Download RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA STATE,
BANGALORE.
PROFORMA SYNOPSIS FOR REGISRATION OF SUBJECT FOR
DISSERTATION.
SYNOPSIS
PRESENTED BY:
GANESH SHETE
Ist Year M.Sc. (Nursing)
East West College of Nursing
Medical Surgical Nursing
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES KARNATAKA STATE,
BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION.
1. NAME OF THE CANDIDATE GANESH SHETE
AND ADDRESS
IST YEAR M.SC(NURSING)
EAST WEST COLLEGE OF NURSING
RAJAJINAGAR 2ND STAGE, ‘E’ BLOCK
SUBRAMANYANAGAR, BANGALORE
10
2. NAME OF THE INSTITUTION
EAST WEST COLLEGE OF NURSING
RAJAJINAGAR 2ND STAGE, ‘E’ BLOCK
SUBRAMANYANAGAR, BANGALORE
10
3. COURSE
OF
STUDY
AND Ist YEAR M.SC.(NURSING)
SUBJECT
MEDICAL
SURGICAL
NURSING
SPECIALTY
4. DATE OF ADMISSION TO THE 02- 06- 2008
COURSE
“EFFECTIVENESS OF HOT AND
5. TITLE OF THE TOPIC
COLD APPLICATION IN REDUCING
LOW BACK PAIN”
PROBLEM
STATEMENT
:
“A
STUDY
TO
COMPARE
THE
EFFECTIVENESS OF HOT AND COLD APPLICATION IN REDUCING LOW
BACK PAIN
BANGALORE.”
AMONG FEMALE PATIENTS OF SELECTED HOSPITALS AT
6. BRIEF RESUME OF INTENDED WORK:
INTRODUCTION:
“PREVENTION IS BETTER THAN CURE”
Low-back pain is a common complaint with the lifetime prevalence reported as
ranging from 11% to 84%. The cause of pain is non-specific in about 95% of people
presenting with acute low-back pain, with serious conditions being rare.. Different health
care disciplines commonly use heat and cold treatments for the treatment of low-back
pain. Both therapies are simple to apply and are inexpensive. They may be used by
people with low-back pain at home, or may be employed by practitioners as part of a
treatment regimen. Superficial heat modalities convey heat by conduction or convection.
Superficial heat includes such modalities as hot water bottles, heated stones, soft heated
packs filled with grain, poultices, hot towels, hot baths, saunas, steam, heat wraps, heat
pads, electric heat pads and infra-red heat lamps. Cold therapy is used to reduce
inflammation, pain and oedema. Superficial cold includes cryotherapy, ice, cold towels,
cold gel packs, ice packs and ice massage.6
Because the spine is such a complex structure, many things can go wrong.
Injuries can occur to disks, joints and ligaments due to acute trauma, poor postural habits,
and the accumulation of physical stress on the spine.. It has been suggested that several
factors can predispose people to the development of LBP. Occupation can also be a risk
factor in the development of LBP, especially for those who work in positions that involve
excessive vibrating movements (eg, crane workers), or positions that involve very little
movement (ie, sedentary occupations).The risk of LBP in the latter of these
classifications, may be due to either an increase in intradiscal pressure in the seated
position, when compared to the standing position, or to the fact that sedentary
occupations are at a greater risk of muscle atrophy, as they lack any form of exercise on
the job. Any other occupation that involves lifting, bending and twisting are also subject
to LBP. Other risk factors include obesity, drug abuse, aging, and it has even been
suggested that genetics may predispose individuals to LBP. Eighty-five percent of
whiplash patients also develop LBP within one year of their original injury.3
Lower back pain, in particular, is one of the most common symptoms that results
in physician visits. It has been estimated that between one quarter and one half of patients
treated by physical therapists in acute care hospital, private office, and outpatient physical
therapy clinics suffer from low-back pain. No one is immune to the risk of LBP, and men
and women are equally affected with LBP.3
Which is better for lower back pain, ice or heat? According to the Texas Back
Institute, the answer is: both. Immediately after an injury and for the following 48 hours,
ice is best. Ice helps decrease inflammation associated with injury. After 48 hours, heat is
generally recommended, but whichever feels more comfortable is also acceptable. Heat
allows blood vessels in the tissues surrounding the injured area to dilate and provide the
extra oxygen and nutrients necessary for rapid healing. This is also true for sprains and
strains of other joints.4
Survey indicates that 70 per cent of the people suffer from low back pain at some
time in their lives. The highest rate of back pain occurs among the 45 to 64 year age
group. The incidence of low back pain is greater among women. In 90 per cent of the
patients, low back pain resolves within six weeks, i.e. self limited. In another 5 per cent
the pain resolves by 12 weeks. Less than 5 per cent of back paid account for true nerve
root. One of the common causes for the backache is poor posture habit. Balanced posture
decreases stress on your back by keeping the muscles, bones and other supporting parts in
their natural position. Any change from normal spinal curve can stress or pull muscles.
This leads to increased muscle contraction, which causes pain. Low back pain can result
due to health problems like osteoporosis, scoliosis, and spinal stenosis. Sprain or strain of
muscles or ligaments in the area can also manifest in low back pain.5
6.1
NEED FOR STUDY:
Low back pain is a very common ailment among workers of all ages.
Approximately 60-90% of the adult population suffers from low back pain at least once
during their life time. The yearly incident rate of low back pain is about 1-2%. A high
rate of low back pain is found among workers involved with heavy physical labour and
also among truck drivers. Risk factors for low back pain are intense heavy labour, lifting
heavy objects, protracted static positions, repetitive movements and awkward body
postures accompanied by vibration. The reliable predictor of future low back pain is the
evidence of previous back pain as disclosed during the preemployment health
examination.6
A Study was conducted in 2008 to investigate incidence and severity of somatic
dysfunction of four lumbar vertebral segments. Patients with back pain make more than
14 million office visits per year to US physicians. Many of these patients have chronic
low back pain and are assumed to have more somatic dysfunction than those without
chronic low back pain. Sixteen subjects with chronic low back pain and 47 subjects
without chronic low back pain were each evaluated by two blinded examiners using
reliable osteopathic palpatory tests. Resistance to anterior springing (P<.001) and
tenderness (P=.002) were found at significantly greater incidence in the chronic LBP
group than in the non-low back pain group, but there were no significant differences
between groups for incidence of tissue texture changes or static rotational asymmetry.7
A study was conducted in 2004 to determine the prevalence ranges of low back
pain together with any related disability in Australian adults. A stratified random sample
of 3000 Australian adults selected from the Electoral Roll. A range of prevalence data
was derived, as were disability scores using the Chronic Pain Grade. There was a 69%
response rate.The sample point prevalence was estimated at 25.6% , 12-month prevalence
was 67.6%, and lifetime prevalence was 79.2%. In the previous 6-month period, 42.6%
of the adult population had experienced low-intensity pain and low disability from it.
Another 10.9% had experienced high intensity-pain but still low disability from this pain.
However, 10.5% had experienced high-disability LBP.8
A study was conducted in 2007 to review the prevalence of LBP in Africa.There
was a general assumption that LBP prevalence in Africa is comparatively lower than in
developed countries. The most common population group involved workers (48%), while
scholars comprised 15% of the population. The result of study revealed that the mean
LBP point prevalence among the adolescents was 12% and among adults was 32%. The
average one year prevalence of LBP among adolescents was 33% and among adults was
50%. The average lifetime prevalence of LBP among the adolescents was 36% and
among adults was 62%.9
The observational cross-sectional study was conducted in 2008 in Belgaum on a
sample of 100 women workers who volunteered. The musculo-skeletal problems were
found to be abundantly present with pain in 91% of the subjects. Region-wise mapping of
pain revealed that postural pain in low back was present in 47% while in neck was 19%.
Though the overall job was light as per peak HR, there was pain due to fatigue and grip
strength weakened by around 10%, at the end of the day's work. In conclusion, pain and
fatigue were found to be the main problems for women in the spinning section of the
small-scale industry under this study. It was considered that ergonomic factors such as
provision of a backrest and frequent rest periods could remediate the musculo-skeletal
symptoms.10
Prevalence of back pain in
India reported in 2008 is 23,494,204, Africa-
11,509,044, Europe- I5,939,890, America- 16,794,178, Asia- 67,601,551. Low back pain
is a major health and socio-economic problem throughout Europe.
The lifetime
prevalence has been estimated at anything between 59% to 90%(3). In any one year, the
incidence of back pain is reported to be ~5% of the population.11
In view of above study and the investigator’s experience, a variety of nonsurgical
treatment alternatives exists for acute and chronic low back pain. Patients should receive
appropriate education about the favorable natural history of low back pain, basic body
mechanics, and methods that can reduce symptoms. Nonprescription medication is
efficacious for mild to moderate pain. The findings of the study might help in providing
vigilant nursing care to patient in reducing the level of low back pain.
6.1.1. CONCEPTUAL FRAMEWORK:
Conceptual framework is an abstract generalization that explains systematically
the relationship among phenomena and helps to summerise the existing effectiveness of
hot and cold application in reducing low back pain among female patients into coherent
systems and explain the nature of relationship between variables.2
The conceptual framework for this study was modified and adopted “Prescriptive
theory” (Helping art of clinical nursing) proposed by Ernestine Wiedenbach.
Wiedenbach’s prescriptive theory described as a system of conceptualization invented to
some purpose. Prescriptive theory may be described as one that conceptualizes both a
desired situation and the perception by which it is to be brought about. The study is based
on the concept that administration of hot and cold application to female patients with low
back pain will reduce their level of low back pain and enhance their wellbeing. The
prescriptive theory directs action toward an explicit goal.2
The factors included in prescriptive theory are central purpose, prescription and
realities. In this study the central purpose refers to the reduction of level of low back pain
in female patients. In this study prescription refers to preparation the schedule of
application of hot and cold therapy for reduction of level of low back pain in female
patients. The realities in the immediate situation that influence the fulfillment of the
central purpose. 2
Central purpose, prescription, realities components of prescriptive theory are
inter dependent on one another as depicted. The prescription was derived by the
researcher for his central purpose and is affected by the realities of the situation. The
researcher develops prescription based on his central purpose, which is implemented in
the realities of the situation. Together these components constitute the substance of
Ernestine Wiedenbach’s prescriptive theory.2
6.2
REVIEW OF LITERATURE:
A study was conducted in 2006 to assess the effects of superficial heat and cold
therapy for low back pain in adults. The result of study revealed that out of nine trials
involving 1,117 participants, in two trials of 258 participants with a mix of acute and
subacute low back pain, heat wrap therapy significantly reduced pain after 5 days
(weighted mean difference,1.06; 95% confidence interval,0.68-1.45, scale range, 0-5)
compared with oral placebo. One trial of 90 participants with acute low back pain found
that a heated blanket significantly decreased pain immediately after application (WMD, 32.20; 95% CI, -38.69 to -25.71; scale range, 0-100). One trial of 100 participants with a
mix of acute and subacute low back pain examined the additional effects of adding
exercise to heat wrap and found that it reduced pain after 7 days. The conclusion was the
evidence base to support the common practice of superficial heat and cold for low back
pain is limited, and there is a need for future higher-quality randomized controlled
trials.12
A study was conducted in 2006 to determine the efficacy of superficial hot or cold
therapies in reducing pain and disability in low-back pain in adults, aged 18 and older.
Out of nine the trials, one had acute low-back pain participants, four had a mix of acute
and subacute low-back pain participants, three had chronic low-back pain participants
and one had a mix of acute, sub-acute and chronic participants. Two trials compared hot
packs to ice massage, one trial compared ice massage to transcutaneous electrical
stimulation, one trial compared a full body active warming electric blanket to passive
warming by way of a woolen blanket and one trial compared a wool body belt that
provided warmth to a lumbar corset. Four trials assessed the effect of a heated lumbar
wrap compared to various interventions. Three of these trials compared the heated wrap
to pain relief medication and to a non-heated wrap and one trial compared the heated
wrap alone to exercise alone, to heat plus exercise and to an educational booklet. Only
four of these trials had pain data in a form that could be extracted and combined in a
meta-analysis, and this was only possible after obtaining further data from the authors of
the studies.13
A study was conducted in 2005 to assess the prevalence of low back pain in
obstetricians and gynecologists in Nagpur, Maharashtra and to study its association with
other variables. Members of local obstetric and gynecological society were approached
with a pre-designed questionnaire to obtain demographic details and issues related to
their practice. Completed questionnaires were obtained from 77 members. The lifetime
prevalence of low back pain was 53%. The occurrence of low back pain was significantly
correlated with the body weight (pain vs no pain; 65+10 kg. vs 59+10 kg; p<0.01). We
found no correlation of occurrence of low back pain with other variables like age, height,
years in practice and number of surgeries performed per month. A large number of
obstetricians and gynecologists suffer from low back pain and it can be a cause of
significant disability.14
Low back pain has an incidence between 1% and 30% in athletes. The natural
history of low back pain is such that greater than 90% will improve without medical
attention. Our treatment algorithm begins by ruling out nonspinal related causes of low
back pain including neoplasm, infection, and serious medical conditions. Low back
strain, herniated nucleus pulposis, spinal stenosis, and degenerative disease are each
discussed with an emphasis on imaging studies finding a correlation between history,
physical, and the neurodiagnostic testing. Athletes over the age of 60 who require back
surgery should understand that they would most likely not return to their previous level of
activity. Recent work has focused on rehabilitative principles such as core stabilization
and their role in the prevention and treatment of athletes with lumbar disorders.15
A study was conducted in 2003 to evaluate the efficacy of 8 hours of continuous
low-level heat wrap therapy for the treatment of acute nonspecific low back pain.
Participants were two-hundred nineteen subjects, aged 18 to 55 years, with acute
nonspecific LBP. Subjects were stratified by baseline pain intensity and gender and
randomized to one of the following groups: evaluation of efficacy (heatwrap, N=95; oral
placebo, N=96) and blinding (oral ibuprofen, N=12; unheated back, wrap N=16). All
treatments were administered for 3 consecutive days with 2 days of follow-up. The result
of study revealed thath heatwrap therapy was shown to provide significant therapeutic
benefits when compared with placebo during both the treatment and follow-up period. On
day 1, the heatwrap group had greater pain relief (1.76[plusmn].10 vs 1.05[plusmn].11, P
[lt ].001), less muscle stiffness (43.1[plusmn]1.21 vs 47.6[plusmn]1.21, P=.008), and
increased flexibility (18.6[plusmn].44cm vs 16.5[plusmn].45cm, P=.001) compared with
placebo. Conclusion was Continuous low-level heatwrap therapy was shown to be
effective for the treatment of acute, nonspecific LBP.16
A study was conducted in 2008 to review of LBP cost of illness studies in the
United States and internationally. The search yielded 147 studies, of which 21 were
deemed relevant; 4 other studies and 2 additional abstracts were found by searching
reference lists, bringing the total to 27 relevant studies. The studies reported on data from
Australia, Belgium, Japan, Korea, the Netherlands, Sweden, the UK, and the United
States. Nine studies estimated direct costs only, nine indirect costs only, and nine both
direct and indirect costs, from a societal (n=18) or private insurer (n=9) perspective.
Methodology used to derive both direct and indirect cost estimates differed markedly
among the studies. Among studies providing a breakdown on direct costs, the largest
proportion of direct medical costs for LBP was spent on physical therapy (17%) and
inpatient services (17%), followed by pharmacy (13%) and primary care (13%). Among
studies providing estimates of total costs, indirect costs resulting from lost work
productivity represented a majority of overall costs associated with LBP.17
STATEMENT OF THE PROBLEM.
“A STUDY TO COMPARE THE EFFECTIVENESS OF HOT AND COLD
APPLICATION IN REDUCING LOW BACK PAIN AMONG FEMALE PATIENTS
OF SELECTED HOSPITALS AT BANGALORE”.
6.3 OBJECTIVES OF THE STUDY
1. To asses pre interventional pain for group A.
2. To asses pre interventional pain for group B.
3. To assess effectiveness of hot application in reducing low back pain among
female patients.
4. To assess effectiveness of cold application in reducing low back pain among
female patients.
5. To compare the effectiveness of hot and cold application in reducing low back
pain among female patients.
6. To find out the association between the level of low back pain and selected
demographic variables.
6.4 OPERATIONAL DEFINITIONS :

Effectiveness: Refers to significant gain in knowledge as determined by
significant change in pre and post test scores.

Hot application: Application of hot fermentation for reduction of low back pain.

Cold application: Application of cold fermentation for reduction of low back
pain.

Low back pain: Pain in the lower back area that can relate to problems with the
lumbar spine, the discs between the vertebrae, the ligaments around the spine and
discs, the spinal cord and nerves, muscles of the low back, internal organs of the
pelvis and abdomen, or the skin covering the lumbar area.
6.5. HYPOTHESIS:
Ho: There is no significant level of pain reduction after hot application.
H1: There is no significant level of pain reduction after cold application.
6.6.
ASSUMPTIONS
It is assumed that :
There may be a significant reduction in the level of low back pain by applying
hot and cold application.
6.7.
DELIMITATIONS:

Study is delimited to all age group female patients of selected hospitals with
low back pain during the time of study.
7.
MATERIAL & METHOD
7.1.
SOURCES OF DATA: Data will be collected from female patients with low
back pain of selected hospitals of Bangalore.
.
7.2.
METHOD OF COLLECTION OF DATA.
7.2.1. RESEARCH DESIGN:
Comparative pre experimental study design will be used.
7.2.2. SETTING:
Selected hospitals, Bangalore.
7.2.3. POPULATION:
The populations of the present study consist of female patients in selected
hospitals, Bangalore.
7.2.4. SAMPLE SIZE:
The sample size of the present study comprises 40 female patients.
20 female patients for hot application and 20 female patients for cold
application.
7.2.5. SAMPLING TECHNIQUE:
Convenient sampling technique will be used to select the sample.
7.2.6. SAMPLING CRITERIA
Inclusive criteria:

Female patients who are admitted in hospitals.

Female patients who are having the level of pain more than 5 in visual
analogue scale.

Female patient who are willing to participate in the study.
Exclusive criteria:

Immediate post operative patient.

Critically ill patient.
7.2.7. TOOL FOR THE DATA COLLECTION
The tool for the data collection consists of two sections.
Section I- Visual analogue scale prepared by the investigator.
Section II- Observation check list prepared by the investigator.
7.2.8. METHOD OF DATA ANALYSIS
Appropriate descriptive and inferential statistics will be used.
Descriptive statistics:
Frequency, percentage, means, median, mode and standard deviation will be
used to explain demographic variables and to compute the level of knowledge
and attitude.
Inferential statistics:
Chi-square test will be used to find the association between selected
demographic variables with the level of low back pain among female patients.
7.2.9. DURATION OF DATA COLLECTION:
6 to 8 weeks.
7.2.10. VARIABLES:
Dependent variable:- low back pain.
Independent variable: - hot and cold application.
7.2.11. PROJECTED OUTCOME:
The study will help to compare the effectiveness of hot and cold
application in reducing low back pain and to enhance the awareness of patients
about the effectiveness of hot and cold application in reducing low back pain.
7.3. Does the study require any investigation or intervention to be conducted on
Patient or other human beings or animals?
- Yes, the study requires administration of visual analogue scale and observation
check list to female patients of selected hospitals at Bangalore city.
7.4. Has ethical clearance been obtained from your institution?
– Yes. Enclosed
8. LIST OF REFERENCES
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publication. Harcourt India. 2001. Volume; 2nd. Page no. 1984-1991.
2. Marilyn E. Parker. Nursing Theories And Nursing Practice. Edition 2nd . Jaypee
Brothers Medical Publishers. New Delhi. Page no.:123-124
3. M.Gaudry (MD). Treatment methods for low back pain. Global Spine Network,
The World’s Leading Spine Directory. 2005. hppt://www.globalspine.net.
4.
D.K.Howe. Hot and cold for low back pain. Aerobic and fitness association of
America. September 2001.http://www.texasback.com.
5. Dr.shrisaiphiro. Article on back pain 2008. http://www.backpain.html.
6. Moshe S, Levin M.Occupational aspects of low back pain. Journal of Harefuah
2005Jul.Volume144(7).Pageno:492-6,526.
http://www.ncbi.nlm.nih.gov/sites/entrez.
7. Snider KT, Johnson JC, Snider EJ, Degenhardt BF. Increased incidence and
severity of somatic dysfunction in subjects with chronic low back pain, USA.
Journal of American Osteopathic Association. August 2008.Volume108(8). Page
no:372-78. http://www.ncbi.nlm.nih.gov/sites/entrez.
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and Associated Disability. Journal of Manipulative Physiological Therapy. May
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Africa: a systematic review. Journal of BioMedCentral Musculoskeletal
Disorder.2007November.Volume1(8).Pageno:105.
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10. DC Metgud, Subhash Khatri, MG Mokashi, PN Saha. An ergonomic study
Women worker in a woolen textile factory for identification of health-related
Problems in Belgaum. Journal of Ergonomic Medicine of India. 2008. Volume:
12. Issue: 1. Page : 14-19. http://ijoem.com/login.asp.
11. Esther Gokhale. Statistics by Country for Back Pain. The Indian American
Journal. November 2008. http://www.back pain.com/www.wrongdiagnosis.com
12. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Cochrane review
of superficial heat or cold for low back pain in Australian adults. Journal of spine.
April 2006. Volume 31(9). Page no: 998-1006.
http://www.ncbi.nlm.nih.gov/sites/entrez?.
13. Simon D French., Melainie Cowdery Cameron, Bruce F Walker, John W Reggars,
Adrian J Esterman. Efficacy of superficial hot or cold therapies in reducing pain
and disability in low back pain. Journal of Cochrane Database Systematic
Reviews. Vol 14, No 8, August 2006. Page no. 477-487.
http://www.jaaos.org/misc/terms.dtl
14. Pande Ketan, Pande Sonali , Saleem Mohammed , Panpaliya Sanjeev ,Bhojwani
Raj. Low back pain in Obstetricians and Gynecologists, Sushrut Hospital
Research Centre and PGI Orthopedics, Ramdaspeth, Nagpur. Journal of Obstetric
and Gynecology of India. October 2005. Volume 55(5). Page no: 440-42.
http://www.back pain.com
15. Graw BP, Wiesel SW. Low back pain in the aging athlete, USA. Journal of sports
MedArthosc.March2008.Volume16(1).Pageno:39-46.
http://www.ncbi.nlm.nih.gov/sites/entrez?.
16. Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW.
Continuous low-level heatwrap therapy for treating acute nonspecific low back
pain. Journal of Health Science. 2003. Volume84(3). Page no:329-34.
http://www.science direct.com/science?.
17. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of
illness studies in the United States and internationally. Journal of Spine. January
2008. Volume 8(1). Page no:8-20. http://www.ncbi.nlm.nih.gov/sites/entrez?