70 F I S I O T E R A P I E SEPTEMBER 1980 THE VALUE OF A HOME TREATMENT PROGRAMME FOR PAEDIATRIC PATIENTS WITH RESPIRATORY DISORDERS L. S C H E E P E R S , A. K N O E T Z E , V. M. P IE T E R S E * SU M M AR Y T o establish the effica cy o f a hom e trea tm en t pro­ gram m e, tw o groups o f short-term patients, aged 1 m onth -1 1 years, hospitalised fo r com plications o f res­ piratory disorders or chronic respiratory disorders, were studied. B oth groups received intensive physiotherapy during hospitalisation, but only in the experim ental group were parents counselled and a hom e treatm ent program m e taught. On com paring readm ission figures for the experim ental and control groups, there was a statistically significant differen ce a t both 5% and 1'% levels, using the chi-square test. INTRO DUCTIO N ■■ “ In the case o f the child w ith chronic resporatory illness it is essential th at parents be tau g h t techniques for draining and aerating the lungs and clearing the upper respiratory tract, so th a t treatm en t com m enced and supervised by the physiotherapist continues regu­ larly a t hom e. T h e teaching of parents is often difficult and tim e-consum ing, b u t w ithout their w ell-trained help no regime o f treatm en t will be successful.” (Shepherd, 1974). T eaching the p aren t an effective hom e treatm en t program m e is very tim e-consum ing and is therefore usually neglected. In this paper we have described a p ro ject w hich was carried out to determ ine th e value of such a program m e to th e patient, to his parents and to the hospital staff. R espiratory disorders are som e o f the com m onest causes o f death in the infant and young child. T hese disorders result from varying causes, viz. infection, co n ­ genital abnorm alities and genetically determ ined diseases. T his project, however, co ncentrates on the disorders w hich w ould possibly have been prevented if proper and effective treatm en t had been executed, i.e. b ro n ­ chiolitis, broncho-pneum onia, bronchitis and asthm a. T h e prim ary problem m ay exist in the upper respira­ tory tra c t w ith infection spreading from a chronic * B.Sc. Physiotherapy student project 1978. U niversity of Stellenbosch, P.O . Box 63, Tygerberg 7505. Received 16 July 1980. OPSOM M ING O m die doelm atigheid van ’n tuisbehandelingspro- gram vas te stel, is tw ee groepe ko rtterm yn pasiente, ouderdom 1 m a a n d -1 1 jaar, w at gehospitaliseer is vir kom pU kasies van respiratoriese siektes o f kroniese respi- ratoriese siektes, bestudeer. Beide groepe h e t intensiewe fisioterapie ontvang gedurende hospitalisasie, maar slegs in die geval van die eksperim entele groep is m e t ouers beraadslaag en ’n tuisbehandelingsprogram aangelers B y vergelyking van hertoelatingssyfers vir die eksp& 1 m en tele en kontrolegroepe, is ’n statistics betekenisvotle yerskil gevind by beide 5% en 1% vlakke, deur gebruik te m aak van die chi-kw adraat toets. sinus infection, or following a com m on cold. I t may also exist in the low er respiratory tra c t follow ing an infection of the trachea, or occurring as p a rt of a generalized inflam m ation of the airways. All o f these disorders m ay be fatal if the p aren ts do not u n derstand the vital necessity of early treatm ent. I f they receive sufficient counselling and advice to carry ou t an effective treatm en t during the stage of increased secretions, they can do m uch to prevent the progression of these disorders. REASONS FOR IN STITUTING A HOME T REATM ENT PROGRAM M E Preventative care: O T o prevent com plications through early and effec­ tive treatm ent. In fan ts and young children are usually hospitalized as a result o f th e com plica­ tions o f the respiratory disorders, e.g. atelectasis and infection. T hese com plications occur because it is difficult fo r the in fan t and young child to clear bronchial obstructions due to its hyperiry'- bile th o rax and underdeveloped m uscular c o n t ' W ith effective postural d rainage such com plica­ tions can be prevented (Fig. 1) (Shepherd, 1974). • T o avoid the adverse psychological effects o f hos­ p italizatio n on the child. C hildren w ho suffer from disorders of the respiratory tract are o ften of an anxious n ature. T his anxiety is obviously increased in a strange hospital environm ent w ithout the reassurance of the m o th er’s presence. Increased secretions A irw ay o bstruction ->■ A telectasis distal to obstruction ♦ | * In fection of stagnant secretions in collapsed segm ent _______ ^ ^ ________ If pulm onary disease progresses beyond this p oint th ere is a danger o f irreversible changes w ithin th e lungs Physical treatm en t aim s at preventing the progression of pulm onary disease a t this p oint Fig. 