Dry heat versus moist heat for relief of arthritic pain

Transcription

1 Dry heat versus moist heat for relief of arthritic pain Item Type text; Thesis-Reproduction (electronic) Authors Robberson, Linda Kay, Publisher The University of Arizona. Rights Copyright is held by the author. Digital access to this material is made possible by the University Libraries, University of Arizona. Further transmission, reproduction or presentation (such as public display or performance) of protected items is prohibited except with permission of the author. Download date 21/06/ :07:25 Link to Item

2 DRY HEAT VERSUS MOIST HEAT FOR THE RELIEF OF, ARTHRITIC PAIN by Linda Kay Robberson A Thesis Submitted to the Faculty of the COLLEGE OF NURSING In Partial Fulfillment of the Requirements For the Degree of MASTER OF SCIENCE In the Graduate College THE UNIVERSITY OF ARIZONA

3 Med V/HA M13 STATEMENT BY AUTHOR This thesis has been submitted in partial fulfillment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library. Brief quotations from this thesis are allowable without special permission, provided that accurate acknowledgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his judgment the proposed use of the material is in the interests of scholarship. In all other instances, however, permission must be obtained from the author. SIGNED:; APPROVAL BY THESIS DIRECTOR This thesis has been approved on the date shown below: KAREN SECHRIST Assistant Professor of Nursing

4 PREFACE This study was done as partial requirement for a Master of Science degree in the area of Medical-Surgical Nursing., In fulfilling this requirement it was necessary that the study be pertinent to nursing and be centered around the purpose of improved patient care. The author would like to acknowledge the cooperation of the Pima County Extended Care Facility Staff, Director of Nursing, Mrs. Helen Cording and Dr, Collins, physician whose patients were used in this study. Special appreciation is extended to the patients who voluntarily took part in this experiment. Also I would like to acknowledge the assistance of my knowledgeable and able thesis committee, Mrs. Karen Sechrist, Chairman, Dr. Harold J. Rowe, and Miss Rose Gerber. iii

5 TABLE OF CONTENTS Page LIST OF TABLES vi LIST OF ILLUSTRATIONS... vii ABSTRACT viii CHAPTER I INTRODUCTION Statement of the Problem Definitions for the Study Hypotheses ^. 6 Null Hypotheses... 6 Theoretical F ramework... 6 Assumptions Limitations... 8 II REVIEW OF THE LITERATURE 9 The Use of Different Methods of Heat Application Rationale for Method of Moist and Dry Heat Application. 10 Precautions in the Application of Heat Other Factors Besides Heat Therapy Which Effect Range of Motion III METHODOLOGY Research Design Measurement Scales Analysis of Data IV CHARACTERISTICS OF THE SAMPLE V REPORT OF FINDINGS Description of the Data Results of Analysis iv

6 V TABLE OF CONTENTS Continued Page VI DISCUSSION OF FINDINGS VII S U M M A R Y APPENDIX A: PATIENT CONSENT F O R M APPENDIX B: PATIENT INFORMATION SHEET APPENDIX C: PAIN SCALE APPENDIX D: NORMAL RANGE OF MOTION SELECTED BIBLIOGRAPHY

7 LIST OF TABLES Table Page 1. Patient Characteristics Independent Variables Affecting the Change in Range of M o t i o n Degree of Change in Range of Motion after a Series of Three Treatments with Moist or Dry Heat Multiple Regression of Variables Related to Degree, of Change of Range of Motion Analysis of Variance Test of the Hypothesis vi

8 LIST OF ILLUSTRATIONS Figure le Page Data Distribution for Change in Range of Motion with Moist Heat Data Distribution for Change in Range of Motion with Dry Heat vii

9 ABSTRACT Increase of range of motion in patients with osteoarthritis is desirable. For the patient with this disease process heat therapy has frequently been employed. This study was designed to evaluate the effectiveness of the use of moist heat in preference to dry heat for increase in range of motion. The other purpose was to determine if there was other significant independent variables affecting the range of motion. The study was conducted with the use of a goniometer to measure change in range of motion after a set of moist or dry heat treatments. The findings were submitted to Pearson r analysis and to a t test of the ;difference between two independent means which showed that moist heat was not more significant than dry heat in influencing change in range of motion. The independent variables were submitted to multiple regression and analysis of variance. As a group, these variables were statistically significant at the.01 level in their influence on changes in range of v motion. The independent variables most influential were barometric pressure, room temperature, and rating of pain.

