Expanding access to rehabilitation using mobile health to address musculoskeletal pain and disability

Introduction Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic. Methods This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone (mHealth) to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability. Results Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan. Conclusion The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability

Nutritional status and weight gain in patients with pulmonary tuberculosis in Tanzania

We assessed nutritional status in 200 adult Tanzanian patients with smear-positive pulmonary tuberculosis before, during, and after 6 months of tuberculosis treatment; 148 patients (74%) were successfully followed for 12 months. Marked nutritional impairment was present on admission: 77% of males and 58% of females had a body mass index (BMI) below 18.5; approximately one-fifth had BMI &lt; 16.0. The length of hospital stay and gender, rather than microbiological response, were the major determinants of weight gain during treatment. Patients infected with human immunodeficiency virus (HIV) gained more weight than uninfected patients. Most patients lost weight after completing treatment and returning home. At 12 months, dB 32% of male and 19% of female patients considered cured of tuberculosis had BMI &lt; 18.5. It is concluded that patients with tuberculosis from this area of Tanzania frequently have evidence of malnutrition both before and after treatment for tuberculosis. Weight gain during therapy appeared to be an unreliable indicator of overall treatment response. However, the results also demonstrated that nutritional rehabilitation can be successfully achieved even in HIV-positive tuberculosis patients and in patients with a suboptimal response to therapy.</p

Nutritional status and weight gain in patients with pulmonary tuberculosis in Tanzania

We assessed nutritional status in 200 adult Tanzanian patients with smear-positive pulmonary tuberculosis before, during, and after 6 months of tuberculosis treatment; 148 patients (74%) were successfully followed for 12 months. Marked nutritional impairment was present on admission: 77% of males and 58% of females had a body mass index (BMI) below 18.5; approximately one-fifth had BMI &lt; 16.0. The length of hospital stay and gender, rather than microbiological response, were the major determinants of weight gain during treatment. Patients infected with human immunodeficiency virus (HIV) gained more weight than uninfected patients. Most patients lost weight after completing treatment and returning home. At 12 months, dB 32% of male and 19% of female patients considered cured of tuberculosis had BMI &lt; 18.5. It is concluded that patients with tuberculosis from this area of Tanzania frequently have evidence of malnutrition both before and after treatment for tuberculosis. Weight gain during therapy appeared to be an unreliable indicator of overall treatment response. However, the results also demonstrated that nutritional rehabilitation can be successfully achieved even in HIV-positive tuberculosis patients and in patients with a suboptimal response to therapy.</p

Evaluation of the safety and efficacy of micronized halofantrine in the treatment of semi-immune patients with acute, Plasmodium falciparum malaria

The efficacy of the standard formulation of halofantrine hydrochloride has been compromised by the formulation's irregular bio-availability. A micronized preparation of the drug has now been evaluated in the treatment of malaria in northern Tanzania. Overall, 100 patients with mild to moderate Plasmodium falciparum malaria were recruited and treated with the preparation over 18 h. Those weighing &gt; 40 kg were each given three, 500-mg doses and those weighing less were given roughly equivalent doses/kg. The 95 evaluable patients were all successfully treated, with a mean fever-clearance time of 22.5 h (range 4-76 h) and a mean parasite-clearance time of 35.6 h (range 15-66 h). There were no relapses. Abdominal pain was the commonest adverse event reported (22 cases). A single patient died suddenly in the recovery phase; the cause of this event was not determined. Further studies are required to evaluate the pharmacokinetics of the halofantrine formulation under field conditions.</p

Evaluation of the safety and efficacy of micronized halofantrine in the treatment of semi-immune patients with acute, Plasmodium falciparum malaria

The efficacy of the standard formulation of halofantrine hydrochloride has been compromised by the formulation's irregular bio-availability. A micronized preparation of the drug has now been evaluated in the treatment of malaria in northern Tanzania. Overall, 100 patients with mild to moderate Plasmodium falciparum malaria were recruited and treated with the preparation over 18 h. Those weighing &gt; 40 kg were each given three, 500-mg doses and those weighing less were given roughly equivalent doses/kg. The 95 evaluable patients were all successfully treated, with a mean fever-clearance time of 22.5 h (range 4-76 h) and a mean parasite-clearance time of 35.6 h (range 15-66 h). There were no relapses. Abdominal pain was the commonest adverse event reported (22 cases). A single patient died suddenly in the recovery phase; the cause of this event was not determined. Further studies are required to evaluate the pharmacokinetics of the halofantrine formulation under field conditions.</p

Clinical Features and Serum β₂-Microglobulin Levels in HIV-1 Positive and Negative Tanzanian Patients with Tuberculosis

Serum β2-microglobulin (β2M) rises in the later stages of HIV disease and has therefore been used to monitor progression to AIDS. However, little work has been done on patients co-infected with HIV and tuberculosis. We studied clinical features and serum β2-M in 35 Tanzanian patients treated for pulmonary tuberculosis (9 HIV-positive, 26 HIV-negative). The provisional WHO clinical definition of AIDS for use in Africa was fulfilled by 89% of the HIV-positive and 65% of the HIV-negative patients. Median serum β2-M on admission was slightly higher in HIV-positive (3.17 mg/l) than in HIV-negative (2.85 mg/1) patients. Serum β2-M fell during treatment in 17/24 (71%) of HIV-negative and 3/7 (43%) HIV-positive patients followed up for 6 months. We conclude that serum β2-M is frequently raised in active tuberculosis, and is therefore an unreliable indicator of the stage of HIV disease in co-infected patients. The WHO clinical definition of AIDS also proved unreliable in patients with tuberculosis.</p