http://doi.org/10.33698/NRF0071 Parminder Kaur, Indarjit Walia, Sushma Kumari Saini
Abstract : Healthy geriatric population make major contribution to health. Providing nursing care for geriatric population is a major area of responsibility in all health care settings. Knee joint pain is the most frequent complaint among the geriatric population. The present study has been undertaken to study the effect of ‘moist heat application’ on the intensity of knee joint pain among geriatric population (³ 60 years of age) residing at Dadu Majra Colony, U.T., Chandigarh. Out of the total geriatric population surveyed in the present research 48% had knee joint pain. Every 3rd individual was selected as a study sample by using a systematic random sampling technique .The sample size consisted of 87 subjects i.e. 43 in the experimental and 44 in the control group. The experimental and the control groups were similar in respect to age, marital status, intensity of knee joint pain, intake of pain killer, duration and experience of knee joint pain. Intensity of knee joint pain was assessed on the 1st and 8th day of intervention among both experimental and control group. ‘Moist heat’ was applied at the knee joint twice a day for seven days in the experimental group. The results show that intensity of knee joint pain and intake of painkiller was reduced significantly in the experimental group as compared to the control group as indicated by chi-square test. Hence, the use of moist heat application is recommended for home base management of knee joint pain.
Key Words :Knee joint pain, Moist heat application
Correspondence at :Sushma Kumari Saini Lecturer, National Institute of Nursing Education PGIMER, Chandigarh, India.
Introduction
Ageing is a natural phenomenon that is experienced by all living organisms. Healthy geriatric population makes major contribution to the health and development of the country. Live well, eat well and be positive. Those who have survived to old age should be well informed about the ways to prevent diseases and to maintain the quality of life to extend their survival.1 Various diseases that commonly affect geriatric population are musculoskeletal pain, hear t diseases, hyper tension, diabetes, asthma and skin diseases.2 Musculoskeletal pain is a major health problem among geriatric population according to the surveys undertaken in both developed and developing countries. Knee and low back pain are the most frequent complaints among this population.3 Knee pain is more common than back pain among this population and with increase in life expectancy in developed and developing countries, this is an epidemic which is destined to grow.4 Most of geriatric population is troubled by chronic knee pain that has a major effect on their quality of life.5 It accounts for approximately one-third of musculoskeletal problems in this population. High prevalence of knee joint pain was reported by various authors i.e. 46.7% among 60 years and above population and 40.7% among 65 years and above.7, 8 Under treated or poorly managed knee joint pain can affect their physical, psychological, social, and emotional life.6 These real life consequences of knee joint pain need to be given adequate attention in the home care settings. So, there is a need to have home based management. Many researchers have studied and recommended the moist heat application for helping the people suffering from knee joint pain.9,10,11 Moist heat application is non pharmacological, inexpensive and simplest approach which has a beneficial effect on knee joint pain.12 It causes vasodilatation and it penetrates deeper into the muscle and hence reduces the muscle spasm and pain.9, 13 It prevents the perception of the pain through its effect on sensory nociceptors by decreasing the conduction time and synaptic activity. Moist heat is more effective than dry heat as it penetrates more than dry heat with the same temperature. It has additional capacity to change the tissue temperature rapidly and more vigorous response from temperature receptors. It increases the extensibility of collagen tissues. It decreases joint stiffness in tendons and ligaments.9,13 Studies show that topical heat application is more easily accepted while cold application is less favorably accepted.12 A study on the use of moist heat application revealed that 20-30 minutes of topical applied heat produce a marked increase in local circulation, with all structure contributing to the response including tissues located three or more centimeters below the surface of the skin.14 While working in the community the investigator has observed that majority of population is suffering from knee joint pain. No standard protocol is being practiced in community for moist heat application. Hence the investigator is motivated to conduct this study on management of knee joint pain following application of moist heat among geriatric population. So, this comprehensive study is designed to find out the change in intensity of pain at knee joint by moist heat application.
Main Objective:To evaluate the change in the intensity of pain by application of moist heat on the knee joint among geriatric population.
