Effect of patients' Education on their Performance and Outcomes regarding Lumbar Disk Herniation

Background; Lumbar disc herniation is a common condition in adults and can impose a heavy burden on both the individual and society. The present study aimed to evaluate the effect of patients' education on their performance and outcomes regarding lumbar disk herniation. Design: Quasi-experimental design used. Setting: The study conducted at the orthopedic outpatient clinic at Benha University Hospital. Subjects: Purposive sample of 63 patients, both genders who aged from (11 63 years old) included in the study, Patients who were attending surgical operation regarding lumbar disk herniation excluded. Tools: Three tools used; 1) Structured interview questionnaire regarding the patients' demographic characteristics, medical data, and patient's knowledge questionnaire regarding lumbar disk herniation. 2) Observational checklist for patient's practice regarding lumbar disk herniation exercises. 3) Modified Oswestry low back pain & disability scale Result: There was a statistically significant improvement in the total level of patient's knowledge, practices & outcomes immediately post and three months post-program implementation. Also, there was a significant statistical correlation between patients' knowledge and pain disability scale three months post-program implementation. Conclusion: The results of the study conclude that the educational program was effective and its results had a significant improvement in patient's knowledge, practice, and outcomes regarding lumbar disk herniation. Recommendations: The study suggested equips the orthopedic department with simple illustrated guidelines protocol covering lumbar disc herniation practices, knowledge; Reapply this research on a more substantial probability sample acquired from different geographical areas in Egypt for generalization.


1-Introduction
Lumbar disc herniation (LDH) is one of the most common spinal degenerative disorders, which can lead to low back pain (LBP) and radicular leg pain. Herniated lumbar disc characterized by lower limb pain radiating below the knee in an area of the leg served by one or more lumbosacral nerve roots. Sometimes, there are other neurological findings, such as sensory and motor deficits. Also, a herniated disc can press on the nerves in the spine and may cause pain, numbness, tingling, or weakness of the leg called 'sciatica' North American Spine Society, (9112). However, it has been reported that LDH has not always accompanied by clinical symptoms such as LBP (asymptomatic LDH). Lumbar disk herniation commonly caused by decreased muscle strength, lack of exercises, and maintaining a poor posture for extended periods during activities. These factors lead to an increased load on the back, which aggravates lumbar pain. Lumbar disk herniation classified into congenital and acquired types. (Jioun Choi M. et al., 9115). Depending on the severity of symptoms, treatments for a herniated lumbar disc include physical therapy, muscle-relaxant medications, pain medications, anti-inflammation medications, local injection of cortisone (epidural injections), and surgical operations. In any case, all people with a disc herniation should rest and avoid reinjuring the disc. Sometimes, even people with relatively severe pain can respond to conservative measures, including physical therapy with an exercises regimen, epidural cortisone injection, or oral cortisone medication. Patient's education is essential to be seen as an interactive process (Copanitsanou P . et al., 9112), which includes an assessment of the person's learning needs, preferences, and readiness to learn. The education of patients is a crucial and challenging aspect of care (Charalambous A. et al., 9112). To provide effective education, patients' age and developmental level (physical/cognitive abilities and psychosocial development) determine the most effective teaching strategies (Euro-Med Info. 9112).
Nurses play a vital role in the early detection and management of clinical deterioration because they are a group of professionals with the highest degree of patient's contact (Iddrisu M. et al., 9112) Advanced practice nurses (APNs) in particular have been demonstrated to improve quality of care and patient's health (Lukosius B et al.,  9116) . Also, it has been a lack of sufficient and consistent patient's education in orthopedic nursing, as well; the desire to develop educational practices has increased in international nursing research. The educational practices and skills of nurses can vary in clinical contexts, also in orthopedic nursing care (Schoberer et al., 9116).