10 CHAPTER I INTRODUCTION The treatment of osteoarthritis to relieve pain associated with the disease process is an area which deserves attention due to its prevalence. Osteoarthritis is found with considerable frequency in radiological examinations of population samples. In a study done in England, evidence of osteoarthrosis was found in at least one joint in 50 percent of the adult population. Changes appeared first as a rule in the metatarso-phalangeal joints of the big toes, and these joints were affected as early as 20 years of age. With increasing age the number of affected joints increased and from age 45 the increases became more rapid in females than in males (Dixon 1965, p. 8). Osteoarthritis is probably the most common of all the joint diseases and is the kind meant when it is said that "everyone gets some arthritis if they live long enough" (Crain 1971, p. 22). Osteo means bone and this type of arthritis is so called because of the bony spurs which occur around the margin of the joints. The term "hypertrophic arthritis" is also used and for a similar reason. Hyper means over and trophic, growth. The little bony deposits are overgrowths of calcium. The third term sometimes used is "degenerative joint disease" referring to the changes in the cartilage during this type of arthritis (Crain 1971, p. 22). 1

11 Osteoarthritis is characterized by spur formation at the edges of the joint surfaces and thickening of the capsule and synovial membrane. The joint cartilages degenerate and atrophy, the. bones harden at their articular surfaces and the ligaments calcify. Nevertheless the joint spaces themselves remain preserved and no adhesions form in them (Brunner et al. 1964, p. 1027)» Symptoms, -which usually come on in middle age or later are predominantly joint pain and stiffness. There are no abnormal laboratory findings, as in rheumatoid arthritis, and no systemic signs or symptoms. The joints may appear normal on physical examination. Crepitus is sometimes noted when moving the joint through range of motion. Radiological studies may be normal or may show a number of changes like sclerosis of the bone or osteophyte formation (Light 1968, pe 288). Osteoarthritis is not confined to the aged. If the aging process per se is not the cause of osteoarthritis it might be thought that reduction in blood supply to the joint produced by atherosclerotic narrowing of the arteries which occurs commonly in old age, might contribute to the pathogenesis of the condition (Boyle and Buchanon 1971, p. 4). This chronic disorder, osteoarthritis, involves weight bearing joints particularly knees, hips, lumbar spines, and the distal inter- phalangeal joints of the fingers. It affects an even greater number of men and women than rheumatoid arthritis, although far less disabling, its medical and economical importance is very considerable. Due to its prevalence and its long term characteristics, the treatment of this disease process is an area which deserves attention. At the present time heat therapy is being utilized with a certain amount of success. Heat has been used for the relief of aches and pains ever since man first experienced what the sun's heat could do for him. In 137 A.D.

12 Surgerish called "the use of heat in therapy instinctual" (Light 1965, p, 196)e However the modern theory of heat began with the epoch of Newton. Robert Boyle shared with Newton, the concept of heat being the result of molecular agitation. However, the development of a general theory of heat depended on a later realization of the laws of conservation of mass and energy. Of all the therapeutic agents used since ancient times, few have been used as continuously or as consistently as has heat. The oldest known sources were those that existed naturally and are still widely used (Light 1965, p. 196). The commonest indication for heat therapy is for the relief of pain. The action of heat, whether applied in the form of moist or dry heat, is its action in increasing blood flow to the area of inflammation by dilating the small blood vessels. This results in a rise in capillary pressure, increase in local chemical activity and augmentation of defense mechanisms in that area (Bland 1960, p. 138). The relaxation of muscle spasms is probably partly induced by the sedative effect as well as by the analgesic effect of local heating. This general relaxing effect is on the tonus of skeletal muscle and in particular pathological tonus of muscles in spasm or reflex contracture. The abnormal state of muscle activity and the pain often connected is not only temporarily relieved, but in many cases with repeated treatment it effects more or less permanent improvement. This may be explained by "the removal of the trigger irritation thus breaking up a vicious cycle in which the pain reinforces, reflexly, the abnormal muscle activity" (Light 1965, p. 158)..

13 Another possible explanation for the diminished increase in reflex tonus may be a direct temperature influence upon the muscle 4 spindles. In osteoarthritis we probably are dealing with an increased proprioceptor reflex mechanism, so it is necessary to consider a reflex effect of heat on the central proprioceptor mechanism or a direct effect of heat on the peripheral proprioceptor apparatus. The muscle spindles of the skeletal muscles are the receptor endorgans for the muscular proprioceptor reflexes. The excitability of these receptors to stretch depends on the efferent innervation reaching the spindles via the fine gamma motor fibers. Gamma fiber's are maintained by the central nervous system in a mild state of activity, which can be influenced reflexly (Light 1965, p. 158). The psychological effect of heat cannot be ignored. A patient who sees and feels something definite which is comforting being done for him may be experiencing a placebo type of effect. "This placebo effect cannot be belittled, for the practice of medicine would be even more difficult without it" (Light 1965, p. 238). In addition to heat there are other environmental factors that appear to play a role in the treatment of this disease. Of particular interest are barometric pressure, and room or air temperature, which are constantly present but are in a state of fluctuation. Lastly, the socio-psychological factors of length of illness and pain must be recognized as they may be interrelated. The physical illness must be viewed not only in terms of effect upon physical functioning, but also in terms of how it has affected overall life style. The converse of this is also true as it is important to consider how

