Category: Caregiving

NewsPsychology (Dec. 6, 2011) — Researchers at the University of Hertfordshire have just begun a three-year project, which uses robots to help people to recover from strokes.

Dr Farshid Amirabdollahian, an expert in rehabilitation robotics and assistive technologies and a senior lecturer in adaptive systems at the University’s School of Computer Science is co-ordinating a new FP7 European project called SCRIPT — Supervised Care and Rehabilitation Involving Personal Tele-robotics.

The project team plans to develop robotic devices, which will facilitate repetitive movement of the hand and wrist to be delivered during the chronic phases of stroke rehabilitation.

“The project focus on hand and wrist exercise presents the least researched area in this field and has the potential to make a big contribution to personal independence,” said Dr Amirabdollahian. “Our developed prototypes will be available for home use and in a motivating and engaging context, which should provide easier and more frequently available tools, which should in turn affect the patient recovery.”

The researchers plan to develop a tele-robotic communication platform which patients can use in their own homes and which can be managed remotely thus reducing the number of hospital visits needed. The research of the UH team will be based on existing research from their interactive systems and robotics lab which hosts state of the art equipment and software for investigating therapeutic human robot interaction. The SCRIPT project will provide additional focus on adapting robot’s interaction forces to those required for a therapeutic interaction. This would allow for a more natural interaction. In addition, the goal is to provide patients with immediate feedback as well as providing immediate feedback to “off-site” health care professionals.

Other project partners are: R.U. Robots Limited (RUR), University of Sheffield, Universiteit Twente, Roessingh Research and Development BV (RRD), MOOG BV, San Raffaele S.p.A. and User Interface Design GMBH.

This project is partially funded by the European Commission under the 7th Framework Programme.

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The above story is reprinted from materials provided by University of Hertfordshire, via AlphaGalileo.

Note: Materials may be edited for content and length. For further information, please contact the source cited above.

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Playing computer-based physical therapy games can help people with Parkinson's disease improve their gait and balance, according to a new pilot study led by the UCSF School of Nursing and Red Hill Studios, a California serious games developer.

More than half the subjects in the three-month research project showed small improvements in walking speed, balance and stride length.

UCSF and Red Hill were the first research team in the United States to receive federal funding in the burgeoning field of low-cost computerized physical therapy games. Unlike off-the-shelf computer games, these specialized games encourage scientifically tested specific physical movements to help people with functional impairments and diseases.

Teams at Red Hill and UCSF collaborated to produce nine "clinically inspired'' games that were designed to improve coordination in people with Parkinson's disease, a chronic, progressive neuromuscular disease characterized by shaking, slowness of movement, limb and trunk rigidity. The clinical team members at UCSF focused on specific body movements and gestures that their previous research had shown to be beneficial for staving off the physical declines of Parkinson's.

The UCSF team was led by Glenna Dowling, RN, PhD, professor and chair of the UCSF Department of Physiological Nursing, and Marsha Melnick, PT, PhD, a clinical professor in the UCSF School of Medicine's Department of Physical Therapy and Rehabilitation Science and professor emerita of the Department of Physical Therapy at San Francisco State University.

The Red Hill team then designed physical games, similar to Wii and Kinect games, in which subjects win points by moving their bodies in certain ways. Each game has multiple difficulty levels so that the clinical team could customize the therapeutic games for each subject's particular abilities.

"Each subject found his or her own gaming 'sweet spot' — the spot where the physical challenge was not too hard, not too easy, just right,'' said Bob Hone, creative director of Red Hill Studios and the lead principal investigator of the study. "And when subjects mastered one game level, they often moved on to harder levels for more beneficial effect. The subjects improved their games scores while improving their gait and balance.''

Red Hill developed a custom sensor suit with nine tracking sensors to analyze subjects' movements with higher resolution and accuracy than is possible with consumer gaming platforms. The PC-based system sent encrypted data to a secure database allowing the research teams to track the subjects' performance daily.

"From the data tracking we could see that there were some subjects who were playing the games more than the specified three times a week,'' Hone said. "Because this was a highly structured research study, we actually had to ask them to play less than they wanted.''

