SYNOPSIS FOR

REGISTRATION OF SUBJECT FOR

DISSERTATION

SUBMITTED TO:

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

IN PARTIAL FULFILLMENT

OF

M.Sc (N) IN MEDICAL SURGICAL NURSING

SUBMITTED BY:

Ms. MARY REEJA PHILIP

M.Sc (N) 1ST YEAR

UNDER THE GUIDANCE OF:

Mrs. MANGAIYARKKARASI .K

ASSISTANT PROFESSOR

MEDICAL SURGICAL NURSING

NARAYANA HRUDAYALAYA COLLEGE OF NURSING

NO: 258/A, BOMMASANDRA INDUSTRIAL AREA

ANEKAL TALUK, BANGALORE-99

1 NAME OF THE CANDIDATE AND

ADDRESS

Ms. MARY REEJA PHILIP,

1ST YEAR M.Sc NURSING,

NARAYANA HRUDAYALAYA

COLLEGE OF NURSING,

#258/A BOMMASANDRA

INDUSTRIAL AREA, BANGALORE –

99.

2 NAME OF THE INSTITUTION NARAYANA HRUDAYALAYA

COLLEGE OF NURSING.

3 COURSE OF STUDY AND SUBJECT 1ST YEAR M.Sc NURSING

(MEDICAL SURGICAL NURSING)

4 DATE OF ADMISSION TO COURSE 04-06-2012

5 TITLE OF THE TOPIC EFFECTIVENESS OF BACK

MASSAGE ON REDUCING

DISABILITY AMONG ELDERLY

PATIENTS WITH CHRONIC LOW

BACK PAIN.

PROBLEM STATEMENT

A study to assess the effectiveness of back massage on reducing

disability among the elderly patients with chronic low back pain at

selected old age homes, Bangalore.

ANNEXURE - 1

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION:

“No One Cares About Your Back Like You Do.”

Aging is a universal process, which every living organism has to pass through as

a biological imperative of life. The term aged, elderly or senior citizen is used to

describe a section of human population, usually refers to a particular group of people

who have reached a certain chronological age. The old age traditionally begins at 60

years and after retirement from the services.1

Currently in the world, the elderly persons constitute about 20% of the total

population, both in the developed as well as in the developing countries like India.

The elderly population is increasing tremendously, with a current estimate of 90

million over the age of 60 in our country. Using data on health and living conditions

from the India's 60th National Sample Survey, it is observed that almost a quarter of

the elderly reported poor health.2

Low back pain is not a specific disease; rather it is a symptom that may occur

from a variety of different processes. Back pain usually occurs as either in cervical or

lumbosacral region. It can result from herniation of the nucleus pulposus in the

intervertebral disc or due to degeneration of the vertebra, or disc injury from

hyperreflexia. Herniation or injury results spinal root compression, which leads to

subsequent motor and sensory manifestations. Low back pain is a common

musculoskeletal symptom that may be either acute or chronic. Low back pain is often

accompanied by sciatica which is the pain that involves the sciatic nerve and is felt in

the lower back, the buttocks, and the backs of the thighs.3

Disability is defined as the “loss of health, where health is conceptualized in

terms of functioning capacity in a set of health domains such as mobility, cognition,

hearing and vision”.4 Considering the health status of the aged in India, 40% of the

elderly people are suffering from the locomotive disorders or musculoskeletal

disorders. As adult ages, their bodies undergo through intense changes. Muscles and

joints stiffen, sensation deteriorates, vision decreases and they become more

sedentary over time. It is seen that up to 88% of elderly suffer from chronic low back

pain making them unable to perform activities.5

If done correctly, massage therapy can work wonders for people with back pain.

