Chronic disease self-management in Aboriginal communities : towards a sustainable program of care in rural communities

The Chronic Disease Self-Management (CDSM) strategy for Aboriginal patients on Eyre Peninsula, South Australia, was designed to develop and trial new program tools and processes for goal setting, behaviour change and self-management for Aboriginal people with diabetes. The project was established as a one-year demonstration project to test and trial a range of CDSM processes and procedures within Aboriginal communities and not as a formal research project. Over a one-year period, 60 Aboriginal people with type-2 diabetes in two remote regional centres participated in the pilot program. This represents around 25% of the known Aboriginal diabetic population in these sites. The project included training for four Aboriginal Health Workers in goal setting and self-management strategies in preparation for them to run the program. Patients completed a Diabetes Assessment Tool, a Quality of Life Questionnaire (SF12), the Work and Social Adjustment Scale (WASAS) at 0, 6 and 12 months. The evaluation tools were assessed and revised by consumers and health professionals during the trial to determine the most functional and acceptable processes for Aboriginal patients. Some limited biomedical data were also recorded although this was not the principal purpose of the project. Initial results from the COAG coordinated care trial in Eyre suggest that goal setting and monitoring processes, when modified to be culturally inclusive of Aboriginal people, can be effective strategies for improving self-management skills and health-related behaviours of patients with chronic illness. The CDSM pilot study in Aboriginal communities has led to further refinement of the tools and processes used in chronic illness self-management programs for Aboriginal people and to greater acceptance of these processes in the communities involved. Participation in a diabetes self-management program run by Aboriginal Health Workers assists patients to identify and understand their health problems and develop condition management goals and patient-centred solutions that can lead to improved health and wellbeing for participants. While the development of self-management tools and strategies led to some early indications of improvements in patient participation and resultant health outcomes, the pilot program and the refinement of new assessment tools used to assist this process has been the significant outcome of the project. The CDSM process described here is a valuable strategy for educating and supporting people with chronic conditions and in gaining their participation in programs designed to improve the way they manage their illness. Such work, and the subsequent health outcome research planned for rural regions, will contribute to the development of more comprehensive CDSM programs for Aboriginal communities generally.

Is client-centred care planning for chronic disease sustainable? Experience from rural South Australia

This qualitative evaluation of a chronic disease self-management project in rural South Australia considers the sustainability of client-centred care planning under current organisational and funding arrangements. The study involved consultation with a range of five stakeholder types over two stages (40 in the beginning stage and 39 in the middle stage) about their satisfaction with the care planning and self-management approach used in the project. All stakeholder types valued the client-centred approach because they perceived that clients were better able to accept and deal with the long-term management of their condition. However, this required that care planning should deal with a wider range of issues than just medical management, and so it took longer, which raised its sustainability in general practice under the current funding through the national health insurance programme (Medicare). The study concludes that sustainability may be addressed through further research into the role of and funding for peer-led self-management groups and the employment of care planners in organisational settings that are conducive to a client-centred approach.

Self-management support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes

The Sharing Health Care SA chronic disease self-management (CDSM) project in rural South Australia was designed to assist patients with chronic and complex conditions (diabetes, cardiovascular disease and arthritis) to learn how to participate more effectively in the management of their condition and to improve their self-management skills. Participants with chronic and complex conditions were recruited into the Sharing Health Care SA program and offered a range of education and support options (including a 6-week peer-led chronic disease self-management program) as part of the Enhanced Primary Care care planning process. Patient self-reported data were collected at baseline and subsequent 6-month intervals using the Partners in Health (PIH) scale to assess self-management skill and ability for 175 patients across four data collection points. Health providers also scored patient knowledge and self-management skills using the same scale over the same intervals. Patients also completed a modified Stanford 2000 Health Survey for the same time intervals to assess service utilisation and health-related lifestyle factors. Results show that both mean patient self-reported PIH scores and mean health provider PIH scores for patients improved significantly over time, indicating that patients demonstrated improved understanding of their condition and improved their ability to manage and deal with their symptoms. These results suggest that involvement in peer-led self-management education programs has a positive effect on patient self-management skill, confidence and health-related behaviour.