The trial involved 20 participants in northern California with moderate levels of Parkinson's disease. After playing the games for 12 weeks, 65 percent of game players demonstrated longer stride length, 55 percent increased gait velocity, and 55 percent reported improved balance confidence.

"These initial studies show the promise of custom-designed physical therapy games promoting specific movements and gestures that can help patients get better,'' Dowling said. "Now that we have this preliminary positive result, we want to conduct a longer term clinical trial with more subjects to confirm these initial findings.''

The study was funded by two Small Business Innovative Research grants totaling $1.1 million from the National Institute of Neurological Disorders and Stroke — part of the National Institutes of Health.

A video of the therapy games is available at: http://www.redhillstudios.com/#/projects/games/pdwii/

Strong leadership, communication and teamwork are essential to successful organizations, especially health care facilities. However, how those organizations achieve improvement is not clearly understood, says a University of Missouri researcher. Amy Vogelsmeier, assistant professor in the Sinclair School of Nursing, found that leadership is critical to supporting open communication and relationship building to generate improvement, such as enhanced safety practices and new technology adoption, in health care organizations.

The Patient Protection and Affordable Care Act and the American Recovery and Reinvestment Act include mandates and incentives to promote the use of new technology in health care. As the aging population increases, the effective use of resources and care practices is essential to enacting health care reform and ensuring patients receive quality care.

"Although technology plays a role in improving resident safety, technology alone isn't the answer," Vogelsmeier said. "The reality is that implementation is much more complicated than people realize. It's not just a bring it in and turn it on kind of thing; it will take strong leadership within organizations to implement technological systems in ways that will enhance patient safety rather than hinder it."

Current challenges for health care providers and facilities include helping patients transition to nursing homes and long-term care, managing chronic illnesses, such as diabetes and heart disease, and coordinating care from different sectors, including hospitals, community clinics and specialists.

"Not only are the numbers in health care facilities increasing, but the complexities of residents' conditions also are increasing as well," Vogelsmeier said. "We need more sophisticated ways to take care of the aging population. Strong leadership is necessary for all organizations to move toward growth and improvement."

Vogelsmeier analyzed data from an intervention study of nursing homes that implemented electronic medication systems and focused quality improvement efforts to enhance medication safety practices. Vogelsmeier compared how nurse leaders from the highest- and lowest-performing nursing homes differed in their communication and teamwork strategies.

The nurse leader from the highest-performing nursing home encouraged team members to share their perspectives and ideas for solving problems. Leaders provided accurate and timely feedback, which motivated team members to work together and establish common goals. As input and feedback occurred, improvement in the nursing home occurred. The nurse leader from the lowest-performing home did not value the team's opinions, resulting in disengagement and lack of improvement in the nursing home.

Vogelsmeier is a John A. Hartford Foundation Claire M. Fagin Fellow at MU. The study, "Achieving Quality Improvement in the Nursing Home: Influence of Nursing Leadership on Communication and Teamwork," was published in September in the Journal of Nursing Care Quality. It was funded by the Agency for Healthcare Research and Quality.

— A new commentary published online in The FASEB Journal argues that patients should be diligent and demand proof of safety and benefit before beginning any treatment regimen for chronic pain, as some treatments have very little scientific evidence that they actually alleviate the conditions for which they are prescribed. In the article, Phillip J. Baker, Ph.D., Executive Director of the American Lyme Disease Foundation, dispels myths surrounding chronic Lyme disease, using it as an example of why patients should ensure that diagnostic and treatment tools are approved by the Food and Drug Administration and not just recommended by other patients and physicians.

"Despite repeated warnings by the Centers for Disease Control and Prevention and the Food and Drug Administration, the diagnosis of chronic Lyme disease often is based on the false results of non-standard test procedures, not approved by the FDA," said Baker. "This is inexcusable since 46 FDA-approved tests are available and used routinely by various state public health laboratories. A false diagnosis can result in patients being placed on prolonged antibiotic therapy or some other unproven and potentially harmful remedy."