Although massage is generally thought of as a complementary therapy, it is now

being acknowledged by healthcare providers as a genuine method of helping in

fighting back pain. Massage therapy should never be considered a substitute for

proper medical attention. It is a therapeutic manipulation of the soft tissues of the

body with the goal of achieving normalization of those tissues. Massage can have

mechanical, neurological, psychological and reflexive effects.6 The word comes from

the Arabic word, ‘Massa’ which means to touch, feel or handle or from the Greek

verb ‘Masso’ which means to handle, touch, to work with the hands.7

Healing through touch goes back to early civilization and is believed to be

originated in Asia 5,000 years ago. Although most cultures have developed some

types of touch therapy, attitude towards touch vary widely from culture to culture.

Touch is a form of energy therapy.8 Back massage involves the manipulation of the

soft tissue structures of the body to prevent and alleviate pain, discomfort, muscle

spasm, stress and, to promote health and wellness. Touch may stimulate the

production of healing and promoting chemicals by the immune or limbic system.9

Though the historic role of nurses has been to relieve pain and reduce disability,

there has been little understanding of the impact of disability and there are only

limited ways to manage it. The nursing interventions should be meaningful and

affordable by the elderly in terms of this aspect the study is relevant to the profession.

6.1: NEED FOR THE STUDY:

“You do not heal old age. You protect it; you promote it; you extend it.”

Sir James Sterling Ross

Ageing is worldwide phenomenon, more evident in the developed countries. It

is mainly due to reduction in overall mortality rates. Ageing population is one of the

indicators of socio-economic development of a society. However ageing population is

a matter of concern, because with ageing, there is breakdown in independence i.e. the

individual gradually becomes dependent physically, functionally, socially and

economically. According to 2001 censes old age population constitutes 7.7% of the

total population and estimated that it will be doubled by 2025.10

The health concerns among the elderly are generally not life threatening but

as the age advances, degeneration of body cells takes place especially in the

musculoskeletal system and they have significant effect on the individual’s normal

activity and productivity. Back pain is due to musculoskeletal disturbances and is

usually aggravated by activity. People with chronic low back pain may develop a

dependence on alcohol or analgesics. Commonly musculoskeletal disorders are the

autoimmune disorders that are manifested by joint pain, back pain, neck pain, calf

pain etc., and these are the most common cause of severe long term pain and physical

disability affecting hundreds of millions of people around the world.3

The number of people with disabilities is increasing due to population

growth, ageing, emergence of chronic diseases and medical advances that preserve

and prolong life, creating a major health concern. Disability is not a characteristic of

the individual per se but rather of the intersection between the individual and their

environment, and the potential of therapeutic environments to maintain or increase

quality of life for older adults.11

An interview conducted by Gurpreet Singh et al (2008) to identify the

severity of disability among 300 patients with chronic low back pain. Among these

were 149 males and 151 females, aged 40-65 years. The study indicated that there is

gradual increase in the pain score with the progressing age in both the sex and that the

prevalence of the low back pain is 60% in India.12

In order to understand the benefits and effects of massage, it is important to

consider how the body responds physiologically. Basically, massage involves two

types of responses (i.e) mechanical responses as a result of pressure and movement as

the soft tissues are manipulated and reflex responses in which the nerves respond to

stimulation. It helps to free adhesions, break down scar tissue and decrease

inflammation. As a result it can help to restore range of motion to stiff joints.

Massage improves muscle tone and balance, reducing the physical stress placed on

bones and joints thereby reducing disability which can have a significant effect on

their general health and well being.13

More recently, a study published by the National Center for Complementary

and Alternative Medicine in 2012 found that massage was the ninth most popular

form of alternative medicine in the country, with an estimated 5 percent of the adult

American population using massage therapy at least once in the past 12 months.14

Based on the above information, the researcher analyzed that the elderly is

vulnerable to experience chronic low back pain and thereby indirectly affecting their

ability to do their activities of daily living and making them disable. A simple

intervention like back massage can bring about a great deal of change in the life of the

elderly by enhancing their comfort and thereby improving their sense of

independence and quality of life and improving the well being. Hence the researcher

felt the need to assess the disability among the elderly and to evaluate the effect of

back massage on reducing the disability among them.

