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 2 . NAME OF THE INSTITUTION 10 EAST WEST COLLEGE OF NURSING RAJAJINAGAR 2ND STAGE, E BLOCK SUBRAMANYANAGAR, BANGALORE 3 . 4 . 5 . COURSE SUBJECT OF STUDY 10 AND Ist YEAR M.SC.(NURSING) MEDICAL SURGICAL NURSING

SPECIALTY DATE OF ADMISSION TO THE 02- 06- 2008 COURSE TITLE OF THE TOPIC EFFECTIVENESS OF HOT AND 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, Africa11,509,044, 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. incidence of back pain is reported to be ~5% of the population.11 In view of above study and the investigators 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: The lifetime prevalence has been estimated at anything between 59% to 90%(3). In any one year, the

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. Wiedenbachs 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 Wiedenbachs 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. 7.1. . 7.2.

MATERIAL & METHOD SOURCES OF DATA: Data will be collected from female patients with low back pain of selected hospitals of Bangalore. 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

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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?