Baker also says that before agreeing to undergo any treatment regimen for chronic pain, patients should ask their physician to provide results from published, placebo-controlled studies proving that the proposed remedy is both beneficial and safe. Testimonials by previously treated patients — regardless of the number — are not sufficient proof of benefit and safety. Unapproved and undocumented treatments are usually not covered by health insurance and therefore result in a huge financial burden to the patient. Chronic Lyme disease must be considered as part of a broad-based, multidisciplinary effort to understand the cause and treatment of chronic pain in general as outlined by the Institute of Medicine's report, "Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research."

"When doctors don't know what's causing a patient to experience chronic pain, desperation can set in," said Gerald Weissmann, M.D., Editor-in-Chief of The FASEB Journal. "That desperation, however, is no excuse for pushing the boundaries of the Hippocratic Oath by diagnosing a patient with a poorly defined health condition, like chronic Lyme disease, for which the only remedies are unproven and may only cause more harm."

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Journal Reference:

1. P. J. Baker. The pain of "chronic Lyme disease": moving the discourse in a different direction. The FASEB Journal, 2011; DOI: 10.1096/fj.11-192898

Many dementia patients are being treated with antipsychotic medications, but a new study shows that simple pain relievers may be a better alternative.

Nearly one in five patients in the study became significantly less agitated and aggressive after treatment with painkillers. The project is a collaborative effort between researchers in Norway and England.

Pain management for aggression and agitation

The study included 352 patients with moderate to serious dementia who exhibited significant behavioural problems such as aggression and agitation. During the eight-week study, all patients received their usual treatment, but half of them received pain treatment in addition.

Agitation is a common symptom of dementia; patients can become anxiety-ridden, upset and short-tempered. Many receive antipsychotic medications intended to reduce their behavioural disturbances, but antipsychotics have a powerful sedative effect and can even exacerbate other dementia symptoms and increase the risk of stroke.

Pain leads to aggressiveness

"The improvement the patients experienced was greater than would have been expected from treatment with antipsychotics," says Bettina Husebø.

Dr Husebø is carrying out post-doctoral research at the University of Bergen's Department of Public Health and Primary Health Care. The study, which she heads, receives funding from the Research Programme on Health and Care Services (HELSEOMSORG) under the Research Council of Norway.

"We hypothesised that behavioural disturbances in dementia patients are sometimes due to pain," she explains. "These patients cannot always communicate to their caregivers that they are in pain, and aggression and agitation become their way of expressing it."

Recurrence after reduction

In the intervention group, patients who were not already taking pain medication were given paracetamol (acetaminophen). Patients who were already taking some form of analgesic painkiller received low doses of morphine or buprenorphine, while those who appeared to suffer neuropathic pain received an antiepileptic drug.

After the eight weeks, the pain treatment was gradually reduced and the intervention-group patients showed marked improvement. But four weeks later the behavioural disturbances began recurring.

"Some people may explain away these positive results by claiming we further sedated the patients. But throughout the study we took control measurements that showed the activity level (in daily living and cognition) of both groups remained unchanged during the eight weeks of pain management," emphasises Dr Husebø.

"Pain assessment training needed"

She believes the results indicate that pain management should be integrated into the clinical treatment of people with dementia in nursing homes.

"Pain assessment is critical in managing pain properly. In the future we must ensure that all nursing home databases have standardised tools for assessing pain based on observation of the patients. Personnel will need training to use these tools, and routines need to be developed to make certain that the tools are actually employed."

Dr Husebø stresses, however, that pain management is not a complete solution but rather part of a comprehensive plan in which activity and communication are essential elements.

Hawthorne effect triggered

The researchers in the study recorded some behavioural improvement in control-group patients as well, i.e. those who did not receive pain medication. This may be explained by the Hawthorne effect — that taking part in a study can in itself produce temporary, positive changes.

"The nursing home personnel in the study received good training and follow-up. This enhanced knowledge and awareness of the issue in general," explains Dr Husebø, "which in turn had an impact on all patients, not only those whose treatment was altered."

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Journal References:

1. B. S. Husebo, C. Ballard, R. Sandvik, O. B. Nilsen, D. Aarsland. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 2011; 343 (jul15 1): d4065 DOI: 10.1136/bmj.d4065
2. P. B. Rosenberg, C. G. Lyketsos. Treating agitation in dementia. BMJ, 2011; 343 (jul15 1): d3913 DOI: 10.1136/bmj.d3913

Many dementia patients are being treated with antipsychotic medications, but a new study shows that simple pain relievers may be a better alternative.

