Friday TIME: 11:00 – 1:00 pm and 3:00 – 5:00 pm (see the program for room assignments and specific times)
Friday February 14, 2020: 11:00 – 1:00 pm
CARDIOMETABOLIC CHARACTERIZATION OF PEOPLE LIVING WITH HIV SEEKING TREATMENT IN THE SOUTH TEXAS REGION
Lira C, Fleck HV, Quiles N, Ortiz A
PURPOSE/HYPOTHESIS: People living with HIV (PLWH) are at an increased risk of developing metabolic syndrome (MetS) as a consequence of the virus itself and antiretroviral medications. The purpose of this investigation was to characterize the cardiometabolic profile of PLWH and their risk of MetS. We hypothesized that the vast majority of PLWH would have 3 or more of the markers for MetS based on the World Health Organization (WHO) criteria.
NUMBER OF SUBJECTS: 200 PLWH in the South Texas Region
MATERIALS AND METHODS: A large dataset from electronic medical records (EMR) of PLWH seeking care at The University of Texas Health San Antonio and affiliates was used for this investigation. We identified from the EMR documented markers for MetS to characterize the cardiometabolic profile of PLWH in this region. The variables considered to meet the diagnosis of MetS per WHO were: cholesterol (≥ 200 mg/dL), triglycerides (TG) (≥150 mg/dL), glucose (≥ 6.5%), body mass index (≥30 kg/m2), and blood pressure (SBP ≥ 140 mmHg / DBP ≥ 90 mmHg). Demographic variables retrieved from the EMR were: height (in), weight (lbs), age (yrs), gender (M/F), race, viral load (copies/mL), and CD4 (%). We identified the first encounter as representation of the initiation of care. A reduced database was created in Microsoft Excel to represent our variables of interest and transferred to the statistical software (SPSS, IBM v.26) for analysis. The database was screened for absurd values and was considered missing values if found. Descriptive statistics such as mean, standard deviation (SD), range, variance, minimum and maximum, and percentiles (25, 50, 75) were estimated for all variables.
RESULTS: The sample comprised of 35% Hispanics and 65% Non-Hispanics, primarily Caucasians (75%) and Black (19%), of which 77% classified themselves as men. Age, weight, and height were 49.88 ± 12.2 yrs; 179.1 ± 44.3 lbs; 77.4 ± 3.8 in, respectively. CD4 and viral load were 20.8 ± 10.5 % and 27,102 ± 102,813 copies/mL, respectively. The average cardiometabolic profile of these individuals was borderline for meeting the criteria for MetS; BMI=29.5 ± 7.4 kg/m2 (range: 21-53); HbA1C=6.17 ± 1.84% (range: 4-13); cholesterol=177 ± 42.7 mg/dL (range: 80-362); TG=190 ± 156.1 mg/dL (range: 37-1,099); SBP= 129.9 ± 17.2 mmHg (range: 92-187); DBP=78.2 ± 11.8 mmHg (range: 52-117). However, by evaluating the range of values of the sample close to 50% of PLWH met the criteria for MetS in at least 3 of the markers.
CONCLUSIONS: PLWH in the South Texas region exhibit an elevated cardiometabolic profile compatible with MetS.
CLINICAL RELEVANCE: Due to the greater morbidity and mortality in PLWH with MetS early intervention is imperative. Physical therapists should be included as healthcare providers at the initiation of care to improve the health and wellness of these individuals.
IMPLEMENTING ONCOLOGY REHABILITATION OUTCOME MEASURES INTO PHYSICAL THERAPY PRACTICE USING A KNOWLEDGE TRANSLATION PROCESS
Lawrence SD, Perry EB
PURPOSE: The purpose of this special interest report is to describe the process used to develop and implement evidence based physical therapy (PT) oncology outcome measures (OM) using a knowledge translation process.
DESCRIPTION: Cancer survivorship and life expectancy have increased dramatically and as a result more people seek PT services for the management of cancer-related sequelae. Until recently, there has been little agreement about which OM are psychometrically strong for this population. To rectify this, a multi-site PT Quality Improvement team used a knowledge to action (KTA) framework to guide the process. A gap between the evidence and practice was confirmed through a clinician survey and medical chart audits of fifty-four patients with breast cancer who received outpatient PT. Only 28.1% of the OM administered by clinicians were reliable and valid for this population. The survey of nineteen clinicians revealed that 89.5% of the PTs reported using OM “often to regularly” and 63.2% reported having challenges with using OM. The barriers to OM use were a lack of knowledge and training (54.1%), access to OM and specific OM psychometrics (12.2%), time (9.1%) and perceived patient factors (24.6%). The team reviewed the evidence published by the Oncology EDGE Taskforce, and selected OM for trial that were psychometrically strong, clinically feasible and valuable, and publicly available. Fourteen OM were then selected creating a toolbox to promote congruency between medical and oncology PT programs and for use across the continuum of care. Clinicians at each site set clinical practice change benchmarks for administering OM and repeat measurement. An implementation plan was tailored to address the barriers identified from the survey and discussion, and included: didactic training, hands-on skill labs, site-specific mentoring, and test-specific psychometric phrases to ensure use of best evidence. The training was completed in four months. All tests, instructions, training tools, and psychometric phrases were embedded into the electronic documentation and an archival system to promote easy access for clinical use and future training.
SUMMARY OF USE: The KT process provided an effective framework for knowledge broker-clinician partnership, innovation and the educational model used for the implementation plan. The clinician-set benchmarks provided targets for performance change. Post-implementation measurement of OM use by clinicians will be assessed through an automated report in six months.
IMPORTANCE TO MEMBERS: Clinicians successfully collaborated on a KT project and utilized evidence published by the Oncology PT EDGE Taskforce to develop and implement a set of standard PT Oncology Rehab outcome measures which are reliable and valid to use with this population for patient evaluation, treatment planning, and measuring response to treatment. This process was a feasible and effective model for implementing best practice in PT oncology rehab practices.
CASE REPORT OF INTRAMUSCULAR DRY NEEDLING-ELECTRICAL STIMULATION TO FACILITATE HAND FUNCTION AFTER BRAIN TUMOR RESECTION
Neuhold RL, Hile ES
BACKGROUND AND PURPOSE: Resection of brain tumors can lead to upper extremity movement dysfunction, often complicated by spasticity. Resulting limitations in activity and participation warrant neuro-oncology rehabilitation, but spasticity can narrow therapeutic options. Electrical stimulation (ES) is used to facilitate neuromuscular re-education, usually as functional electrical stimulation (FES), but surface electrodes may not achieve specific, dissociated contractions to retrain functional hand movements. Intramuscular dry needling (IMDN) is an emerging technique with potential to reduce tone and improve motor control following neurological insults. There is limited evidence to guide the application of IMDN with ES for the treatment of impaired upper extremity (UE) motor control in the presence of spasticity. Authors of a case report of a patient with a benign brain tumor reported short-term outcomes of improved spasticity (modified Ashworth scale, or MAS, decreased from 1 to 0) and active motion (wrist extension increased from 40 to 53 deg) after 3 sessions of DN without concurrent ES. The purpose of this case report is to describe application of IMDN with ES immediately prior to functional movement retraining in an individual with disabling, chronic spasticity after brain tumor resection.
CASE DESCRIPTION: A 31-year-old male with history of right basal ganglia pilocytic astrocytoma, partially resected 2.5 years earlier, presented to outpatient oncologic physical therapy with movement dysfunction. Examination revealed left hemiparesis with spasticity, and greatest deficits in isolated hand function. He demonstrated 0 degrees of active wrist extension, no dissociated finger movements, and grade 3 spasticity by MAS. He required an orthosis to fish, and was unable to perform work to repair his boat. He had completed 2 years of intermittent rehabilitation, including constraint-induced therapy, mirror therapy and surface FES, with little improvement in hand function. He self-rated his improvement with prior rehabilitation as only 1+ (‘a little better) on a 7-point Global Rating of Change (GRoC) scale. IMDN (Needles .2 × 30 mm) with ES was initiated at the start of his weekly physical therapy sessions, to facilitate dissociated active hand movement for more successful repetitions of functional movement. Needles were applied to the survivor's left forearm, specifically in the muscle's extensor carpi radialis longus, brevis, and ulnaris, with parameters adjusted to elicit a twitch response for 8 min.
OUTCOMES: Immediate post-IMDN improvements included 23-degree increase in active wrist extension, reduction in spasticity to 1+ (MAS), and dissociated active finger movement. These immediate intra-session improvements allowed greater participation in therapeutic interventions that were otherwise not feasible, although <25% of spasticity and motion gains were retained between sessions. However, after 8 weekly sessions, despite low retention of reduced spasticity, the brain tumor survivor reported significant improvement in UE function (GRoC 3+), and described the ability to fish independently without modification, and to install a motor in his boat.
DISCUSSION: This case highlights immediate, but transient, spasticity reduction with application of IMDN-ES, allowing dissociated finger movements, for improved muscle activation and motor control during therapy; as a result, UE impairment, activity, and participation improved. The limitations of a single case report are many, and formal research is needed using IMND-ES in individuals with spasticity and other hypertonicity resulting from brain tumors.
EFFECTS OF AEROBIC AND RESISTANCE EXERCISES ON LEAN MASS AND INSULIN RESISTANCE IN OBESE BCS
Gorgi VJ, Serrano T, Sami N, Lee K, Dieli-Conwright C
PURPOSE/HYPOTHESIS: Insulin resistance (IR) is associated with increased cancer recurrence and mortality, potentially as a result of the promotion of the survival and growth of residual cancer cells by excess insulin.1 Furthermore, reductions in lean mass, often as a result of cancer treatments, are associated with worsened IR.2 We previously found that aerobic and resistance exercise improved IR assessed by Homeostatic model assessment (HOMA-IR) and lean mass among obese sedentary breast cancer survivors (BCS).3 In this secondary analysis we sought to examine whether exercise-induced improvements in HOMA-IR were associated with increased lean mass in obese sedentary BCS. We hypothesized that reductions in HOMA-IR were associated with improvements in lean mass in obese sedentary BCS.
NUMBER OF SUBJECTS: 100
MATERIALS AND METHODS: BCS were randomized to either the exercise group (n=50) or the usual care (CON) group (n=50). The exercise (EX) group participated in three weekly sessions for 16 weeks in a supervised moderate-to-vigorous aerobic and resistance program (65%-85% heart rate maximum). HOMA-IR was used to estimate insulin resistance using the validated equation: Fasting Plasma Insulin/Fasting Plasma Glucose (mmol/L)/22.5. Whole-body dual-energy X-ray absorptiometry (DEXA) scans were performed to assess lean mass (Lunar GE iDXA; Fairfield, CT). Outcome measures were assessed at baseline and post-intervention (4 months). Pearson's correlation was used to evaluate the association between HOMA-IR and lean mass in the EX group.
RESULTS: On average our sample included women 53.5±10.4 years old, who were postmenopausal (60%) and Hispanic (55%) with a BMI of 33.5±5.5 kg/m2. Exercise adherence was 95% and post-intervention assessments were available on 91% of participants. HOMA-IR and lean mass were significantly improved in the EX group when compared to baseline and the CON group (p<0.001). Post-exercise, significant correlations were found between reductions in HOMA-IR and improvements in lean mass in the EX group (r=0.94; p<0.01).
CONCLUSIONS: Following a 16-week aerobic and resistance exercise intervention, HOMA-IR was associated with the improvement in lean mass of obese sedentary BCS. Our findings emphasize the need for aerobic and resistance exercise in obese sedentary BCS to potentially reduce the risk of disease recurrence.
CLINICAL RELEVANCE: Clinicians should consider the incorporation of aerobic and resistance exercises into treatment plans for BCS to improve lean mass and insulin resistance.
HIGH-INTENSITY INTERVAL TRAINING DID NOT CHANGE BLOOD PRESSURE IN BREAST CANCER PATIENTS UNDERGOING ANTHRACYCLINE CHEMOTHERAPY
Zhou J, Lee K, Dieli-Conwright C
PURPOSE/HYPOTHESIS: Anthracyclines are common chemotherapy agents used to treat early and late stage breast cancer, despite several negative cardiovascular consequences. This class of drugs has been shown to increase systolic blood pressure (SBP) due to oxidative stress, endothelial cell impairment, and fibrotic/inflammatory changes in the vascular wall, leading to a higher risk of developing anthracycline-induced cardiotoxicity. High intensity interval training (HIIT) has been shown to decrease SBP in overweight/obese adults, and those with hypertension. This study was conducted to determine the effect of an 8-week HIIT intervention concurrent with anthracycline chemotherapy on resting SBP in breast cancer patients.
NUMBER OF SUBJECTS: 30
MATERIALS AND METHODS: Women, ≥18 years of age, sedentary, diagnosed with stage I-III primary invasive breast cancer, and receiving (neo)adjuvant anthracycline chemotherapy were recruited from breast cancer clinics at the Norris Comprehensive Cancer Center and the Los Angeles County Medical Center. Eligible and consented participants completed baseline testing at the Integrative Center for Oncology Research in Exercise prior to initiation of the intervention period. Participants were randomized to a HIIT group (n=15) or a control (CON) group (n=15) for the 8-week intervention period, with participants in the HIIT group completing three HIIT sessions a week for a total of 90 exercise minutes each week. The CON group was instructed to maintain their current level of physical activity, while not exceeding 30 minutes of structured exercise per week. Blood pressure was recorded with an automated sphygmomanometer after 15 minutes of quiet resting. Post-testing was conducted within one week of completion of the intervention.
RESULTS: At baseline, the HIIT and CON groups did not differ by age (46.9±9.8 years), BMI (31.0±7.5 kg/m2), and SBP (123.4±16.8 mmHg). Following 8 weeks, SBP was not significantly changed in both HIIT group (120.9±13.9 to 119.0±10.9 mmHg; p=0.50) and CON group (125.7±19.2 to 127.7 ±19.9; p=0.51). There was no group (HIIT and CON) by time interaction for SBP (P=0.25).
CONCLUSIONS: An 8-week HIIT intervention did not change SBP in patients undergoing anthracycline chemotherapy. Our results may indicate the need for future studies with either 1) a longer intervention and follow-up period or 2) a larger sample size.
CLINICAL RELEVANCE: As exercise prescription becomes increasingly common in the treatment and management of patients with active cancer, physical therapists who treat cancer patients concurrently undergoing anthracycline chemotherapy must be informed about possible exercise interventions (including their duration, intensity, and frequency) and their effect on the cardiovascular system.
HEALTH BELIEFS ABOUT PHYSICAL THERAPY FOR BREAST CANCER-RELATED IMPAIRMENTS: INSIGHTS FROM SURVIVORS AND THEIR PROVIDERS
Flores AM, Iverson MD, Rosales A, Penedo F, Gradishar W, Hansen N
PURPOSE/HYPOTHESIS: This preliminary report describes health beliefs about physical therapy (PT) for cancer-related impairments for older (≥ age 65) breast cancer survivors (BCS) and oncology specialists (OS). We hypothesize that there are differences between BCS and OS regarding beliefs about PT for BCS.
NUMBER OF SUBJECTS: 50 BCS and 48 OS.
MATERIALS AND METHODS: We used computer assisted telephone interviews to conduct a one-time, observational surveys of BCS (identified with the Enterprise Data Warehouse at Northwestern University) and OS (referred by our BCS). The study received human subjects' approval.