9-Significance of the problem
Lumbar disc herniation is considered as one of the most crucial problems of the health system and become a costly burden to society. 136 of the people suffer from it during their lifetime. It is one of the prevalent causes for referral to the physician and leading to the restriction of daily and occupational activities. LDH can occur in any disc in the spine, but the two most common forms are lumbar disc herniation and cervical disc herniation. Lumbar disc herniation occurs 15 times more often than cervical (neck) disc herniation, and it is one of the most common causes of low back pain.
About (1333) of patients with herniated lumbar disc admitted to the orthopedic department and outside clinic from (Benha University Hospital Census, 9112)

Aim of the study.
The present study aimed to evaluate the effect of patient's education on their performance and outcomes regarding lumbar disk herniation.
I.3. Research Hypotheses H1:-Patient who exposed to the educational program will exhibit improved knowledge level compared to their pre-program level. H2:-Patient who exposed to the educational program will exhibit improved practice level compared to their preprogram level H3:-Patient who exposed to the educational program will exhibit better outcomes compared to their preprogram level. H4:-There will be a significant correlation between patients' knowledge and low back pain and disability scale three months post-program implementation. Patients' outcomes: outcomes are intended in this study to measure patients' low back pain and disability. Nurses' performance: are included in this study to assess patients' knowledge & practice regarding lumbar disk herniation.

1-Research design: Quasi-experimental design was
utilized to conduct the current study. 9-Setting: -This study conducted in the orthopedic outpatient clinic at Benha University Hospital.

Subjects:
Purposive sample of 63 adult patients from both genders who aged from (11 -63 years old) with a diagnosis of a herniated lumbar disk. Patients who were attending surgical operation of lumbar disk herniation excluded. Size: The sample size of patients was calculated based on the previous year census report of admission in the orthopedic department from Benha University Hospital Census, 2312, utilizing the following formula (Yamane, 1262).

Tools of Data Collection:
Four tools utilized in this study:

Tool (1): Structured interview questionnaire (preprogram)
It developed by the researchers based on reviewing the current literature; that used to assess patients' demographic characteristics. It divided into two parts: patient's medical data & patient's knowledge regarding lumbar disk herniation. It wrote in the Arabic language.

Part 1: patient's demographic characteristics & medical data:
This tool was filled pre-program implementation only, it concerned with demographic characteristics of the patients including; (age, educational level, marital status & occupation, height, weight, history of disease) Part 9: patient's knowledge Questionnaire regarding lumbar disk herniation: It utilized for testing patient's knowledge related to a lumbar herniated disk. It consists of items covering the following: Knowledge related to lumbar herniated disk (definition, causes, types, signs and symptoms, diagnosis, treatment, and protection from its complication). This tool filled two times; the first time pre-program implementation, the second time immediately and three months postprogram implementation.

Knowledge scoring system:
All knowledge variables weighted according to the items included in answer to each question. The data collected from the knowledge test computed and the test received a grade out of 12 questions, the scores allocated as follows: complete (2), incomplete (1), wrong (3) The total score of all questions will be represented in 1336 and categorized into two levels, unsatisfactory (<636) and satisfactory (>636)

Tool (9): Patient practice observation checklist:
It used to assess patient's practice regarding lumbar disk herniation exercises. It developed by Mcquilkie &Turesky (9112) and adapted by the researchers. It consisted of seven exercises ( Spinal decompression exercise, Standing Extension exercise, Half cobra pose exercise, Full cobra pose exercise, Cat-Cow exercise, Plank exercise, and Bird dog exercise). This tool filled two times; the first time pre-program implementation, the second time immediately and three months post-program implementation.

Scoring system:
All exercises weighted according to the items included in each exercise and the test received a grade out of 23 items (each exercise included three items except Bird dog exercise included five items), the scores allocated as follows: completely done (2), incompletely done (1), not done (3). The total score of all exercises will be represented in 1336 and categorized into two levels, unsatisfactory (<236) and satisfactory (≥ 23).

