Levels of secretory leukocyte protease inhibitor expression in acute wounds.

OBJECTIVE: Even with our best practices, we are frequently unable to prevent slow and stalled wound healing-particularly in people with impaired circulation and conditions such as diabetes. As a result, greater insight into the nature of wound healing and alternative treatment approaches is needed. An avenue that may be of particular promise is increasing understanding of the role of secretory leukocyte protease inhibitor (SLPI) as there is evidence that it enhances wound healing, its expression increases in response to inflammation and infection, and it exhibits anti-protease, anti-inflammatory, antiviral antibacterial and antifungal activities. METHOD: The response of SLPI levels to wounding and skin injury was assessed by taking punch skin biopsies from healthy volunteers and assessing the levels of SLPI at the site of injury at the time of wounding (baseline) as well as one, two, three, four, seven, nine and 12 weeks later. RESULTS: A total of 35 volunteers took part in the study. Significant elevations were found: levels of SLPI were greatly increased, 12 times that at baseline, and remained elevated at three weeks despite re-epithelialisation having occurred. CONCLUSION: These findings not only suggest that levels of SLPI rise rapidly following wounding, but that these elevations are sustained, and continue to increase even when re-epithelialisation has occurred. These results suggest that the role and potential benefits of this protease inhibitor deserve further exploration.

Association of Function, Symptoms, and Social Support Reported in Standardized Outpatient Clinic Questionnaires With Subsequent Hospital Discharge Disposition and 30-Day Readmissions.

OBJECTIVE: To determine whether patient-reported information, routinely collected in an outpatient setting, is associated with readmission within 30 days of discharge and/or the need for post-acute care after a subsequent hospital admission. DESIGN: Retrospective cohort study. Six domains of patient-reported information collected in the outpatient setting (psychological distress, respiratory symptoms, musculoskeletal pain, family support, mobility, and activities of daily living [ADLs]) were linked to electronic health record hospitalization data. Mixed effects logistic regression models with random intercepts were used to identify the association between the 6 domains and outcomes. SETTING: Outpatient clinics and hospitals in a Midwestern health system. PARTICIPANTS: 7671 patients who were hospitalized 11,445 times between May 2004 and May 2014 (N=7671). INTERVENTION: None. MAIN OUTCOME MEASURES: 30-day hospital readmission and discharge home vs facility. RESULTS: Domains were significantly associated with 30-day readmission and placement in a facility. Specifically, mobility (odds ratio [OR]=1.30; 95% confidence interval [CI], 1.16, 1.46), ADLs (OR=1.27; 95% CI, 1.13, 1.42), respiratory symptoms (OR=1.26; 95% CI, 1.12, 1.41), and psychological distress (OR=1.20; 95% CI, 1.07, 1.35) had the strongest associations with 30-day readmission. The ADL (OR=2.52; 95% CI, 2.26, 2.81), mobility (OR=2.35; 95% CI, 2.10, 2.63), family support (OR=2.28; 95% CI, 1.98, 2.62), and psychological distress (OR=1.38; 95% CI, 1.25, 1.52) domains had the strongest associations with discharge to an institution. CONCLUSIONS: Patient-reported function, symptoms, and social support routinely collected in outpatient clinics are associated with future 30-day readmission and discharge to an institutional setting. Whether these data can be leveraged to guide interventions to address patient needs and improve outcomes requires further research.

Multidimensional Computerized Adaptive Testing: A Potential Path Toward the Efficient and Precise Assessment of Applied Cognition, Daily Activity, and Mobility for Hospitalized Patients.

OBJECTIVE: To develop and evaluate an efficient and precise variable-length functional assessment of applied cognition, daily activity, and mobility to inform mobility preservation and rehabilitation service delivery among hospitalized patients. DESIGN: A multidimensional item bank tapping into these dimensions was developed, with all items calibrated using a multidimensional graded response model. The items were adaptively selected from the item banks to maximize the test information, and the test ended when a joint stopping rule was satisfied. A simulation study was conducted based on the completed instrument, the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), to compare its measurement precision and efficiency capabilities relative to conventional unidimensional computerized adaptive testing. Precision was measured by the bias and root mean squared error between the estimated and true (ie, simulated) θ estimates, whereas efficiency was measured by average test length. Data were collected by an interviewer reading questions from a tablet computer and entering patients' responses. SETTING: A large Midwestern hospital. PARTICIPANTS: A total of 4143 patients hospitalized with medical diagnosis and/or surgical complications, with 2060 in the calibration sample and 2083 in the validation cohort. INTERVENTION: Not applicable. RESULTS: Among the 2083 patients in the validation sample, FAMCAT administration required an average of 6 (SD=3.11) minutes. Ninety-six percent had their tests terminated by the standard error rule after responding to an average of 22.05 (SD=7.98) items, whereas 15 were terminated by the change in θ rule, with an average test length of 45.27 (SD=11.49). The remaining 76 responded until reaching the maximum test length of 60 items. CONCLUSIONS: The FAMCAT has the potential to satisfy the need for structured, frequent, and precise assessment of functional domains among hospitalized patients with medical diagnosis and/or surgical complications. The results are promising and may be informative for others who wish to develop similar instruments when concurrent assessment of correlated domains is required.

Can Proxy Ratings Supplement Patient Report to Assess Functional Domains Among Hospitalized Patients?

OBJECTIVE: To (1) characterize the agreement between patient and proxy responses on a multidimensional computerized adaptive testing measure of function, and to (2) determine whether patient, proxy, or multidimensional computerized adaptive testing score characteristics identify when a proxy report can be used as a substitute for patient report in clinical decision making. DESIGN: A psychometric study of the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Testing (FAMCAT) and its 3 scales (Applied Cognition, Daily Activity, and Basic Mobility). SETTING: An upper midwestern quaternary academic medical center PARTICIPANTS: A total of 300 pairs of patients (average age 60.9 years; range, 19-89) hospitalized on general medical services or readmitted to surgical services for postoperative complications and their proxies (average age 60.5 years; range, 20-88). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: There were 3 outcomes: (1) agreement between patient and proxy scores on the FAMCAT domains, as well as age and sex, analyzed with univariate and multivariate analysis of variance (MANOVA); (2) associations of patient-proxy relationship and FAMCAT score characteristics with patient-proxy score agreement; and (3) presence of psychometrically significant intra-dyad differences in FAMCAT scores. RESULTS: The results of the MANOVA and follow-up ANOVAs indicated that there were no statistically significant differences in FAMCAT scale scores between patient and proxy estimates for either the Daily Activity or Basic Mobility scales. There were significant differences for the Applied Cognition scale (P<.005) between mean patient and proxy scores, with proxies rating patients as functioning at a higher level (mean=0.42) than patients did themselves (mean=0.00). However, psychometrically significant intra-dyadic Applied Cognition score differences occurred in only 14% of dyads, compared with 25% in the other 2 scales. Sex and age were associated with patient-proxy agreement, but the patterns were not sufficiently consistent to permit generalizations regarding the likely validity of a proxy's scores. CONCLUSIONS: Patient and proxy FAMCAT Daily Activity and Basic Mobility scores did not differ significantly, and proxy reporting offers a creditable surrogate for patient report on these domains. Low rates of psychometrically significant intra-dyadic score differences suggest that proxy report may serve as a low-resolution screen for functional deficits in all FAMCAT domains. Approximately half the proxies provided multi-domain profile ratings on the 3 scales that did not differ significantly from these of the associated patients, but more research is needed to identify situations in which proxy profiles could be used in place of those provided by patients.

Does the Mode of PROM Administration Affect the Responses of Hospitalized Patients?

