CHAPTER I THE PROBLEM AND ITS BACKGROUND Introduction Almost everybody has, thinks he or she has, or knows someone

who has arthritis. Arthritis is a common and thoroughly miserable group conditions. Arthritis can affect people differently. It's common in adults 65 and older, but it can affect people of all ages, races, and ethnic groups. Arthritis is an inflammation usually accompanied by pain, swelling and stiffness, and resulting from infection, trauma, degenerative changes, metabolic disturbances, or other causes. It occurs in various forms such as bacterial arthritis, osteoarthritis or rheumatoid arthritis. Pain is one of the most frequent symptoms observed to a patient with arthritis and various treatments are proposed for its relief, including relaxation techniques one of these is the Progressive muscle relaxation technique. Real relaxation is something most of the people have not done since they were in their cradles. With pain people tend to tense up and relaxing becomes all but impossible. Muscle tension is so habitual that people hardly even notice it. The tension increases the pain which then further increase stress and tension. With the help of the relaxation exercises described here people can learn to overcome the pain. There is more than one way to achieve relaxation and people would be able to decide for their selves which they find most effective. The study that will be conducted by the researchers will focus on Progressive muscle relaxation technique (PMRT).

Progressive muscle relaxation technique was developed by Doctor Edmund Jacobson in the 1930s. He found that his patients were unable to release tension when trying to relax. He taught them to progressively contract and then releases each muscle group in order to recognize the difference the relaxed and the tense state. This method is very useful for beginners as it gives a real sensation of difference between the tense and relaxed state. This knowledge can then be used during normal every day activities to reduce muscle tension. With the purpose of testing the effect of a specific intervention which is the progressive muscle relaxation technique in pain, this study aimed at verifying the level of pain in patients with arthritis prior to and after the application of progressive muscle relaxation technique. Background of the study A variety of relaxation techniques can help people bring their nervous system back into balance, including progressive muscle relaxation. While almost all types of exercise are effective of relieving pain and can also help relieve pent-up muscle tension. By coordinating their breathing with their movements and focusing their attention on how they are feeling in the different areas of their body, they can boost the stress relieving benefits, leaving them feeling calmer and more balanced. The human body is a wonderful creation as it works perfectly without being told. However, in cases that is experiencing some health problems; it will become fragile and can easily get damaged if left untreated. The immune system has its own mind that it is responsive to anything that happens inside the body especially if there are infections. The word "arthritis" was probably heard before. And now, people may be wondering if it

could be affecting them already. By definition, arthritis means "joint inflammation," and it's used to describe more than 100 different diseases and conditions that affect joints, the tissues that surround joints, and other connective tissue. The years of medical and nursing advancement changed the faces of different disorders affecting older people. With the discovery of new drugs and the application of preventive measures, the problems brought about by the signs and symptoms of these diseases have been remarkably reduced. However, there are still a lot of people who suffer from the effects of these diseases, not only physically but also psychosocially. Among these disorders, arthritis could be considered one of the most debilitating conditions affecting mostly the older people in the Philippines, not to mention other groups in their early age. The disabling effects of arthritis may be manifested in an individuals personal, social and employment activities (Porth 2002). Most of the older Filipino people are now commonly suffering from these debilitative conditions. Age groups under the cohort of baby boomers are most likely candidates for arthritic disorders in this decade. Arthritis is increasing significantly, affecting every race but there are differences in the prevalence and distributions in different populations and countries. About one (1) percent of worlds population is affected by arthritis. And it is estimated that around 350 million people have arthritis worldwide. Majority of affected individuals are women; children are also victims of this disorder. Arthritis can affect people differently. It's common in adults 65 and older, but it can affect people of all ages, races, and ethnic groups. In fact, 1 out of every 5 adults in the United States over 46 million people has reported being diagnosed by their doctor with some form of arthritis. In the

Philippines, arthritis is also increasing every year, particularly affecting older individuals who do not seek medical attention since they do not have enough resources for the treatment. Treatments are neglected because older people think that arthritis is part of the aging process. It has been said that there are over one hundred types of arthritis. While that may be something of an exaggeration, it is nonetheless clear that many types exist. Figuring out what type of arthritis a person has carries important implications, both for assessing the risk of disability and for successfully treating that person. Two of the most common forms of arthritis are osteoarthritis and rheumatoid arthritis. Osteoarthritis and rheumatoid arthritis have different causes, risk factors, and effects on the body. Even though they have these differences, osteoarthritis and rheumatoid arthritis often share common symptoms which are joint pain, stiffness and inflammation or swelling. Adults including those with arthritis are recommended to have at least 150 minutes (2.5 hours) of moderate-intensity aerobic activity per week (activity that makes you breathe a little harder, or your heart beat a little faster) and muscle strengthening exercises on 2 or more days per week. Individuals at greater risk of falling should also include balance exercises 3 days per week. If meeting the physical activity recommendations seems a little daunting, exercising for at least 10 minutes at a time and gradually increasing the number of days a week and duration is one way to achieve your activity goals over time. The main thing to remember is to be as active as your ability allows. Even small amounts of exercise can

help and any activity is better than none. It may hurt a bit when you first get started, but in 4 to 6 weeks you should be feeling benefits. Learning techniques to reduce pain and limitations can also be beneficial to people with arthritis. Progressive muscle relaxation technique has been utilized to effectively control stress, fear, anxiety, insomnia and chronic pain. Through conditioned practice you can quickly learn to recognize-and-differentiate a tensed muscle from a completely relaxed muscle. With progressive muscle relaxation technique, the researchers would want the respondents to reduce his/her pain felt because of arthritis. This relaxation technique,
focused on slowly tensing and then relaxing each muscle group. This helps you focus on the difference between muscle tension and relaxation. You become more aware of physical sensations. One method of progressive muscle relaxation is to start by tensing and relaxing the muscles in your toes and progressively working your way up to your neck and head which will only last about 10-30 minutes or more depending on the time

that they have, will somehow help them relieve their pain. The study will be pursued by the researcher to know the effectiveness of progressive muscle relaxation technique on geriatrics who has arthritis so that it will help to decrease their pain. Conceptual Framework Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage.

After tissue injury occurs, nociception to the spinal cord via the A and C fibers continues. The fibers enter the dorsal horn, which is divided into lamnae on the cell type. The lamnae II is referred to as the substantia gelatinosa. In the substantia gelatinosa are projections that relay nociception to other partsof the spinal cord. Nociception continues from the spinal cord to the reticular formation, thalamus, limbic system, and celebral cortex. Here nociception is localized, and its characteristics become apparent, including the intensity. The involvement of the reticular formation, limbic, and reticular activating systems is responsible for individual variations in the perception of noxious stimuli. People may report the same stimulus differently based on their anxiety level, past experiences, and expectations. This is a result of the conscious perception of pain. For pain to be consciously perceived, neurons in the ascending system must be activated. Activation occurs as a result of input from the nociceptors located in the skin and internal organs. Once activated, the inhibitory interneuronal fibers in the dorsal horn inhibit or turn off the transmission of noxious stimulating information in the ascending pathway. The descending control system is a system of fibers that originate in the lower and midportion of the brain (specifically, in the periaqueducal gray matter) and terminate on the inhibitory interneuronal fibers in the dorsal horn of the spinal cord. This system is always active; it prevents continuos transmission of painful stimuli, partly through the action of the endorphins. As nociception occurs, the descending control system is activated to inhibit pain.

Cognitive processes may stimulate endorphin production in the descending control system. The effectiveness of this system is illustrated by the effects of distraction. The distractions provided by visitors or a favorite TV show may increase activity in the descending control system. Therefore, patients who have visitors may not report pain, because activation of the descending control system results in less noxious or painful information being transmitted to consciousness. Once the distraction by the visitors ends, activity in the descending control system decreases, resulting in increased transmission of painful stimuli. The interconnections between the descending neuronal system and the ascending sensory tract are called inhibitory interneuronal fibers. These fibers contain enkephalins and are primarily stimulated through the activity of non-nociceptor peripheral fibers (fibers that normally do not transmit painful or noxious stimuli) in the same receptor field as the pain receptor, and descending control. The enkephalins andendorphins are thought to inhibit pain impulses by stimulating the inhibitory interneuronal fibers, which in turn reduce the transmission of noxious impulses via the ascending system (Porth & Matfin, 2009). The classic gate control theory of pain described by (Melzack and Wall in 1965). This theory proposed that stimulation of the skin evokes nervous impulses that are then transmitted by three systems located in the spinal cord. The substantia gelatinosa in the dorsal horn, the dorsal column fibrins, and the central transmission cells act to influence nociceptive impulses. The noxious impulses are influenced by a gating mechanism. Stimulation of the large-diameter fibers inhibits the transmission of pain, thus closing the gate. Conversely, when smaller fibers are stimulated, the gate is opened. The gating

mechanism is influenced by nerve impulses that descend from the brain. This theory proposes as specialized system of large-diameter fibers that activate selective cognitive process via the modulating properties of the spinal gate. The gate control theory was the first theory to suggest that psychological factors play a role in the perception of pain. The theory guided research toward identifying cognitive behavioral approaches to pain management. Therefore this theory helps explains how alternative intervention like progressive muscle relaxation technique helps to relieve the pain in patients with arthritis. Melzack (1996) extended the gate control theory after studying phantom limb pain. He proposed that a large, widespread network of neurons exists that consist of loops between the thalamus and cortex and between the cortex and the limbic system. Melzack labeled this network the neuromatrix. Melzack (1996) theorized that in the absence of modulatory inputs from the missing limb, the active neuromatrix produces a neuro signature pattern that is perceived as pain. The neuromatrix theory highlights the role of the brain in substaning the experience of pain. Progressive muscle relaxation is a technique for combating tension and anxiety by systematically tensing and relaxing muscle groups. It was developed by American physician Edmund Jacobson (1920s). the steps on how to perform this technique which include, first is take a three deep breathing and then exhale slowly, then open the eyes as wide as possible to tense the muscle and then relax. Next, close the eyes tightly to tense it and then relax. Then open up the mouth as wide as possible to create tension and then relaxed. Next. The lips are pressed together as tightly as possible to create tension and

then relaxed. Then pull back the shoulders to tense the muscle and then relax, then push the shoulders forward or hunch it to create tension and then relax.

Next is tighten your biceps by drawing your forearms up toward your shoulders and making a muscle with both arm then hold and relax, followed by tightens your triceps muscle on the under sides of your upper arms by extending your arms out straight and locking your elbows, hold then relax, then next by clenching your fists, hold then relax. Then suck in the stomach as much as possible to create tension and then relax completely. Next, push out the stomach to create tension and then relax. Then tightens your hips along with your thighs, since the thigh muscles attach at the pelvis, hold and then relax, feel your thigh muscles smoothing out and relaxing completely. Next tightens your calf muscle by pulling your toes toward you but carefully avoid cramping, then hold and relax. Then tighten your feet by curling your toes downward, hold and then relax then perform three deep breathing. Every muscle should tightens for 7-10 seconds and for every relaxation takes approximately 5-10 seconds. Some literatures said that in using Progressive muscle relaxation as alternative technique is effective way to reduce the pain due to particular disease or condition. According to Kwekkebom and Gretorsdotirr (2006)) they proven that using PMRT in client with arthritis was reducing the pain when using these technique, because they had conduct a study about reduction of pain in client with arthritis by using this technique, researchers found that in every 8 client out of 15 respondents have complaining the pain cause by arthritis after using PMRT they are reducing their pain.

Pre-assessment

Arthritis pain

Post assessment

Figure 1. The variable and their relationship (controlled group) As shown in figure 1, first box shows the level pain in pre-assessment to the controlled group, as measure by standard pain scale and vital signs. Second box shows the respondents having arthritis pain without doing any intervention to relieve the pain. Third box shows the level of pain in post-assessment to the controlled group without doing progressive muscle relaxation technique measured by standard pain scale and vital signs.

Progressive Pre-assessment Muscle Relaxation Post assessment

Figure 2. The variables and their relationship (experimental group) in figure 2, first box shows the level of pain in pre-assessment before doing the progressive muscle relaxation technique as measure by standard pain scale and vital signs. Second box show the respondents using progressive muscle relaxation technique while their having arthritis pain. Third box show the level of pain in the post assessment to the experimental group after doing progressive muscle relaxation technique measure by standard pain scale and vital signs. Statement of the Problem The study will determine the effectiveness of progressive muscle relaxation technique on clients with arthritis in a selected community. Specifically, answer the following questions:

1. What is the level of pain of pre- assessment under control group without doing progressive muscle relaxation technique? 2. What is the level of pain of pre-assessment under experimental group by doing progressive muscle relaxation technique? 3. What is the level of pain of post-assessment under control group without doing progressive muscle relaxation technique? 4. What is the level of pain of post-assessment under experimental group after doing the progressive muscle relaxation technique? 5. Is there is a significance difference between the pre-assessment and post-assessment of control group without doing progressive muscle relaxation technique? 6. Is there a significance difference between pre-assessment and post-assessment of experimental group after doing progressive muscle relaxation technique? 7. What are the benefits of using Progressive muscle Relaxation Technique to the arthritis client. Hypothesis Based from the problem of the study, the research hypothesis was formulated and tested at the level of significance of 0.05: There is no significance difference on pre and post assessment of pain in arthritis patient.

