Assessment, treatment goals and interventions for oedema/lymphoedema in palliative care.

BACKGROUND: Little is known about the treatment of oedema in palliative care patients. AIM: To outline the assessment, goals, and interventions for patients with oedema. METHOD: A 6-month chart review of a specialist physiotherapy-led oedema service was carried out. RESULTS: Of the sample group (n=63), 28.6% of patients had lymphoedema, 15.9% had non-lymphatic oedema, 46% had mixed oedema and 9.8% had lymphorrhoea; 58 patients (92%) had cancer. The most common interventions were providing education (100%, n=63), using compression garments (58%, n=37), bandaging (51%, n=32), exercise (38%, n=24), lymphatic massage and kinesio-taping (35%, n=22 each). Treatment regime differed depending on the type of oedema present. Treatment goals were pragmatic: the most common were to maintain skin quality (54%, n=34), reduce limb volume (52%, n=32), and improve quality of life (48%, n=30). CONCLUSION: Palliative care oedema can be treated using manual methods, including compression and massage. Goals differ from other oedema populations. Research is hampered by lack of suitable measures to record skin changes and quality of life.

A profile of hospice-at-home physiotherapy for community-dwelling palliative care patients.

AIM: To profile a specialised palliative care physiotherapy service to community-dwelling patients. DESIGN: Retrospective audit. SETTING: Milford Care Centre, Limerick, Ireland. PARTICIPANTS: Patients referred to hospice-at-home physiotherapy during September 2010-February 2011. OUTCOME MEASURE: Edmonton Functional Assessment Tool (EFAT-2). RESULTS: 165 patients were referred, of whom 90% had cancer. Nurses referred 120 (73%). Referrals appeared to be increased by the presence of physiotherapists in the nursing bases. No asssessment was conducted for 55 referrals (33%), mainly owing to clinical deterioration. The remaining 110 patients were assessed, with 47 (43%) being contacted within 2 days of referral (mean 4 days, standard deviation 4.2, range 0-21 days). Physical function ranged from 0-18 (median 7, mode 4) on the EFAT-2 scale. The most commonly used treatments were exercises and advice/education. CONCLUSION: Referrals to the at-home physiotherapy service are heavily dependent on nurses and their understanding of the physiotherapy role. Patients tended to be relatively high functioning and tolerated numerous interventions.

Project ECHO: Enhancing palliative care for primary care occupational therapists and physiotherapists in Ireland.

Project ECHO (Extension for Community Healthcare Outcomes) uses videoconferencing technology to support and train healthcare professionals (HCPs) remotely. A 4-month fortnightly ECHO programme was developed and implemented to enhance palliative care provision by primary care therapists. Teaching and case-based discussions were facilitated by palliative care specialists. A mixed-methods cohort study was used to evaluate the project. ECHO participants completed pre- and post-programme questionnaires regarding their knowledge and skills across key palliative care domains. Focus groups were held before programme commencement to explore participants' attitudes and experiences of palliative care and after programme conclusion to explore their experiences of ECHO. Twenty-six primary care HCPs commenced the ECHO programme. Mean scores in self-rated confidence in knowledge and skill improved significantly (p < .002) following the programme. Twenty-one primary care HCPs completed the post-ECHO surveys and scores of self-rated confidence in knowledge and skills were significantly higher than pre-ECHO scores. Ninety-five percent of participants (n = 19) reported ECHO met their learning needs and was an effective format to enhance clinical knowledge. Eighty-five percent of participants (n = 17) would recommend ECHO to their colleagues. Project ECHO improved palliative care knowledge and skills of primary care HCPs in Ireland, with potential to address the growing need for integrated palliative care services.

Hip protectors in fracture prevention for aging adults at risk of falling: a study of user compliance.