We collected survey data on medical history (verified by standardized medical chart review), patient reported breast cancer-related impairments, and physician PT referral priorities. We modified the Health Beliefs Model Scale (HBMS) to measure susceptibility, benefits, barriers, self-efficacy, and fear sub-scales with respect to PT to address breast cancer-related impairments. Responses were measured with a Likert scale (1=not at all likely to 5=very likely). Each subscale has good internal consistency (Cronbach =0.69-0.85), test-retest reliability (Pearson r=0.40-0.68) and construct, convergent and discriminant validity. We use descriptive statistics to characterize BCS (survival length, age, race, ethnicity, medical history, household income) and OS (provider type). We compared each HBMS subscale with independent t-tests (p < .05; 1-tailed) to detect differences between BCS and OS.
RESULTS: On average, BCS were diagnosed 4 years ago (SD=1.3), 71 years old (SD=4.9), 91% white, 100% non-Hispanic; 3.0 (SD=1.9) medical comorbidities; household incomes ≥$60k; 67% had lumpectomy and radiation; 28% chemotherapy; 63% had sentinel or axillary lymph node dissection; reconstruction with natural tissue (6%) or implant (12%). All were female. Ninety three percent of OS were oncology physicians and 7% were oncology nurse practitioners or primary care providers. The top 3 OS referral priorities were lymphedema (94%), limited shoulder ROM (56%) and pain (31.3%). BCS top 3 impairments were pain (56%), fatigue (56%) and limited shoulder ROM (47%).
Compared to OS, BCS reported significantly lower susceptibility to ever needing PT (t=-5.12; p<001); fewer benefits (t=-3.50; p<.001) and barriers to PT (t=-5.37; p<001); higher self-efficacy about receiving PT (t=3.40; p<.001); and less fear of PT (t=-5.40; p<.001).
CONCLUSIONS: Our preliminary findings support our earlier work that prevalence of breast cancer-related impairments is high. OS appear to have a mismatch between PT referral priorities and patient reported impairments. Health beliefs about PT are substantially different between BCS and OS. BCS believe they are less susceptible to needing PT, see little benefit of PT, have few barriers to utilizing PT, high self-efficacy about accessing PT, and little fear of PT. OS seem to have a disconnect between their beliefs and PT referral priorities. However, they have a great deal of confidence that their patients are able to seek and obtain PT services without their referral. Limitations include a small sample of primarily white BCS.
CLINICAL RELEVANCE: Our study sheds light on an underlying behavioral mechanism – health beliefs - that might be leveraged to deliver targeted patient and provider education about the benefits of PT and requirements for referral. BCS have high self-efficacy, few barriers and little fear about getting PT which may help optimize care for older BCS.
MOVEMENT, FUNCTION, AND LYMPHEDEMA IN WOMEN WITH AND WITHOUT AXILLARY WEB SYNDROME: 5 YEAR FOLLOW-UP
Koehler LA, Hunter DW, Blaes AH, Haddad TC
PURPOSE/HYPOTHESIS: Axillary web syndrome (AWS) is a tight band of tissue that develops in the axilla following breast cancer surgery with lymph node removal. The short to mid-term physical issues associated with AWS includes reduced shoulder movement, upper extremity dysfunction, and higher arm lymphedema measures (CITE-Koehler 2015, 2018, O'Toole). The purpose of this study was to determine the prevalence of AWS in a cohort of women that have been followed longitudinally for 5 years post breast cancer surgery and determine the long-term physical issues associated with AWS. We hypothesized that 1) women would have lingering signs of AWS at 5 years, 2) the 5-year prevalence would be >50%, and 3) women with AWS would have significantly lower shoulder range of motion, worse upper extremity function, and higher lymphedema measures compared to those without AWS.
NUMBER OF SUBJECTS: 27 subjects at 5 years
MATERIALS AND METHODS: Thirty-six women enrolled in this 5-year longitudinal, observational study with visits at 2, 4, 12, and 78 weeks and 5 years after surgery. Women were diagnosed with AWS if they were identified with AWS on physical exam at any time point within 5 years of surgery. Descriptive statistics determined the prevalence of AWS. An independent student t-test compared goniometric shoulder range of motion, upper extremity function using the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and lymphedema measures using limb volume, bioimpedance spectroscopy (BIS), and trunk tissue dielectric constant (TDC) in women with and without AWS who completed the 5 year follow up visit.
RESULTS: Fourteen of the 27 women (52%) who completed the 5 year follow up visit had lingering signs of AWS at 5 years. Women with AWS (identified at any time point within 5 years) had significantly lower abduction passive (p=0.037) and active (p=0.047) range of motion compared to women without AWS. Active and passive flexion range of motion were lower in the AWS group but did not reach a statistical difference (p=0.142, p=0.223, respectively). There was no statistically difference in upper extremity DASH scores (p=0.667) or lymphedema measures (BIS p=0.585, arm volume p=0.783, chest TDC p=0.290) between the two groups.
CONCLUSIONS: AWS is a common condition that can linger for up to 5 years after breast cancer surgery and is associated with long term reduced shoulder range of motion.
CLINICAL RELEVANCE: AWS is a chronic condition in breast cancer survivors and presents as a tight band of tissue in the axilla that limits shoulder movement.
BREAST CANCER SURVIVORS' POSTURAL SWAY EXCEEDS EXPECTATIONS FOR AGE OR VESTIBULAR PATHOLOGY: A CROSS–SECTIONAL ANALYSIS
Hile ES, Day J, Lin C-C, Dvorak J, Ding K, Whitney SL
PURPOSE/HYPOTHESIS: Breast cancer survivors (BCS) fall at rates expected of individuals who are decades older. They also perform below age-based expectations on balance tests, a documented cancer phenomenon known as ‘Accelerated Aging.’ Mechanisms for accelerated aging of postural control are unclear, but systems potentially at risk for cancer and treatment-related decline include somatosensory, vestibular, visual, and motor. Postural sway during tests of quiet standing can be quantified in the Anteroposterior (AP) and Mediolateral (ML) planes using the validated NIH Toolbox Balance Accelerometry Measure (BAM), as Normalized Path Length (NPL). Our purpose is to compare BAM-sway between 3 groups of females over the age of 35 years: BCS, vestibular patients (VP), and normal controls (NC).
NUMBER OF SUBJECTS: 88 females (mean age 61.5 ± 11.9 yrs, range 39.1-86.1) were compared, including 41 BCS (stage 0-III, all on Aromatase Inhibitors after curative resection), 13 VP, and 34 NC (no evidence of cancer or neuro-vestibular pathology).
MATERIALS AND METHODS: We performed a cross-sectional secondary analysis of AP and ML BAM sway data, obtained from 3 studies with the same testing positions: 1) Feet side-by-side or ‘Narrow,’ 2) Heel-to-toe or ‘Tandem,’ and 3) Narrow on a Foam Cushion. Participants repeated each position with Eyes Open (EO) and Eyes Closed (EC). We analyzed only trials held for the full 45-seconds, and normalized participant sway in all subsequent positions to sway during Narrow EO stance. Median and interquartile ranges for normalized sway were compared between 6 participant groups, formed by dividing each of the 3 groups (BCS, VP, NC) into Midlife (M) & Older (O) sub-groups, using a cut-off of 60.5 years: MNC (n=19), ONC (n=15), MVP (n=7), OVP (n=6), MBC (n=16), OBC (n=25). We compared baseline-normalized NPL among these groups using Kruskal-Wallis ANOVA on ranks with Bonferroni correction for multiple testing. For significant outcomes, we conducted post-hoc pairwise comparisons with Wilcoxon rank-sum tests and Bonferroni corrections.
RESULTS: In all stance positions, normalized AP sway for MBC is 1.2 to 1.9-fold greater than MNC, p = 0.016 to < 0.0001. Further, MBC sway is 1.2 to 1.7-fold higher than both ONC and MVP sub-groups in positions of Narrow EC, Narrow EC Foam, and Tandem EO, p = 0.012 to < 0.0001. In the ML direction, BCS sway more than age-matched NC only in Narrow EC, and mid-life BCS sway more than both ONC and MVP (p=0.011 to <0.0001). In contrast, during Narrow EO Foam, BCS have lower normalized ML sway than comparison groups (p=0.0001).
CONCLUSIONS: While holding a balance position for 45 seconds, midlife BCS demonstrate greater normalized AP sway than cancer-free controls of similar age. In most stance positions, AP sway of MBC also exceeds that of vestibular patients of similar age, and older controls. These findings reinforce Accelerated Aging in cancer, but also suggest that postural sway in BCS, even those who can hold a test position for 45 seconds, exceeds that of individuals with known vestibular pathology requiring rehabilitation. Limitations include small group sizes, especially for vestibular patients, and missing data rates because of difficulty holding more challenging positions (EC Tandem, EC Narrow on Foam) for a full 45 sec.
CLINICAL RELEVANCE: Postural control should be routinely assessed in BCS, and thresholds for rehabilitation referrals should be reconsidered. BAM and similar technologies are increasingly available in clinics and may add value to prospective surveillance of balance from the time of cancer diagnosis, to capture early deficits before falls begin. Even ‘low-level’ balance tasks (Narrow Eyes Open and Closed without Foam) may be informative.
Friday February 14, 2020: 3:00 – 5:00 pm
COMPARING FUNCTIONAL ASSESSMENT IN THOSE WITH CIPN VS. COMMUNITY DWELLING OLDER ADULTS
Behnke AD, Gibbs D, Jansen SS, Stewart JC, Westlake FL, Harrington SE
PURPOSE/HYPOTHESIS: Chemotherapy-induced peripheral neuropathy (CIPN) can negatively impact quality life and independence in activities of daily living for survivors of cancer. Platinum-based chemotherapy agents that can lead to CIPN are used to treat breast, colorectal and gynecological cancers. Little is known about the functional deficits that commonly occur in this population and how these deficits compare to community dwelling older adults. The purpose of this study is to compare individuals with CIPN to community dwelling older adults by comparing gait speed, patient-reported balance confidence, and lower extremity function.
NUMBER OF SUBJECTS: 44 subjects (breast=15, colorectal=15, gynecological=13, pancreatic=1) between the ages of 18 and 90 years, referred to Oncology Rehab in Centennial, Colorado and currently receiving or previously received platinum-based chemotherapy treatment were included. Four subjects were diagnosed with stage 1 cancer, 10=stage 2, 18=stage 3, 10=stage 4, and 2 were unreported.
MATERIALS AND METHODS: A pragmatic prospective cohort clinical based study was conducted. Subjects with history of CIPN from platinum-based chemotherapy treatments were assessed by licensed physical therapists prior to starting physical therapy for the following: gait speed, the Activity Based Confidence Scale (ABC) and Lower Extremity Functional Scale (LEFS). Means from our study were then compared to reported literature for the 3 measures in community dwelling older adults.
RESULTS: Subjects had an average gait speed of 0.94 m/sec, while community-dwelling older adults average 0.88 m/sec. Scoring < 1.0 m/sec are at a higher risk of mortality. Subjects scored 70.5% on the ABC scale, while community-dwelling older adults reported average was 79.9%. Subjects scored 44.4/80 on the LEFS, while community-dwelling older adults reported average was 66.0/80.
CONCLUSIONS: Individuals with CIPN present with greater deficits in balance and LE function than community dwelling older adults.
CLINICAL RELEVANCE: Deficits in this CIPN cohort are apparent when compared to community dwelling older adults. This population may benefit from a personalized physical therapy program to ameliorate these impairments. We recommend those with CIPN be referred to physical therapy as soon as symptoms develop.
EFFECTIVENESS OF YOGA AND MEDITATION FOR CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY: A PILOT STUDY FEATURING MINORITY RECRUITMENT
Galantino ML, Brooks J, Tiger R, Jang S, Wilson KA
PURPOSE/HYPOTHESIS: Chemotherapy-induced peripheral neuropathy (CIPN) causes significant pain and is an adverse effect of cancer treatment. Yoga is a popular movement therapy used by cancer survivors, with prior studies representing Caucasian, suburban, female middle-aged breast cancer survivors.1-5 Minorities and other populations are definitively underrepresented in the existing research on yoga for cancer survivors, with notable barriers.6-8 This study explored a somatic yoga and meditation (SYM) intervention on functional outcomes and quality of life (QOL) in a predominantly minority population with CIPN in an urban setting. The goals of this single-arm feasibility study are to describe recruitment strategies, test feasibility, and determine preliminary effectiveness of an 8-week protocol for CIPN.
NUMBER OF SUBJECTS: Eight individuals diagnosed with CIPN self-reported as 63% African American and 37% Caucasian. Mean age was 65.0 years (49-73) with 81% attendance and no adverse events.
MATERIALS AND METHODS: SYM was provided once a week for 8 weeks × 1.5 hours, with home program, journaling, and group debriefing at mid- and end-study. Primary outcomes: Sit and Reach (SR), Functional Reach (FR), and Timed Up and Go (TUG). Self-reported secondary outcomes: Patient Neurotoxicity Questionnaire (PNQ), FACT-GOG-Ntx, Brief Pain Inventory (BPI), Perceived Stress Scale (PSS), Pittsburgh Sleep Quality Index (PSQI), and Falls Efficacy Scale (FES). Vibration sensation measured via biothesiometer.
Results: Quantitative Findings: Improvement trended in flexibility (SR) (mean reduction 3.20, SD 5.33, p=0.133) and balance (FR) (mean reduction 1.45, SD 7.41, p=0.597). TUG showed reduced fall risk (mean reduction 1.16, SD 1.84, p=0.119). CIPN symptoms (FACT-GOG-Ntx) improved significantly (88.88 to 106.88, SD 20.03, p=.039), with improvement in sensory symptoms and muscular weakness (PNQ) (3.56 to 3.31, p=.316). Decreased fear of falling (FES) approached significance (39.26 to 34.38, SD 6.081 p=.058). Stress (PSS) reduced (15.75 to 15.00 p=0.608), with sleep quality (PSQI) improved (9.75 to 9.38 p=0.644). Spirituality (FACIT-SP) improved (101.75 to 115.63 p=.496). Participants experienced slight increase in BPI pain severity (3.50 to 3.75, p=0.041) which may reflect musculoskeletal co-morbidities.
QUALITATIVE FINDINGS: Four themes emerged: 1) Variation of CIPN symptoms, with musculoskeletal pain, 2) Utility of learned skills, 3) Improvement in self-confidence, balance, and stability, 4) Social support, with CIPN experience validation and increased health literacy.
CONCLUSIONS: Recruitment challenges require specific outreach, community level trust, and health literacy assistance. Preliminary data suggests SYM for CIPN may reduce fear of falling and CIPN symptoms, and improve QOL.
CLINICAL RELEVANCE: Rehab professionals may choose components of yoga (e.g. balance poses, breath work) for intervention, including referral to gentle community yoga programs. An inclusive randomized controlled trial, utilizing methods of representative recruitment, is needed to establish efficacy of SYM for CIPN for cancer survivors.
UTILIZING RASCH ANALYSIS TO VALIDATE HEAD AND NECK CANCER EDGE RECOMMENDATIONS FOR SHOULDER DYSFUNCTION
PURPOSE/HYPOTHESIS: The aims of this research study were to: (1) use Rasch methodologies to assess construct validity and overall appropriateness of test score interpretation of patient-reported outcome measures (PRO) recommended by the Head and Neck Cancer (HNC) EDGE Taskforce, including the Disability of the Arm, Shoulder and Hand (DASH), QuickDASH, Shoulder Pain and Disability Index (SPADI) and Neck Dissection Impairment Index (NDII); and (2) determine appropriateness of use of University of Washington Quality of Life (UW-QoL) shoulder subscale as a screening tool for shoulder impairment.