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) SEPTEMBER 1980 P H Y S I O T H E R A P Y 71 © To educate the parents: • T o understan d as fa r as possible and execute the various therapeutic m anoeuvres. T hey can then play a role in helping to p rom ote th e norm al functioning o f the child and preventing fu rth er deterioration of the condition. Exercises m ust be sim ple yet effective. • T o learn and accept the lim itations placed on the child by the handicap, so preventing th em from dem anding too m uch from the child. • T o understand the im portance o f continuing tr e a t­ m ent at home. • To recognise any d eterio ratio n in the ch ild ’s con­ dition so th a t early m edical intervention can take place. To fulfil the following psycho-dynamic or counselling tasks: • To help the p a re n t accept the child em otionally and to adjust to its handicap. R ejection o f the child will have a d etrim ental effect on the child’s progress. • T o provide th e p aren t w ith em otional su p p o rt and reassurance, p articu larly w hen the p ro g re sse s slow and the treatm en t is o f a long-term nature. • T o reduce the p aren ts’ anxiety ab o u t the child and their fears for h im /h e r being h urt when they help him. • To instil in the parents a realistic sense of co n ­ fidence concerning th eir ch ild ’s fu tu re potential. Confidence felt by the parents is com m unicated to the child and is of p rofound value in m otivating the child to p articip ate fully in treatm ent. • To m otivate the p aren ts to work diligently together w ith the child on th e hom e treatm en t program m e. • T o provide the parents w ith the oppo rtu n ity to discuss freely any problem s th a t they are expe­ riencing w ith the child. • T o bring the parents to the realization th at only a p a rt of the child’s tre a tm e n t takes place in the hospital. T h e m ajo r p a rt o f the treatm en t regime m ust take place in the home. To include the parents in the treatment team: • Physiotherapists are often involved in their own little world of physiotherapy and fail to allow m em bers of th e p a tie n t’s fam ily to aid actively in the treatm ent regim e. Provided th at counselling is adequate, the p aren t will be m otivated to tre a t the child effectively and will o b tain great satisfaction from this. To save valuable treatment time and unnecessary expense: • I t is som etim es im possible for the parents to bring the child to the o u t-p atien t d ep artm en t fo r regular treatm ent due to factors such as distance, transport problem s, lack of m oney and lack o f tim e (the m other is w orking), etc., so th a t it is essential for the child to receive treatm en t at home. ® T he hospitalisation period o f a long-term p atien t can be shortened considerably when th e p aren t carries on w ith the treatm en t at hom e. A t the time of w riting (1978), the running cost of a teaching hospital bed was R 53,78 per day. H ospital expenses can be kept to a m inim um by reducing the hospitalisation period. METHOD Short-term patients (between the age o f 1 m onth and years) hospitalised for com plications from their res­ piratory disorders and also those w ith chronic resp ira­ tory disorders were selected for the study. They were divided into an experim ental and a control group. T he experim ental group received intensive physiotherapy treatm en t during their stay in hospital and the parents were educated as to an effective hom e treatm ent regime. T he control group received intensive physio­ therapy treatm en t during hospitalisation only. T h e selection o f the groups was done p roportionally so th a t the two groups were equal and to prevent bias influencing the results. T h e advantage o f selecting sh o rt­ term p atien ts was th at the g reater p art o f th e treatm en t w ould have to be on an o u t-p atien t basis o r as a hom e treatm en t program m e. A lthough the parents were seen only once or twice there was enough tim e to educate and assist them . Sim ple equipm ent such as th at which they w ould have a t hom e, i.e. chairs, blankets, etc., were used w hen dem onstrating the treatm en t regim e. T h e treatm en t program m e was standardized w ith em phasis on the most im p o rtan t techniques for each disorder. T he p aren ts were taught to use postural drainage, percussion and vibration techniques, breathing and coughing exercises, relaxation m ethods, “ nose-drill” and general fitness exercises. G eneral advice was also given. E very p atien t was categorized according to age, dis­ order and date o f hospitalisation. A fter a period of 3 m onths (M ay to July 1978) a follow -up study was done to determ ine the frequency of re-ad m ittan ce to hospital. R ESU LTS T h e n u m b er o f children re-adm itted to h ospital fo r the sam e condition or a com plication thereof, was recorded (Fig. 2). “ F req u en cy ” indicates the num ber o f tim es re ­ adm itted, “ ch ild ren ” the num ber o f children re-adm itted. E xp erim en ta l group (those w ith a home treatm en t program m e) C ontrol group (those w ith o u t a hom e treatm en t program m e) Frequency 0 1 2 3 4 5 T otal C hildren 23 4 1 1 1 0 30 Frequency 0 1 2 3 4 5 T otal C hildren 8 10 8 1 2 1 30 Fig. 2 B efore the experim ent was started th e following hypothesis was p ro p ag ated : “T h ere is no difference betw een the experim ental and th e control gro u p ” . If this hypothesis proved incorrect, th e assum ption could be m ade th at hom e treatm en t program m es were a suc­ cess. T h e chi-square test was used to com pare th e two groups and the theoretical