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HA Convention 2017 Clinical Safety & Quality Service I
Vera Chan sui-mei Occupational Therapy
16.5.2017
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Title of Pilot Study
To investigate the effect of group-
based activity program on health
related quality of life ( HR-QOL ) for
patients with musculoskeletal injuries
in work rehabilitation program
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Background
Musculoskeletal disorders ( MSKD ) are one of the largest work
related problems being encountered in work rehabilitation program
( Antonio, 2013 )
Patients displayed significant pain & functional limits mentally &
physically especially for lower back & lower limbs injuries
Activity program are frequently advocated for the management of
musculoskeletal disorders & improved QOL ( Antonia, 2013 )
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Background 3 Interventions Improving Patients’ QOL
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Stretching Exercise can increase the range of joint movement & encourage circulation & oxygenation of joints, muscles & tendon units ( Sihawong, 2014 ). It was associated with improved QOL for many chronic conditions with sedentary lifestyle ( Corby, 2009 )
Progressive Muscle Relaxation is a mind-body technique involves alternately tensing & relaxing muscle groups in sequence throughout the body. It is a well established psychological therapy for alleviating psychological distress in patients with chronic illnesses & improving QOL ( Tahereh, 2007 )
Ba Duan Jin ( Chinese Ba Duan Jin Qigong ) is a long term component of Chinese medicine, which demonstrated the effectiveness for relieving pain & improving quality of life ( Wang, 2014 )
Study Design : Randomized Control Trial
Control Group
The subjects in the control group received the conventional
work hardening program
Intervention Group
The subjects in the intervention group received the
conventional work hardening program & join the group-
based activity program
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Study Design : Subjects Recruitment
Inclusion Criteria
- Both gender referring for work hardening program
- Manual workers
- Duration of injury on duty (IOD) > 6 months
- Suffering from either low back pain or lower limbs injury
Exclusive Criteria
- Received Rx including physiotherapy, psychiatry intervention
or other medical Rx outside ( i.e. acupuncture )
- CTD, burns, cardiac, medical or neurological diseases 6
Intervention : Content of Group-based Activity Program
1. Stretching exercises ( neck, shoulder, elbow,
wrist, fingers, trunk, hip, knee & ankle )
2. Progressive muscle relaxation
3. Ba Duan Jin ( Ready position, Routine 1-3 )
4. Ba Duan Jin ( Revision Routine 1-3, Routine 4-5 )
5. Ba Duan Jin ( Revision Routine 4-5, Routine 6-8 )
6. Ba Duan Jin ( Revision Routine 1-8 ) 7
Group-based activity program is :
: A closed group with 4 - 6 patients
: Included 6 sessions
: Carried out by trained PCA in 6 week
Outcome Measurement (1)
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Each subject completed a self-report survey by using Chinese version of SF-36 with 8 domains of health at baseline ( Week 1 ) & post intervention ( Week 6 ) as the primary outcome measure of health status
8 Domains
1. Physical functioning 5. Emotional well being
2. Role limitations due to physical problems 6. Social Functioning
3. Role limitations due to emotional problems 7. Bodily Pain
4. Vitality 8. General health
Outcome Measurement (2) Group-based Activity Program Evaluation Form
11 items with 5- point scale (strongly satisfied to strongly dissatisfied )
& 5 open questions
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Statistical Analysis
Descriptive characteristics of baseline
subjects ( continuous & categorical variables )
Gender ( male & female )
Age
Injury site ( low back pain - LBP & lower limbs
injury - LL )
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Statistical Analysis Mann-Whitney U test ( Independent sample t-test )
Compare the pretest & posttest mean scores of 8 domains in SF-36 between
the control & intervention group, gender & injury group
Wilcoxon Sign Rank test ( Paired sample t-test )
Compare the pretest & posttest mean scores of 8 domains in SF-36 of
control, intervention, male, female, low back pain & lower limbs injury group
All statistical test were one-sided with significance level P value <
0.05
All analyses were conducted with Mac SPSS version 20
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Results : The Flow of Subjects
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Randomized Sampling
Intervention Group ( n=11 )
Control Group ( n=11 )
Complete SF-36 questionnaire at week 1 & week 6
Data Analyzed
Complete SF-36 questionnaire at week 1 & week 6
Total 22 subjects had recruited & completed initial work capacity evaluation ( LBP & LL )
even no. odd no.
