The Relationship Between Cold Water Immersion and the Progression in Gout Arthritis

Study Overview
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Brief Summary
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Gouty arthritis is a type of autoinflammatory arthritis that generates higher levels of pain with only minimum movement in the joint. The pain is shown to have a negative correlation with the physical function, reduced peak ankle joint angular, mobility velocity , and physical function. As such, the investigator can conclude that gout arthritis led to raises intolerance foot pain, physical inactivity, and joint mobility reduction. Currently, intermittent drugs use for pain relief is suggested to contribute to the renal impairment side effect. However, the investigator found that there is a limited study that investigated non-pharmacological intervention among people with gouty arthritis. The pain among people with gouty arthritis has also been shown to increase the degree of depression, anxiety, and depression. Also, the high levels of pain, psychological distress, anxiety, and depression were found as the risk factor of poor Quality of Life (QOL). Cold therapy (cryotherapy) application has been proven as useful adjuvant therapy on pain among people with gouty arthritis. CWI therapy has twofold reduced the inflammation. Firstly, it attenuates metabolic processes in stressed tissues and slowing cytokine and myokine up-regulation that mediates inflammation. Second, CWI induces microvasculature vasoconstriction by perfusing stressed tissue and reducing the circulatory of tissue access to inflammatory cells. Meanwhile, the high prevalence of gouty arthritis has been presented in North Celebes, Indonesia. Moreover, more than 50% of patients are too late for effective therapy and they had observed tophi for 7 to 9 years before presenting for treatment. These empirical issues indicate that it is vital to investigate gouty arthritis-related risk factors to protect Indonesians from this disease. The investigator aims to investigate a unique analysis of the CWI (20-30C) therapy effect on pain, joint mobility, stress, anxiety, depression, QOL (encompasses PCS and MCS), physical activity (MET-h/week) in the multicenter-community setting with a longitudinal study design.

Detailed Description
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This research was conducted at North Celebes, Indonesia. Participants were recruited using the multi-stage sampling method, which began in July 2019. North Celebes Province was conveniently selected in the first stage sampling, which had the highest prevalence of gouty arthritis. North Celebes province is stratified it into 15 regions. In the second stage, two regions of fifteen regions were randomly selected, including urban and rural areas. Tomohon City is the one urban area that has been able to engage in this partnership. Seven Community Health Service (CHS) centers in Tomohon City have been randomly chosen in the final level. Four qualified professional nurses collected all the data. The data source of diagnoses was their medical records in the Public Community Health Services (CHS) of Tomohon City. The sample calculation utilized G-Power 3.1 software with the alpha level (α) of 0.01, power (1-ß) of 0.80, and the effect size is 0.9, the total estimated sample size required 31 in each group. An estimated 20% dropout rate increases; the sample size is 36 for each group. Variable description 1.1.1. Participants Characteristic Blood pressure and BMI were examined in a standardized medical examination. Demographic data were collected by using a self-designed questionnaire. The questionnaire included the demographic characteristics of the participant, including age, gender, marital status, educational level, income, occupation, family gout history, gouty arthritis drug consumption, alcohol consumption, and smoking status. The translated food frequency questionnaire was employed with Cronbach's alpha as 0.95. 1.1.2. Pain The Visual Analog Scale (VAS) instrument has 10 centimeters length. The standard scale anchored by no pain marked as a score of 0 and the worst imaginable pain marked as a score of 10 cm. The higher score identifies greater pain intensity. The reliability test showed that VAS was good (r = 0.94, p = 0.001). The reliability test of the VAS instrument has been done in Indonesia with the Cronbach's alpha as 0.89. 