OBJECTIVE: To determine whether a multidimensional computerized adaptive test, the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), could be administered to hospitalized patients via a tablet computer rather than being orally administered by an interviewer. DESIGN: A randomized comparison of the responses of hospitalized patients to interviewer vs tablet delivery of the FAMCAT and its assessment of applied cognition, daily activity, and basic mobility. SETTING: Two quaternary teaching hospitals in the Upper Midwest. PARTICIPANTS: A total of 300 patients (127 men, 165 women), average age 61.2 (range, 18-97) hospitalized on medical services or rehospitalized on surgical services were randomly assigned to either a tablet (150) or an interview (150) group. INTERVENTION: Electronic tablet vs interview. MAIN OUTCOME MEASURES: Item response theory point estimates of the FAMCAT latent scales, their psychometric standard errors, number of items administered per domain, the determinant (an indicator of overall precision of the latent trait vector), as well as the time that patients required to complete their FAMCAT sessions. RESULTS: Of the 300 patients, 292 completed their assessments. The assessments of 4 individuals in each group was interrupted by clinical care and were not included in the analyses. A significant (P=.009) mode effect (ie, interview vs tablet) was identified when all outcome variables were considered simultaneously. However, the only outcome that was affected by the administration mode was test duration: tablet administration reduced the roughly 6-minute test time required by both approaches by only 20 seconds, which, though statistically significant, was clinically insignificant. CONCLUSIONS: The results of a FAMCAT assessment, at least for this cohort of hospitalized patients, are independent of administration via tablet computer or interview.

Adaptive Measurement of Change: A Novel Method to Reduce Respondent Burden and Detect Significant Individual-Level Change in Patient-Reported Outcome Measures.

OBJECTIVE: To describe the adaptive measurement of change (AMC) as a means to identify psychometrically significant change in reported function of hospitalized patients and to reduce respondent burden on follow-up assessments. DESIGN: The AMC method uses multivariate computerized adaptive testing (CAT) and psychometric hypothesis tests based in item response theory to more efficiently measure intra-individual change using the responses of a single patient over 2 or more testing occasions. Illustrations of the utility of AMC in clinical care and estimates of AMC-based item reduction are provided using the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT), a newly developed functional multidimensional CAT-based measurement of basic mobility, daily activities, and applied cognition. SETTING: Two quaternary hospitals in the Upper Midwest. PARTICIPANTS: Four hundred ninety-five hospitalized patients who completed the FAMCAT on 2 to 4 occasions during their hospital stay. INTERVENTION: N/A. RESULTS: Of the 495 patients who completed more than 1 FAMCAT, 72% completed 2 sessions, 13% completed 3, and 15% completed 4, with 22.1%, 23.4%, and 23.0%, respectively, exhibiting significant multivariate change. Use of the AMC in conjunction with the FAMCAT reduced respondent burden from that of the FAMCAT alone for follow-up assessments. On average, when used without the AMC, 22.7 items (range, 20.4-24.4) were administered during FAMCAT sessions. Post hoc analyses determined that when the AMC was used with the FAMCAT a mean±standard deviation reduction in FAMCAT number of items of 13.6 (11.1), 13.1 (9.8), and 18.1 (10.8) would occur during the second, third, and fourth sessions, respectively, which corresponded to a reduction in test duration of 3.0 (2.4), 3.0 (2.8), and 4.7 (2.6) minutes. Analysis showed that the AMC requires no assumptions about the nature of change and provides data that are potentially actionable for patient care. Various patterns of significant univariate and multivariate change are illustrated. CONCLUSIONS: The AMC method is an effective and parsimonious approach to identifying significant change in patients' measured CAT scores. The AMC approach reduced FAMCAT sessions by an average of 12.6 items (55%) and 2.9 minutes (53%) among patients with psychometrically significant score changes.

A View of the Development of Patient-Reported Outcomes Measures, Their Clinical Integration, Electronification, and Potential Impact on Rehabilitation Service Delivery.

