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.

Prashma

Government College of Nursing, Hassan, Karnataka (RGUHS)

*Corresponding Author Email: Prashma1989@gmail.com

ABSTRACT:

Background and Objectives: Musculoskeletal problems affect hundreds of millions of people worldwide. Fractures account for a high percentage of traumatic injuries. An average of approximately 50% of the hospitalized individuals has mobility impairment. Prolonged immobilization and bed rest contribute to complications like joint stiffness which may lead to joint contracture, ligament tightening and limitation of function etc. To offset these complications associated with prolonged immobility, specific activity is required. Activities that the patient should include are range of motion exercises of unaffected joints. This study is aimed to assess the existing Knowledge and Practice regarding range of motion exercises, evaluate the effectiveness of VATP, find the correlation between Post test Knowledge and Practice scores and to find the association between the Post test Knowledge and Practice scores and demographic variables of restricted mobile patients.

Methods: An evaluative approach with one group Pre-test Post-test Pre- experimental design was used with purposive sampling technique to select the study sample (N=50) from orthopedic wards at SC hospital, Hassan. Data was collected by using structured interview schedule and observation checklist and analyzed by using descriptive and inferential statistical techniques.

Results: The data analysis revealed that the mean % of Post test Knowledge score (87.2%) was higher than that of Pre test Knowledge score (27.0%). The calculated paired ‘t’ test value (t= 24.71*) is greater than table value (p<0.05, 49df). Followed by the mean % of Post test Practice score (94.8%) was higher than that of Pre test Practice score (5.9%). The calculated paired ‘t’ test value (t= 59.87*) is greater than table value (p<0.05, 49df) which is suggestive of significance difference between mean Pre test and Post test Knowledge and Practice score. There exists a positive relationship between Knowledge and Practice (Correlation Coefficient = +0.768*) at 0.05 level of significance. Calculated χ² value revealed significance association between age group and type of family of respondents and with their Post test Knowledge level and calculated χ² value revealed significance association between gender of respondents and with their Post test Practice level.

Interpretation and Conclusion: The study concluded that the VATP regarding range of motion exercises was an effective method of enhancing the Knowledge and Practice of restricted mobile patients and this helped in the improvement of quality of life.

KEYWORDS: Effectiveness; VATP; Knowledge; Practice; Range of motion exercises; Restricted mobile patients.

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. 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. ^{1, 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

BACKGROUND OF THE STUDY:

An average of approximately 50% of the hospitalized individuals has mobility impairment. Immobilization and inactivity are frequently present in patient with involvement of musculoskeletal and neurological systems and also among critically ill patients. An immobilized individual is at a greater risk of developing complications. Patients on the orthopedic service are almost immobilized due to fracture, RTA, or surgery either for short duration or for extended period of time which ultimately leads to complications like deep vein thrombosis, pulmonary embolism, pneumonia, calculi, and pressure ulcer. ³

More recent researches by the National Aeronautics and Space Administration (NASA) produced additional evidence for the damaging effects of prolonged inactivity and immobility. Like muscle, bone is living tissue that responds to exercise by becoming stronger. Those who exercise regularly generally have greater bone mass (bone density and strength) than those who do not. Although weight-bearing activities contribute to the development and maintenance of bone mass, weightlessness and immobility can result in bone loss. ⁴

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.⁵

The effects of muscular deconditioning associated with lack of physical activity may be apparent in a matter of days. The normal individual on bed rest loses muscle strength form baseline levels at a rate 3% a day. The term disuse atrophy has been used to describe the pathological reduction in normal size of muscle fibers after prolonged inactivity form bed rest, trauma, and casting or local nerve damage .⁷

Since the hospital stay of fracture patients is prolonged, the chances of developing possible complications high. 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.^{8, 10}

Bone has a capability to repair itself when it is fractured. But due to unawareness among patients about infection control, proper diet, mobilization, exercise and proper weight bearing, most of the patients land into several complications. This will cause economic loss among them by extending hospital stay. And in some of the cases there requires longer time to heal which will cause increased psychological stress among patients .⁵

Limited mobility itself has been found to be a major contribution in hampering a patient’s recovery. In terms of morbidity and mortality the consequences of morbidity are legion. Awareness, Exercises, scrupulous nursing care and early rehabilitation, interventions can prevent or minimize most of these complications without pacing the patients in jeopardy .³