PURPOSE: A compliance survey was conducted to establish factors that influence low user compliance with hip protectors amongst aging adults at risk of hip fracture. Medical professionals who deal with patients at risk of hip facture were also included in this survey. METHODS: For this descriptive study 2 questionnaires were designed, 1 for community dwelling aging adults at high risk of fall and hip fracture and 1 for medical professionals dealing with these patients. The questionnaires were presented, completed, and collected at individual appointments with aging adults and by group appointments with medical professionals. All data was statistically analysed to detect the most significant factors related to poor user compliance with hip protectors. For this descriptive study, frequency tests were used to analyse the data and therefore percentage of response was also reported. Certain demographic data such as age and gender was also collected. RESULTS: The outcomes in both interviewed groups were very similar. The main findings demonstrate that 51% of users find hip protectors very valuable while 41% reported the product to be uncomfortable and 29% of users found them difficult to put on. For potential users the high cost of the product and its appearance remains an issue. Also negative psychological aspects of wearing the hip orthoses appear to be common reasons for not wearing a hip protector. CONCLUSION: The study confirmed poor user compliance with hip protectors (18.9%). The information gathered from users and medical professionals regarding hip protectors provides valuable information which allows for the identification and development of new design features.

Pilot Study: The Effectiveness of Complex Decongestive Therapy for Lymphedema in Palliative Care Patients with Advanced Cancer.

BACKGROUND: Complex decongestive therapy (CDT) is a regimen of physical treatment for lymphedema. Its effectiveness is unknown in advanced cancer patients. This study evaluates effectiveness of CDT in this population. METHOD: This is a prospective observational cohort study for 18 months of advanced cancer patients with lymphedema, who received three or more CDT interventions. Measurements were taken before the first (T1), third (T3), and sixth (T6) treatments as follows: limb volume using circumferential measurements, quality of life (QOL) using qualitative questions, skin quality using a locally developed scale measuring color, thickness, and texture. The treating physiotherapists collected data. Analysis was carried out using Microsoft Excel and SPSS. RESULTS: Twelve patients, age range 42-73 years (median 69.5) were included. Survival from last recorded treatment ranged from 3 to 262 days (median 40). At T3 (n = 21 limbs), volume reduction was significant (Wilcoxin Signed Rank Test Z = -2.5, p = 0.01, r = 0.5). At T6 (n = 13 limbs), volume reduction was significant (Z = -2.4, p = 0.013, r = 0.66). At both time points, there were significant reductions in abnormal skin thickness and surface, but not color. Improvements occurred independent of volume changes. QOL changes included better function, improved limb aesthetics, and less pain and tightness. CONCLUSION: For the first time, this study shows that CDT is effective for a cohort of palliative cancer patients with limited survival. Improvements in limb volume, skin quality, and lymphedema-related QOL were recorded. Valid skin and QOL measures need to be developed. Larger, blinded trials need to be conducted to determine which patients benefit from CDT.

Palliative Care Edema: Patient Population, Causal Factors, and Types of Edema Referred to a Specialist Palliative Care Edema Service.

BACKGROUND: Edema in palliative care patients is a common symptom, however, the research base for all aspects of its care is extremely poor. OBJECTIVE: To evaluate a specialist palliative care edema service in order to report on the patient population referred, the types of edema encountered, and the causes of edema. DESIGN: Prior to study, three different edema types were described for evaluation: lymphedema, nonlymphatic edema, and a combination of the two. Retrospective chart evaluation was completed from August 2013 through January 2014. SUBJECTS: Patients with edema assessed by the specialist palliative care physiotherapy edema service. RESULTS: Sixty-three cases were included, comprising 10.5% of all new palliative care referrals during the study period. Ninety-two percent (n = 58) had a diagnosis of cancer and 57% (n = 36) were female. Age ranged from 45-97 years. The most common edema type was a mixed edema (46%, n = 29), followed by lymphedema (27%, n = 18) and nonlymphatic edema (16%, n = 10). Lymphorrhea occurred in 9.5% of cases. The most common reasons for edema, based on clinical opinion, were blocked lymphatics (33%) and dependency from immobility (27%). The most common site for edema was in the lower limbs (89%, n = 56). The time lapse from the last treatment to death ranged from 1-225 days. Having a mixed edema type or lymphorrhea was a relatively poor prognostic sign. CONCLUSIONS: This is the first study to describe in detail the occurrence of edema in palliative care patients. Edema may be present for many months prior to death making the search for effective treatments imperative.