Daily living activities disability among elderly patients with Lumbar Herniated Disc
EmanShokryAbd Allah1, Reda Abdel Rahman Ahmed2, AmanyRashad Abo El-Seoud3, HanaaHamdy Ali El Zany4
1Professor and Head of Gerontological Nursing Department, Faculty of Nursing, Zagazig University, Egypt,
2Assistant Lecturer of Gerontological Nursing, Faculty of Nursing, Zagazig University, Egypt,
3Professor of Community Medicine, Faculty of Medicine, Zagazig University, Egypt,
4Assistant professor of Psychiatric Health Nursing, Faculty of Nursing, Zagazig University, Egypt
Corresponding author: Eman Shokry Abd Allah, Email: [email protected] Abstract
Intervertebral disc diseases are the leading cause of low back pain and disability. Disability in basic activities of daily living implies a loss of independence and increases the risk for hospitalization, nursing home admission, and death.The present study aimed to assessdaily living activities disability among elderly patients with lumbar herniated disc.A descriptive design was utilized to conduct the study inthe neurology and orthopedic outpatient clinics at Zagazig University Hospitals, Egypt.The study‟s sample was composed of 65 older adults who fulfilled the inclusion criteria. Visual analogue scale (VAS) was used to measure the intensity of pain and the Oswestry Disability Index (ODI) was used to assess the disability of the patients on daily living.The results revealed that more than half (56.9%) of the studied elderly had moderate pain, while more than one third (35.4%) of them had severe pain.More than one third (38.5% and 35.4%) of them had severe and moderate disability respectively.
So, further research is recommended to explore the effectiveness of multiple-approach nursing interventions in improving the QOL of elderly with lumbar herniated disc.
Keywords: Daily living activities disability, Lumbar herniated disc, Elderly patients.
Introduction
The world‟s population is ageing: globally, population aged 60 or over is growing faster than all younger age groups. According to data from World Population Prospects, there were 703 million people in the age group 65 years and over worldwide in 2019. By 2050 the number of older people is forecasted to double to 1.5 billion (United Nations, 2019). In Egypt, the number of older adults aged 60+ years reached 7.63 million; 3.80 million males and 3.82 million females, accounting for 7.6 % of the total population according to the Central Agency for Public Mobilization and Statistics [CAPMAS](CAPMAS, 2020).Aging can result in significant changes in the musculoskeletal system, such as loss of muscle strength and power due to a decreased number of muscle fibers. These factors have a direct effect on muscle function and potentially predispose individuals to low back injury. The frequent co- occurrence of other health conditions may also have an important impact on the choice of treatment for LBP in the older person (Jesus-Moraleida et al., 2016).The functions of the spine make it endure abrupt and great physical strain (carrying, lifting, etc.). These functions, its anatomical structure, in addition to the vertical posture, contribute to early degeneration of the intervertebral discs and discogenic diseases. Even at rest, the spine is exposed to numerous forces which cause slippage along its bone part or on the muscle-ligament part.
Prolapsed or herniated disc is the most common cause of unbearable low back pain (Kasnakova et al., 2018),LBP in the older adult challenges healthcare systems, leading to
significant social and economic costs. The condition is one of the most common reasons for seeking primary health care. Compared to other age groups, LBP in older adults is more disabling and is associated with poorer prognoses (Jesus-Moraleida et al., 2016). A prolonged duration of pain in the lumbar region and inactivity reduces quality of life and restricts activities of daily living and social life. Consequently, the patients are forced to cope with pain to continue their daily activities (Kose et al., 2019).Difficulty performing a basic daily activity independently is understood as a functional limitation, or disability, in that activity area.Activities of daily living (ADLs) are self-care tasks that include bathing, dressing, toileting, transferring (e.g. in and out of bed), and eating.Within the home, ADLs may be partially addressed through accessible housing: difficulty bathing and toileting, for example, may be eased by the installation of walk-in showers, grab bars, and raised toilet seats.
However, individuals with ADL disabilities often also need the help of caregivers(Mlinac&Feng, 2016).Nurses are often the first to note when patients' functionality declines during hospitalization; therefore, routine screening of ADLs is imperative and nursing assessment is performed on all hospitalized patients. Assessment of ADL's assists healthcare providers to assess the patient‟s status, plan, and to intervene appropriately. It is important for a provider to address a patient‟s general medical condition when determining level of accomplishing functional capabilities that otherwise ensures independent living and personal care. An ADL assessment helps to determine whether or not a patient may require further rehabilitation or assistance at home or if a skilled nursing or long-term care facility would be a safer environment for the patient (Edemekong et al., 2020).
Aim of the study
The aim of the current study was toassess daily living activities disability among elderly patients with lumbar herniated disc.
This aim would be fulfilled through the following objectives:
1. Assess elderly's low back pain severity.
2. Determine elderly's ability of performing daily activities.
3. Investigate the relationship between low back pain severity and daily living activities disability among elderly patients with lumbar herniated disc.
Research questions
1. What is the elderly‟sseverityof low back pain?
2. What is the elderly‟s ability of performing daily activities?
3. Is there a relationship between low back pain severity and daily living activities disability among elderly patients with lumbar herniated disc?
Subjects and Methods
Study Design and Ethical Considerations
A cross- sectional descriptive research design was used to conduct the current study from the beginning of November 2019 up to the end of February 2020 in the neurology and orthopedic outpatient clinics at Zagazig University Hospitals, Egypt. The study was approved by the Research Ethics Committee (REC) and the Postgraduate Committee of the Faculty of Nursing at Zagazig University, Egypt. Verbal consent was obtained from the patients after a description of the purpose of the study.
Setting
The study was conducted in the neurology and orthopedic outpatient clinics at Zagazig University Hospitals, Egypt.
Sample
A purposive sample composed of 65 patients aged 60 years or above with a diagnosis of lumbar herniated disk, independent in performing their daily activity, and able to cooperate and agree to participate in the study was selected in the recruitment of this study.
Tools of Data Collection:
Three tools were used to collect necessary data. Tool I: A structured interview questionnaire that was developed by the researcher after reviewing the related literature. It composed of two parts; Part one used to assess the demographic characteristics which included age, gender, marital status, educational level, occupation before retirement, current occupation, residence, monthly income, and income source. Part two involved questions aboutthetype and number of chronic diseases, smoking history, previous hospitalization, family history, and herniated disk history (duration, causes, and complaints).
Tool II: Visual analogue pain scale (Wewers& Lowe, 1990).
Itis a self-report device consisting of a horizontal line used for subjective estimation of patient's pain. It comprises 10 point numerical scale,with “0” at one end representing no pain, and “10” at the other representing the worst pain ever experienced. The pain score consists of a measurement of the segment selected by the patient, with a higher score indicating more severe pain. The scoring system consists of score from 1 to 3 denoted mild pain, score from 4 to 6 denoted moderate pain, and score from 7 to 10 indicated severe pains.
Tool III: Oswestry low back pain disability questionnaire (Fairbank &Pynsent, 2000).
It is considered the gold standard for assessing the level of back pain and its effect on performance of daily activities. It consists of ten sections covering pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, travelling, and employment/homemaking. Each section includes six options ranked from zero to five with higher values indicating more severe impact on activities of daily living then all points in all sections were summed up and plug it into the following formula in order to calculate level of disability. Level of disability = Total point / 50 X 100 = % ranging as from 0% to 20% (minimal disability), from 21% to 40% (moderate disability), from 41%
to 60% (sever disability), from 61% to 80% (crippled or complete disability), and from 81% to 100% (bed bound).
Results
Among 65 older patients, the mean age was 64.91 ± 3.8years, 60% were females, 80% were married, and 35.4% had intermediate education. 67.7% of the participant worked as employees before retirement, 56.9% belonged to rural areas, and 73.8% had sufficient monthly income (Table 1).Figure 1 sketches that the most commonly diseases among the studied elderly were diabetes (36.9%) followed by hypertension (32.3%). Concerning low back pain self-report among the studied elderly, table 2 illustrates that 56.9% of the studied elderly had moderate pain, 35.4% of them had severe pain, while 7.7% of them had mild pain.As for the daily living activities disability among the studied elderly table 3shows that, 38.5% of the studied elderly had severe disability, 35.4% of them had moderate disability, and 18.5% of them had complete disability (crippled).Table 4 simplifies the correlation matrix of visual analogue pain scale and oswestry low back pain disability scores. The table indicates a statistically significant positive correlation between visual analogue pain scale and oswestry low back pain disability (r= .506).
Discussion
The present study intervention sample involved 65 elderly patients who had lumbar herniated disk, where, half of them had no family history of disc herniation. This is concurrent with
Alshehri et al. (2019) in Saudi Arabia who found that more than half of the participants had no family history of herniated lumbar disc. The mean age of the studied elderly in the present study was 64.91 ± 3.8which is close to the mean reported by Donatti et al. (2019) in Brazil (65 ± 5.54 years) and Hareni (2019) in Sweden (71.5 ± 5.4 years). The present study sample had a slight preponderance of women. This finding might be explained by thattheattendants of the neurology and orthopedic outpatient clinics were commonly women and the higher life expectancy of women in general. This finding is in congruence with similar previous studies such as in Turkey (Koçak et al., 2018) and Iran (Pakbaz et al. 2019).The current study findings also revealed that the highest frequency of the studied elderly was married, had intermediate education, employees, and were living in rural areas. In agreement with this,Weheida et al. (2016) in Egypt clarified that the majority of the studied elderly were married, had secondary education, and coming from rural regions. In the same context, the results of study conducted in Saudi Arabia by Sahrahet al. (2016) revealed that half of the study subjects were married and employees. The present study findings also clarified that the most commonly diseases among the studied elderly were diabetes followed by hypertension.
This finding might be contributed to the fact that diabetes can affect many organs, including the bone and cartilage, and these changes result in catabolic and anabolic unbalanced responses that lead to intervertebral disc degeneration. In addition being hypertensive increases associated risk for disk herniation, the proposed mechanism is an accelerated growth of atherosclerotic plaque to the arteries that supply the lumbar disk (Souza, 2016).On the same line with foregoing study results, Abbady et al. (2019) &Hablass et al. (2020), in Egypt assured that hypertension and diabetes were the most common chronic diseases among elderly patients.According to the present study results, more than half of the studied elderly had moderate LBP and more than one third of them had severe LBP. This might be related to that pain is a subjective feeling that varies from individual to another. Also age related changes in prevalence, perception of low back pain and approaches to assessment and treatment of chronic low back pain in older adults. This finding consistent with the result of Billis et al. (2017), in Greece who stated that the pain intensity of the study subjects categorized from moderate to severe pain. In Egypt, this finding is in accordance with Hemedet al. (2017) who found that more than half of the studied participants had moderate LBP and about one third of them had severe LBP.Regarding daily living activities disability among the studied elderly, the present study findings clarified that more than one third of the studied elderly had severe disability and moderate disability respectively. This might be due to that the intensity of low back pain among the studied elderly ranged from moderate to severe LBP. In Malaysia, this finding was in alignment with Yusoff et al. (2019) who mentioned that nearly half of the respondents had both severe disability and moderate disability respectively. In the same vein, a study carried out by Khalid et al. (2019) in Pakistan, demonstrated that more than one third of the studied subjects had severe disability and about one third of them had moderate disability.A statistically significant positive correlation between the scores of visual analogue pain and oswestry low back pain disability was confirmed in the present study. This finding might be attributed tothatas the pain increases, disability also increases. The finding is in congruence with many similar previous studies such as,Maccormick and Sharma (2018) in Plymouth, UK, Nassar et al.
(2019) in Egypt, and Sruthi et al. (2019) in India.
Conclusion
Based upon the findings of the present study and answer of hypothesis,it can be concluded that the studied elderly had moderate low back painand moderate to severe disability in the daily living activities.
Recommendations
In view of the current study findings,further study is recommended to evaluate the association between low back pain and other factors. Moreover, Replication of the study using a larger probability sample from different geographical areas to help for generalization of the results.
Table 1: Demographic characteristics of the studied elderly (N=65)
Demographic characteristics Frequency Percent Age group: /year
60- 70- Mean ± SD (range)
58 7
64.91 ± 3.8 (60 – 77)
89.2 10.8
Gender:
Male Female
26 39
40.0 60.0 Marital status:
Married Divorced Widow
52 8 5
80.0 12.3 7.7 Education:
Not read & write Read & write Basic
Intermediate University/ post
6 10 5 23 21
9.2 15.4 7.7 35.4 32.3 Occupation before retirement:
Employee Worker Farmer Housewife
44 7 3 11
67.7 10.8 4.6 16.9 Residence:
Rural Urban
37 28
56.9 43.1 Income:
Sufficient Insufficient
48 17
73.8 26.2 Income source:@
Pension (father pension-husband pension)
Relative help
Official social assistance
52 12 3
80.0 18.5 4.6
Figure 1: chronic diseases among the studied elderly (n=65)
Table (2): Pain self-report percentages among the studied elderly (N=65) Pain self-report No %
No pain 0 0.0
Mild pain 5 7.7
Moderate pain 37 56.9 Severe pain 23 35.4
Table (3): Total percentages of daily living activities disability among the studied elderly (N=65)
Total score of daily living activities disability
No % Minimal disability 3 4.6 Moderate disability 23 35.
4 Sever disability
25 38.
5
Crippled 12 18.
5
Bed bound 2 3.1
Table (4): Correlation matrix of visual analogue pain scale and oswestry low back pain disability Scores
Scores
Spearman's rank correlation coefficient Visual analogue
Pain scale
Oswestry low back painDisability
Visual analogue Pain
scale .506**
Oswestry low back
painDisability .506**
R: Pearson's correlation coefficient (*) statistically significant at p<0.05 (**) statistically significant at p<0.01
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