1.1.3. Joint mobility The range of knee joint motion was calculated using an International Standard Orthopedic Measurement (ISOM) goniometric. Its method using the Sagittal Frontal Transverse Rotation (SFTR) system to an accuracy of 10. Goniometry provides an objective assessment tool to measure the range of motion. The validity and reliability of Goniometry are 0.98 and 0.97, respectively. The validity score of the Indonesian version is 0.97, and the Cronbach alpha as 0.51. 1.1.4. Stress, anxiety, depression The Depression Anxiety Stress Scale (DASS-21) questionnaire is used to measure the negative states of three mental health conditions: depression, anxiety, and stress using a self-report 4-point Likert scale. Data was collected by reflects the thoughts, feelings, and behavior. The result will be defined by the total scores of responses from the 7-item subscale of this questionnaire. The Cronbach's alphas of Indonesian translated is 0.72 to 0.87. 1.1.5. Quality of Life (QOL) 36 Health Survey (SF-36) questionnaire was employed to estimate QOL. It included Physical Component Summary (PCS), Mental Component Summary (MCS). Total QOL range from 0 to 100. The Indonesia version of the SF-36 questionnaire has tested the reliability with the Cronbach's alphas 0.7. 1.1.6. Physical activity (MET-h/week) The physical activity level was investigated as metabolic equivalent of task (MET)-hr/week by using three questions based on the modified Physical Activity Guideline from the Advisory Committee for Americans and the Godin Leisure-Time Exercise Questionnaire. The investigator then categorized participants based on the exercise type (that is divided into the following categories: mild (e.g., yoga, bowling, or floor-sweeping), moderate (e.g., gym, baseball, or badminton), and strenuous exercise (e.g., hiking, soccer, or running)), duration in minutes and exercise intensity they presented during a typical week. The investigator multiplied the amount of mild, moderate, and strenuous exercise hours and duration by 3, 5, and 9, respectively. By summing the exercise pattern of the separate things, the investigator measured total weekly PA in arbitrary units. The per-protocol method was employed to deal with the missing data. Each participant is allowed to immediately report the adverse event during the intervention. The Chi-square and t-test were employed to analyze the homogeneity of subject characteristics between the experimental and control group. The Generalized Estimating Equation (GEE) model was applied to compare the differences pain, joint mobility, stress, anxiety, depression, QOL (included PCS and MCS), physical activity (MET-h/week) within one-month intervention between the intervention and control group. The interaction between group and time was also further analyzed to determine if the mean differences in their pain, joint mobility, stress anxiety, and depression, QOL, and physical activity between groups differed significantly over time. p<0.05 was applied as statistically significant. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) vers. 25.0 (Chicago, IL, USA). Besides, Structural Equation Modeling (SEM) was also employed to analyze the mediating effect between variables through the Analysis of Moment Structures (AMOS) vers. 24. Then the investigator evaluate the measurement and structural models by utilizing the goodness fit index.

Official Title
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Effect of a Cold Water Immersion (CWI) on Pain in People With Gouty Arthritis: A Community Based Randomized Controlled Trial

Conditions
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Gout Arthritis

Intervention / Treatment
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* Behavioral: Cold Water Immersion


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: People with gouty arthritis in the knee or ankle or metatarsophalangeal or metacarpophalangeal or olecranon bursa or wrist Participants were Indonesian nationals aged ≥18 years They had visited a clinic of the Public CHS of Tomohon City They had agreed to participate in the study. Exclusion Criteria: Participants who self-reported the presence of other types of inflammatory arthritis, including RA or spondyloarthritis

