Implementing and sustaining a breast cancer prospective surveillance rehabilitation program: an institutional perspective.

BACKGROUND: The prospective surveillance model (PSM) is an evidence-based rehabilitation care delivery model that facilitates functional screening and intervention for individuals undergoing cancer treatment. While PSM is empirically validated and feasible in practice, implementation into cancer care delivery has languished. The purpose of this manuscript is to characterize the barriers and facilitators to implementing PSM in a breast cancer center and to share policy and process outcomes that have sustained the model in practice. METHODS: The PSM implementation was undertaken as a quality improvement initiative of our cancer center. We retrospectively assessed barriers to implementation and define those according to the Consolidated Framework for Implementation Research (CFIR). Implementation strategies are defined based on the Expert Recommendations for Implementation Change (ERIC) taxonomy. Breast center policy changes and stakeholder-reported process improvement outcomes at the clinic and system level are described. RESULTS: PSM implementation facilitation was driven primarily by adapting the model to align with the cancer center workflow, engaging interdisciplinary stakeholders as program champions, enhancing knowledge and awareness among cancer care providers, and changing infrastructure to support the model. System and clinic-level policy and process changes included the development of clinical pathways, EHR order sets and automated referrals, new staffing models, and adapted clinical workflows. CONCLUSION: Our report provides insight on implementing the PSM at a single institution in a cancer care delivery setting. Successful implementation strategies addressed individual, clinic, and system-level barriers and facilitated process and policy changes that have enabled PSM sustainment. Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity. IMPLICATIONS FOR CANCER SURVIVORS: Improving integration of rehabilitation services into oncology care has significant implications for survivorship care by enhancing proactive management of functional morbidity.

A Systematic Review of Exercise Systematic Reviews in the Cancer Literature (2005-2017).

BACKGROUND: Evidence supports the benefits of exercise for patients with cancer; however, specific guidance for clinical decision making regarding exercise timing, frequency, duration, and intensity is lacking. Efforts are needed to optimize clinical recommendations for exercise in the cancer population. OBJECTIVES: To aggregate information regarding the benefit of exercise through a systematic review of existing systematic reviews in the cancer exercise literature. DATA SOURCES: PubMed, CINAHL Plus, Scopus, Web of Science, and EMBASE. STUDY ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses of the impact of movement-based exercise on the adult cancer population. METHODS: Two author teams reviewed 302 abstracts for inclusion with 93 selected for full-text review. A total of 53 studies were analyzed. A Measurement Tool to Assess Systematic Reviews (AMSTAR) was used as a quality measure of the reviews. Information was extracted using the PICO format (ie, participants, intervention, comparison, outcomes). Descriptive findings are reported. RESULTS: Mean AMSTAR score = 7.66/11 (±2.04) suggests moderate quality of the systematic reviews. Exercise is beneficial before, during, and after cancer treatment, across all cancer types, and for a variety of cancer-related impairments. Moderate-to-vigorous exercise is the best level of exercise intensity to improve physical function and mitigate cancer-related impairments. Therapeutic exercises are beneficial to manage treatment side effects, may enhance tolerance to cancer treatments, and improve functional outcomes. Supervised exercise yielded superior benefits versus unsupervised. Serious adverse events were not common. LIMITATIONS: Movement-based exercise intervention outcomes are reported. No analysis of pooled effects was calculated across reviews due to significant heterogeneity within the systematic reviews. Findings do not consider exercise in advanced cancers or pediatric populations. CONCLUSIONS: Exercise promotes significant improvements in clinical, functional, and in some populations, survival outcomes and can be recommended regardless of the type of cancer. Although generally safe, patients should be screened and appropriate precautions taken. Efforts to strengthen uniformity in clinical trial reporting, develop clinical practice guidelines, and integrate exercise and rehabilitation services into the cancer delivery system are needed.

Feasibility of Using Low-Cost Motion Capture for Automated Screening of Shoulder Motion Limitation after Breast Cancer Surgery.