Nearly one in five patients in the study became significantly less agitated and aggressive after treatment with painkillers. The project is a collaborative effort between researchers in Norway and England.

Pain management for aggression and agitation

The study included 352 patients with moderate to serious dementia who exhibited significant behavioural problems such as aggression and agitation. During the eight-week study, all patients received their usual treatment, but half of them received pain treatment in addition.

Agitation is a common symptom of dementia; patients can become anxiety-ridden, upset and short-tempered. Many receive antipsychotic medications intended to reduce their behavioural disturbances, but antipsychotics have a powerful sedative effect and can even exacerbate other dementia symptoms and increase the risk of stroke.

Pain leads to aggressiveness

"The improvement the patients experienced was greater than would have been expected from treatment with antipsychotics," says Bettina Husebø.

Dr Husebø is carrying out post-doctoral research at the University of Bergen's Department of Public Health and Primary Health Care. The study, which she heads, receives funding from the Research Programme on Health and Care Services (HELSEOMSORG) under the Research Council of Norway.

"We hypothesised that behavioural disturbances in dementia patients are sometimes due to pain," she explains. "These patients cannot always communicate to their caregivers that they are in pain, and aggression and agitation become their way of expressing it."

Recurrence after reduction

In the intervention group, patients who were not already taking pain medication were given paracetamol (acetaminophen). Patients who were already taking some form of analgesic painkiller received low doses of morphine or buprenorphine, while those who appeared to suffer neuropathic pain received an antiepileptic drug.

After the eight weeks, the pain treatment was gradually reduced and the intervention-group patients showed marked improvement. But four weeks later the behavioural disturbances began recurring.

"Some people may explain away these positive results by claiming we further sedated the patients. But throughout the study we took control measurements that showed the activity level (in daily living and cognition) of both groups remained unchanged during the eight weeks of pain management," emphasises Dr Husebø.

"Pain assessment training needed"

She believes the results indicate that pain management should be integrated into the clinical treatment of people with dementia in nursing homes.

"Pain assessment is critical in managing pain properly. In the future we must ensure that all nursing home databases have standardised tools for assessing pain based on observation of the patients. Personnel will need training to use these tools, and routines need to be developed to make certain that the tools are actually employed."

Dr Husebø stresses, however, that pain management is not a complete solution but rather part of a comprehensive plan in which activity and communication are essential elements.

Hawthorne effect triggered

The researchers in the study recorded some behavioural improvement in control-group patients as well, i.e. those who did not receive pain medication. This may be explained by the Hawthorne effect — that taking part in a study can in itself produce temporary, positive changes.

"The nursing home personnel in the study received good training and follow-up. This enhanced knowledge and awareness of the issue in general," explains Dr Husebø, "which in turn had an impact on all patients, not only those whose treatment was altered."

The results have been published in the British Medical Journal.

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Journal References:

1. B. S. Husebo, C. Ballard, R. Sandvik, O. B. Nilsen, D. Aarsland. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ, 2011; 343 (jul15 1): d4065 DOI: 10.1136/bmj.d4065
2. P. B. Rosenberg, C. G. Lyketsos. Treating agitation in dementia. BMJ, 2011; 343 (jul15 1): d3913 DOI: 10.1136/bmj.d3913

The rising prevalence of obesity around the globe places an increasing burden on the health of populations, on healthcare systems and on overall economies. A major challenge for researchers is to quantify the effect of these burdens to inform public policies. Using a simulation model to project the probable health and economic consequences from rising obesity rates in the United States and the United Kingdom, researchers at Columbia University's Mailman School of Public Health and Oxford University forecast 65 million more obese adults in the U. S. and 11 million more in the U.K. by 2030, leading to millions of additional cases of diabetes, heart disease, stroke, and cancer. The findings suggest that medical costs associated with treatment of these preventable diseases in the U.S. alone will increase by $48-66 billion per year.