Results – Baseline Demographics
Recruitment Period : Jan, 2015 – Aug, 2015
Intervention Group ( n=11)
Control Group (n=11)
P - value
Occupation Manual worker
Age range ( years ) Mean SD
25 - 59 44.36 13.0
36 - 62 52.36 7.54
0.428
Gender
Male 13 (59%) 6 7 1.0
Female 9 (41%) 5 4
Injury site
LBP 16 (73%) 7 9 0.635
LL 6 (27%) 4 2
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Baseline characteristics of subjects were homogenous in the group-based activity program ( intervention group ) & conventional work hardening program ( control group )
Results – Intervention Vs Control Group Scale Week Intervention Group Control Group P - value
Physical Functioning W1 W6
12 12.68
11 10.32
0.716 0.387
Role Limitation due to Physical Health
W1
W6 13 13.82
10 9.18
0.069
0.041*
Role Limitation due to Emotional Problems W1 W6
12.68 13.23
10.32 9.77
0.274 0.167
Vitality W1 W6
11.50 14.09
11.50 8.91
1.000 0.057
Emotional Well Being W1 W6
13.82 13.86
9.18 9.14
0.090 0.082
Social Functioning W1 W6
13.45 14.00
9.55 9.00
0.148 0.065
Bodily Pain W1
W6 14.23 14.91
8.77 8.09
0.043
0.012* General Health W1
W6 11.64 13.00
11.36 10.00
0.920 0.276
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• There are statistically difference in role physical health ( p=0.041) & bodily pain (p=0.012) between intervention & control group after 6-week program
Results – LBP Vs LL Scale Week Low back pain Lower limbs
injury P - value
Physical Functioning W1 W6
9.84 10.31
15.92 14.67
0.049* 0.156
Role Limitation due to Physical Health
W1
W6 12.06 10.06
10.00 15.33
0.256
0.039*
Role Limitation due to Emotional Problems W1 W6
10.38 10.44
14.50 14.33
0.089 0.165
Vitality W1
W6 10.72 9.03
13.58 18.08
0.353
0.003* Emotional Well Being W1
W6 10.44 10.25
14.33 14.83
0.205 0.084
Social Functioning W1 W6
10.94 9.63
13.00 14.83
0.497 0.132
Bodily Pain W1
W6 9.75 9.63
16.17 16.50
0.034*
0.023*
General Health W1
W6 10.56 9.44
14.00 17.00
0.257
0.014*
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• There are statistically difference in role physical health (p=0.039), vitality (p=0.003), bodily pain ( p=0.023) & general health (0.014) between LBP & LL group after 6-week program
Results – Male Vs Female Scale Week Male Female P - value
Physical Functioning W1 W6
12.73 13.42
9.72 8.72
0.282 0.091
Role Limitation due to Physical Health W1 W6
12.54 12.85
10.00 9.56
0.130 0.154
Role Limitation due to Emotional Problems W1 W6
11.81 12.04
11.06 10.72
0.732 0.605
Vitality W1 W6
11.23 12.15
11.89 10.56
0.814 0.564
Emotional Well Being W1 W6
10.73 10.92
12.61 12.33
0.499 0.609
Social Functioning W1 W6
14.42 11.81
10.17 11.06
0.412 0.785
Bodily Pain W1 W6
13.65 12.15
8.39 10.56
0.055 0.561
General Health W1 W6
9.77 11.73
14.00 11.17
0.123 0.840
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• There are NO statistically difference between male & female group after 6-week program
Results – Intervention Group Scale W1 W6 Mean
difference P - value
Physical Functioning 52.73 63.64 10.91 0.16
Role Limitation due to Physical Health 6.82 20.45 13.63 0.157
Role Limitation due to Emotional Problems 24.24 30.30 6.06 0.577
Vitality 43.18 48.64 5.46 0.095
Emotional Well Being 54.91 57.45 2.54 0.242
Social Functioning 47.82 56.77 8.95 0.123
Bodily Pain 41.45 45.91 4.46 0.594
General Health 40.91 48.64 7.73 0.048*
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• There are statistically difference in general health (p=0.048) in intervention group after 6-week program
Results – Control Group Scale W1 W6 Mean
difference P - value
Physical Functioning 50.91 56.82 5.91 0.105
Role Limitation due to Physical Health 0.00 4.55 4.55 0.317
Role Limitation due to Emotional Problems 6.06 15.15 9.09 0.102
Vitality 38.64 36.36 - 2.28 0.474
Emotional Well Being 42.18 45.82 3.64 0.014*
Social Functioning 34.18 40.91 6.73 0.155
Bodily Pain 29.82 30.09 0.27 0.928
General Health 36.64 37.45 0.81 0.583
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• There are statistically difference in emotional well being (p=0.014) in control group after 6-week program
Results – Male Group Scale W1 W6 Mean
difference P - value
Physical Functioning 55.77 65.38 9.61 0.03*
Role Limitation due to Physical Health 5.77 13.46 7.69 0.157
Role Limitation due to Emotional Problems 15.38 23.08 7.70 0.339
Vitality 37.69 40.77 3.08 0.390
Emotional Well Being 45.85 49.54 3.69 0.112
Social Functioning 44.31 49.00 4.69 0.371
Bodily Pain 40.92 39.46 - 1.46 0.551
General Health 34.46 42.08 7.62 0.023*