To offset these complications associated with prolonged immobility, specific activity is required. Activities that the patient should include are range of motion exercises of unaffected joints.Every joint that is not immobilized should be exercised and moved through its range of motion to maintain function.^{1, 9, 6}

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.⁶

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%).¹¹

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 2000.¹²

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 2050.¹⁰

A study was conducted in between May 2001 and May 2005, where all 8834 adults admitted to hospital with fractures to the lower limbs and pelvis were prospectively entered onto a database. 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.¹³

A study conducted in developing countries states that road traffic injuries are the 9^th leading cause of disability adjusted life years in the world, are projected to rank 3^rd 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.¹¹

Some people can't perform weight-bearing activity. They include, for example, people who are on prolonged bed rest because of surgery, serious illness, or complications of pregnancy; and those who are experiencing immobilization of some part of the body because of stroke, fracture, spinal cord injury, or other chronic conditions. These people often experience a significant bone loss and are at high risk for developing complications like deep vein thrombosis, constipation, osteoporosis, etc. It is suggested that there is a good chance to fully recover the lost bone if the immobilization period is limited to 5 to 8 weeks.⁹

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 bed rest contribute to the following complications; deep vein thrombosis, joint contractures, muscle atrophy, pulmonary embolism, kidney stone formation, urinary stasis etc.⁶

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.⁶

Studies have shown thatprolonged immobilization can promote urinary stasis or stagnation in the flow of urine from the kidneys to the bladder and thus leads to infection. Prolonged immobility also causes an increase of minerals and salts to circulate in the blood that can promote the formation of kidney stone. ¹⁴

The immobility leads to limited movement of chest wall and it cause collection of secretions, creation of dead spaces in the lung and collapse of alveoli can leads to stasis, pneumonia, pneumothorax and oxygen carbon dioxide imbalance. A study conducted by Goldhil Dr (2007) on Rotational bed therapy to prevent and treat respiratory complications. In this study he stated as the usual control to prevent and treat the respiratory complications were turning the patient by nurse every 2hrs.¹⁵

A prospective observational study conducted on frequency and turn in orthopedic immobilised patients. In the study the research considered 40 British orthopedic units and analyzed 393 samples. Patients were on back for 46.1% turned left for 28.4% and right for 25.5% and head up for 97.4%. In this study he defined a turn as change between on back, turn left and right. The average time between turn was 4.85 (3.3) h. The study was concluded as there was significant difference between with which the patients were turned.¹⁶

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.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.^{17, 6}

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.¹⁸

The injury to pelvic and leg vein as a result or trauma during surgical repair prompt activation of coagulation and prolonged immobility combined to produce a profound hyper coagulable state in pelvic and other orthepaedic trauma patients. The incidence of deep vein thrombosis in patients with pelvic fracture is 35% - 60% with proximal thrombosis occurring in 25-35% of this population. Range of motion exercise prevents the formation of thrombi. Activity causes contraction of skeletal muscles, which in turn exerts pressure on veins to promote venous return and thereby reducing venous stasis.¹⁹

STATEMENT OF THE PROBLEM:

“A study to evaluate the 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”.

OBJECTIVES OF THE STUDY:

1) To assess the existing Knowledge and Practice regarding range of motion exercises among restricted mobile patients in orthopaedic wards at SC hospital Hassan.

2) To evaluate the 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.

3) To find the correlation between Post-Test Knowledge and Practice scores of restricted mobile patients in orthopaedic wards at SC hospital Hassan.

4) To find the association between the Post-Test Knowledge and Practice scores of restricted mobile patients and their selected demographic variables.

Hypotheses:

H1: There will be a significant difference between mean Pre-test and Post-test Knowledge scores of restricted mobile patients.

H2: There will be a significant difference between mean Pre-test and Post-test Practice scores of restricted mobile patients.

H3: There will be a significant correlation between Post-test Knowledge and Practice scores of restricted mobile patients.

H4: There will be a significant association between Post-test Knowledge scores and their selected demographic variables of restricted mobile patients.

H5: There will be a significant association between Post-test Practice scores and

their selected demographic variables of restricted mobile patients.

Variables:

(a) Independent variable: Video Assisted Teaching Programme regarding range of motion exercises.

(b) Dependent variable: Knowledge and Practice of restricted mobile patients regarding range of motion exercises.

(c) Extraneous variables: Demographic variables of restricted mobile patients Viz. Age, gender, religion, marital status, type of family, educational qualification, occupation, family income, duration of hospitalization, previous source of information.

Operational definitions:

a) Effectiveness: Effectiveness refers to a measure of the ability of Video Assisted Teaching Programme regarding range of motion exercises to enhance the Knowledge and Practice of restricted mobile patients that can be quantitatively measured.

b) Video Assisted Teaching Programme: It refers to a planned Video Assisted Teaching Programme in Kannada language for 30 minutes, regarding importance and benefits of range of motion exercises among restricted mobile patients, indications for range of motion exercises, performance of range of motion exercises of unaffected joints of restricted mobile patients and precautionary measures to be taken during the performance of range of motion exercises.

c) Knowledge: It refers to the ability of respondents to give correct responses to the questions in the structured interview schedule.

d) Practice: It refers to the scores obtained by the restricted mobile patients while performing range of motion exercises of unaffected joints as measured by structured observation check list.

e) Restricted mobile patients: Refer to the adult patients who are admitted in the orthopaedic wards at SC hospital with fracture and under treatment imposed restricted mobility.

f) Range of motion exercises: They refer to exercises that can be performed either actively, active assistedly and passively, to improve the movements that move and stretch a specific joint through the fullest range of movement of which the joint is capable, which are influenced by several structures, configuration of bone surfaces within the joint, joint capsule, ligaments, tendons, and muscles acting on the joint.

Assumptions:

1) Restricted mobile patients may have some Knowledge regarding range of motion exercises.

2) Restricted mobile patients may be willing to express and also to improve their Knowledge and Practice regarding range of motion exercises.

3) Increased level of Knowledge and improved Practice of range of motion exercises among restricted mobile patients in orthopaedic wards may help them to improve their quality of life.

Delimitations:

1. Study is delimited to 50 restricted mobile patients in orthopaedic wards at SC hospital Hassan.

RESEARCH METHODOLOGY:

Research Approach:

An quantitative evaluative approach was considered as appropriate research approach for the present study.

Research Design:

The research design adopted for the present study is one group Pre-test and Post-test Pre-experimental design.

Setting of the study:

This study was conducted at SC hospital, Hassan.

Population:

The population of the study is restricted mobile patients in orthopaedic wards at SC hospital, Hassan.

Sample and sampling technique:

The sample for the study comprised of 50 restricted mobile patients in orthopaedic wards at SC hospital, Hassan. Purposive sampling technique was used to draw the samples.

Data collection method

Sampling criteria

Inclusion criteria for sampling:

1. Restricted mobile patients who are admitted in orthopaedic wards at SC hospital, Hassan.

2. Restricted mobile patients who are present at the time of data collection.

3. Restricted mobile patients who are willing to participate in the study.

Exclusion criteria for sampling:

1. Restricted mobile patients who are not able to understand Kannada.

2. Restricted mobile patients who are critically ill at the time of study.

Description of the Tool:

The tool used in this study consists of two parts;

Part-I: consisted of 10 items related to demographic data of the subjects such as age, gender, religion, marital status, type of family, educational qualification, occupation, family monthly income, duration of hospitalization and previous exposure to information regarding range of motion exercises.

Part-II: Consisted of section-A and section-B.

Section-A: Structured interview schedule consisted of 45 items on knowledge regarding range of motion exercises. It consists of three aspects;

ASPECT-I: Knowledge regarding anatomy and physiology, immobility.

ASPECT-II: Knowledge regarding exercises for immobility patients.

ASPECT-III: Knowledge regarding range of motion exercise.

Section-B: Observation Checklist consists of 53 items on practice of restricted mobile patients regarding range of motion exercises.

RESULT:

The data is analyzed and presented under the following headings.

Section 1: Analysis of demographic characteristics of respondents under study.

Section 2: Analysis of Pre-test and Post-test scores and effectiveness of Video Assisted Teaching Programme.

a) Analysis of Pre-test Knowledge and Practice scores.

b) Analysis of Post-test Knowledge and Practice scores.

c) Effectiveness of Video Assisted Teaching Programme on Knowledge and Practice scores.

Section 3: Correlation between the Post test Knowledge and Practice on range of motion exercises among restricted mobile patients.

Section 4: Analysis of association between demographic variables with Post-test Knowledge scores of restricted mobile patients.

Section 5: Analysis of association between demographic variables with Post-test Practice scores of restricted mobile patients.

Section I: Demographic characteristics

This section describes the respondent’s characteristic in terms of frequency and percentage and is depicted in Table 1.

Table 1: Frequency and Percentage distribution of respondents by Personal Characteristics. N=50

Characteristics	Category	Respondents
Characteristics	Category	Number	Percentage (%)
Age group (years)	20-40	22	44.0
Age group (years)	41-60	28	56.0
Gender	Male	31	62.0
Gender	Female	19	38.0
Religion	Hindu	48	96.0
Religion	Muslim	2	4.0
Marital status	Married	41	82.0
	Unmarried	4	8.0
	Widow/ Widower	5	10.0
Type of family	Nuclear	15	30.0
Type of family	Joint	35	70.0
Educational qualification	Illiterate	38	76.0
Educational qualification	Primary	12	24.0
Occupation	Labourer	41	82.0
	Private	4	8.0
	House wife	5	10.0
Family income/month	Below Rs.5,000	42	84.0
Family income/month	Rs.5,001-10,000	8	16.0
Duration of Hospitalization (Days)	6-15	21	42.0
	16-20	15	30.0
	21-30	14	28.0
Previous exposure to Range of Motion exercise	Electronic media	10	20.0
	Health personnel	33	66.0
	Family members/ Relatives	7	14.0
Total		50	100.0

The data in Table 1 depicts the frequency and percentage distribution of the Respondents by Personal Characteristics .

Table 4: Aspect wise mean Pre test and Post test Knowledge scores regarding Range of motion exercises among stricted Mobile patients. N = 50

No.	Knowledge Aspects	Respondents Knowledge (%)						Paired ‘t’ Test
		Pre test		Post test		Enhancement
		Mean	SD	Mean	SD	Mean	SD
I	Anatomy and Physiology, Immobility	25.1	17.0	93.6	12.4	68.4	18.6	26.00*
II	Exercise for Immobility Patients	28.5	18.4	83.8	14.2	55.3	22.5	17.38*
III	Range of motion exercise	27.2	16.0	86.1	9.9	58.9	18.6	22.39*
	Overall	27.0	14.5	87.2	10.0	60.1	17.2	24.71*

* Significant at 5% level; t (0.05, 49df) = 1.96

Figure.1: Aspect wise Pre test and Post test Knowledge on Range of motion exercise among restricted Mobile patients

Table 5: Classification of Respondents on Pre test Practice level on Range of motion exercises N=50

Practice Level	Category	Respondents
Practice Level	Category	Number	Percent
Low	≤ 50 % Score	50	100.0
Moderate	51-75 % Score	0	0.0
High	> 75 % Score	0	0.0
Total		50	100.0

Table 6: Aspect wise Mean Pre test Practice scores of Respondents on Range of Motion exercise N=50

No.	Practice Aspects	Statements	Max. Score	Respondents Practice
No.	Practice Aspects	Statements	Max. Score	Mean	SD	Mean (%)	SD (%)
I	Practice of neck and shoulder range of motion exercises	13	13	3.14	3.9	6.9	6.6
II	Practice of elbow and wrist range of motion exercises	9	9	1.11	0.8	11.5	9.9
III	Practice of hands, fingers and thumb range of motion exercises	10	10	1.36	1.1	13.6	11.5
IV	Practice of hip and knee range of motion exercises	10	10	1.34	1.2	13.4	12.0
V	Practice of ankle and foot range of motion exercises	4	4	0.65	0.6	15.0	16.4
VI	Practice of toe and trunk range of motion exercises	7	7	0.84	0.9	12.0	13.1
	Combined	53	53	3.14	3.9	5.9	7.3

Table 9: Aspect wise Mean Post test Knowledge scores of Respondents on range of Motion exercise N=50

No.	Knowledge Aspects	Statements	Max. Score	Respondents Knowledge
No.	Knowledge Aspects	Statements	Max. Score	Mean	SD	Mean (%)	SD (%)
I	Anatomy and Physiology, Immobility	9	9	8.42	1.1	93.6	12.4
II	Exercises for Immobility Patients	8	8	6.70	1.1	83.8	14.2
III	Range of motion exercise	28	28	24.10	2.8	86.1	9.9
	Combined	45	45	39.22	4.5	87.2	10.0

Table 10: Classification of Respondents on Post test Practice level on Range of motion exercises