Materials and Methods:A quasi-experimental study was conducted during the months of January and February 2007 in Daddu Majra Colony, U.T., Chandigarh. Daddu Majra Colony is a resettlement Colony, chosen purposively for the study because of familiarity with the area. It is situated on the Nor thwest corner of Chandigarh and is at a distance of 5 km from National Institute of Nursing Education (NINE) PGIMER, Chandigarh and 6 km from the Interstate Bus Terminus sector 17 of Chandigarh. The investigator developed a procedure for ‘Moist Heat Application’ on knee joint pain, Survey Per forma, Interview Schedule and Pain Assessment Scale according to the objectives.Nine experts from the field of Nursing, one from Community Medicine and one from Physiotherapy validated the tool. The experts’ suggestions were incorporated into the final draft of the tool. The survey Performa, interview schedule and pain assessment scale were translated into Hindi and again retranslated into English to check the validity of translated tools. The tools were assessed for their completeness, contents and language clarity during pilot study. Tools were found complete in terms of contents and clarity of language. For checking the reliability of the tools test retest method was used and value of Spearman’s rank correlation was found to be 0.90 and hence significant and tool was reliable.Survey was done to enlist the total geriatric population of the DMC U.T., Chandigarh. Total 612 (3.73%) of total population approximately subjects were enlisted during the survey. Every 3rd individual was selected as a study sample by using a systematic random sampling technique i.e. 89 subjects were selected as a study sample and 2 subjects were not available. Hence, 43 subjects were in experimental and 44 in control group. First day data was collected through interviewing and pain assessment performa. As part of the experiment in the study, moist heat was applied at the knee joint for 20 minutes twice daily for 7 days in the experimental group. No intervention was given among the control group. The knee joint pain was assessed in both experimental and control group on 1st and 8th day of intervention. The data was analyzed as per objectives by applying both descriptive and inferential statistics.
Results: Mean age ± SD of the subjects was 66.65±6.86 years and 66.19±17.24 years in experimental and control groups, ranging between 60-83 and 60-95 years respectively.
Table – 1 : Socio demographic characteristics of the study subjects N=87
n=43 n=44Characteristics Expt. Group Control Group
f (%) f (%)
Age (years)
60-65 21 (48.8)
66-70 12 (27.9)
Mean 66.65±6.86
Range Rs. 60-83
27 (61.4)
07 (15.9)
Mean 66.19±7.24
Range Rs. 60-95
c2 =2.04
- f. =2**
71-75 03 (07.0) 05 (11.3)
³76 07 (16.3) 05(11.4)
Gender
| Male | 08 (18.6) | 10 (22.7) |
| Female | 35 (81.4) | 34 (77.3) |
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Marital status NS*
c2 =0.04 1.f. =1 NS*
Income (Rs.)
<500 07 (16.2) 10 (22.7)
501 -1000 26 (60.5) 1001-1500 06 (14.0)
Mean 1016+846
Range Rs. 250-4287
19 (43.1) Mean 858+393
12 (27.2) Range Rs. 250-1957
c2 =2.60
- f. =2***
³1501 04 (09.3) 03 (07.0)
* NS – Not significant
** While applying chi-square test the frequencies in the age group 71-75 and ³76 were merged
NS**** While applying the chi-square test the frequencies in the education status of can read, primary, middle and matric were merged
**** While applying the chi-square test the frequencies in the Rs.1001- 1500 and Rs. <1501 were merged Out of the total subjects 81.4% in experimental and 77.3% in control group were female subjects. Total 41.9% in experimental and 54.5% in control group were married and reaming were widow/widower. Nearly three- fourth of subjects (76.7%) in the experimental and most of subjects (95.4%) in the control group belonged to Hindu religion. Per capita monthly income of the subjects ranged between Rs. 250/- to Rs. 4287/- with mean per capita income ± SD as Rs. 1016±846 in the experimental group and Rs. 858±393 in the control group. Variables such as age, gender, marital status, educational and per capita income of the experimental and control group were similar as no statistical difference was observed amongst the experimental and control group (Table 1).Two third of the subjects (62.8%) in the experimental and control group were experiencing knee joint pain all the time. In the experimental group, the range of duration of knee joint pain was between 0.6-30 years with mean ± SD as 5.73±6.38 years. In the control group the range of the duration of the knee joint pain was between 0.6-22.5 years with Mean ± SD as 5.71±6.04 years. Both the groups were comparable as per experience and duration of knee joint pain as indicated by chi-square test (p>0.05) (Table 2)
Table – 2 : Distribution of subjects as per their experience and duration of knee joint pain N=87
Variables Expt. Group Control Group
n=43 f (%) n=44 f (%)
Experience of Knee Joint Pain
All the time 27 (62.8) 27 (61.4)
While Standing 02 (04.7) 01 (02.2)
On Sitting 01 (02.3) 03 (06.8)
On walking 13 (30.2) 13 (29.6)
Duration of Knee Joint Pain
c2 =0.01
- f. =1* p>0.005
<1 Year 01 (02.3)
1-5 year 29 (67.5)
6-10 year 05 (11.6)
11-15year 05 (11.6)
Mean±SD 5.73±6.38
Range 0.6 – 30years
03 (06.8) Mean±SD
27 (61.4) 5.71±6.04
03 (06.8) Range
06 (13.6) 0.6 – 22.50 years
c2 =0.1
- f. =1** p>0.005
* The frequency in while sitting, on standing and on walking were merged while calculating chi-square test
>16 year 03 (07.0) 05 (11.4)
** The frequency upto 10 year and from>10 were merged while calculating chi-square test.Nearly two-third of the subjects i.e. 69.8% in experimental group and 63.6% in the control group were taking pain killer. Only 8 subjects in experimental and 6 subjects in control group were taking both calcium as well as painkillers. Nearly half of the subjects i.e. 43.4% in experimental and 42.8% in control group were taking pain killer once a day. About 30% of subjects in experimental and 35.8% in control group were taking pain killer twice a day. Only 26.6% and 21.4% of subjects in experimental and control group respectively were taking painkiller occasionally (Table 3).
