11

Feasibility and Effectiveness of Feasibility and Effectiveness of E-Therapy on Fatigue Management in Home-E-Therapy on Fatigue Management in Home-Based Older Adults With Congestive Heart Based Older Adults With Congestive Heart

FailureFailure

Bin-Min Tsai, MS, OTRDepartment of Rehabilitation Science

University at Buffalo

Presented atNYSOTA Conference

Buffalo, NYSeptember 27-29, 2007

22

IntroductionIntroduction

Fatigue in CHFFatigue in CHFFatigue: a significant predictor for developing Fatigue: a significant predictor for developing severe CHF severe CHF (Ekman, et al., 2005)(Ekman, et al., 2005)

Fatigue intervention requires attention Fatigue intervention requires attention

Currently CHF patients may receive fatigue Currently CHF patients may receive fatigue management education before discharge but management education before discharge but they may not have opportunity to access the they may not have opportunity to access the education after going home.education after going home.

33

IntroductionIntroduction

Community-based program for other chronic Community-based program for other chronic conditions:conditions:

Multiple sessions; in a face-to-face group Multiple sessions; in a face-to-face group format format Low adherence rate Low adherence rate (Lamb, et al., 2005) (Lamb, et al., 2005)

Traveling was challenging (Traveling was challenging (Cox, 2004)Cox, 2004)

Internet - based program:Internet - based program:Can increase access to healthcare serviceCan increase access to healthcare serviceMay be as effective as a community-based May be as effective as a community-based education programeducation program

– (Tomita, Sewall, & Tsai; 2005)(Tomita, Sewall, & Tsai; 2005)

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Purpose of the StudyPurpose of the Study

To createTo create a supportive environment a supportive environment via the via the internetinternet for for home-based older adults with home-based older adults with CHF CHF and test the feasibility & effectiveness and test the feasibility & effectiveness of “of “e-therapye-therapy” ” on fatigue managementon fatigue management

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Literature Review: Literature Review: Impacts of FatigueImpacts of Fatigue

Difficulties in carrying out ADL/IADL tasksDifficulties in carrying out ADL/IADL tasks (Warner, 2001)(Warner, 2001)

FFunctional status unctional status

– Impaired physical, cognitive, social functioningImpaired physical, cognitive, social functioning

(Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003)(Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003)

Current hCurrent health and health- related quality of lifeealth and health- related quality of life (Warner, 2001; (Warner, 2001; Mathiowetz et al., 2001; 2005; Vanage et al, 2003)Mathiowetz et al., 2001; 2005; Vanage et al, 2003)

Decreased satisfaction with lifeDecreased satisfaction with life (Stephen, 2000)(Stephen, 2000)

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The Energy Conservation EducationThe Energy Conservation Education

EffectsEffects:: – Increase in use of energy conservation strategiesIncrease in use of energy conservation strategies– Reduction in fatigue severity and impactReduction in fatigue severity and impact– Improving sense of self-efficacy for managing fatigueImproving sense of self-efficacy for managing fatigue– Improving health-related qualify of life. Improving health-related qualify of life.

(Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003)(Mathiowetz et al., 2001; 2005; Vanage, Gilbertson, & Mathiowetz, 2003)

Challenges: Challenges: – Only less than a half of participants were able Only less than a half of participants were able

to attend all sessions.to attend all sessions. (Lamb, et al., 2005; Mathiowetz et al., 2005) (Lamb, et al., 2005; Mathiowetz et al., 2005)

77

Internet-based Internet-based Energy Conservation EducationEnergy Conservation Education

““In order for the energy conservation In order for the energy conservation strategies to be most effective, the strategies to be most effective, the environment needs to support people who environment needs to support people who would like to learn and use the strategies” would like to learn and use the strategies” (Matuska et al., 2007) (Matuska et al., 2007)