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: The randomized control trial study with two parallel-intervention-groups was employed to examine the effect of CWI (20-30C) therapy. All participants were randomly assigned to either CWI (20-30C) therapy intervention group or the control group. Block random sampling was then employed to generate the intervention and control group sequence. All participants were assessed on their pain as the primary outcome, joint mobility, stress, anxiety, depression, QOL (included PCS and MCS), physical activity (MET-h/week) at three times points: before the intervention, 2nd and 4th-week of the intervention.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Cold Water Immersion<br>The participants maintained their daily activities during the intervention. When daily activity ended, the intervention was begun. CWI therapy by immersed the whole part of inflamed target joints in the water at 20-30C for 20 minutes/day. The intervention was continued for four weeks. The researchers work together with the nurses of community health services to give the intervention. | Behavioral: Cold Water Immersion<br>* The participants maintained their daily activities during the intervention. When daily activity ended, the intervention was begun. CWI therapy by immersed the whole part of inflamed target joints in the water at 20-30C for 20 minutes/day. The intervention was continued for four weeks. The researchers work together with the nurses of community health services to give the intervention.<br>|
| No Intervention: No Intervention<br>The participants would not receive Cold Water Intervention. However, they are allowed to received the usual care | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pain Level assessed by the Visual Analog Scale (VAS) at 4th week/immediately after intervention | Pain Level assessed by the Visual Analog Scale (VAS) instrument has 10 centimeters length. The standard scale anchored by no pain marked as a score of 0 and the worst imaginable pain marked as a score of 10 cm (Huskisson et al., 1974; Scott & Huskisson, 1976). The higher score identifies greater pain intensity. The reliability test showed that VAS was good (r = 0.94, p = 0.001) (Ferraz et al., 1990). The reliability test of the VAS instrument has been done in Indonesia with the Cronbach's alpha as 0.89 (Suwendar et al., 2017) | 4th week/immediately after intervention | 
| Pain Level assessed by The Visual Analog Scale (VAS) at the baseline | Pain Level assessed by the Visual Analog Scale (VAS) instrument that has 10 centimeters length. The standard scale anchored by no pain marked as a score of 0 and the worst imaginable pain marked as a score of 10 cm (Huskisson et al., 1974; Scott & Huskisson, 1976). The higher score identifies greater pain intensity. The reliability test showed that VAS was good (r = 0.94, p = 0.001) (Ferraz et al., 1990). The reliability test of the VAS instrument has been done in Indonesia with the Cronbach's alpha as 0.89 (Suwendar et al., 2017) | Baseline/ pre-intervention | 
| Pain Level assessed by The Visual Analog Scale (VAS) at the 2nd week/during the intervention | Pain Level assessed by The Visual Analog Scale (VAS) instrument that has 10 centimeters length. The standard scale anchored by no pain marked as a score of 0 and the worst imaginable pain marked as a score of 10 cm (Huskisson et al., 1974; Scott & Huskisson, 1976). The higher score identifies greater pain intensity. The reliability test showed that VAS was good (r = 0.94, p = 0.001) (Ferraz et al., 1990). The reliability test of the VAS instrument has been done in Indonesia with the Cronbach's alpha as 0.89 (Suwendar et al., 2017) | 2nd week/during the intervention | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Joint mobility assessed by Goniometry at the baseline | Joint mobility assessed by Goniometry. The range of knee joint motion was calculated using an International Standard Orthopedic Measurement (ISOM) goniometric. Its method using the Sagittal Frontal Transverse Rotation (SFTR) system to an accuracy of 10 (Dorwart, Hansell, & Schumacher, 1974). Goniometry provides an objective assessment tool to measure the range of motion (Rose & Norton, 1987). The validity and reliability of Goniometry are 0.98 and 0.97, respectively (Rose & Norton, 1987). The validity score of the Indonesian version is 0.97, and the Cronbach alpha as 0.51 (Hafiyah, 2013). | Baseline/ pre-intervention | 