Tool (3): Modified Oswestry low back pain &disability scale:
It developed by (Fritz, & Irrgang, 9111) and adopted by the researchers, this tool utilized to assess low back pain & disability, it included ten sections (Pain intensity, Personal care, Lifting, Walking, Sitting, Standing, Sleeping, Social life, Traveling and Homemaking). Each section contained six items, the first item in each section scored (3), the second item scored (1), the third item scored (2), the fourth item scored (3), the fifth item scored (4), the sixth item scored (5). This tool filled two times; the first time pre-program implementation, the second time immediately and three months post-program implementation.

Scoring system:
For each section, the total possible score is 5: if the first statement is marked the section score = 3, if the last statement is marked it = 5. If all ten sections completed, the score calculated as follows; 16 (total score) 53 (total possible score) X 133 =32 % If one section is missed or not applicable the score is calculated: 16 (total scored) 45 (total possible score) X 133 =3555 %

Validity and Reliability:
Face and content validity were done for the tools by five Professions and expertise working in the medical surgical nursing in the faculty of nursing and orthopedic medicine department at Benha University, and the researchers did the necessary modifications, accordingly the reliability of the tolls was tested using the internal consistency method. It approved to be high with Cronbach's alpha reliability coefficients 35914.

Procedures: Pilot Study
A pilot study was carried out on six patients of study to test the content of the questionnaire as well as to estimate the time needed for data collection, and the necessary modifications have done. Patients who shared in the pilot study excluded from the study sample.

Field of work
Data collected in the following sequence: -Once official permission to carry out the study obtained from relevant authorities after an explanation of its purpose. Patient's assessment questionnaire distributed for patients who included in the study, assure confidentiality obtain informed written consent.

Procedures:
The designed educational program comprised the following phases:

Assessment phase:
In the beginning, the researchers visited the orthopedic clinic to collect necessary data in orthopedic clinic working days (three days /week), frequency of cases (about 2 to 6 cases per week) and get the agreement to conduct the research. The researchers meet the patient after registration to clinic time (9 am to 13 am) and introduce themselfs; explain the aim of the study to each patient to gain their cooperation to share in the study. The researchers initiated data collection by interviewing each patient' for assessing demographic characteristics, medical data, and patients' knowledge by using a structured interviewing questionnaire (pre-program). Each patient was asked to answer specific questions to evaluate his knowledge about lumbar disc herniation (definition, causes, signs, symptoms, diagnosis, risk factor, treatment types, complication, prevention, type of exercise & its importance in decreasing patients' disability and pain). Also, the researchers assess the patients' practice regarding lumbar disc herniation exercises through the observational checklist and assessing patients' disability through Owestry low back pain and disability scale (pre-program).

Planning phase:
The researchers developed the educational program based on the explored needs, requirements, and deficiencies that translated to the aims and objectives of the program. Moreover, teaching materials were prepared, i.e., audiovisual materials related to lumbar disk herniation, with focusing on that covered theoretical and practical information.

Implementation phase
The educational program was developed and implemented for the studied patients. They attended four sessions (2 sessions for the theoretical part, two sessions for the practical part). Regarding theoretical sessions, the first session was included a general overview of lumbar disk herniation as: (definition, causes, signs & symptoms, diagnosis, risk factor, treatment, and complications). The second session included information about (the type of exercise & its importance in decreasing patients' disability and pain regarding lumber disc herniation. The duration of each session was (15-23) minutes. Each session followed by a summary of essential points. At the end of the second theoretical sessions, the researchers have arranged another appointment for the practical sessions and take patients' telephone numbers for communication with them. The patients attended two practical sessions (physical exercises).
Regarding practical session, The first session included (Spinal decompression exercise, Standing Extension exercise, Half cobra pose exercise, Full cobra pose exercise). The second session included (Cat-Cow exercise, Plank exercises, and Bird dog exercise). The duration of each session was (23-33) minutes. Demonstration and remonstration have done for the patients. At the end of the practical sessions, Practical video CD about exercises procedure given to each patient. Each patient provided a booklet which contained a theoretical part about herniated lumbar disk & practical part about its exercises procedures.

Evaluation phase
Immediately after implementation of the designed educational program, patients' knowledge was evaluated by the researchers through filling the study toll 1, part 2, also, patients' practice and outcomes were evaluated using tool 2 & 3 immediately and three months post-program implementation.

Ethical considerations:
This study conducted after primary approval obtained from the Ethics Committee, faculty of nursing, Benha University. Then official permission was obtained from the director of the orthopedic department in Benha University. Study purpose explained to participants, and they also informed that they could withdraw from the study at any time before the completion of the study. After agreement for Participation in the study, participants were asked to sign a consent form. Moreover, they reassured that all information gathered would be confidential and used only for the study.

Statistical Analysis:
Upon completion of data collection through the previously mentioned tools, data were computed and analyzed using the Statistical Package for Social Sciences (SPSS), version 23535353. Data were presented in tables using numbers, percentages, X2, P-value, and r-test. Level of significance was a threshold at 3535.

5-Results
"Table (1)" Frequency and percentage distribution of the studied patients according to their demographic characteristics. This table shows regarding age more than half (23536) of the patients were in the age category ( ≥ 43 years old) also (556) are males, more than three quarters (136) were married. Regarding residence (636) was from an urban area, (63%) had Intermediate education. As well as regarding occupation (436) manual work.
" Table (2)" Frequency and percentage distribution of the studied patient according to their illness-related data. Showed that, regarding means of weight (123511  1563), body mass index (456 ) overweight & (46526) obese, all patients had the previous admission to hospital and they had pain during watching T.V. and driving a car (1336). Twothirds of the studied group (23536) had a herniated lumbar disk from 6 to 9 months. Moreover, the majority of them (13536) did not have any information about the herniated lumbar disk. Table (3)" Show frequency distribution of patient's knowledge pre-program, immediately post and three months post-program implementation. Shows, all patients had an unsatisfactory level of knowledge pre-program. However, the majority of patients (1353. %) had a satisfactory level of knowledge immediately post-program implementation. More than half of patients (61526) had a satisfactory level of knowledge after three months of implementing the program. There is a statistically significant differences observed between knowledge preprogram, immediately and three months post-program implementation as paired (P < .333).
"Table (4)" Show frequency distribution of patient's practice pre-program, immediately post and three months of program implementation. This table shows that the majority of patients (9151 %) had unsatisfactory levels of practice pre-program. However, (9352 %) had a satisfactory level of practice, immediately post-program implementation. About two-thirds of patients (65556) had a satisfactory level of practice after three months of implementing the program. With highly statistically significant differences observed between practice pre-program and immediately postprogram (P < .333 ), and after three months as paired (P < .331 ).
"Table(5)" Distribution of total pain and disability score among patient's pre-program, immediately post and after three months of implementing the program, this table reveals that there were statistically significant differences observed between total pain & disability score pre and after three months post-program implementation as paired ( P < .333).
"Table (6)" : Correlation between total knowledge score and total pain & disability score among patients after 3 months of implementing the program ,this table reveals that, there was a highly statistically significant negative correlation between patients total knowledge and their total pain & disability score after three months post-program implementation as ( r = -. 432 with P-value < 35331) inverse relationship .

