Home Therapy Research Articles

Ethical Tensions in the Pain Management of an End-Stage Cancer Patient with Evidence of Opioid Medication Diversion.

At the end of life, pain management is commonly a fundamental part of the treatment plan for patients where curative measures are no longer possible. However, the increased recognition of opioid diversion for secondary gain coupled with efforts to treat patients in the home environment towards the end of life creates the potential for ethical dilemmas in the palliative care management of terminal patients in need of continuous pain management. We present the case of an end-stage patient with rectal cancer who required a continuous residential narcotic infusion of fentanyl for pain control due to metastatic disease. His functional status was such that he had poor oral intake and ability to perform other activities of daily living, but was able to live at home with health agency nursing care. The patient presented to this institution with a highly suspect history of having lost his fentanyl infusion in a residential accident and asking for a refill to continue home therapy. The treating physicians had concerns of diversion of the infusion medication by caregivers and were reluctant to continue the therapeutic relationship with the patient. This case exemplifies the tension that can exist between wanting to continue with palliative care management of an end-stage patient and the fear of providers when confronted by evidence of potential diversion of opioid analgesic medications. We elucidate how an ethical framework based on a combination of virtue and narrative/relationship theories with reference to proportionality can guide physicians to a pragmatic resolution of these difficult situations.

Paediatric hereditary angioedema: a survey of UK service provision and patient experience.

Hereditary angioedema (HAE) is a rare disease characterized by episodes of potentially life-threatening angioedema. For affected children in the United Kingdom, there are relatively few data regarding disease prevalence, service organization and the humanistic burden of the disease. To improve knowledge in these areas, we surveyed major providers of care for children with HAE. A questionnaire was sent to major paediatric centres to determine patient numbers, symptoms, diagnostic difficulties, management and available services. In addition, all patients at a single centre were given a questionnaire to determine the experiences of children and their families. Sixteen of 28 centres responded, caring for a total of 111 UK children. Seven children had experienced life-threatening crises. One-third of patients were on long-term prophylactic medication, including C1 inhibitor prophylaxis in four children. Eight centres reported patients who were initially misdiagnosed. Broad differences in management were noted, particularly regarding indications for long-term prophylaxis and treatment monitoring. We also noted substantial variation in the organization of services between centres, including the number of consultants contributing to patient care, the availability of specialist nurses, the availability of home therapy training and the provision of patient information. Ten of 12 patient/carer questionnaires were returned, identifying three common themes: the need to access specialist knowledge, the importance of home therapy and concerns around the direct effect of angioedema on their life. To our knowledge, this study represents the first dedicated survey of paediatric HAE services in the United Kingdom and provides useful information to inform the optimization of services.

Hand therapy following elbow release for passive elbow flexion and long head of the triceps transfer for active elbow flexion in children with amyoplasia

Children born with the Amyoplasia form of arthrogryposis multiplex congenita (AMC) who lack elbow flexor muscles and have elbow extension contractures usually require assistance in performing ADL's that require reaching their hand to their face, head, and upper body. For tasks involving the UE, the elbow is the key to functional independence. Children born with Amyoplasia may benefit from selective surgeries to enhance functional independence and improve quality of life. Home therapy and splinting following these surgeries is an important part of gaining motion and improving function. This abstract will review the rehab and splinting following an elbow release to gain passive elbow flexion, and a long head of the triceps transfer for active elbow flexion in children with Amyoplasia.

Machine-Based, Self-guided Home Therapy for Individuals With Severe Arm Impairment After Stroke

Background. Few therapeutic options exist for the millions of persons living with severe arm impairment after stroke to increase their dose of arm rehabilitation. This study compared self-guided, high-repetition home therapy with a mechanical device (the resonating arm exerciser [RAE]) to conventional therapy in patients with chronic stroke and explored RAE use for patients with subacute stroke. Methods. A total of 16 participants with severe upper-extremity impairment (mean Fugl-Meyer [FM] score = 21.4 ± 8.8 out of 66) >6 months poststroke were randomized to 3 weeks of exercise with the RAE or conventional exercises. The primary outcome measure was FM score 1 month posttherapy. Secondary outcome measures included Motor Activity Log, Visual Analog Pain Scale, and Ashworth Spasticity Scale. After a 1-month break, individuals in the conventional group also received a 3-week course of RAE therapy. Results. The change in FM score was significant in both the RAE and conventional groups after training (2.6 ± 1.4 and 3.4 ± 2.4, P = .008 and .016, respectively). These improvements were not significant at 1 month. Exercise with the RAE led to significantly greater improvements in distal FM score than conventional therapy at the 1-month follow-up (P = .02). In a separate cohort of patients with subacute stroke, the RAE was found feasible for exercise. Discussion. In those with severe arm impairment after chronic stroke, home-based training with the RAE was feasible and significantly reduced impairment without increasing pain or spasticity. Gains with the RAE were comparable to those found with conventional training and also included distal arm improvement.

Perspectivas de futuro en láseres, nuevas tecnologías y nanotecnología en dermatología

We review novel technologies with diagnostic and therapeutic applications in dermatology. Among the diagnostic techniques that promise to become part of dermatologic practice in the future are optical coherence tomography, multiphoton laser scanning microscopy, Raman spectroscopy, thermography, and 7-T magnetic resonance imaging. Advances in therapy include novel light-based treatments, such as those applying lasers to new targets and in new wavelengths. Devices for home therapy are also appearing. We comment on the therapeutic uses of plasma, ultrasound, radiofrequency energy, total reflection amplification of spontaneous emission of radiation, light stimulation, and transepidermal drug delivery. Finally, we mention some basic developments in nanotechnology with prospects for future application in dermatology.

Use of ThermaCare heat wraps as an adjunct to physical therapy

Aims: To find out if the use of heat at home between physical therapy sessions results in better therapy outcomes in people with acute, non-specific back pain. Setting: Longitudinal, single-blind study at physical therapy outpatient rehabilitation centres. Methods: A total of 144 people with acute, non-specific back pain underwent 45 minutes to 1 hour of therapy, twice a week for 2 weeks. Participants were instructed to accomplish 30 minutes of therapeutic exercise at home daily. Half of the participants used ThermaCare heat wraps for 6 hours before home therapy. The measures were the OSWESTRY, Roland-Morris and Visual Analogue Pain scales, range of motion of the lower back, strength of the lower back and home exercise compliance. Results: In the heat group, compared to the non-heat group, the OSWESTRY reduced (3 times), strength increased (twice), range of motion increased (3 times), pain reduced (twice) and compliance for home exercise doubled. All differences were significant (p=<0.01). Conclusions: Using heat at home before home exercise sessions and between therapy sessions was associated with faster recovery from acute, non-specific back pain and better home exercise compliance than was seen in the non-heat group.

Home gammaglobulin therapy: a patient survey of intravenous and subcutaneous options in Canada

Introduction: For close to half a century immunoglobulin replacement therapy has been the main therapy for patients unable to produce functioning antibodies. To date, both subcutaneous (SC) and intravenous delivery methods have been successful at effectively and safely replacing immunoglobulin. Home intravenous and SC therapy programs have been established and have gained attention, but the true motivation and frequency of switching from traditional hospital-based treatment to these alternatives remains unknown. This study aims to determine the willingness of patients in Canada to switch to a home-based gammaglobulin treatment program by quantifying related experiences and preferences.Methods: A cohort of 169 patients in Ontario currently on hospital-based intravenous immunoglobulin (IVIG) replacement therapy (referral centers or community hospitals) were sent a 2.5 page survey consisting of 25 questions. Data were collected and statistically analyzed using Fisher, χ2, and McNemar tests, where P < 0.05 was considered statistically significant.Results: Ninety-one patients responded and most agreed to consider home therapy regardless of the administration route, based on recommendations from an immunologist (IVIG, P = 0.006; SC, P < 0.001). Patients preferred switching to home IVIG rather than to SC (P = 0.01), but their concerns regarding home healthcare costs were more prominent with IVIG (P = 0.01). The main concern with current intravenous therapy was the overall loss of time (P = 0.0001), whereas for home therapy it was the loss of supervision (P = 0.0009) and possible associated costs. Patients considered home treatment more convenient, as it is less time consuming (P = 0.01), and this was perceived as an improvement in quality of life (P = 0.001). It was considered less convenient because it may be unsafe and (or) more expensive.Conclusion: This survey demonstrates that home intravenous therapy maybe the preferred option for patients with antibody deficiency in Ontario, provided this decision was supported by a specialist in the field, secured supervision was available, and it was not associated with personal expenses.Statement of novelty: The first study to examine patient willingness to try a new route of gammaglobulin administration at home.

Foot-mounted inertial measurement unit for activity classification.

This paper proposes a classification technique for daily base activity recognition for human monitoring during physical therapy in home. The proposed method estimates the foot motion using single inertial measurement unit, then segments the motion into steps classify them by template-matching as walking, stairs up or stairs down steps. The results show a high accuracy of activity recognition. Unlike previous works which are limited to activity recognition, the proposed approach is more qualitative by providing similarity index of any activity to its desired template which can be used to assess subjects improvement.

Pediatric lower limb Ilizarov lengthening with functional evaluation in adulthood: A report on underprivileged patients

PurposeIlizarov lengthening, with the principles of Ilizarov, requires a collaboration and supervision of the physiotherapist, nurse, and psychologist, preferably in a group-therapy set-up. We report the mid- and long-term functional outcome of cases that had none of the above listed supporting elements. In addition, we tried to observe the effect of the disease category on the final outcome in the patient. MethodIn this study, 35 children who had undergone Ilizarov lower limb lengthening were evaluated using the following methods: clinical, radiographic, and by four functional scoring systems, and parent/patient satisfaction questionnaires, after an average of 17.2 years (10–25 years). ResultsIn this study, 19 boys and 16 girls aged 5–16 years received 18 femoral and 20 tibial lengthening. An average of 6.2 cm lengthening in the femur and 8.4 in the tibia was achieved, with a healing index of 26.5 days. The disease category did not significantly affect the healing index, but the complications, 0.5 per femoral and 0.7 per tibial segment, were more common among congenital, and least among post-traumatic discrepancies. A complete improvement in joint stiffness was observed by 6–12 months post-frame removal in 83% of the cases, following home therapy by parents alone. ConclusionThe long-term results of Ilizarov lengthening for lower limb discrepancy in children, even without group-therapy or good supportive aids, can improve function and maintain patient satisfaction in two thirds of the cases, over an average period of 17 years. Levels of evidenceIV.

Home Visit Program Improves Technique Survival in Peritoneal Dialysis

Background: Peritoneal dialysis (PD) is a home therapy, and technique survival is related to the adherence to PD prescription at home. The presence of a home visit program could improve PD outcomes. We evaluated its effects on clinical outcome during 1 year of follow-up. Methods: This was a case-control study. The case group included all 96 patients who performed PD in our center on January 1, 2013, and who attended a home visit program; the control group included all 92 patients who performed PD on January 1, 2008. The home visit program consisted of several additional visits to reinforce patients' confidence in PD management in their own environment. Outcomes were defined as technique failure, peritonitis episode, and hospitalization. Clinical and dialysis features were evaluated for each patient. Results: The case group was significantly older (p = 0.048), with a lower grade of autonomy (p = 0.033), but a better hemoglobin level (p = 0.02) than the control group. During the observational period, we had 11 episodes of technique failure. We found a significant reduction in the rate of technique failure in the case group (p = 0.004). Furthermore, survival analysis showed a significant extension of PD treatment in the patients supported by the home visit program (52 vs. 48.8 weeks, p = 0.018). We did not find any difference between the two groups in terms of peritonitis and hospitalization rate; however, trends toward a reduction of Gram-positive peritonitis rates as well as prevalence and duration of hospitalization related to PD problems were identified in the case group. The retrospective nature of the analysis was a limitation of this study. Conclusion: The home visit program improves the survival of PD patients and could reduce the rate of Gram-positive peritonitis and hospitalization. Video Journal Club “Cappuccino with Claudio Ronco” at http://www.karger.com/?doi=365168.

284 Prevalence of Staphylococcus aureus (SA) infection in patients with cystic fibrosis in a reference unit

Objectives: To test the internal consistency of markers for pulmonary exacerbations in cystic fibrosis patient registry data and to validate findings against clinical opinion. Methods: The Australian Cystic Fibrosis Data Registry holds data from individual occasions of measurement of lung function, episodes of hospitalisation and home therapy for respiratory indications and results from respiratory cultures. Initial analysis of 2010 to 2012 data using stata software will identify occasions of measurement of lung function (FEV1 per cent of predicted) that are 10 per cent or more below a ‘normal’ level calculated as the patient’s average of highest measures recorded in each of the preceding four quarters. The temporal relationship of such occasions with hospital and home therapy episodes for respiratory indications will permit internal validity checking and sensitivity analysis of the nominated percentage below ‘normal’. The usefulness of recent prior respiratory cultures as a potential additional consistency check will also be examined. A sample of results will be compared with independently formed clinical opinion. Results: Results are not available at time of abstract submission. They will include findings and an outline of methodology. Conclusion: The occurrence or frequency of pulmonary exacerbations can be a specified outcome for clinical trials and is of interest in general research into the progress of cystic fibrosis. Use of pulmonary exacerbations as an outcome in the emerging use of CF patient registries for post-market surveillance of long term drug efficacy requires an understanding of the validity of markers that are available in registry data.

Exploring views on long term rehabilitation for people with stroke in a developing country: findings from focus group discussions

BackgroundThe importance of long term rehabilitation for people with stroke is increasingly evident, yet it is not known whether such services can be materialised in countries with limited community resources. In this study, we explored the perception of rehabilitation professionals and people with stroke towards long term stroke rehabilitation services and potential approaches to enable provision of these services. Views from providers and users are important in ensuring whatever strategies developed for long term stroke rehabilitations are feasible and acceptable.MethodsFocus group discussions were conducted involving 15 rehabilitation professionals and eight long term stroke survivors. All recorded conversations were transcribed verbatim and analysed using the principles of qualitative research.ResultsBoth groups agreed that people with stroke may benefit from more rehabilitation compared to the amount of rehabilitation services presently provided. Views regarding the unavailability of long term rehabilitation services due to multi-factorial barriers were recognised. The groups also highlighted the urgent need for the establishment of community-based stroke rehabilitation centres. Family-assisted home therapy was viewed as a potential approach to continued rehabilitation for long term stroke survivors, given careful planning to overcome several family-related issues.ConclusionsBarriers to the provision of long term stroke rehabilitation services are multi-factorial. Establishment of community-based stroke rehabilitation centres and training family members to conduct home-based therapy are two potential strategies to enable the continuation of rehabilitation for long term stroke survivors.

Extending the role of peritoneal dialysis: can we win hearts and minds?

The ability of peritoneal dialysis (PD) to achieve low-molecular weight solute clearance and ultrafiltration at low haemodynamic cost makes it an attractive therapy in situations where more aggressive therapy may be undesirable due to sudden reductions in cerebral, coronary or renal blood flow. We undertook a review of the literature to examine the recent evidence for this in two specific examples: the removal of glutamate following acute stroke and ultrafiltration for the treatment of diuretic resistant heart failure. In acute stroke, glutamate, when released into the extracellular tissues, causes neuronal cell death due to its excitotoxic properties. Experimental evidence from animal models indicates that its removal, including via PD, can reduce infarct size and restore functional brain tissue. PD is effective in removing glutamate in patients treated for renal failure. In heart failure, PD has a number of both theoretical and practical advantages for extending treatment, especially as an established home therapy. Several recent cohort studies describing its use in approaching 300 patients with diuretic resistance show consistent benefits in hospitalization and severity. Both these applications require substantial further clinical evaluation before they can justify wider adoption but their potential to alleviate morbidity on a large and potentially highly cost-effective scale demands further study.

Abstract T P118: Participation in Extended Activities of Daily Living is an Important Determinant of Long-Term Quality of Life in Stroke Patients after an Early Supported Discharge Program

Objective: We previously found stroke patients who underwent home therapy in our Early Supported Discharge (ESD) program had excellent improvement in basic activities of daily living (ADL). Their extended ADL remained impaired after ESD but showed significant improvement after 1 year. We hypothesize that improvement in extended ADL is an important determinant of long-term quality of life (QOL) in this group of stroke patients. Methods: Consecutive stroke patients enrolled in an ESD program in a tertiary hospital in Singapore from August 2007 to July 2012 were recruited. Basic and extended ADL functions were assessed using the Functional Independence Measure (FIM) and Frenchay Activities Index (FAI) respectively, pre- and post-ESD. FAI and SF-36 were administered via telephone interview 1 year after stroke onset. Multiple linear regression analyses with the 8 scales of SF-36 were carried out to determine their associations with variables including age, sex, FIM pre-ESD, FIM change (pre- to post-ESD), premorbid FAI, FAI post-ESD and FAI change (post-ESD to 1 year follow-up). Results: Data from 243 patients (60.9% male, mean age 64.7, SD11.8 years) were available for analysis. They received an average of 7.5 home therapy sessions. FIM improved from 100(17) pre-ESD to 115(15) post-ESD. FAI was 21.7(9.4) premorbid, 11.1(7.6) post-ESD and 17.9(10.3) at 1 year. Multiple regression analyses revealed 8 models which were statistically significant and explained 10-50% of the variance in SF-36 scales. In particular, 50% of the variance in Physical Functioning can be explained by the following factors: female gender (β=-.20, p<.001), FIM pre-ESD (β=.28, p<.001), FIM change (β=.15, p<.01), FAI post-ESD (β=.28, p<.001) and FAI change (β=.40, p<.001). Improvement in FAI scores from post-ESD to 1 year follow-up was positively associated with all 8 scales of SF-36 at 1 year. Conclusion: Compared to improvement in basic ADL after ESD, continued improvement in extended ADL including leisure, work and outdoor activities is a more important determinant of long-term QOL after stroke. Facilitating stroke patients in extended ADL participation and community reintegration after ESD is therefore a potentially important but currently neglected aspect in ESD for stroke patients.

Hereditary Angioedema – Consequences of a New Treatment Paradigm in Denmark

Experiences from a Danish patient cohort with hereditary angioedema are reported with focus on home therapy and burden of illness. Eighty patients have been prospectively followed over 11 years, having experienced a total of 7,809 attacks over 469 patient years. More than half of the patients stopped long-term prophylaxis with danazol or tranexamic acid and changed treatment regimen to on-demand treatment with C1 inhibitor concentrate or icatibant. At least 10% of the attacks remained un-treated. More than half of the patients felt that hereditary angioedema had a significant psychological impact on their lives and restricted their physical activities. By December 2012, a total of 39 patients (49%) were practicing home treatment of acute attacks. Home therapy reduced the mean number of acute hospital visits by 84% and significantly improved burden of illness items. In conclusion, home therapy has profoundly improved the lives of hereditary angioedema patients.

EPA-0053 - Personality profile, anxiety, and sexual satisfaction: A comparison between implanted penile prosthesis and intracorporeal injection

Purpose of the study To evaluate personality profile, anxiety, patient satisfaction in patients with erectile dysfunction treated with penile prosthesis as compared to those on Intracorporeal Injection (ICI) home therapy. Patients and methods A total of 40 male patients complaining of erectile dysfunction were classified into two equal groups according to the line of treatment: Intracorporeal Injection (ICI) and penile prosthesis. Patients were subjected to the following questionnaires: Beck Anxiety Scale, Eysenck Personality Questionnaire, sexual Satisfaction Scale and International Index of Erectile Function Questionnaire (IIEF-5). Results Results for Beck Anxiety Scale showed statistically significant difference between both groups (P = 0.000), while for Eysenck Personality Questionnaire, no significant difference was found in Psychoticism (P = 0.056), Neuroticism (P = 0.169), in Extraversion (P = 0.225), Lie scale (P = 0.159), and in Criminality (P = 0.378). Statistically significant difference between both groups was found in the results of sexual Satisfaction Scale, (P = 0.013) and for the results of International Index of Erectile Function Questionnaire (IIEF-5), (P = 0.000). Conclusion Patients who underwent penile prosthesis implantation showed lower level of anxiety, better sexual satisfaction and erectile function, while no significant difference was found when comparing personality profile five dimensions Psychoticism, Neuroticism, Extraversion, Lie scale and Criminality.

