain over osteoarthritis. Further, I request you to kindly extend your co-operation in the smooth
completion of the study.

Thanking You.
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DEMOGRAPHIC VARIABLES
1. Age in years ……………..

a) 40– 50 years.

b) 51- 60 years.

c) 61 – 70 years.

d) 71 – 80 years.

2. Gender …………….

a) Male

b) Female

3. Marital Status…………..

a) Single

b) Married

c) Widower

d) Divorcee

4. Type of Family…………………

a) Nuclear family

b) Joint family

5. Education…………..

a) Middle school

b) High school

c) Higher secondary

d) Graduate

e) None
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6. Type of work……………

a) Sedentary work

b) Moderate work

c) Heavy work

7. Family income (Rs.)……………

a) < 5000

b) 5001 – 10000

c) >10000

8. Duration of illness……………

a) 0 month-5years

b) 5years-10years

c) 10years and above

9. Duration of medical interventions………………….

a) 0 month-5years

b) 5years-10years

c) 10years and above

10. Co-morbid illness……………

a) Diabetes mellitus

b) Hypertension

c) Cardiac disorders.

d) Others.
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MODIFIED NUMERICAL PAIN RATING SCALE

RATINGS:

0 - NO PAIN.

1-3 - MILD, ANNOYING PAIN.

4 -5 - TOLERABLE PAIN.

6 -7 - MISERABLE PAIN.

8 -10 - WORST, UNBEARABLE PAIN.

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APPENDIX- C
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