88

Development of the Development of the E-Therapy E-Therapy ProgramProgram

Application of e-health method in Wellness Application of e-health method in Wellness Network study (Tomita & Naughton, 2004)Network study (Tomita & Naughton, 2004)The principle investigator (PI) developed the The principle investigator (PI) developed the e-e-therapy therapy program providing three types of program providing three types of support:support:

1.1. Informational support : Created energy conservationInformational support : Created energy conservation online education material for CHF-related fatigue online education material for CHF-related fatigue managementmanagement

2. Instrumental support: provided means to self-2. Instrumental support: provided means to self-mange fatigue in a secure web site called daily log mange fatigue in a secure web site called daily log to record daily activity level & use of energy to record daily activity level & use of energy conservation strategies. conservation strategies.

3. Emotional support: developed 6 discussion topics 3. Emotional support: developed 6 discussion topics and led discussions in an online support groupand led discussions in an online support group

99

Research QuestionsResearch Questions

RQ1: Does the RQ1: Does the e-therapye-therapy group use the e- group use the e-therapy program and implement the energy therapy program and implement the energy conservation strategies instructed in the conservation strategies instructed in the program? program?

RQ2 : Does the e-therapy group increases RQ2 : Does the e-therapy group increases knowledge of fatigue management in CHF?knowledge of fatigue management in CHF?

RQ 3: Does e-therapy group have RQ 3: Does e-therapy group have higher higher physical, cognitive & social functionsphysical, cognitive & social functions than the than the control group after the intervention? control group after the intervention?

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Research QuestionsResearch Questions

RQ 4: Does e-therapy group have RQ 4: Does e-therapy group have less fatigue less fatigue using Global Fatigue Indexusing Global Fatigue Index than the control than the control group after the intervention? group after the intervention?

RQ 5: Does e-therapy group have RQ 5: Does e-therapy group have higher overall higher overall and individual activity levelsand individual activity levels than the control than the control group? group?

RQ 6: What energy conservation strategies are RQ 6: What energy conservation strategies are perceived as the most beneficial?perceived as the most beneficial?

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Method: Research DesignMethod: Research Design

Quasi-experimental two group mixed design Quasi-experimental two group mixed design

2-wk 12 weeks2-wk 12 weeks 6 weeks 6 weeks Baseline Pretest Posttest Follow-Up Baseline Pretest Posttest Follow-Up

T OT O1 X O X O22 (X) (X) O O33

C C O O1 O O22 O O33

- O: Observation- O: Observation - X: Active intervention with both e-therapy technology and a - X: Active intervention with both e-therapy technology and a therapisttherapist

- (X): Passive intervention with technology only- (X): Passive intervention with technology only

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Method: ParticipantsMethod: Participants

CHF patients in the Wellness Network study (Tomita & CHF patients in the Wellness Network study (Tomita & Naughton, 2004) Naughton, 2004) – ≥ ≥ 55 years old55 years old– CHF: New York Heart Association (NYHA) Functional CHF: New York Heart Association (NYHA) Functional

Classification level II or III Classification level II or III Slight or marked limitations in physical activitiesSlight or marked limitations in physical activitiesOrdinary or less than physical activities could Ordinary or less than physical activities could contribute to shortness of breath, fatigue, or contribute to shortness of breath, fatigue, or palpitation palpitation

– MMSE: 24 or higherMMSE: 24 or higher– Living in their own home Living in their own home

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Method: ProceduresMethod: Procedures

Obtaining HSIRB ApprovalObtaining HSIRB Approval

Pilot study (n=5)Pilot study (n=5)

2- week baseline2- week baseline

Initial Interview (n=31)

12-week active Intervention12-week active Intervention

12th week interview (n=31)

6-week passive intervention6-week passive intervention

18th week interview (n=29)18th week interview (n=29)

Recruitment of participants (n=31)Recruitment of participants (n=31)

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E-Therapy Program: E-Therapy Program: 12-week active intervention12-week active intervention

1. Use of a daily health log

2. Access to online education for fatigue management in CHF patients ((www.agingresearch.buffalo.eduwww.agingresearch.buffalo.edu))