OBJECTIVE: To determine if a low-cost, automated motion analysis system using Microsoft Kinect could accurately measure shoulder motion and detect motion impairments in women following breast cancer surgery. DESIGN: Descriptive study of motion measured via 2 methods. SETTING: Academic cancer center oncology clinic. PARTICIPANTS: 20 women (mean age = 60 yrs) were assessed for active and passive shoulder motions during a routine post-operative clinic visit (mean = 18 days after surgery) following mastectomy (n = 4) or lumpectomy (n = 16) for breast cancer. INTERVENTIONS: Participants performed 3 repetitions of active and passive shoulder motions on the side of the breast surgery. Arm motion was recorded using motion capture by Kinect for Windows sensor and on video. Goniometric values were determined from video recordings, while motion capture data were transformed to joint angles using 2 methods (body angle and projection angle). MAIN OUTCOME MEASURE: Correlation of motion capture with goniometry and detection of motion limitation. RESULTS: Active shoulder motion measured with low-cost motion capture agreed well with goniometry (r = 0.70-0.80), while passive shoulder motion measurements did not correlate well. Using motion capture, it was possible to reliably identify participants whose range of shoulder motion was reduced by 40% or more. CONCLUSIONS: Low-cost, automated motion analysis may be acceptable to screen for moderate to severe motion impairments in active shoulder motion. Automatic detection of motion limitation may allow quick screening to be performed in an oncologist's office and trigger timely referrals for rehabilitation.

Inspiratory muscle strength relative to disease severity in adults with stable cystic fibrosis.

BACKGROUND: Due to heterogeneity in pulmonary disease, current literature may misrepresent inspiratory muscle involvement in cystic fibrosis (CF). This study investigated inspiratory muscle strength (IMS) relative to disease severity in adults with CF. METHODS: Maximal inspiratory pressure (MIP) was assessed in 58 adults with stable CF grouped by disease severity (20 mild, 20 moderate, 18 severe) and compared to 20 controls. Relationships between MIP, lung function, dyspnea and anthropometrics were evaluated using multivariable linear models. RESULTS: MIP in cmH2O and %-predicted was decreased in advanced CF lung disease as compared to mild disease and healthy controls (p<0.05). Disease severity accounted for 24% of the variance in IMS after controlling for confounding variables (p<0.001). CONCLUSIONS: IMS is decreased in some adults with stable CF with moderate and severe pulmonary disease, and is related to dyspnea. Future studies should determine if decreased IMS contributes inefficient breathing patterns, respiratory pump dysfunction, and/or exercise intolerance in advanced CF.

Exercise and dietary advice intervention for survivors of triple-negative breast cancer: effects on body fat, physical function, quality of life, and adipokine profile.

PURPOSE: Regular exercise and healthy eating are routinely recommended for breast cancer survivors, and past studies show benefits in quality of life and decreased inflammation. However, this has not been tested specifically in triple-negative breast cancer survivors. Increasing physical activity and losing body fat are thought to positively affect inflammatory biomarkers that have been associated with breast cancer. Therefore, the primary purpose of this study was to determine if participation in an exercise and dietary counseling program can improve body fat, physical function, and quality of life in survivors of this aggressive breast cancer. Secondarily, we sought to determine if participation in the program had beneficial effects on obesity-related markers of the adipokine profile. METHODS: Sixty-six survivors of triple-negative breast cancer with BMI >25 were invited to participate. Twenty-eight enrolled and 23 completed the randomized, controlled trial (13 intervention, 10 control). Moderate-intensity aerobic exercise (150 min per week, for 12 weeks) and diet counseling were compared to usual care, education only. The primary outcome of interest was weight loss (body mass, BMI, % fat), and secondary outcomes included physical function (exercise capacity), quality of life (Function After Cancer Therapy-Breast (FACT-B)), cytokines (C-reactive protein (CRP), TNF-α, IL-6), and adipokine profile (leptin, adiponectin, insulin). RESULTS: Participants in the program lost more body fat (2.4 % loss vs. 0.4 % gain, p < 0.05) than the control group. The intervention group also improved quality of life (FACT-B total score +14 pts) and decreased sedentary time but did not improve peak exercise capacity. The intervention had no effect on serum cytokines and adipokines after 12 weeks in the program. However, serum leptin and adiponectin and their ratio were significantly correlated with BMI in the intervention group (p < 0.05). CONCLUSIONS: Exercise and dietary counseling led to loss of body fat and improved quality of life in survivors of triple-negative breast cancer. BMI was associated with favorable changes in leptin and adiponectin which may reflect a change in adiposity with intervention. Exercise and healthy eating may be equally effective in this high-risk population as in other breast cancer survivors and should be encouraged as a part of a cancer survivorship program.

Educating Physical Therapist Students in Tobacco Cessation Counseling: Feasibility and Preliminary Outcomes.

BACKGROUND: Smoking is the leading preventable cause of chronic disease and premature morbidity. People with physical disabilities experience elevated smoking prevalence when compared with their non-disabled peers. The physical therapy profession is dedicated to meeting needs of people with physical disabilities, yet most physical therapists (PT) do not typically provide tobacco cessation interventions. Similar deficits exist among other health professions, creating a demand for improved services to address smoking-related health burdens. Within other health professions, insufficient tobacco cessation counseling (TCC) education has been linked to a lack of interventions and may account for similar deficits in physical therapy practice. STUDY PURPOSE: Goals were to assess feasibility, implementation, and results of a tailored TCC educational program for entry-level physical therapist (PT) students. SUBJECTS: Two cohorts of entry-level physical therapist (PT) students (n = 12 and n = 17). METHODS: Educational objectives were established based on prior review of the literature, a survey of national PT education programs, and clinical guidelines for TCC established by the United States Public Health Service (USPHS). Based on these objectives, the team designed a 3-hour workshop involving didactic content and problem-based skills practice. A pre- and post-test survey was used to measure 6 dimensions: knowledge, perceived barriers, perceived facilitators, self-efficacy, outcome expectations, and self-rated skill in TCC. Within each cohort, changes in score were compared using a paired t test. The ability to apply clinical guidelines for TCC was assessed using case scenarios and structured observation. These outcomes were selected based on the Theory of Reasoned Action, which states that future behavior is determined by intention to act. Intention to act is a product of knowledge, a positive balance between perceived barriers and facilitators, strong self-efficacy, favorable outcome expectations, and necessary skills. Student satisfaction with training was assessed through anonymous written feedback. Feasibility was based on cost analysis, including material resources, as well as faculty time and effort. RESULTS: Following participation, both cohorts improved in knowledge, perceived facilitators, outcome expectations, and self-rated skill. Cohort 2 also showed an increase in self-efficacy (P < .01). Structured observation revealed competencies in application of clinical guidelines for case-based scenarios. Mean student satisfaction ratings for the educational experience were 5/5, and cost-estimate for delivery of the 3-hour educational intervention was approximately $32 per student. CONCLUSIONS: This research study demonstrated feasibility and impact of an evidence-based curricular model designed to increase likelihood of TCC by future PTs by enhancing factors known to promote TCC behaviors. The program was well-received by students, and objectives were achieved through efficient use of faculty time and resources. Subsequent research should examine the effects of training on the provision of TCC within clinical settings, as well as the impact of TCC on smoking quit rates for patients who have received this intervention as a component of their physical therapy plan of care.

Tobacco cessation counseling training in US entry-level physical therapist education curricula: prevalence, content, and associated factors.

BACKGROUND: The US Public Health Service (USPHS) recommends tobacco cessation counseling (TCC) training for all health care professionals. Within physical therapist practice, smoking can have adverse effects on treatment outcomes in all body systems. In addition, people with physical disabilities have a higher smoking prevalence than the general population, creating a strong need for tobacco cessation among physical therapy clientele. Therefore, TCC training is an important component of entry-level physical therapist education. OBJECTIVE: The aims of this study were: (1) to determine need for TCC training within entry-level physical therapist education and (2) to identify potential barriers to implementation of USPHS guidelines in the academic environment. DESIGN: A descriptive cross-sectional survey was conducted. METHODS: Directors or academic coordinators of clinical education from entry-level physical therapist programs (N=204) were surveyed using an online instrument designed specifically for this study. Data regarding program and faculty characteristics, tobacco-related training content, and faculty opinions toward TCC in both physical therapist practice and education were analyzed descriptively. RESULTS: The response rate was 71%. A majority (60%) of programs indicated inclusion of tobacco-related training, most commonly 1 to 2 hours in duration, and of these programs, 40% trained students in the implementation of USPHS clinical guidelines for TCC. LIMITATIONS: Data analyses were constrained by limited or missing data in some areas. A single faculty member completed the survey for each program. CONCLUSIONS: There is a need for TCC training in entry-level physical therapist education. Inclusion may be facilitated by addressing perceived barriers toward TCC as a component of physical therapist practice and promoting the relevance of TCC as it relates to intended outcomes of physical therapy interventions.

Weight change associated with third-generation adjuvant chemotherapy in breast cancer patients.

BACKGROUND: Studies have shown that breast cancer treatment can cause an increase in weight. Weight gain during chemotherapy is usually significant and may be associated with poor survival. However, the role of third- generation chemotherapy regimens and weight gain is not well reviewed. METHODS: We retrospectively analyzed the mean percentage weight change during the first year after breast cancer diagnosis in 246 patients at West Virginia University during September 2007 and October 2010. Kruskal-Wallis test and post hoc pairwise comparisons were used to assess the influence of age, histology, stage, ER/PR/HER2/neu status, menopausal status, and types of therapeutic modalities received on the percentage weight change. Kaplan-Meier method with log-rank test was used to evaluate recurrence-free survival (RFS). Local or distant recurrence and disease progression were events for RFS analysis and disease-free patients were censored at last follow-up. RESULTS: Mean weight gain was 0.39% (SD, 0.40) of baseline body weight, 1 year after diagnosis of breast cancer. Premenopausal status was the only factor associated with significant weight gain (+1.67% vs -0.10% for postmenopausal patients; P = .02). Stages ≥ III was associated with significant weight loss (-1.64% for stages III, IV vs +0.85% for stages 0, I, II; P = .02) and a lower RFS at 3 years and 5 years (P < .0001). Higher baseline weight (> 90th percentile) did not have any significant impact on RFS (0.84 vs 0.91; P = .19). There was no significant change in weight relative to other factors. CONCLUSIONS: Our study in patients receiving third-generation adjuvant chemotherapy regimens did not show any significant change in percentage weight with chemotherapy. Premenopausal status was the only significant factor associated with weight gain. As expected, stage III or higher disease was associated with significant weight loss and lower RFS.

Clinical trial registration in physiotherapy journals: recommendations from the International Society of Physiotherapy Journal Editors.

Clinical trial registration involves placing the protocol for a clinical trial on a free, publicly available, and electronically searchable register. Registration is considered to be prospective if the protocol is registered before the trial commences (ie, before the first participant is enrolled). Prospective registration has several potential advantages. It could help avoid trials being duplicated unnecessarily and it could allow people with health problems to identify trials in which they might participate. Perhaps more importantly, however, it tackles 2 big problems in clinical research: selective reporting and publication bias. Prospective clinical trial registration is of great potential value to the clinicians, consumers, and researchers who rely on clinical trial data, and that is why the International Society of Physiotherapy Journal Editors (ISPJE) is recommending that members enact a policy for prospective trial registration.