6.2: REVIEW OF LITERATURE:

Review of literature is an integral component of research process. It enhances the

depth of knowledge and inspires a clear insight into crux of problem. It helps the

researcher to know what data are available to narrow the problem itself as well as the

technique that might be used.15

Review of literature for this study is divided under following headings:

Chronic low back pain causing disability among elderly.

Effect of back massage on pain.

SECTION A: REVIEW OF LITERATURE ON CHRONIC LOW BACK PAIN

CAUSING DISABILITY IN ELDERLY PATIENTS.

A study was done to assess the prevalence and functional correlates of low back

pain at the rural parts of United States by surveying 3097 rural persons of the age 65

years and older. The low back pain was reported by 23.6% women and 18.4% men.

The functional limitation with walking, sitting, bending over, and performing

household chores was reported by 15-40% and 21% reported sleep disturbances

due to the low back pain and nearly 75% of subjects with low back pain reported first

onset of the problem prior to the age of 65 years. The researcher concluded that the

functional burden of low back pain is substantial though the prevalence rate is

declining with age and requires the evaluation of risk factors and its impact on

health.16

A descriptive study was conducted to identify the prevalence of pain and

persistent pain among elderly at France. Out of the 741 subjects, 530 (71.5%)

reported pain somewhere, 244 (32.9%) reported persistent pain (daily pain for more

than 6 months) and 241 subjects (32.5%) reported episodic pain. The prevalence of

pain was 44.5% for limb joints, 29.6% for lower back, 11.6% for neck and 11.3% for

limbs (joints expected).The prevalence of persistent was 19% for limb joints, 12% for

back and 10.4% for limbs (joints expected).The researcher concluded that the

frequency of persistent pain increased slightly with age in both the sexes but was

higher in women and the prevalence of episodic pain was statistically higher in men

over 75 years. Thus the study found that the persistent pain is an important health

problem in elderly people.17

A 7 year research project was conducted in Jerusalem to assess the prevalence,

nature and predictors of chronic back pain among the older people. 277 subjects aged

70 years at the beginning of the study were considered. The study found that the

prevalence of chronic back pain increased from 44% to 58% at ages 70 & 77years

respectively and the frequency and severity decreased. The females with economic

difficulty, loneliness, and fatigue, or self rated health, dependence in activities of

daily living, joint pain and obesity were more associated with chronic back pain. The

predictors of chronic back pain at age 77 years included female gender, loneliness,

joint pain, hypertension and pre existing chronic back pain. The researcher concluded

that the chronic back pain is increasingly common in elderly and the psychological

factors, female gender, hypertension and existing joint pain identify individuals most

at risk.18

A study was conducted in Sweden to analyze if pain increases or decreases with

age among the oldest age group and to study the gender difference regarding pain.

The study comprising of 537 samples of 77 years and above. The study showed that

there is some evidence of decreased musculoskeletal pain with the age and among

women the pain decreases with age and among men, there is an increase in severe

pain with age. The prevalence of mild and severe pain on one part of the body was

73% among the samples above the age of 77 and for the samples above the age of 85

years, the prevalence was 68%. Nearly 47% of samples above 77 years reported

multiple pain and 46% of samples over the age of 85 years complaints of the same.

The researcher concluded that there is gender difference in pain and it directly implies

with the severity of the pain.19

The University of Iowa studied the prevalence and nature of pain on a

population of 3097 rural persons with 65 years of age. Among them nearly 86%

reported pain in the year prior to the interview and 59% reported multiple pain

complaints. The researcher concluded that joint were the most prevalent site of pain

followed by back pain, leg pain and the increasing severity of pain had corresponding

increase in hindering the activities of daily life.20

SECTION B: REVIEW OF LITERATURE ON THE EFFECTS OF MASSAGE

ON PAIN.