distribution depended on the assum ption th a t th e frequency o f re-ad m ittan ce was co­ incidental and th a t there was no difference w hatsoever betw een the tw o groups of patients. T h e acquired x s > criticalx" at both th e 5% and 1% levels. (Fig. 3.) T h e negative hypothesis was th erefore not acceptable and a significant difference betw een the two groups was evident. T he percentage of children re-adm itted to hospital was 23,3% in the case of the experim ental group and 73,3% in th e case of the control group. C O N C L U SIO N A hom e treatm en t program m e could be o f great benefit to everyone involved. T h e child could be saved R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 72 F I S I O T E R A P I E SEPTEMBER 1980 E x p erim ental group C ontrol group Class / f f - r ( f - r y Cf - f f f 0 23 15,5 7,5 56,25 3,63 1 - 2 5 11,5 - 6 , 5 42,25 3,68 3 + 2 3 - 1 1 0,33 0 8 15,5 - 7 , 5 56,25 3,63 1 - 2 18 11,5 6,5 42,25 3,68 3 + 4 3 1 1 0,33 ef = 60 e/1 60 15,28 / = actual freq u en cy o f re-adm ittance f = theoretical frequency of re-adm ittance x ' = 15,28 (acquired chi-square). D egrees of freedom = 2. C ritical 5% level = 5,991. 1 % level = 9,210. from unnecessary psychological and physical trau m a during recu rren t periods of hospitalisation and the fam ily will be spared unnecessary expense. E very physiotherapist should th erefore m otivate th e p a re n t of such a child to becom e a m em ber o f th e team . References 1. Burgess, J. (1965). T h e m anagem ent o f sick children in hospital from th e physiotherapist p oint o f view. P hysiother., 51. 183 -186. 2. G oldin, C. J. (1965). T h e physical therapist as p aren t Fig. 3 counsellor: an em erging role. Phys. Ther., 45, 6 7 § T 682. ? - 3. H obson, E. P. G . (1961). Physical therapy in relation to th e disabled p atient and the hom e. P hysiother., 47, 133- 135. 4. Porter, A. L. (1967). Physiotherapy in the treatm en t o f b ro n ch io litis and bro n ch o p n eu m o n ia in babies and young children. P hysiother., 53. 333 - 335. 5. R eynolds, R . J. S. (1975). P aed iatric physiotherapy in th e past 25 years. Physiother., 61, 106 - 108. 6. Shepherd, R . (1974). Physiotherapy in Paediatrics. A lden and M ow bray. O xford. T R E A T M E N T N O T E : SHORTWAVE DIATHERMY (S.W.D.) IN THE TREATMENT OF UNRESOLVED PNEUMONIA S. H. M. B L A C K W O O D , M .C.S.P., Dip. T.P.* OPSOM M ING D it is gevind dat p n eum onie in die konsolidasie stadium e ffe k tie f behandel kan word m e t kortgolfdiaterm ie om sodoende resolusie aan te help. Som m ige chroniese borskwale, byvoorbeeld asma en em fiseem , vind ook hierby baat. 'n D eur-en-deur aanw ending word gebruik en asem halingsoefeninge m o et altyd daarm ee saam ge- doen word. How m any physiotherapists know the fru stratio n of treating a p neum onia w hich refuses to resolve. In spite o f chem otherapy, postural drainage, percussion, shaking and vibrations, rib-springing, breathing exercises and the p a tie n t’s ow n activity, back come the chest ra d io ­ graphs still show ing th a t resolution has no t occurred. M any years ago, w hen all efforts to clear up a p neum onia in a p atien t who was herself a d octor had failed, it was decided to try shortw ave diatherm y. T he p atien t was in term itten tly febrile and chronically unwell. T h e resistant p atch of inflam m ation was situated in the a n terio r segm ent of the right lower lobe. A pplication was through-and-through this area w ith a large m alleable electrode placed posteriorly and a m edium glass electrode placed anterio rly with close spacing. Initially fo u r m ild therm ic treatm en ts o f fifteen m inutes d u ratio n were given tw ice a day fo r tw o days. T he patient was sent for chest radiographs which show ed a m arked red u ctio n in th e size o f the inflam m atory patch. A fu rth er six treatm en ts were given in exactly the sam e, way fo r th e next th ree days. A t th e com pletion of tW course th e chest radiographs were clear and the patiA*.' was feeling well. As a consequence, over the years SW D has been used routinely by m e and now in m y practice for unresolved pneum onia. A pplication has alw ays been as described, the electrom agnetic field being directed as n early as possible through the area o f inflam m ation. I t has been found, however, th a t one daily tre a tm e n t of tw enty m inutes’ d u ratio n is equally effective. A m axim um of six to eight treatm ents should be given. I f there is no change in the size of the pulm onary opacity, then som e o ther lesion is present, possibly sinister, and th e p atien t should be referred for fu rth er investigation. C heck radiographs should be carried out after th ree o r four treatm ents an d if th ere is seen to be an increase in the size of th e opacity th en treatm en t should be stopped im m ediately. As a fu rth e r consequence SW D was tried fo r som e o th er chronic resp irato ry disorders and found to be useful in th e treatm en t o f em physem a, asthm a and chronic bronchitis. I t is N O T used, how ever, in the * P rivate P ractice, W estville, N atal. R eceived 16 Ju ly 1980. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )