PLATFORM PRESENTATIONS—SESSION 1: ONCOLOGY PART 1
Friday January 25, 2019. 11AM – 1PM
Walter E. Washington Convention Center – Platform Area 3
TISSUE DIELECTRIC CONSTANT MEASURES ON THE TRUNK IN WOMEN FOLLOWING BREAST CANCER SURGERY
PURPOSE/HYPOTHESIS: Women are at risk of developing lymphedema in the ipsilateral upper extremity or trunk following breast cancer surgery with axillary lymph node removal.1 Diagnosis of trunk lymphedema relies on a physical assessment because there is no standardized methods to quantify trunk lymphedema.2 Tissue dielectric constant (TDC) measures localized tissue water content.3 Recent literature demonstrated the potential of using TDC to quantify breast and trunk lymphedema following breast cancer surgery with lymph node removal.4-5 The purpose of this study was to 1) compare TDC measures on the trunk to a physical assessment for trunk lymphedema following breast cancer surgery, and 2) investigate TDC's potential ability to detect the early onset of trunk lymphedema.
NUMBER OF SUBJECTS: 32
MATERIALS/METHODS: Tissue dielectric constant (TDC) was measured bilaterally on the lateral trunk wall at 2, 4, and 12 weeks and 18 months post-surgery in women undergoing surgical breast cancer treatment with one or more axillary lymph nodes removed. A TDC ratio was calculated (TDC ipsilateral/TDC contralateral = TDC ratio). Physical assessment for trunk lymphedema was assessed at 18 months. Correlation coefficients and a two sample t-test compared TDC measures in women with and without lymphedema identified by physical assessment at 18 months. A repeated measures ANOVA was used to analyze the change in TDC measures between groups over time. The area under the curve (AUC) investigated the accuracy of TDC ratios.
RESULTS: There was a significant correlation between TDC ratios and physical assessment. The TDC ratios were statistically higher in the Trunk Lymph group than the No Trunk Lymph group at 18 months. The TDC ratios on the lateral chest wall in the Trunk Lymph group were significantly higher than those in the No Trunk Lymph group collapsed across time. Trunk TDC ratios significantly declined over time in both groups. The AUC demonstrated moderate accuracy in using TDC measures.
CONCLUSIONS: TDC is able to quantify trunk lymphedema following breast cancer surgery and may be valuable in the early detection of trunk lymphedema.
CLINICAL RELEVANCE: TDC appears to be a useful device in the assessment of trunk lymphedema following breast cancer surgery with lymph node removal and could be used as an adjunct to physical assessment. Physical therapists with lymphedema training should continue to rely on their experience and expertise in making lymphedema assessments and treatment decisions until further research is performed to determine the clinical utility of TDC measures.
UPPER EXTREMITY REGIONAL SWELLING PHYSICAL FUNCTION MEASURE: DEVELOPMENT, CALIBRATION, AND INITIAL VALIDATION
Deutscher D, Cook K, Kallen M, Hayes D, Werneke MW, Mioduski J
PURPOSE/HYPOTHESIS: To develop item response theory (IRT)-based calibration of an item bank to measure physical function of patients with regional swelling affecting upper-extremity activities and to evaluate the validity of its derived scores.
NUMBER OF SUBJECTS: Patients with regional swelling affecting upper extremity function who started an episode of care during 2017 or 2018 and responded to 27 items at admission to rehabilitation therapy [N = 1,371; 93% female; mean age (SD) = 60.1 (12.6); minimum to maximum age = 19 to 89].
MATERIALS/METHODS: Development of a pool of candidate items was guided by reviews of the literature and input by a panel of 30 physical and occupational therapists with expertise in caring for patients with lymphedema and other forms of regional swelling. Unidimensionality was assessed via exploratory and confirmatory factor analyses; item-to-adjusted total score correlations helped determine item-level validity and monotonicity, and inter-item response consistency was evaluated with Cronbach's alpha and person reliability estimates. Results guided selection of a final item set meeting IRT assumptions. Item calibration was then conducted using the Andrich Rating Scale Model, a Rasch model appropriate for items with ordinal response options. Floor and ceiling effects were calculated, and potential item bias was investigated by differential item functioning (DIF) analyses. Construct validity was evaluated based on known-groups for gender, acuity, exercise and surgical history, related medication use, and number of comorbidities, controlling for age.
RESULTS: After deleting 4 items not meeting IRT assumptions, response data from 23 items were judged to be essentially unidimensional and locally independent [e.g., Factor 1 explained 74% of variance; the ratio of variance explained by Factors 1-to-2 was 14, and only 3 pairs of residual correlations were > |0.20| (all negative)]. Cronbach's alpha and person reliability were high (0.94−0.96), as were item-to-adjusted total correlations (mean = 0.78). The percentages of scores at floor (0-5 points) and ceiling (95-100 points) were 0.15% and 7.2%, respectively. Item difficulty hierarchical structures were highly consistent across age group, sex, and acuity, indicating negligible DIF. All factors assessed for known-groups validity were significant (P < 0.02) and differentiated patient groups in clinically logical ways.
CONCLUSIONS: The 23-item Upper Extremity Regional Swelling (UERS) measure met IRT assumptions and was internally consistent. Construct validity was supported. A minor ceiling effect could be ameliorated with the addition of more difficult items. The UERS item bank was found to be psychometrically sound and appropriate for computer adaptive test administration to minimize patient burden.
CLINICAL RELEVANCE: This is the first IRT-based measure designed to assess FS of patients with UERS, offering clinicians a tool that could improve management of common physical function deficits.
INITIAL RELIABILITY, VALIDITY AND CLINICAL EFFICIENCY OF THE LYMPHATECH SYSTEM TO ASSESS ARM VOLUME IN PATIENTS DURING AND AFTER TREATMENT FOR BREAST CANCER
Binkley J, Weiler M, Frank N, Bober L, Dixon BJ
PURPOSE/HYPOTHESIS: There are significant diagnostic challenges related to the accurate, efficient and cost-effective measurement of lymphedema in breast cancer patients. The LymphaTech 3D Imaging System (LymphaTech System) is a novel mobile-based and non-invasive platform that provides limb geometry measurements. The system consists of an infrared depth camera interfaced with a smartphone or tablet computer. Custom software captures three-dimensional depth data on a mobile device, such as an iPad, and processes the data to create a 3-dimensional image of the limb that is analyzed to produce the limb volume. The purpose of this study was to assess the reliability, construct validity and clinical feasibility of LymphaTech to measure arm volume in breast cancer patients.
NUMBER OF SUBJECTS: 90 breast cancer patients.
MATERIALS/METHODS: The setting was a specialty breast cancer rehabilitation clinic and the study was approved by the LymphaTech Institutional Review Board. Patients with stage I-IV breast cancer were eligible for inclusion at any point during or after breast cancer treatment. All patients had lymphedema or were at risk for developing lymphedema. Informed consent was obtained. Arm volume was measured in 90 patients using the LymphaTech and Perometer methods. While not a gold standard, the Perometer is considered one of the most accurate methods of measuring arm volume. Two measures of arm volume were obtained for each arm using each device in a single session. Measurements were length-matched between the devices. Intraclass correlation coefficients (ICC) were used to estimate intra-rater reliability of each method of measurement. A Pearson correlation between LymphaTech and Perometer measures was used to examine construct validity of the LymphaTech system. The average time to complete each measure was determined on a subgroup of patients.
RESULTS: The intra-rater reliability correlations for the LymphTech and Perometer were R = 0.998 [95% lower limit confidence interval (CI) =0.996] and R= 0.997 [95% lower limit CI = 0.993], respectively. Correlations between the LymphaTech System and Perometer measures were high (r = 0.995 [lower 95% CI = 0.990]). The average time to complete a LymphaTech scan and analysis for both arms was less than 3 minutes, similar to a Perometer measure.
CONCLUSIONS: The LymphaTech System demonstrates excellent intra-rater relibility and measures correlate highly with the Perometer. Further investigation related to the validity of the LymphaTech System, particularly when the goal is to detect small volume changes in early lymphedema, would be worthwhile.
CLINICAL RELEVANCE: The LymphaTech portable 3D imaging system provides accurate and reproducible limb volume and circumference measurements in approximately 3 minutes per patient. This portable technology has a potential role in prospective surveillance for lymphedema and in improving the assessment and monitoring of lymphedema in clinical, research and home settings.
CANCER-RELATED FATIGUE CLINICAL PRACTICE GUIDELINE DEVELOPMENT - AN UPDATE
Fisher MI, Harrington SE, Lee J, Malone D, Cohn JC
PURPOSE/HYPOTHESIS: Cancer-related fatigue (CRF), defined as physical, emotional, or cognitive tiredness occurring during the cancer experience but is unrelated to activity, impacts more than 70% of those with cancer. Recognizing CRF is a mandate of the National Comprehensive Cancer Network (NCCN) standards of care. NCCN states that CRF must be screened, assessed and managed according to clinical practice guidelines (CPG). Presently, while several CPGs for CRF are published, none are specific to rehabilitation. The purpose of this presentation is to provide preliminary results of the development of a CPG for screening and assessment of CRF for physical therapy.
NUMBER OF SUBJECTS: Final included number of studies pending.
MATERIALS/METHODS: A broad, exhaustive literature search of Medline/PubMed, CINAHL, OVID, Cochrane Reviews, and Google Scholar using the search terms “cancer related fatigue,” “cancer-related fatigue,” “cancer” AND “fatigue” was completed. Studies of adults with any cancer type, published after 2000, that examined the psychometric properties of screening or assessment methods and were published in the English language were included. Any study which was either an intervention, non-peer reviewed, or with a pediatric population was excluded. Title/abstract and full text screening was completed by a team of five content experts. Critical appraisal of studies was completed using the Scottish Intercollegiate Guidelines Network (SIGN) Checklist for Diagnostic Studies, or the Quality Appraisal of Diagnostic Reliability (QAREL) for Reliability studies. Each study was appraised by two reviewers (one content expert) who were trained and assessed for reliability first. Data extraction for each CRF screening or assessment tool then took place.
RESULTS: The literature search yielded 5,571 studies, after duplicates were removed. After title and abstract review, 238 studies underwent full text screening. Following full text screening, an anticipated 150+ studies will meet inclusion/exclusion criteria and be reviewed for bias assessment and data extraction. Recommendations for use for screening and assessment of CRF among those with cancer will be based on the strength of the evidence.
CONCLUSIONS: Because CRF is a widespread problem among those treated for cancer, and addressing this is mandated by cancer quality organizations, it is essential to utilized evidenced-based methods for screening and assessment. Screening tools need to be efficient to use, while good assessment tools will capture the multidimensional nature of CRF.
CLINICAL RELEVANCE: Accurate and efficient tools to screen for and assess CRF are critical for use with those with cancer. Appropriate screening for the CRF allows for referral to rehabilitation professionals for thorough assessment. The multi-dimensional nature of CRF requires accurate assessment that is comprehensive, such that intervention plans are derived which address the specific impairments and needs of the patient.
ONCOLOGY SECTION EDGE TASK FORCE ON CANCER: A SYSTEMATIC REVIEW OF MEASURES OF FUNCTIONAL MOBILITY AND CAPACITY
Hannah L, Pfalzer LA, Ness KK, Fisher MI
PURPOSE/HYPOTHESIS: The number of cancer survivors in the United States will continue to grow with advancements in early detection and treatment. Physical impairments occur in greater numbers than psychological ones, and these impairments negatively impact functional mobility. A decline in functional mobility can lead to the inability to perform activities of daily living and ultimately reduce health-related quality of life. The purpose of this systematic review was to make evidence-based recommendations on tools and measures for clinical assessment of functional mobility and capacity across all cancers.