14 socio-psychological functioning affects patients1 adjustment to physical illness (Krusen 1965, p.169). Statement of the Problem Is moist heat more effective than dry heat for the increase in range of motion in wrists or ankles of persons with osteoarthritis? Or are other factors, such as social, socio-psychological, and environmental also significantly associated with range of motion of individuals with characteristics of osteoarthritis? Definitions for the Study 1. Moist heat-~a pan of water maintained at 105 degrees Fahrenheit. 2. Dry heat--a heat lamp (luminant source) at a distance of inches. 3. Osteoarthritis--,,cartilage degeneration and bony eburnation with the formation of hypertrophic bony spurs at diathroidal joint margins leading to derangement in joint function and mechanics and producing pain" (Crain 1971, p. 22). 4. Difference in perception of pain--the amount of perceived "discomfort, distress, or suffering. Pain may be varying in intensity from mild discomfort to intolerable agony" (Taber 1965, p. 2). 5. Effective that which decreases discomfort and allows for increased function of the joints involved with the disease process. 6. Range of motion--the degree of joint movement measured by the angle obtained through the use of a goniometer.

15 Hypotheses 1, The association between moist heat and the variation in range of motion is greater than the association between dry heat and the variation in the range of motion. 2. There is a significant relationship between the independent variables; barometric pressure, room temperature, pain tolerance, age, sex, skin pigmentation, length of illness, and medication, and the dependent variable, range of motion. Null Hypotheses 1. The association between moist heat and the variation in range of motion is not greater than the association between dry heat and the variation in the range of motion. 2. There is no significant relationship between the independent variables; barometric pressure, room temperature, pain tolerance, age, sex, skin pigmentation, length of illness, and medication, and the dependent variable, range of motion. Theoretical Framework Heating by conduction with moist heat raises skin temperature more rapidly and maintains the temperature at that point more consistently than does heating by convection with infrared light (Seagrave 1971). Surface-to-surface transfer of heat is more rapid than heat transmitted through air-to-surface areas. One of the chief weaknesses of luminous heat therapy has been the difficulty of measuring the amount of heat absorbed by the patient (Light 1965, p. 10).

16 \ In heating by convection the heat is transmitted through air or atmosphere to the body from an outside radiating source. within the infrared portion of the spectrum (Bland 1960). This heat falls Although reflex stimulation and alteration of collateral circulation do occur, the effects of infrared therapy are more or less restricted to the surface. In heating by conduction the heat is transferred from one surface to another. This causes a more rapid change in surface temperature. With this occurrence the heat more rapidly penetrates the tissues allowing for a greater increase in temperature in a shorter period of time, "Hot water is the basis of many forms of conductive heating because water has a high specific heat and is a relatively good conductor of heat" (Light 1965., p. 242). Another advantage of the transfer of heat through conduction by the method of water immersion is that it prevents heat loss by evaporation, thus maintaining a constant temperature to the area. In addition, this temperature is not continuously changing due to the fluctuation of air temperatures as is seen in the transfer of heat by convection. There are also other independent variables that must be taken into consideration in this theoretical framework. The psychosocial aspects of osteoarthritis must be considered in terms of the patient and his total life situation. "Any disability has its impact on the psychosocial aspects of the patient and his life situation" (Krusen 1965,p.169). The impact may be benign and the patient can handle this impact with little outside help; or there may be considerable dislocation with the disability and require extensive help, in the area of psychosocial functioning (Krusen 1965).

17 There is also the environmental factors, which have been credited over the years by the lay people with the disease process, causing pain 8 when they reach certain levels. These factors appear to be such.things as increase in barometric pressure and air temperature. However, there are no studies at present to support these beliefs. It has been stated by Boyle and Buchanon (1971, p. 6) that ^climate does not appear to cause it (referring to osteoarthritis), but it does effect clinical expression of symptoms." Assumptions 1. Heat is effective for the relief of pain and increase in mobility for patients with osteoarthritis. 2. Twenty minutes at 105 degrees Fahrenheit is the appropriate time and temperature for application of moist heat. 3. Twenty minutes with an luminant lamp inches from the area is the appropriate time and distance for application of dry heat. Limitations 1. The researcher was the only one involved in the collection of the data. 2. The sample was limited to fifteen patients, each patient getting two types of treatment. 3. The participants all came from one Extended Care Facility in one city. 4. The sample was limited to patients with osteoarthritis of the wrists or ankles, who were coherent and capable of communicating verbally.

18 CHAPTER II REVIEW OF THE LITERATURE The Use of Different Methods of Heat Application. Throughout the literature on the subject of heat application, the use of heat for its relieving effect; its relief of muscle spasms, and its ability to increase the local blood supply is cited. Artificial heat was first used in 3000 B.C. by the Egyptian and Hindu cultures. At present artificial heat is used in many forms. The action of heat,whether applied as infrared radiation, wax bath, poultices, short-wave diathermy, or moist heat (soaks or compresses) is beneficial in its soothing and pain relieving properties by increasing local blood flow to the inflamed or effected area. This increased blood flow hastens the process of recovery and resolution of the inflammatory response (Rose.1967). Almost without exception, joints that are the site of osteoarthritis will be benefited by local applications of heat. This holds true whether the joint is inflamed chronically or temporarily. A joint acutely inflamed responds most satisfactorily to moist heat (Crain 1971). On the other hand, lamps (single bulbs or banks of bulbs) are frequently prescribed. "In our experience they are less effective than wet hot packs or paraffin and less acceptable to the patients" (Shestack and Ditto 1966, pe 136).