6-Discussion
A disc herniation is considered as one of the most crucial problems of the health system and become a costly burden to society. 136 of people suffer from low back pain (LBP) during their lifetime. It is one of the prevalent causes for referral to the physician and leading to the restriction of daily and occupational activities. Different mechanisms described and numerous therapeutic methods have been assigned to cope with this problem. The mechanical factors, among other factors, have been stated as the primary cause of the LBP. (Braddom M. 2315) So, the present study aimed to evaluate the effect of patient's education on their performance and outcomes regarding lumbar disk herniation.
Regarding demographic characteristics of studied patients, the current study showed that near to three-fourths of patients are older than 43 years old. The study is consistent with (Yazdani, A. et al., 9115) who study the "effects of six-weeks exercise training protocol on pain relief in patients with lumbar disc herniation." Yazdani's study revealed that more than half of the studied subjects were (≥43 years old). This finding may be related to the physiological changes that occur in vertebrae with aging and also may be related to decrease calcium level or improper use of body mechanics during performing activities of daily livings.
Regarding hospital admission, the present study reported that all patients previously admitted to the hospital. This finding may be related to severe pain without previous knowledge about pain-relieving measures at home such as massage; exercises used to relief pain, patient's distraction from pain, and guided imagery. Lack of information about these strategies for pain relief at home result in frequent patient's admission to hospital to seek pain relief medications. This study is congruent with (Shimia et al., 9113). Whose study about" Risk factors of recurrent lumbar disk herniation." whose study revealed that more than threequarters of patients previously admitted to hospital for pain relief. However, it is not agreed upon by Karimi, 9116), whose study about" Effectiveness of controlled accelerated functional lumbar stabilization exercises on nonspecific chronic low back pain." The study indicated that more than half of the patients in his study group control their pain managed at home without hospital admission.
Concerning marital status, this study showed that about two-thirds of patients were married. This finding is consistent with Albert et al., (9114) about" Upper lumbar disc herniation "whose study revealed that a large number of the study subjects, about three-quarters of them, were married. Regarding residence, the present study indicates that more than half of the studied subject resides in an urban area. This finding agreed with Bombardier, C. ( 9115), whose study about "Outcome assessments in the evaluation of treatment of spinal disorders." The study revealed that about two-thirds of patients live in the urban area; this may be as 436 of them had manual work. This finding also may be related to unhealthy diet and obesity, which increase weight stress on the patient's vertebrae and subsequently increase the risk for disc herniation.
This finding also evidenced in this study as the mean weight of the study sample was 92541  14551, with body mass index of 31516  4562, this is consistent with Buttermann, G.R. (9114). Whose study about "Outcome assessments in the evaluation of treatment of spinal disorders" who indicated that about two-thirds of his study group were obese.
The study also revealed that all patients experience pain during regular activity. This finding agreed with (Albert et al., 9114), who study the"upper lumbar disc herniation." The study revealed that about two-thirds of the study group experience pain after performing vigorous physical activities such as carrying heavy objects.
Regarding the total patient's level of knowledge about disc herniation, the study results showed that all patients had unsatisfactory total knowledge scores preprogram implementation. This finding implies that patients were not equipped with at least some basic knowledge about the disease. These findings were consistent with (Carragee et al., 9113) whose study about "Clinical outcomes after lumbar disk exercises" who conducted a study to explore patient's knowledge and competence in performing self -care. The findings revealed that about three-quarters of the subjects have unsatisfactory knowledge about the disease process. This finding may be related to lack of exposure to such information about the disease, insufficient training on exercises and factors that may alleviate their pain, lack of patient's motivation and improper patient's education at the time of discharge. These findings are supporting the first research hypothesis As regarding the total patients' knowledge, immediately and three months post-program implementation, the current study showed that the majority of patients had a satisfactory level of knowledge immediately post-program implementation. Also, about two-thirds of patients had a satisfactory level of knowledge after three months of implementing the program with a statistically significant difference between the three study phases. This finding may be related to lack of exposure to such information pre-program results in unsatisfactory knowledge. However, the patient's knowledge was satisfactory immediately post-program implementation. This finding may be due to practical, comprehensive, concise, and clear program, active learning methods, and explicit learning materials & increased patient's motivation. The satisfactory knowledge level slightly decreased after three months post-program implementation. It may be due to lack of patients adherence to the educational program, which may result in missing some information, and the satisfactory knowledge level decreased less than immediately post-program implementation.
