|Year : 2016 | Volume
| Issue : 3 | Page : 186-192
Impact of physical exercise on daily living activities among women with early osteoarthritis
Reda M El-sayed Ramadan1, Jehan Sayyed Ali2, Reda Mohamed-Nabil Aboushady3
1 Department of Medical Surgical Nursing, Faculty of Nursing, Ain Shams University, Egypt
2 Department of Adult Nursing, Faculty of Nursing, El-Minia University, Egypt
3 Department of Maternal and Newborn Health Nursing, Faculty of Nursing, Cairo University, Egypt
|Date of Submission||27-Aug-2016|
|Date of Acceptance||11-Sep-2016|
|Date of Web Publication||15-Feb-2017|
Reda Mohamed-Nabil Aboushady
Department of Maternal and Newborn Health Nursing, Faculty of Nursing, Cairo University, P.O. Box 11562
Source of Support: None, Conflict of Interest: None
Osteoarthritis (OA) is the most common rheumatic disease of the knee and causes uncontrolled pain and disability. It affects millions of people across different races at different ages and of both sexes. Daily physical exercise is the first line of management for women with early OA to maintain muscle strength, physical fitness, and overall health.
The aim of the study was to evaluate the impact of physical exercise on the activities of daily living in women with early OA.
Participants and methods
A quasiexperimental design ‘time-series’ was used to achieve the objectives of the study. A total of 46 women were recruited from the outpatient clinic of El-Demerdash University Hospital.
Tools of data collection
Three tools were developed and used by researchers to collect the data: (a) a structured interview questionnaire; (b) scale of daily living activities; and (c) a physical exercise questionnaire for women with OA. The women performed exercises at the rate of one session per week for a period of 1 month in the presence of researchers, who clarified any queries.
The women were aged 43–65 years, with a mean age of 41.8±14.67 years. There are significant differences regarding pain intensity, degree of difficulty, and need for assistance after practicing physical exercises.
A regular exercise program improved the daily living activity levels of women with early OA. There was also a significant improvement in pain, knee flexion, muscle strength, and functional capacity after practicing physical exercise.
Nurses have an active role in raising awareness about the importance of physical exercise in the treatment of early OA. Hospitals should implement a plan of action to include exercise in early OA treatment for women.
Keywords: daily living activities, early osteoarthritis, physical exercise, women
|How to cite this article:|
El-sayed Ramadan RM, Ali JS, Aboushady RM. Impact of physical exercise on daily living activities among women with early osteoarthritis. Egypt Nurs J 2016;13:186-92
|How to cite this URL:|
El-sayed Ramadan RM, Ali JS, Aboushady RM. Impact of physical exercise on daily living activities among women with early osteoarthritis. Egypt Nurs J [serial online] 2016 [cited 2018 Apr 23];13:186-92. Available from: http://www.enj.eg.net/text.asp?2016/13/3/186/200180
| Introduction|| |
Osteoarthritis (OA) is a progressive joint disease that is characterized by joint inflammation and a reparative bone response and is associated with cartilage destruction, subchondral bone remodeling, and inflammation of the synovial membrane (Kapoor et al., 2011; Bhatia et al., 2013). Worldwide, OA is the fourth cause of disability. Most of this disability is attributable to the involvement of the hips or the knees (Fransen et al., 2011). Before age 45, OA is more common in men than in women. After age 45, OA is more common in women. It is estimated that 33.6% (12.4 million) of individuals aged 65 and older are affected by the disease (National Institute of Health, 2016). It has multifactorial etiology and affects millions of people across different races at different ages and of both sexes (Suri et al., 2012).
Causes of OA have not been clarified, but each phase in the process of joint deterioration is controlled by combinations of genetic, mechanical, and environmental factors. Age, heredity, trauma, and obesity play an important role in alteration of the cartilage. There are also secondary causes that may include calcium deposition, endocrinopathy, infection, neuropathy, congenital malformation, and metabolic disease (Oegema et al., 2006). The authors concluded that, there were no systematic reviews available on risk factors for knee OA, as injury and overweight (Blagojevic et al., 2010). Risk factors contributing to the development of OA include age, trauma, and increased body weight. However, OA commonly manifests in non-weight-bearing joints (Gkretsi et al., 2011; El-Said et al., 2013). Several studies have found that age, female sex, injuries, overweight, and strong physical activity in sport and work are associated with increased risk for developing OA of the hip or knee (Andersen et al., 2012).
The clinical manifestations of OA are joint pain, stiffness, decreased range of movement, muscle weakness of the quadriceps, and alterations in proprioception. Decreased strength in the muscle groups involving the joints is significant because it causes progressive loss of function. These symptoms significantly restrict the individual’s ability to arise from a chair, walk, or climb stairs and results in walking with a limp, poor alignment of the limb, and instabilities (Pisters et al., 2007).
The American College of Rheumatology has developed guidelines for nonpharmacological treatment of the hip and knee OA, such as patient education, weight loss if overweight, physical therapy, orthotics, occupational therapy, and exercise programs (Sisto and Malanga, 2006). Daily or regular physical exercise is the first line of management for women with OA. Physical exercise can be defined as any activity that enhances or maintains muscle strength, physical fitness, and overall health. People exercise for different reasons such as weight loss, strengthening muscles, and obtaining relief from symptoms of OA (Fransen and McConnell, 2008).
Nurses should encourage women to exercise regularly and should then contact them frequently to ensure adherence to the activity plan. The women must also be counseled to progressively increase their activity level (French et al., 2011).
Significance of the study
It has been observed that OA is the most common musculoskeletal problem in individuals above 45 years of age. The Center for Disease Control and Prevention anticipates that the prevalence, health impact, and economic consequences of OA will surge during the next few decades. It is a progressive disease that can worsen physical function over time and affect the quality of life, mainly walking and climbing stairs (Prieto-Alhambra et al., 2014). According to the National Health and Nutrition Examination Survey III (NHANES III) 25% of women with OA cannot perform major activities of daily living and about 12% require help with personal care and routine. Therefore, the present study will contribute to a greater understanding of the impact of physical exercise on daily living activities among women with early OA; it will also provide evidence about the effect of physical exercise on daily living activities.
Aim of the study: The aim of the current study was to evaluate the impact of physical exercise on daily living activities in women with early OA.
Women with early OA who perform physical exercise are less likely to suffer impairment in their daily living activities.
| Participants and methods|| |
A quasiexperimental design ‘time-series’ was utilized to achieve the aims of the current study. A quasiexperimental time series design is one in which measurements of the same variables are taken at different points in time (Nieswiadomy, 2012).
The current study was conducted at the outpatient clinic of El-Demerdash University Hospital.
A purposeful sample of 46 women with early OA was selected from the OA group at the outpatient clinic of El-Demerdash University Hospital. The researchers selected those women who met the following inclusion criteria: had early OA, expressed their willingness to participate and gave permission for the interview, were free from any chronic disease and primary OA, and were ambulatory without assistance or assistive devices.
Tools for data collection
Three tools were used for data collection after extension of literature review.
Tool 1: Structured interview questionnaire
It was developed and used by the researcher after extensive literature review and consisted of two parts: part I included personal data of the participants such as age, marital status, educational level, and occupation; part II included health-related data such as anthropometric measurements, history of disease, and treatment strategies.
Tool 2: Scale of daily living activities
It was developed by O’sullivan and Schmitz (1994) to assess the performance of daily living activities in three dimensions (intensity of pain, degree of difficulty, and need for assistance during performance). Each dimension contained 19 items; each one was scaled from 0 to 4. Each dimension had a total score of 0–76 points. Responses to the questions regarding intensity of pain and degree of difficulty were scored as 0 for no pain/difficulty, 1 for mild pain/difficulty, 2 for moderate pain/difficulty, 3 for severe pain/difficulty, and 4 for extreme pain/difficulty. Responses to the questions regarding need for assistance were scored as 0 for independent, 1 for using devices, 2 for using human assistance, 3 for using devices and human assistance, and 4 for dependent. Responses to the questions regarding intensity of pain and degree of difficulty were scored as 0 for no pain/difficulty, 1–19 for mild pain/difficulty, 20–38 for moderate pain/difficulty, 39–57 for severe pain/difficulty, and 58–76 for extreme pain/difficulty.
Tool 3: Physical exercise questionnaire for women with early osteoarthritis
This questionnaire was first developed by Sands and Dennison (1999) and then by Kern and Belangee (2011). It concerned physical exercises before and after implementation of an exercise program (behavior of women to maintain physical fitness and management of pain related to exercise).