NUMBER OF SUBJECTS: One hundred and eight-two individuals who received a neck dissection procedure for HNC within the past 2 weeks to 18 months
MATERIALS AND METHODS: Rasch methodologies were utilized to address the primary aim of the study through consideration of scale dimensionality [principal components analysis, item and person fit, differential item functioning (DIF)], scale hierarchy (gaps/redundancies, floor/ceiling effects, coverage of ability levels), response scale structure, and reliability (person and item reliability and separation statistics). The secondary aim was addressed through correlational analysis of the UW-QoL (shoulder subscale), with the 4 PROs.
RESULTS: The DASH did not meet criteria for unidimensionality, and was deemed inappropriate for utilization in this sample. The QuickDASH, SPADI and NDII were determined to be unidimensional. All scales had varying issues with person and item fit, DIF, coverage of ability levels, gaps/redundancies, and optimal rating scale requirements. The NDII meets most requirements. All measures, except for the QuickDASH, were found to meet thresholds for person and item separation and reliability statistics.
CONCLUSIONS: Rasch analysis indicates the NDII is the most appropriate measure recommend for this population. The QuickDASH and SPADI are appropriate but have limitations. The DASH and UW-QoL (shoulder subscale) are not recommended.
CLINICAL RELEVANCE: Rasch analysis provides an objective methodology to validate recommendations for PROs recommended by clinical experts in forums such as the EDGE TaskForce
THE ROLE OF PHYSICAL THERAPISTS PRACTICING IN NATIONS WITH ADVANCED PALLIATIVE CARE INTEGRATION
Wilson CM, Stiller C, Doherty D, Thompson K, Smith AB, Turczynski KL
PURPOSE/HYPOTHESIS: Palliative care (PC) is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. The purpose of this study was to explore the perceptions and experiences of physical therapists (PT) outside of the United States (US) and Canada regarding their role in PC when practicing in nations with advanced integration of PC services into mainstream healthcare.
NUMBER OF SUBJECTS: Thirteen PTs from eight different nations (outside the US and Canada) with high PC integration into mainstream healthcare (Categorized by Lynch et al 2013)
MATERIALS AND METHODS: This was a qualitative study with an electronic demographic survey and a semi-structured interview. Inclusion criteria was that the participant had at least 5 years of experience as a PT, 5 years practicing with patients in PC, and be able to speak and understand English. Participants were recruited by searching professional organization websites, personal contacts of authors and via snowball sampling. After informed consent was obtained, an electronic demographic survey was completed followed by individual semi-structured interviews via web conferencing. Data was analyzed using descriptive statistics for demographic information and interview analysis employed the constant comparative method until saturation.
RESULTS: Four roles and responsibilities were identified: 1) role of PTs in patient and family care, 2) as an interdisciplinary team (IDT) member, 3) professional responsibilities of PTs beyond direct patient care, and 4) factors influencing the role of PTs in PC. Concepts identified were shifting priorities, care across the continuum, and changing perceptions about PT in PC. Within shifting priorities, themes included increased family involvement, emphasis on psychosocial aspects, and differences in care philosophy. For care across the continuum, themes included accommodating changes in patient status, increased awareness of the PT's role in varying disease states, and working with the IDT. For changing perceptions about PT in PC, themes included perceptions of PTs and others regarding PTs' role in PC as well as professional responsibilities of the PT in PC.
CONCLUSIONS: Within PC, PTs play a key role on the IDT and can improve quality of life, however multiple barriers exist to providing PT care within PC. Further advocacy is needed from PTs and professional organizations to integrate these services.
CLINICAL RELEVANCE: From the participant responses in this study a conceptual framework (originally from Wilson et al 2015) was refined. Commonalities between this study and Wilson et al 2015 included the PTs' important role in relieving symptoms, providing direct patient/family care, and being a key member of the IDT. Barriers to integration of PT services included a lack of specialized education and awareness of PT within PC. Findings that were different than Wilson et al 2015 included an increased emphasis on patient wishes and dignity, treating breathlessness, the patient within the family, and use of technology and networking.
POST-OPERATIVE REHABILITATION PROTOCOL FOR VASCULARIZED LYMPH NODE TRANSFER FOLLOWING COMPLEX PRESENTATION OF LOWER EXTREMITY LYMPHEDEMA
Jan M, Perdomo M
BACKGROUND AND PURPOSE: Lower extremity lymphedema (LEL) occurs in 3-25% of patients after treatment for gynecological cancer and results in impaired quality of life (QOL) and increased risk of cellulitis, subsequent hospitalization, and supportive care. Lymphedema is commonly treated with complete decongestive therapy (CDT), which includes skin care, compression, manual lymphatic drainage (MLD), and exercise. For more advanced stages of lymphedema, vascularized lymph node transfer (VLNT) aims to reduce the lymphedematous limb by transferring an autologous flap with lymph nodes to the affected limb. While this newly established surgical technique improves LEL in 35-53% of cases, this is the first case study to this author's knowledge that discusses post-operative rehabilitation protocols to enhance the success of surgical outcomes in patients.
CASE DESCRIPTION: The patient was a 66-year-old female with history of hysterectomy with right salpingo-oophorectomy secondary to pelvic mass in 1998, cervical cancer status post radical trachelectomy and associated lymph node removal in 2003, and frequent urinary tract infections. Left LEL began in 2011, and she experienced recurrent cellulitis, yearly. She presented to PT after a bout of cellulitis with Grade 2+ left LEL as well as pitting and fibrosis below the knee. During 6 months of aggressive CDT, she experienced 4 bouts of cellulitis, resulting in worsening lymphedema and fibrosis. Therefore, she was referred to a plastic surgeon for evaluation of surgical intervention. Pt returned to PT 1-month status post VLNT from omentum to left groin and left lower leg.
OUTCOMES: Outcome measures included LE strength, range of motion (ROM), circumferential measurements, and health-related quality of life (HRQOL) measurements. Circumferential measurements were taken weekly at 10cm increments and converted to volumetric measurements. HRQOL measures included Lymphedema Quality of Life Tool (LYMQOL)-Leg and Lower Extremity Functional Scale (LEFS). Outcome measures were assessed 1 week before surgery and 1 month post-operatively. PT interventions included MLD plus a progressive use of compression and resistance exercises. Outcome measures were re-assessed at 3 months post-operatively and demonstrated improvements in strength, ROM, and QOL. Volumetric measurements did not show significant change; however, tissue quality and fibrosis were improved, and the patient required less aggressive compression to maintain tissue quality.
DISCUSSION: LE strength, ROM, and quality of life improved with utilization of PT post-operatively. LE volumetric measurements did not have a significant change at 3-month follow-up; however, the patient had significant improvement in tissue quality and required less aggressive compression. This case study suggests that a post-operative PT protocol may be helpful to maximize results after VLNT. However, longer follow-up may be required to see significant changes in volumetric measurements and validated measures to detect changes in tissue quality are necessary to accurately capture change in the post-operative period.
OUTCOMES FOLLOWING POST FIBULAR FLAP RESECTION WHERE AMBULATION WAS INITIATED POST OP DAY 1
BACKGROUND AND PURPOSE: Patients with oral cancers with osteo involvement of the mandible, that require reconstruction, typically require a bone graft. The most common bone graft is a fibular free flap. Common protocol for weight bearing following fibular free flap is non-weight bearing or toe-touch weight bearing for 5 days post-op. Since, early ambulation has shown to be beneficial with many other procedures including, but not limited to, lower extremity burns and total knee arthroplasty this case series was devised. This case series was designed to measure outcomes of 19 patients in an early ambulation (EA) group: status post free fibular flap with weight bearing as-tolerated (WBAT) ambulation initiated on post op day one. These outcomes were compared to the control group; 19 previous patients who began WBAT ambulation per traditional protocol on post op Day 5. Mean age: 60 years of age (YOA) for the EA group and 58 YOA for the control group.
CASE DESCRIPTION: Length of Stay (LOS), first and last Activity Measure for Post-Acute Care – Mobility (AM-PAC-M), last Gait Distance (GD), and discharge location with needs (D/C) were measured in both groups. Additionally, first and last Gait Speed (GS) were measured in the EA group only. Patients in both groups were seen by Physical Therapy once a day and given an appropriate plan of care that was updated daily. Ambulation with WBAT was initiated POD1 for patients in the EA group and POD5 in the control group.
OUTCOMES: Mean LOS was 1.9 days less for patients in the EA group (7.5 days) than the control group (9.4 days). Mean Last AM-PAC-M for the EA Group was 20.4 and 21.2 in the control group. Mean last GD was the same (360 ft in the EA Group and 356 ft in the control group). D/C to home with NO skilled Physical Therapy (PT) needs was greater in the EA group with 12 patients as compared to 7 patients in the control group. D/C location for each patient was: EA Group: Skilled Nursing Facility (SNF): 4, Home with Home Health PT (HHPT): 3, and Home with NO PT: 12; Control Group: Inpatient Rehab: 1, SNF: 2, HHPT: 9, and Home with NO PT: 7. Also, within the EA group, gait speeds improved significantly from first to last session as seen by an average increase of 0.19 m/s (0.1 to 0.2 m/s = significant)
DISCUSSION: This case series shows the potential to improve patient outcomes including decreasing LOS and reducing needs post discharge when early ambulation is initiated. Although several factors influence discharge following surgery (decannulation, tube feeds, flap failure, social factors, etc.), early ambulation may help to facilitate decreased LOS. Reducing patient needs post discharge can directly decrease costs to the health system. In addition, early ambulation and increasing gait speed could be beneficial as low gait speed has been shown to be associated with frailty, institutionalization, mortality, and increased fall risk. These measures may also have a significant impact on patient quality of life post discharge, which would need to be measured in future studies.
MOBILE APPS FOR EXERCISE IN CANCER SURVIVORS: ALIGNMENT WITH ACSM RECOMMENDATIONS
Burgess K, Bendul K, Packel L.
PURPOSE/HYPOTHESIS: Mobile applications (apps) are feasible and effective in increasing physical activity (PA) and eliciting behavior change in individuals without cancer. In cancer survivors (CS), PA has been found to be safe and effective in improving; muscular strength, endurance, cardiorespiratory fitness, cancer-related fatigue, self-esteem, anxiety, depression, and quality of life. The American College of Sports Medicine (ACSM) recommends 150 minutes of moderate intensity aerobic exercise, 2-3 days of strength training and flexibility for CS to optimize benefits. However, less than 10% of CS will be active during treatment and 20-30% of survivors will be active following treatment. Cancer survivors are receptive to PA apps which may serve as a modality to improve exercise behaviors, however the alignment of these apps with recommendations is not known. The purpose of this study was to determine the congruence between ACSM recommendations for PA dose in CS and apps commercially available on android and Apple devices.
NUMBER OF SUBJECTS: Sixty-five apps were screened with initial search terms
MATERIALS AND METHODS: Google Play and Apple App stores were searched with terms: fitness, exercise, workout. The first 15 apps that appeared with each of the three search terms were then queried with the term cancer. Apps were then eliminated if they were duplicates, body part specific, gender specific, or cost $5 or more to download. Apps were independently evaluated by two researchers using the scoring instrument created by Guo et al. Apps were be ranked by total score, with an analysis of sub-components.
RESULTS: Six apps met inclusion criteria. All of the apps scored below 35 out of 70 possible points, with 70 indicating total congruence with ACSM recommendations. The Nike Training Club app earned the highest overall score of 33.43/70. Many of the apps lacked safety warnings needed for exercise, especially in those undergoing active treatment. The highest congruence with recommendations was seen in the area of aerobic exercise, with the lowest congruence in the area of flexibility.
CONCLUSIONS: Apps may be an important tool to enhance PA behaviors in CS, potentially resulting in improved fitness and quality of life. The apps presently available do not meet ACSM recommendations for PA dose. An opportunity exists to create evidenced based apps to promote physical activity in cancer survivors.
CLINICAL RELEVANCE: Free or low-priced mobile apps for exercise in cancer survivors are not aligned with ACSM recommendations for PA. Therapists should use caution when recommending these apps to CS.
FINGER SWELLING RESULTING FROM DISTAL LYMPHATIC ABNORMALITY FOLLOWING AXILLARY SURGERY
Van Diepen N
BACKGROUND AND PURPOSE: Breast cancer-related lymphedema (BCRL) is conventionally described as involving the entire upper extremity due to damaged axillary lymph nodes and vessels secondary to surgery and/or radiotherapy. It is not uncommon, however for patients to present with variations in timing and distribution of swelling, calling into question this simple ‘stopcock’ hypothesis. Recent research demonstrates no significant change in axillary activity following axillary lymph node surgery and indicates some patients are constitutively predisposed to BCRL, suggesting the physiological mechanisms underlying BCRL are more complex than the traditional theory describes. The aim of the present report is to discuss an abnormal presentation of BCRL in three patients and review successful conservative treatment strategies including use of one patient's indocyanine green (ICG) lymphography results to identify a specific lymphatic abnormality and demonstrate how results can help direct conservative treatment.
CASE DESCRIPTION: Three patients were referred for lymphedema therapy at our center with complaint of hand swelling, primarily in the second digit. All three patients underwent complete decongestive therapy with a certified lymphedema therapist including manual lymphatic drainage (MLD), training in self-MLD, education regarding exercise, skin care, and risk reduction precautions, and kinesiotaping. Treatment also included procurement of compression garments including trials of several brands and styles of ready-to-wear and custom compression arm sleeves and gloves.
OUTCOMES: All patients achieved visual improvement in finger and hand swelling and subjective report of improved comfort with daily use of a seamless glove with full-length fingers. One patient underwent ICG lymphography, which showed functional lymphatic channels draining to the axilla, however extravasation of ICG from a lymphatic channel at the distal radial forearm. Based on this finding, the patient's self-MLD sequence and compression strategy were modified. All patients ultimately required daily use of seamless glove only resulting in better compliance, and all demonstrated stable limb volume and independence in self-management at discharge.
DISCUSSION: Finger swelling consistent with lymphedema can develop following axillary surgery and may be associated with a lymphatic abnormality distal to the area of surgical insult. Further investigation of this phenomenon is warranted. Finger swelling can cause discomfort and impact hand function sufficiently to necessitate treatment. Experience indicates it can be successfully managed with traditional conservative methods including use of a custom, seamless, full-fingered compression glove and daily self-MLD. ICG lymphography provides useful information to identify the specific abnormality and direct treatment.
MINDFUL MOVEMENT: A COMMUNITY-BASED EXERCISE PROGRAM ADDRESSING CANCER-RELATED FATIGUE: A PILOT STUDY
Frederick D, Matheny CR
BACKGROUND AND PURPOSE: Cancer-related fatigue is a common side effect for individuals who have a history of cancer. The purpose of this case report is to convey how the development of a community-based wellness program can help combat the effects of cancer-related fatigue (CRF) and promote a healthy lifestyle through movement.
CASE DESCRIPTION: Four participants with a past medical history of cancer were recruited from a local cancer treatment facility. All individuals had completed the treatment protocol prescribed by their oncologist. Participants in this study were supervised by a licensed physical therapist and a DPT student.