Practice Level	Category	Respondents
Practice Level	Category	Number	Percent
Low	≤ 50 % Score	0	0.0
Moderate	51-75 % Score	0	0.0
High	> 75 % Score	50	100.0
Total		50	100.0

Table 11: Aspect wise Mean Post test Practice scores of Respondents on range of Motion exercise. N=50

No.	Practice Aspects	Statements	Max. Score	Respondents Practice
No.	Practice Aspects	Statements	Max. Score	Mean	SD	Mean (%)	SD (%)
I	Practice of neck and shoulder range of motion exercises	13	13	11.54	4.4	88.7	16.0
II	Practice of elbow and wrist range of motion exercises	9	9	8.16	3.5	90.6	8.4
III	Practice of hands, fingers and thumb range of motion exercises	10	10	9.42	1.1	94.2	11.5
IV	Practice of hip and knee range of motion exercises	10	10	8.86	1.1	88.6	11.7
V	Practice of ankle and foot range of motion exercises	4	4	3.52	0.6	87.5	15.2
VI	Practice of toe and trunk range of motion exercises	7	7	6.42	0.8	91.7	11.7
	Combined	53	53	50.24	3.0	94.8	5.7

Table 11 depicts the aspect wise mean Post test Practice on range of motion exercises among restricted mobile patients. (Fig.3)

Figure.3: Aspect wise Post test mean Practice scores of respondents on Range of motion exercises

Table12: Over all Pre test and Post test Knowledge scores on Range of motion exercise among restricted Mobile patients. N=50

Aspects	Max. Score	Respondents Knowledge				Paired ‘t’ Test Value
Aspects	Max. Score	Mean	SD	Mean (%)	SD (%)	Paired ‘t’ Test Value
Pre test	45	12.16	6.5	27.0	14.5	24.71*
Post test	45	39.22	4.5	87.2	10.0	24.71*
Enhancement	45	27.06	7.7	60.1	17.2

* Significant at 5% level, t (0.05, 49df) = 1.96

Table 15: Classification of Respondents on Pre-test and Post-test Practice level on range of motion exercise

Practice Level	Category	Classification of Respondents				Χ ² Value
		Pre test		Post test
		Number	Percentage	Number	Percentage
Low	≤ 50 % Score	50	100.0	0	0.0	100.00*
Moderate	51-75 % Score	0	0.0	0	0.0
High	> 75 % Score	0	0.0	50	100.0
Total		50	100.0	50	100.0

* Significant at 5% level, χ² (0.05, 1df) = 3.841

Table16: Correlation between Post test Knowledge and Practice scores on Range of Motion exercises among restricted Mobile patients N=50

Aspects	Max. Score	Response				Correlation coefficient (r)
Aspects	Max. Score	Mean	SD	Mean (%)	SD (%)	Correlation coefficient (r)
Knowledge	45	39.22	4.5	87.2	10.0	+ 0.768*
Practice	53	50.24	3.0	94.8	5.7	+ 0.768*

*Significant at 5% level,

Table17: Association between selected demographic variables and Post test Knowledge level on Range of Motion exercises patients N=50

Demographic Variables	Category	Sample	Knowledge Level				Χ ² Value	P Value
			< Median		>Median
			N	%	N	%
Age group (years)	20-40	22	2	9.0	20	90.9	4.32*	P<0.05 (3.84,1df)
Age group (years)	41-60	28	11	39.2	17	60.7	4.32*	P<0.05 (3.84,1df)
Gender	Male	31	13	41.9	18	58.0	0.11 NS	P>0.05 (3.84, 1df)
Gender	Female	19	8	42.1	11	57.8	0.11 NS	P>0.05 (3.84, 1df)
Religion	Hindu	48	12	25.0	36	75.0	0.62 NS	P>0.05 (3.84, 1df)
Religion	Muslim	2	1	50.0	1	50.0	0.62 NS	P>0.05 (3.84, 1df)
Marital status	Married	41	16	39.0	25	60.9	0.13 NS	P>0.05 (5.99, 2df)
	Unmarried	4	1	25.0	3	75.0
	Widow/Widower	5	1	20.0	4	80.0
Type of family	Nuclear	15	7	46.7	8	53.3	4.76*	P<0.05 (3.84, 1df)
Type of family	Joint	35	6	17.1	29	82.9	4.76*	P<0.05 (3.84, 1df)
Educational qualification	Illiterate	38	17	44.7	21	55.2	0.13 NS	P>0.05 (3.84,1df)
Educational qualification	Primary	12	4	33.3	8	66.6	0.13 NS	P>0.05 (3.84,1df)
Occupation	Labourer	41	15	36.5	26	63.4	0.11 NS	P>0.05 (5.99,2df)
	Private	4	1	25.0	3	75.0
	House wife	5	1	20.0	4	80.0
Family income/month	Below Rs.5,000	42	11	26.2	31	73.8	0.13 NS	P>0.05 (3.84, 1df)
Family income/month	Rs.5,001-10,000	8	2	25.0	6	75.0	0.13 NS	P>0.05 (3.84, 1df)
Duration of hospitalization(days)	6-15	21	6	28.6	15	71.4	0.40 NS	P>0.05 (5.99, 2df)
	16-20	15	3	20.0	12	80.0
	21-30	14	4	28.6	10	71.4
Previous exposure to Range of Motion exercise	Electronic media	10	2	20.0	8	80.0	0.24 NS	P>0.05 (5.99, 2df)
	Health personnel	33	9	27.3	24	72.7
	Family members/Relatives	7	2	28.6	5	71.4