Bihemispheric-tDCS and upper limb rehabilitation improves retention of motor function in chronic stroke: A pilot study

Background: Single sessions of bihemispheric transcranial direct-current stimulation (bihemispheric-tDCS) with concurrent rehabilitation improves motor function in stroke survivors, which outlasts the stimulation period. However few studies have investigated the behavioral and neurophysiological adaptations following a multi-session intervention of bihemispheric-tDCS concurrent with rehabilitation. Objective: This pilot study explored the immediate and lasting effects of 3-weeks of bihemispheric-tDCS and upper limb (UL) rehabilitation on motor function and corticospinal plasticity in chronic stroke survivors. Methods: Fifteen chronic stroke survivors underwent 3-weeks of UL rehabilitation with sham or real bihemispheric-tDCS. UL motor function was assessed via the Motor Assessment Scale (MAS), Tardieu Scale and grip strength. Corticospinal plasticity was indexed by motor evoked potentials (MEPs), cortical silent period (CSP) and short-interval intracortical inhibition (SICI) recorded from the paretic and non-paretic ULs, using transcranial magnetic stimulation (TMS). Measures were taken at baseline, 48 h post and 3-weeks following (follow-up) the intervention. Results: MAS improved following both real-tDCS (62%) and sham-tDCS (43%, P < 0.001), however at 3-weeks follow-up, the real-tDCS condition retained these newly regained motor skills to a greater degree than sham-tDCS (real-tDCS 64%, sham-tDCS 21%, P = 0.002). MEP amplitudes from the paretic UL increased for real-tDCS (46%: P < 0.001) and were maintained at 3-weeks follow-up (38%: P = 0.03), whereas no changes were observed with sham-tDCS. No changes in MEPs from the non-paretic nor SICI from the paretic UL were observed for either group. SICI from the non-paretic UL was greater at follow-up, for real-tDCS (27%: P = 0.04). CSP from the non-paretic UL increased by 33% following the intervention for real-tDCS compared with sham-tDCS (P = 0.04), which was maintained at 3-weeks follow-up (24%: P = 0.04). Conclusion: bihemispheric-tDCS improved retention of gains in motor function, which appears to be modulated through intracortical inhibitory pathways in the contralesional primary motor cortex (M1). The findings provide preliminary evidence for the benefits of bihemispheric-tDCS during rehabilitation. Larger clinical trials are warranted to examine long term benefits of bihemispheric-tDCS in a stroke affected population.

Quantitative electroencephalographic comodulation : an investigation of patterns in chronic fatigue syndrome

Introduction. This is a pilot study of quantitative electro-encephalographic (QEEG) comodulation analysis, which is used to assist in identifying regional brain differences in those people suffering from chronic fatigue syndrome (CFS) compared to a normative database. The QEEG comodulation analysis examines spatial-temporal cross-correlation of spectral estimates in the resting dominant frequency band. A pattern shown by Sterman and Kaiser (2001) and referred to as the anterior posterior dissociation (APD) discloses a significant reduction in shared functional modulation between frontal and centro-parietal areas of the cortex. This research attempts to examine whether this pattern is evident in CFS. Method. Eleven adult participants, diagnosed by a physician as having CFS, were involved in QEEG data collection. Nineteen-channel cap recordings were made in five conditions: eyes-closed baseline, eyes-open, reading task one, math computations task two, and a second eyes-closed baseline. Results. Four of the 11 participants showed an anterior posterior dissociation pattern for the eyes-closed resting dominant frequency. However, seven of the 11 participants did not show this pattern. Examination of the mean 8-12 Hz amplitudes across three cortical regions (frontal, central and parietal) indicated a trend of higher overall alpha levels in the parietal region in CFS patients who showed the APD pattern compared to those who did not have this pattern. All patients showing the pattern were free of medication, while 71% of those absent of the pattern were using antidepressant medications. Conclusions. Although the sample is small, it is suggested that this method of evaluating the disorder holds promise. The fact that this pattern was not consistently represented in the CFS sample could be explained by the possibility of subtypes of CFS, or perhaps co-morbid conditions. Further, the use of antidepressant medications may mask the pattern by altering the temporal characteristics of the EEG. The results of this pilot study indicate that further research is warranted to verify that the pattern holds across the wider population of CFS sufferers.