OUTCOMES: Pre-exercise fatigue levels were measured using the Fatigue Severity Scale (FSS). Following the 12-week class, post-exercise fatigue levels were also measured using the FSS. With the three that completed the post FSS, one participant reported a decrease in CRF while the other two subjects reported a slight increase in fatigue (by one point). Along with the FSS, each participant completed an exit survey in which they all reported a decrease in their CRF since attending the wellness classes. One participant reported an increase in ROM helping to improve the functional use of her upper extremities. Throughout each of the participant's exit survey, they all indicated this class taught them about the importance of movement and how movement has helped to improve their quality of life.
DISCUSSION: With the implementation of mindful movement classes over the course of 12 weeks, there was a decrease in CRF. The exercises used in the mindful movement class focused on strength, balance, stretching and increased ROM. The outcomes of this case report help conclude that these forms of exercise are beneficial in reducing the amount of CRF the participants experience and improving their overall quality of life. In future studies, implementing the FSS more frequently throughout the 12 weeks and providing a through explanation on how to complete the measurement scale may help eliminate discrepancies found on the pre and post exercise fatigue level scores. The results show promise as a viable treatment for CRF and will require further research with larger sample sizes to conclude significant findings.
SYSTEMATIC REVIEW: EXERCISE AND NUTRITION INTERVENTIONS ON QUALITY OF LIFE IN PEDIATRIC BRAIN TUMOR PATIENTS
Yoon LH, Runco DV, Grooss SA, Wong CK
PURPOSE/HYPOTHESIS: As a consequence of life saving treatment, pediatric brain tumor survivors are at risk for long term adverse effects which impact Quality of Life (QOL). This is a systematic review of the literature on exercise and nutrition interventions on QOL in pediatric brain tumor patients.
NUMBER OF SUBJECTS: 7 articles
MATERIALS AND METHODS: This systematic review analyzed controlled or single group studies examining clinical and QOL changes with exercise or nutrition interventions. An electronic search of MEDLINE, CINAHL, AMED, EMBASE, and Cochrane databases was completed through May 2019. The search was time-limited to 10 years, English language publications, and human subjects. Randomized control trials, prospective, single group, or case-controlled studies were included. Case studies, reviews, practice guidelines, and expert opinions were excluded. MeSH terms included: brain tumor, nutrition, exercise, pediatric, childhood, feeding, and quality of life. Keywords included: physical activity, diet, and nutrition supplement. Brain tumor was combined with terms using “and”, while other keywords combined with “or”. Two readers reviewed each article, with a third available in case of disagreements. Subject samples consisted of at least 20% of patients 0-18 years old with primary brain tumors. Interventions included diet or nutritional supplement or exercise or physical activity. Outcomes included measures of QOL (self-report, cognitive, medical, behavioral, functional) in combination with quantifiable measures of exercise or nutrition. The nutrition articles search yielded no QOL measures so surrogate markers were included (i.e. febrile neutropenia, hospital length of stay (LOS), and nutritional status). Study design, sample, intervention, and outcome were compiled. Patient characteristics, measures of nutrition or exercise and QOL were included. Study quality was assessed with potential biases analyzed.
RESULTS: Overall, 375 papers were identified with 14 papers fully reviewed and seven ultimately included. Four exercise and three nutrition studies were analyzed. Included patients represented varied treatment, diagnoses, time since diagnoses, and comorbidities. Aerobic exercise elicited improvements in physical function and fitness, and impacted white cortical development and vascular function in long term survivors. Higher levels of physical activity were linked with improvement in QOL. Nutritional status improved with proactive enteral tube feeding and improvement in QOL surrogates were demonstrated with nutritional supplements.
CONCLUSIONS: Although the evidence favors the clinical and QOL benefit of exercise and nutrition interventions in pediatric brain tumor patients, the lack of prospective, controlled trials limits generalizability and supports the need for further research.
CLINICAL RELEVANCE: Pediatric patients with brain tumors have the most physical and long-term impairments. As survival continues to improve, the focus must shift to include: proactive interventions, and controlled research to inform best practice and support the development of evidence-based guidelines to improve QOL.
IMPACT OF SCRAMBLER THERAPY (CALMARE) FOR THE TREATMENT OF CHEMO-INDUCED PERIPHERAL NEUROPATHY
Tabak Tran RT, Varatkar GV, McManus LC, Eggleston S, Vanderbrink R, Allen LA, Corrin D, Prakash N
PURPOSE/HYPOTHESIS: Chemotherapy-induced peripheral neuropathy (CIPN) is a common and serious consequence of cancer treatment that is often the cause for a reduction or discontinuation of chemotherapy. It has been reported to occur in up to 30% of patients 6-months after completing chemotherapy.1 CIPN is characterized by sensory loss, paresthesia, pain, and numbness in a “stocking and glove” distribution.2 Conventional treatment of CIPN with pharmacological agents has limited effectiveness.3 Calmare is a therapeutic modality with emerging evidence that supports its ability to decrease CIPN related pain.4-6 Calmare provides a non-pain sensation through afferent pain signals via electrostimulation. Our hypothesis is that Calmare will decrease pain, numbness and improve light touch sensation, balance, fine motor coordination, and quality of life in individuals with CIPN.
NUMBER OF SUBJECTS: 25 patients total; 12 patients received Calmare on all four extremities, 12 patients received Calmare on the lower extremities only and 1 patient received Calmare on her upper extremities only.
MATERIALS AND METHODS: Data was collected retrospectively through a convenience sample of patients who completed 10 sessions of Calmare for CIPN in the City of Hope Outpatient Physical Therapy Department. All patients were weaned off of anticonvulsant medication prior to starting treatment. Patients received Calmare for approximately 45 minutes each session with the 10 sessions completed over the span of 2 weeks. Patients received a standardized assessment pre- and post Calmare that included the EORTC chemotherapy-induced peripheral neuropathy questionnaire (QLQ-CIPN20), sensory assessment of the distal extremities using mono-filaments, and reported intensity of pain and numbness. Numbness was measured on a 0-4 scale of intensity (0= no numbness, 1= mild numbness, 2= moderate numbness, 3= significant numbness, 4= complete numbness). Extensor hallicus longus strength and balance (Timed Up and Go (TUG), Romberg, and single leg balance) were assessed for those with lower extremity involvement and fine motor coordination was assessed via the 9-Hole Peg Test for those with upper extremity involvement. Patients with secondary diagnoses that largely contributed to their pain or caused neurologic dysfunction were excluded from this sample.
RESULTS: Significant changes were seen in the post-treatment assessment of quality of life as measured by the QLQ-CIPN-20 and the intensity of numbness in all extremities treated. The QLQ-CIPN-20 is 20 item questionnaire with 3 subscales for sensory, motor, and autonomic symptoms. The maximum score for this test is an 80 with a higher score indicating more severe symptoms. Post-treatment QLQ-CIPN-20 total scores decreased by an average of 7.1 points (n= 24, p<0.01). Numbness in the left upper extremity decreased by an average of 0.93 points on the 0-4 point scale (n= 14, p=.021) and 0.79 points on the right upper extremity (n=14, p =.045). Numbness in the left lower extremity decreased by an average of 1 point of the 0-4 point scale (n=24, p<.0007) and 1.09 points on the right lower extremity (n=24, p <0.0004). Improvements were noted in pain, monofilament testing, single leg balance, and Romberg test, though they did not reach a level of significance.
CONCLUSIONS: These findings support our hypothesis that Calmare will decrease numbness and improve quality of life but does not support our hypothesis that Calmare will improve light touch sensation, pain, balance, and fine motor coordination in individuals with CIPN.
CLINICAL RELEVANCE: CIPN is a common and debilitating side effect of chemotherapy with little effective treatment options. Calmare may be an efficacious intervention to improve numbness and quality of life for patients with CIPN. Our results did not demonstrate decrease pain post scrambler therapy unlike previous studies though very few patients included in this sample (4 of 25) reported pain from CIPN upon the start of treatment. Additionally, the lack of significant improvement noted in these balance measures post-intervention may be related to the sample's baseline scores as the average initial TUG was 11.2 seconds (categorizing these patients as not at risk for falls) and the initial Romberg was 25 seconds (out of a 30 second test). This data adds to the growing literature supporting the use of Calmare for the treatment of CIPN. Further studies are needed on the effects of Calmare on balance and pain in individuals with more severe deficits.
TREATMENT OF BREAST CANCER-RELATED LYMPHEDEMA WITH A NEGATIVE PRESSURE DEVICE: A PILOT RANDOMIZED CONTROLLED STUDY
Lampinen R, Leano J, Smoot B, Mastick J, Miaskowski C, Lisa Brinker L, Lee JQ
PURPOSE/HYPOTHESIS: 1 in 5 women develop lymphedema (LE) following breast cancer (BC) treatment. If untreated, LE may become chronic and result in persistent swelling, inflammation, skin thickening and abnormal fibro-adipose tissue deposition. Current conservative treatments do not specifically address secondary tissue changes that may limit response to treatment. The purpose of this pilot randomized controlled trial (RCT) is to evaluate efficacy of treatment for chronic LE using a negative-pressure device, which mobilizes skin and subcutaneous tissue to support lymphatic circulation.
NUMBER OF SUBJECTS: Data were analyzed for 24 women (informed consent provided) who were ≥ 1 year post active BC treatment and have had unilateral upper extremity LE for ≥ 1 year. Women were randomized into a negative pressure device treatment group (n=12) or a manual lymphatic drainage (MLD) control group (n=12).
MATERIALS AND METHODS: This study compared negative pressure massage using the Lymphatouch device (Helsinki, Finland) to MLD. Both groups followed the Vodder unilateral upper extremity LE sequence. All participants received twelve 1-hour treatments over 4 to 6 weeks. Patients completed demographic and clinical questionnaires, as well as the Disability of Arm, Shoulder, Hand (DASH) questioannaire. Objective measures included bioimpedance (L-Dex, Impedimed) and limb volume calculated from limb circumference. T-tests and ANOVA (GLM-Repeated Measures) were used to evaluate within and between-group differences and interaction effects. Non-parametric tests were used for any non-normally distributed data.
RESULTS: Mean age of participants was 62.9 years (SD 12.8) and body mass index (BMI) was 27.3 kg/m2 (SD 5.4). Mean baseline interlimb (affected vs. unaffected) volume difference was 499.4 ml (SD 362.3) and L-Dex was 31.8 (SD 23.4). Differences between groups at baseline were not statistically significant for age (p=0.55), BMI (p=0.11), or L-Dex (p=0.11), but were for interlimb volume difference (MLD = 354.8 ± 312.2; Lymphatouch = 643.96 ± 362.5; p=0.48). After 12 sessions, the Lymphatouch group demonstrated slightly greater improvements in L-Dex score, volume, and DASH scores compared to the MLD group. However, only the between-group difference in the change in L-Dex scores reached statistical significance, favoring the Lymphatouch group (L-Dex change: MLD = +1.5 L-Dex units ± 2.7; Lymphatouch = −4.8 L-Dex units ± 7.9, interaction p=0.02).
CONCLUSIONS: Treatment with a negative pressure massage device resulted in statiscally significant improvements in L-Dex scores compared to MLD in women with unilateral upper extremity LE of ≥ 1 year duration. Slightly greater improvements, though not statistically significant, were also observed in upper limb volume and self-reported upper extremity function.
CLINICAL RELEVANCE: Further research is needed to identify effective treatments for chronic LE that may not be responsive to MLD alone. These treatments can improve our ability to offer targeted interventions and improve outcomes for patients impacted by BC-related LE. Results from this pilot study will guide the development of a larger, hypothesis driven RCT.
IMPACT OF EARLY REHABILITATION IN WOMEN ACTIVELY RECEIVING TREATMENT FOR BREAST CANCER
Becker AM, Vanlandingham S, Grogan MM, McGowan MH, Harrington SE
PURPOSE/HYPOTHESIS: There are 3.1 million women surviving a diagnosis of breast cancer in the U.S., but only 1-2% of those with cancer are referred to rehabilitation. Breast cancer treatments have deleterious effects on upper extremity strength, range of motion (ROM), function, and quality of life (QOL), yet early rehabilitation is not currently the standard treatment. The purpose of this study was to examine the effectiveness of an early rehabilitation program in improving upper extremity active ROM, QOL, and fatigue following a diagnosis of breast cancer.
NUMBER OF SUBJECTS: 22 females (aged x=52.6 (SD=13.8) years, BMI x=28.0 (SD=6.6) kg/m2).
MATERIALS AND METHODS: A pragmatic, prospective cohort study was conducted. Individualized early rehabilitation was administered by two skilled, licensed, lymphedema-certified physical therapists. Common treatments provided included patient education, ROM, strengthening and stretching exercises, manual therapy and/or deep breathing exercises. Outcomes included active shoulder flexion and external rotation ROM, FACT-B+4 to examine QOL and the one-item fatigue scale. Paired sample t-tests were conducted to compare ROM, QOL and fatigue at baseline (BL) with 3-8 weeks post-operation and 3-8 weeks post-operation with 11-25 weeks post-operation.
RESULTS: Significant differences were found between flexion ROM at BL (x=167°, SD=17.3) and 3-8 weeks post-operation (x=127°, SD=21.9); t(16)= 6.37, p<0.001 and between flexion ROM at 3-8 weeks post-operation (x=127°, SD=17.4) and 11-25 weeks post-operation (x=154°, SD=19.8); t(15)= −4.09, p<0.001. Significant differences were found between external rotation ROM at BL (x=87.6°, SD=8.57) and 3-8 weeks post-operation (x=65.8°, SD=20.8); t(17)= 4.66, p<0.001 and between external rotation ROM at 3-8 weeks post-operation (x=65.8°, SD=19.3) and 11-25 weeks post-operation (x=81.7°, SD=9.21); t(15)= −3.67, p<0.002. Significant differences were found between the FACT-B+4 social well-being subscale at BL (x=25.0, SD=5.06) and 3-8 weeks post-operation (x=24.0, SD=5.19); t(17)= 2.92, p<0.010, between the emotional well-being subscale at BL (x=15.5, SD= 5.58) and 3-8 weeks post-operation (x=18.7, SD=4.41); t(17)= −2.71, p<0.015) and between the arm subscale at BL (x=17.5, SD=4.60) and 3-8 weeks post-operation (x=12.3, SD=5.66); t(18)= 3.24, p<0.005. Significant differences were found for fatigue between 3-8 weeks post-operation (x=3.60, SD=2.85) and 11-25 weeks post-operation (x=4.80, SD=2.57); t(14)= −2.40, p<0.031.
CONCLUSIONS: Deficits in shoulder flexion and external rotation ROM and the FACT-B+4 social well-being, emotional well-being and arm subscales were identified at 3-8 weeks post-operation when compared to pre-operative measures. Improvements in shoulder flexion and external rotation ROM were found after implementation of physical therapy at 11-25 weeks post-operation returning near BL. Fatigue increased from 3-8 weeks to 11-25 weeks post-operation despite the implementation of physical therapy.
CLINICAL RELEVANCE: Early intervention physical therapy was beneficial, as ROM and QOL values returned towards pre-operation BL, however fatigue increased, possibly due to continued chemotherapy treatments throughout the study.
PERCEIVED BARRIERS AND FACILITATORS TO EXERCISE DURING AND SUBSEQUENT TO CANCER TREATMENT IN CANCER SURVIVORS
Shoaf LD, Hilton AL, Patel RH
PURPOSE/HYPOTHESIS: The purpose of the study was to gather information about why a cancer survivor may or may not exercise during and after treatment despite the known short and long-term benefits through a qualitative method that allowed for more in-depth exploration of the barriers and facilitators around this topic.
NUMBER OF SUBJECTS: 13 with a range of cancer diagnoses
MATERIALS AND METHODS: Participants were recruited via flyers at a local hospital, several PT clinics, generic facebook postings, e-mails, through word of mouth at local community organizations, and through referrals of health care professionals in a rural area in the south. Any type of cancer diagnosis was accepted for the study. Participants were interviewed while undergoing treatment or after completion of treatment that had been delivered within 3 years. Interviews were recorded and conducted in a semi-structured format. The interviews were transcribed and analyzed using open coding, axial coding, and selective coding in order to develop a conceptual model.
RESULTS: Thirteen major themes were identified. The most frequently identified barriers to exercise were side effects such as fatigue, gastrointestinal disturbances, and bone/joint pain. Other barriers included fear of infection, toxicity of treatment, and several psychological factors such as uncertainty and fear of exercising, resignation, and mental exhaustion. Cancer location also was a barrier. The most frequently identified facilitators to exercise were strong exercise beliefs, support from another individual, changes made in intensity and type of exercise to address the limitations from cancer treatment effects, and self-motivation and the good feeling gained from exercising. An additional finding expressed was the lack of information about the benefits of exercise provided by the health care team to the patient receiving cancer care. Many of the participants expressed that the physicians involved in their care did not address exercise at all. They also expressed the desire for more specific information about exercise and/or directed exercise programs specific to their needs as this information and these programs were minimal, regardless of the type of cancer diagnosis. The conceptual model created included side effects of cancer, psychological factors, timing in the sequence of cancer management, and lack of education from health professionals while facilitators in the model were exercise beliefs and motivational level, support, the ability to modify exercise programs, and reported benefits from exercise.
CONCLUSIONS: Many barriers and facilitators to exercise that have been described previously in the literature were also identified in this study, however, it was unique in that the participants represented a variety of cancer diagnoses and the findings were similar across them. There is a clear need for information about exercise to be integrated and consistently provided as part of a cancer management program by all members of the health care team. Additionally, exercise programs should be cancer type and location, treatment, and patient specific addressing side effects as much as possible. There appears to be a need for phased exercise programs that can be initiated and modified based on the timing of cancer treatment cycles (post-diagnosis, pre-treatment, with treatment, and post-treatment). More education for oncologist and radiologists appears to be indicated as these practitioners often did not discuss anything about the benefits of exercise with the participants in this study.
CLINICAL RELEVANCE: Identifying the barriers and facilitators to exercise in cancer management can help the health care team working with these patients better provide comprehensive care that includes exercise. The physical therapist with expertise in exercise prescription for special populations should be an important part of the cancer management team. More research is needed to determine the best methods for enhancing comprehensive cancer care that includes exercise as a required element of care.
ROLE OF REHABILITATION IN PATIENTS RECEIVING CAR-T
BACKGROUND AND PURPOSE: After traditional lines of chemotherapy and radiation treatment, patients and providers look towards immunotherapy as another means of treatment for patients with lymphoma. The administration of Chimeric Antigen Receptors on T cells (CAR-T) to patients with lymphoma as a means of immunotherapy is on the rise. More and more cases of patients receiving this type of immunotherapy are being reported and it has become an integral form of treatment at major medical centers across the country. The purpose of this case study is to demonstrate the role of physical therapy in a patient receiving CAR-T.
CASE DESCRIPTION: The patient is a 20-year-old male from China with Diffuse Large B Cell lymphoma. Patient had no notable co-morbidities and was previously independent with all functional mobility and activities of daily living. He had received chemotherapy in China and came to MD Anderson Cancer Center for further treatment options where he was administered CAR-T. He underwent a complicated two-month hospital course including time in the intensive care unit. During this time, the patient required a tracheostomy and developed severe neurotoxicity. Physical therapy was consulted during his course in the intensive care unit and then continued to follow him throughout his hospital stay.
OUTCOMES: The patient was discharged from inpatient rehabilitation after two weeks of intensive therapy where he was modified independent with functional mobility. He stayed locally for three months receiving outpatient therapy services. After three months, he returned to China with his family.
DISCUSSION: The role of rehabilitation in patients receiving Stem Cell Transplants with hematologic cancers has been documented. Although many similarities exist between CAR-T and Stem Cell Transplants, the complications from these immunotherapies are vastly different. This form of treatment is associated with high chances of neurotoxicity that can lead to potentially permanent impairments for patients. There is an integral role for rehabilitation services during patient's lengthy hospital stays. However, there is currently minimal evidence describing or even supporting the role of rehabilitation, specifically physical therapy with patients after receiving CAR-T infusions. This patient case example demonstrates the important need for rehabilitation to be involved early in the process of patient's receiving CART.
KATZ ACTIVITIES OF DAILY LIVING DISABILITY BY AGE, STAGE AND TYPE OF CANCER
Blackwood JA, Karczewski H, Huang MH, Pfalzer LA
PURPOSE/HYPOTHESIS: In older adults activities of daily living (ADL) impairments contribute to lower quality of life, falls and medical costs. ADL impairments have been reported in cancer survivors primarily by reporting of impairments. The use of a standardized measure, the Katz ADL Index, has had limited use in describing ADL impairment in older cancer survivors. Further the degree and type of ADL impairments likely varies by age, stage and cancer type. Therefore, the purpose of this study was to describe ADL impairments in older survivors of colorectal, lung, breast, or prostate cancer by age, stage and cancer type.
NUMBER OF SUBJECTS: 5,630
MATERIALS AND METHODS: In this cross-sectional study, data from cohorts 9-14 (year 2006-2013) of the Surveillance, Epidemiology and End Results national cancer registry and Medicare Health Outcomes Survey linkage were used to describe ADL performance in older survivors of colorectal, lung, breast, or prostate cancer. ADL performance was measured using the Katz ADL Index which examines six functions: bathing, dressing, toileting, transferring, continence, and feeding with lower scores (out of 6) indicating more impairment. Average Katz scores as well as the prevalence of impairment in each ADL were reported for each cancer type and across the age and stage categories.
RESULTS: ADL deficits were greatest in lung cancer survivors (mean Katz score: 4.74, SD: 1.64) with the greatest deficits in bathing (26.7%), transferring (34.4%) and continence (34.4%). When the population was analyzed by cancer stage, stage 4 prostate cancer survivors had the most ADL impairments reported with (mean Katz score: 4.13, SD: 1.82) with impaired bathing (41.1%) and transferring (49.1%) most common. Incontinence was reported most commonly in stage 2 prostate (55%) and stage 1 breast cancer survivors (49%). When age was considered, overall Katz scores were most impaired survivors age 85 years and older in breast cancer survivors (mean Katz score: 3.9, SD: 1.93) and prostate cancer survivors (mean Katz score: 4.35, SD: 1.83).
CONCLUSIONS: ADL disability differs by cancer type, age and stage. Interventions to address ADL limitations and improve functional mobility should be considered in older cancer survivors.
CLINICAL RELEVANCE: Health professionals should consider tailoring care plans for patients with cancer based on the type of cancer, stage, and age group to better address ADL impairments which contribute to quality of life.
MINDFULNESS-BASED THERAPY AND CANCER-RELATED FATIGUE: A SYSTEMATIC REVIEW
Matheny CR, Trantham MA, Anger J, Frederick, D Griggs JL, Liming M
PURPOSE/HYPOTHESIS: Research surrounding cancer-related fatigue has been growing, but there is still a lack of scientific evidence determining the best treatment protocol for this clinical population. Cancer-related fatigue (CRF) is multi-faceted and is the result of several elements such as the cancer itself, the treatment, anemia, pain, and various psychosocial factors such as anxiety and depression. The purpose of this study was to determine the efficacy of using Mindfulness-Based Stress Reduction/Mindfulness-Based Cancer Recovery (MBSR/MBCR) in conjunction with traditional physical therapy to improve CRF compared to the sole use of traditional physical therapy.
NUMBER OF SUBJECTS: 858
MATERIALS AND METHODS: This study was designed as a systematic review of 7 randomized control trials. A systematic review was performed on current, peer-reviewed literature using EBSCO databases and Google Scholar. Key search terms used to search EBSCO databases were: mindfulness or spiritual well-being and cancer fatigue and breast cancer. Breast cancer was included as an outlier for articles not found in the original search. Articles outside the EBSCO database were found through Google Scholar, using search terms: “RTC physical therapy and spirituality for patients with cancer fatigue”. Four authors were involved in the search and reviewed all the studies. Using the Downs and Black Scale, three of the four authors individually assessed and scored each article for methodological quality. In the event of a score discrepancy, the fourth author determined the final overall score of the article.
RESULTS: The original database search returned 88 articles and four additional articles were identified through other sources. After duplicates were removed, 61 articles remained for screening. Articles were screened by title and abstract with 34 articles being excluded by title and 20 articles being excluded by abstract screening. Seven articles remained for qualitative synthesis. According to the Downs and Black Scale, six of the seven articles chosen, were determined to be a good quality of evidence while one article was determined to be only a fair quality of evidence.
CONCLUSIONS: The use of MBCR/MBSR resulted in significant improvements in CRF and should be used in conjunction with physical therapy as a holistic treatment for patients suffering from CRF.
CLINICAL RELEVANCE: Cancer Related Fatigue is one of the most common and debilitating symptoms of cancer and is experienced differently by each patient. It is essential to determine an effective treatment targeting all the associated elements to improve functional outcomes and the quality of life for these patients. Mindfulness-Based Stress Reduction/Mindfulness-Based Cancer Recovery (MBSR/MBCR) is a recent multi-modal intervention, designed to target both physical and psychosocial factors of CRF. Therefore, by implementing both MBSR and exercise into a patient's oncology plan of care, physical therapists can offer a more comprehensive and holistic approach to care for a patient experiencing CRF ultimately improving their quality of life.
COMPARATIVE STUDY OF TRANSLATED VERSION OF EQ-5D VERSUS WHOQOL-BREF ON HRQOL FOR VARIOUS CANCER SURVIVORS
Choi B, Jang M, Kim SH, Yoon T, Kim OK, Choi K, Bang S
PURPOSE/HYPOTHESIS: Purpose/Hypothesis: Assessing health-related quality of life (HRQoL) for various cancer survivors will guide clinicians to first consider whether there may be positive outcomes from palliative rehabilitation programs. Although the original versions of the WHOQoL-BREF and the EQ-5D were found to be reliable and valid, the culturally adapted versions of them may not be comparable to their original versions in psychometric properties. Dimensionality of HRQoL measurements appears to be changed following cultural adaption process. Using Rasch rating scale model, this study was designed to investigate: 1) dimensionality of Korean version of the WHOQoL-BREF and the EQ-5D, 2) hierarchical item difficulty continuum, and 3) person-item match.
NUMBER OF SUBJECTS: 77
MATERIALS AND METHODS: A total of 77 cancer survivors undergoing palliative rehabilitation programs from an oriental medicine hospital and a rehabilitation hospital in Korea was recruited from April 16, 2018 to June 26, 2019. Subjects consisted of all appropriate clients presenting to the participating sites during the period. Subjects were asked to fill out the Korean version of WHOQoL-BREF and EQ-5D for various cancer survivors undergoing palliative rehabilitation programs at the sites. Scores were analyzed with Winsteps Rasch analysis computer program, using the rating scale model [10-12]. Rasch fit statistics were examined using to determine the dimensionality of the two measurements and item difficulty calibrations were compared.
RESULTS: All items except two items of Negative feeling and Pain/Discomfort of the WHOQoL-BREF were found to be acceptable (MnSq=2.28 and 2.78, respectively), while only one item (anxiety/depression) of the EQ-5D was misfit (MnSq=1.61). Item difficulty calibrations of the WHOQoL-BREF match person ability measures (i.e., HRQoL) fairly well. However, the person ability distribution showed obvious ceiling effects for the EQ-5D. All items of the EQ-5D were appeared to be more challenged in comparison with those of the WHOQoL-BREF.
CONCLUSIONS: Item-level analysis using the Rasch model supports the quality of culturally adapted items used to measure the HRQoL one exception; that is, whether or not to include misfit items as part of the HRQoL measurements. Additionally, cancer survivors undergoing palliative rehabilitation program appear to have more of a tendency to view the EQ-5D items as being more challenging than the WHOQoL-BREF.
CLINICAL RELEVANCE: Clinicians should acknowledge inconsistencies in capturing HRQoL construct in many disease-specific patient populations and potential changes in psychometric properties when creating culturally adapted versions of the measurements. Moreover, clinicians should carefully consider in selecting a specific HRQoL measurement for cancer related populations.
THE RELATIONSHIP OF CHEMOTHERAPY-INDUCED PERIPHERAL NEUROPATHY AND OBESITY: A SYSTEMATIC REVIEW
PURPOSE/HYPOTHESIS: The purpose of this systematic review is to determine the relationship of being overweight/obese with the incidence and severity of chemotherapy-induced peripheral neuropathy (CIPN).
NUMBER OF SUBJECTS: This systematic review identified 12 studies including 4089 subjects.
MATERIALS AND METHODS: Electronic databases PubMED, PEDro (Physiotherapy Evidence Database), CENTRAL (Cochrane Central Register of Controlled Trials), Ovid, and EBSCO were systematically searched in March 2019 for articles dated within the last 10 years. Reference lists of relevant articles were also hand searched. The following search terms were used: chemotherapy, neuropathy, risk factors, BMI (body mass index), obesity. Inclusion criteria included studies, systematic reviews, or meta-analyses that included adult subjects who were diagnosed with CIPN and that presented qualitative or quantitative data regarding presence of neuropathy and documentation of BMI or weight. Articles were excluded if documentation of BMI or weight was not quantified or if CIPN was not identified.
RESULTS: Twelve articles met the inclusion criteria. These studies included subjects who were receiving or had received taxane therapy, platinum compound therapy, or bortezomib for treatment of breast cancer, multiple myeloma, esophagogastric cancer, or colorectal cancer. In this review, 11 of the 12 studies showed increased incidence of CIPN in subjects with higher BMI or BSA (body surface area). Also, the two studies that looked at severity of CIPN symptoms showed that overweight/obesity was a risk factor for higher grades of neuropathy.
CONCLUSIONS: An association between overweight/obesity and CIPN is documented. The mechanisms influencing this relationship may be related to the necessary increased dosing of chemotherapy related to a higher BSA as well as the link of obesity with metabolic syndrome. The systemic inflammation often present with metabolic syndrome can lead to peripheral and central sensitization in the pain transmission system as well as axonal damage and demyelination of the nerves occurring as a result of proinflammatory cytokines. Also a consideration with obesity is the presence of diabetes and related microvascular changes that may occur. No studies were found on associations between CIPN and the effect of weight gain or loss.
CLINICAL RELEVANCE: Overall, being overweight or obese may put one a higher risk for the development and severity of CIPN. As clinicians, encouragement in healthy lifestyles including weight management and physical activity are important so that patients can complete prescribed treatment at recommended doses. Delays or dosing reductions could impact the desired results on the disease process. Awareness of the increased risk of the development of CIPN in this patient group might warrant increased monitoring of the incidence and severity of symptoms. Further research on the effect of weight loss on the incidence and severity of symptoms would also be helpful in directing care of patients.
INVESTIGATING THE FUNCTIONAL IMPLICATIONS OF CAR T-CELL THERAPIES
Child CE, Maryak SA
BACKGROUND AND PURPOSE: Advanced immunocellular therapy using genetically-modified, CD19-directed CAR-T cells to treat acute lymphoblastic leukemia (ALL) and diffuse large B cell lymphoma (DLBCL) has shown remarkable rates of remission and a reduction in mortality. This novel therapeutic modality is associated with an increased risk of unique and potentially serious side effects, including cytokine release syndrome (CRS) and neurotoxicity. In the acute phase, these side effects can have implications for physical performance, neurocognitive status, and quality of life. Two case studies are contrasted that represent a broad spectrum of post CAR-T cell infusion presentations, physical performance levels, and functional outcomes that clinicians might encounter in this contemporary area of precision medicine.
CASE DESCRIPTION: The first case describes the clinical presentation of a 74-year-old male with relapsed DLBCL treated with axicabtageneciloleucel (Yescarta®). His acute post-infusion phase was complicated by Grade 3 CRS and Grade 3 neurotoxicity, requiring multiple ICU transfers, and atypical prolonged post-acute rehabilitation needs due to persistent cognitive changes and physical performance decline. The second case describes the clinical presentation of a 54-year-old female with relapsed/refractory AML treated with CART123 immunocellular therapy (in Phase 1 Clinical Trial). Her post-infusion phase was complicated by neutropenic sepsis, Grade 3 CRS, and a brief stay in the ICU. She had a brief decline in her physical performance status with the onset of CRS and critical care needs. However, she recovered close to her baseline physical performance status by the time of discharge from the hospital and had no post-acute rehabilitation needs.
OUTCOMES: Using the International Classification of Functioning, Disability and Health (ICF), a brief analysis of patient-specific impairments, activity limitations, and participation limitations is provided. Physical performance metrics were regularly tracked from a baseline pre-infusion time point throughout the post-infusion inpatient hospital stay, using the ECOG Performance Status, the Karnofsky Performance Status, and the AM-PACTM “6-Clicks” Inpatient Basic Mobility Short Form. In both cases, there was a strong correlation between the onset of toxicities and a decline in physical performance status.
DISCUSSION: These case studies are representative the broad spectrum of patient presentations in the acute phase after CAR-T immunocellular infusion. While the side effects of CRS and neurotoxicity are often temporary, and guidelines for medical management are available, the onset of more severe side effects, especially neurotoxicity, can have lasting implications for physical performance, neurocognitive status, and quality of life. Pre-rehabilitation, early mobility, and structured rehabilitation after CAR-T cell infusion are investigated as ways to enhance functional outcomes. Larger descriptive studies are needed to better characterize the post-infusion sequelae after CAR-T cell therapies, describe the impact of toxicities on domains of functioning, and inform clinical practice guidelines for rehabilitation.
MULTIMODAL REHABILITATION FOLLOWING GRADE IV GLIOSARCOMA RESECTION
van Rij SM, Andrews AW, Freund J, Bailey SP
BACKGROUND AND PURPOSE: Gliosarcoma is a highly malignant brain cancer with an exceptionally poor medical prognosis. Despite poor prognostic indicators, rehabilitation may improve quality of life and restore independence. Little research is available to guide physical rehabilitation in this population. Medical and rehabilitation prognoses are interdependent, yet distinct in terms of objective. Predicted disease course and survival are defined by medical diagnoses, whereas rehabilitation prognoses include a critical appraisal of potential for improved physical function. The purpose of this case was to provide an alternative to palliative plans of care for patients with achievable self-care goals despite a shortened life expectancy.
CASE DESCRIPTION: The patient was a female in her 70s diagnosed with a grade IV gliosarcoma of the left superior frontoparietal region. The tumor was surgically resected and severe postoperative complications resulted. Following medical stabilization, five months were spent in a hospice setting. She was discharged to a skilled nursing facility for rehabilitation including physical, occupational and speech therapy. Physical therapy interventions included intensive neuromotor, resistance, and gait training over a six week period to maximize motor function and improve independence.
OUTCOMES: The minimal detectable change (MDC) was met or exceeded for fast gait speed, Berg Balance Scale, Timed Up and Go, and Dynamic Gait Index. The minimal clinically important difference (MCID) was exceeded for comfortable gait speed, Six Minute Walk Test, and grip strength dynamometry. She was discharged to an assisted living facility.
DISCUSSION: Little research is available to guide intervention parameters for those with highly malignant gliomas. Skilled rehabilitation improved independence in an individual following gliosarcoma resection and should be considered for similar patients.
RELATIONSHIPS OF QUALITY OF LIFE AND FITNESS CHANGES IN CANCER SURVIVORS FOLLOWING AN EXERCISE PROGRAM
Marker R, Scorsone J, Peters J
PURPOSE/HYPOTHESIS: Physical impairments and decreased quality-of-life (QoL) are common in cancer survivors (Marker et al., 2018). Physical therapy and exercise interventions often target physical impairments in order to improve holistic, patient-centered outcomes, such as QoL. While exercise programs have been shown to improve both physical fitness and QoL in cancer survivors (Loughney et al., 2015; Mishra et al., 2015; Speck et al., 2010), the relationships between changes in specific measures of fitness and QoL are unknown. The purpose of this investigation is to assess these relationships to determine what fitness changes best translate to improved QoL in cancer survivors.
NUMBER OF SUBJECTS: 194 cancer survivors, undergoing or within six months of completing active cancer treatment. The mean age of the sample was 55 years (SD=14) and there were 135 women and 59 men. No cancer types were excluded.
MATERIALS AND METHODS: Participants completed the BfitBwell Program, a three-month individualized exercise program for cancer survivors. The program performs in-depth pre and post assessments which are entered into an IRB-approved research database. Pre and post assessment data were extracted from all participants who had completed the program, and changes across the program were calculated. Grip strength, 30-second sit-to-stand (StS), timed up and go (TUG), regular and fast gait speed, and six-minute walk test (6MWT) were used to assess physical function, and the Functional Assessment of Cancer Therapy General (FACT-G) questionnaire was used to assess QoL. The FACT-G was further divided into its four subscales: physical, functional, social, and emotional well-being. Paired t-tests were performed to assess significant changes during the program, and correlation coefficients were calculated between changes in physical fitness measures and the FACT-G and its subscales to assess the relationships between these changes. Significance was defined as p < 0.05.
RESULTS: All measures of fitness and QoL significantly improved from pre to post assessments. Only changes in fast gait speed (r = 0.2) and 6MWT (r = 0.2) were significantly correlated with changes in the total FACT-G score. StS (r = 0.2) and 6MWT (r = 0.3) were correlated with changes in physical well-being, and 6MWT (r = 0.2) was correlated with changes in functional well-being. Changes in physical fitness measures were not correlated with changes in social or emotional well-being.
CONCLUSIONS: While all measures of fitness and QoL improved after completing the three month exercise program, only some of these improvements were significantly associated. Improvements in the 6MWT was most consistently associated with improvements in the FACT-G and its subscales. Improvements in other measures known to be related to medical outcomes, such as grip strength (García-Hermoso et al., 2018), did not seem to translate to improvements in QoL. Further research is needed to investigate whether interventions specifically targeting measures such as the 6MWT could improve QoL outcomes.
CLINICAL RELEVANCE: While exercise programs are effective at improving many aspects of physical fitness, these improvements do not always translate to improved patient-centered outcomes such as QoL. Exercise programs and healthcare practitioners should consider these specific relationships when determining a plan of care, whether a goal is to improve QoL or other medical outcomes.
IMPACT OF PHYSICAL ACTIVITY ON LOWER EXTREMITY LYMPHEDEMA IN PATIENTS WITH GYNECOLOGICAL CANCER: SYSTEMATIC REVIEW
Trantham MA, Matheny CR, Figueroa A, La Pointe P, Lester BE, Wommack L
PURPOSE/HYPOTHESIS: Lymphedema, a condition characterized by abnormal swelling of the limbs is often the result of cancer. The current literature focuses primarily on upper extremity lymphedema most commonly as a result of breast cancer. However, it is clinically necessary to consider the impact of cancers that would affect the lower extremity, specifically gynecological cancers. Therefore, based on the lack of current literature regarding lymphedema in the lower limbs, the purpose of this systematic review was to define the relationship between physical activity and lower limb lymphedema in patients with gynecological cancers.
NUMBER OF SUBJECTS: 275
MATERIALS AND METHODS: Multiple databases were searched using a PRISMA strategy with keywords physical activity, lymphedema, and gynecological cancer. Articles were critically analyzed using the AACPDM methodology by four individual researchers. For group studies, a conduct level was assigned to each individual article as Strong (6 or7), Moderate (4 or 5), or weak (<3). Each study was given a level of evidence (I-IV) based on the “hierarchy of evidence.”
RESULTS: The original search yielded 55 articles for screening. After removing duplicates, screening, and assessment, a total of three articles met the inclusion criteria and were critically analyzed for this systematic review. Using the AACPDM analysis tool, two of the articles reviewed were determined to be strong and one article was determined to be weak, two of the studies were identified as level II and one was identified as level IV. All studies included the use of physical activity and two studies also included decongestive therapy as part of the treatment regime. All of the studies concluded that lower extremity lymphedema decreased by adding physical activity to treatment strategies.
CONCLUSIONS: Despite a high incidence of lower limb lymphedema, a review of the current research examining the effects of physical activity on lower limb lymphedema secondary to gynecological cancer indicates that this is an area of new research. Based on the three studies that met the inclusion criteria, there appears to be preliminary evidence supporting the use of exercise in the management of lower extremity lymphedema in this population.
CLINICAL RELEVANCE: While this is an area of research in need of further development, there seems to be the initial evidence of the safety and efficacy of physical activity in the treatment of lower limb lymphedema. Integration of exercise and physical activity into a treatment plan for lower limb lymphedema secondary to gynecological cancers has been shown to decrease limb volume, improve physical function, affect overall health and improve quality of life.
PRIMARY LYMPHEDEMA IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS
BACKGROUND AND PURPOSE: Systemic lupus erythematosus (SLE) is a chronic disease that causes inflammation in connective tissues. Lymphedema is the accumulation of excess protein rich fluid in the body caused by obstruction of the lymphatic drainage mechanisms. There is a dearth of information regarding lymphedema's presence in patients with SLE. To the author's knowledge, there has been only 1 case report discussing patients with this comorbidity, and no published information on the prevalence and treatment of lymphedema in this population. The purpose of this case is to describe a successful treatment plan for lymphedema in a patient with SLE.
CASE DESCRIPTION: A 72 year old woman with a history of well-controlled SLE was diagnosed with lymphedema and referred to Lymphedema Clinic. At evaluation, she presented with bilateral lower extremity pitting edema, rigid tissue mobility, positive stemmer's sign, decreased lower extremity range of motion, and compensatory strategies with functional movements. She had a lymphedema life impact scale (LLIS) of 35. She was seen for 8 treatment sessions (2 to 3 times per week) for complete decongestive therapy consisting of manual lymphatic drainage, exercise, compression, skin care, and patient education.
OUTCOMES: At the conclusion of treatment, the patient was independent in self-management of her edema with bilateral thigh high compression garments, exercise program, skin care regimen, and self manual lymph drainage. She had a decrease of 24.5 cm total girth in her left lower extremity girth and 33 cm total girth in her right lower extremity girth, as well as a decrease of 26 points in her LLIS score (minimal clinically important difference = 7.31 points), demonstrating a clinically significant improvement in quality of life. Her gait mechanics were improved, she was able to place equal weight on bilateral lower extremities during sit to stand, and she regained full ankle and knee range of motion.
DISCUSSION: This patient did not have an apparent cause for her lower extremity edema and was referred to lymphedema clinic for management. She had a robust response to treatment and had significant improvements in her LLIS score, which is a validated scoring system for quality of life in patients with lymphedema. Lymphedema in itself is a relatively rare condition, let alone in patients with SLE. The pathogenicity is unknown. Vasculitis and lymphadenitis are common features of SLE, therefore it is possible that inflammation of the lymphatic vessels may predispose patients to lymphedema. Lymphedema may be an unrecognized symptom in SLE, which may warrant referral to a lymphedema physical therapist for management and education on prevention.
THE WALKABOUT PROJECT: USE OF TELEHEALTH TO ENGAGE RURAL CANCER PATIENTS IN GROUP EXERCISE
Larson ML, Heifetz LJ, Ditterich K
BACKGROUND AND PURPOSE: Exercise has numerous positive effects on active and recovering cancer patients. The purpose of this project is to utilize telehealth to engage cancer patients, who are unable to attend a live class, by providing an alternative method to deliver group exercise.
CASE DESCRIPTION: Two participants were recruited from the Gene Upshaw Memorial Tahoe Forest Cancer Center in Truckee, CA in January, 2018. Participant A had completed chemo-radiation for stage IVA base of tongue cancer. Participant B had completed chemo-radiation for synchronous anal and prostate cancers. Both presented with reports of fatigue and decreased balance; neither participated in a regular exercise program. A 7-week telehealth program was developed enabling both participants and a physical therapist to communicate on a common smartphone platform, simultaneously. Technical and HIPPA issues were addressed, allowing the therapist to supervise the participants in real time. As outlined in Physical Activity Guidelines for Americans, the class included aerobic and strengthening activities. Classes were held twice a week, for 30-40 minutes. Before, during and after classes, participants would give a subjective report on how they were feeling, so modifications could be made. Classes included upper and lower body stretches, after which, an upper and a lower body exercise were instructed. Each week one additional upper and lower body exercise was added. Weekly, participants were asked to log minutes per week of walking or biking.
OUTCOMES: The Functional Assessment of Cancer Therapy-General (FACT-G) and unipedal stance tests were administered prior to the start of the class and again following completion of the class. Each participant had clinically significant improvement in the FACT-G. A clinically meaningful change corresponds to a total FACT-G raw score in the range of 5-7 points. Participant A had a change of 8.4 points or 9% improvement in the FACT–G, with an initial score of 92.6 and a final score of 101. Participant B had a change of 20 points or 27% improvement in the FACT-G, with an initial score of 72 and a final score of 92.
Normative data suggests that unipedal stance is largely age dependent. The mean of 3 trials of unipedal stance for participant A improved from 4 seconds to 20 seconds, with an age adjusted mean of 37. The mean for unipedal stance for participant B improved from 32 seconds to 60 seconds, with an age adjusted mean of 15.
Participant A completed 9 of 14 classes and B completed 12 of 14 classes; missed classes were due to illness or physician appointments.
DISCUSSION: Quality of life as assessed by the FACT-G and unipedal stance scores improved following a 7-week, telehealth, group exercise class. These results suggest that telehealth may be an effective delivery method to engage cancer patients who are unable to attend a live class. Further research with a larger sample size on this novel method for delivery of group exercise is needed.
EFFECTS OF EXERCISE INTERVENTIONS ON MOTOR OUTCOMES DURING AND AFTER TREATMENT FOR CHILDREN WITH ALL
Coombs AH, Sargent BA
PURPOSE/HYPOTHESIS: The objective of this systematic review is to evaluate the effect of exercise and motor interventions on motor outcomes of children with ALL during and after medical treatment.
NUMBER OF SUBJECTS: A total of 444 children with ALL ranging in age from 1 to 18 years participated in the studies.
MATERIALS AND METHODS: Nine databases were searched from 1998 to 2018 for clinical trials and cohort studies on the motor outcomes of exercise and motor interventions for children with ALL. Level of evidence and risk of bias were assessed.
RESULTS: Sixteen studies were included: 9 randomized clinical trials and 7 cohort studies. Interventions were provided during acute chemotherapy (n=1), maintenance chemotherapy (n=8), clinical remission (n=3), or across all three phases (n=4). Intervention occurred either through direct intervention (n=7) or a supervised home program (n=9). Interventions included: aerobic training, general strengthening and/or ankle dorsiflexor (DF) strengthening, gastrocsoleus stretching and/or general stretching, bone strengthening, motor skill training, and balance training. Risk of bias was moderate to high across studies. Across phases, outcomes at the body structure and function level (strength, flexibility, endurance) were measured in 94% of studies, with 66% of outcomes resulting in statistically significant improvements. Outcomes at the activity level were measured in 44% of studies, with 43% of outcomes resulting in statistically significant improvements. Outcomes at the participation level were measured in 50% of studies, with 38% of outcomes resulting in statistically significant improvements.
CONCLUSIONS: A growing body of evidence supports the feasibility, safety and efficacy of motor and exercise interventions for children and adolescents with ALL. However, overall quality of evidence continues to be low. More rigorous research is required to determine the effect of intervention type, frequency and duration across phases of medical intervention, specifically in the acute chemotherapy and remission phases.
CLINICAL RELEVANCE: Acute lymphoblastic leukemia (ALL) is the most common childhood cancer, representing 35% of pediatric cancer diagnoses worldwide. Children with ALL experience deficits in flexibility, strength, endurance, function, and participation both during and after medical intervention for ALL. Exercise and motor interventions may prevent or manage these limitations. This review is the first to analyze results of studies within specific phases of medical intervention. This is clinically relevant as children present with distinct motor impairments during each phase of medical intervention. It is critical to understand how the motor function of children with ALL can be optimized both during and after chemotherapy to improve the health and quality of life of children with ALL across their lifespan.
FEASIBILITY OF HIGH INTENSITY INTERVAL LOCOMOTOR TRAINING IN NEURO ONCOLOGY REHABILITATION: A CASE STUDY
BACKGROUND AND PURPOSE: High intensity aerobic exercise has been shown to be superior in the functional recovery of individuals following a variety of both acute and chronic diseases, including those with neurological injuries. Furthermore, evidence suggests high intensity interval training (HIIT) to be effective in promoting positive cardiovascular, neuroplastic, and neuromotor changes in both individuals with and without neurological dysfunction. While several studies have investigated the impact of interval training in the broader oncology population, little has been reported regarding the efficacy and feasibility of implementing high intensity interval training in the neuro oncology population. The purpose of this study was to assess the feasibility of implementing high intensity interval training (HIIT) in patients receiving acute inpatient rehabilitation for a neuro oncology diagnosis.
CASE DESCRIPTION: Patient X presented to acute inpatient rehabilitation with a past medical history of ocular plasmacytoma presenting with metastatic lesions of the frontal lobe, cauda equina and thoracic spinal cord confirmed as diffuse large B cell lymphoma. He presented with primary impairments in decreased functional balance control as assessed by the Berg Balance Scale (BBS), decreased motor planning and sequencing in functional mobility assessed via the Functional Independence Measure (FIM), decreased gait speed as assessed by the 10 Meter Walk Test (10MWT), and decreased endurance as assessed by the timed 6 Minute Walk Test. Patient X was an appropriate candidate to initiate locomotor training with the ultimate goal of introducing high intensity aerobic exercise into rehabilitation program.
OUTCOMES: Patient X participated in 5 sessions of high intensity interval training (HIIT) program over the course of his 12 day inpatient acute rehabilitation hospital stay. HIIT locomotor training was performed on Zero G Body Weight Support Treadmill (BSWTT) with 10-20% body weight support. Each training session consisted of a 2 minute warm up period at an active recovery pace (2.0-2.2mph). Following warm up phase, patient X performed 60 seconds of maximal exertion walking (dictated by RPE between 12-15 and HR at 65-85% age predicted HR max at a speed between 3.2-3.8 mph) followed by a 60 second active recovery period. He completed 5 intervals (10 minutes training time total). Perceived exertion was measured with the Borg Rate of Perceived Exertion (RPE) scale and aerobic training intensity was measured via digital heart rate (HR) monitor on second digit of left hand. Additional outcomes included assessment of functional independence as assessed with the FIM, dynamic balance as assessed by the BBS, gait speed via 10 Meter Walk Test, ambulatory endurance via 6 Minute Walk Test, and endurance as assessed via RPE. RPE and HR were measured at start of HIIT training and in last maximal exertion phases.
Patient X demonstrated improvement in functional independence as indicated by increased FIM scores from initial evaluation to discharge periods (transfers from evaluation score of 3 to discharge score 7), ambulation (evaluation score of 3 to discharge score 7), stair negotiation (evaluation score of 3 discharge score of 7). Significant improvement in balance was observed as indicated by improved Berg Balance Scale score of 50/56 (evaluation score 32/56.) The greatest improvements in gait speed and endurance were noted with increase in Timed 10 Meter Walk Test Average Self Stated Velocity from 0.54 meters/second to 1.09 meters/second at discharge and Timed 6 Minute Walk Test, ambulating 350.52 meters at discharge as compared 155.45 meters at initial evaluation.
DISCUSSION: Gait speed, ambulatory endurance, functional balance, and functional independence all improved after performance of HIIT program. No adverse events were reported both before, during and after HIIT program. The outcomes of this case study demonstrates both the feasibility and efficacy of implementation of a high intensity interval training program in the locomotor training of patients with neuro oncology diagnosis. As such, this protocol was completed for an additional patient presenting with a primary neuro oncological diagnosis, demonstrating similar clinically significant differences in BBS and FIM scores. Further research needs to be conducted in order to evaluate formal standardization of maximal exertion and rest periods in appropriately dosing HIIT training in this patient population. This case report suggests that high intensity interval training can be safely utilized in high intensity locomotor training for those receiving neuro oncology rehabilitation.
MATCHING PRECISION MEDICINE WITH PRECISION REHABILITATION: A FRAMEWORK FOR CLINICAL DECISION MAKING IN ONCOLOGY REHABILITATION
Lelis A, Bolanos JL, Wong M
THEORY/BODY: With cancer treatment becoming increasingly targeted, there has been a rise in the overall cancer survival rate. However, cancer treatments continue to have multi-system side effects, many of which may go undiagnosed for years after completion of cancer treatment. It begs the question—are we doing an adequate job of identifying system-based impairments associated with cancer therapies? Currently, there is great need for research on tests/measures specific to oncology rehabilitation and defining of optimal practice patterns. We propose a battery of tests/measures for routine use in oncology rehabilitation in a matrix with cancer treatment risk factors (i.e. specific antineoplastic agents), relevant systems (cardiovascular, somatosensory, vestibular, and connective tissue), and the corresponding impairments being assessed.
As an illustration, certain antineoplastic agents are associated with degeneration of C-fibers and the development of chemotherapy induced peripheral neuropathy (CIPN). Thus, we propose that all patients with a history of taking medications such as Taxanes, Platinum compounds, Vinka Alkaloids, etc will receive a battery of validated tests for C-fiber function and balance (i.e. standardized light touch and sharp/dull sensory testing using an inexpensive Neuropen® device). Through consistent application of a standardized battery of tests, baseline values are established and the chance of identifying CIPN related impairments, before pain is a factor, is increased. Furthermore, the matrix provides recommended interventions for these CIPN related impairments (i.e. Balance retraining, desensitization and education for fall prevention, skin care, etc).
In another example, patients that undergo radiation therapy to the left chest area are at higher risk for cardiotoxicity (myocardial infarction and heart failure) leading to deconditioning. Via the matrix, these patients would receive a validated modified exercise tolerance test (i.e. Queen's College Step Test or YMCA Cycle Ergometer Test), at evaluation to establish cardiovascular response through such measures as rating of perceived exertion and heart rate recovery. Moreover, the patients' level of cardiovascular response would then be used to delineate exercise dosage and parameters via evidence-based guidelines for interval and aerobic training from the American Heart Association, American Cancer Society and American College of Sports Medicine (i.e. 30-60 second rest breaks for patients with CHF and cancer; exercising at 65-85% of cardiac reserve for aerobic conditioning).
Given the lack of literature specific to oncology rehabilitation, we utilized evidence from other specialty areas to create a theoretical framework/matrix for oncology rehabilitation evaluation and management based on physiological systems. Specific clinical pathways will be described for each relevant system to assist guide the therapist in performing efficient, individualized exercise selections and dosage. This framework may help to guide research in this area and stimulate discussion on best practice patterns in Oncology rehab.
IMPACT OF YOGA AND MEDITATION ON FALLS, FUNCTION, AND QOL FOR CIPN IN CANCER SURVIVORS
Galantino ML, Brooks J, Wilson KA, Jang S
PURPOSE/HYPOTHESIS: Chemotherapy-induced peripheral neuropathy syndrome (CIPN) causes significant pain in hands and feet and is an adverse effect of treatment. Few non-pharmacological interventions have been tested and individuals experience CIPN symptoms years after treatment. This is the first study to explore a somatic yoga and meditation (SYM) intervention on functional outcomes and quality of life (QOL).
NUMBER OF SUBJECTS: Ten participants with median age 64.4 years (47-81) attended 61% of the sessions. Eighty percent adhered to the home SYM.
MATERIALS AND METHODS: Individuals diagnosed with CIPN were enrolled in an open label, single arm mixed methods feasibility trial. Participants met twice per week for 8 weeks and taught by certified yoga instructors. The protocol was created by a physician and certified yoga therapist using previous yoga research for cancer survivors.
INTERVENTION: SYM was provided twice a week for 8 weeks for 1.5 hours and participants completed home-based SYM and journal entries. Abbreviated versions of the SYM and meditation program were placed on four audio files for home practice during week 1 of the sessions and participants were asked to record home practice. Weekly phone calls and support were routine by the research team to verify all participants were able to access the four files and address particular concerns throughout home practice.
MAIN OUTCOME MEASURES: Primary functional outcomes included Sit and Reach (SR), Functional Reach (FR) and Timed Up and Go (TUG). Self-reported Patient Neurotoxicity Questionnaire (PNQ), FACT-GOG-NTX, Brief Pain Inventory (BPI), Perceived Stress Scale (PSS), Pittsburgh Sleep Quality Index (PSQI), FACIT-Spirituality (FACIT-Sp) and Falls Efficacy Scale (FES) were secondary outcomes. Biomarkers included salivary cortisol (stress) and bioesthesiometer (vibration).
QUANTITATIVE FINDINGS: Significant improvements were found in flexibility (SR) (p=0.006); balance (FR) (p=0.001) and gait speed (TUG) (p=0.004). Pain severity (p=0.041) and pain interference reduced (p=0.011). PNQ was significant (p=0.003) and stress (PSS) reduced (p=0.056). Sleep (PSQI), QOL (FACT-GOG-Ntx), and fear of falling (FES) measures improved but not significantly. Decreased cortisol trends (p=.116) with vibration sense improvements were achieved (p=0.035.)
QUALITATIVE FINDINGS: Five themes emerged through non-participant observations and participant journal entries, weekly in person conversations, through phone contact and e-mail, and mid and final focus group meeting transcription; and was confirmed among participants through member checks. (1) Vacillation of CIPN pain perception over time; (2) Transferability of skills to daily activities learned; (3) Improvement in physical function leading to return to various work and hobbies; (4) Perceived relaxation as an effect of SYM; (5) Group engagement provided a social context for not feeling isolated with CIPN. No adverse events were observed.
CONCLUSIONS: Preliminary data suggests that SYM may improve QOL and flexibility, gait speed and balance in cancer survivors with CIPN. Eight participants were high risk for falls as measured by FR and none were fall risk at the end of the intervention. A randomized controlled trial is needed to establish the definitive efficacy of yoga for functional improvement and QOL in CIPN.
CLINICAL RELEVANCE: Aging cancer survivors with CIPN are at risk for falls. Screening by clinicians is prudent and yoga and meditation interventions may be incorporated into traditional exercise during cancer rehabilitation for CIPN to improve function and QOL.
PUBLIC AWARENESS OF CANCER RELATED PHYSICAL THERAPY REHABILITATION AS SURVEYED AT CANCER RELATED VENUES
Wingard C, Bareiss, SK Stockwell AT, Forti AM, Sullivan MM
PURPOSE/HYPOTHESIS: Although rehabilitation is an integral part of care for patients affected with cancer, recent reports suggest there may be significant underutilization of rehabilitation and physical therapy services. Barriers to receiving physical therapy include lack of awareness by patients and their health providers. The purpose of this study was to assess knowledge and awareness of physical therapy rehabilitation for patients with cancer.
NUMBER OF SUBJECTS: Three hundred and ninety one participants completed the survey. Participants were recruited from cancer-related fundraising and awareness events in Louisville, KY. The events included Bike to Beat Cancer (251 participants), Making Strides of Louisville (105 participants) and through cancer support organizations such as Hope for Scarves, LIVESTRONG, and Twisted Pink (35 participants).
MATERIALS AND METHODS: This study was a non-experimental, prospective survey design. Surveys included 5 custom made questions related to the respondents' awareness of physical therapy for cancer rehabilitation.
RESULTS: Twenty percent (79) of the survey respondents were patients undergoing cancer treatment or a cancer survivor. Nearly 57% (222) of the respondents were aware of a role for PT in the management of cancer related impairments. Only 29 % (114) were aware that physician referral was not required to obtain physical therapy services. Only 25% of the respondents reported knowledge of the cancer patient having received or offered physical therapy treatment.
CONCLUSIONS: Our survey results show two main themes: 1. nearly half of the participants did not know physical therapy was a component of cancer related treatment/management; 2. Most (70%) of the participants did not know that direct access was available for physical therapy services. Our findings support a lack of awareness by patients and the public related to the benefits of physical therapy for the oncology population.
CLINICAL RELEVANCE: Although cancer rehabilitation and physical therapy services is increasingly recognized as an integral part of the oncologic team, there is general lack of patient and public awareness about the benefits of physical therapy services for this population. Increasing patient and public awareness, along with health provider knowledge, may reduce barriers that limit access to care and enhance movement and wellness for the oncology patients.
PHYSICAL THERAPY MANAGEMENT OF A BREAST CANCER SURVIVOR WITH UNDIAGNOSED THYROID DISEASE: A CASE REPORT
Pier VL, Drouin JS
BACKGROUND AND PURPOSE: Epidemiologic studies indicate that with women with breast cancer (BCA) are at higher risk for thyroid disease (ThD) with an Odds Ratio of 3.94.1 However, symptoms of ThD are not commonly recognized in the physical therapy (PT) management of individuals with BCA. This case report describes PT clinical decisions and management of a female breast cancer survivor with symptoms of an endocrine disorder from undiagnosed thyroid disease.
CASE DESCRIPTION: The patient was 56-years old female with a diagnosis of Stage I estrogen positive (ER+) breast cancer. She was referred to PT three-months post-radiation with a diagnosis of left upper extremity lymphedema, but her main complaints were limited movement and aching pain at the shoulder, upper extremity and hand, and generalized fatigue.2 The only edema found was moderate swelling in the entire left index finger and minimal swelling in the dorsum of the hand. She was initially treated with a recommended protocol of manual lymphatic drainage and therapeutic range of motion exercises. At her follow up appointment three days later, she reported that not only were her symptoms no better, but now she had a fine tremor in her left hand, was experiencing intermittent tachycardia and complained of bilateral exophthalmos. Upon further questioning, she reported unintentional weight loss in the last month, thinning hair, and a family history of a sister with hypothyroid disease. Her resting heart rate was taken and found to be 80 beats per minute.3 Since her collective symptoms indicated a differential diagnosis of a possible endocrine disorder, she was immediately referred back to her primary care physician (PCP).
OUTCOMES: The PCP prescribed a beta blocker for her irregular heartbeat and tremors. The following morning, she met with an endocrinologist and was diagnosed with hyperthyroidism. She received an anti-thyroid medication that would reduce the tremor, swelling, exophthalmos and shoulder stiffness. She returned to PT and upon re-evaluation, the tremor and edema were resolved by the anti-thyroid medication; however, the shoulder stiffness remained. Examination of the soft tissue found no underlying trigger-points and since this person was independent with her shoulder stretching and strengthening activities it was decided that she continue her home program to improve her mobility and function.4 She was discharged from PT with follow up as needed.
DISCUSSION: When symptoms do not fit the diagnosis or individuals do not respond to treatment as expected, it may be necessary for the PT to consider how other systems possibly affect shoulder function. This enables an appropriate differential diagnosis for proper care and/or referrals. As BCA is associated with increased ThD risk, PTs are uniquely positioned to screen for possible symptoms of ThD such as unexpected weight loss, family history, cardiovascular symptoms, tremor, thinning hair, and uncharacteristic pain, edema, and fatigue. The PT can also provide patient education on thyroid symptoms to women with BCA for self-advocacy.5
ANTI-GRAVITY TREADMILL USE IN AN ADULT WITH SEVERE HEMOPHILIC ARTHROPATHY: A CASE REPORT.
Tankersley JB, Truluck KA
BACKGROUND AND PURPOSE: Recurring hemarthrosis and chronic synovitis in persons with hemophilia A and B often leads to debilitating hemophilic arthropathy. Over 80% of hemarthroses occur in the knee, elbow, or ankle affecting ability to participate in aerobic exercise. The purpose of this case report was to determine the effects of anti-gravity treadmill use on walking endurance, mobility, and quality of life in an adult with severe hemophilic arthropathy and limited options for exercise.
CASE DESCRIPTION: The participant in this case report was a 53-year-old male with a diagnosis of hemophilia A severe, hypertension, HIV+ (undetectable viral load), obesity (BMI: 36.5) and diabetes mellitus type 2. His past medical history included bilateral knee replacements, a right total hip replacement, and bilateral ankle fusions. The participant's primary complaints were deconditioning, activity-induced back spasms, bilateral ankle pain, and impaired balance. He expressed a desire to lose weight and improve his walking endurance without increasing his pain and risk of joint bleeds.
OUTCOMES: Pre-test video analysis of gait was recorded, functional mobility and fall risk was assessed with the Timed Up and Go (TUG), aerobic capacity and endurance was measured by the 6 Minute Walk Test (6MWT), disease impairment severity was measured by the Hemophilia Joint Health Score (HJHS), participation was measured by the Functional Independence Score in Hemophilia (FISH) and the Hemophilia Activities List (HAL) and quality of life was measured by the PROMIS Global Health Score. Intervention included four sessions of walking using the AlterG® anti-gravity treadmill™ with self-selected parameters for speed and duration after body weight percentage was reduced to 40% to achieve pain free walking. Sessions were over a four week period to minimize the risk of a joint bleed. Post-test measures of all outcome measures and video gait analysis were recorded. The participant improved in all six outcome measures post-treatment. Distance covered during the 6MWT increased by 120 meters post-treatment (44% increase), the HJHS improved 4 points (6.6%), FISH improved 5 points (17.3%), HAL improved 9 points (5.3%) and the PROMIS Global Health Score improved 14 points (30.4%). The TUG improved from 15 seconds to 13 seconds, placing our participant below the 14 second cut off for high-fall risk. He reported a preference for this intervention over other modes of exercise because upright activity-induced back spasms and ankle pain were eliminated. Gait and posture analyses revealed improvements in cadence, speed, alignment, and step length while walking in the AlterG® compared to land walking. Duration of exercise increased each session, peak speeds were reached sooner each session, and participant's ability to assume full weight bearing during cool down was achieved sooner each session. Participant reported both short-term and long-term reduction of anxiety and depressive symptoms post-treatment (62% increase in PROMIS sub-category of mental health). No joint bleeds were reported during the intervention phase.
DISCUSSION: The results of this case report show the potential benefits of anti-gravity aerobic exercise for adults with severe hemophilic arthropathy. Therapeutic interventions incorporating reduction in body weight while walking, such as, therapeutic pool, body-weight support harness, lowering BMI, and AlterG® could be incorporated in physical therapy intervention plans for patients with severe hemophilic arthropathy to allow aerobic fitness training while minimizing stress on joints. To conclude, anti-gravity treadmill training using the AlterG® can be a safe, effective intervention for improvement of walking endurance, mobility, and quality of life in an adult with severe hemophilic arthropathy, though future research with more subjects and utilizing a randomized control trial is needed.
AQUATIC THERAPY REDUCES PAIN AND FATIGUE IN PEOPLE WITH BREAST CANCER: A SYSTEMATIC REVIEW
Smith JM, Barbagelata K, Eadi J, McNamara M, Sayles MC
PURPOSE/HYPOTHESIS: Pain and fatigue are frequent impairments resulting from the medical and surgical therapies for breast cancer. Aquatic therapy, the application of water based exercise or activity for rehabilitation, has been recommended as effective for the problems of pain and fatigue. The purpose of this systematic review was to determine if aquatic therapy reduced pain and fatigue among people with breast cancer.
NUMBER OF SUBJECTS: Included were 6 studies involving 271 subjects (adults with breast cancer).
MATERIALS AND METHODS: The protocol for this systematic review of the literature was prospectively registered with PROSPERO, and PRISMA standards were followed for the review. Search terms were pilot tested with a research librarian and four databases were searched through February, 2019. Two reviewers screened titles and abstracts (first phase), and full text (second phase) to determine eligibility for inclusion. Two reviewers assessed methodological quality (risk of bias) of included studies with the APTA Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI), and level of evidence with the Oxford Centre for Evidence-based Medicine Levels of Evidence for Therapy / Prevention Studies. Relevant data was extracted into a predetermined template for analysis and thematic synthesis.
RESULTS: Six studies involving 271 subjects (137 subjects who received aquatic therapy) were included. The studies included female subjects with breast cancer, the mean age of the intervention subjects was 49.8 years and the mean age of the control group subjects was 47.8 years (there was not an appreciable between group difference that could skew data). All subjects in the studies received surgical treatment (mastectomy or lumpectomy). All studies had a high or acceptable level of evidence and five studies had high or acceptable quality (ie, low risk for bias).
Themes within the aquatic therapy regimens were the use of strengthening and aerobic exercise, with sessions that were performed for 60 minutes, three times/week, for eight or more weeks. The reported responses to aquatic therapy were significant reduction in ratings of pain and fatigue. Reported adverse responses to aquatic therapy were minimal, with minor symptoms (eg, delayed onset muscle soreness) that resolved within days and had no effect on attrition in the studies.
CONCLUSIONS: Based on high level evidence with acceptable quality (risk of bias) the intervention of aquatic therapy is recommended as a treatment for the impairments of pain and fatigue resulting from breast cancer or the accompanying medical/surgical interventions for breast cancer. The intervention is safe and feasible in this population.
CLINICAL RELEVANCE: Pain and fatigue are common sequelae of surgical and medical interventions for breast cancer. Aquatic therapy is an effective intervention for these symptoms and is a safe and feasible intervention that physical therapists can employ.
TEMPORAL CHANGES IN UPPER EXTREMITY FUNCTION IN WOMEN TREATED FOR BREAST CANCER
Koehler LA, Taylor L, Medina EM, Moore M, Murray PS
PURPOSE/HYPOTHESIS: Breast cancer treatments contribute to upper extremity dysfunction; however, few studies have investigated long-term upper extremity function in patients following breast cancer surgery. The purpose of this 5 year study was to characterize the temporal nature of upper extremity function following breast cancer surgery using the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. We hypothesize there will be a difference in upper extremity dysfunction in women treated for breast cancer over time.
NUMBER OF SUBJECTS: 27
MATERIALS AND METHODS: The DASH questionnaire was used to assess upper extremity functional changes over 5 years. The DASH consists of 30 questions scored from 0-100 where high scores indicate greater disability and low scores indicate less disability. Data was collected 2 weeks, 1 month, 3 months, 18 months, and 5 years post-operation.
RESULTS: There was a statistical change in upper extremity function over time (p=0.0004, F=5.58). Upper extremity function was statistically lower at 2 weeks (mean=25) compared to 3 months (mean=7) and 18 months (mean=9), but was not statistically different at 1 month (mean=16) and 5 years (mean=13). This presents a U-shaped temporal pattern indicating early and late upper extremity dysfunction following surgery.
CONCLUSIONS: Upper extremity function improved over the first 3 months followed by an overall 5 year decline. This observed decline in upper extremity function could possibly be attributed to delayed emergence of cancer treatment complications, aging, alterations in patient perception of their condition, or an interplay of these factors.
CLINICAL RELEVANCE: This study indicates breast cancer patients experience upper extremity disability for years following treatment. Awareness of longstanding impairments suggests that surveillance and early rehabilitation could be critical in decreasing long-term disability in breast cancer patients.
ASSOCIATION OF PHYSICAL FITNESS AND QOL IN BREAST CANCER SURVIVORS FOLLOWING A 16-WEEK EXERCISE INTERVENTION
Grullon J, Poon D, Sami N, Lee K, Dieli-Conwright C
PURPOSE/HYPOTHESIS: There are over 3.5 million women diagnosed with breast cancer, which has a 5-year survival rate of 89.9%. However, many breast cancer survivors (BCS) experience adverse treatment side effects such as weight gain and worsened physical fitness, which can lead to poor quality of life (QOL). We previously reported that structured progressive exercise can improve physical fitness and QOL in BCS. The purpose of this secondary analysis was to examine the association between physical fitness (muscle strength and cardiorespiratory fitness) and QOL in BCS following a 16-week aerobic and resistance exercise intervention.
NUMBER OF SUBJECTS: 100
MATERIALS AND METHODS: BCS (stage I-III) were randomized to either the exercise group (n=50) or usual care group (n=50). The exercise group received a 16-week supervised exercise intervention consisting of moderate-vigorous (65-85% HR maximum) aerobic and resistance exercise 3 times per week. Outcome measures were assessed at baseline and post-intervention. Physical fitness was assessed using a submaximal treadmill walk test to estimate VO2max and 10-repetition maximum test to estimate 1-repetition max strength for leg press, knee flexion, knee extension, chest press, and seated row. QOL was assessed using the Functional Assessment of Cancer Therapy-Breast (FACT-B). Pearson's correlations were used to assess the association between post-exercise measures of physical fitness and QOL.
RESULTS: BCS were 53.5±10.4 years old, postmenopausal (60%), Hispanic (55%) with a BMI 33.55.5 kg/m2. Adherence to the intervention was 95% and post-intervention assessments were available on 91% of participants. Post-exercise, significant correlations were found between all measures of physical fitness and QOL (r>0.80). Specifically, leg flexion (r=0.97, p<0.01), leg extension (r=0.95, p<0.01), chest press (r=0.91, p<0.01), and latissimus pulldown (r= 0.719, p<0.05) showed significant correlation with QOL.
CONCLUSIONS: Exercise-induced improvements in physical fitness following a supervised exercise intervention may result in increased psychosocial health in BCS.
CLINICAL RELEVANCE: Participation in exercise is an effective strategy to improve multiple health outcomes in BCS that may ultimately mitigate adverse treatment-related side effects.
MOBILITY AND COGNITIVE MEASURES IN OLDER CANCER SURVIVORS: EXAMINATION OF RELIABILITY AND MINIMAL DETECTABLE CHANGE
Blackwood JA, Rybicki K, Karczewski H, Huang MH
PURPOSE/HYPOTHESIS: Cancer has been recognized as a chronic condition of older adults with the number of cancer survivors aged 65 years and over projected to reach 20 million by 2026 in the United States. Cancer and its treatment contribute to multiple sequelae affecting physical function, including pain, fatigue, muscle weakness, and difficulty in balance and walking. Cognitive function may also be affected, resulting in impaired executive functioning and multi-tasking abilities. These sequelae put older cancer survivors at a higher risk for falls and fall-related injuries compared to those without cancer. Although clinical tests should be used to assess fall-risk in older cancer survivors, the literature describing the validity, reliability and minimal detectable change (MDC) values of the measures is lacking. The purpose of this study was to describe the reliability and MDC95 of mobility and cognitive measures used in older cancer survivors.
NUMBER OF SUBJECTS: 45
MATERIALS AND METHODS: Forty-five community dwelling breast, prostate, lung, or colorectal cancer survivors age 65+years were recruited to participate in this study. Measures of gait speed (GS) (usual, fast, and dual-task) in meters/second, mobility (timed-up-and-go (TUG), TUG cognitive, TUG manual) and cognition (Trail-Making Test parts A (TMT-A) and B (TMT-B) and the Mini-Cog test) were performed once and then repeated two weeks later. Test-retest reliability was examined using intraclass correlation coefficient (ICC2,1). The MDC95 and standard error of the mean (SEM) were calculated.
RESULTS: The mean age of participants was 73.59 ± 6.73 years with 57% female. The sample included breast (52%), prostate (38%), lung (7%), and colorectal (2%) cancer survivors. Test-retest reliability was excellent for all GS and mobility measures: usual GS (ICC=0.95), fast GS (ICC=0.96), dual-task GS (ICC=0.90), TUG (ICC=0.98), TUG cognitive (ICC=0.98), and TUG manual (ICC=0.95). Moderate test-retest reliability was found for TMT-B (ICC=0.79) and Mini-Cog (ICC=0.60) and poor test-retest reliability was found for TMT-A (ICC=0.07). The MDC95 and SEM varied by test.
DISCUSSION: Excellent reliability was found for all GS and TUG measures. However, due to the variation in performance and level of comorbidity within different cancer survivors, and that the majority of the sample were breast cancer survivors, further study is indicated to establish the psychometric values by type of cancer. TMT-B had the highest reliability of the three cognitive measures, however results may be influenced by the large standard deviation indicating potentially a more cognitively impaired subgroup may exist in the sample. This may have also impacted the large degree of change needed to determine true change on the measure.
CONCLUSIONS: Measures of usual, fast, and dual task GS as well as TUG have excellent reliability and should be considered for use to assess mobility in older cancer survivors. TMT-B was the only cognitive measure that had good reliability and could be used by physical therapists in this population.
CLINICAL RELEVANCE: Gait speed and TUG measures are reliable instrucments to measure mobility in older cancer survivors.