– CHF-related fatigueCHF-related fatigue– 14 energy conservation strategies & their applications in daily lives14 energy conservation strategies & their applications in daily lives

3. Participation in online support group ((www.agingresearch.buffalo.eduwww.agingresearch.buffalo.edu))

– With peer and professional support– Facilitated by an rehab professional– Discussion topics:

Diet and nutritionCHFHelpful tips for health managementExerciseComputer useFatigue management

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Energy Conservation StrategiesEnergy Conservation Strategies1.1. Make sure your work is at the proper heightMake sure your work is at the proper height2.2. Keep your work within easy rangeKeep your work within easy range3.3. Use adaptive equipment, gadgets, or energy-saving devicesUse adaptive equipment, gadgets, or energy-saving devices4.4. Use proper posture and body mechanics throughout your dayUse proper posture and body mechanics throughout your day5.5. Eliminate part or all of an activity to conserve energy Eliminate part or all of an activity to conserve energy 6.6. Delegate part or all of an activity to another person Delegate part or all of an activity to another person 7.7. Communicate need for assistance to family members or others Communicate need for assistance to family members or others 8.8. Modify standards by changing the frequency or expected outcome Modify standards by changing the frequency or expected outcome

of an activity of an activity 9.9. Adjust priorities by choosing how to spend available energy Adjust priorities by choosing how to spend available energy 10.10. Simplify activities so they require less energy Simplify activities so they require less energy 11.11. Plan your day and week to balance work and rest times Plan your day and week to balance work and rest times 12.12. Change the time of day that you do an activity to reduce fatigue Change the time of day that you do an activity to reduce fatigue 13.13. Include rest periods in the day, or rest at least one hour/day Include rest periods in the day, or rest at least one hour/day 14.14. Rest during tiring activities that take 30 minutes or longer Rest during tiring activities that take 30 minutes or longer

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E-Therapy Program: E-Therapy Program: 6-week passive intervention6-week passive intervention

No rehab professional support No rehab professional support

Emotional support Emotional support

Online Support Group (Peer support only)Online Support Group (Peer support only)

Informational & Instrumental supportInformational & Instrumental support

Online Education Material (Online Education Material (www.agingresearch.buffalo.eduwww.agingresearch.buffalo.edu))

Daily log (Daily log (http://http://dailyheathlog.infodailyheathlog.info//))

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Method: MeasurementsMethod: Measurements

Process measuresProcess measures– Daily log record (activity level & energy conservation Daily log record (activity level & energy conservation

strategies used)strategies used)

Outcome measuresOutcome measures 1. Knowledge about fatigue management in CHF1. Knowledge about fatigue management in CHF22. The Energy Conservation Strategies Survey. The Energy Conservation Strategies Survey33. The Modified Fatigue Impact scale. The Modified Fatigue Impact scale4. The Multidimensional Assessment of Fatigue scale 4. The Multidimensional Assessment of Fatigue scale 5. Activity Level Measure5. Activity Level Measure66. The Short-Form Health Survey . The Short-Form Health Survey

7. Evaluation Form7. Evaluation Form

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Method: Outcome MeasuresMethod: Outcome Measures

11. Knowledge about fatigue management in CHF - 20 multiple-choice questions- to test how much they learned from the online education

2. The Energy Conservation Strategies Survey (Mallik et al., 2005) (Mallik et al., 2005) -14 strategies- Ask what strategies were implemented?- Ask what strategies were implemented?

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Method: Outcome MeasuresMethod: Outcome Measures

3. The Modified Fatigue Impact scale (MFIS)3. The Modified Fatigue Impact scale (MFIS)

- 3 subscales (Physical, Cognitive, & Psychosocial - 3 subscales (Physical, Cognitive, & Psychosocial Functioning)Functioning)

- 21 items- 21 items

-- Ex. -- Ex. Because of my fatigue, I have limited my physical Because of my fatigue, I have limited my physical activities.activities.