The paper, "Health and Economic Burden of the Projected Obesity Trends in the USA and the UK," is part of a series of articles on obesity published in the August 27 issue of Lancet. The research was led by Y. Claire Wang, MD, ScD, Mailman School assistant professor of Health Policy and Management, with colleagues from Oxford University.

To construct historic trends in BMI the researchers analyzed data from two nationally representative surveys: the U.S. National Health and Nutrition Examination Survey (NHANES) from 1988 to 2008, and the Healthy Survey for England (HSE) from 1993 to 2008. The U.S. and U.K. have the highest obesity rates among the countries belonging to the Organization for Economic Cooperation and Development.

Projecting from these data sets: the researchers predicted the following impacts for the U.S. by 2030:

• Obesity prevalence among men would rise from 32% in 2008 to approximately 50% and from 35% to between 45% and 52% among women.
• 7.8 million extra cases of diabetes
• 6.8 million more cases of coronary heart disease and stroke
• 539,000 additional cases of cancer
• Annual spending on obesity-related diseases would rise by 13-16%, leading to 2.6% increase in national health spending.
• Total medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year.

For the U.K., researchers predicted the following developments by 2030:

• Prevalence of obesity among men would increase from 26% to between 41 — 48%, and among women from 26% to 35-43%.
• 668 000 more cases of diabetes
• 461,000 more cases of heart disease and stroke
• 139,000 additional cases of cancer.
• In the U.K., annual spending on obesity-related health would increase even more rapidly than in the U.S. due to its older population, rising 25%.

"Many chronic and acute health disorders associated with excess bodyweight burden society — not only by negatively affecting the health-related quality of life but also by incurring significant costs," says Dr. Wang. These stem not only from increased healthcare expenditures but also from worker absenteeism, disability pensions, less productivity at work due to poor health, and earlier retirement."

The new study shows that even a small drop in average body mass index (BMI) would have a major health and economic impacts. They therefore recommend action to promote healthier body weights.

"Taking no action would have the catastrophic consequences described in our study, but a population level decrease in BMI by 1% would avoid as many as 2.4 million cases of diabetes, 1.7 million cases of heart disease and stroke, and up to 127 000 cases of cancer in the U.S. alone ."

There are currently 99 million obese individuals in the U.S and 15 million in the U.K. The distribution of obesity is somewhat different in the two nations. In the U.S. about one-quarter of all men are obese regardless of ethnicity. Almost half of black American women (46%) are obese, compared with a third of Hispanic women and 30% of white women. In the U.K., the proportion of obese white men (19%) is slightly higher than black men (17%) and much higher than Asian men (11%). One-third of black women in the U.K. are obese, compared with 1 in 5 white women and 1 in 6 Asian women.

While there is some evidence that the rise in obesity is levelling off in some nations and possibly in the U.S., the jury is still out, says Dr. Wang. "Population weight changes are slow to manifest. Whether or not the U.S. and UK have turned a corner or plateaued will not be clear until survey results over the next few years provide additional data points."

The suggestion that obese people die earlier, thus saving the likely expected social and healthcare costs if that person survives to old age, is also discussed in the paper. However the authors conclude, "Without a doubt, healthcare expenditure is high for elderly people, but these costs should not be used to justify the cost-savings of dying younger, or to suggest that obesity prevention has no benefit."

The study was funded by the National Collaborative on Childhood Obesity Reseach, a joint effort of the National Institutes of Health, Center for Disease Control and Prevention, Department of Agriculture, and the Robert Wood Johnson Foundation. Dr. Wang is also a contributing author on two other related papers in the Lancet series on obesity.

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Journal Reference:

1. Y Claire Wang, Klim McPherson, Tim Marsh, Steven L Gortmaker, Martin Brown. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet, 2011; 378 (9793): 815 DOI: 10.1016/S0140-6736(11)60814-3

 The rising prevalence of obesity around the globe places an increasing burden on the health of populations, on healthcare systems and on overall economies. A major challenge for researchers is to quantify the effect of these burdens to inform public policies. Using a simulation model to project the probable health and economic consequences from rising obesity rates in the United States and the United Kingdom, researchers at Columbia University's Mailman School of Public Health and Oxford University forecast 65 million more obese adults in the U. S. and 11 million more in the U.K. by 2030, leading to millions of additional cases of diabetes, heart disease, stroke, and cancer. The findings suggest that medical costs associated with treatment of these preventable diseases in the U.S. alone will increase by $48-66 billion per year.