* Significant at 5% Level, NS: Non-significant

Table18: Association between selected demographic variables and Post test Practice level on Range of Motion exercises N=50

Demographic Variables	Category	Sample	Knowledge Level				Χ ²Value	P Value
			< Median		>Median
			N	%	N	%
Age group (years)	20-40	22	10	45.4	12	54.5	0.91 NS	P>0.05 (3.84,1df)
Age group (years)	41-60	28	9	21.6	19	67.8	0.91 NS	P>0.05 (3.84,1df)
Gender	Male	31	12	38.7	19	61.2	5.20*	P<0.05 (3.84, 1df)
Gender	Female	19	1	5.26	18	94.7	5.20*	P<0.05 (3.84, 1df)
Religion	Hindu	48	12	33.3	36	75.0	0.21 NS	P>0.05 (3.84, 1df)
Religion	Muslim	2	1	50.0	1	50.0	0.21 NS	P>0.05 (3.84, 1df)
Marital status	Married	41	11	26.8	30	73.1	0.37 NS	P>0.05 (5.99, 2df)
	Unmarried	4	1	25.0	3	75.0
	Widow/Widower	5	1	20.0	4	80.0
Type of family	Nuclear	15	8	53.3	7	46.6	0.45 NS	P>0.05 (3.84, 1df)
Type of family	Joint	35	15	42.8	20	57.1	0.45 NS	P>0.05 (3.84, 1df)
Educational qualification	Illiterate	38	20	52.6	18	47.3	3.23 NS	P>0.05 (3.84, 1df)
Educational qualification	Primary	12	2	16.6	10	83.3	3.23 NS	P>0.05 (3.84, 1df)
Occupation	Labourer	41	19	46.3	22	53.6	0.11 NS	P>0.05 (5.99, 2df)
	Private	4	1	25.0	3	75.0
	House wife	5	2	40.0	3	60.0
Family income/month	Below Rs.5,000	42	16	38.0	26	61.9	0.13 NS	P>0.05 (3.84,1df)
Family income/month	Rs.5,001-10,000	8	3	37.5	5	62.5	0.13 NS	P>0.05 (3.84,1df)
Duration of hospitalization(days)	6-15	21	5	23.8	16	76.1	0.16 NS	P>0.05 (5.99, 2df)
	16-20	15	4	26.6	11	73.3
	21-30	14	5	35.7	9	64.2
Previous exposure to Range of Motion exercise	Electronic media	10	4	40.0	6	60.0	0.24 NS	P>0.05 (5.99, 2df)
	Health personnel	33	13	39.3	20	60.6
	Family members/Relatives	7	3	42.8	4	57.0

* Significant at 5% Level, NS: Non-significant

Table18 reveals that the calculated χ ²Value with regard to gender (χ ²= 5.20*, P<0.05) is more than table value at 0.05 level of significance. Hence the stated research hypothesis H5 is accepted with regard to above mentioned demographic variable. But calculated χ ²Value with regard to the age (χ ²=0.91, NS), religion (χ ²=0.21, NS), marital status (χ ²=0.37, NS), type of family (χ ²=0.45, NS), educational qualification (χ ²=3.23, NS), occupation (χ ²=0.11, NS), family income (χ²= 0.13, NS), duration of hospitalization (χ ²=0.16, NS) and previous exposure to range of motion exercises (χ ²=0.16, NS) P>0.05 were less than table values at 0.05 level of significance, hence the stated research hypothesis H4 is rejected to these demographic variables. It is concluded that Post-test Practice level of respondents are significantly associated with gender of respondents. Age, religion, marital status, marital status, educational qualification, occupation, family income, duration of hospitalization and previous exposure to information of respondents are not significantly associated with their Post-test Practice scores.

DISCUSSION:

Objective 1: To assess the existing Knowledge and Practice regarding range of motion exercises among restricted mobile patients in orthopaedic wards at SC hospital, Hassan.

The present result was consistent with the results of a study conducted to investigate Knowledge and Practice of range of motion exercises among patients with orthopedic trauma. A quantitative, cross-sectional survey design was used, and 48 participants with fracture were participated in the study. Least hospitalized orthopedic patients (45%) were aware that range of motion exercises was performed to prevent complications and remaining 55.0% of participants were having limited knowledge and practice of range of motion exercises. Participants reported hearing about range of motion exercises more frequently from friends, family or the media than from healthcare providers, including nurses. Findings suggest that patients require further information on range of motion exercises during their hospitalization. This study also highlights the need to strengthen the nurses' role in providing patient education about range of motion exercises. ²⁰

Objective 2: To evaluate the 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.

The study findings were compared with the results of a study was conducted by Garima Gupta and Stuti Sehgal (2012) to evaluate the comparative effectiveness of video tape and hand out mode of instructions for teaching exercises among orthopedic patients. A total of 115 orthopedic patients aged 24-28 years of age were studied. The patients were randomized into two groups: A) the video group, and B) the handout group. The video group viewed the video for physical therapy and ROM exercises while the handout group was provided with paper handouts. The group 'A', which viewed the video comprised of 25 males and 19 females with a Mean ± SD age of 24.36 ± 16.3 years. Group B, which viewed the handouts comprised of 32 males and 11 females with a Mean ± SD age of 26.83 ± 17.0 years.The statistical analysis using unpaired 't' test on acquisition day between the groups showed significant difference .The 't' value for the acquisition phase was 4.28 (P value < 0.79). These findings suggest that the videotape techniques can be an effective instructional aid for teaching exercises to orthopedic patients compare to hand out mode.²¹

Objective 3: To find the correlation between Post-test Knowledge and Practice scores of restricted mobile patients in orthopaedic wards at SC hospital Hassan.

The study findings was compared with the results of a study conducted on 70 healthy adul females to determine ankle and subtalar joint active and passive range of motion (in sitting and lying). Subjects were assigned into two groups according to their age. Group A – elderly (60-80 years) Group B – young (20-30years). The results show that there were significant differences in ankle and subtalar ROM and balance scores between the two groups. A Significant positive correlation of functional reach with active and passive dorsiflexion (in sitting and lying) was found in both Group A and B. Timed Up and Go scores and active and passive dorsiflexion (in sitting and lying) showed a significant negative correlation in both Group A and B. No Significant correlation was found between ankle plantarflexion (active and passive) in sitting and lying and subtalar ranges of motion (inversion and eversion) and either of the balance test scores (functional reach value and timed up and go test scores) in any of the Groups.It is concluded that Correlations exist between ankle Dorsiflexion ROM and balance in females. ²²

Objectives 4: To find the association between the Post-test Knowledge and Practice scores of restricted mobile patients and their selected demographic variables.

The results of present study can also be supported by the cross sectional study was conducted on 113 study participants (226 elbows) .The study was conducted to determine the effect of BMI on orthopedic parameters of the elbow joint, including range of motion, flexion, extension, and carrying angle. Healthy adult’s aged 22 to 26 years were recruited at an urban orthopedic clinic as adult orthopedic patients or as the siblings or friends of patients. Measures of range of motion (flexion and extension) and carrying angle of 226 elbows and of BMI from 113 study participants were analyzed. The results show that BMI was negatively correlated with right and left elbow range of motion (r = −0.54, P<0.01; r = −0.43, P <0.01) and right and left elbow flexion (r = −0.59, P <0.01; r = −0.50, P <0.01). BMI had a positive correlation with right elbow extension (r = 0.20, P = 0.04). BMI did not correlate with left elbow extension or right or left carrying angle. After adjustment for age, sex, and ethnic group, BMI was associated with right (P <0.01) and left (P <0.01) elbow range of motion. It is concluded that increased BMI in adults is negatively correlated with range of motion of the elbow joint.²³

IMPLICATIONS:

The findings of the present study have implications in the field of nursing education, nursing practice, nursing administration and nursing research.