According to the American Massage Therapy Association (AMTA),

therapeutic massage has been found to foster peace of mind, promote a relaxed state

of mental alertness, help relieve mental stress, improve ability to monitor stress

signals and respond appropriately, reduce levels of anxiety, and increase awareness of

mind and body connection. The elderly population is more prone to develop low back

pain as a result of which they become unable to perform activities. Massage can be a

complementary therapy to reduce the tension and also to make them enable to do

things.21

The back massage helps in improving blood circulation and lymph flow. It

helps to carry nutrients to cells and remove impurities and toxic substances from the

stressed body by making it free of stress. Back massage also increases the ability of

blood to carry oxygen. In fact it is known that massage helps increase red blood cells

and white blood cells which fight with infection.22

A pilot study was conducted in Germany to compare the effectiveness of

classical massage to the standard medical care among 29 patients experiencing

chronic back pain. 19 among them received the massage and 10 patients received the

standard medical care. The effectiveness of massage during pre-treatment and post

treatment period and after three month was observed. The study shows that the

massage is effective when compared to the standard medical care during the follow

up.23

A study was conducted to find the effectiveness of slow stroke back massage

on anxiety and shoulder pain among 102 elderly stroke patients. The pain score,

anxiety, blood pressure and heart rate were assessed before, immediately after the

intervention and 3 days after later. The massage therapy continued for seven

consecutive days with 10 minutes of duration each day. The study showed that the

massage intervention reduced the pain and anxiety and the vital parameters indicated

relaxation suggesting the researcher that the massage therapy can be implemented as

an effective nursing intervention.24

An experimental study was conducted to determine the effectiveness of

massage therapy on reducing pain and anxiety among 113 patients who had

undergone cardiac surgery. The visual analogue scale and the vital parameters were

assessed before and after the interventions on post operative day 2 and 4.The study

resulted that the pain score thereby limiting the vital parameters within the normal

range. The researcher concluded that the massage therapy is effective and is most

feasible when compared to the other complimentary therapies.25

A study was conducted to compare the effectiveness of massage therapy and

progressive muscle relaxation therapy among 24 adults who were randomly assigned

to either group with low back pain with duration of 6 months. The therapy lasted 30

minutes, twice a week for continuous 5 weeks. The study proved that the samples

who received the massage experienced less pain; depression, anxiety and improved

sleep and they also improved the trunk and plantar flexion.26

6.3: OBJECTIVES OF THE STUDY:

1. To assess the level of disability by using modified Quebec pain disability

scale among elderly patients with chronic low back pain.

2. To assess the effectiveness of back massage on reducing disability among

patients with chronic low back pain.

3. To find an association between the pre interventional level of disability with

the selected demographic variables.

6.4: ASSUMPTIONS:

1. Back massage promotes a sense of well being to the elderly patients.

2. Back massage improves the range of motion among the elderly

patients.

6.5: HYPOTHESES:

H1 : There will be significant difference in the disability level before and after

back massage.

H2 : There will be significant association between pre interventional level of

disability and selected demographic variables in elderly patients with chronic low

back pain .

6.6: OPERATIONAL DEFINITION:

1. EFFECTIVENESS: It refers to the reduction of disability level among the

elderly population after back massage. It is measured in terms of modified

Quebec back pain disability scale.

2. DISABILITY: It is defined as the condition of the person who has physical

impairment that has substantial and long term adverse effect on his or her

ability to carry out normal day to day activities. The score of 50 and above in

the modified Quebec back pain disability scale is considered as a person with

disability.

3. BACK MASSAGE: It is defined as the scientific manipulation of the soft

tissues of the body, consisting of manual technique such as applying fixed

pressure, holding and moving muscles and body tissues by efflurage ,

petrissage ,friction and treatment.

4. LOW BACK PAIN: Low back pain is defined as pain localized between the

12th vertebrae and the inferior gluteal fold of the elderly patients. In this study,

the pain is assessed by the modified Quebec back pain disability scale.

5. ELDERLY PATIENTS: It refers to the patients who are above 60 years old.

In this study, it refers to the male and female people who are above the age of

60 years and are disabling as per the score with modified Quebec back pain

disability scale.