19 Rationale for Method of Moist and Dry Heat Application Heat should be comfortable during the entire treatment. Then following the heat application "the skin should be pink and warm, not hot and red" (Light 1968, p. 17) with the deep pink color disappearing in about 20 minutes following completion. This criteria remains the same regardless of the method of heat application, be it moist or dry heat. When using moist heat the temperature of the water is gradually raised from 95 degrees Fahrenheit to 105 degrees Fahrenheit and the treatment length is from 30 to 40 minutes (Bland 1960) Crain (1971) states that the water temperature be adjusted to the point it feels comfortably warm at about degrees Fahrenheit. The time can be reduced to 20 minutes with like results as demonstrated in the study by " Abramson and associates (1967) where the maximum tissue level was reached in 15 minutes of the heat application. With the use of dry heat from a luminous source the heat energy absorbed should fall in the range of 3,900-7,600 angstroms. This is closely that heat received from a 45 watt bulb which is placed inches from the surface being heated. The application of dry heat should also last 30 minutes (Shestack and Ditto 1966, p0 36). A similar study to the one which is being conducted compares the effectiveness of moist heat to dry heat. Abramson and associates conducted an experiment in 1957 to determine whether dry or wet heat was more effective in raising temperature of tissues. They studied the effect of wet and dry heat on 17 normal subjects using the forearm as the area of exposure. The method used in this experiment to measure the

20 effectiveness of the heat was to insert thermocouples on the surface of the skin, subcutaneously, and into the muscle to measure the different 11 temperature levels. Dry heat was applied by a 250 watt heating unit for a period of 15 minutes. A 33.8 degree Centigrade water bath was used to provide the moist heat for a 15 minute period of time. It was concluded that wet heating is more effective than a similar level of dry heating in raising all tissue temperatures. However, the fact that it produces discomfort and pain limits its usefulness. Conversely the finding that dry heat is much better tolerated than wet heat permits its application at higher temperature intensities, thus making it possible to attain similar degrees of deep heating with each of the two procedures (Abramson and associates 1967, p. 661). Precautions in the Application of Heat All physical treatment should be prescribed in terms of dosage. When prescribing heat the amount should be related to the therapeutic effect and the physiology of the tissue being treated. Heat treatments can be dangerous if executed carelessly or with errors in quantity and time. "Precautions of thermotherapy are based primarily on lowered heat sensitivity, diminished skin sensation, circulatory embarrassment, and unreliability of patients" (Light 1968, p. 17). This is particularly true when heat is being used with small children or with aged individuals. Since heat can cause edema and burns, the part being treated should be visible for inspection at all times. Some patients may feel that if a little heat is good, a whole lot should be better. This is an error in logic. Although it is difficult to know what is the optimum, it is known that beyond a certain point, the

21 12 affects of too much heat can be deleterious. This is especially important to remember when conduction of heat is through water, because skin burns more rapidly in water at 125 degrees Fahrenheit than in air at 190 degrees Fahrenheit. Other Factors Besides Heat Therapy Which Effect Range of Motion These independent variables can be placed into three major categories. They could be thought of as: (1) social factors; (2) socio- psychological factors; (3) environmental factors. The social factors of age, sex, and skin pigmentation have not been shown to have a causal effect. However, we still must cope with 40 million Americans with radiological evidence of osteoarthritis and a majority of others beyond the age of 20 years who show early histologic evidence of the disease. About 5% of persons past 50 years of age have osteoarthritic symptoms (Stillman 1972, p. 45), Hoaglund (1971, p._ 10).states, "There.is a progressive increase,in number of joints involved and the severity of involvement with increasing age in both sexes." The perception of pain and length of illness can be classified as socio-psychological factors. There is interrelatedness of physical, psychological, and social aspects of disease states. There may be effects of one factor felt on another factor. How the patient handles these psychosocial factors may affect his adjustment to the disease (Krusen 1965). The third set of factors to be considered are the environmental ones. These take into consideration a range of such variables as room temperature, barometric pressure, and the application of heat.

22 13 One of the environmental factors which appears to be of some significance in osteoarthritis is the weather or more specifically the barometric reading. This factor has not, however, been substantiated with facts and remains questionable. It is not uncommon to hear remarks made to,the effect that it is going to rain or snow because my joints are painful. There may be some truth to these statements as increase in barometric pressure may have some influence on the affected joints. Boyle and Buchanon (1971, p. 6) state that "climate does not appear to cause it (referring to osteoarthritis), but it does affect clinical expression of symptoms."

23 CHAPTER III METHODOLOGY Research Design In conducting this research to determine the effectiveness of moist heat versus dry heat application for the relief of pain and increased range of motion the researcher used the following method. The first step was contacting the director of nursing and the patients physician to gain their written permission for the use of their patients with osteoarthritis of the wrists and ankles. Fifteen patients were chosen at random from all the patients with this disease process in the nursing home. The restrictions placed on this selection were that they have osteoarthritis in at least one wrist, or one ankle, that they were coherent, and that they could communicate verbally with the researcher. Then the treatments were explained to the patients and, those agreeing to participate were asked to sign the patient consent forms (see Appendix A). With the completion of this preliminary work the research began, and Doctor s Orders were written for the treatments, A patient information sheet was completed on each subject (see Appendix B), Then the subjects were randomly picked for either Treatment I or Treatment II, which would be given first. Each set of treatments was given on three 14

24 15 consecutive days and after a week interval the subjects received the other alternate treatment for three consecutive days. By definition, control by constancy was used in setting up the methodology. This is, if one fixes the values of all but the independent and dependent variables during an experiment, by definition one has effected control by constancy. Control by constancy, as it is used in psychophysical,neurophysical, and attitudinal experiments, as well as in experiments in physics, per se (Baird 1962), simply requires that every variable that is directly manipulatable in an experiment (including the subjects) must remain constant across all experimental conditions. The only exceptions to this rule are the independent variables, which are manipulated and measured systematically and the order of their manipulation and measurement. Ideally, all of the subjects are subjected to the experimental manipulations and measurements, each in a different random order, to randomize and order presentation and measurements effects which usually are very small (Hamblin 1973). Prior to beginning each treatment the subjects were tested with a goniometer to determine their degree of range of motion in the affected extremity. extension. These measurements were the subjects1 degree of flexion and Secondly, the subjects were asked to rate the amount of pain they were having prior to the treatment using an analogue scale (see Appendix C). Treatment I was conducted by placing the patient1s affected area in a water bath at 105 degrees Fahrenheit and the water was maintained at this temperature for 20 minutes. Following the removal of the

25 affected area from the water bath the patient's extremity was moved only to the degree of flexion and extension possible before the treatment and 16 was again asked to rate the pain. The patient's range of motion was again tested and rated by degrees of flexion and extension possible after the treatment. The subjects received the same method of treatment on the next two consecutive days to make a total of three treatments. The procedure was carried out in the preceding manner at those times. Treatment II was conducted by placing the patient's affected area under a luminous lamp which utilized radiant energy by carbon or tungsten filament bulbs reinforced by reflecting surfaces. The lamp was placed 18 inches above the area to be treated and kept there for a period of 20 minutes. Following the treatment the patient's extremity was moved only to the degree of flexion and extension possible before the treatment and was again asked to rate the pain. The patient's range of motion was then tested and rated by degrees of flexion and extension possible after the treatment. The subjects received the same method of treatment on the next two consecutive days to make a total of three treatments. The procedure was carried out in the above manner at those times. On each day at the time of each treatment a barometric reading was taken. This was done to determine if there was any correlation between the patient's pain and the barometric pressure. Measurement Scales The measures in this research were designed to meet the criteria of true metric scales in order to make multiple regression analysis

26 17 possible. The scales used are interval, as they have a true zero point representing a complete absence of the variable being measured and each point on the scale is designed to represent an equal interval (Blalock 1972). The first scale used was the measurement of range of motion on flexion and extension taken with a goniometer before and after the treatment. This normal range of motion chart is found in Appendix D. The second scale was the subjective assessment of pain carried out using an analogue scale. The sensitivity and reliability of this scale was reported in 1964 by Clark and Spear (in Bond 1971). Its use for the assessment of pain in patients with malignant disease has been reported previously by Bond and Pearson in 1966 and 1969 (in Bond 1971). Patients were asked to make a single vertical mark on a 10 cm line. At the left end is typed f,i have no pain at all" and at the right end, "My pain is as bad as it could possibly be." The distance from the left end to the intersection mark was measured in millimeters and designated as a pain score (Bond 1971). The advantage of this technique is that it is 11self-anchoring" and results in a continuous and theoretically equal-interval measure... It is self-anchoring in the sense that it is relative to each person's own conception of maximum and minimum amount of pain. This self-rated pain sensation represents the worst possible pain (10 cm) at the top and no pain (0 cm) at the bottom of the scale. The third tool was a barometer, which was used to take the barometric reading at the time of the treatment. A barometric reading like

27 18 the previous measures, is interval measurement with a zero point and equal interval scaling. Analysis of Data The first hypothesis was tested with the use of the Pearson r, correlation coefficient, and with the use of central tendencies (mean, median, and standard deviation). These statistical tests were used to determine the difference if any between the use of dry and moist heat for increase of range of motion of subjects with osteoarthritis. In the simultaneous multiple regression procedure used in the analysis of hypothesis II, an attempt was made to evaluate the relative influence of the independent variables which were categories as follows: social factors, socio-psychological factors, and environmental factors, upon the dependent variable, range of motion. The reported results of the relative influence of the independent variables on the dependent variable is reported in terms of multiple correlation. According to Blalock (1972, p. 454) since our main interest is in the explanatory power of a group of independent variables taken collectively rather than in the relationship between the dependent variable and each of the independent variables taken separately, a multiple 2 correlation coefficient, R, is an appropriate measure of the goodness of fit of the least squares surface to the data. Just as the square of the zero-order correlation coefficient indicates the percentage of the variation explained by the best-fitting straight line, the square of the multiple correlation coefficient can be used to give the percentage of variation explained by the best-fitting equation of the form:

28 19 7^ = a + b1x1 + b2x b ^ (Blalock 1972., p. 408) The results of the assessment of the independent variables when all independent variables are controlled is reported in terms of beta weights. The betas which appear in the equation linking Y to the independent variable can in a sense be interpreted as partials. They represent the slopes of the regression or least-squares equations in the dimension of the appropriate independent variable, i.e., with all other independent variables held constant. Each coefficient therefore represents the amount of change in Y that can be associated with a given change in one of the X s with the remaining independent variables held fixed.

29 CHAPTER IV CHARACTERISTICS OF THE SAMPLE The sample consisted of 11 women and four men. Their ages ranged.from 63 to 100 years of age. Each subject,has had osteoarthritis for a period ranging from two to ten years. The characteristics gathered in this study on each individual are listed in Table 1. Table 1. Patient Characteristics. Patient Age (Years) Sex Skin Pigment Length of Time with Disease (in Years) 1 87 F Dark F Light F Light M Light M Light F Light F Light F Light F Light F Light M Light F Light F Dark F Light M Light 8 20

30 CHAPTER V REPORT OF FINDINGS Description of the Data Each subject was randomly given either the moist or dry heat set of three treatments first followed by the other set of three treatments. Table 2 gives the results of each set of treatments in degree of change in range of motion. This change was a determination of the difference in range of motion from the beginning of a set of treatments to the end of the set. Table 2. Independent Variables Affecting the Change in Rangei of Motion. Patient Room Variations in Pain Rating Pain Rating Temperature Barometric Read- with with in ing Range :During: Moist Heat Dry Heat Fahrenheit Moist Heat Dry Heat cm 0 cm cm 4 cm cm 2 cm cm 2 cm cm 0 cm cm 2 cm cm 0 cm cm 1 cm cm 2 cm cm 0 cm cm 2 cm cm 0 cm cm 2 cm * cm 2 cm cm 0 cm 21

31 Each subject who started in the study was able to complete the 22 study without any omission of treatments. Therefore, there were no failures in the experiment or loss in sample size. The total of all the subjects' change in range of motion with moist heat was 355. The total of all the subjects' change in range of motion with dry heat was 305. Even though it is not statistically significant, it is interesting to note that of the 15 subjects, five had increased range of motion with dry heat, seven had increase range of motion with moist heat, and three had the same results with both types of heat (see Table 3). Table 3. Degree of Change in Range of Motion after a Series of Three Treatments with Moist or Dry Heat. Patient Moist Heat Treatment 15 I I: $ Dry Heat Treatment c 3^ S30C 25C

32 Other independent variables collected which were felt might in- ' fluenee the patients1 range of motion were barometric reading, room 23 temperature, and pain ratings. These independent variables are found in Table 2. Results of Analysis Hypothesis I, the association between moist heat and the variation in range of motion is greater than the association between dry heat and the variation in the range of motion, was submitted to Pearson's r analysis. The standard deviation for moist heat was and for dry heat was The mean for moist heat was 23,66 and the mean for dry heat was The correlation coefficient (r) was.642. This data was further submitted to a t test of the difference between two independent means. The results of the t test was.424, which is significantly high correlation of the two independent means at the.01 level. The distribution of the data was highly skewed. Therefore, the median of both sets of data was determined, because in distributions which are strongly asymmetrical, the median is a better choice to represent the bulk of the scores and not give undue weight to the relatively few deviant ones (Minium 1970). The median for change of range of motion for both moist and dry heat was 15, These results are found in Figures 1 and 2. Since a high correlation of Pearson r was obtained and a high correlation of the t test was found significant at the.01 level, it would appear to show that there is only a small difference in the two types of heat. With the Pearson r (.642), the results lie closely to

33 Figure 1. Data Distribution for Change in Range of Motion with Moist Heat. Median S = x Q C/3 Q CO Figure 2. Data Distribution for Change in Range of Motion with Dry Heat.

34 1.0 which would be a perfect correlation between the two types of heat treatment, meaning there is over 64.2 percent of overlapping in the 25 treatments' results. Also in light of the highly skewed distribution with a median of 15 for both groups there appears to be little difference. On this basis the hypothesis was rejected and the null hypothesis was accepted. In Hypothesis II, there is a relationship between the independent variables, social, socio-psychological, and environmental factors, and the dependent variable, change in range of motion* was submitted to analysis with the use of multiple regression..table 4, multiple regression of variables related to degree of change of range of motion, contains the results of this analysis. Table 4. Multiple Regression of Variables Related to Degree of Change of Range of Motion. Variable Non-Standardized Standardized 0 Coefficients 3 Coefficients Age Sex Skin Pigmentation Length of Disease Room Temperature Pain Rating Medication Barometric Pressure Heat Therapy Multiple R Squared =.6108 Multiple R =.7815

35 The standardized beta coefficients rank the variables in order 26 of importance. The correlation is a measure of the amount of variation explained by each independent variable toward the whole, which is change in range of motion or the dependent variable (Blalock 1972). This means each standardized beta coefficient indicates how much change in the dependent variable is produced by a standardized change in one of the independent variables when the others are controlled. Referring to the table, it is seen that skin pigmentation with a standardized beta coefficient of.008 is the least significant in predicting the dependent variable, range of motion. However, patient age, room temperature, and barometric reading, whose standardized beta coefficients range from.526 to.669, are significant in predicting the dependent variable. The variable heat has a standardized beta coefficient of -.168, which only predicts 16 percent of the variation in the dependent variable. Next, an analysis of variance (F) test was done to test Hypothesis II, that the independent variables significantly influence range of motion. The F Table value for F at the.01 level of significance is 3,23. The computed F value of 3.49 is greater than this F value. Therefore the null hypothesis of no significant difference is rejected and the hypothesis of significant influence of independent variables on range of motion is accepted. Table 5 contains the analysis of variance test of the hypothesis.

36 27 Table 5. Analysis of Variance Test of the Hypothesis. Sum of Square Degrees of Freedom Estimates of Variance F Total Explained Unexplained

37 CHAPTER VI DISCUSSION OF FINDINGS The data from the study did not substantiate thefuse of moist heat in preference to dry heat. However it did suggest that there are other significant independent variables affecting the range of motion of joints affected with osteoarthritis. Further, only 16 percent of the change in range of motion can be shown to be due to the use of heat both moist and dry. The data from the study did not statistically substantiate the use of moist heat in preference to dry heat, but in seven patients of the 15 there was increased range of motion with moist heat. In light of this data, it appears that the type of heat therapy, moist or dry, could be left to the discretion of the patient and/or physician if heat treatment is desired. Apparently the barometric pressure, room temperature and patient's pain tolerance or rating are significant factors in the treatment of osteoarthritis. While the study explored heat and other variables as possible contributions to increase in range of motion, the intangible elements of pain relief, i.e., other psychological factors cannot be discreetly analyzed. Therefore, if the patients feel they get relief with heat, moist or dry, the patients' wishes should be followed. It does not hurt and it does help a little. 28

38 CHAPTER VII SUMMARY Increase of range of motion in patients with osteoarthritis is desirable. For the patient with this disease process heat therapy has. frequently been employed. This study was designed to evaluate the effectiveness of the use of moist heat in preference to dry heat for increase in range of motion. The other purpose was to determine if there was other significant independent variables affecting the range of motion. The study was conducted with the use of a goniometer to measure change in range of motion after a set of moist or dry heat treatments. The findings were submitted to Pearson r analysis and to a t test of the difference between two independent means which showed that moist heat was not more significant than dry heat in influencing change in range of motion. The independent variables of age, sex, length of illness, skin pigmentation, barometric pressure, room temperature, medication, and pain rating were submitted to multiple regression and analysis of variance. As a group, these variables were statistically significant at the.01 level in their influence on changes in range of motion. The independent variables most influential were barometric pressure, room temperature, and pain rating. 29

39 30 Traditional theory is that moist heat is more effective than dry heat for the production of change in range of motion. This study did not substantiate that belief. In fact, other factors may be more influential than either type of heat in producing these changes. The following implications for further study are suggested: 1. A study using subjects from a wide variety of age groups with osteoarthritis to see if this is significant in the results. 2. A study with a larger number of subjects under this format to aid in verification of significance of the data analysis. 3. A study which would include subjects on medication, being specific as to type and amount, to correlate their relationship to change in range of motion. 4. A similar study format using other modalities in the treatment of osteoarthritis. 5. A study of experimental design in a physically controlled environment in which barometric pressure and room temperature could be held constant or manipulated to determine effect.

40 APPENDIX A PATIENT CONSENT FOEM I, Linda Robberson, am a student at The University of Arizona, School of Nursing, where I am working on my masters degree in nursing. I am presently working on a paper for the completion of my degree. I am requesting your assistance with treatments to help relieve the pain of osteoarthritis. The treatments will consist of soaking your hand or foot in warm water for 20 minutes and placing your hand or foot under a heat lamp for 20 minutes. At the beginning and the end of the treatment I will check the amount of movement you have in the hand or foot and ask you how much pain you have. If you choose to assist me you will remain anonymous. You can stop the treatment at any time you choose to do so. This treatment will not be done without your consent. If you choose not to participate it. will in no way affect your care. I have discussed this treatment with your doctor and have his approval. The results of this study will be used in the paper I am writing. The knowledge I gain will be used to help you and other patients with the same disease. Date Signature Witness 31

