Blog Title: Manage Your Illness

Behavioral therapy for incontinence

Women with urge urinary incontinence are commonly treated with antimuscarinic medications, although many discontinue therapy. A study by Burgio and colleagues attempted to determine whether combining antimuscarinic drug therapy with supervised behavioral training, compared with drug therapy alone, improved the ability of women with urge incontinence to achieve clinically important reductions in incontinence episodes and to sustain these improvements after discontinuing drug therapy. The study featured a two-stage, multicenter, randomized clinical trial conducted from July 2004 to January 2006 at 9 university-affiliated outpatient clinics. Subjects included 307 women with urge-predominant incontinence. The intervention consisted of10 weeks of open-label, extended-release tolterodine alone (n = 153) or combined with behavioral training (n = 154), followed by discontinuation of therapy and follow-up at 8 months. The primary outcome, measured at 8 months, was no receipt of drugs or other therapy for urge incontinence and a 70% or greater reduction in frequency of incontinence episodes. Secondary outcomes were reduction in incontinence, self-reported satisfaction and improvement, and scores on validated questionnaires measuring symptom distress and bother, and health-related quality of life. Study staff who performed outcome evaluations, but not participants and interventionists, were blinded to group assignment. A total of 237 participants completed the trial. According to life-table estimates, the rate of successful discontinuation of therapy at 8 months was the same in the combination therapy and drug therapy alone groups (41% in both groups; difference, 0 percentage points). A higher proportion of participants who received combination therapy than drug therapy alone achieved a 70% or greater reduction in incontinence at 10 weeks (69% vs. 58%). Combination therapy yielded better outcomes over time on the Urogenital Distress Inventory and the Overactive Bladder Questionnaire at both time points for patient satisfaction and perceived improvement but not health-related quality of life. Adverse events were uncommon (12 events in 6 participants [3 in each group]).

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER. The authors concluded that behavioral therapy components (daily bladder diary and recommendations for fluid management) in the group receiving drug therapy alone could have attenuated between-group differences.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: The addition of behavioral training to drug therapy may reduce incontinence frequency during active treatment but does not improve the ability to discontinue drug therapy and maintain improvement in urinary incontinence. Combination therapy has a beneficial effect on patient satisfaction, perceived improvement, and reduction of other bladder symptoms.

KL Burgio et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Annals of Internal Medicine, 2008;149:161-169.

Psychological factors in the treatment of early-stage prostate cancer

Treatments for early-stage prostate cancer (PCa) are highly effective; therefore, research studies that explore quality of life (QOL) issues associated with different treatments are important. The purposes of a study by Lev and coworkers were to (a) examine differences among treatment groups of men treated with either radiation therapies or radical prostatectomy for PCa and (b) examine quality of life outcomes over time. The investigation explored outcomes 6 and 12 months after 159 men began treatment for PCa with either one of two types of radiation treatment: (a) (intensity-modulated radiation therapy plus high dose rate or intensity-modulated radiation therapy plus seed implantation); or (b) radical prostatectomy. Significant differences among groups were described. Significant predictors of QOL at 6 months included urinary, bowel, sexual symptoms, anxiety, depression, problem-focused coping, and physiological self-efficacy. Significant predictors of QOL at 12 months were urinary and bowel symptoms, stress, depression, problem-focused coping, and physiological self-efficacy. Demographic variables, race, and living status were significant predictors of quality of life at 12 months.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The authors concluded that physiological symptoms and psychological symptoms were both significant predictors of QOL. The psychological factors that predicted quality of life in this study have potential for intervention and point to the next stage of the research.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: It appears, as least with respect to the two treatments investigated in the study, they should be augmented with the teaching of coping and problem solving skills. These techniques could be taught under the umbrella of a self-management program. Such instruction is a major point stressed by the authors of the study.

EL Lev et al. Quality of life of men treated for localized prostate cancer: outcomes at 6 and 12 months. Support Care Cancer, August 22, 2008.

High treatment burden for adults with cystic fibrosis

More aggressive management of cystic fibrosis (CF), along with the use of new therapies, has led to increasing survival. However, the recommended daily treatment regimens for most CF adults are complex and time consuming. In the Project on Adult Care in CF (PAC-CF), an ongoing longitudinal study of CF adults, Sawicki and coworkers assessed self-reported daily treatment activities and perceived treatment burden as measured by the CF Questionnaire-Revised (CFQ-R), a disease-specific quality of life measure. Among the 204 respondents, the median number of daily therapies reported was 7 (IQR 5-9), and the mean reported time spent on treatment activities was 108 minutes per day (SD 58 min). Respondents reported a median of three inhaled and three oral therapies on the day prior to the survey. Only 49% reported performing airway clearance (ACT) on that day. There were no differences in the number of medications or the time to complete therapies based on gender, age, or FEV1. The mean CFQ-R treatment burden domain score was 52.3 (SD 22.1), with no significant differences in the treatment burden based on age or FEV1. In a multivariable model controlling for age, gender, and FEV1, using two or more nebulized medications and performing ACT for >/=30 min were significantly associated with increased treatment burden.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The level of daily treatment activity is high for CF adults regardless of age or disease severity. Increasing number of nebulized therapies and increased ACT time, but not gender, age, or pulmonary function, is associated with higher perceived treatment burden. Efforts to assess the effects of high treatment burden on outcomes such as quality of life are warranted.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: Patients with cystic fibrosis are living longer and longer lives. The disorder is no longer the early death sentence that it once was. However, living longer requires greater self-management on the part of the patient. The performance of self-management skills must be incorporated into the daily living of each patient. However, the payoff--a higher quality of life for more years--is well worth the extra effort.