| Joint mobility assessed by Goniometry at the 2nd week/during the intervention | Joint mobility assessed by Goniometry. The range of knee joint motion was calculated using an International Standard Orthopedic Measurement (ISOM) goniometric. Its method using the Sagittal Frontal Transverse Rotation (SFTR) system to an accuracy of 10 (Dorwart, Hansell, & Schumacher, 1974). Goniometry provides an objective assessment tool to measure the range of motion (Rose & Norton, 1987). The validity and reliability of Goniometry are 0.98 and 0.97, respectively (Rose & Norton, 1987). The validity score of the Indonesian version is 0.97, and the Cronbach alpha as 0.51 (Hafiyah, 2013). | 2nd week/during the intervention | 
| Joint mobility assessed by Goniometry at the 4th week/immediately after intervention | Joint mobility assessed by Goniometry. The range of knee joint motion was calculated using an International Standard Orthopedic Measurement (ISOM) goniometric. Its method using the Sagittal Frontal Transverse Rotation (SFTR) system to an accuracy of 10 (Dorwart, Hansell, & Schumacher, 1974). Goniometry provides an objective assessment tool to measure the range of motion (Rose & Norton, 1987). The validity and reliability of Goniometry are 0.98 and 0.97, respectively (Rose & Norton, 1987). The validity score of the Indonesian version is 0.97, and the Cronbach alpha as 0.51 (Hafiyah, 2013). | 4th week/immediately after intervention | 
| Stress, anxiety, depression assessed by The Depression Anxiety Stress Scale questionnaire at the baseline | The Depression Anxiety Stress Scale questionnaire is used to measure the negative states of three mental health conditions: depression, anxiety, and stress using a self-report 4-point Likert scale. Data was collected by reflects the thoughts, feelings, and behavior (Oei, Sawang, Goh, & Mukhtar, 2013). The result will be defined by the total scores of responses from the 7-item subscale of this questionnaire. The lower score shows a better result. If the total number of depressions is 9 or below and the extremely severe is 34 or over. The Cronbach's alphas of Indonesian translated is 0.72 to 0.87 (Susilowati, Isahak, & Harncharoen, 2016). | Baseline/ pre-intervention | 
| Stress, anxiety, depression assessed by The Depression Anxiety Stress Scale questionnaire at the 2nd week/during the intervention | The Depression Anxiety Stress Scale questionnaire is used to measure the negative states of three mental health conditions: depression, anxiety, and stress using a self-report 4-point Likert scale. Data was collected by reflects the thoughts, feelings, and behavior (Oei, Sawang, Goh, & Mukhtar, 2013). The result will be defined by the total scores of responses from the 7-item subscale of this questionnaire. The lower score shows a better result. If the total number of depressions is 9 or below and the extremely severe is 34 or over. The Cronbach's alphas of Indonesian translated is 0.72 to 0.87 (Susilowati, Isahak, & Harncharoen, 2016). | 2nd week/during the intervention | 
| Stress, anxiety, depression assessed by the Depression Anxiety Stress Scale at 4th week/immediately after intervention | The Depression Anxiety Stress Scale questionnaire is used to measure the negative states of three mental health conditions: depression, anxiety, and stress using a self-report 4-point Likert scale. Data was collected by reflects the thoughts, feelings, and behavior (Oei, Sawang, Goh, & Mukhtar, 2013). The result will be defined by the total scores of responses from the 7-item subscale of this questionnaire. The lower score shows a better result. If the total number of depressions is 9 or below and the extremely severe is 34 or over. The Cronbach's alphas of Indonesian translated is 0.72 to 0.87 (Susilowati, Isahak, & Harncharoen, 2016). | 4th week/immediately after intervention | 
| Quality of Life (QOL) level assessed by 36 Health Survey (SF-36) questionnaire at Baseline | Quality of Life (QOL) level assessed by 36 Health Survey (SF-36) questionnaire that was employed to estimate QOL. It included Physical Component Summary (PCS), Mental Component Summary (MCS). Total QOL range from 0 to 100 (Rias et al., 2020). The Indonesia version of the SF-36 questionnaire has tested the reliability with the Cronbach's alphas 0.7 (Salim, Yamin, Alwi, & Setiati, 2015) | Baseline, pre-intervention | 