The scoring system was divided into two parts. Each one contained a number of statements about physical exercise, and were scored as never=0, rare=1, sometimes=2, often=3, and always=4.
Content validity and reliability
The designed booklet was subjected to a content validity test to determine whether the tools were adequate to achieve the study objectives. The tools were submitted to a panel of five experts in the field of medical surgical nursing and maternity nursing. Test reliability of the proposed tools was ascertained with Cronbach’s α (0.84, which showed a strong significant positive correlation between test A and retest B).
A total of 10% of the study sample was included in the pilot study in order to assess the feasibility and clarity of the tool and determine the time needed to answer the questions. These women were excluded from the total sample.
Before conducting the study, permission was obtained from administrative personnel of El-Demerdash University Hospital and informed consent of the women who were participating. The data collection period was for 12 months, starting from the beginning of September 2014 to the end of August 2015. Data collection was carried out in three phases: interviewing and assessment phase, implementation phase, and evaluation phase.
Interviewing and assessment phase
During the first visit the researcher explained the aim of the study, the components of the tools, the natural course of the disease, activities of daily living, and the program of physical exercise. The time needed for completing the questionnaire ranged from 15 to 20 min for each woman.
In this phase, all recruited women were divided into six groups. Each session took about 30–60 min. The women were also given handouts based on the researchers’ ‘booklet’ after extensive literature review and included color photographs and guidance related to the disease in clear Arabic and how to perform physical exercise to improve early OA. Each instructional session included 5–8 women. The researchers gave instructions on how to perform the physical activity and the type of activity; each group performed exercise at one session per week for a period of 1 month by referring to the researcher’s manual. The researchers assessed the effectiveness and continuity of the exercise sessions by telephone.
In this phase, women were reassessed at 3 months and then 6 months after the first assessment. All women attended the follow-up sessions at the outpatient clinic to complete the questionnaire.
Ethical and administrative considerations
Women were informed that participation in this study was voluntary and they could withdraw at any time without giving reasons. The researchers explained the aims of the study to all participants. Written informed consent was obtained from women who were willing to participate in the research. Confidentiality and anonymity of the women were assured during coding of the data. Women were assured that the data would not be used in another research without their consent.
Data were coded, entered, and analyzed using the Statistical Package for Social Sciences (SPSS), version 19 (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp, USA). Data were presented using statistics in the form of frequencies and percentage. Interval and ratio variables were presented in the form of means and SD. The significance level was chosen as P-value less than 0.05.
| Results|| |
The findings of the current study are presented in four main parts: (a) sociodemographic characteristics of the studied sample; (b) physical exercise; (c) description of daily living activity of the studied sample; and (d) total mean score before and after practicing physical exercise.
Sociodemographic characteristics and health-related data of the studied sample
The ages of the women ranged from 43 to 65 years, with a mean age of 41.8±14.67 years. More than half of the women fell in the age group 40–60 years; a small percentage were younger than 40 years. In relation to the educational level, more than one-third of the women had high-level education compared with one-fourth of women who could not read and write. A high percentage of women lived in urban areas (69.6%), less than two-third were married (63%), about one-quarter (30.4%) were housewives, and more than two-third of them performed heavy physical work. More than half of the women were obese (63%), 89.1% had knee problems, and 52.2% had early OA since more than 3 years with pain relief measurement being taken by 67.4% ([Table 1],[Table 2],[Table 3]).
|Table 1: Percentage distribution of the women according to their sociodemographic characteristics|
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|Table 2: Percentage distribution of the women as regards their occupation and nature of work|
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|Table 3: Percentage distribution of the women according to their health-related data|
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Description of physical exercise in the studied group.
[Table 4] shows that after performing exercise there was an increase in the mean score of the study sample in terms of behavior to maintain physical fitness and in terms of management of pain, with statistically significance differences.
|Table 4: Physical exercise before and after practicing physical activity|
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Description of the activity of daily living of the studied sample
[Table 5] shows that differences in activities of daily living in terms of pain intensity, degree of difficulty, and need for help were significant 3 and 6 months after practicing physical activity compared with the levels before physical exercise.