- Scoring: three subscale score and a total score- Scoring: three subscale score and a total score

- Higher scores indicate a greater impact of fatigue- Higher scores indicate a greater impact of fatigue

- High internal consistency: - High internal consistency: Cronbach's alpha of .91, .95, & .81 Cronbach's alpha of .91, .95, & .81

2020

Method: Outcome MeasuresMethod: Outcome Measures

4. The Multidimensional Assessment of Fatigue 4. The Multidimensional Assessment of Fatigue (MAF) scale (Belza, 1995)(MAF) scale (Belza, 1995)

- 5 dimensions of fatigue: - 5 dimensions of fatigue:

degree, severity, distress, interference with daily activities, degree, severity, distress, interference with daily activities, and frequency. and frequency.

- Rating scale: 10-point rating scales (1: no fatigue; 10: - Rating scale: 10-point rating scales (1: no fatigue; 10: extreme fatigue), extreme fatigue),

- Total of 5 dimensions called Global fatigue index (GFI): - Total of 5 dimensions called Global fatigue index (GFI): range from 1 to 50.range from 1 to 50.

- High test-retest reliability (.73) & concurrent validity (.64)- High test-retest reliability (.73) & concurrent validity (.64)

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Method: Outcome MeasuresMethod: Outcome Measures

5. A5. Activity Level Measurectivity Level Measure- 13 activity items (ADL and IADLs)- 13 activity items (ADL and IADLs)- 5 point rating: - 5 point rating:

Q: To what degree did you complete each daily activity? Q: To what degree did you complete each daily activity?

5 –Complete 100% without any limitation 5 –Complete 100% without any limitation 4 –Mildly-adapted completeness 4 –Mildly-adapted completeness 3 –Moderately adapted completeness3 –Moderately adapted completeness2 – Complete 50% and more at a time2 – Complete 50% and more at a time1 – Complete less than 50% at a time1 – Complete less than 50% at a time0 – Complete 0% or I do not do this activity. 0 – Complete 0% or I do not do this activity.

- Internal Consistency: Chronbach’s α=.89- Internal Consistency: Chronbach’s α=.89 - Test-retest reliability: .94- Test-retest reliability: .94

- Construct validity: factor analysis yielding 2 factors (mild and moderate - Construct validity: factor analysis yielding 2 factors (mild and moderate activity), accounting for 65.9% of the total variances. activity), accounting for 65.9% of the total variances.

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Method: Outcome MeasuresMethod: Outcome Measures6. The Short-Form Health Survey (SF-36) (6. The Short-Form Health Survey (SF-36) (Ware, et al., 1993Ware, et al., 1993))

- Health-related quality of life- Health-related quality of life- Measure 6 dimensions: - Measure 6 dimensions: 1. Physical Functioning1. Physical Functioning 2. Role-Physical (limitation in physical activities),2. Role-Physical (limitation in physical activities), 3. Role-Emotional (accomplished less than would like),3. Role-Emotional (accomplished less than would like), 4. Social Functioning4. Social Functioning 5. Vitality 5. Vitality 6. Mental Health6. Mental Health

- Scoring: - Scoring: transformed to a 0 -100 scoretransformed to a 0 -100 score- Internal consistency: .80 -.92- Internal consistency: .80 -.92

- Test-retest reliability: .60 - .81- Test-retest reliability: .60 - .81- Validity was established.- Validity was established.

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Method: Outcome MeasuresMethod: Outcome Measures

77. Evaluation of the program. Evaluation of the program

- Asks treatment group participants to rate the e-therapy - Asks treatment group participants to rate the e-therapy program, including satisfaction, & the most beneficial program, including satisfaction, & the most beneficial feature, and strategies learned from the program.feature, and strategies learned from the program.