Robotic/virtual reality intervention program individualized to meet the specific sensorimotor impairments of an individual patient: a case study.

A majority of studies examining repetitive task practice facilitated by robots for the treatment of upper extremity paresis utilize standardized protocols applied to large groups. This study will describe a virtually simulated, robot-based intervention customized to match the goals and clinical presentation of a gentleman with upper extremity hemiparesis secondary to stroke. MP, the subject of this case, is an 85-year-old man with left hemiparesis secondary to an intracerebral hemorrhage 5 years prior to examination. Outcomes were measured before and after a 1-month period of home therapy and after a 1-month virtually simulated, robotic intervention. The intervention was designed to address specific impairments identified during his PT examination. When necessary, activities were modified based on MP's response to his first week of treatment. MP's home training program produced a 3-s decline in Wolf Motor Function Test (WMFT) time and a 5-s improvement in Jebsen Test of Hand Function (JTHF) time. He demonstrated an additional 35-s improvement in JTHF and an additional 44-s improvement in WMFT subsequent to the robotic training intervention. A 24-h activity measurement and the Hand and Activities of Daily Living scales of the Stroke Impact Scale improved following the robotic intervention. Based on his responses to training we feel that we have established that a customized program of virtually simulated, robotically facilitated rehabilitation was feasible and resulted in larger improvements than an intensive home training program in several measurements of upper extremity function in our patient with chronic hemiparesis.

Subcutaneous IgG in neurologic diseases

Subcutaneous administration of IgG (SCIG) has become widely used in primary immune deficiency diseases but it has only recently been studied for maintenance therapy in autoimmune peripheral neuropathies, such as chronic idiopathic demyelinating polyneuropathy and multifocal motor neuropathy. Weekly self-administration of SCIG is safe and well-tolerated, and results in steady-state serum IgG levels, as contrasted with the peaks and troughs of monthly immune globulin (human) for intravenous use. Freedom from the need for venous access or medical personnel for infusions, flexibility in scheduling, convenience of home therapy, and improved clinical stability due to the steady-state IgG levels, lead many patients to prefer SCIG to immune globulin (human) for intravenous use. Long-term studies are needed to determine if the constant IgG levels and clinical stability translate into better long-term outcomes.

On the Borderland of Medical and Disability History: A Survey of the Fields

This essay explores the multiple sites where disability appears in the history of medicine and suggests ways in which medical historians can self-consciously incorporate a disability perspective into their own work. Just as medical historians have much to learn from disability historians, disability historians could benefit from looking more closely at the history of medicine. While disability cannot (and should not) be reduced to disease, the fact remains that some forms of disability are brought about by disease processes, and some require daily regimes of home health care, therapy, and pain management. How the disabled have interacted with health care institutions, caretakers, and the medical establishment is too significant to be written out of its history.

Home treatment in paediatric patients with Hunter syndrome: the first Italian experience

Hunter syndrome (mucopolysaccharidosis type II [MPS II], OMIM309900) is a rare X-linked lysosomal storage disorder caused by the deficiency of the enzyme iduronate-2-sulphatase, resulting in accumulation of glycosaminoglycans, progressive multisystem organ failure, and early death. Enzyme replacement therapy (ERT) with weekly intravenous infusions of idursulfase, a treatment for MPS II and commercially available since 2007, has been shown to improve certain symptoms and signs of the disease. The efficacy and safety data of this enzyme preparation have been widely reported and, after a change to the idursulfase Summary of Product Characteristics in March 2010, home ERT by infusion is now an option for selected patients. Previously reported experiences of home therapy in MPS II have shown increased treatment compliance and an improvement in quality of life for both patients and families. We report the results of the home therapy experience of 3 paediatric patients with MPS II in southern Italy. This pilot experience with home infusion is the first reported from Italy.