Rajiv Gandhi University of Health Sciences



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

|NAME OF THE : |MS. PRASHMA |

|CANDIDATE AND |I YEAR M.SC. NURSING |

|ADDRESS |GOVERNMENT COLLEGE OF NURSING |

| |BEHIND D.C RESIDENCE, B.M ROAD |

| |HASSAN – 573201 |

|2. NAME OF THE : |GOVERNMENT COLLEGE OF NURSING, HASSAN. |

|INSTITUTION | |

|3. COURSE OF THE STUDY : |I YEAR M.SC NURSING |

|AND SUBJECT |MEDICAL-SURGICAL NURSING |

|4. DATE OF ADMISSION : |28/07/2012 |

|5. TITLE OF THE TOPIC : |“EFFECTIVENESS OF VIDEO ASSISTED TEACHING PROGRAMME ON KNOWLEDGE AND |

| |PRACTICE REGARDING RANGE OF MOTION EXERCISES AMONG RESTRICTED MOBILE |

| |PATIENTS IN ORTHOPAEDIC WARDS AT SC HOSPITAL HASSAN” |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Lack of activity destroys the good condition of every human being,

While movement and methodical physical exercise save it and preserve it.”

PLATO

The unique structures of the musculoskeletal system allow human beings to complete complex movements in their interactions with the environment.1 dynamic system is made up of bones, joints, muscles, and supporting structures, all the components working together to produce movement and to supply structure and support to the body. Any disturbance in this well-integrated system results in musculoskeletal dysfunction. 2

Musculoskeletal problems affect hundreds of millions of people worldwide, with a huge economic burden to society. The orthopaedic problems include fractures, dislocations, sprains, osteoporosis, and rheumatoid arthritis. Fracture is the most common musculoskeletal condition, occur in all age-groups, but the higher incidence is in young men and in older adults. Fractures account for a high percentage of traumatic injuries. They can create significant changes in one’s quality of life by causing activity restrictions, disability, and economic loss. 2

Fractures may require weeks and sometimes months to heal, so bed rest is often necessary for healing injured or diseased parts of the body. However, it is now well established that extensive periods of bed rest can cause harm to the rest of the body. The most obvious effects of long periods of immobility are seen in the musculoskeletal system. 3

Since the hospital stay of fracture patients is prolonged, the chances of developing possible complications high.4 Prolonged immobilization and bed rest contribute to complications like joint stiffness which may lead to joint contracture, ligament tightening or muscle atrophy, and limitation of function. Other complications include deep vein thrombosis, pulmonary embolism, kidney stone formation etc.3

To offset these complications associated with prolonged immobility, specific activity is required.1 Activities that the patient should include are range of motion exercises of unaffected joints.5 Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function. 4

6.1 NEED FOR THE STUDY

Skeletal system is the system of bones, associated cartilages and joints of human body. Together these structures form the human skeleton. Skeleton can be defined as the hard framework of human body around which the entire body is built. Almost all the hard parts of human body are components of human skeletal system. Joints are very important because they make the hard and rigid skeleton allow different types of movements at different locations. If the skeleton were without joints, no movement would have taken place and the significance of human body; no more than a stone. Joints are important components of human skeleton because they make the human skeleton mobile. A joint occurs between “two or more bones”, “bone and cartilage” and “cartilage and cartilage”. When a person is inactive, the joints are pulled into a flexed (bent) position. If this tendency is not counteracted with exercise and position change, the muscles become permanently shorten and joint becomes fixed in a flexed position.4

The National Centre for Health Statistics estimates that annually an average of 1 in 10 persons suffers acute injury to the musculoskeletal system. The most common injuries are fractures, dislocations and sprains.2 India has highest incidence of road traffic accidents (RTA) the highest number of victims of RTA (29.4%) was between the age group of 20-29years. The people of the third decade are more commonly involved in traffic injuries. 64.9%of the victim were between15-44yrs age group. Similar observation was reported by WHO in the injury chart book. This shows that the people of the most active and productive age groups are involved in road traffic injuries, which adds a serious economical loss to the community. It was observed that 80% of victims were males. The gender difference probably related to both exposure and risk taking behaviours’. Among the fractures, lower limbs (46.3%) were the commonest site for fracture, followed by fracture of upper limbs (24.7%) and skull (13.2%).6

Musculoskeletal conditions are the second greatest cause of disability globally according to a report by international experts. In the first comprehensive study of the worldwide impact of all diseases and risk factors, musculoskeletal (MSK) conditions such as arthritis and back pain affect over 1.7 billion people worldwide, and have the fourth greatest impact on the overall health of the world population, considering both death and disability. 560.978 million of people are affected by other musculoskeletal conditions. This burden has increased by 45% over the last 20 years and will continue to do so unless action is taken. This landmark study of the global burden of all diseases provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease. Musculoskeletal problems are the leading cause of physician office visits, with more than130 million visits annually, and are a leading cause of disability. As a result of these concerns; the World Health organization initiated the Bone and joint Decade in 2000.7

Road traffic injuries (RTIs) result in death of more than 100,000 people and hospitalization of 1.5 million people in India resulting in an estimated economic loss of 3% of GDP for the country.6 Globally, RTIs contribute for over 1.2 million deaths and more than 50 million hospitalizations .. The morbidity as measured by estimated to be 38 million for the year 2004. It is estimated that nearly 1/3 of disabilities are due to RTI injuries in India and 25 – 30% of these are due to RTIs .7

In a sample of 30,554 subjects in Delhi, Verma and Tiwari reported that 31% of injuries were due to RTIs. In a study of 10,459 persons in Hyderabad Disability rate due to RTI was found to be 35 / 1,00,000 .7 According to National Crime Records Bureau, 1,52,689 persons died due to road transport accidents in India in 2009 .Among them, 1,26,896 persons died due to road accidents and 1516 persons due to rail road accidents. RTIs accounted for 36% of total accidental deaths in India in 2009. In the same year, 4, 70,941 persons were injured in transport accidents. The RTI mortality rate in India for 2009 was 110 / million population per year. 6

According to a WHO report, 4.4 lakh Indians suffer from hip fractures annually while osteoporosis patients number 26 million now, that is projected to increase to 36 million by 2013. For every man, three women suffer hip fractures every year in India. By 2020, India is estimated to record 6 lakh hip fractures annually a number that is expected to increase to a million in 2050.8

A study conducted in developing countries states that road traffic injuries are the 9th leading cause of disability adjusted life years in the world, are projected to rank 3rd by the year 2020 and 90% occur in developing countries. Road traffic injuries result in death of more than 100,000 people and hospitalization of 1.5 million people in India resulting in an estimated economic loss of 3% of GDP for the country.6

Prolonged bed rest and immobilization inevitably lead to complications. Such complications are much easier to prevent than to treat. Research studies in relation to complication of immobilization are conducted more often in western countries, but have not gained importance as a major health problem in India. Immobilization and 8bed rest contribute to the following complications; deep vein thrombosis, joint contractures, muscle atrophy, pulmonary embolism, kidney stone formation, urinary stasis etc.4

The risk of venous thromboembolism is particularly great after reconstructive hip surgery. The incidence of deep vein thrombosis is 45%-70%. About 20% of patients with deep vein thrombosis develop pulmonary embolism. Therefore measures to promote circulation and decrease venous stasis are priorities for the patient, to perform ankle and foot exercises hourly while awake.4

Exercise is a type of physical activity defined as a planned, structured and repetitive bodily movements performed to improve or maintain one or more components of physical fitness. In general, regular exercise is essential for maintaining mental and physical health. Exercise increases joint flexibility, stability, and range of motion. Patients with a fracture who are confined to bed should do full range of motion exercises for all unaffected joints daily to maintain joint function. The range of motion exercises refers to deliberate active, passive and active assisted maximum movement of a joint that is possible for that joint. Range of motion exercises varies from person to person and is determined by the amount of physical activity in which the person normally engages.9 Range of motion exercises help to prevent muscle atrophy and maintain strength and joint function, it also helps to prevent the development of joint contractures that limit mobility. Without exercise the patient will lose muscle mass and strength and rehabilitation will be greatly prolonged.4

A randomized controlled trial conducted on 31 hip osteoarthritis (OA) patients to determine the effectiveness of exercise therapy (ET) compare a ET with adjunctive manual therapy (MT) for people with hip osteoarthritis (OA); and to identify if immediate commencement of treatment (ET or ET+MT) was more beneficial than a 9-week waiting period for either intervention .Control group participants were rerandomized into either ET or ET+MT, control groups after 9 week follow-up. The results showed that improvements occurred in both treatment groups compared with the control group. The investigator concluded that Self-reported function, hip ROM, and patient-perceived improvement occurred after an 8-week program of ET for patients with OA of the hip. MT as an adjunct to exercise provided no further benefit, except for higher patient satisfaction with outcome.10

During clinical posting, the investigator felt that education regarding range of motion exercises among restricted mobile patients in orthopedic wards is important while planning patient care. Many orthopedic patients were found to have inadequate knowledge regarding range of motion exercises and most of them suffer with complications. After conducting review of related literature and getting suggestion from the experts, the investigator has decided to conduct this study in an attempt to improve knowledge and practice of orthopedic patients regarding range of motion exercises with the help of a video assisted teaching programme. Thus the patients are able to prevent complications arising due to treatment imposed restricted mobility.

6.2 REVIEW OF LITERATURE

“Literature review is a critical summary of research on a topic of interest often prepared, to put a research problem in the context or as the basis for an implementation project.” Polit and Hungler

The investigator studied and reviewed the related literature to broaden the understanding and gain insight into the selected problem under study.

The literature review has been presented under the following heddings.

1. Incidence of orthopaedic problems which require admissions and morbidity of orthopaedic inpatients.

2. Complications associated with immobility among orthopaedic patients.

3. Effectiveness of exercise therapy.

4. Effectiveness of range of motion exercises.

1. Incidence of orthopaedic problems which require admissions and morbidity of orthopaedic patients.

A prospective review of data base on 8834 adults admitted to a hospital with pelvis and limb fracture between 2001-05. Results revealed that, neck of femur fractures accounted for 32% of admissions. Younger patients were more likely to be male and older patients more likely to be female. Overall 30-day and 1-year mortalities were 4.5 and 13%respectively. Increased mortality was associated with age, male gender and fractures of the femur or pelvis.11

A study conducted by a WHO scientific group on the burden of musculoskeletal conditions states that, the incidence of hip fracture being expected to exceed 6 million by 2050 in world wide. 40% of people over the age of 70 years suffer from osteoarthritis of the knee. 80% of patients with osteoarthritis have some limitation of movement.6

2. Studies related to complications associated with immobility among orthopaedic patients.

A cross sectional study was conducted to investigate Magnetic Resonance Imaging (MRI) biomarkers of muscle atrophy during cast immobilization of the lower leg among eighteen patients who had one lower leg immobilized in a cast. 3.0 Tesla (T) MR imaging was used on 5, 8, 15, 29, and 43 days after casting. Measurements were made on both lower legs of total muscle volume and were measured in tibialis anterior (TA), gastrocnemius medialis (GM) and lateralis (GL) and soleus (SOL). Analysis of the data reveals total muscle volume decreased by 17% (P < 0.001) over the 6 weeks of immobilization. The investigator concluded that, quantitative MR imaging can detect and monitor progressive biochemical and biophysical changes in muscle during immobilization content .12

