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Health Promotion of patients visiting daily Orthopedics OPD at Federal Government

Polyclinic Hospital (Postgraduate Medical Institute), Islamabad

By

Dr Abubakar,
Evening MSPH 2018-19

On Job Practicum Report

Submitted in fulfillment of the
requirement for the degree of
Master of Science in Public Health

_____________
Word Count

Student Signature

Faculty Signature

Date project submitted:

Date project accepted:

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Contents
Title ....................................................................................................................................................................... 1

Acknowledgements ............................................................................................................................................... 3

Summary ............................................................................................................................................................... 4

Introduction ........................................................................................................................................................... 6

Learning Objectives and Expected Outcomes ...................................................................................................... 8

Results:................................................................................................................................................................ 10

Discussion and Conclusion ................................................................................................................................. 12

References ........................................................................................................................................................... 13

Appendix A: Pamphlet for home-based backache exercise ................................................................................ 15

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Acknowledgements
I sincerely acknowledge the sincere efforts of my supervisor, Dr Syed Junaid Ismail, Associate
Surgeon Spine Surgery for guiding me throughout this daunting task. His affection and kind help are
gratefully acknowledged.

To my elder sister, Ms. Aafia Sarmad whose help and motivation in difficult times are sincerely
acknowledged.

Finally, to God Almighty, whose omnipresence and awareness are always a source of spiritual
comfort and solace.
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Summary

Public Health in Pakistan is an emerging field. Various institutions, either public or private, are
playing important roles in uplifting the status of public health in the country. Among these are
NGOs like the World Health Organization, various government institutions like National Institute
of Health, as well as different vertical programmes like National TB Programme, National Polio
Eradication Programme and National AIDS Programme. Moreover, there has always been a
competition between curative and preventive health services. Federal Government Polyclinic
Hospital is a tertiary care hospital based in Islamabad which was established in 1966 as an 8-
bedded facility. Today, it is a 550-bedded hospital which has a wide catchment area, catering to a
large number of patients from different areas such as Murree, Kohistan, Taxila and Azad Kashmir.
It provides regular emergency, outpatient as well as inpatient care to 7000-8000 patients on a daily
basis. Many common medications for a variety of conditions are available in the hospital
pharmacy and are provided free of cost to patients. In addition, many laboratory investigations and
surgical procedures are conducted at a very nominal or no cost. Outpatient clinics in various
specialties such as Internal Medicine, General Surgery, Cardiology, Dermatology, Psychiatry and
Orthopedics run daily in the morning. Some outpatient clinics also run in the evening. The patient
load is quite high with some clinics registering 700-800 patients per day. The hospital remains
overcrowded and congested with limited infrastructure and lack of modern facilities and
equipment. The Orthopedics OPD runs on alternate days in the hospital and caters to a variety of
patients presenting with different musculoskeletal conditions such as Bone Fractures,
Osteoarthritis, Rheumatoid Arthritis, Polyarthritis, Polyathralgia, Generalized as well as Localized
Myospasm and other benign as well as malignant conditions. Female patients constitute most of
the bulk of patients visiting the Orthopedics OPD with the most common ailments being
Osteoarthritis Knee, Frozen Shoulder and Generalized aches and pains. Most of these patients are
treated on an Outpatient basis without admitting them for in-patient care; however, in a minority of
cases, some patients are admitted and treated in the hospital wards. Common treatment options for
such patients are pain killers (or NSAIDs), muscle relaxants, topical creams and other anti-
inflammatory medications. These are known as pharmacological interventions which involve use
of a pharmacological agent. In addition to these, many non-pharmacological interventions are
available for the above-mentioned health conditions which do not involve use of any medicine or
drug, but are proven to be effective in providing relief to the patient. They have been shown to
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interact in a synergistic manner with pharmacological interventions. Occasionally, they can prove
to be even more effective in alleviating the symptoms of the patient and can help reduce his/her
dependence on oral medications. Furthermore, they can enhance a patient’s well-being, self-
efficacy, confidence, resilience and sense of satisfaction. Non-pharmacological interventions are
also effective in providing primary and to some extent, secondary prevention against diseases.
Thus, they form a very important constituent of Health Promotion of the sick. Many patients who
visit the hospital, just obtain their weekly or monthly quota of medication and leave without
getting properly counseled regarding lifestyle, diet and exercise. In addition, Health Professionals
often forget to include this important aspect of health care in their daily dealing with patients.
Instead, they rely only on prescribing various medications which not only partially treats the
underlying condition but also has serious adverse effects of its own. These include complications
from chronic use of drugs e.g. Gastric Ulceration, Renal damage, Liver damage, Allergic
Reactions and Hypertension. Furthermore, patients may develop dependence on drugs which is a
serious issue (1). In addition, patients may think it sufficient to just take their daily medication and
may not focus on adopting healthy behaviors (e.g. not doing sufficient exercise in case of
Osteoarthritis and not drinking enough water in case of Gouty Arthritis) which would lead to a
sub-optimal response to oral treatment. Health is a bio-psycho-social phenomenon, according to
the World Health Organization, and thus it is important to cater to the psychological and social
component of disease as well (2). This concept of ‘holistic care’ is essential to the practice of
curative as well as preventive medicine (3). Therefore, a good public health/preventive medicine
approach would be to reduce the dependence of patients on medications and instead promote a
healthy lifestyle which would have a protective effect against developing many diseases. Common
non-pharmacological interventions for common musculoskeletal conditions like osteoarthritis of
the knee, for example, include regular land-based and/or aquatic exercise, adequate hydration,
mental relaxation, massage, physical therapy or physiotherapy, hot fomentation, ice packing, knee
supports, various kinds of footwear to reduce impact on the affected joint, acupuncture and dietary
supplementation with vitamins, minerals, milk-based products and exposure to adequate amount of
sunlight (4).
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Introduction