- Use both close-ended and open-ended questions- Use both close-ended and open-ended questions

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Results:Results: Demographics & Health Demographics & Health characteristicscharacteristics

29 participants (14 treatment, 15 control)29 participants (14 treatment, 15 control)

– Age: 75 years (T: 73, C: 77)Age: 75 years (T: 73, C: 77)– Gender: 20 (69%) F, 9 (31%) MGender: 20 (69%) F, 9 (31%) M– Race: 24 (82%) Caucasian, 5 (27%) minorityRace: 24 (82%) Caucasian, 5 (27%) minority– Education: 13 (45 %) middle or high school, 16 (55%) some Education: 13 (45 %) middle or high school, 16 (55%) some

college or highercollege or higher– Marital Status: 13 (45%) married, 12 (42%) widowed, 4 (14%) Marital Status: 13 (45%) married, 12 (42%) widowed, 4 (14%)

single or separatedsingle or separated– Living status: 11 (38%) lived alone, 18 (62%) with someoneLiving status: 11 (38%) lived alone, 18 (62%) with someone– # of chronic illnesses: 10# of chronic illnesses: 10– # of medications taken: 8# of medications taken: 8

No group differencesNo group differences

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Amount of exerciseAmount of exercise

Note. Total minutes of aerobic exercise (walking and biking) during the Note. Total minutes of aerobic exercise (walking and biking) during the previous week of the time of pretest, posttest, and follow-up previous week of the time of pretest, posttest, and follow-up

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Results: Use of the ProgramResults: Use of the Program

Online education materials: 14 (100 % )Online education materials: 14 (100 % )

Daily log: 13 (93 %) used 78 % of 12 weeks Daily log: 13 (93 %) used 78 % of 12 weeks (active intervention period) and 64% of 6 weeks (active intervention period) and 64% of 6 weeks (passive intervention period). (passive intervention period).

Online support group: 8 (57%) participated Online support group: 8 (57%) participated

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Results:Results: Implement of Energy Implement of Energy Conservation StrategiesConservation Strategies

Energy Conservation StrategiesEnergy Conservation Strategies Implemented StrategyImplemented Strategy

Number of users (%of 14)Number of users (%of 14)

Include rest periods in the day or at least 1 Include rest periods in the day or at least 1 hour/dayhour/day

12 (85.7%)12 (85.7%)

Change body position to do a certain Change body position to do a certain activity activity

12 (85.7%)12 (85.7%)

Plan the day to balance rest and work Plan the day to balance rest and work 12 (85.7%)12 (85.7%)

Delegate part or all of an activity to another Delegate part or all of an activity to another person person

12 (85.7%)12 (85.7%)

Communicate needs for assistance to Communicate needs for assistance to others others

12 (85.7%)12 (85.7%)

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Results:Results: The Most Beneficial StrategiesThe Most Beneficial Strategies

Energy Conservation StrategiesEnergy Conservation Strategies The most beneficialThe most beneficial

Number of strategies used in Number of strategies used in 18 weeks (% of 5314) 18 weeks (% of 5314)

Include rest periods in the day or at Include rest periods in the day or at least 1 hour/dayleast 1 hour/day

1104 (20.8%) 1104 (20.8%)

Communicate needs for assistance to Communicate needs for assistance to others others

582 (11.0%) 582 (11.0%)

Plan the day to balance rest and work Plan the day to balance rest and work 576 (10.8%) 576 (10.8%)

Eliminate part or all of an activity Eliminate part or all of an activity 793 (14.9%) 793 (14.9%)

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Results:Results: Knowledge Knowledge

20

25

30

35

40

Pretest Posttest Follow-up

T

C

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Results: Results: Modified Fatigue Impact ScaleModified Fatigue Impact Scale

Total ScoreTotal Score

20

25

30

35

40

45

50

Pretest Posttest Follow-up

T

C

3131

Results: Multidimensional Assessment of Results: Multidimensional Assessment of Fatigue ScaleFatigue Scale

SeveritySeverity

2

3

4

5

6

7

8

Pretest Posttest Follow-up

T

C

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Results: Multidimensional Assessment of Results: Multidimensional Assessment of Fatigue ScaleFatigue Scale

Overall Figure Impact on Daily ActivitiesOverall Figure Impact on Daily Activities

2

3

4

5

6

7

8

Pretest posttest Follow-up

T

C

3333

Results: Fatigue interference with Results: Fatigue interference with Individual Daily ActivitiesIndividual Daily Activities

At follow-up: More fatigue during cooking, At follow-up: More fatigue during cooking, showering, during dressing socializing & showering, during dressing socializing & shopping in the control group while the shopping in the control group while the treatment maintained the same level. treatment maintained the same level.