|Table 5: Mean score of activity of daily living after practicing physical exercise (n=46)|
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Total mean score before and after practicing physical exercise
One-way analysis of variance repeated-measures analysis was conducted. The result of analysis of variance indicated significant time effect [Wilks λ=0.081(2, 2.45), P<0.05]. There was significant evidence that physical exercise had an effect on daily living activities. Follow-up comparison indicated that each pairwise difference was significant (P<0.05). There was a significant increase in the scores of daily living activity over time.
| Discussion|| |
OA is a common public health problem. Physical exercise is an important component in the treatment of OA. Physical exercise helps to increase flexibility, maintain range of motion of the joint, strengthen surrounding muscles, decrease associated inflammation, and improve the overall health of the patient. Therefore, the current study is conducted to evaluate the impact of physical exercise on daily living activities among women with early OA. Findings of the current study are discussed within the following frame of references: (a) sociodemographic characteristics and health-related data; (b) description of activities of daily living of the studied sample; and (c) total mean score before and after practicing physical activity.
Sociodemographic characteristics and health-related data
More than three-quarter of the women were between 43 and 65 years of age and more than three-fifth were obese. This may be because older age among women is associated with estrogen deficiency, which plays a role in the development of disease. This finding was in accordance with that of Blagojevic et al. (2010), who mentioned that increased BMI and older age are risk factors for the onset of knee OA in older adults. The increased risk for OA of the knee among overweight persons is stronger in women than in men. In an observational study, women who lost an average of 11 lbs had a reduction in their risk for knee OA by 50% (Felson et al., 2000). A meta-analysis study found that progression from normal weight to overweight during adult life may give a slightly higher risk of developing knee OA leading to arthroplasty than being constantly overweight during life. Another study found that among women at an elevated risk for OA due to high BMI, weight loss decreased this risk substantially (Blagojevic et al., 2010).
In the present study, half of the women were sitting for long periods (more than 2 h) and more than two-third of them were engaged in heavy physical work. This is similar to the observations made by Andersen et al. (2012), who stated that occupations with heavy physical work present a strong risk for hip and knee OA in both men and women, and the risks increase with cumulative years in occupation. There was evidence of an increased risk for excessive kneeling, squatting, climbing steps, standing (>2 h/day), and lifting (Blagojevic et al., 2010).
In the present study, the majority of women had knee OA. This finding was in accordance with the observations of Hewitt et al. (2010), who stated that knee OA is more prevalent than hip OA.
In this study, more than two-fifth of women were on physiotherapy and more than two-third of them were on pain relievers. This finding was in line with those of Anandacoomarasamy (2010), who mentioned that in women diagnosed with OA conservative management options should be implemented, including a combination of education, exercise and physiotherapy, and weight loss.
Description of daily living activities in the studied sample
In the current study, there was an increase in the mean scores of pain intensity, degree of difficulty, and need for assistance during performance of daily living activities among women. This might be due to OA interfering with daily living activities. This finding was in line with that of Arthritis Foundation (2014), which found that OA symptoms usually include pain, stiffness, and swelling in and around the joints. OA can make daily activities more difficult.
Mean scores before and after practicing physical exercise
As regards physical exercise, the present study revealed that there was a statistically significant difference in the behavior of patients for maintaining physical fitness and how to manage pain related to exercise between preprogram and postprogram phases. This is similar to the results of Mahmoud (2010), who found that patients with OA who underwent the program had improved energy conservation and management of pain after exercises after implementation of the program.
The present study reported that there was a statistically significant difference among the study participants before and after program implementation regarding pain intensity, degree of difficulty, and need for help during performance of daily living activities. This finding might be related to the knowledge and skills acquired from the program. This finding was supported by Penninx et al. (2001), who mentioned that exercise may be an effective strategy for preventing activities of daily living disability and, consequently, may prolong older people’ independence. In the same context Arthritis Foundation (2012) identified that physical activity is the best nondrug treatment for improving pain and function in OA. Rather it would appear that exercise has positive salutary benefits for joint tissues in addition to its other health benefits.
| Conclusion|| |
Regular physical exercise improves the daily living activity levels of women with early OA. There is significant improvement in pain, ROM knee flexion, muscle strength, and functional capacity after practicing physical exercise. 
- Health education programs for early OA should have an active role in raising awareness about the importance of physical exercise.
- Hospitals should implement a plan of action to include exercise in the treatment of early OA among women.
- Mass media should have an active role in raising the awareness of the importance of physical exercise in early OA.
- Further research is needed with a large sample size to generalize the results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]