Definition of Pelvic Girdle Pain(PGP) in pregnancy

PGP refers to a type of back ache during pregnancy which is characterized by shooting pain/dull ache predominantly in the low back which may or may not radiates to the buttocks, thighs and knees unilaterally or bilaterally as diagnosed by obstetrician and orthopedic surgeon by following the criterions of European guidelines.

Statement of the Problem

A study to evaluate the effectiveness of Nurse Directed Interventions in the management of PGP during pregnancy in selected hospitals of Kasaragod district, kerala.

Research Question

Is Nurse directed Intervention effective in relieving the pain and disability among pregnant with PGP?

Objectives of the study

1. To assess the intensity of pain and degree of disability among pregnant women with PGP. 2. To evaluate the effectiveness of nurse directed interventions in the management of PGP during pregnancy. 3. To correlate the level of pain and disability among pregnant women with PGP. 4. To find the association of pain among pregnant women with PGP with selected background variables. ( The selected background variables include-age, parity, occupation, socio-economic status, type of family, history of previous backache and posture ).

Hypotheses

All hypotheses will be tested at .05 level of significance. H1: There is a significant difference in pain scores among the pregnant women with PGP who receive nurse directed Interventions than those who do not receive them. H2: There is a significant difference in disability scores among pregnant women with PGP before and after the Nurse Directed Interventions. H3: There is a relationship between pain and disability among pregnant women with PGP H4: There is a significant association of pain scores among pregnant women with selected background variables.

Operational Definitions

1. Effectiveness-refers to the extent to which the antenatal women express reduction in pain and disability on VAS and Oswestry Disability Index respectively. 2. Pelvic Girdle Pain (PGP) refers to a type of back ache during pregnancy which is characterized by shooting pain/dull ache predominantly in the low back which may or may not radiates to the buttocks, thighs and knees unilaterally or bilaterally as diagnosed by obstetrician and orthopedic surgeon by following the criterions of European guidelines.

Operational Definitions

3. Nurse directed interventions-refers to various strategies implemented by the nurse to reduce the pain and disability among pregnant women with PGP. In this study Nurse Directed Interventions refers to the supervised exercises taught to pregnant women with PGP and also distribution of Pamphlet on back care advices to the experimental group by the nurse to the pregnant women with PGP. 4. Exercise- refers to all the activities that are taught by the researcher to pregnant women with PGP during pregnancy with a goal of relieving pain as measured by a Visual analogue scale. These exercises will be performed by the subjects. The exercises include 10 types namely postural correction, diaphragmatic breathing, TVA activation, pelvic floor strengthening exercises, pelvic tilt, Super mum, Kegels, Hip bridge, Adapted squat and Cat and Cow exercises.

Operational Definitions

5. Pamphlet- Refers to an information sheet containing information on back care for pregnant women with pelvic girdle pain.

Conceptual Framework

The conceptual frame work found to be suitable for this study is Weidenbachs Prescriptive Theory. It is a situation producing theory which may be described as one that conceptualizes both a desired situation and the prescription by which it is to be brought about. Weidenbachs prescriptive theory has 3 compeers or concepts

The Three Concepts

1. The central purpose: - It is the purpose which the practitioner recognizes as essential to the practice of discipline. In this study, the central purpose is the identification of the need to relieve PGP of the antenatal women with PGP by the investigator through the assessment made on the patients level of pain and disability. 2. The Prescription: - Prescription is for the fulfillment of the central purpose. It is directive of at least 3 kinds of voluntary actions. Mutually understood and agreed upon action, recipients directed action and practitioner directed action. In this study, prescription refers to the administration of nursing interventions to the patient after explaining the subjects about the nursing interventions and obtaining the informed consent from them to participate in the study 3. The realities: The realities are the immediate situations that influence the fulfillment of the central purpose. It consists of all the factors physical physiological, emotional and spiritual that are at play in a situation in which nursing action occurs at a given moment

Weidenbach defines the five realities as:

a. The agent who is a practicing nurse or her delegate is

characterized by personal attributes, capacities and most importantly committed and competent in nursing. In this study, the agent is the investigator. b. The recipient, the patient is characterized by personal attributes, problems capacities, aspirations and most importantly ability to cope with the problems being experienced. The patient is the recipient of the nurses action. . In this study, the recipients are the antenatal women, with PGP who are attending the OPD of selected hospitals of Kasaragod. c. The goal is the desired outcome the nurse wishes to achieve. In this study, the goal is the reduction in PGP of the antenatal women.

d. The framework consists of human, environmental, professional and organizational facilities that not only makeup the context within which nursing is practiced, but also contributes to its currently existing limits. In this study, the framework is the philosophy, policies, rules and regulations of the hospital, the caregivers role, medical treatment received by the patient and nursing interventions put together. e. The means is the prescription for care which the nurse develops based on her central purpose which is implemented in the realities of the situation. In this study, the means is Nursing interventions through which the investigator achieves the goals.

According to Weidenbach, nursing practice has three components.

a) Identification of patients need for help b) Ministration of the help needed c) Validation that action taken was helpful to the patient. In this study, the investigator identifies the comfort need of the antenatal women through the assessment of PGP. The antenatal women carry out Exercise and follow back care advices with a view to get relief from pain and disability. The effect of the nursing interventions is then validated through post assessment of pain and disability.

Research Methodology

Research Approach An evaluative approach will be utilized. The study will be conducted in two phases. A radomised controlled design will be adopted to determine the effectiveness of nursing interventions on pelvic girdle pain among antenatal mothers in selected hospitals of kasaragod district.

Research design

A randomized control research design will be adopted for the study. G1 = O1 X O2 X O3 X O4 X O5 G2 = O1 O2 O3 O4 O5

O1 = Assessment of pain (On recruitment for the study) X= Nursing interventions (Exercise and pamphlet) O2 = Assessment of pain (on the 2nd week from the time of intervention) O3 = Assessment of pain (on the 4th week from the time of intervention) O4 = Assessment of pain (on the 6th week from the time of intervention) O5 = Assessment of Pain (on the 8th week from the time of intervention)

Research Design
Target population Antenatal women with PGP between 12th to 32 weeks of pregnancy.

Accessible population

Antenatal women with PGP between 12th to 32 weeks of pregnancy attending OPDs of selected hospitals of Kasaragod.

Sample =210

Block randomisation

Experimental Group N1=105

Control Group N2=105

Pre-test on Day-1 O1

Experimental Group
N1=105

Control Group

N2=105

Experimental Group

Control Group

Pamphlet &Exercise

Conventional care

only

Post -tests onWK2, WK4, WK6, WK8. O2, O3, O4, O5

Population

Population consists of antenatal women with PGP attending the OPDs of the selected hospitals of Kasaragod

Sample Size

Sample size of 198 was estimated by power analysis. To combat attrition 10% of the calculated sample size was added. In this study the sample size is 210 antenatal women with PGP (105 in the experimental and 105 in the control group) in the selected hospitals of kasaragod.

Sampling Technique

In this study, a sampling frame of 210 pregnant women with PGP fulfilling eligibility criteria will be made. Block randomization technique will be adopted to allocate the subjects randomly to experimental and control group.

Criteria for sample selection

Inclusion Criteria All antenatal women between 12-32 weeks diagnosed as PGP by an obstetrician or an orthopedic surgeon on the basis of European guidelines ; 1 . Who visit OPDs/antenatal clinics of various hospitals of Kasaragod district. 2. Who can read and write in Malayalam or English. 3. Willing to participate in the study

Exclusion Criteria

Antenatal women with PGP who have:1. Low back pain 2. PGP plus LBP 3. PGP with severe disability 4. Other pain conditions 5. Systemic disorders 6. High risk pregnancy 7. Gestation week>32 8. Twin pregnancy

Setting of the study

The settings for the study include various OPDs of selected hospitals of kasaragod. The clients will be selected from the OPDs. List of sample fulfilling the criterions will be selected. Randomisation will be done from this list. The intervention will be carried out on individual basis by following up these subjects to their homes in community.

Tools & techniques

Part-l-Tools for screening the subjects for PGP 1. Pain drawing scale 2. Severity of PGP a. The posterior pelvic pain provocation test b. Patricks Faber test c. Modified Trendelenburg test d. Palpation of the pubic symphysis e. The Active Straight Leg Raising test (ASLR test)

Interventions

Nursing interventions include:

Nursing interventions-1 Pamphlet on Back care advices during PGP Nursing interventions-2- Exercises such as: Postural correction Diaphragmatic breathing exercises TVA activation Pelvic floor strengthening exercise Pelvic tilt Super mum (adapted) Kegels exercise Hip Bridge Adapted squat Cat and cow

Part-ll Tools for outcome measurement

Tool-1-Baseline Performa Tool-2-Visual Analogue Scale Tool-3-Oswestry Disability Scale

Plan for Pilot study

Pilot study will be conducted in 1/10 of the sample size. Ie.22 sample will be selected, 11 in control group and 11 in experimental group. Pilot study will be conducted in Periya Province of kasaragod.

Plan for Data collection:

Data will be collected in two phases

Phase I: Formal permission to conduct the study will be obtained from the concerned authority. Pain drawing scale will be administered to the clients with complaints of back ache. The clients will undergo further screening tests for PGP according to the European Guidelines. Visual analogue scale will be administered to those who are positive for PGP. All those have a pain score of 60mm and above on VAS will be entered into the list of eligible population.

Phase II:

After the antenatal women with PGP are identified, the investigator will assign the subjects to both experimental and control groups randomly by block randomisation. The investigator will introduce her to the subjects, and then demographic data and other information related to the study such as disability scores will be collected from both the group before the implementation of intervention. Selected Nursing Interventions will be administered to experimental group alone. Back care advices will be instructed verbally followed by distribution of pamphlet. The researcher will teach various exercises to the antenatal women with PGP. The subjects are advised to carry out the exercises twice a day. A log book will be given to each of them. The subjects will be followed up at 2nd, 4th, 6thand 8th week were by the data regarding pain and disability will be collected.

Plan For Data Analysis

Data analysis will be done by Descriptive and inferential statistics (mean, median, mode,SD,paired t-test and ANOVA)

Action Plan
1 2 3 4 Selection area of research, proposal submission-January-February 2009. Modification of proposal and submission-March-April 2009. Presentation of area of research-April 2009. Review of literature, Data acquisition-May -December 2009. January 2010-11. 5 Expanding methodology, proposal presentation-February-June 2010-11. 6 Ethical clearance-June-August 2010-11. 7 Development of tools for data collection-April-August 2010-11. 8 Validation of tools-August-October 2010-11. 9 Testing of tools-November-December 2010-11. 10 Pilot study and analysisJanuary-March 2012. 11 Finalization of tools for data collection-February-May 2012. 12 Data Collection-June-December 2012. January-May 2013. 13 Analyzing data-August-September 2012. January-August 2013 14 Validation of data-September-December 2013 15 Report Writing-January-December 2014. January 2015.