GS Sawicki et al. High treatment burden in adults with cystic fibrosis: Challenges to disease self-management. Journal of Cystic Fibrosis, October 24, 2008

Self-management of osteoarthritis

Self-management (SM) programs are effective for many chronic conditions, although the evidence for osteoarthritis SM is inconclusive. The aim of a case series project by Coleman and coworkers was to determine whether a newly developed specific SM program for people with osteoarthritis of the knee, implemented by health professionals, could achieve and maintain clinically meaningful improvements. There were 79 participants enrolled in the study; their mean age was 66 years, with established osteoarthritis of the knee. People with coexisting inflammatory joint disease or serious co-morbidities were excluded. The intervention consisted of a 6-week disease and site (knee) specific self-management education program that included disease education, exercise advice, information on healthy lifestyle, and relevant information within the constructs of self-management. The program was conducted in a community health care setting and delivered by health professionals. Measures of pain, physical function, and mental health scales were assessed at baseline, 8-weeks, 6- and 12-months using WOMAC and SF-36 questionnaires. Changes in pain during the 8-week intervention phase were monitored. Pain improved during the intervention phase: mean (95% CI) change 15 (8 to 22) mm. Improvements (0.3 to 0.5 standard deviation units) in indices of pain, mental health, and physical functioning, assessed by SF-36 and WOMAC questionnaires, were demonstrated from baseline to 12 months.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The authors concluded that their disease and site-specific self-management education program improved health status of people with osteoarthritis of the knee both in the short and medium term.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: Considerable research on self-management programs for arthritis has emerged in the past two decades. Anyone with either osteoarthritis or rheumatoid arthritis should learn self-management skills. Ask your health care provider to refer you to an established program or strongly suggest that he or she initiate such self-management training for you and others with your condition. There are programs available, such as that developed by Kate Lorig and her colleagues at Stanford, that can fit into any medical setting.

S Coleman et al. Short and medium-term effects of an education self-management program for individuals with osteoarthritis of the knee, designed and delivered by health professionals: a quality assurance study. BMC Musculoskeletal Disorders, 2008;9:117.

Psychological approaches to the treatment of COPD

Ad Kaptein and his coworkers reviewed behavioral research on patients with COPD over the past 50 years in order to suggest better clinical management techniques and future research on psychosocial aspects of COPD. The study featured a narrative literature review. Nine orientations in behavioral research on COPD patients are identified and concisely examined: (1) psychoanalytic approach; (2) psychosomatics; (3) neuropsychology; (4) quality of life; (5) psychomaintenance; (6) patient education; (7) coping and illness cognitions; (8) self-management; and (9) collaborative care. The approaches form a historical sequence of psychosocial perspectives on COPD, and of successively increasing utility in COPD research and care. In the past 50 years, behavioral research on COPD patients has evolved considerably. Over time, a trend for the patient to play the central role in the management of the illness is clearly delineated. Evidence-based reviews indicate that self-management offers COPD patients effective options for managing their illness, leading to positive outcomes such as reduced frequency of hospitalization, greater exercise tolerance, and enhanced quality of life. Future research should focus on how self-management skills can be incorporated formally into medical care.

WHAT THE STUDY MAY MEAN TO YOU AS A HEALTH CARE PROVIDER: The authors concluded that offering suggestions on how clinicians may be instrumental in improving self-management behavior in COPD patients and, therefore, improve care outcomes. They also highlighted the importance of gaining insight into the perceptions of patients of their own situation, and incorporating a respect for patient perspectives into the philosophy of care.

WHAT THE STUDY MAY MEAN TO YOU AS A PATIENT: If you have COPD, you should be taught self-management skills and perform them on a regular basis. This will not only improve clinical aspects of your care, but enhance the quality of life you experience. That is the central message of this fine review. If you haven't been taught self-management, discuss where you can find such training with your health care provider. It will be well worth your effort.

AA Kaptein et al. 50 Years of psychological research on patients with COPD - Road to ruin or highway to heaven? Respiratory Medicine, October 17, 2008.