Scope and Delimitation of the study The study aims to determine the effectiveness of progressive muscle relaxation technique on clients with joint pain associated by arthritis regardless of cause and type, age from 40 to 70 years old since this is the age group wherein arthritis usually sets in, not taking pharmacological treatment. The researcher utilized a descriptive and quasi experimental research design. Researchers want to know the effectiveness of progressive muscle relaxation technique on arthritic patients in selected communities. Sixty (60) respondents will be utilized by the researchers of which all came from the selected communities in Las Pinas City and are being selected purposively. The course of the study will be conducted within the month of December. The researcher will have the controlled group and the experimental group. Control group will be observed and assess for their pre and post assessment of pain and vital signs without doing any intervention to relieve their pain. The experimental group will be observe and assess for their pre and post assessment of pain and vital signs before and after doing the relaxation technique. The researchers also provides a questionnaire which is the Arthritis impact measurement scale 2 which is a disease-measure of physical, social, and emotional wellbeing designed as a measure of outcome in arthritis. They will also use a standard pain scale for assessing the pre and post pain. Data will be gathered upon the approval of the request letter. The respondents are gathered in the health center for the instructions and to teach them the step by step procedure in doing the relaxation technique. One of their relative will be also involve

because the researchers will teach them on how to get their vital signs and the pain scale so that if the researchers are not around there will be someone who will be getting their vital signs and pain scale. The experimental group as well as the controlled group should not be taking any pharmacological medication for pain. The experimental group will do the relaxation technique twice a day. The study will not cover those patients who are taking pharmacological medications for pain and have deformities. One of the weaknesses of our study is environment, diet, lifestyle, pain threshold, pain tolerance, proper execution of progressive muscle relaxation technique and clients with underlying diseases. Significance of the Study The researchers believe that the result of the study may benefit the following. Community. This study will help them understand more about alternative medication like progressive muscle relaxation technique. Progressive muscle relaxation is less expensive and easily affordable to people who are in low socio-economic income that they cannot afford to buy pain reliever and also be a source of medication and mode of relaxation. Nursing Practice. This study is to enhance the understanding of nursing students with the use of progressive muscle relaxation technique and its effectiveness on relieving pain in clients with arthritis. Presenting the use of progressive muscle relaxation technique to the health care practitioners more option to provide therapeutic relief of pain, by means of progressive muscle relaxation technique.

Nursing Education. This study will contribute to the nursing educator or much deeper understanding and knowledge about progressive muscle relaxation technique. As one of the effective means and therapeutic therapies in relieving pain in which they can disseminate the information to their students and the students can use these technique and also they can share this information to their different families who has arthritis Nursing Research. This study will also enhance the interest of future researcher for them to rediscover., The findings of the study may help them in doing further research related for this matter. This study can also help other researcher for this may provide information especially on the effectively of muscle relaxation technique to the client with arthritis in a selected communities, and will allow for future comparisons and references for their research. Definition of Terms For better understanding of the study, the following terms were used and defined operationally. Arthritis - inflammation of one or more joints, characterized by swelling, warmth, redness of the overlying skin, pain, and restriction felt by the client. Early adulthood either male or female with age of 40 to 70 years old. Progressive muscle relaxation technique it refers to a non-pharmacological therapy to relieve pain.

CHAPTER III METHOD AND PROCEDURE This chapter presents the methodology of the study specifically the research design, research locale, sample and sampling technique, the procedures of data gathering and research instrument that employed. Research Design The researchers utilized descriptive and quasi experimental research design. Researchers wanted to represent the data about the effectiveness of progressive muscle relaxation technique on arthritic patients in a selected community. The researchers will have two groups; the controlled group and the experimental group. The control group will be observe and assessed for pain level and vital signs without doing any intervention to relieve their pain. The experimental group will be observe and assess for their pain scale and vital signs before doing the relaxation technique and after doing the relaxation technique. Sample and Sampling technique The study will be held within the premises of Pamplona 3, Pulang Lupa, and Daniel Fajardo located along Las Pinas City. The patients who with arthritis regardless of cause and type, ages 40 to 70 years old, with pain upon movement of affected joint and does not taking any pain reliever were the selected respondents for the study. They will be selected through purposive sampling technique. Sixty (60) individuals were purposively selected to answer the researchers questionnaires then they will be divided