Nursing Education:

The health care delivery system at present is giving more emphasis on preventive rather than curative aspect. It is the responsibility of each individual to keep physically healthy and competent. The study gives priority for the education programme as it upholds and maintains the Knowledge and Practice thus making restricted mobile patients more confident in performing range of motion exercises to prevent the complications. The VATP can be used as an informational and educational mode by the nurses for educating the restricted mobile patients. Nursing students can be trained to acquire knowledge on range of motion exercises and to plan out teaching programmes based on the same in the community setting.

Nursing Practice:

Health education is an important tool for health care agency. It is one of the most cost effective interventions to promote healthy living. Nurses working in the major hospitals, educational institutions as well as in the community can be equipped with knowledge on range of motion exercises. Work towards empowering restricted mobile patients by providing them with essential knowledge to that making them healthy. Nurses in their educative role are in better position to mould the health related behavior. Nurses are acting as the health promoters.

Nursing administration:

Nurse administrators can take initiatives in creating plan and policies for the continuing education programme to the staff nurses .In each session they can assess their level of knowledge and skill before and after the continuing education programme, and evaluate its effectiveness as well as the problem they face. They can plan for manpower, money, material, methods and time to conduct successful educational programmes. The staff can be encouraged to prepare teaching materials and audio visual aids regarding various health related topics and display them in their respective work areas. Health administration can create awareness about the range of motion exercises among restricted mobile patients and assign the staff for conducting the planned teaching programme in hospital and the community in general.

Nursing research:

The emphasis on research and clinical studies is needed to improve the quality of nursing care. The present study is only on the initial investigation in the area of teaching the restricted mobile patients on range of motion exercises. Musculoskeletal injuries are increasing the global burden of disease especially among the restricted mobile patients. Hence the nurse researchers should be aware about the changing incidences of musculo skeletal injuries. There is a great need for research in the area of range of motion exercises and measures to increase the practical application of these in orthopedic wards. This study has highlighted the effectiveness of VATP on range of motion exercises.

Limitations:

*The study was conducted over a small group of target population selected by purposive sampling technique. Hence generalization is limited to the restricted mobile patients in orthopedic wards at SC hospital, Hassan.

*Extraneous variables like age, exposure to media, learning in hospital environment, peer contact or any other events occurred in the period between Pre-test and Post-test test were beyond the investigators control as control group was not used; therefore there were possibilities of threats to internal validity.

*Teaching plan was not based on learning needs of the subjects under the study but on the basis of the review of literature and investigators experience.

*No attempts were made to do the follow up to check the retention of Knowledge and Practice of restricted mobile patients.

RECOMMENDATIONS:

On the basis of study findings, following recommendations have been made for further study.

*The study can be a replicated on a large sample with a control group.

*A comparative study may be conducted to find out the effectiveness of VATP regarding the same topic.

*Similar study can be undertaken using other teaching strategies.

*Similar study can be conducted using larger number of sample selected by probability sampling for wider generalization.

*A similar study can be replicated with an increased period of time provided for training programme and with still elaborative and in-depth programme like work shop.

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No	Practice Aspects	Respondents Practice (%)						Paired ‘t’ Test
		Pre test		Post test		Enhancement
		Mean	SD	Mean	SD	Mean	SD
I	Practice of neck and shoulder range of motion exercises	6.9	6.6	88.7	16.0	79.7	15.8	23.91*
II	Practice of elbow and wrist range of motion exercises	11.5	9.9	90.6	8.4	80.2	12.8	32.61*
III	Practice of hands, fingers and thumb range of motion exercises	13.6	11.5	94.2	11.5	84.2	12.4	40.31*
IV	Practice of hip and knee range of motion exercises	13.4	12.0	88.6	11.7	75.8	13.3	14.15*
V	Practice of ankle and foot range of motion exercises	15.0	16.4	87.5	15.2	71.5	21.6	10.12*
VI	Practice of toe and trunk range of motion exercises	12.0	13.1	91.7	11.7	83.5	8.6	32.82*
	Combined	5.9	7.3	94.8	5.7	88.9	10.5