paper regarding implementation of shakers exercise for impaired swallowing patients and compare pre , immediate and post implementation of the exercises

1. 1
Effect of Heat Application and Physical Exercise on Pain and Morning Stiffness
for Knee Osteoarthritis Patients: A comparative Study
‫على‬ ‫البدنية‬ ‫والتمارين‬ ‫الحرارة‬ ‫استخدام‬ ‫تأثير‬
‫دراسة‬ :‫الركبة‬ ‫مفاصل‬ ‫التهاب‬ ‫لمرضى‬ ‫الصباحي‬ ‫والتصلب‬ ‫األلم‬
‫مقارنة‬
Protocol
Submitted for Publication of A scientific Paper
By
‫معانا‬ ‫اللي‬ ‫الدكاترة‬ ‫اسماء‬ ‫تضيفي‬ ‫يادكتور‬ ‫حضرتك‬ ‫استاذن‬
Zeinab Gamal Mohamed Ellatif Abouelezz,
Fellow Medical Surgical Nursing, Student Hospital, Mansoura University

2. 2
Effect of Heat Application and Physical Exercise on Pain and Morning Stiffness
for Knee Osteoarthritis Patients: A comparative Study
Musculoskeletal diseases are major public health problems in most countries; they cause
more functional disabilities in the adult and geriatric population than any other category
of disorders. Osteoarthritis (OA) is considered the most common musculoskeletal
disease all over the world, it is a painful and disabling inflammatory disease of the joints.
It is caused by multiple factors as joint injury or overuse, obesity, heredity and dramatical
increases in prevalence with age (Wagner and Luna, 2018).
Knee osteoarthritis (OA) is a common degenerative disease that causes the bones
and cartilage to break down in a joint characterized by the loss of articular cartilage
tissue. The most evident symptoms of knee OA are localized pain in a joint at rest; is
well-recognized as typically transitioning from intermittent weight-bearing pain to
chronic pain, morning stiffness usually lasting fewer than 30 minutes, bony tenderness
and bony enlargement in the joint line, deformities, physical function limitation, and
incapacity (Springer, 2019 & CDC, 2018), therefore cause several negative effects on
the quality of life in individuals with knee OA (Elsiwy, et al., 2019).
Since knee OA is not cured, its care typically focuses on preserving the patient's
functional ability by managing pain, other symptoms, and improving joint movement
and function; treatment involves both pharmacological and non-pharmacological
modalities (Lundgren-Nilsson et al., 2018). Although the role of pharmacological
management is well recognized in reducing swelling and pain, also the costs of treatment
and the prolonged-term side effects of medication should not be underestimated
(Salmon, et al., 2018).

3. 3
Different non‐pharmacological methods like patient education, protection of the
joint, losing weight, exercise, heat and cold application, joint protection techniques,
exercises, use of ancillary devices, thermal methods, Tai chi, acupuncture, and
transcutaneous electrical nerve stimulation (TENS) can be applied for the treatment of
knee OA (Uludağ and Kaşikçi, 2019 & Hochberg, et al., 2012). Previous studies
demonstrated that nonpharmacological methods, used independently or in combination
with pharmacological methods, are effective in pain management (Özveren, 2011&
Zhang et al., 2008).
Hot compresses are safe and low-cost option that can be used on its own or in
conjunction with other therapies, for long-term control of pain, stiffness, and
inflammation (Shafii, et al., 2018). In general, the physiological effects of heat therapy
can encourage the healing of damaged tissues and causes the blood vessels of the
muscles to dilate, which increases the flow of oxygen and nutrients to the muscles. In
addition to, warmth with gentle bending and flexing, can spur joint fluid production,
which can relax muscles and help lubricate joints, relieve muscle and joint stiffness, help
warm up joints before activity, or ease a muscle spasm. Warmth also, can stimulate
sensory receptors in the skin and decrease the transmissions of pain signals to the brain
(Zamri, et al., 2019).
Another nonpharmacological method used to eliminate pain and ensure
symptomatic relieve in knee OA is physical exercise. Exercise is crucial for knee OA
patients, as it can recover tendons, strengthen leg muscles, reduce the burden on joints,
and stimulate beneficial biochemical changes in synovial fluid by increasing blood
circulation in knee joints. Exercise can help controlling symptoms of osteoarthritis such
as pain, lack of flexibility, decreased strength, and morning stiffness. Controlling each