A prospective randomized experimental study conducted to determine the method of mental practice, meaning the systematic repetition of a consciously imagined movement or action without simultaneous practical execution, can positively influence these findings ,on 21 right-handed males with application of a circular forearm plaster for immobilization of their left radio carpal joint, and also on , three "real" patients suffering from a distal radial fracture demanding plaster immobilization all of them were mentally treated.. It was concluded that mental practice can have a positive influence on the outcome of distal radial fractures demanding immobilization. 13

A study conducted to determine the rate of venous thrombo embolic disease in patients with a malignant neoplasm and major orthopaedic surgery of the lower limb, on 169 patients. All patients were given knee-high intermittent pneumatic compression devices for prophylaxis. Postoperative surveillance for thrombosis was performed on all patients with venous duplex Doppler ultrasonography. It was concluded that When intermittent compression boots were used for prophylaxis in conjunction with ultrasound screening, the risk of proximal DVT was substantial (14.2%), but the rate of symptomatic PE was low (0.6%).14

A multicentre study was conducted on deep venous thrombus among orthopaedic patients at New Delhi, to determine the ideal prophylaxis for deep vein thrombosis. The researcher grouped 30 patients in group 1 were not given any thromboprophylaxis while 100 patients in group 2 were put on mechanical prophylaxis. The result showed that 7 patients in group 1 developed deep vein thrombosis while no patient in group 2 had this complication. The researcher concluded that mechanical prophylaxis may be a safe tool in preventing deep vein thrombosis and nurses should provide effective educational programmes in relation to mechanical prophylaxis. 15

3. Effectiveness of exercise therapy.

A randomized controlled trial study was conducted to determine which method of mobilization—(1) standardized exercises (SE) and continuous passive motion (CPM), (2) SE and slider board (SB) therapy, that requires minimal knee active range of motion (ROM), or (3) SE alone—achieved the maximum degree of knee ROM in the first 6 months following primary total knee arthroplasty (TKA) on 120 patients. The examination consisted of measurement of knee ROM and completion of the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).  It was concluded that, when postoperative rehabilitation regimens that focus on early mobilization of the patient are used, adjunct ROM therapies (CPM and SB) that are added to daily SE sessions are not required. 16

A randomized control trial study conducted to investigate the influence of a 6-wk hamstring-stretching program on knee extension range of motion, passive resistive forces, and muscle stiffness on 43 school-age subjects. The intervention group participated in a 6-wk hamstring-stretching program. The control group did not stretch over the 6-wk intervention period. Measurements of hamstring extensibility were repeated at the end of the 6-wk intervention. The analysis of data reveals that, after the intervention period, significant (P < 0.05) increases in knee extension range of motion, passive resistive force, and stiffness were observed in the experimental group. The investigator concludes that increased stiffness in the new range of motion, gained as a result of the stretching program, provides some evidence that structural changes had occurred in the stretched muscles.17

4. Effectiveness of range of motion exercises

A randomized controlled trial study was conducted to evaluate the range- of- motion exercise programme at improving joint flexibility, activity function on 59 bedridden older stroke. Participants were randomly assigned to usual care or one of two intervention groups, and consisted of full range-of-motion exercises of the upper and lower extremities. The analysis reveals that, both intervention groups had statistically significant improvement in joint angles, activity function, compared with the usual care group (P < 0.05). joint angles in intervention group II were statistically significantly wider than in both the other groups (P < 0.01). The investigator concludes that, a simple nurse-led range-of-motion exercise programme can generate positive effects in enhancing physical function of bedridden older people with stroke.18

A Randomized controlled cohort study was conducted to determine the effect of two different postoperative therapy approaches after operative stabilization of the wrist fractures on Volunteers (N=48) with fractures of the distal radius after internal fixation with locking plates . Treatment by a physical therapist with 12 sessions and an unassisted home exercise program. The results showed that, after a 6-week period of postoperative treatment, the patients (n=23) performing an independent home exercise program using a training diary showed a significantly greater improvement of the functionality of the wrist, ROM in extension and flexion 79% (P ................
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