Recognition of the importance of a patient's perception of their status and experience has become central to medical care and its evaluation. This recognition has led to a growing reliance on the use of patient-reported outcome measures (PROMs). Nevertheless, although awareness of PROMs and acceptance of their utility has increased markedly, few of us have a good insight into their development; their utility relative to clinician-rated and performance measures such as the FIM and 6-minute walk test or how their "electronification" and incorporation into electronic health records (EHRs) may improve the individualization, value, and quality of medical care. In all, the goal of this commentary is to provide some insight into historical factors and technology developments that we believe have shaped modern clinical PROMs as they relate to medicine in general and to rehabilitation in particular. In addition, we speculate that while the growth of PROM use may have been triggered by an increased emphasis on the centrality of the patient in their care, future uptake will be shaped by their embedding in EHRs and used to improve clinical decision support though their integration with other sources of clinical and sociodemographic data.

Improving the Delivery of Function-Directed Care During Acute Hospitalizations: Methods to Develop and Validate the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT).

OBJECTIVE: To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans. DESIGN: This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics. SETTING: A large (2000-bed) Midwestern Medical Center. PARTICIPANTS: The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Not applicable. RESULTS: The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization. CONCLUSIONS: The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Assessing whether ad hoc clinician-generated patient questionnaires provide psychometrically valid information.

BACKGROUND: The provision of psychometrically valid patient reported outcomes (PROs) improves patient outcomes and reflects their quality of life. Consequently, ad hoc clinician-generated questionnaires of the past are being replaced by more rigorous instruments. This change, while beneficial, risks the loss/orphaning of decades-long information on difficult to capture/chronically ill populations. The goal of this study was to assess to the quality of data retrieved from these legacy questionnaires. METHODS: Participants included 8563 patients who generated a total of 12,626 hospital admissions over the 2004-2014 study period. Items used to screen for issues related to function, mood, symptoms, and social support among patients with chronic disease were identified in our medical center's patient information questionnaire. Cluster and exploratory factor analyses (EFA) followed by multidimensional item response theory (MIRT) analyses were used to select items that defined factors. Scores were derived with summation and MIRT approaches; inter-factor relationships and relationships of factor scores to assigned diagnostic codes were assessed. Rasch analyses assessed the constructs' measurement properties. RESULTS: Literature review and clinician interviews yielded four hypothesized constructs: psychological distress/wellbeing, symptom burden, social support, and physical function. Rasch analyses showed that, while all had good measurement properties, only one, function, separated individuals well. In exploratory factor analyses (EFA), 11 factors representing depression, respiratory symptoms, musculoskeletal pain, family support, mobility, activities of daily living, alcohol consumption, weight loss, fatigue, neurological disorders, and fear at home were identified. Based on the agreement between EFA and cluster analyses as well as Cronbach's alpha, six domains were retained for analyses. Correlations were strong between activities of daily living and mobility (.84), and moderate between pain and mobility (.37) and psychological distress (.59) Known-group validity was supported from the relationships between factor scores and the relevant diagnostic code assignments (.12 to .20). CONCLUSIONS AND DISCUSSION: Items from ad hoc clinician-generated patient information questionnaires can be aggregated into valid factors that assess supportive care domains among chronically ill patients. However, the binary response options offered by many screening items limit their information content and consequently, as highlighted by Rasch analyses, their ability to meaningfully discriminate trait levels in these populations.

The impact of arm lymphedema on healthcare utilization during long-term breast cancer survivorship: a population-based cohort study.

PURPOSE: Cancer treatment-related late effects degrade survivors' quality of life, independence, and societal integration, yet may be ameliorated, or even reversed, with effective care. Unfortunately, survivors inconsistently receive this care and the impact on their healthcare utilization is unknown. We sought to estimate differences in utilization between breast cancer (BC) survivors with and without upper extremity lymphedema; a common, remediable late effect. METHODS: We conducted a population-based, retrospective longitudinal cohort study of survivors with incident BC diagnosed from January 1, 1990, through December 31, 2010. HC utilization was characterized using the Berenson-Eggers Type of Service (BETOS) categories. Outcomes included overall healthcare utilization as well as its compartmentalization into the BETOS categories of (1) Evaluation and management, (2) Procedures, (3) Imaging, (4) Tests, (5) Durable medical equipment, (6) Physical/occupational therapy, (7) Other, and (8) Exceptions/Unclassified. RESULTS: The cohort included 1906 subjects of which 94% (1800) had records meeting the inclusion criteria. Mean follow-up per survivor was 12.8 years (mean, 11, range 1-25 years). Analysis revealed that (1) survivors with BC-associated lymphedema used > 30% more services annually; (2) their increased utilization lessened but persisted for at least 10 years after diagnosis; and (3) this finding of increased utilization extends across all BETOS categories, is further amplified as BMI increases, and cannot be explained solely by lymphedema-directed care. CONCLUSIONS: BC-related lymphedema appears to be an important driver of survivors' healthcare utilization and guideline-concordant activities to reduce its incidence and severity may be cost neutral or saving. IMPLICATIONS FOR CANCER SURVIVORS: Early detection and effective management of cancer-related late effects like lymphedema may reduce survivors' healthcare needs in the decades that follow their cancer treatment.

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value.

PURPOSE: A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function. METHODS: Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment. RESULTS: The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow. CONCLUSION: This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations.

Rehabilitation Medicine Approaches to Pain Management.

Rehabilitation medicine offers strategies that reduce musculoskeletal pain, targeted approaches to alleviate movement-related pain, and interventions to optimize patients' function despite the persistence of pain. These approaches fall into four categories: modulating nociception, stabilizing and unloading painful structures, influencing pain perception, and alleviating soft tissue musculotendinous pain. Incorporating these interventions into individualized, comprehensive pain management programs offers the potential to empower patients and limit pain associated with mobility and required daily activities. Rehabilitative approach may be particularly helpful for patients with refractory movement-associated pain and functional vulnerability, and for those who do not wish for, or cannot, tolerate pharmacoanalgesia.

The rationale, design, and methods of a randomized, controlled trial to evaluate the effectiveness of collaborative telecare in preserving function among patients with late stage cancer and hematologic conditions.

Disablement affects over 40% of patients with advanced stage cancer, devastates their quality of life (QoL), and increases their healthcare costs. Proactively treating the causes of disablement; physical impairments, pain, and immobility, can prolong functional independence, improve QoL and, potentially, reduce utilization. However rehabilitation service delivery models are reactive in nature and focus on catastrophic rather than incipient disability. A validated collaborative approach, the Three Component Model (TCM), optimizes important clinical outcomes and may provide an ideal framework to overcome barriers to proactively integrating rehabilitation into cancer care. A novel expansion of the TCM that targets disablement by engaging local physical therapists to address physical impairments and immobility, the TCM-Rehabilitation Services (TCM-RS), benefits and is well received by patients. However, its effectiveness has not been rigorously assessed. The 3-arm randomized COllaborative Care to Preserve PErformance in Cancer (COPE) Trial compared: 1) enhanced usual care, 2) rehabilitation services targeting physical impairments and immobility via the TCM-RS, and 3) TCM-RS plus conventional TCM pain management TCM-RS+Pain. Of the 516 participants, those randomized to arms 2 and 3 underwent an initial 4-week intervention period and were then followed for 6months with remote monitoring and monthly telephone calls. The trial's primary outcome, functional status, and secondary outcomes were assessed at baseline, 3, and 6months. Utilization was abstracted from clinical records. By estimating the effectiveness and cost-utility implications of the TCM-RS and TCM-RS+Pain, COPE will inform future delivery research, practice and policy in the means to reduce disablement in chronically diseased populations.

Integrating Function-Directed Treatments into Palliative Care.

The growing acceptance of palliative care has created opportunities to increase the use of rehabilitation services among populations with advanced disease, particularly those with cancer. Broader delivery has been impeded by the lack of a shared definition for palliative rehabilitation and a mismatch between patient needs and established rehabilitation service delivery models. We propose the definition that, in the advanced cancer population, palliative rehabilitation is function-directed care delivered in partnership with other clinical disciplines and aligned with the values of patients who have serious and often incurable illnesses in contexts marked by intense and dynamic symptoms, psychological stress, and medical morbidity to realize potentially time-limited goals. Although palliative rehabilitation is most often delivered by inpatient physical medicine and rehabilitation consultation/liaison services and by physical therapists in skilled nursing facilities, outcomes in these settings have received little scrutiny. In contrast, outpatient cancer rehabilitation programs have gained robust evidentiary support attesting to their benefits across diverse settings. Advancing palliative rehabilitation will require attention to historical barriers to the uptake of cancer rehabilitation services, which include the following: patient and referring physicians' expectation that effective cancer treatment will reverse disablement; breakdown of linear models of disablement due to presence of concurrent symptoms and psychological distress; tension between reflexive palliation and impairment-directed treatment; palliative clinicians' limited familiarity with manual interventions and rehabilitation services; and challenges in identifying receptive patients with the capacity to benefit from rehabilitation services. The effort to address these admittedly complex issues is warranted, as consideration of function in efforts to control symptoms and mood is vital to optimize patients' autonomy and quality of life. In addition, manual rehabilitation modalities are effective and drug sparing in the alleviation of adverse symptoms but are markedly underused. Realizing the potential synergism of integrating rehabilitation services in palliative care will require intensification of interdisciplinary dialogue.

Nested Cohort Study to Identify Characteristics That Predict Near-Term Disablement From Lung Cancer Brain Metastases.

OBJECTIVE: To test whether the presence of patient- and imaging-level characteristics (1) are associated with clinically meaningful changes in mobility among patients with late-stage cancer with metastatic brain involvement, and (2) can predict their risk of near-term functional decline. DESIGN: Prospective nested cohort study. SETTING: Quaternary academic medical center. PARTICIPANTS: The study population consisted of a nested cohort of the patients with imaging-confirmed brain metastases (n=66) among a larger cohort of patients with late-stage lung cancer (N=311). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional evaluations with the Activity Measure for Post-Acute Care Computer Adaptive Test (AM-PAC-CAT) and symptom intensity ratings were collected at monthly intervals for up to 2 years. RESULTS: In exploratory univariate models, whole brain radiation therapy (WBRT) and imaging findings of cerebellar or brainstem involvement were associated with large AM-PAC-CAT score declines reflecting worsening mobility (-4.55, SE 1.12; -2.87, SE, 1.0; and -3.14, SE 1.47, respectively). Also in univariate models, participants with new neurologic signs or symptoms at imaging (-2.48; SE .99), new brain metastases (-2.14, SE .99), or new and expanding metastases (-2.64, SE 1.14) declined significantly. Multivariate exploratory mixed logistic models, including WBRT, cerebellar/brainstem location, presence of new and expanding metastases, and worst pain intensity, had excellent predictive capabilities for AM-PAC-CAT score declines of 7.5 and 10 points (C statistics ≥0.8). CONCLUSIONS: Among patients with lung cancer and brain metastases, cerebellar/brainstem location, new and expanding metastases, and treatment with WBRT may predict severe, near-term mobility losses and indicate a need to consider rehabilitation services.

How Receptive Are Patients With Late Stage Cancer to Rehabilitation Services and What Are the Sources of Their Resistance?

OBJECTIVE: To describe the proportion and characteristics of patients with late stage cancer that are and are not receptive to receiving rehabilitation services, and the rationale for their level of interest. DESIGN: Prospective mixed-methods study. SETTING: Comprehensive cancer center in a quaternary medical center. PARTICIPANTS: Adults with stage IIIC or IV non-small cell or extensive stage small cell lung cancer (N=311). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Telephone-acquired responses to the administration of (1) the Activity Measure for Post Acute Care Computer Adaptive Test (AM-PAC-CAT); (2) numerical rating scales for pain, dyspnea, fatigue, general emotional distress, and distress associated with functional limitations; (3) a query regarding receptivity to receipt of rehabilitation services, and (4) a query about rationale for nonreceptivity. RESULTS: Overall, 99 (31.8%) of the study's 311 participants expressed interest in receiving rehabilitation services: 38 at the time of enrollment and an additional 61 during at least 1 subsequent contact. Participants expressing interest were more likely to have a child as primary caregiver (18.18% vs 9.91%, P=.04) and a musculoskeletal comorbidity (42.4% vs 31.6%, P=.05). Function-related distress was highly associated with receptivity, as were lower AM-PAC-CAT scores. Reasons provided for lack of interest in receiving services included a perception of their limited benefit, being too busy, and prioritization below more pressing tasks/concerns. CONCLUSIONS: One-third of patients with late stage lung cancer are likely to be interested in receiving rehabilitation services despite high levels of disability and related distress. These findings suggest that patient misperception of the role of rehabilitation services may be a barrier to improved function and quality of life. Efforts to educate patients on the benefits of rehabilitation and to more formally integrate rehabilitation as part of comprehensive care may curb these missed opportunities.

Scrambler Therapy for the management of chronic pain.

PURPOSE: Chronic pain is a widespread and debilitating condition, encountered by physicians in a variety of practice settings. Although many pharmacologic and behavioral strategies exist for the management of this condition, treatment is often unsatisfactory. Scrambler Therapy is a novel, non-invasive pain modifying technique that utilizes trans-cutaneous electrical stimulation of pain fibers with the intent of re-organizing maladaptive signaling pathways. This review was conducted to further evaluate what is known regarding the mechanisms and mechanics of Scrambler Therapy and to investigate the preliminary data pertaining to the efficacy of this treatment modality. METHODS: The PubMed/Medline, SCOPUS, EMBASE, and Google Scholar databases were searched for all articles published on Scrambler Therapy prior to November 2015. All case studies and clinical trials were evaluated and reported in a descriptive manner. RESULTS: To date, 20 reports, of varying scientific quality, have been published regarding this device; all but one small study, published only as an abstract, provided results that appear positive. CONCLUSION: The positive findings from preliminary studies with Scrambler Therapy support that this device provides benefit for patients with refractory pain syndromes. Larger, randomized studies are required to further evaluate the efficacy of this approach.

Physical Therapists' Perceptions and Use of Exercise in the Management of Subacromial Shoulder Impingement Syndrome: Focus Group Study.

BACKGROUND: Shoulder pain resulting from subacromial impingement syndrome (SAIS) is a common problem with a relatively poor response to treatment. There is little research exploring physical therapists' perspectives on the management of the syndrome. OBJECTIVES: The study objective was to investigate physical therapists' perceptions and experiences regarding the use of exercise in the treatment of patients with SAIS. DESIGN: This was a qualitative focus group study. METHODS: Three 60- to 90-minute focus group sessions containing 6 to 8 experienced musculoskeletal physical therapists (total number=20) were conducted. Thematic content analysis was used to analyze transcripts and develop core themes and categories. RESULTS: Exercise was seen as key in the management of SAIS. The overarching theme was the need to "gain buy-in to exercise" at an early stage. The main subtheme was patient education. Therapists identified the need to use education about SAIS etiology to foster buy-in and "sell" self-management through exercise to the patient. They consistently mentioned achieving education and buy-in using visual tools, postural advice, and sometimes a "quick fix" of pain control. Furthermore, experienced practitioners reported including educational interventions much earlier in treatment than when they first qualified. Therapists emphasized the need for individually tailored exercises, including: scapular stabilization; rotator cuff, lower trapezius, and serratus anterior muscle strengthening; and anterior shoulder and pectoralis minor muscle stretching. Quality of exercise performance was deemed more important than the number of repetitions that the patients performed. LIMITATIONS: Expanding the geographical area over which the focus groups were conducted and including therapists with less than 5 years of postgraduate experience may have strengthened the findings of this study. CONCLUSION: Experienced musculoskeletal physical therapists believe that exercise is central in treating patients with SAIS and that gaining patient buy-in to its importance, patient education, promoting self-management, and postural advice are central to the successful treatment of people with SAIS.