The paper, "Health and Economic Burden of the Projected Obesity Trends in the USA and the UK," is part of a series of articles on obesity published in the August 27 issue of Lancet. The research was led by Y. Claire Wang, MD, ScD, Mailman School assistant professor of Health Policy and Management, with colleagues from Oxford University.

To construct historic trends in BMI the researchers analyzed data from two nationally representative surveys: the U.S. National Health and Nutrition Examination Survey (NHANES) from 1988 to 2008, and the Healthy Survey for England (HSE) from 1993 to 2008. The U.S. and U.K. have the highest obesity rates among the countries belonging to the Organization for Economic Cooperation and Development.

Projecting from these data sets: the researchers predicted the following impacts for the U.S. by 2030:

• Obesity prevalence among men would rise from 32% in 2008 to approximately 50% and from 35% to between 45% and 52% among women.
• 7.8 million extra cases of diabetes
• 6.8 million more cases of coronary heart disease and stroke
• 539,000 additional cases of cancer
• Annual spending on obesity-related diseases would rise by 13-16%, leading to 2.6% increase in national health spending.
• Total medical costs associated with treatment of these preventable diseases are estimated to increase by $48-66 billion/year.

For the U.K., researchers predicted the following developments by 2030:

• Prevalence of obesity among men would increase from 26% to between 41 — 48%, and among women from 26% to 35-43%.
• 668 000 more cases of diabetes
• 461,000 more cases of heart disease and stroke
• 139,000 additional cases of cancer.
• In the U.K., annual spending on obesity-related health would increase even more rapidly than in the U.S. due to its older population, rising 25%.

"Many chronic and acute health disorders associated with excess bodyweight burden society — not only by negatively affecting the health-related quality of life but also by incurring significant costs," says Dr. Wang. These stem not only from increased healthcare expenditures but also from worker absenteeism, disability pensions, less productivity at work due to poor health, and earlier retirement."

The new study shows that even a small drop in average body mass index (BMI) would have a major health and economic impacts. They therefore recommend action to promote healthier body weights.

"Taking no action would have the catastrophic consequences described in our study, but a population level decrease in BMI by 1% would avoid as many as 2.4 million cases of diabetes, 1.7 million cases of heart disease and stroke, and up to 127 000 cases of cancer in the U.S. alone ."

There are currently 99 million obese individuals in the U.S and 15 million in the U.K. The distribution of obesity is somewhat different in the two nations. In the U.S. about one-quarter of all men are obese regardless of ethnicity. Almost half of black American women (46%) are obese, compared with a third of Hispanic women and 30% of white women. In the U.K., the proportion of obese white men (19%) is slightly higher than black men (17%) and much higher than Asian men (11%). One-third of black women in the U.K. are obese, compared with 1 in 5 white women and 1 in 6 Asian women.

While there is some evidence that the rise in obesity is levelling off in some nations and possibly in the U.S., the jury is still out, says Dr. Wang. "Population weight changes are slow to manifest. Whether or not the U.S. and UK have turned a corner or plateaued will not be clear until survey results over the next few years provide additional data points."

The suggestion that obese people die earlier, thus saving the likely expected social and healthcare costs if that person survives to old age, is also discussed in the paper. However the authors conclude, "Without a doubt, healthcare expenditure is high for elderly people, but these costs should not be used to justify the cost-savings of dying younger, or to suggest that obesity prevention has no benefit."

The study was funded by the National Collaborative on Childhood Obesity Reseach, a joint effort of the National Institutes of Health, Center for Disease Control and Prevention, Department of Agriculture, and the Robert Wood Johnson Foundation. Dr. Wang is also a contributing author on two other related papers in the Lancet series on obesity.

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Journal Reference:

1. Y Claire Wang, Klim McPherson, Tim Marsh, Steven L Gortmaker, Martin Brown. Health and economic burden of the projected obesity trends in the USA and the UK. The Lancet, 2011; 378 (9793): 815 DOI: 10.1016/S0140-6736(11)60814-3