Osteoarthritis is the most common form of arthritis and can lead to significant pain and disability (5).
Treatment of osteoarthritis of the knee and hip aims to reduce joint pain and stiffness, maintain or
improve mobility, and optimize patient functioning and quality of life while limiting the progression
of joint damage. A recent expert review of the management of osteoarthritis by the Osteoarthritis
Research Society International supports a combination of nonpharmacological and pharmacological
interventions. The review also indicates that patient education is critical in the early stages of care,
and that weight loss and exercise are key to any nonpharmacological treatment. The guidelines
include health promotion and health education of patients for prevention and treatment of hip and
knee osteoarthritis (6).

Non-pharmacological approaches for osteoarthritis include orthoses, insoles, exercise, diet, patient
education, modification of health behavior, reducing weight and thermotherapy as described above.
For each anatomical site, the non-pharmacological approach must be adapted to the individual
patient. Pharmacological treatments, however, are usually the same, whatever the anatomical site.
Some of the non-pharmacological approaches are described below:

Orthoses or braces and insoles are mainly prescribed to modulate mechanical stress on the
symptomatic joint compartment. Besides this mechanical effect, they may have effects on muscle
contraction and proprioception (8). Information on the use of orthoses and insoles is usually provided
by the physiotherapist who prescribes a certain variety according to patient’s symptoms and site of
disease. Such devices dramatically improve a patient’s symptoms, reduce his/her dependence on
medication and provide long-lasting relief which cannot be achieved through medication alone (9).

Exercise therapy is widely used for knee OA to improve joint range of motion, muscle strength,
tendon lengthening, aerobic performance and proprioception. Aerobic, strengthening, range-of-
motion and proprioceptive exercise is recommended to decrease pain and improve function and
quality of life in knee OA. Inexpensive aerobic exercise can include sport, walking, swimming,
cycling and any physical activity the patient particularly enjoys. Exercise is widely used by health
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professionals and patients to reduce pain and improve function. Exercise and physical activity can be
targeted at the affected joint(s) and also at improving general mobility, function, well-being and self-
efficacy. More intensive exercise can also strengthen muscles around the affected joint. The types of
exercise are numerous and should be adapted to the joint affected and the health of the patient.
Exercise therapy is delivered mainly by physiotherapists. It tends to improve joint range of motion,
strengthen muscle and tendon, enhance endurance and decrease pain. With regular exercise,
improvements are seen in walking ability and daily activities, including sports. The possible
modalities of exercise treatments are numerous and each modality should be modified according to
the patient presenting in the OPD (10).

There is a wide misconception among people who believe that activity ‘wears out’ joints. Patients
who have followed an exercise programme sometimes report they have experienced an exacerbation
of their symptoms and are reluctant to continue. However, patients with significant osteoarthritis can
ride a bicycle, go swimming or exercise at a gym with often no or minimal discomfort. Health
professionals, therefore, must be very clear about goals set with regard to exercise.