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• There are statistically difference in physical functioning (p=0.03) & general health (p=0.023) in male group after 6-week program
Results – Female Group
Scale W1 W6 Mean difference
P - value
Physical Functioning 46.11 52.78 6.67 0.058
Role Limitation due to Physical Health 0.00 11.11 11.11 0.317
Role Limitation due to Emotional Problems 14.81 22.2 7.39 0.317
Vitality 45.56 45 - 0.56 0.888
Emotional Well Being 52.44 54.67 2.23 0.132
Social Functioning 36.22 48.61 12.39 0.017*
Bodily Pain 28 35.89 7.89 0.075
General Health 45 44.44 - 0.56 0.931
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• There are statistically difference in social functioning (p=0.017) in female group after 6-week program
Results – LBP Group Scale W1 W6 Mean
difference P - value
Physical Functioning 48.13 57.19 9.06 0.003*
Role Limitation due to Physical Health 4.69 6.25 1.56 0.655
Role Limitation due to Emotional Problems 6.25 16.67 10.42 0.066
Vitality 37.81 37.19 - 0.62 0.727
Emotional Well Being 44.50 47.25 2.75 0.017*
Social Functioning 39.13 43.66 4.53 0.248
Bodily Pain 31.88 32.56 0.68 0.874
General Health 35.31 37.50 2.19 0.374
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• There are statistically difference in physical functioning (p=0.003) & emotional well being (p=0.017) in LBP group after 6-week program
Results – LL Group Scale W1 W6 Mean
difference P - value
Physical Functioning 61.67 68.33 6.66 0.156
Role Limitation due to Physical Health 0.00 29.17 29.17 0.039*
Role Limitation due to Emotional Problems 38.89 38.89 0.00 0.165
Vitality 49.17 56.67 7.50 0.003*
Emotional Well Being 59.33 63.33 4.00 0.084
Social Functioning 46.00 62.67 16.67 0.132
Bodily Pain 45.67 52.50 6.83 0.023*
General Health 48.00 57.83 9.83 0.014*
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• There are statistically difference in role physical health (p=0.039), vitality (p=0.003) & bodily pain (p=0.023) in lower limbs injury group after 6-week program
Results – Patients Feedback
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3
8
0
5
10
Very satisfied Satisfied
Group was encouraging &
interactive
02468
10
Very satisfied Satisfied
1
10
Group objectives
2
7
2
Group content
Very satisfied Satisfied Neutral
0 5 10
Very satisfiedSatisfiedNeutral
Verysatisfied Satisfied Neutral
Giveninformation was
useful3 6 2
Useful information
Results – Patients Feedback
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Verysatisfied
Satisfied
Group tutorhad adequate
knowledge5 6
Group tutor had adequate knowledge
4.55
5.56
Verysatisfied
Satisfied
Group tutor hadadequate
preparation6 5
Group tutor had adequate preparation
Patients Feedback in Open Questions
• Patients expected more training space & increased training
time or Rx sessions for them to practice
• Patients had positive feedback towards the group
Discussion 1) Intervention Group showed significant improvement in
role physical health & bodily pain than control group
2) Male had improvement in physical functioning
3) Female had improvement in social functioning
4) LBP Group had significant improvement only in physical
functioning & emotional well being
5) LL Group had 3 aspects of improvement including role
physical health, vitality & bodily pain 25
Limitation of Study
Small Sample Size ( n=22 ) in this pilot study. Larger sample size are
recommended to confirm the findings
Short Study Duration with 6 week & only twice time for data collection,
carry-over effect had not explored & observation period was too brief
Researcher Was Not Blinded that there will be a bias on planning the
content of conventional work hardening program between control or intervention group
It may be Too Subjective to use single SF-36 as an evaluative & outcome
measure. Further studies should aim to utilize more objective measure for assessing
dysfunction in individuals with low back pain & lower limbs injury
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Conclusion & Clinical Application This pilot study suggested that a group-based activity program had
significant & positive effect in physical functioning than
emotional well being in HR-QOL among different groups
Evidence-based effect & patients were satisfied with favorable feedback about the combination of stretching exercises, progressive muscle relaxation & Ba Duan Jin practice
Explore the group Rx as the routine or early intervention program for work rehabilitation patients suffering from low back pain & lower limbs injury
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