Table – 3 : Management of knee joint pain by study subjects N=87
| Variables | Expt. Group | Control Group |
| n=43 | n=44 | |
| f (%) | f (%) | |
| Pain Killer | 30 (69.8) | 28 (63.6) |
| Calcium (Supplements) | 09 (20.4)* | 06 (13.6)* |
| Not Using Any Drugs** | 12 (27.9) | 16 (36.4) |
| Frequency of taking Pain Killer | n=30 f(%) | n=28 f(%) |
| Once a day | 13(43.4) | 12 (42.8) |
| Twice a day | 09 (30.0) | 10 (35.8) |
| Occasionally | 08 (26.6) | 06 (21.4) |
*Eight subjects in experimental and Six subjects in control group were taking both calcium & pain killer
*One subject was taking calcium only
**Painkiller + calcium only
In the left knee at the time of pre intervention in the experimental and control groups 25.6% and 27.3% subjects had worst pain respectively while 23.3% and 9.1% subjects had severe pain respectively. Another one-third subjects in experimental (32.5%) and (27.3%) in control group had moderate pain. Only 18.6% subjects in experimental and 36.3% subjects in control group had mild pain. Experimental and control group were comparable as indicated by Chi-square test (p>0.05). After the intervention pain decreased significantly in the experimental group and it was observed that 37.2% had no pain, 39.5% had mild pain, 16.3% had moderate pain, 7% subject had severe pain and no subjects had worst pain in experimental group. In the control group their was no significant change in the pain and it was found that 34.1% subject had mild pain 25% had moderate pain, 27.3% had severe pain and 25% had the worst pain. Hence there was significant change in the knee joint pain among subjects in the pre intervention to post intervention period in the experimental group (p<0.01) (Table 4).
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Table – 4 : Intensity of left knee joint pain among experimental and control group before and after the intervention N=87
p<0.01
While applying chi- square frequency against no pain and mild pain were merged and similarly severe pain and worst pain were merged In the right knee at the time of pre intervention 23.2% had mild pain, 34.9% had moderate pain, 18.7% had severe pain and 23.3% had worst pain in experimental group. In control group 25% had mild pain, 27.3% had moderate pain, 18.2% had severe pain and 29.5% had worst pain. There was no statistically difference in experimental group as indicated by the chi-square test (p>0.05). After the intervention pain decreased significantly in the experimental group and it was found that 34.9% had no pain, 46.4% had mild pain, 16.4% had moderate pain and 2.3% had severe pain. In control group 25% had mild pain, 29.5% had moderate pain, 18.2% had severe pain and 27.3% had worst pain. The statistically significant change was observed in the intensity of knee joint pain from the intervention to post intervention period in the experimental group as compared to control group (p<0.01) (Table 5).
Table – 5 : Intensity of right knee joint pain among experimental and control group
| before and after the intervention | N=87 | ||||
| Variables | Right Knee
Before Intervention (1st Day) Expt. Group Control Group |
Right Knee
After Intervention (8th Day) Expt. Group Control Group |
|||
| (n=43) f(%) (n=44)f(%) | (n=43) f(%) (n=44)f(%) | ||||
| No Pain | 15 (34.9) – | ||||
| Mild Pain | 10 (23.2) | 11 (25.0) 20 (46.4) 11 (25.0) | |||
| Mod. Pain | 15 (34.9) | 12 (27.3) c2 =0.76 07 (16.4) 13 (29.5) c2 =25.55
08 (18.2) d. f. =3 01 (02.3) 08 (18.2) d. f. =1* |
|||
| Severe Pain
Worst Pain |
08 (18.7)
10 (23.2) |
13 (29.5) p>0.05 | – | 12 (27.3) | p<0.01 |
- Subjects having no pain and mild pain were merged together for calculating chi-square test similarly subjects with moderate, severe and worst pain were merged together for calculating chi-square testNearly two-third of the subjects i.e. 69.77% in experimental group and 63.64% subjects in control group were taking pain killer. Nearly one-third of the subjects i.e. 30.23% and 36.36% subjects in experimental and control group were not taking pain killer. Both the groups were comparable and did not differ statistically from each other for taking pain killer before intervention as indicated by chi-square test (p>0.05). After intervention in the experimental group only 37.2% of subjects were taking painkiller whereas in control group 61.3% taking were pain killer. Statistically frequency of subjects taking painkiller in the experimental group was found to be significantly lesser than control group during same period as indicated by chi-square test (p<0.05) (Table 6).Table – 6 : Comparison of subjects taking pain killer among experimental and control group before and after the intervention N=87
(1st Day) (8th Day)Variables Before Intervention After Intervention
Expt. Group Control Group Expt. Group Control Group (n=43) (n=44) (n=43) (n=44)
f(%) f(%) f(%) f(%)
Taking pain 30 (69.77) 28 (63.64) c2 =0.143
16 (37.20) 27 (61.36)
c2 =4.155
killer
- f. =1
- f. =1
Not taking 13 (30.23) 16 (36.36) NS* pain killer
- Not significant
27(62.80) 17 (38.64)
p<0.05 Discussion
High prevalence of knee joint pain was reported by various authors.7,8 Out of the total geriatric population surveyed in the present study 48% had knee joint pain. This is in agreement with the findings of other studies.7,8 The study was quasi experimental in which the experimental and the control groups were similar in respect to age, marital status, intensity of knee joint pain, intake of pain killer, duration and experience of knee joint pain. This shows the similarity between the experimental and the control group. Range of the age in the study subjects between 60-83 years and 60-95 yrs in experimental and control group respectively. This group was taken, as the prevalence of knee joint pain was high in this age group.The study sample was 43 in experimental group and 44 in control group. This size of sample was taken due to limited study time period. The null hypothesis was formulated that there is no significant difference in the intensity of knee joint pain with or without application of moist heat. Intensity of knee joint pain was assessed with the visual analogue scale after modification. This is a standardized scale.In the present study, moist heat was used as an intervention of knee joint pain as it is safe simple and non-pharmacological approach. Many authors have recommended moist heat application for pain relief.9,10,11 At the time of pre intervention there was statistically no difference in the intensity of knee joint pain in the left and right knee in the experimental and the control group Moist heat was applied for 20 min twice a day among experimental group for seven days. No intervention was given among the control group. On the 8th day there was significant reduction in the intensity of pain in the right as well as the lef t knee (p<0.01) in experimental group as compared to the control group as per chi-square test. Time period for applying heat for 20 min. bid was recommended by Lehmann9 and Tepperman10 Moist heat was applied for seven days only due to short duration of study period. Ferrell BA15 applied the moist heat for 6 weeks, the findings of the study revealed that the application of moist heat led to significant reduction of intensity of knee joint pain, when compared to the control group. In addition, it was observed that moist heat application had an indirect effect on intake of painkillers among the experimental group as compared to control group i.e. the percentage of subjects taking pain killer reduced after intervention in the experimental group which shows that subjects were benefited from moist heat application.So while applying chi square test the null hypothesis was rejected, as there is significant difference in the reduction of intensity of knee joint pain after applying moist application in both knees. This shows that moist application is effective treatment for reduction of intensity of knee joint pain. Findings in current study are almost the same as Ferrell BA15 He reported that significant improvement in pain (p<0.05) in interventional group.The findings of the study indicated that moist heat application at knee joint decreases the intensity of knee joint pain. Results were statistically significant in favor of the use of moist heat application while comparing the pain between experimental and control group on 1st day and 8th day of intervention in the current study (p<0.01) as indicated as chi- square test. Hence the use of moist heat application can be promoted in community for home based management of knee joint pain. Based on present study findings it is recommended that a similar study may be conducted on a larger sample to generalize the findings
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