41 APPENDIX B PATIENT INFORMATION SHEET Age_ Sex Skin Pigmentation^ Length of time patient has had osteoarthritis^ Temperature in the room when each treatment was given: Moist Heat Dry Heat a. a._. b. b. c. The patients range of motion before and after treatment Moist Heat a. Flexion (before^ Extension (before)_ b» Flexion (before) Extension (before) Co Flexion (before) Extension (before) Moist Heat ae Flexion (after) Extension (after) Dry Heat a. Flexion (before) Extension (before) bo Flexion (before)..extension (before) Co Flexion (before) Extension (before) Dry Heat a. Flexion (after) Extension (after)

42 33 bo Flexion (after) b. Flexion (after) Extension (after) ; Extension (after)_ Co Flexion (after) Extension (after) c. Flexion (after) Extension (after)_ 7. Patients rating before and after each treatment of their pain: Moist Heat a«(before) (after) b. (before) (after) Co (before) (after) Dry Heat a. (before) (after) b. (before) (after) Co (before) (after) 80 Date of the first treatment and the type Date of the second treatment and the type_ Date of the third treatment and the type_ Date of the fourth treatment and the type_ Date of the fifth treatment and the type_ Date of the sixth treatment and the type_

43 34 Barometric reading at the time of each treatment: a* b. c. e.

44 APPENDIX C PAIN SCALE*. 0 I have no pain at all. 1 cm 2 cm 3 cm 4 cm 5 cm 6 cm.7 cm 8 cm * The scale has made small in order for an example of it to be given. 9 cm My pain is as bad as 10 cm it could possibly be. 35

45 APPENDIX D NORMAL RANGE OF MOTION* 1. Wrist: Extension 0-70 Flexion Ankle: Extension 0-20 Flexion 0-45 and Ditto,

46 SELECTED BIBLIOGRAPHY Abramson) David I., Samuel Tuck, Jr., Eduardo Buso, Sul W. Lee, George Richardson and Marsha Levin. HComparison of Wet and Dry Heat in Raising Temperature of Tissues. 1 Archives of Physical Medicine and Rehabilitation, December Baird, D. C. Experimentation: An Introduction to Measurement Theory and Experiment Design. Englewood Cliffs, New Jersey: Prentice- Hall, Inc., Blalock, Hubert, Jr. Social Statistics. 2nd ed. New York: McGraw- Hill Book Company, Bland, John H. Arthritis Medical Treatment and Home Care. New York: The Macmillan Co., Bond, M. R. "The.Relation of Pain to the Eysenck Personality Inventory, Cornell Medical Index and Whiteley Index of Hypochondriasis." British Journal of Psychiatry, 119:671, Boyle, James A. and W. Watson Buchanon. Clinical Rheumatology. Oxford: Blackwell Scientific Publications, Brunner, Lillian, Charles Emerson, L. Kraeer Fergerson and Doris Suddarth. Textbook of Medical-Surgical Nursing. Philadelphia: J. B. Lippincott Company, Crain, Darrell C. The Arthritis Handbook: A Patient's Manual on Arthritis, Rheumatism, and Gout. 2nd ed. New York: Exposition Press, Dixon, Allan St. J. (ed.) Progress in Clinical Rheumatology. Boston: Little, Brown and Co., Hamblin, Robert L. "Social Attitudes: Magnitude Measurement and Theory." Unpublished Paper, Department of Sociology, The University of Arizona, Tucson, 1973, Hoaglund, Franklin T. "Osteoarthritis." Orthopedic Clinics of North America, 2:1, March Hollanderj Joseph Lee (ed.) Arthritis and Allied Conditions. Philadelphia: Lea and Febiger,

47 Krusen3 Frank H 0 (ed.) Handbook of Physical Medicine and Rehabilitation. Philadelphia: W. B0 Saunders Company, Light, Sidney (ed.) Therapeutic Heat and Cold. 2nd ed. Baltimore: Waverly Press Incorporated, Light, Sidney (ed.) Rehabilitation and Medicine. New Haven: Elizabeth Licht Publisher, Minium, Edward W. Statistical Reasoning in Psychology and Education. New York: John Wiley and Sons, Inc., Rose, Anthony H. (ed.) Thermobiology. London: Academic Press, Rosenfeld, Michael (ed.) Manual of Medical Therapeutics. Little, Brown and Company, Boston: Seagrave, R. C. Biomedical Applications of Heat and Mass Transfer. Ames: Iowa State University Press, Shestack, Robert. Handbook of Physical Therapy. Publishing. Co., Inc., New York: Springer Shestack, Robert and Edward W. Ditto, III. Physician Physical Therapy Manual. Englewood Cliffs: Prentice-Hall, Inc., Sokoloff, Leon. The Biology of Degenerative Joint Disease. Chicago: University of Chicago Press, Stillman, J. Sydney. "Medical Management of Osteoarthritis." Post- Graduate Medicine, 51:5, May Taber, Clarence Wilbur. Taber's Cyclopedic Medical Dictionary. 10th ed. Philadelphia: F. A. Davis Co., 1965.

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