4. 4
of these can improve function which will result in improvement of quality of life (Bieler
et al., 2018).
The combination of heat application and exercises for knee OA patients has been
stated to reduce pain, ensure comfort, and enhance stiffness and physical function
(Shereif & Hassanin, 2011). In brief, heat application and exercises are reported to
reduce pain and enhance function levels among patients with knee OA. Randomized
controlled studies are further needed for nonpharmacological treatment methods
including thermal therapies in knee OA (Çalışkan, 2013). Nevertheless, the number of
studies using these two methods simultaneously is limited (Kim et al., 2013; Shereif &
Hassanin, 2011). Hence, the current study aimed to assess the effect of physical
exercise, heat application, and combination of physical exercise and heat application on
relieving pain and morning stiffness for knee OA patients.
Aim of the study:
The current study aimed to assess effect of physical exercises, heat application,
and exercises after heat application on relieving pain and morning stiffness for knee OA
patients.
Through the following objectives:
1. Assess effect of heat application on relieving pain and morning stiffness for
patients with knee OA.
2. Assess effect of physical exercises on relieving pain and morning stiffness for
patients with knee OA.
3. Assess effect of combination of heat application and physical exercises on
relieving pain and morning stiffness for patients with knee OA.
4. Compare between physical exercises, heat application, and combination of heat

5. 5
application and physical exercises on relieving pain and morning stiffness for
patients with knee OA.
Research hypothesis:
Post application of heat application, physical exercises, or combination of both treatment
regimens, patients will exhibit improved relieving pain and morning stiffness for patients
with knee OA than pre application of the intervention.
Materials and method:
Design:
A quasi-experimental design was used in the present study.
Setting:
This study will be conducted at the orthopedic outpatient clinics in Suez Canal
University Hospital which serving the Suez Canal region including Ismailia, Port Said,
Suez, and Sinai with free services.
Subjects:
A purposive sample of 120 patients with osteoarthritis was enrolled in this study using
pre and posttest based on the following criteria:
Inclusion criteria:
1- Patient aged above 21 years.
2- Have no comorbid diseases (cardiac patients).
3- Have no joint surgeries.
Exclusion criteria:
1- Have communication disability.
2- Body mass index of patients above 35.

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Tools for Data Collection:
Two tools were used for collection of data and achieve the aim of the study as the
following:
Tool 1: Structured Interview Questionnaire:
This tool was developed by the researcher and reviewed by a panel of five experts
in medical surgical nursing aimed to identify patient demographic data, health relevant
data, and assess patient's knowledge about the disease and its management, it takes about
(10) minuets to be completed: it is divided into three parts as follow:
Part I: Demographic data:
It included (6) multiple choice closed ended questions ask about patients' gender,
age, and educational level, occupation, marital status and life environment(rural/urban).
Part II: Health relevant data: It included (5) questions to assess past history and
present health status for patients.
Part III: Knowledge regarding knee osteoarthritis and its management:
It included (8) questions ask about duration, symptoms, and management methods of
osteoarthritis.
Tool 2: The Knee Injury and Osteoarthritis Outcome Score (KOOS):
The Knee Injury and Osteoarthritis Outcome Score (KOOS) is a questionnaire
adapted from Roos, et al (1998), designed to assess short and long-term patient-relevant
outcomes following knee injury. The KOOS is self-administered and assesses five
outcomes: pain, symptoms, activities of daily living, sport and recreation function, and
knee-related quality of life. The researcher excluded the part of quality of life because it
is not suitable for the study aim.
Scoring System:
The KOOS's tool contains (38) questions, and takes about 10 minutes to fill
out the total questions and includes four patient-relevant dimensions which scored
separately: Pain (nine items); Symptoms (seven items); ADL Function (17 items); Sport
and Recreation Function (five items). A Likert scale is used and all items have five
possible answer options scored from 0 (No problems) to 4 (Extreme problems) and each
of the four scores is calculated as the sum of the items included. Scores are transformed
to a 0–100 scale, with zero representing extreme knee problems and 100 representing no

7. 7
knee problems as common in orthopedic scales and generic measures. Scores between 0
and 100 represent the percentage of total possible score achieved.
Total score for each subscale will categorized into
< 100 – 66 Mild
< 66- 33 Moderate
< 33- 0 Extreme
Phases of the Study
1. An official letter from the Faculty of Nursing will be submitted to the appropriate
authorities in the selected setting for obtaining the permission.
2. Ethical considerations:
Approval will be obtained from the research ethics committee, Faculty of Nursing,
Mansoura University. Informed consent will be obtained from study participants, who
will be informed of the purpose of the study and will be assured that their identities and
responses to the questionnaire would be confidential; answering was voluntary, and
participation (or not) would have no effect on their current or future condition.
 The validity of the study will be tested by:
- A jury that involves five experts of medical surgical nursing and neurologist will
test validity of the developed tools, and the required modification will be carried
out.
- A Pilot study on 10 % persons who are not included in the study to test the validity
and reliability of the questionnaire. Accordingly, any required modifications will be
done.
- Accordingly, any required modifications will be done.

8. 8
Results
Data collection will be coded, tabulated and presented in tables, figures and proper
statistical analysis will be used.
Discussion
Discussion of the obtained data will be done based on the findings, other related
studies and literature review.

9. 9
Conclusion and Recommendations
Appropriate conclusion and recommendation will be made based on the findings.

10. 10
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