6.7 DELIMITATIONS

1. The study is limited to patients who are willing to participate.

2. The duration of the study is only for a period of six weeks.

3. Generalization of the finding will be limited to the population studied.

ANNEXURE – 2

7. MATERIALS AND METHODS:

7.1 Sources of data

Elderly patients residing in old age homes in Bangalore.

7.2 Research Methodology

7.2.1 Research Approach: A quantitative approach.

7.2.2 Research design: The research design adopted for the study will be a true

experimental design comprising of pre test-post test with control group

design.

7.2.3 Sample: Sample size: total samples will be 60 will be selected, with

……… 30 samples as control group and 30 as experimental group.

7.2.4 Sampling technique: Simple Random Sampling Technique.

7.2.5 Sampling criteria

Inclusion criteria:

Elderly adults with chronic low back pain and are disable as per the

modified Quebec disability scale.

Elderly adults above 60 years of age.

Elderly adults who are willing to participate in the study.

Exclusion criteria:

Elderly adults who are diagnosed with degenerative disk

prolaspse,ruptured disk, sciatica and Interverterbral Disk Prolapse and

have underwent recent spine surgeries.

Elderly adults who are unconscious and critically ill.

7.2.6 Variables:

Independent variable: Back massage.

Dependent variable: Disability due to chronic low back pain.

7.2.7 Setting:

The study will be conducted among elderly patients at selected old age homes, Banaglore.

7.2.8 Data collection technique

Description of the tool:

Section A : Demographic variables - Age, gender, marital status,

education, habits, occupation, previous history of hospitalization, family

history of any diseases, duration of any illness, type of treatment undergoing.

Section B: The modified Quebec back pain disability scale.

Interventional protocol:

i. Get informed consent from the patient.

ii. Assess the level of disability by modified Quebec back pain disability scale.

iii. Apply liquid paraffin as an emollient and provide back massage for 30

minutes each day for 10 consecutive days.

iv. The intervention will be discontinued if the patient develops any discomfort.

Data collection procedure:

i. Obtain formal administrative permission.

ii. Patients meeting the inclusion criteria will be randomly selected

iii. Obtain informed consent.

iv. Assess the level of disability using the modified Quebec back pain disability

scale.

v. Provide back massage to experimental group and comfort devices for the

control group respectively for 30 minutes each day for the 10 consecutive

days.

vi. Assess the level of disability in both experimental group and control group

with modified Quebec back pain disability scale after 10 days.

7.2.9 Data analysis: Data obtained will be analyzed in terms of objectives. Plan for

. data analysis include descriptive and inferential statistics.

1. Descriptive statistics

Frequency and percentage distribution will be used to describe the

demographic variables.

Mean and standard deviation will be used to assess the level of disability.

2. Inferential statistics

Paired t test will be used to compare the pre and post level of disability among

elderly patients with chronic low back pain.

Chi-square test will be used to associate the level of disability.

7.3. Does the study require any investigation or interventions to be conducted

on patients or other humans or animals? If so, please describe briefly.

Yes, it requires intervention (back massage) on elderly patients with chronic

low back pain.

The pre interventional disability score will be assessed with modified Quebec back

pain disability scale. After applying the emollient, the back massage is provided for

30 minutes for 10 consecutive days and later on the 10 th day the disability level is

assessed using the modified Quebec back pain disability scale. Discontinuation of the

therapy will be done if patient experiences any discomfort.

7.4 Has ethical clearance been obtained from your Institution?

Ethical clearance is obtained from the Institution.

9. Signature of Candidate

10. Remarks of the Guide

11. Name & Designation of

a. Guide : Mrs. MANGAIYARKKARASI . K

Assistant Professor,

Medical surgical Nursing,

Narayana Hrudayalaya College of Nursing.

b. Signature :

c. Co-Guide (if any) :

d. Signature :

e. Head of Department : Mrs. Padmapriya Head of the Department, Medical Surgical Nursing. Narayana Hrudayalaya College of Nursing.

f. Signature :

12. 12.1 Remarks of the Chairman & Principal

12.2 Signature

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