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Result: Overall Activity LevelResult: Overall Activity Level

20

25

30

35

40

Pretest posttest Follow-up

T

C

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Result: Individual Activity LevelResult: Individual Activity Level

At posttest, the treatment group had At posttest, the treatment group had higher activity level of lunch (p=.012) and higher activity level of lunch (p=.012) and dinner preparation (p=.04)dinner preparation (p=.04)

Control group decrease activity level of Control group decrease activity level of showering (pretest to follow-up) & light showering (pretest to follow-up) & light housework (pretest to posttest, pretest to housework (pretest to posttest, pretest to follow-up)follow-up)

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Result: Participants’ Perceptions Result: Participants’ Perceptions

All (100%) satisfied with the programAll (100%) satisfied with the programAll (100%) like to recommend it to other peopleAll (100%) like to recommend it to other people13 (93%) perceived 13 (93%) perceived e-therapye-therapy very informative very informative and helpfuland helpful9 (64%) perceived e-therapy helped with 9 (64%) perceived e-therapy helped with managing fatigue & improving their energy levelmanaging fatigue & improving their energy level8 (57%) perceived e-therapy improved their 8 (57%) perceived e-therapy improved their quality of life while 6 (23%) felt the same quality of life while 6 (23%) felt the same The most helpful features: The most helpful features: – Daily log & energy conservation online Daily log & energy conservation online

educationeducation

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Discussion: FeasibilityDiscussion: Feasibility

Overall, patients with CHF had a high level of use of e-Overall, patients with CHF had a high level of use of e-therapy especially when they felt the feature was easy to therapy especially when they felt the feature was easy to use and helpful.use and helpful.– Online education materials: 100 % of patients Online education materials: 100 % of patients – Daily log: 93 % of patientsDaily log: 93 % of patients

However, the level of online support group use was However, the level of online support group use was lower (57%) due to:lower (57%) due to:– lack of interestlack of interest– fear of communicating with strangersfear of communicating with strangers– fear of providing wrong information to othersfear of providing wrong information to others– not understanding how to operate itnot understanding how to operate it

These characteristics may be dissipate when older adults become These characteristics may be dissipate when older adults become more computer literate in the future. more computer literate in the future.

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Discussion: Patterns of use of energy Discussion: Patterns of use of energy conservation strategiesconservation strategies

Participants learned and used the strategy of how to pace themselves in daily life more than other strategies because of its immediate result.

The strategy to take more time to implement was least applied.

Use of assistive devices became common strategies – contradictory to other studies using younger patients– because the study participants were older and were

more disabled

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Clinical ImplicationsClinical Implications

The use of a client-centered approach to OT practice The use of a client-centered approach to OT practice has developed rapidly during the last decadehas developed rapidly during the last decade

E-therapyE-therapy is an application of client-centered practice is an application of client-centered practice– Make services available to the client at the time of greatest need– Allow clients more flexibility in their daily schedule – The therapist as a facilitator enable the client to generate

strategies of coping

Therapists can efficiently deliver therapy through the internet after the initial personal evaluation and training with the clients.

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ConclusionConclusion

The e-therapy program is feasible and effective in maintaining fatigue severity, overall fatigue impact on functions, level of activities & mental health among older adults with CHF, if they were motivated, have means, and skills. In this technology age, e-therapy may be actualized in the near future.

The further study is strongly needed to provide clear evidence of effectiveness of e-therapy including cost effectiveness.