The study is consistent with (Karimi, 9116) whose study about" Effectiveness of controlled accelerated functional lumbar stabilization exercises on nonspecific chronic low back pain." The results revealed that almost all patients had unsatisfactory knowledge before program implementation. Besides, about two-thirds of his study group patients had satisfactory knowledge immediately 1 post-program implementation, and more than half of patients had satisfactory knowledge three months postprogram implementation As regarding the total patients' practice pre-program, immediately post and three months post-program implementation, the current study showed that most of the patients had unsatisfactory total practice scores pre-program implementation. However, the majority of patients had a satisfactory level of practice immediately post-program implementation. The study also, showed that about twothirds of patients had a satisfactory level of practice after three months of implementing the program with a statistically significant difference between the three phases. This finding may be related to lack of exposure to such practice and inappropriate performance of such practice pre-program implementation, which results in unsatisfactory practice.
The patient's practice was satisfactory immediately post-program implementation; this may be due to effective, clear demonstration and re-demonstration of practice about lumbar disc herniation. These results in adequate patient's adherence to skills that improve health status and decrease pain perception. Whenever the level of practice slightly decreased after three months of implementing the program, this may be as a result of lack of follow up to the patients' practice and acquired skills.
These findings were in agreement with (Ibrahim and Elsaay, 9115) whose study about " The Effect of Body Mechanics Training Program for Intensive Care Nurses in Reducing Low Back Pain." The study reported that the mean practice scores of the studied nurses immediately and three months post-program implementation were higher than their pre-training scores, and this difference was statistically significant. On the same line (Dammer and Koehler, 9116) whose study about" Lumbar disc prolapse Level increases with age, who stated that there was a significant improvement of practice and skills about disc prolapse treatment and pain relief among patients postprogram implementation than pre-program implementation. These findings are supporting the second research hypothesis.
Concerning the distribution of patient's pain and disability score, this study showed a statistically significant difference observed between total pain score pre-program and three months of post-program implementationthis study on the Same line with Standaert C. et al., (9113). The study examined the " Evidence-informed management of chronic low back pain with lumbar stabilization exercises. " The study indicated that pain significantly decreased after program implementation. This finding may be due to the effect of educational program and exercises on stabilizing muscles which become stronger so that pain will reduce, and the patient will exercise better and get the ability to move correctly and save the healthy posture, so the pain cycle brakes. This finding is supporting the third research hypothesis.
The current study is congruent with Hemmati et al. (2315) study " Effects of consecutive supervised core stability training on pain and disability in women with nonspecific chronic low back pain." The study described the effects of the educational program, stabilizing exercises, and training on decreasing the pain and improving the patients' abilities against chronic LBPs. Also, Standaert C. et al., (9113) have reported that stabilizing exercises of the vertebras are effective in improving the performance and relieving the pain for the various groups with the LBP.
Regarding correlation between total knowledge and total pain scale among patients, the current study revealed that there was a highly statistically significant negative correlation between patient's total knowledge and their total pain scale after three months post-program implementation. It means that the more the patient increase in their knowledge about disc herniation and pain control measure, the little. The study is agreed with (Narayan, 9116), who study " Culture's effects on pain assessment and management. " The study revealed that there is a significant negative correlation between patient's knowledge and pain scale score. It indicated that the higher the patients' knowledge, the more adherence to pain reliving measures & the lower patients' perception of pain. The study is not congruent with (Nasser M. 9115), who revealed that there is no apparent significant relation between the patients' knowledge and pain relieve. This finding may be explained by the ineffective or unclear educational program, which made his patients not adhere to the treatment regimen and frequent reporting pain and hospitalization.

2-Conclusion
The results of the study revealed that the educational program was effective, and its results had a significant improvement on patient's knowledge, practice, satisfaction, and outcomes regarding lumbar disk herniation.

1-Recommendations
1) Further research is necessary to measure long term adherence to the therapeutic exercises among herniated lumbar disc patients. 2) The study suggested equips the orthopedic department with simple illustrated guidelines protocol covering lumbar disc herniation practices, knowledge. 3) Reapply this research on a more substantial probability sample acquired from different geographical areas in Egypt for generalization.