Changing health behavior with education and advice are positive ways of enabling patients to
exercise regularly. Pacing, where patients learn to incorporate specific exercise sessions with periods
of rest interspersed with activities intermittently throughout the day, can be a useful strategy. Pain
killers may be needed so that people can undertake the advised or prescribed exercise. The majority
of the evidence related to osteoarthritis of the knee, has found exercise to be extremely valuable in
decreasing pain and restoring mobility of the knee joint (11).

Obesity is a major risk factor for the onset and progression of knee OA, and reducing weight can
alleviate impairment and disability. Obesity is also associated with osteoarthritis of the hand and
multiple other sites. It plays a key role in the pathophysiology of OA by causing excess or abnormal
mechanical loading of the joint which appears to be one of the main factors leading to the
development and progression of osteoarthritis (12).

In addition, research has shown that weight loss results in decreased knee pain and functional
improvement, especially when combined with physical exercise. Weight loss has been recommended
by multiple patient-care societies. Weight loss is usually achieved with either dietary manipulation
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alone or combined with exercise. It is a difficult process for obese patients, however if done
regularly, can result in massive improvement in signs and symptoms. The patient should be
repeatedly counseled and informed regarding other metabolic and cardiovascular advantages of
losing weight as well. The association of obesity with the development and progression of
osteoarthritis, especially at the knee, provides the justification for weight reduction. Because of the
deleterious effects of obesity, overweight OA patients should aim to lose weight (12).

Thermotherapy is a useful supplement to pharmacological therapies. Ice is used for acute injuries and
warmth is used for sprains and strains. Both hot and cold packs are frequently used in osteoarthritis
and have proven benefit in reducing symptoms. Heat can relax muscles and help lubricate joints. Heat
therapy may be used to relieve muscle and joint stiffness, help warm up joints before activity, or ease
a muscle spasm. Cold can reduce inflammation, swelling, and pain related to arthritis and activity. It
is also recommended to treat many acute injuries (13).

Self-management can be defined as any activity that people undertake to promote health, prevent
disease and enhance self-efficacy. People who are able to recognize and believe in their ability to
control symptoms (self-efficacy) can become more active participants in managing their condition
and thus potentially improve their perceived control over their symptoms. This may improve
adherence with treatment options offered and reducing reliance upon healthcare interventions (14).

Learning Objectives and Expected Outcomes

The learning objectives for the practicum were:

1.To promote health of patients visiting daily Orthopedics OPD at Federal Government Polyclinic
Hospital, Islamabad using various non-pharmacological interventions.

The proposed outcomes of the practicum study include:

1. Better pain control of patients with less visits to hospital, less reliance on medication, and with
adoption of healthy lifestyles.
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Methods:
Patients visiting the daily Orthopedics OPD were registered over a 3-month period and their major
complaints with the treatment received was recorded. Patients suffering from different
musculoskeletal conditions including osteoarthritis, backache and muscular spasm/stiffness were
included. Patients who were registered on day 1 were divided into two groups through random
selection. The first group received only oral medication whereas the second group was also offered
advice regarding health promotion and health education and was also referred to a physical
therapist in addition to the routine medications. Both groups were followed up at 2 weeks, 6 weeks
and ultimately 12 weeks. At each visit, patients were asked to report the severity of their pain on a
1-10 pain scale. Health promotion advice was delivered by means of pamphlets, charts as well as
verbal advice (Appendix A).

Predominant Non-pharmacological
Complaint/Diagnosis intervention advised
Knee twist Ice Packing
Chronic Knee Pain Hot fomentation
Pain big toe (Due to Gout) Increase intake of water
Intense Backache (due to Wear a Lumbar Belt
heavy weight lifting) Apply Hot Water Bottle to
affected area
Chronic Osteoarthritis Knee Avoid climbing stairs
Use English Toilet
Offer prayers on chair
Pain in thighs Regular quadriceps exercises
(by physiotherapist)
Muscle Spasm/Stiffness in Regular isometric neck
neck exercises (taught by health
professional or
physiotherapist)
Heartburn due to chronic use Increase intake of milk
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of painkillers Do not lie down within 30

minutes of having meals
Avoid spicy and deep fried
foods
Body weakness and Increase intake of milk
generalized aches and pains products, adequate sun
exposure, increase intake of
fresh fruits and vegetables

Results:
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Data was collected from the two groups of patients who were followed up at same time intervals
and was compiled and analyzed. Basic frequencies and proportions/percentages were calculated
and then presented in the form of tables.

Group 1 Group 2
Treatment Received Painkillers, Vit D Medications (as in Group1) +
Supplements, Muscle Physical therapy + Advice on
relaxants, Creams/Lotions Exercise, Thermotherapy,
Optimum Diet, Weight Loss,
Sunlight Exposure and other
non-pharmacological
interventions
Number of patients 50 50
Intervention received Pharmacological Pharmacological and Non-
pharmacological
Patients with >2 grades 13% 20%
improvement in pain at 2-
weeks follow up
Patients with >2 grades 21% 38%
improvement in pain at 2-
weeks at 6-weeks follow up
Patients with >2 grades 32% 50%
improvement in pain at 12-
weeks follow up

The results showed a significant difference in the pain severity reported by patients at 2,6 and 12-
week intervals in the two groups. Group 2 performed significantly better than Group 1 in reduction
of pain due to various musculoskeletal conditions. This difference could be attributed to the
additional benefit of physical therapy, exercise, weight reduction programs and other non-
pharmacological interventions.
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Discussion and Conclusion

Health promotion is an important aspect of health care (15). Optimum health care must incorporate
this aspect in order to achieve the best results. Health promotion includes health education and
information in a conducive environment. A ‘conducive environment’ is one in which the message
delivered by the health provider is readily taken up and assimilated by the patient with a firm
commitment by the patient to act upon the delivered health message. Health promotion requires that
steps to create environments for health must be taken at all levels of public policy, community and
individual action (15). The content of health education and information process in an Orthopedics
OPD must be delivered by the physician and encouraged by the nurse or physiotherapist. To improve
the health status of the patient, regular reminders are helpful, including pamphlets, charts as well as
phone calls. Various non-pharmacological interventions including thermotherapy, transcutaneous
electrical nerve stimulation and acupuncture are recommended by Orthopedic societies to decrease
pain in patients suffering from various musculoskeletal conditions (6). These recommendations are
based on independent systematic reviews showing a slight but significant effect on pain. Many of
these interventions have been studied in this report and have been found to be significantly effective
in reducing pain of patients, improving their clinical status and reducing dependence on medications
as well as on the health care system and providers. Education and information about non-
pharmacological treatments of various musculoskeletal conditions including osteoarthritis is mainly
aimed at encouraging adherence to various treatment modalities, managing pain at home, reducing
hospital visits and is very different from a simple pharmacological prescription (6). Therefore, non-
pharmacological treatments must be explained properly and in a detailed manner to patients in order
to achieve positive outcomes. All patients with osteoarthritis should be given information access and
education about the significance of non-pharmacological treatment and the importance of changes in
lifestyle, exercise, physical activities, weight reduction, and other similar measures to provide relief
to the damaged joint(s) and affected areas. The initial focus should be on self-help and patient-driven
treatments rather than on passive therapies delivered by health professionals. Subsequently emphasis
should be placed on encouraging adherence to the regimen of non-pharmacological therapy. Patients
with hip and knee osteoarthritis, who are overweight, should be encouraged to lose weight and
maintain their weight at a lower level. In patients with knee osteoarthritis who are elderly, a knee
brace can reduce pain, improve stability and diminish the risk of falling. Patients with advanced
osteoarthritis may benefit from referral to a physical therapist for evaluation and instruction in
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appropriate exercises to reduce pain and improve functional capacity. They may also be advised
assistive devices such as canes and walkers, as appropriate. Patients with hip and knee osteoarthritis
should be encouraged to undertake, and continue to undertake, regular aerobic, muscle strengthening
and range of motion exercises. For patients with symptomatic hip osteoarthritis, exercises in water
like swimming can be effective (6,7).

There are two major barriers to the uptake of routine exercise in the osteoarthritis population: 1)
failure on the part of health professionals to properly recommend exercise to patients or make
appropriate referrals to exercise professionals and 2) failure of patients to comply with prescribed
exercise programs. Therefore, physicians should be aware of the important role exercise and other
non-pharmacological interventions play in the overall health of patients and they should supplement
their medical prescriptions with appropriate advice on patient-driven care and home-based
interventions. Secondly, they must make referrals to physical therapists, counsellors and fitness
specialists whenever appropriate in order to provide ‘holistic care’ which is the ultimate aim of
modern health-care (3).

References

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Research. 2000; 13(6):398-4

13. Brosseau L, Yonge KA, Welch V, Marchand S, Judd M, Wells GA et al. Thermotherapy for
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arthritis in primary care: randomized controlled trial. BMJ. 2006; 333(7574):879

15. https://www.who.int/features/qa/health-promotion/en/

Appendix A: Pamphlet for home-based backache exercise

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