NUMBER OF SUBJECTS: Final number of studies included pending.
MATERIALS/METHODS: The primary search strategy was conducted using multiple electronic databases, including; Web of Science, Pubmed/Medline, CINAHL, Ovid, Google Scholar, Sports Discus, Cochrane Review, PEDro, PT NOW, and Academic Search. Studies of functional mobility and cancers had to have reported psychometric properties, be clinically feasible methods, have adult participants, and be published in English. Studies were excluded if they included non-clinical measures of functional mobility, or, balance and fall or cardiopulmonary/aerobic testing methods. The publication dates were limited to 1/1/2008 and after. Each outcome measure was reviewed independently and rated by two reviewers separately using the EDGE (Evaluation Database to Guide Effectiveness) Cancer Rating Scale. If an outcome measure rating was found to be in disagreement between the two reviewers, the disagreement was resolved by discussion with 4 reviewers until agreement was obtained.
RESULTS: Studies were rated using the Cancer EDGE Rating Scale where a rating of 4 is a highly recommended measure with good psychometric properties and clinical utility, and has been used in research on individuals with or post cancer. A rating of 3, recommended, is a measure with good psychometric properties and clinical utility however with no published evidence that the measure has been applied to research on individuals with or post cancer. A rating of 2 implies that there is insufficient information to support a recommendation for the outcome measure. A rating of 1 is assigned to a measure with poor psychometrics and poor clinical utility and is not recommended to use. Preliminary search results yielded a total of 819 studies to be reviewed for inclusion and exclusion criteria. Approximately 211 measures will be reviewed and rated.
CONCLUSIONS: Assessing functional mobility is an important part of cancer survivorship. Many tools exist which accurately and reliably assess functional mobility, activities of daily living, walking, and community participation. Further research is needed to determine if a single, small set of tools can be used across all cancer types.
CLINICAL RELEVANCE: Investigating the impact of functional mobility in all cancer populations helps clinicians identify and address barriers to recovery. Accurate measures provide necessary information to direct the plan of care, and serve to measure effectiveness of intervention.
ONCOLOGY SECTION EDGE TASK FORCE ON CANCER: A SYSTEMATIC REVIEW OF MEASURES OF BALANCE AND FALLS RISK
Huang MH, Coarkin E, Blackwood J, Hile E, Wampler-Kuhn M, Colon G, Pfalzer LA
PURPOSE/HYPOTHESIS: Physical impairments and co-morbidities occur in greater numbers in older cancer survivors and survivors with advanced cancer. Cancer survivors fall at higher rates than individuals without cancer and falls often results in serious injury, leading to the difficulty in performing activities of daily living and reduced health-related quality of life. The purpose of this systematic review was to provide healthcare professionals with evidence-based recommendations on tests and measures for clinical assessment of balance and falls risk in adult cancer survivors.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: The primary search was conducted in databases including Pubmed, OVID Medline, CINAHL, EMBASE, SCOPUS, and PT NOW. Study inclusion criteria were balance or fall risk tests and measures, reported psychometric properties, adult participants, all cancer diagnosis, and published in English and between 1/1/2008 to 4/30/2018. Exclusion criteria were tests and measures not for balance and fall risk, pediatric population, case reports or case series, and conference abstracts. Each study was reviewed independently by two reviewers, and each test and measure in included studies was rated by two reviewers separately using the EDGE (Evaluation Database to Guide Effectiveness). Disagreement in review and rating between the two reviewers was resolved by discussion with a 3rd reviewer until a consensus was obtained.
RESULTS: Studies are rated using the Cancer EDGE Rating Scale; a rating of 4 is highly recommended, indicates good psychometric properties and clinical utility, and the measure was used in research on individuals with or post cancer. A rating of 3 is recommended, has good psychometric properties and clinical utility; however, there is no published evidence that the measure was applied to research of cancer survivors. A rating of 2 implies that there is insufficient information to support a recommendation for the measure. A rating of one implies poor psychometrics and clinical utility, and the measure is not recommended to use.
CONCLUSIONS: Assessing balance and falls risk is an important part of cancer survivorship from diagnosis through survivorship. Many measurement tools exist which accurately and reliably assess balance and falls risk and we describe the tools with the highest levels of evidence for measurement in clinical practice. Further research is needed to determine if a single, small set of tools can be used across all cancer types.
CLINICAL RELEVANCE: Investigating the impact of functional mobility in patients across all cancer types help clinicians identify and address barriers to recovery for this population. It is essential to integrate rehabilitation services into the care of the cancer survivors and to have outcome measures to justify the need for physical therapy throughout the continuum of their care.
PREDICTING FALLS IN BREAST, COLORECTAL, LUNG AND PROSTATE CANCER SURVIVORS
Huang MH, Blackwood J, Godoshian M, Grabijas C, Pfalzer LA
PURPOSE/HYPOTHESIS: This study examined older breast, colorectal, lung and prostate cancer survivors' responses to fall-risk screening questions at baseline with relation to falls at follow-up.
SUBJECTS: N = 437 breast, 256 colorectal, 113 lung, and 673 prostate cancer.
MATERIALS/METHODS: The study utilized population-based data, SEER-MHOS (Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey). Each SEER-MHOS cohort was surveyed at baseline and resurveyed two years later. Inclusion criteria were cohorts 9-13, age > = 65 years, primary breast, colorectal, lung and prostate cancer, baseline MHOS completed during years 2-3 post-cancer diagnosis, and follow-up MHOS completed during years 4-5 post-diagnosis. At baseline, survivors were asked: (1) Did you fall in the past 12 months? (2) In the past 12 months, have you had a problem with balance or walking? (3) In the past 12 months, did you talk with your doctor or other health provider about falling or problems with balance or walking? (4) Has your doctor or other health provider done these or anything else to help prevent falls or treat problems with balance or walking? Responses to each question were coded as Yes or No. Baseline covariates were (1) demographics, (2) Veterans RAND 12-Item Health Survey, comorbidity, body-mass-index, and (3) cancer type, time since cancer diagnosis, stage, surgery, and radiation. At follow-up, main outcome was Yes vs. No falls in the past 12 month. Logistic regression was constructed to examine the relationship of each fall-risk question with falls while controlling for covariates. Questions significantly associated with falls were reentered into logistic regression to evaluate the model accuracy in classifying survivors by falls. We calculated accuracy (ACC), sensitivity (Sn), specificity (Sp), positive (LR+) and negative (LR-) likelihood ratios, positive (PPV) and negative (NPV) predictive values for each question in predicting falls. Two-tailed significant level was p <0.05.
RESULTS: Relationships between fall-risk questions and falls differed across cancer diagnoses. The question about a history of falls was significantly associated with falls at follow-up in breast, lung and prostate cancer (ORs = 3.1-5.4, p < 0.01)(ACC = 66%-68%, Sn = 24%-45%, Sp = 92%-96%, LR+ = 5.16-6.28, LR- = 0.56-0.79, PPV = 63%-74%, NPV = 80%-82%). In lung cancer only, all fall-risk questions were significantly associated with falls at follow-up. In colorectal cancer, no fall risk questions was associated with falls.
CONCLUSIONS: Breast, colorectal, and lung cancer survivors' responses to fall-risk questions at baseline were significantly predictive of falls at follow-up. The type of questions linked to falls, however, varied across these cancers. The extent to which fall-risk questions relates to cancer-specific impairments remains to be examined. More research to identify self-reported, fall-risk screening questions is needed in colorectal cancer.
CLINICAL RELEVANCE: Current results provide diagnostic values for fall risks based on screening questions in older breast, lung, and prostate cancer survivors.
CHALLENGING CONTRAINDICATIONS: MODULATION OF BUTTOCK PAIN IN THE PRESENCE OF A BONE METASTASIS
BACKGROUND & PURPOSE: Metastatic skeletal growths interrupt bone homeostasis causing severe bone pain and functional decline. A review of the literature reveals the underutilization of outpatient rehabilitation to manage patients with cancer related bone pain. OMPT is frequently used to modulate musculoskeletal pain, however, there exists a paucity in the research to support the modulation of metastatic cancer pain with manual therapy secondary to the potential risk of incurring pathologic fracture. There are rehabilitation contraindications in the presence of metastatic lesions to reduce incidence of fracture. However, it can be argued this is prematurely assumed risk as not all metastases have equivalent pathologic fracture risk. This case report illuminates the role of OMPT in the modulation of buttock pain in a patient with an ischial bone metastasis.
CASE DESCRIPTION: A 53-year-old female with metastatic breast cancer was referred to physical therapy with recent onset of right deep gluteal pain. Imaging revealed a ipsilateral ischial bone metastasis. Aggravating activities included prolonged sitting, ascending stairs, and walking with a long stride. The pain was constant, yet variable in intensity (Numeric Pain Rating Scale (NPRS) Worst: 6/10; Best: 2/10) and her Lower Extremity Functional Scale score was 68/80. Functional exam revealed pain during terminal stance phase of gait and 6” forward step up. Significant objective findings include symptom reproduction with slump and straight leg raise and hypomobility with passive accessory intervertebral motion at right L4-5. Prone passive and active hip extension was limited and elicited familiar gluteal pain. Strength was appreciated via observation: right gluteus maximus 3-/5 and right hamstrings 3+/5.
OUTCOMES: The patient was seen for 12 visits. Focus of visits 1-7 was OMPT consisting of neural mobilizations, coxafemoral joint mobilizations, and lumbar joint mobilizations. At visit 3, pain was rated 0/10 with functional tests of step up/gait and her Global Rating of Change scale (GROC) was scored at +6 (A great deal better). During visits 4-7, her NPRS remained 0/10 and GROC improved to +7 (very great deal better). Visits 7-12 focused on painfree stabilization. She was able to resume her Zumba and water aerobics as well as walk without pain.
DISCUSSION: This case report demonstrates the potential role for manual therapy and exercise in the modulation of pain in the presence of a metastatic lesion. To date, manual therapy has not been extensively evaluated for it's effect on pain modulation and management in metastatic bone pain. More research is needed to outline safe and efficacious interventions as well as guidelines to determine their utilization.
PLATFORM PRESENTATIONS—SESSION 1: ONCOLOGY PART 2
Friday January 25, 2019. 3PM – 5PM
Walter E. Washington Convention Center – Platform Area 3
EFFECTS OF A 16-WEEK COMBINED EXERCISE INTERVENTION ON PHYSICAL FITNESS AND BODY COMPOSITION IN HISPANIC AND NON-HISPANIC BREAST CANCER SURVIVORS
Sweeney FC, Stewart CF, Sami N, Lee K, Dieli-Conwright CM
PURPOSE/HYPOTHESIS: Hispanic breast cancer survivors (HBCS) have a 1.1-1.5 greater risk of breast cancer mortality when compared to non-Hispanic white breast cancer survivors. Disparities may be due to decreased levels of physical activity, adult weight gain, and increased body mass index in HBCS. The purpose of this study was to examine the effects of a 16-week aerobic and resistance exercise intervention on physical fitness (cardiovascular fitness [CVF] and muscle strength [MST]) and body composition (fat mass [FM] and [LM]) between HBCS and non-Hispanic breast cancer survivors (NHBCS). We hypothesized that HBCS would have significantly lower CVF, decreased MS, and poorer body composition at baseline and would therefore derive greater outcomes from the exercise intervention when compared to NHBCS.
MATERIALS/METHODS: Women diagnosed breast cancer (stage I-III) were randomized to the Control (CON; N = 50) or the Exercise (EX; N = 50) group. The EX group underwent moderate-to-vigorous aerobic and resistance exercise sessions 3 times/week for 16 weeks. CVF was assessed using the 4-minute walk test to estimate
O2max. MS was evaluated by the 10-repetition maximum (RM) protocol to calculate 1-RM for chest press (CP), latissimus pulldown (LP), knee extension (KE) and knee flexion (KF). FM and LM were measured from a whole-body scan using Dual-Energy X-ray Absorptiometry. Linear mixed-models were used to assess effect modification of the intervention by ethnicity as an interaction test.
RESULTS: 57 HBCS and 43 NHBCS with an average age of 53.5 ± 10.4 years and BMI of 33.5 ± 5.5 kg/m2 were included. At baseline, HBCS had significantly lower CVF, MS, and LM, and higher FM compared to NHBCS (p < 0.01). Post-Intervention, the EX group experienced significant improvements in physical fitness and body composition when compared to the CON group (p <0.01). HBCS in the EX group experienced significantly greater improvements in CVF (76% vs NHBCS 34%) and MS (CP- 150% vs NHBCS 67%; LP- 63% vs NHBCS 26%; KE- 106% vs NHBCS 67%; KF- 93% vs NHBCS 42%) when compared to NHBCS in the EX group (p < 0.05). HBCS in the EX group experienced significantly greater reductions in FM (6% vs NHBCS 3%) and improvements in LM (4% vs NHBCS 2%) when compared to NHBCS in the EX group (p < 0.05).
CONCLUSIONS: At baseline, HBCS had significantly lower physical fitness and body composition when compared to NHBCS. A 16-week aerobic and resistance exercise intervention garnered significantly greater benefit in physical fitness and body composition in HBCS when compared to NHBCS.
CLINICAL RELEVANCE: Clinicians working with diverse groups of breast cancer survivors should be aware of disparities surrounding health-related outcomes, including physical fitness and body composition. Physical therapists can implement exercise programs that may attenuate ethnocentric disparities in cancer prognosis.
EFFECT OF A 16-WEEK AEROBIC AND RESISTANCE EXERCISE INTERVENTION ON SHOULDER FUNCTION IN BREAST CANCER SURVIVORS
Yu B, Sweeney FC, Lee K, Sami N, Yamada KA, Dieli-Conwright CM
PURPOSE/HYPOTHESIS: Shoulder impairments are a common, detrimental consequence of several current treatment modalities for breast cancer.1-6 Inadequate shoulder function is associated with a decrease in health-related quality of life (HRQoL).7-8 Exercise mitigates shoulder impairments induced by cancer treatment. Hence, it is critical to explore whether such exercise benefits on shoulder function are associated with improved HRQoL.9-10 This study assessed the effects of a 16-week progressive, aerobic and resistance exercise intervention on shoulder function in breast cancer survivors. Subsequently, we examined whether shoulder function was associated with HRQoL post-exercise intervention. We hypothesized that a progressive, aerobic and resistance exercise intervention significantly improves shoulder function, and that these specific outcomes would be correlated with improved HRQoL.
NUMBER OF SUBJECTS: 100
MATERIALS/METHODS: Breast cancer survivors (Stage I-III) were randomized to the exercise (EX) or control(CON) groups. The EX group underwent supervised, progressive aerobic and resistance exercise sessions 3 times/week for 16 weeks. The CON group was asked to maintain their current level of activity. Shoulder strength and mobility were tested at baseline and within one week of completing the intervention. Shoulder strength was measured using a handheld dynamometer for forward flexion and external rotation. Shoulder mobility was evaluated by measuring degrees of range of motion for shoulder forward flexion and external rotation. HRQoL was assessed using the Functional Assessment of Cancer Therapy for patients with Breast Cancer (FACT-B) questionnaire. Within and between group differences were assessed by paired t-test and repeated measures ANOVA. Pearson's correlation was computed to assess the association between shoulder function and FACT-B in the EX group.
RESULTS: Participants were 53 ± 10.4 years old, primarily overweight (BMI > 25.0 kg/m2; 54%) and Hispanic (63.1%), had undergone a mastectomy (90%) and chemotherapy and radiation therapy (76%). Adherence to the intervention was 95% and post-intervention assessments were available on 91% of participants. Shoulder strength and mobility in the EX group significantly improved from baseline and when compared to the CON group (p < 0.001). Post-intervention, there were no changes in all shoulder measures in the CON group (p > 0.05). Post-exercise, significant correlations were found between shoulder strength, mobility, and FACT-B scores (p < 0.01).
CONCLUSIONS: A progressive aerobic and resistance exercise intervention is an effective way to improve shoulder function in breast cancer survivors. Breast cancer survivors who experience exercise-induced improvements in shoulder function may also experience improved overall HRQoL.
CLINICAL RELEVANCE: Clinicians working with breast cancer survivors should consider the inclusion of a progressive aerobic and resistance exercise program as a treatment option to positively influence not only the musculoskeletal, but also the emotional and psychological well-being of said patients.
RESTING HEART RATE VARIABILITY AND CARDIOVASCULAR DISEASE RISK AMONG FEMALE BREAST CANCER SURVIVORS: A PILOT STUDY
Drouin J, Kennedy K, Sheehan S, Schummer A, Krawczyk M, Murley M, Marks CR
PURPOSE/HYPOTHESIS: Women in breast cancer survivorship (BCS) are at increased risk for cardiovascular disease (CVD). Heart Rate Variability (HRV) is a non-invasive measure of cardiac autonomic dysfunction that predicts CVD risk; however, few studies used HRV to assess CVD risk among women in long term BCS. Therefore, this study determined CVD risk from HRV measures among women in BCS. The study also examined trends in HRV related to age, treatment type, and exercise participation.
NUMBER OF SUBJECTS: Seven females
MATERIALS/METHODS: Following institutional review board approval, data was collected from females [60.9 (8.1) years] who completed cancer treatments between two to 16 years prior to the study. Participants' mean BMI was 29.2 (4.8) kg/m and cancer stages were between 0 (DCIS) and 2B. Cancer treatment regimens were surgery alone (two subjects), surgery and chemotherapy (one subject), and surgery with radiation and chemotherapy (4 subjects). The HRV measure was the 5-minute Standard Deviation (SDNN) of Peak-to-Peak heart rate intervals using a metabolic cart, an electrocardiogram and Biopac MP-150 software (ICC reliability > .96). Two HRV measures were taken in the morning following an overnight fast and exercise abstention the prior day. Subjects rested for 10 minutes prior to testing in a quiet, dimly lit laboratory and breathing rates were standardized using a metronome. The two HRV measures were repeated again within 10 days and the four measures were averaged for the analysis. Differences between HRV measures and predicted norms were assessed using paired samples t-tests with significance set at p < .05. Clinical relevance was determined according to Hillebrand (2013) with the mean millisecond (ms.) difference from the predicted norm being equal to the percent increase or reduction in CVD risk.
RESULTS: Data from six subjects was used to calculate the outcomes, as one subject's data was determined to be an extreme outlier. The mean HRV measure of 39.5 (12.0) ms. was significantly lower (t = 2.78; df = 5; p = .039) compared to the mean predicted HRV of 52.1 (3.3) ms. Clinically, this represents an average 12.6% increase in CVD risk among these subjects. Secondary analyses, found that HRV reductions were not consistently associated with age; however, reductions were associated with radiation and/or chemotherapy compared to surgery alone. HRV also improved with exercise participation.
CONCLUSIONS: This study found that HRV measures were significantly lower than predicted norms and differences represented an increased risk in CVD in this population. A limitation of this study is the small sample size, the 5-minute measurement period, and self-reported exercise participation.
CLINICAL RELEVANCE: Women in long-term breast cancer survivorship have reduced HRV responses that are associated with higher risk for CVD. Study results support the need for cardiovascular screening and healthy lifestyle interventions to reduce CVD risks in this population.
A MODEL OF PHYSICAL THERAPY TO ADDRESS MOBILITY IMPAIRMENTS FOLLOWING STEM CELL TRANSPLANTATION
Barnes C, Sweetser E, Couriel DR, Lee CJ, Noren CS, LaStayo PC
PURPOSE: 1) Expose a need for integrated physical therapy rehabilitation services in standard care for people with hematopoietic stem cell transplant (HSCT) for hematologic cancers, and 2) report on the ongoing implementation of a clinically-integrated physical therapist (CI-PT) in an outpatient bone marrow transplant (BMT) clinic.
DESCRIPTION: A CI-PT embedded in the outpatient BMT clinic team at the Huntsman Cancer Hospital used the Activity Measure for Post-Acute Care outpatient basic mobility short form (AMPAC) to stage patients by self-reported mobility level, and to direct the mode and dosage of CI-PT intervention. 305 consecutive patients were assessed and managed by a CI-PT between October 2016 and August 2017. NIH Consensus Criteria (NIHCC) score, which characterizes the severity of graft-versus-host disease (GVHD), and Karnofsky performance status (KPS) score were collected and correlated with AM-PAC scores, using logistic and panel regressions. Two-minute walk tests (2MW) were also described on a subgroup of 120 patients.
SUMMARY OF USE: Patient-reported and performance-based physical function measures indicated that impairment was common in this population. Among all patients, 1% of AM-PAC scores were in stage 1, 12% were in stage 2, and 50% were in stage 3, indicating difficulty with bed mobility, home mobility, and community mobility, respectively. Mobility limitations appear linked to performance status, and GVHD severity. Patients with moderate or severe GVHD (NIHCC score = 2 or 3) had significantly worse mobility (AMPAC stage 1,2,3) than people with no or mild GVHD (NIHSS = 0 or 1) (Chi-squared statistic = 24.2, p < .001), and people with lower AM-PAC scores had significantly lower KPS scores (r = 0.59, p < 0.001). Patients also experienced a clinically-important decline in 2MW distance immediately post-transplant, with a return to near pre-transplant levels by 100 post-trasnplant days. Mean pre-transplant 2MW distance was 166.2 m, which declined to 145.5 m in the acute (<30 days) post-transplant period, and increased to 159.9m at 100 days post-transplant. Functional monitoring and treatment by a CI-PT was found to be feasible in the outpatient BMT clinic setting, with n = 412 CI-PT treatments performed.
IMPORTANCE TO MEMBERS: Hematologic cancers are a significant health burden in the US, with over 137,000 new cases and 56,000 attributable deaths estimated by the CDC in 2012. HSCT offers the only chance of survival for many people with lymphoma or leukemia, but often leaves patients with permanent loss of physical function. Exercise can moderate the risk of functional loss in people undergoing stem cell transplantation, but, despite guidelines recommending integrated rehabilitation services in standard care for this population, exercise interventions have not been widely adopted in standard clinical practice. The CI-PT model is a clinically pragmatic approach to implementing care guidelines for monitoring and intervention to improve patient physical function, and may be ideal for wide implementation in BMT outpatient clinics.
STENGTH, BALANCE AND GAIT SPEED OF PERSONS UNDERGOING HEMATOPOIETIC STEM CELL TRANSPLANTATION
Swisher A, Burkart M, Peck C, Goff L, Craig M
PURPOSE/HYPOTHESIS: People who undergo cancer treatment are known to have very high risk for functional impairments. However, these risks are rarely systematically assessed and persons who undergo stem cell transplantation are particularly poorly characterized. By performing a standard battery of tests before and at key points following transplant, we aim to identify risk factors and triggers for rehabilitation interventions to prevent falls and maintain optimal functional levels.
NUMBER OF SUBJECTS: Beginning in December 2017, a standard battery of tests was performed for all patients scheduled for stem cell transplant at our institution. To date, 35 individuals (13 female, 22 male, mean age 58 years) have been assessed.
MATERIALS/METHODS: Participants performed balance (Timed Up and Go), functional endurance and gait velocity (2-Minute Walk Test), lower body strength (5 Times Sit-to-Stand), and upper body strength (isometric grip strength) tests during a pre-transplant visit. Performance on all tests was compared to age- and gender-specific norms.
RESULTS: TUG score: mean = 8.17 sec, SD = 2.0 sec. 14 of 33 (42%) scored below predicted values, while 19 of 33 (58%) scored equal to or above norms. 2-minute walk test: mean distance = 149 meters, SD = 28 meters. 13 of 30 (43%) scored below norms, while 17 of 30 (57%) scored at or above norms. Gait velocity: mean 1.24 meters/sec, SD = 0.23 meters/sec. 17 of 33 (52%) scored below norms, while 16 of 33 (48%) scored at or better than norms. 5 Times Sit to Stand: mean = 28.00 sec., SD = 4.04 sec. 26 of 34 (76%) scored below norms, while 9 of 34 (26%) scored equal to or better than norms. Isometric hand grip: mean = 28 kg, SD = 11 kg. 32 of 35 (91%) scored below norms, while 3 of 35 (9%) scored equal to or above norms.
CONCLUSIONS: At baseline, a majority of patients were impaired in upper and lower body strength and gait speed compared to norms for their age/sex. This is likely related to a combination of prior cancer treatment in order to achieve remission prior to transplantation, as well as general deconditioning or low physical activity levels. While fuctional balance and endurance are less impaired, many patients are limited prior to transplant. It is anticipated that the acute stem cell transplantation period will further impair performance and will indicate need for greater involvement of rehabilitation services throughout the treatment and survivorship course. Future work will assess the same functions at standard times following transplantation to determine the effect of baseline status on recovery of function.
CLINICAL RELEVANCE: Data from this project will contribute vital information regarding pre-transplant norms for these patients, as well as identifying key predictors of rehabilitation needs from pre-transplant through survivorship. Based on the large percentage of patients with muscular weakness prior to transplantation, a strengthening program prior to and during the acute transplantation period may be warrented to help minimize deficits and risk of weakness-related mobility problems.
PRE-HOSPITAL FUNCTIONAL STATUS AS AN INDICATOR FOR FUNCTIONAL STATUS POST CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY IN PATIENTS WITH DIFFUSE LARGE B-CELL LYMPHOMA
Miller LM, Ward CM
PURPOSE/HYPOTHESIS: Non Hodgkin lymphoma (NHL) is a heterogeneous disease entity comprising diverse B-cell and T-cell lymphoma subtypes. In 2018, roughly 74,680 people will be diagnosed with NHL and 19,910 will die from the disease.1 Diffuse large B-cell lymphoma (DLBCL) is the most common form of B-cell NHL. The use of chimeric antigen receptor (CAR) modified T cells targeting CD-19 expressing tumor cells is emerging as a successful treatment of refractory B-cell lymphoid malignancies. Although this treatment has shown promising effects, including partial and complete responses, it has also been shown to cause serious toxicities.2 The two most common toxicities are cytokine release syndrome (CRS) and CAR T-cell related encephalopathy syndrome (CRES). Symptoms of CRS can include: hypoxia leading to the need for supplemental oxygen or mechanical ventilation, hypotension leading to the need for vasopressor support, and other specific organ toxicities. CRES typically manifests as a toxic encephalopathy causing confusion, agitation, aphasia, somnolence, motor weakness, incontinence, mental obtundation, seizures, and even cerebral edema or increased intracranial pressure. There is limited research documenting changes in functional status, and investigation of this would help guide the physical therapist's management of these patients. Our hypothesis is that the patients with a higher functional status and exercise tolerance upon initiation of CAR T-cell infusions will have better functional outcomes upon discharge.
NUMBER OF SUBJECTS: 12
MATERIALS/METHODS: We performed a retrospective review of patients with DLBCL, who received CAR T-cell infusions at the University of Chicago Medical Center between December 2017 and June 2018, and received a physical therapy consult. We reviewed documentation regarding the subject's functional status, as well as the Boston University Activity Measure for Post Acute Care (AM-PAC) Short Form score upon physical therapy evaluation on admission for CAR T-cell infusion and their functional status and calculated AM-PAC upon discharge.
RESULTS: Our preliminary data review suggests that a patient's functional status upon receiving CAR T-cell infusion is indicative of their functional status upon discharge.
CONCLUSIONS: Though the use of CAR T-cell therapy has shown promising effects in the treatment of DLBCL, it is not without serious side effects. These side effects have the potential to greatly impair functional mobility. Our preliminary data demonstrates that despite diversity in patient demographics, disease burden, and prior treatments, those with greater functional independence prior to receiving CAR T-cell therapy have better functional outcomes at hospital discharge with reduced severity of associated side effects from treatment.
CLINICAL RELEVANCE: Physical therapists can play a role in maximizing functional independence prior to undergoing CAR T-cell therapy to optimize outcomes and can assist in recovering functional mobility for those impacted by the treatment's side effects.
PHYSICAL ACTIVITY ATTITUDES, BEHAVIORS, AND PREFERENCES IN LOW-INCOME INDIVIDUALS WITH CANCER AND THEIR FAMILY CAREGIVERS: A NEEDS ASSESSMENT
Packel L, Dychtwald D, Pontiggia L, Brady K, Coneray K, Hanna M, Ho KH, Lukose A, Morgan A, Pathyil A, Ogbogu O, Barksdale B, Milliron BJ
PURPOSE/HYPOTHESIS: Physical activity (PA) is associated with lower cancer-related fatigue and improved physical and mental health. However, cancer survivors (CS) are not sufficiently active. Low-income CS, especially those with lower education levels, may have inaccurate perceptions of the risks and benefits of PA, impacting their participation. PA also declines for cancer caregivers (CC) who experience a decline in their own health during caregiving. The purpose of this research was to elucidate the role of PA beliefs and behaviors that influence CS and CC intention to improve healthy behaviors.
NUMBER OF SUBJECTS: 31
MATERIALS/METHODS: Using a convergent mixed methods design, individuals with cancer and their caregivers were recruited from American Cancer Society's Philadelphia Hope Lodge to complete a survey and in-depth interview. Survey components included demographics, cancer history, PA attitudes and beliefs, constructs from the Theory of Planned Behavior (TpB), and PA dose as measured by the Godin Leisure-Time Exercise Questionnaire. Semi-structured recorded interviews explored PA beliefs and behaviors which were transcribed and coded. Descriptive statistics were used to characterize the sample. Data were reported as median (interquartile range) and non-parametric tests were used to determine the influence of factors on the TpB constructs and PA behavior. Interview data is pending.
RESULTS: Preliminary data is reported here; full data analysis will be reported during presentation. Sixty-six percent of CS were male and Caucasian, and 73% were over 55 years of age. There were statistically significant negative correlations between fatigue and PA (pho = −0.571, p = 0.03), with a median reported fatigue level of 7 (scale 1-10). There were no significant associations between the TpB and PA. Sixty-eight percent of CC were female and 62% were over the age of 55. Seventy-eight percent were Caucasian and 56% were retired. Daily median hours of caregiving was 6, with significantly more hours reported by CC between the ages of 18-24 years compared to those over 55 years (3.5,4; p = 0.03). Median (Interquartile range) scores for TpB were; 4 (3.5, 6) for intention, 7 (6.1, 7.7) for attitude, 5.42 (4, 6) for social norm, and 5.75 (4.25, 6.75) for perceived behavioral control (PBC). There was a significant association between PBC and volume of PA and between intention and PA (p = 0.01). No significant differences were found between pre and post-diagnosis PA levels by intensity or volume for CC. There was no statistically significant association between hours of caregiving and PA.
CONCLUSIONS: Different modifying variables influence the PA behaviors of CS and CC. To improve PA, physical therapists should focus on improving fatigue in CS, and enhancing positive attitudes towards exercise and PBC in CC.
CLINICAL RELEVANCE: Findings should be used to create a tailored approach to the promotion of PA in low-income CS and CC. Enhancement of PA could improve the psychological and physical health of both populations.
CHARACTERIZING BODY COMPOSITION AND PHYSICAL FITNESS IN BREAST CANCER PATIENTS PRIOR TO INITIATION OF ANTHRACYCLINE CHEMOTHERAPY
Serrano T, Gorgi VJ, Lee K, Dieli-Conwright CM
PURPOSE/HYPOTHESIS: Women diagnosed with breast cancer often experience negative changes in body composition and declined physical fitness during chemotherapy.1,2 Since cardiovascular disease (CVD) risk worsens with deleterious changes in body composition and physical fitness, it is important to characterize these measures in women undergoing chemotherapy.3 In particular, women who undergo anthracycline chemotherapy are at an increased risk for CVD due to the cardiotoxic nature of anthracyclines.4,5 Evaluating body composition and physical fitness prior to initiation of treatment is necessary to devise appropriate interventions to offset CVD risk. The purpose of this study was to characterize body composition and physical fitness in breast cancer patients prior to the initiation of anthracycline chemotherapy. We hypothesized that breast cancer patients have higher percent body fat and lower lean mass, along with lower physical fitness compared to age-matched norms in women without a history of breast cancer.
NUMBER OF SUBJECTS: 20
MATERIALS/METHODS: Breast cancer patients diagnosed with stage I-III breast cancer, prior to initiation of anthracycline chemotherapy, were recruited to participate in this study as a part of a larger ongoing exercise trial. The InBody 770 Body Composition Analyzer (BioSpace, Cerritos, CA, USA) was used to measure lean mass, fat mass, percent body fat, and body weight. Physical fitness was assessed using a maximal effort cycling protocol to measure maximal oxygen uptake (
O2max). Descriptive characteristics were obtained using SPSS (version 22).
RESULTS: Our sample included 20 breast cancer patients with an average age of 48.4 ± 10.5 years, body fat percentage 40.42% and BMI of 29.4 kg/m. Participants were diagnosed with predominantly Stage II (44%) and Stage III (56%) breast cancer and had undergone a mastectomy (100%). Average values for body composition were as follows: lean mass- 43.9 ± 8.3 kg, fat mass- 31.3 ± 12.8 kg, and percent body fat- 40.4% ± 7.6%. According to the American College of Sports Medicine (ACSM), the average percent body fat for women ages 29-60 is 20.6-31.5%. The mean percent body fat for our sample exceeds this average, placing this group in the overfat category. Average
O2max was 19.71 ml/kg/min which according to ACSM, places the participants below the 10th percentile in women between the ages of 30-60 years.
CONCLUSIONS: Prior to initiation of chemotherapy, women diagnosed with breast cancer have an elevated percent body fat and a lower
O2max than age-matched women without breast cancer, which may place them at a greater risk for CVD. Our findings emphasize the need for lifestyle interventions to offset poor body composition and physical fitness to mitigate CVD risk in this population.
CLINICAL RELEVANCE: Prior to treatment, clinicians should be aware of the increased CVD risk induced by poor body composition and low physical fitness that may be further exacerbated by anthracycline chemotherapy.
POSTER PRESENTATIONS 2019
Group 2 - Friday January 25, 2019, 1PM-3PM
Walter E. Washington Convention Center Exhibit Hall
AEROBIC EXERCISE FOR CANCER SURVIVORS RECEIVING RADIATION THERAPY: A SYSTEMATIC REVIEW
PURPOSE/HYPOTHESIS: The purpose of this systematic review is to determine the appropriate intensity of an aerobic exercise program for cancer survivors receiving radiation therapy.
NUMBER OF SUBJECTS: This is a systematic review of studies that identified 19 studies including 927 subjects.
MATERIALS/METHODS: The following databases were searched in May 2018 for articles dated within the last 10 years: PubMed, Ovid, PEDro, CENTRAL. Reference lists of relevant articles were also hand searched. The following search terms were used: cardiotoxicity, radiation therapy, and exercise. Inclusion criteria included studies describing aerobic exercise programs for patients receiving radiation therapy, studies describing both the intensity and duration of the exercise, and studies with outcome measures of aerobic performance. Articles were excluded if the exercise intervention was not described in terms of intensity and duration, if aerobic performance outcomes were not recorded, or if subjects were not currently receiving radiation therapy. Studies were reviewed for outcomes achieved with various exercise programs. Quality of studies were assessed using the PEDro scale.
RESULTS: Nineteen articles met the inclusion criteria. In these studies, the aerobic intensity of exercise was measured by heart rate, perceived exertion, or
O2max. Seventeen of the studies used a moderate level intensity for individualized exercise with positive aerobic outcomes. The two studies that used a low to moderate level of individualized exercise listed no exclusions of cardiac conditions in their subjects and reported improved aerobic capacity.
CONCLUSIONS: These studies showed exercise as a beneficial way to increase, or limit decline, in aerobic capacity of cancer survivors receiving radiation therapy. Even in patients who warrant a program of low intensity, improvement is possible. Future research on exercise during radiation therapy among patients may be helpful in this population to give clinical guidelines for safe and effective programs in this growing population.
CLINICAL RELEVANCE: Although radiation is very beneficial in the treatment of cancer, cardiac injury is a risk of treatment. Specifically, groups at high risk for left ventricular dysfunction are those who receive high-dose radiotherapy and those who receive a combination of low-dose anthracycline and low-dose radiotherapy. The cumulative oxidative stress from chemotherapy and/or radiation treatments and exercise may result in damage to cardiac tissue and affect the intensity of exercise that can be safely tolerated. Exercise is supported early in survivorship, however, due to a quicker increase in antioxidant capacity and decrease in protein oxidative stress than would normally occur over time. Exercise participation at a monitored level in the radiation treatment period has been shown to improve aerobic capacity in this population as well as limit declines related to cancer-related fatigue and other cardiac comorbidities and should therefore be prescribed. Clinicians should be aware of current cardiac status when prescribing exercise programs.
HIGH INTENSITY EXERCISE AND CANCER-RELATED FATIGUE: A SYSTEMATIC REVIEW
Matheny CR, Trantham M, Kay D, Reichard G, Stewart S
PURPOSE/HYPOTHESIS: The overall benefits of general exercise for patients recovering from cancer treatments are beginning to become widely accepted in the medical community, and studies have found that supervised exercise and physical therapy can help patients with quality of life and being able to more fully participate in the community and work. Unfortunately, little is known about which type of exercise intensity is the most useful for patients fighting the effects of cancer and additional symptoms of fatigue. The purpose of this systematic review was to investigate the effects of high intensity exercise on outcome measures of cancer related fatigue (CRF) post-cancer treatment as compared to standard care.
NUMBER OF SUBJECTS: 449 subjects
MATERIALS/METHODS: After searching the evidence related to the clinical question, nine databases were searched utilizing a PRISMA strategy with key words related to exercise and CRF. Following screening, five articles were chosen for data evaluation and analysis. Two reviewers appraised the quality of evidence using the Downs and Black scale while the third reviewer resolved differences concerning article quality. The inclusion criteria for this systematic review included: a minimum score of 20 on the Downs and Black scale, completion of cancer treatments, participants 18 years of age and older, and the utilization of high intensity aerobic and resistance exercises.
RESULTS: Five randomized controlled trials were critically analyzed for this systematic review. All studies analyzed received a score above 20. Despite that exercise parameters such as dosing, frequency and duration of high intensity exercise are varied, the research as a whole shows clinicians and physicians that there may be a wider range of intensity this population can tolerate than previously thought.
CONCLUSIONS: Based on this systematic review, the hypothesis of high intensity exercise producing better outcomes in treating CRF compared to other interventions was found inconclusive. High intensity exercise appears to produce better outcomes in CRF when compared to no exercise, however more research is warranted. In addition to this, high intensity exercises is safe to implement for patients post-cancer treatment. The knowledge that high-intensity exercise is safe and equally beneficial allows physical therapists to include high-intensity exercise in their rehabilitation program if the patient requests or prefers it.
CLINICAL RELEVANCE: Based on the evidence, high intensity and low-to-moderate intensity exercises improved CRF with no significant differences between high and low-to-moderate intensity exercises. The use of high intensity exercise appears to produce better outcomes in CRF when compared to no exercise, however more research with stricter guidelines to prevent control group contamination is needed. Among all studies, no adverse events were reported with some studies reporting cost-benefits and time-efficiency in the clinic. Overall, high intensity exercise appears to be a viable alternative option for treatment of this population.
USE OF THE BNAT, A NOVEL OBJECTIVE PHYSICAL ASSESSMENT TOOL, TO DISCRIMINATE BETWEEN SPECIFIC CANCER DIAGNOSES AND THEIR ECOG PERFORMANCE STATUS SCORES
Penney JC, Imel R, Swartz K, Weiss J, Wilson J, Hamm JT, Flynn JM, Crandell CE, Quinn SE, Wingard CJ
PURPOSE/HYPOTHESIS: Individuals with cancer experience loss of function, disability and fatigue. There is growing interest in functional and physical assessment as part of a comprehensive oncology care plan.1,2,3 single comprehensive assessment tool is routinely applied to oncology care. The Bellarmine Norton Assessment Tool (BNAT) was developed to provide a new objective physical assessment tool for utilization among patients with cancer. The purpose of this study was to evaluate the BNAT and correlate its outcomes with ECOG scores across groups diagnosed with pancreatic (P), breast (B) and lung (L) cancers.
NUMBER OF SUBJECTS: Initially 18 participants were identified 6 in each of the diagnosis groups form the original recruitment cohort of 57. The avg. age for P was 68.8 ± 9 yrs 4♀,2♂; B 71.5 ± 15.8 yrs 6♀; L 65.0 ± 12.4 yrs 3♀,3♂.
MATERIALS/METHODS: The BNAT was developed by Bellarmine University Physical Therapy students and faculty utilizing previously validated physical assessment tests. BNAT consists of 1 subjective question about physical activity frequency followed by 4 objective tests: 2-Minute Step Test (2MST), 30 Sec Sit-to-Stand, Timed Arm Curl (TAC) and Timed Up and Go. Appropriate materials were used per established testing protocol. The ECOG was administered by attending oncologists during the same visit as BNAT testing. Study was IRB approved.
RESULTS: The combined mean ± SD ECOG score was 1.2 ± 1.0 with a range of 0-3 while the combined BNAT score was 15.4 ± 6.5 with a range of 7-29. Mean diagnosis BNATs: P 16.6 ± 7.4 (range 7-29); B 13.0 ± 5.5 (range 7-21); & L 18.3 ± 5.7 (range 12-28). Spearman correlation analysis of BNAT and ECOG scores revealed a significant (p = 0.0001) large negative correlation of agreement (r = −0.791). Both B & L cancers had significant (p < 0.05) correlation of agreement (B r = −0.71 & L r = −0.88). TAC correlation to ECOG was strongest in L group (r = −0.86) but 2MST strongest in the P group (r = −0.62). There was reciprocal relationship of slopes between TAC & 2MST based on diagnosis. L steepest slope in TAC (-6.2 with deviation form 0, p = 0.014) while P had steepest slope with 2MST (−13.1). Slope for B group consistently fell between the 2 other diagnoses.
CONCLUSIONS: There was a strong linear relationship of BNAT, TAC & 2MST to ECOG scores across the 3 cohorts of cancer diagnoses. The BNAT subcomponents have varying degrees of contribution to the total that can be attributed to diagnosis-related functional deficits, thus giving providers information to determine appropriate care.
CLINICAL RELEVANCE: Current research supports the need for objective measurements to assess physical function and provide early screenings of individuals with cancer who may need focused rehabilitation.4 An impairment-based approach is critical to improve the overall physical and psychological health of the patient and to decrease health care costs. Utilization of BNAT may provide a representation of overall physical function and contribute to decisions made about therapeutic approaches.
HOME EXERCISE PROGRAMS FOR CANCER SURVIVORS: CAN A WEEKLY PHONE CALL IMPACT COMPLIANCE, FUNCTION OR QUALITY OF LIFE?
Plumeau K, Marcyan RA, Heubeck A, Thomas Z, Fitzsimons J, Mayer JE
PURPOSE/HYPOTHESIS: Exercise for cancer survivors during and after treatment has been shown to improve quality of life (QoL), fatigue, and physical/emotional function, while providing strength and aerobic endurance enhancements. These benefits can be achieved with a home exercise program (HEP) provided patients demonstrate some level of compliance. Evidence to support compliance with exercise programs is limited. Regular follow up with a health professional may improve patients' adherence, though the extent has not been well documented. The purpose of this research is to determine the impact of weekly phone calls on participant function, QOL and adherence to an individualized HEP designed by a physical therapist (PT).
NUMBER OF SUBJECTS: 16
MATERIALS/METHODS: This was a case control of a heterogeneous sample of participants with various types of cancer in active treatment or less than 90 days since treatment. At PT initial evaluation and following the 8 week program, participants completed the European Organization of Research and Treatment of Cancer QoL Questionnaire-Cancer 30 (EORTC), Functional Assessment of Chronic Illness Therapy (FACIT) Fatigue Scale, 6 Minute Walk Test (6MWT), and Fullerton Advanced Balance Scale (FAB). Participants were allocated based on blocked randomization and provided with an individualized HEP including strength and aerobic exercise. They were instructed to perform at a frequency consistent with the American College of Sports Medicine (ACSM) guidelines and maintain activity logs. The intervention group received weekly phone calls by a student PT to address concerns, record motivators and barriers to completion, and promote compliance. The control group did not receive communication with the researchers throughout the 8 weeks. Descriptive statistics and non-parametric tests including the Mann Whitney U and Wilcoxin signed-rank tests were used to analyze data.
RESULTS: All participants increased overall activity with only 3 participants achieving ACSM guidelines. Between groups there was a significant difference at program completion in the FACIT (p = .003) and EORTC physical functioning subscale (p = 0.042). While both groups saw improvements in QoL and function, the intervention group demonstrated significant improvements in FACIT (p = .018), EORTC physical functioning subscale (p = 0.17), EORTC QoL subscale (p = .046), and FAB (p = .027).
CONCLUSIONS: ACSM guidelines may be unachievable for all cancer survivors due to variations in recovery and personal characteristics. These results suggest that individualized home exercises prescribed by a PT can demonstrate positive change in this population.
CLINICAL RELEVANCE: The home setting may be an optimal starting point for physical therapy given adequate support. Weekly phone calls may not have a direct impact on patient adherence; however, given the results of this study, this form of communication is essential in significantly affecting patient outcomes.
THE EFFECTS OF PHYSICAL ACTIVITY ON QUALITY OF LIFE IN THE PEDIATRIC ONCOLOGY POPULATION: A SYSTEMATIC REVIEW
Keenan H, Koski-Klein A, du Mosch M, Leslie E, Lajoie K, Brown D, Parent-Nichols J
PURPOSE/HYPOTHESIS: To examine current research regarding the impact of physical activity (PA) on quality of life (QOL) for the pediatric population diagnosed with cancer.
NUMBER OF SUBJECT: N/A
MATERIALS/METHODS: A literature search from January 2014 to 2018 was conducted using all combinations of the following terms: cancer*, pedi*, physical therapy, infant*, child*, physical activit*, and oncolo*. Five search engines were used: CINAHL, PubMed, SPORTDiscus, Medline, and the Cochrane Library. Inclusion criteria were: experimental design, PA intervention, QOL outcome measure, participants ages 0-19 years with cancer. The exclusion criteria were: studies not in English, articles published before 2014, and only abstracts available. MINORS scale, ROBINS-I tool, and RoB 2.0 were used to assess study quality.
RESULTS: Ten studies met inclusion and exclusion criteria. MINORS scale scores for the ten studies ranged from 11-24 out of 24 total points. The average was 16.8. Five of eight articles assessed with the ROBINS-I tool had a serious risk of overall bias. The remaining three articles had a critical risk of overall bias. One of the two randomized control trials assessed with the RoB 2.0 tool had a low risk of overall bias; the other had a high overall risk of bias. PA interventions used in the studies were yoga, computer-based PA, individualized interventions, and semi-structured PA programs. Three studies utilized forms of yoga that had a statistically significant improvement in QOL. In single studies, computer-based PA programs and individualized interventions produced statistically significant improvements in QOL. Semi-structured PA programs with protocols focused on strength and endurance had positive effects on QOL, though not statistically significant.
CONCLUSIONS: Children with a diagnosis of cancer experienced improved QOL after interventions including PA. Limitations across studies included methodological quality, non-standardization of PA, use of a variety of outcome measures, and inconsistent timing between diagnosis and intervention. Risk of bias for non-randomized control trials was found consistently in the domains of confounding factors and measurement of outcomes. Risk of bias for the randomized control trials was found consistently in the selection of the reported result. Future studies should address these limitations to strengthen conclusions. Literature prior to this review has been inconclusive regarding the impact of PA on QOL for pediatric patients with cancer. In two previous systematic reviews, statistically significant improvements in QOL were found in one measure in one included study. This review provides additional support for use of PA as a means to increase QOL for pediatric patients with cancer.
CLINICAL RELEVANCE: Decreased QOL for pediatric patients during and following treatment for cancer is a common issue. Prior literature supports PA interventions increase QOL in other populations. The results of this review indicate that healthcare practitioners should consider yoga and other PA to improve QOL for pediatric patients with cancer.
EFFECTIVENESS OF PHYSICAL OR BEHAVIORAL INTERVENTIONS FOR MANAGEMENT OF CHRONIC PAIN IN PEOPLE LIVING WITH HIV INFECTION
Kietrys D, Foster B, McCormick M, Million E, Nguyen A, Ottstadt C
PURPOSE/HYPOTHESIS: To systematically review the literature regarding effectiveness of physical or behavioral interventions for management of chronic pain in people living with HIV infection (PLHIV).
MATERIALS/METHODS: The initial search of Medline, CINAHL, and PubMed included terms HIV or AIDS or HIV/AIDS; those results were combined (“AND”) with Chronic Pain or Pain, and was limited to English, Humans, and randomized controlled trials (RCTs). Articles were excluded if they did not include pain as an outcome or if they were not a RCT. A hand search of reference lists from relevant articles was performed, and a secondary search using keywords associated with behavioral or physical interventions was conducted. Articles included in the review were assessed with the Cochrane Risk of Bias Tool by a consensus of 6 authors, and a Sackett rating was ascribed to each article. Key data regarding pain outcomes were extracted by the team of authors. Meta-analysis was not feasible due to clinical heterogeneity of the studies under consideration.
RESULTS: The initial search yielded 749 articles. When duplicates were removed, 322 articles remained; 317 of those were excluded (because they did not measure pain or did not use a physical or behavioral intervention or were pilot studies), yielding 5 articles for inclusion in this review. The hand search and the secondary search did not yield any additional articles. Cochrane risk of bias scores ranged from 9/16 to 12/16. Each study explored a different intervention. Use of night splints resulted in a clinically meaningful decrease in pain (within group), but was not superior to control; vibratory stimulus resulted in clinically meaningful decrease in pain (within group; immediate effects), but was not superior to control; aerobic or strengthening exercise was superior to control, but did not result in within group clinically meaningful decreases in pain; exercise combined with education resulted in a clinically meaningful decrease in pain (within group), but was not superior to education alone; education alone resulted in a clinically meaningful decrease in pain (within group) and was superior to usual care.
CONCLUSIONS: Night splints, vibratory stimulus, exercise, education, or combined exercise/education may be helpful in the management of chronic pain in PLHIV. More studies are needed to confirm the findings reported here and to assess long term outcomes.
CLINICAL RELEVANCE: Evidence is emerging to suggest that certain physical or behavioral interventions may be effective in the management of chronic pain in PLHIV. Factors such as practitioner training, resources, and patient preferences should be considered when selecting behavioral or physical interventions for management of chronic pain in PLHIV.
COMPRESSION GARMENT CONSIDERATIONS FOR A PATIENT WITH MALIGNANT LYMPHEDEMA AND METASTATIC WOUNDS
BACKGROUND & PURPOSE: Cutaneous metastases occur in 0.7% to 10.4% of patients with cancer and 5% to 10% of these patients develop metastatic wounds. The incidence of metastatic wounds in patients with malignant lymphedema is not well documented. Management of patients with complex presentations of malignant lymphedema requires an approach responsive to the patient's needs, including modification of conventional treatments. There is limited research on rehabilitation considerations in this population. The purpose of this case is to describe challenges treating malignant lymphedema in a patient with complex presentation and demonstrate effects of modifying compression garments on quality of life.
CASE DESCRIPTION: 77-year-old female with history of breast cancer metastatic to skin, soft tissue, lymph nodes and bone. Oncologic treatment included chemotherapy, endocrine therapy and radiation therapy to left upper arm and chest wall. Patient with chronic left upper extremity (UE) malignant lymphedema treated previously with Complete Decongestive Therapy (CDT). Patient with increased limb volume after palliative radiation therapy to chest wall. She was referred to Rehabilitation with worsening lymphedema and disease progression with malignant wounds to left volar wrist. She presented with advanced stage 3 lymphedema, radiation fibrosis, impaired skin integrity and decreased range of motion and strength. Limb volume and circumference increased since previous episode of CDT. Patient's primary goal was to obtain compression garments that accommodate fluctuating limb volume and concurrently enable independence with activities of daily living.
OUTCOMES: Variable compression bandaging alternative was recommended due to fluctuating limb size. Patient tolerated this well at night however its weight and bulk were challenging to daytime tasks. Therefore, custom flat-knit compression garments were recommended for daily activities. Patient was prescribed a glove extended to mid-forearm with sufficient girth to accommodate wound dressings. An arm sleeve was measured to cover from mid-forearm (above wrist wound) to mid-upper arm (below radiation fibrosis). With training, patient could don and doff all garments over wound dressings independently. She reported improvement in managing lymphedema and household chores without assistance, with clinically significant 4 point increase on Patient Specific Functional Scale score.
DISCUSSION: Research is limited on management of patients with metastatic wounds and malignant lymphedema. This case demonstrates the positive impact of unconventional compression garment modifications for a patient with advanced disease. The role of flat-knit compression garments should be further evaluated for patients with fluctuating limb volume and/or chronic wounds. When worn during periods of smaller limb volume or donned independently over wound dressings, these garments may increase daily independence and quality of life for patients who are otherwise limited to standard prescription of compression bandaging or bandaging alternative.
VIGOROUS INTENSITY RESISTANCE TRAINING AND BREAST-CANCER RELATED LYMPHEDEMA: A SYSTEMATIC REVIEW
Kay D, Reichard G, Sager C, Matheny C, Trantham M
PURPOSE/HYPOTHESIS: The positive effects of exercise on patients receiving and recovering from cancer treatments on outcomes such as quality of life is well established. Specifically, recent research has shown the positive effect of resistance training on breast-cancer related lymphedema (BCRL). Unfortunately, little is known about the effects of different resistance training intensity on BCRL. The purpose of this systematic review was to investigate the effects of vigorous intensity resistance training on BCRL.
NUMBER OF SUBJECTS: 125
MATERIALS/METHODS: The search utilized a PRISMA strategy with key words including exercise and BCRL within the previous 5 years. Nine databases were used resulting in a total of 480 articles. Two reviewers appraised the quality of evidence using the Downs and Black scale. The inclusion criteria included a minimum score of 15 on the Downs and Black scale, a diagnosis of breast cancer, and have received or is receiving cancer treatments.
RESULTS: After removal of duplicates, screening and assessment, four studies were chosen for critical analysis. Of the four studies used, one was a randomized controlled trial and three were randomized cross-over designs. The mean score on the Downs and Black scale was 19.75, with a range of 19-21. No adverse events were reported. No statistical significant difference was observed between vigorous resistance training and low-to-moderate resistance training in reducing limb volume in patients with BCRL.
CONCLUSIONS: This systematic review compared the efficacy of vigorous intensity resistance training to low-to-moderate intensity resistance training in the reduction of limb volume in patients with or at risk of developing BCRL. Results showed no statistical significant difference between the two interventions, although, the vigorous resistance training did show slight improvements in certain cases. With this research being so new, there are a limited number of studies that look at this comparison, therefore, clinicians are advised to rely on clinical judgement and a thorough knowledge of patient history before selecting vigorous intensity resistance training as a treatment option. Higher quality studies are warranted to assess vigorous intensity resistance training on limb volume in patients with breast-cancer related lymphedema.
CLINICAL RELEVANCE: The results of this study suggests vigorous intensity resistance training produces similar results to low-to-moderate intensity training. In addition, it indicates vigorous intensity resistance training is safe for patients with BCRL andf does not exacerbate BCRL. However, due to the number and quality of the included studies, clinicians should be cautious and use clinical judgement when considering vigorous intensity resistance training as a viable treatment option for patients with breast-cancer related lymphedema.
SHORT PHYSICAL PERFORMANCE BATTERY IN HEAD AND NECK CANCER PATIENTS RECEIVING OUTPATIENT RADIATION THERAPY
Ray A, Wendel E, Saya B, Singh A
PURPOSE/HYPOTHESIS: Cancer treatment is associated with numerous side-effects that prevent patients from returning to their pre-diagnoses physical and mental health.1 Radiation therapy represents one of the primary approaches to managing patients with head and neck cancers. Importantly, these patients are at increased risk for weight loss including cachexia, decreased physical functioning, numbness, tingling, pain and fatigue.2 The presence of functional deficits are not only detrimental to quality of life but are also associated with hospital admissions, longer lengths of stay and increased readmission rates.3 The Short Physical Performance Battery (SPPB) is a well-established assesment of functional performance4 and all-cause mortality (SPPB < 10 points).5 This study was designed to investigate the effects of outpatient radiation therapy on the SPPB in patients with head and neck cancers. We hypothesize that radiation therapy will negatively influence the SPPB.
NUMBER OF SUBJECTS: n = 59
MATERIALS/METHODS: A cross sectional approach was used to study two independent groups of patients at different points of their treatment: Group A patients were tested on their first day (n = 29) and Group B patients were tested on their last day (n = 30) of outpatient radiation therapy (6-7 weeks). All patients completed the Short Physical Performance Battery (SPPB), a valid and reliable measure of functional performance.6 The SPPB includes tests of sit-to-stand, walking speed, and balance. There are four possible points for each test (max of 12 total points). Higher scores represent greater function. Independent t-tests (SPSS) were used to establish differences between groups.
RESULTS: Average age was 64.8 ± 12.8 years and 63.5 ± 11.2 years in groups A and B, respectively. Total SPPB scores were 10.3 ± 2.7 and 8.5 ± 3.3 (−18%, p = 0.026) in groups A vs. B, respectively. Lower scores post-radiation were mainly due to a decrease in balance (3.9 ± 0.4 points vs. 3.4 ± 1.1 points, p = 0.033) and marginally in sit-to-stand (3.1 ± 1.5 points vs. 2.3 ± 1.4 points, p = 0.061) in groups A vs B, respectively.
CONCLUSIONS: Radiation therapy negatively influenced physical performance as measured by the total SPPB.
CLINICAL RELEVANCE: The lower functional performance in Group B supports a role for rehabilitation services earlier during the cancer care continuum to maintain and/or improve functional performance. Future work is needed to determine whether the SPPB can be used to predict outcomes such as frailty, hospital admissions and survival in persons with head and neck cancer.
A CASE REPORT ON WEEKDAY PHYSICAL THERAPY INTERVENTIONS IN THE ACUTE CARE SETTING FOR A PATIENT WITH A NEW ONCOLOGY DIAGNOSIS AND MULTIPLE CEREBRAL VASCULAR ACCIDENTS
Houlihan S, Rexer P, Nagy T, Kaphade G, Andrews C
BACKGROUND & PURPOSE: Research supports the growth of cancer rehabilitation as a subspecialty and evidence shows that patients with cancer diagnoses benefit from inpatient rehabilitation services. There is a growing need to improve the cancer treatment therapy options for patients in the acute care setting. The Mobile Comprehensive Oncology Rehabilitation (MCORE) team was designed to increase frequency and intensity of rehabilitation care provided to patients in the acute care setting. Prior to the implementation of the MCORE team, physical therapy visits varied based on many factors including staff levels, prioritization of patients in the hospital and potential to discharge home. To promote and maximize a patient's level of functional performance prior to discharge, we began a service line emulating inpatient rehab. The focus of this program was for weekday, individualized, intensive physical therapy while in the acute care setting.
CASE DESCRIPTION: The patient is a 56-year-old female who was transferred from an outside hospital with decline in function for two months and had stroke-like symptoms. She was diagnosed with diffuse large B-cell lymphoma with central nervous system involvement. Upon further imaging, cerebral artery vasospasms and related multifocal cerebral vascular accidents were identified. She was one of the first patients enrolled in the MCORE program. She was admitted six times for R-EPOCH chemotherapy treatment with MCORE enrollment during each cycle. Physical therapy was attempted with the goal of five days per week during each admission.
OUTCOMES: For the purpose of this report, relevant information was reviewed from the patient's electronic medical records including Activity Measure for Post-Acute Care (AM-PACTM) scores, level of assist needed for functional mobility and discharge recommendations. The patient was admitted to the hospital six times from November 2017 to March 2018. The patient was able to discharge to inpatient rehabilitation twice and subsequent admissions was able to discharge home with home services. Her initial AM-PACTM score was seven and progressed to eleven at the end of her sixth admission. Her initial level of assist was maximal/dependent for bed mobility and sitting at edge of bed. She progressed to contact guard to min assist for bed mobility, contact guard assist for sitting at the edge of the bed, moderate assist for slide board transfers and moderate assist of two persons for stand pivot transfers. At her last follow up with her physiatrist in March 2018, she was able to complete stand pivot transfers with one person assist from her husband.
DISCUSSION: This case study supports the benefit of increased frequency of physical therapy in an acute care setting. Improvements in functional mobility, positive change in AMPAC score and the ability to achieve a safe discharge home reinforces the benefits this program could provide to this patient population.
WEEKDAY PREHABILITATION IN ACUTE CARE FOR AN ONCOLOGY PATIENT DURING PROLONGED HOSPITALIZATION
Nagy T, Houlihan S, Marck K
BACKGROUND & PURPOSE: Research suggests cancer rehabilitation can improve quality of life and physical function in cancer survivors throughout their course of treatment. Prehabilitation starts from initial diagnosis to start of treatment. The purpose of this study was to identify benefits of daily prehabilitation interventions within the acute care setting for a patient with a new oncology diagnosis. At Michigan Medicine, a new multidisciplinary team was established to meet the increasing needs of oncology rehabilitation services in the acute care setting. The Mobile Comprehensive Oncology REhabiltiation (MCORE) team is comprised of a dedicated group of physician, physical therapist, and occupational therapist staff. This enabled physical therapy services to increase the frequency of interventions for patients with cancer Monday through Friday.
CASE DESCRIPTION: The subject was a 61-year-old female admitted to Michigan Medicine for newly diagnosed Cushing's syndrome and neuroendocrine tumor. Further imaging revealed metastases to her right hip and liver. During her hospital stay, she had multiple intensive care unit admissions due to hypoxemia, influenza, and acute respiratory distress syndrome. Her length of stay was between January 2018 through April 2018. She was added to the MCORE team in March 2018 for 30 days, 26 of which she received physical therapy interventions. These interventions included therapeutic exercise, functional mobility, and endurance activities.
OUTCOMES: Outcome measures included AM-PAC (Activity Measure for Post Acute Care), level of assist needed for functional mobility, 30 second repeated sit to stand, gait speed, and discharge recommendations. During her intensive care unit stay, the physical therapist evaluation reported an AM-PAC score of eleven, two person moderate to maximum assist for transfers, sit to stand one time, gait speed not applicable as she was not ambulatory, and a discharge recommendation of sub-acute rehabilitation. Post MCORE treatment revealed an AM-PAC score of 16, contact guard assist to minimal assist for transfers and ambulation of 90 feet with two wheeled walker, sit to stand three times, gait speed 0.4 m/s, and a discharge recommendation of inpatient rehabilitation facility. She also increased strength and mobility to qualify for a bilateral laparoscopic adrenalectomy. Ultimately patient discharged to acute rehab for two and half weeks at Michigan Medicine followed by discharge home with home health. At time of discharge, she was modified independent with ambulation using a two wheeled walker.
DISCUSSION: Subject demonstrated an improved AM-PAC score, higher frequency of sit to stands in 30 seconds, and more independent functional mobility. She was also able to qualify for cancer related surgery due to improvement in mobility. Increased frequency of therapy in the acute care setting for oncology patients throughout the continuum of care may improve physical function, reduce time spent in a rehab setting, while increasing cancer treatment options.
USE OF NEGATIVE PRESSURE DEVICE IN TREATMENT OF UNILATERAL UPPER EXTREMITY BREAST CANCER-RELATED LYMPHEDEMA: TWO CASES
Klas R, Castro S, Steele S, Stoll L, Smoot B, Lee J
BACKGROUND & PURPOSE: Breast cancer-related lymphedema (BCRL) is a chronic complication that can affect women treated for breast cancer (BC). BCRL requires lifelong management and can negatively impact quality of life (QOL). Current physical therapy (PT) standard of care for BCRL is combined decongestive therapy consisting of manual lymphatic drainage (MLD), compression bandages, therapeutic exercises, and skin care. Physiotouch is a negative pressure device designed to lift and mobilize subcutaneous fascial layers to increase soft tissue mobility and improve lymphatic circulation. Few studies have examined the use of Physiotouch as an intervention in the treatment of BCRL. The purpose of these case studies is to describe changes in upper extremity (UE) volume, shoulder range of motion (ROM), tissue induration, and grip strength following Physiotouch treatment in two females with unilateral BCRL.
CASE DESCRIPTION: Subject 1 is a 72 year-old (y.o.) female diagnosed with right BC in 2000 and treated with lumpectomy, radiation therapy (RT), and chemotherapy (2001). In 2016, she was diagnosed with left BC, received accelerated RT, and developed left UE lymphedema (LE). Subject 1 was seen for six 50-70 minute Physiotouch treatment sessions. Subject 2 is a 58 y.o. female diagnosed with right BC treated with mastectomy, RT, and chemotherapy in 2010. Subject 2 is currently on subcutaneous Herceptin and prophylactic Xarelto (an anticoagulant). She developed right UE LE in 2011. She was seen for six 60-70 minute Physiotouch treatment sessions and will continue to be seen for 12 total sessions. Vodder's MLD sequence and pathway was utilized during treatments for both subjects. Suction pressures ranged from 80–150 mmHg. Neither subject reported pertinent comorbidities. Both subjects perform occasional self-massage, wear a compression sleeve infrequently, and intermittently exercise with no reported changes.
OUTCOMES: UE circumference was measured at 5 locations proximal to the ulnar styloid to determine limb volume. Overall affected arm volume decreased in both subjects (130.2 ml and 43.7 ml). Both subjects reported softer and less fibrotic skin texture. No significant changes in affected shoulder flexion and abduction ROM. Minimal decrease in tissue induration (measured at 7 sites with a fibrometer) noted in both participants. Grip strength increased for both subjects on the affected side (2 kg and 4 kg). No evidence of adverse skin response or symptoms.
DISCUSSION: Small improvements were observed for both subjects in arm volume, tissue induration, and grip strength of affected arm from pre to post-treatment using Physiotouch. Quality of the skin on the affected limb was also improved. These improvements may correlate to improved function and QOL for patients with BCRL. Use of Physiotouch was well tolerated and may serve as a useful adjunct for the treatment of BCRL. An area for further research is comparing the effects of Physiotouch to MLD in order to establish criterion-related validity for BCRL treatment.
THE IMPACT OF A NOVEL, CUSTOMIZED ORTHOSIS ON PAIN AND FUNCTION IN A PATIENT FOLLOWING AN INTERNAL HEMIPELVECTOMY
Tucker J, Burke H, Eden M
BACKGROUND & PURPOSE: Individuals who undergo an internal hemipelvectomy for management of osteosarcoma often present with impaired function secondary to pain, weakness and instability. One cause of pain could be related to traction on the soft tissue of the hip from the residual limb. In the acute rehabilitation setting, participation in therapy interventions are often limited by these impairments. A novel orthosis was fabricated to lend support to the lower limb with the objective to alleviate pain and instability, allowing for improved function. The purpose of this case study is to describe the impact of pain and function of a patient with an internal hemipelvectomy with and without a custom orthosis.
CASE DESCRIPTION: A 74 year-old male diagnosed with T-cell lymphoma and osteosarcoma of the right hemipelvis, extending from the right pubic ramus to the medial acetabulum, underwent a right cystoprostatectomy with an ileal conduit and a right internal hemipelvectomy in October 2017. He was admitted to the inpatient rehabilitation facility (IRF) for a four week stay. The patient was readmitted for two weeks in February 2018 due to acute hyponatremia.
OUTCOMES: Upon admission to the IRF the patient required total assistance for all functional mobility. On Day 6 following this admission, a custom fabricated orthosis was applied, allowing the patient to participate in therapeutic activities with less discomfort. Pain, measured by the Numeric Pain Rating Scale, was noted to have improved[JT1] at discharge. Additionally, upon discharge the patient was able to perform functional mobility with minimal assistance and ambulation improved from 5 to 60 feet using a front wheeled walker. For his second hospitalization, function was assessed by the Timed Up and Go (TUG) and gait speed as measured by the Ten-Meter Walk Test at admission and discharge. At admission, gait speed was 0.26 m/s with the orthosis and 0.23 m/s without. Upon discharge, gait speed improved to 0.30 m/s with orthosis and 0.26 m/s without. At admission, TUG was 55.35 seconds (s) with the orthosis and 62.88 s without. At discharge, the TUG score improved to 40.33 s with the orthosis and 47.73 s without. The patient verbally reported his pain was “cut in half” during transfers and ambulation while wearing the novel orthosis.
DISCUSSION: Utilization of the custom fabricated orthosis appeared to improve the TUG, gait speed, functional mobility, and pain for this patient. It is possible that utilization of the custom orthosis to optimize stability and decrease traction on the soft tissues had an impact on function, allowing for greater participation with therapeutic activities. More research is necessary to determine the effect of a custom orthosis on pain and function in patients following internal hemipelvectomy.
BARRIERS AND FACILITATORS OF PARTICIPATION IN STRUCTURED EXERCISE PROGRAMS AMONG PATIENTS WITH CANCER IN THE UNITED STATES: A SYSTEMATIC REVIEW OF THE LITERATURE
Hickey MA, Carty C, McIlvenny C, Winberg E, Young TD
PURPOSE/HYPOTHESIS: Strong evidence supports the effectiveness of physical activity in cancer survivors, and its role in the overall management of the disease and related sequelae has been well-described. The American Cancer Society recommends that survivors of oncological diagnoses participate in 150 minutes of moderate-intensity exercise per week. Current data suggest that only 40% of survivors are meeting this recommended guideline. The purpose of this study was to identify the barriers and facilitators to exercise adherence among patients with oncological diagnoses in the United States.
MATERIALS/METHODS: Relevant studies published between 2008-2018 were obtained, screened, and narrowed down to a total of twelve for quality analysis. These twelve studies were blindly assigned to two pairs of opposing researchers. Quality analysis was completed using the Joanna Briggs Critical Appraisal tool and the Critical Appraisal Tool Programme for Qualitative Studies. Eleven studies were identified for inclusion in the review.
RESULTS: Thematic analysis revealed several key areas of focus which were categorized as intrinsic or extrinsic barriers and/or facilitators of exercise adherence. Intrinsic barriers included fatigue, lack of time, competing responsibilities, lack of knowledge, other physical barriers, and psychosocial aspects. Extrinsic barriers included geographic factors, the present support system, and inconsistent exercise prescription. Facilitators to exercise adherence included awareness of exercise programs, home-based exercise programs, physician encouragement and education, and in-person exercise discussions. Patient and provider preferences were also identified as separate contributors across all categories.
CONCLUSIONS: There are a number of barriers that may be present that could inhibit patients from participating in structured exercise programs after oncologic diagnosis. Insufficient patient education may perpetuate misconceptions regarding the safety and benefits of exercise when experiencing side-effects of cancer treatment. Oncologists reported seeking out ‘experts’ in exercise prescription, and identified those individuals as exercise physiologists rather than physical therapists. Many of these identified barriers may be turned into facilitators with proper planning.
CLINICAL RELEVANCE: There has been a dramatic increase in cancer survivorship. Physical therapists are experts in the areas of exercise testing and prescription. An experienced physical therapist has the potential to play a pivotal role in bridging the gap between patient and oncologist preference for exercise adherence and management, yet the evidence suggests that physical therapists are not regularly being consulted for these services. Advocacy on behalf or our profession and the patients who could benefit from our services will be an essential component to changing this.
THE USE OF DRY NEEDLING INTERVENTION IN CONJUNCTION WITH SPEECH THERAPY INTERVENTION FOR HEAD AND NECK CANCER PATIENTS WITH SWALLOWING IMPAIRMENT: A MULTIDISCIPLINARY APPROACH
Gauriloff S, Janezic K
PURPOSE: The purpose of this platform is to introduce an innovative approach to treating cancer patients with swallowing impairments who also seek care from speech therapy services. Growing use of dry needling intervention in Physical Therapy lends support to an alternative method of treating myofascial restriction with adaptation in the neuromuscular system at the head and neck region.
DESCRIPTION: The current treatment for head and neck Cancer patients with dysphagia is led through interventions lead by Speech Language Pathologists. Based on the complexity of their disease, dysphagia may result from multimodality treatments which can include surgery, radiation therapy, chemotherapy, and general poor health due to comorbidities. After treatment is completed for cancer occurring in the oral cavity, pharynx or larynx, findings in clinical practice are that of weak intrinsic and extrinsic muscles with subsequent high potential for aspiration. As length of time between medical intervention and dysphagia rehabilitation increases the extrinsic muscles become restricted in their range of motion due to fibrotic tissue. One primary goal of Speech Language Pathology intervention is to improve superior laryngeal elevation and anterior hyoid excursion to minimize aspiration. Upon seeking further guidance from a physical therapist, it was found that advanced manual techniques could assist in the improvement of range of motion of the extrinsic laryngeal muscles through reducing myofascial restriction. Physical Therapy assessment found collective deficits in the myofascial restriction of the masseter, suprahyoid muscles, sternocleidomastoid, suboccipitals, cervical multifidi and scalenes. Treatment intervention for physical therapy included dry needling of the above mentioned musculature as well as an exercise program focused on the endurance musculature of cervical postures.
Following treatment of manual techniques and cervical exercise program along with speech therapy intervention, there were positive findings on the Modified Barium Swallow. These findings included improved laryngeal elevation and hyoid excursion. Patient subjective reports included an unrestricted ability to turn the neck, capacity to produce more force with swallowing and increase in sensation of the swallowing musculature
SUMMARY OF USE: For this platform, a multidisciplinary method to treat dysphagia in head and neck Cancer patients will be identified. It will support the innovative practice of dry needling intervention in the field of Physical Therapy as we attempt to support use of current interventions in unique patient cases. The use of visualization for better understanding the change in swallowing mechanics will be presented via video of a Modified Barium Swallow study.
IMPORTANCE TO MEMBERS: This platform is designed to engage physical therapist with dry needling certification to integrate care for those patient cases that lay outside the orthopedic spectrum.
LIPOSUCTION DEBULKING FOR ADVANCED LYMPHEDEMA WITH SECONDARY FIBROADIPOSITY OF THE LEFT UPPER EXTREMITY
BACKGROUND & PURPOSE: A novel treatment of lymphedema with fibroadiposity was performed on a patient which long term chronic breast cancer related lymphedema was performed by Dr Mark Victor Schaverian at MD Anderson Cancer Center. The patient was treated for multiple episodes of care over many years due to multiple cancer and reconstructive surgeries. The fibroadiposity worsened significantly such that the patients pain, function and self-image required an approach that is rarely performed in the United States. This presentation will discuss the preoperative condition, the operation and the post-operative changes using the Shoulder Pain and Disability Index (SPADI), Physical Appearance Comparison Scale – Revised (PACS-R) and Lymphedema Life Impact Scale (LLIS).
CASE DESCRIPTION: The patient presented with a PMHX of left carcinoma in 2006 treated with chemotherapy, a bilateral mastectomy followed by radiation to the left chest wall and axilla due to positive lymph node involvement. Desmoid fibromatosis of the left axilla occurred in 2008 for which she underwent left chest wall resection along with the first and second ribs. The patient hreceived physical therapy utilizing Complete Decongestive Therapy along with manual therapy to address the thixotropic properties. However, over time due to the non-patent lymphatic system and multiple surgical procedures to the left axillary region she developed chronic lymphedema with fibroadipose. On May 2017, the patient underwent a liposuction debulking. The patient had been fitted with a Circaid reduction class II compression garment which was measured to the contralateral normal extremity which was donned immediately following the debulking. The patient was ordered to wear the garments always unless when performing hygiene. Prior to the surgical procedure the patient completed the indices. Following the surgery, the patient received physical therapy to address the post-operative pain and fibrosis prevention with manual therapy. At the 6-month point, the patient again completed the same indices. The patient reports that in conversations with the surgeon that he stated that “the surgery was one of the most difficult procedures that he ever completed”
OUTCOMES: Volume of the left UE decreased from 2084 ml to 1290 ml or 61.6% following the debulking surgery. SPADI changed from 75 – 41, PACS_R changed from 29 to 1 and LLIS changed from 87 to 20.
DISCUSSION: The patient had exhausted conservative treatment for her lymphedema and the advancement of the fibroadiposity progressively resulted in loss of function and body image dysfunction. The patient at 6 months following the debulking improved dramatically in all the indices. The most impactful for the patient was the PACS-R which virtually normalized. At the 6-month post-surgical time the patient reports improvement in post-operative pain and increased in function. She is now in consideration of a lymph node transplant for august 2018 and a potential future of no longer requiring a pneumatic pump or wearing of the sleeve as per the surgeon.
CERVICAL PAIN IN A PATIENT WITH A POSITIVE HISTORY OF CERVICAL CANCER
Butsick M, Keating C
BACKGROUND & PURPOSE: Exercise treatment for patients with side effects of cancer stands supported in current literature to be advantageous independent of type or stage of cancer. However, many students/clinicians are timid in their approach of patients when cancer is present at or near the site of symptoms. With expanding cancer rates and expanding roles of outpatient Physical Therapists, clinician's must improve their clinical reasoning competencies for red-flag screening and understanding of the barriers and facilitators of safe exercise and manual therapy treatment options. The purpose of this study is to describe the clinical decision-making process for the management of a patient with insidious onset of cervicalgia in the presence of significant red-flags and diagnosed cervical cancer.
CASE DESCRIPTION: Female patient in her 5 decade of life experienced acute onset of cervical pain/stiffness. Red-flag screening exposed difficulty with bowel/bladder, dizziness/fainting, HA, and nausea. In addition, psychosocial barriers to participation of physical therapy included a fear of movement and limited health literacy. The patient's chief compliant was pain radiating down the spinal column into her bilateral upper extremities with weakness and paresthesia. The patient presented to an outpatient therapy clinic after two weeks of symptoms to address her impairments. Using the cervical spine classification system to develop a POC, the patient was treated successfully with specific extension-based exercises, manual mobilizations, and elevated intensity exercises.
OUTCOMES: Post Physical Therapy treatment, the patient experienced improvements in muscular flexibility surrounding the cervical spine, reduced dural tension signs into her upper extremities/L'hermitte's Sign, and improved her functional strength to regain participation in social activities. Standardized subjective improvements were recorded in a Focus On Therapeutic Outcomes (FOTO) score of 22 points, and a Neck Disability Index (NDI) score reduction by 29 points.
DISCUSSION: Patients with cancer related symptoms are just beginning to experience the benefits of Physical Therapy as the previously limited literature and educational levels of Entry-Level Clinicians grows. This case report is evidence of the growing positive outcomes seen current literature for patients with cancer related symptoms via the use of conservative exercise treatment. By reviewing the clinical decision-making process, this study suggests the diagnosis of cancer continue to be a contraindication for certain intervention options, but not be a strict limitation in treatment of the patient. While the presence of red and yellow flags influences our expected prognosis, we must challenge these barriers to inform better treatment. This case serves as a guide to the clinical decision-making needed for complex cases in outpatient orthopedics.