into two (2) groups which are the controlled group and the experimental group. The controlled group consist of thirty (30) respondents will be observe and assessed for pain level and vital signs without doing any intervention to relieve their pain. The experimental group consist also of thirty (30) will be observe and assess for their pain scale and vital signs before doing the relaxation technique and after doing the relaxation technique. The researchers followed a certain criteria in selecting the respondents. First, the respondents must be from Pamplona3, Pulang Lupa and Daniel Fajardo Las Pinas City. Second, they should belong to the age group of 40 to 70 years old since this is the age group wherein arthritis usually sets in. Third, they must be in pain in selected joints such as the feet, hands, legs, spine and the neck. Research Instrument and technique The instrument that the researcher will utilize is the Arthritis impact measurement scale 2 (AIMS 2). This instrument is adopted from a study of Kristine Kwekkeboom, PhD, RN. Her study was about progressive muscle relaxation technique applied on people who have arthritis. This instrument is a disease-measure of physical, social, and emotional well-being designed as a measure of outcome in arthritis. There are 9 scales: mobility, physical activity (walking, bending, lifting), dexterity, household activity (managing money and medications, housekeeping), social activities, activities of daily living, pain, depression and anxiety. It also includes arm function, social support, and work.

The questionnaire has twenty-six (26) questions that will be answered with Always (1), Very often (2), Sometimes (3), Almost Never (4), Never (5). The range of score is 0-10 for each section. Total health score 0-60. Zero represents good health status, 10 and 60 represent poor health status. Higher scores indicate greater disability. The score for each section is standardized to a 0-10 scale using a standardization formula. The total health score is calculated by summing the standardized scores for mobility, physical and household activities, dexterity, pain, and depression. Another tool that will be utilized by the researchers is the standard pain scale for assessing the pain before and after doing the progressive muscle relaxation technique. This scale has 10 divisions with 0 being pain free and 10 being the intolerable pain. Data Gathering The data will be gathered based on the following procedures: The researchers will look for health centers that will allow them to conduct their study and caters the criteria they are looking for their respondents. After looking for health centers, the researchers will submit a letter of request that will be approve by the researchers adviser and the dean of college of nursing. After which it will be sent to the city health office to have it signed by the city health officer allowing us to conduct our study in those selected health centers. After the approval of each request, the researchers will present the approved letter to the health center and will start to look for the respondents. The researcher will ask the nurse on duty for the list of people who has arthritis. Researcher will go to their houses, ask for some time and invite them to go to the health center. After gathering all the

respondents in the health center, the researchers first introduce their selves and from where school they came from. Researchers will have some introduction about the study that they are conducting which is Effectiveness of progressive muscle relaxation technique on clients with arthritis in selected communities. Researchers will discuss the dos and donts for this study. The respondents should monitor their vital signs: blood pressure, respiratory rate and pulse rate aside from vital signs the pain scale is also assessed. The respondents should not be taking any pain reliever. The researchers will also explain to their respondents on how to answer the questionnaire. After all those discussion the researchers will divide the sixty (60) respondents into two groups: thirty respondents for the controlled group and another 30 for the experimental group. The controlled group will be instructed to answer the questionnaire provided by the researcher, have their vital signs and their pain scale monitored every time they experience pain but they will not take any pain reliever and they will not do the relaxation technique. After thirty (30) minutes vital signs and pain scale are taken again to know if there is any changes. The experimental group will also be instructed to have their vital signs; pain scale monitored and answers the questionnaire provided by the researcher. They will not take any pain reliever but they will perform the progressive muscle relaxation technique. The step by step procedure of the relaxation technique will be demonstrated first by the researchers to the experimental group. After the demonstration they will let the respondents do the technique and correct them if the respondents do not do the proper way. The experimental group should do the relaxation technique twice a day in the morning and before going to bed. After doing the relaxation technique vital

signs and pain scale will be taken again to know if there are any changes and ask the respondents if progressive muscle relaxation technique help them ease their pain. The researchers will teach one of the relative of the respondent in taking blood pressure, pulse rate, respiratory rate and the pain scale. The relative will demonstrate those things to the researcher to know if he/she understands what the researcher taught him/her this will be done also to the controlled group. The researchers will monitor the two groups every Wednesday for one month. After gathering all the data the researcher will have it analyse and interpret. Statistical Treatment of Data