| Quality of Life (QOL) level assessed by 36 Health Survey (SF-36) questionnaire 2nd week/during the intervention | Quality of Life (QOL) level assessed by 36 Health Survey (SF-36) questionnaire that was employed to estimate QOL. It included Physical Component Summary (PCS), Mental Component Summary (MCS). Total QOL range from 0 to 100 (Rias et al., 2020). The Indonesia version of the SF-36 questionnaire has tested the reliability with the Cronbach's alphas 0.7 (Salim, Yamin, Alwi, & Setiati, 2015) | 2nd week/during the intervention | 
| Quality of Life (QOL) level assessed by36 Health Survey (SF-36) questionnaire 4th week/immediately after intervention | Quality of Life (QOL) level assessed by 36 Health Survey (SF-36) questionnaire that was employed to estimate QOL. It included Physical Component Summary (PCS), Mental Component Summary (MCS). Total QOL range from 0 to 100 (Rias et al., 2020). The Indonesia version of the SF-36 questionnaire has tested the reliability with the Cronbach's alphas 0.7 (Salim, Yamin, Alwi, & Setiati, 2015) | 4th week/immediately after intervention | 
| Physical activity (MET-h/week) level assessed by questions based on the modified Physical Activity Guideline at the baseline | The physical activity level was investigated as metabolic equivalent of task (MET)-hr/week by using three questions based on the modified Physical Activity Guideline from the Advisory Committee for Americans (Shiroma, Sesso, Moorthy, Buring, & Lee, 2015) and the Godin Leisure-Time Exercise Questionnaire (Godin & Shephard, 1997). We then categorized participants based on the exercise type (that is divided into the following categories: mild (e.g., yoga, bowling, or floor-sweeping), moderate (e.g., gym, baseball, or badminton), and strenuous exercise (e.g., hiking, soccer, or running)), duration in minutes and exercise intensity they presented during a typical week. We multiplied the amount of mild, moderate, and strenuous exercise hours and duration by 3, 5, and 9, respectively. By summing the exercise pattern of the separate things, we measured total weekly PA in arbitrary units (Rias et al., 2020). | Baseline, pre-intervention | 
| Physical activity (MET-h/week) level assessed by questions based on the modified Physical Activity Guideline at 2nd week/during the intervention | The physical activity level was investigated as metabolic equivalent of task (MET)-hr/week by using three questions based on the modified Physical Activity Guideline from the Advisory Committee for Americans (Shiroma, Sesso, Moorthy, Buring, & Lee, 2015) and the Godin Leisure-Time Exercise Questionnaire (Godin & Shephard, 1997). We then categorized participants based on the exercise type (that is divided into the following categories: mild (e.g., yoga, bowling, or floor-sweeping), moderate (e.g., gym, baseball, or badminton), and strenuous exercise (e.g., hiking, soccer, or running)), duration in minutes and exercise intensity they presented during a typical week. We multiplied the amount of mild, moderate, and strenuous exercise hours and duration by 3, 5, and 9, respectively. By summing the exercise pattern of the separate things, we measured total weekly PA in arbitrary units (Rias et al., 2020). | 2nd week/during the intervention | 
| Physical activity (MET-h/week) level: Change from Baseline and 2nd week time point | The physical activity level was investigated as metabolic equivalent of task (MET)-hr/week by using three questions based on the modified Physical Activity Guideline from the Advisory Committee for Americans (Shiroma, Sesso, Moorthy, Buring, & Lee, 2015) and the Godin Leisure-Time Exercise Questionnaire (Godin & Shephard, 1997). We then categorized participants based on the exercise type (that is divided into the following categories: mild (e.g., yoga, bowling, or floor-sweeping), moderate (e.g., gym, baseball, or badminton), and strenuous exercise (e.g., hiking, soccer, or running)), duration in minutes and exercise intensity they presented during a typical week. We multiplied the amount of mild, moderate, and strenuous exercise hours and duration by 3, 5, and 9, respectively. By summing the exercise pattern of the separate things, we measured total weekly PA in arbitrary units (Rias et al., 2020). | 4th week/immediately after intervention | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Gout Arthritis, Cold Water Immersion, Pain