Brief resume of the intended work:

Introduction:

Aging is a natural process of living organisms. Commonest health problem among elderly population is a musculoskeletal pain based on the health surveys undertaken in both developed and developing countries. Knee and low back pain are the most frequent complaints among the elderly population. Knee joint pain is more common among elderly than back pain.⁽¹⁾

            Elderly people are troubled with chronic knee joint pain caused by osteoarthritis. Its prevalence increases with age and generally affects female than male. It affects the majority of the elderly and contributes major ill effect on health and their quality of life.⁽²⁾

            Chronic rheumatic diseases, hip and knee osteoarthritis (OA) is leading cause of pain and disability in most countries worldwide.⁽³⁾

            Osteoarthritis is a disorder of cartilage which leads to degradation of joint and inflammation of the synovial membrane. It acts as a cushion-like structure present in-between the joints and bones and prevents the rubbing of each other.⁽⁴⁾

A systematic review and meta-analysis was conducted of cohort studies for risk factors for the onset of knee pain. 6554 papers were identified and after screening 46 studies were included. The main factors associated with onset of knee pain were being overweight (pooled OR 1.98, 95% confidence intervals (CI) 1.57–2.20), obesity (pooled OR 2.66 95% CI 2.15–3.28), female gender (pooled OR 1.68, 95% CI 1.37–2.07), previous knee injury (pooled OR 2.83, 95% CI 1.91–4.19). Hand OA (pooled OR 1.30, 95% CI 0.90–1.87) was found to be non-significant. Smoking was found not to be a statistically significant risk or protective factor (pooled OR 0.92, 95% CI 0.83–1.01). PAFs indicated that in patients with new onset of knee pain 5.1% of cases were due to previous knee injury and 24.6% related to being overweight or obese.⁽⁵⁾

The signs and symptoms of osteoarthritis may include stiffness, crepitus, swelling, bony tenderness, and limp. Osteoarthritis affects every aspect of an individual’s day-to-day activities and quality of life. The primary type of osteoarthritis is most commonly caused by aging process. The second most common rheumatologic problem is osteoarthritis and frequent knee joint disease with the prevalence rate of 22–39% in India. The prevalence rate increases with aging process. Nearly 45 and 70% of the women have the symptoms and radiological evidences of pathology. It is one of the major causes of mobility impairment among females.⁽⁴⁾

Several key prevention strategies have been proposed to prevent osteoarthritis and control the disease progression. In particular, reducing overuse of joints and promoting healthy lifestyles play an important role.⁽⁶⁾

Management should be comprehensive and individualized. The management plan should be reviewed regularly which is based on non-pharmacological and pharmacological measures. People residing in rural area prefer non-pharmacological treatment plan which include exercise, hot application, cold application, oil massage, yoga, electrical heat application, and use of naturopathy. Several complementary therapies may play an important role in the management of joint pain. Epsom salt is a natural mineral. Magnesium and sulphates are absorbed through the skin and into the body, which have an effect to reduce nee pain. The study aims to compare Epsom salt, hot water, or both for knee joint pain relief, based on prior research.⁽⁷⁾

6.1 Need for the study:

Key facts as per WHO,

·     In 2019, about 528 million people worldwide were living with osteoarthritis; an increase of 113% since 1990.

·     About 73% of people living with osteoarthritis are older than 55 years, and 60% are female.

·     With a prevalence of 365 million, the knee is the most frequently affected joint, followed by the hip and the hand.

·     344 million people living with osteoarthritis experience Osteoarthritis.

^·      With ageing populations and increasing rates of obesity and injury, the prevalence of osteoarthritis is expected to continue to increase globally_.⁽⁸⁾

            Adam Ramsay (2014), is a nutritional therapist, says at Margaret Hills Clinic regarding the Epsom salt compress which helps patients with arthritis, Epsom salts, which are high in magnesium, can help to relieve joint pain. Dissolve three teacups of Epsom salts mixed with hot water then soak a clean cloth into hot water and make a compress, apply the compress to the affected knee joint area for 10–15 minutes and slowly exercising the joints and muscles this will help to relieve the joint pain. In India, among Osteoarthritis patients, nearly 80% of the population had knee joint pain, out of which approximately 20% reported in capabilities in daily activities and around 11% need peculiar care. Approximately 40% of the population had Osteoarthritis above the age group of 70 years, in which nearly 2% have severe knee pain and disability. In a study, 43.4% of elderly had a complaint of joint pain and stiffness problem. The gender distribution of prevalence rate for male and female was 40.8–59.2%, respectively.⁽⁹⁾

         According to world health organization (who), 18.0% of women and 9.6% of men over the age of 60 years have symptomatic osteoarthritis which leads knee pain in worldwide. They have limitations in movement around 80% of 25% of them cannot perform their major daily day-to-day activities of life.⁽³⁾

        During the preliminary survey in the community area the researcher found that, majority of elderly were expressed of joint pain, difficulty in walking and sitting, considering the high prevalence of knee joint pain among older adults this study aimed to evaluate the effectiveness of self-management strategies using Epsom salt hot water application on pain intensity in elderly population at community settings.

6.2 Review of literature:

Review of Literature under following headings as follows:

  1. Prevalence related to Knee Joint pain among elderly

  2.  Epsom salt effectiveness on knee joint pain

1. Prevalence related to Knee Joint pain

            A cross sectional study to study the magnitude of knee osteoarthritis among adult population aged 40 years and above in rural area at Maharashtra, India. The technique adapted is a stratified multistage random sampling method, sample size 150 with knee joint pain were included in the study. The tool used for the study is American rheumatology criteria (ACR), statistics is Chi square test and Fischer’s exact test was applied, result of the study revealed that prevalence of knee OA was found higher in age group >60 years 32 (43.2%) as compared to age group 40-60 years 20 (26.3%) and it was statistically significant. In this study, males were having a prevalence of 26 (36.6%) compared to females which were having 26 (32.9%)and found to be significant, hence study highlighted that the prevalence of knee osteoarthritis  was higher in client The sociodemographic factors like age >60 years, education, occupation, low socioeconomic status and lifestyle risk factors like DM and BMI≥25 was found to be significantly associated with knee osteoarthritis.⁽¹⁰⁾

            A cross-sectional study was conducted Knee pain and health-related quality of life among older patients with different knee osteoarthritis severity in Saudi Arabia, sample size was 209 consecutive males and females aged ≥55 years with patients were classified into two groups: mild/moderate knee osteoarthritis, severe knee osteoarthritis using the pain visual analogy scale (VAS), a statically association found that on average, one year older than those with mild/moderate knee osteoarthritis. The majority of the patients with severe knee osteoarthritis were female (73%), had primary school or less education (51%), and were self-employed or retired (76%). Most patients with severe knee osteoarthritis had knee osteoarthritis in both knees (83%), high body mass index (BMI) scores (33.5 ± 5.7), long duration of knee osteoarthritis (average 7.5 years), and high pain VAS scores (8.2 ± 0.9). the study concluded that knee pain and osteoarthritis which are high in elders.¹¹

            A cross-sectional study to assess the Relationship between knee joint discomfort, self-management behaviour, and quality of life in the middle-aged and elderly people in China, the technique adapted is a stratified multistage random sampling method, The tools consist of four parts, including General Information Questionnaire, Self-Rating Scale for Knee Joint , Behaviour management Scale for Knee Joint Discomfort, a Descriptive statistics analysis is used, results of the study revealed that, the average age of the middle-aged and elderly people was 58.99 ± 12.00 years, and an overwhelming number of them were female (52.7%). The BMI was mostly <24 kg/m2 (67.2%) hence the study found be significant, and study concludes that Knee joint discomfort was prevalent in the middle-aged and elderly people. ¹²

            A cross sectional study to estimate the Prevalence of Knee Pain and the association between Illness Perception Profiles and Self-Management Strategies in the Frederiksberg questionnaire, among elderly citizens between 60 and 69 years of age. The results of the study revealed that among a total of 9086 citizens aged between 60–69 years. Thus, among the 8204 were invited to respond to the survey. At the end of the six-week data collection period, 4292 (52.3%) had initiated the questionnaire. Among these, 1758 (40.9%) reported knee pain and 570 (13.3%) reported self-reported knee osteoarthritis the proportion having self-reported knee pain ranging from 19.9% to 22.7%. From this sample, it is fair to assume that the prevalence of knee OA is between 6.4% and 7.4% in this group of individuals in the age 60 to 69 years of age, hence this study found to be significant and the study highlighted found the prevalence of knee pain in the elderly between 60–69 years to be 21.4%, while the prevalence of self-reported knee osteoarthritis was 6.9%.¹³

            A cross-sectional study to assess patients with pain in knee at different hospitals. Questionnaire was designed to assess demographics, socioeconomic status, and knee pain level. 714 patients participated in study by fulfilling eligibility criteria. (64.8%) patients experienced pain less than one year History of previous prescribed medications was present in 91.6% of patients, supplements in 68.6% of patients, whereas non-pharmacological mode of treatment used to manage pain of osteoarthritis were present in 81.9% of patients¹⁴

2. literature of intervention on Epson salt effectiveness

            A quantitative research approach and pre experimental research design to assess the Effectiveness of Epsom Salt with Hot Water Application on Knee Joint Pain among Elderly in a Selected Rural Area at Puducherry, among the elderly aged above 60 years ,a purposive sampling technique used for this study ,In total, 29 samples of elderly aged above 60 years. Results of the study revealed that Epsom salt with hot water application, the posttest mean pain score was 2.17 with the standard deviation of 0.384. The effectiveness was statistically tested by paired t test which was found to be highly statistically significant at p < 0.001. It indicates that Epsom salt with hot water application was effective in reduction of knee joint pain and found to significant, hence the study concludes that main conclusion of this study was hot water application with Epsom salt was effective in reducing knee joint pain among elderly.¹⁵     

            A quasi experimental  study to assess the effectiveness of hot water application with Epsom salt to reduce knee joint pain the among elderly in selected villages at Madurai district, simple random technique used and study of 60 elders, A modified structure questioner  is used to assess level of knee joint pain among elderly, and the selected sample size result of the study revealed that the level of knee joint pain among the elderly before the administration of hot water application with Epsom salt is (Mean=63.41, SD=6.79), and the level of knee joint pain after administration of hot water application with Epsom salt is (Mean=19.76, SD=5.76), the mean score and standard deviation score was decreased after the intervention of hot water application with Epsom salt and found to be significant , hence the study concludes researcher used hot water application with Epsom salt to reduce post-assessment level of knee joint pain. Many of the elderly reported that after application, they feel reduced pain and feel comfortable during work. ¹⁶

A Comparative true experimental Study to Assess the Effectiveness of Epsom Salt with Hot Water Versus Plain Water on Pain and Functional Performance Among Arthritis Patients at Selected Hospital, Udaipur, Non-probability purposive sampling technique was used to select the samples, with sample size 60 elderly arthritis patients (30 in Epsom salt with hot water and 30 in Epsom salt with plain water) ,Quantitative approach with Comparative true experimental method is used with Description of tool, results of the study revealed that s. In Epsom salt with hot water, 70-79 age groups constituted 36.7%, 80+ age group 33.3%, 60-69 age group 30%. Females were 63.3%, males 36.7%. Plain water pre-test: 50% moderate pain, 50% severe, mean 6.80±1.606. Post-test: 53.3% moderate, 46.7% severe, mean 6.47±1.756. Paired t test (t=3.808, p=0.001) showed significant reduction in plain water’s pain level and the study found to be effective with intervention of study , hence study concludes that Arthritis a common cause of pain and reduced functionality in older adults, necessitates diverse strategies for pain management and functional improvement. In this study, Epsom salt baths demonstrated significant pain reduction in the hot water group compared to plain water, along with notable enhancement in functional performance.¹⁷

            A true experimental study to assess Effectiveness of Application of Warm Compress with Epsom Salt to Reduce Knee Joint Pain among Women. By non-probability purposive sampling technique, tool used to assess pain is India-based knee osteoarthritis evaluation (iKare) sample size 60 samples were selected consist two group, warm Epsom salt application group and control group. The quasi-experimental two group pre posttest research design was used. The result of the result was compared with each other by analysis of the data. Finding shows that Majority i.e. 46% of them were between the age group 50-54 years. Majority i.e. 100% were married. Majority i.e. 36% had income 5000-10000/- In pre-test score, 2% were having mild knee joint pain 10% had moderate pain 18% severe pain in experimental group. Where as in posttest the samples with mild and moderate pain with mean of 1.03 had excellent reduction in pain. The finding of posttest experimental group (1.03) than that in per test 8.22. It was also evident that mean +SD post-test pain score was (1.48+0.93) was low than that per test pain score was (1.25+1.70) hence the study Conclude that warm Epsom salt application is highly effective in reduction knee joint pain in arthritis patient. ¹⁸

6.3 Objectives of the study:

STATEMENT OF THE PROBLEM

“Effectiveness of Epsom Salt hot Water application on Knee Joint Pain among

Elderly people at Selected Community Areas, Kolar’’.

OBJECTIVES OF THE STUDY

1. To assess level of knee joint pain among elderly in both the experimental and control group using standardized Oxford knee score scale.

2. To determine the effectiveness of Epsom salt hot water application on knee joint pain among elderly by comparing pretest and posttest scores of experimental & control group.

3. To find the association between the levels of knee joint pain and selected demographic variables. 

Hypotheses:

H1: There will be significant difference on Knee joint pain among elderly people before and after Epsom salt hot water application.

H2: There will be significant association between level of pain and selected demographic variables.

Assumptions: 

1.       Patients with knee osteoarthritis have pain, swelling, inflammation.

2.       Epsom salt hot water application reduces knee joint pain and inflammation.

Delimitation:

1.       The study is limited to only patients with Knee joint pain.

2.       The study is limited to only one setting.

Operational definitions:

Effectiveness 

            In this study, Refers to significant improvements in the relieving knee joint pain after the application of Epsom salt hot water fomentation among elderly.

Elderly people: It refers to an individual, who is in the age group of 60 years and above residing in selected community areas, Kolar.

Knee Joint pain:

            It is an inflammatory joint pain, perceived and expressed the symptoms by the elderly, as swelling, stiffness, congestion as a result of deterioration of the involved knee joint which will be measured by oxford knee score scale

Epsom salt hot water application:

            It is a local application of moist heat by means of a small bag of cotton cloth prepared by adding 30 grams of Epsom salt to one litter of Hot water (The temperature of the Hot water was 125-degree Fahrenheit).It is applied to area for about 15 minutes a day for 15 days.

Material and Methods:

 Source of data:

Data will be collected from all the geriatric clients with the age group 65 years and above at selected community areas, Kolar.

Research Approach: Quantitative  Research approach

Research Design: True experimental pretest posttest only design.

Variables:

Sociodemographic variables:

Age, Gender, Religion, education status, marital status, Type of physical activity, Type of diet, BMI, Previous occupation, Duration of knee pain in years, History of comorbid illness, Treatment for joint pain.

RESEARCH VARIABLES:

Independent variables: Epsom salt hot water application

Dependent Variables: Knee joint pain

SETTING:

The Study will be conducted at selected community areas, Kolar.

POPULATION:

 All the target population consisting of elderly (aged 60 years) suffering from knee joint pain at selected community areas.

SAMPLE AND SAMPLE SIZE:

SAMPLE: Elderly clients aged 60 years and above with knee joint pain.

SAMPLE SIZE:  60 (Experimental=30 & Control=30).

Description: Considering a pain score mean difference of 3.4 in degree of knee joint pain in experimental group and control group, 5% alpha error with an absolute error of 80% and 95% Confidence interval and assuming 10% to be an attrition rate the final estimated sample size is 30 for each group)   

SAMPLING TECHNIQUE

Probability sampling using Simple random sampling technique.

Sampling criteria:

            Inclusion criteria: Geriatric clients who are

                                         1. Aged 60 years & above, both males and females.

                                         2. Having knee related symptoms

                                         3. Willing to participate

    Exclusion criteria:

                                  1. Having other type of joint pains

                                        2. Having other acute illness and psychological illness.

                                       3. Undergoing treatment for joint pains

Data collection tool:

The tool consists of Part I and Part II

Part-I: Consists of demographic variables: Family Profile-Such as Age, Gender, Religion, education status, marital status, Type of physical activity, Type of diet, BMI, Previous occupation, Duration of knee pain in years, History of comorbid illness, Treatment for joint pain.

Part II: It consists of a standardized Oxford knee score. The score contains a total of 48 grades

Method of data collection:

Data will be collected in the following steps.

Step 1: Ethical clearance will be obtained from the Institutional Ethical Committee of Sri Devaraj Urs College of Nursing, Tamaka, Kolar.

Step 2: Formal permission will be obtained from the concerned Medical officer of selected community areas, Kolar.

Step 3: As an investigator, the study objective, purpose and duration of study will be explained and obtain informed consent and participant information sheet from the participants.

Step 4: 60 samples will be randomly selected using simple random sampling technique of which 30 samples will be considered for Experimental group and 30 samples will be in control group.

Step 5: The pre-test will be conducted on the selected participants (elderly aged 60years and above) by screening for knee joint pain by using standardized oxford knee score scale in both the experimental and control group.

Step 6:  The Epsom salt hot water application prepared by adding 30 grams of Epsom salt to one litter of Hot water (The temperature of the Hot water was 125-degree Fahrenheit) Then the investigator will give Epsom salt hot water application to the experimental group for 15minutes, for 15 days and Routine care will be given to the control group.

Step 7:   Post-test will be assessed in both the groups after 15 days using the same Oxford knee score scale.

Step 8: Finally thank all the participants.

Plan for data analysis:  Data was analysed on the basis of objective and hypothesis by using descriptive and inferential statistics.

1. Descriptive statistics was used to analyse the frequency, percentage, mean and standard deviation of demographic variables.

2. Inferential statistical was used to determine the comparison, relationship, and association.

3. Paired “t” test will be used to compare the differences within the groups of experimental and control group.

4. Independent “t” test will be used to find out the effectiveness of Epsom salt hot water application by comparing pre-test and post-test scores between the groups.

5.  Chi-square was used to find out the association between socio-demographic variables.

7.3. Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly

YES, Epsom salt hot water application prepared by adding 30 grams of Epsom salt to one litter of Hot water (The temperature of the Hot water was 125-degree Fahrenheit) Then the investigator will give Epsom salt hot water application to the experimental group for 15 minutes a day for 15- Days and Routine care will be given to the control group. As it’s a topical application and accessible way to treat knee joint pain as a home remedial measures within an affordable way with medicinal benefits.  Ethical considerations will be taken into account.

7.4. Has ethical clearance been obtained from your institution in case of 7.3

Yet to be obtained

References/ Bibliography - Follow Vancouver style

1.       Sankar L. Effectiveness of Epsom salt with hot water application on knee joint pain among elderly in a selected rural area at Puducherry. Pondicherry Journal of Nursing (PJN). 2019;12(2):42-5p.

2.       Heidari B. Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian journal of internal medicine. 2011;2(2):205.

3.       Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian journal of orthopaedics. 2016 Oct;50(5):518-22.

4.       Osteoarthritis

      https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925

5.       Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP. Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthritis and cartilage. 2015 Apr 1;23(4):507-15.

6.       Osteoarthiritis

       https://www.who.int/news-room/fact-sheets/detail/osteoarthritis

7.       Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan JL, Protheroe J, Jordan KP. Current evidence on risk factors for knee osteoarthritis in older adults: a systematic review and meta-analysis. Osteoarthritis and cartilage. 2015 Apr 1;23(4):507-15.

8.       Osteoarthritis

            https://www.who.int/news-room/fact-sheets/detail/osteoarthritis

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10.   Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian journal of orthopaedics. 2016 Oct;50(5):518-22.

11.   Jadhao A, Dambhare PM. Study of magnitude of knee osteoarthritis among adult population with age 40 years and above in rural area: a cross sectional study. Int J Community Med Public Health. 2021;8:707-11.

      Https://dx.doi.org/10.18203/2394-6040.ijcmph20210225    

12.   (R MI 1)M bindawas saad etm ,Knee pain and health-related quality of life among older patients with different knee osteoarthritis severity in Saudi Arabia,  published by pubmed ID: 29763420 ,and published on  May 15, 2018

Https://pubmed.ncbi.nlm.nih.gov/29763420/   

13.   Su M, Zhou Y, Zhao P, Zeng B, Zhou Q. Relationship between knee joint discomfort, self-management behaviour, and quality of life in the middle-aged and elderly people in China: A cross-sectional study. Frontiers in Public Health. 2022 Dec 20;10:1029443.

| https://doi.org/10.3389/fpubh.2022.1029443                   

14.   Ginnerup-Nielsen E, Christensen R, Heitmann BL, Altman RD, March L, Woolf A, Bliddal H, Henriksen M. Estimating the prevalence of knee pain and the association between illness perception profiles and self-management strategies in the Frederiksberg cohort of elderly individuals with knee pain: a cross-sectional study. Journal of Clinical Medicine. 2021 Feb 9;10(4):668.         

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17.   Nimkar P, Gawaie S, Vivek V, Deshmukh P, Gawande V. Effectiveness Of Hot Water Application With Epsom Salt To Reduce Knee Joint Pain In Osteoarthritis Among Women Residing In Selected Urban Community Of Maharashtra State. European Journal of Molecular and Clinical Medicine. 2021 Jan 1;8(1):243-54.                                                                                                       

18.   Dinesh Chandra. A Comparative Study to Assess the Effectiveness of Epsom Salt with Hot Water Versus Plain Water on Pain and Functional Performance Among Arthritis Patients at Selected Hospital, Udaipur international Journal of Health Sciences and Research Vol.13; Issue: 9; September 2023.                                                                              

19.   Parag Sancheti, Vijay Shetty D, Mandeep Dhillon S, Sheila Sprague A, Mohit Bhandari. India-Based Knee Osteoarthritis Evaluation (ikare): A Multi-Centre Cross-Sectional Study on the Management of Knee Pain and Early Osteoarthritis in India. 2017; 9(3). Clinics in orthopedic surgery.

a.       Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567023/