Anne K. Swisher

The Role of Physical Therapists in Smoking Cessation: Opportunities for Improving Treatment Outcomes

Tobacco use constitutes one of the greatest threats to public health worldwide. As a preventable cause of mortality and chronic disease, tobacco use in the United States results in an estimated 443,000 deaths each year through both direct exposure and secondhand smoke.1 An additional 8,600,000 people across the nation have chronic illness due to smoking.1 As physical therapists, we must realize that tobacco use affects all areas of our practice, including cardiovascular, musculoskeletal, neurological, and integumentary health throughout the life span. In order to provide optimal care for the clients we serve, it is essential for physical therapists to screen for tobacco use and incorporate cessation strategies as part of our interventions.2 There is a substantial unmet demand and opportunity for our profession to promote tobacco cessation.2 Despite evidence that links successful cessation to counseling by health care providers, fewer than 40% of insured adults report receiving such advice.3 In addition, receiving advice from 2 or more health care practitioners more than doubles the odds of successful cessation,4 further supporting the need for physical therapists and physical therapist assistants to contribute our skills and expertise as part of the interdisciplinary health care team. Successful cessation efforts have been demonstrated by other health care professionals, including physicians, dentists, dental hygienists, nurses, and pharmacists, and are an important component of preventive medicine and population health.5 According to the US Medical Expenditure Panel Survey, in 2007, physical therapists conducted a total of 88 million ambulatory visits for approximately 9 million adults aged 18 years and over.6 The number of visits (an average of 9.6 per patient, per episode)6 and nature of our interactions, which include extended, personalized, one-on-one care, present a unique opportunity for physical therapists and physical therapist assistants to provide support for …

frequency and Severity of Self-reported Upper Extremity Impairments, Activity Limitations, and Participation Restrictions Following Breast Cancer Treatment

Objective: Upper quarter impairments, activity limitations, and participation restrictions have been commonly reported in breast cancer survivors. However, use of a standardized tool to assess the frequency and severity of these problems has not been performed. Therefore, we sought to identify the type and severity of upper limb problems following breast cancer treatment, and the impact of those impairments on self‐reported participation in daily activities. Methods: 76 participants completed a survey regarding their cancer treatment and any upper extremity complaints during that time. If they reported current problems with the affected arm, they were asked to complete the Disabilities of the Shoulder Arm and Hand (DASH) Outcome Measure. Results: 96% of respondents indicated upper extremity problems related to cancer treatment, most commonly: arm weakness (59%), lymphedema (53%), pain (52%), stiffness (21%), and frozen shoulder (20%). Of those reporting problems, only 33% received physical therapy intervention. Mean DASH score was 24 (SD = 18), indicating mild to moderate disability. Conclusion: Problems in the upper extremity are common following breast cancer treatment. Some of these problems, even if rated as mildly disabling, are long‐lasting and lead to self‐reported activity limitations and participation restrictions. Few women with these complaints received physical therapy intervention.

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.

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

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.

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.

Chemotherapy Induced Peripheral Neuropathy: Risk Factors, Pathophysiology, Assessment, and Potential Physical Therapy Interventions

&NA; Chemotherapy induced peripheral neuropathy (CIPN) affects many people treated for various types of cancer. Though advances in cancer treatment have led to improved survival rates, patients are now exposed to greater levels of neurotoxic agents, resulting in increased incidence of CIPN. Symptoms of CIPN include pain, sensory loss, proprioceptive deficits, distal weakness, decreased fine motor control, reduced balance, and gait impairments. Chemotherapy induced peripheral neuropathy interferes with function, social roles, and quality of life. The purpose of this literature review is to present chemotherapeutic agents frequently associated with peripheral neuropathy, describe pathogenesis and symptoms, and describe potential impact of the physical therapist in assessment and treatment of persons affected by CIPN.

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 oncologists office and trigger timely referrals for rehabilitation.

The Effect of Exercise on Peripheral Muscle in Emphysema: A Preliminary Investigation

Emphysema has been associated with loss of aerobic muscle fibers and decreased blood supply. However, when these changes begin and whether exercise can prevent these changes is unknown. The purpose of this study was to examine peripheral muscle at different time points during the development of emphysema and to determine the additional effects of muscle activity. In a series of 3 experiments, emphysema was induced in hamsters. Exercise was simulated through surgical overload (OV) of the plantaris muscle of one leg. Animals were sacrificed at 1, 3, and 5 months following emphysema induction. Fiber type composition and capillary-to-fiber ratio (CFR) were determined. There were no significant changes in fiber type composition in the 1-month group. A significant increase in type IIA fiber composition (mean 72.0 vs. 54.5%) and decrease in type IIB fiber (mean 13.3 vs. 28.1%) was seen in the non-overloaded muscles following 3 months. In the 5-month group, there was a significant decrease in percentage of type I fibers (mean 14.7 vs. 28.0%). There were no significant differences in fiber type composition in the OV limb, regardless of duration. The CFR was significantly lower in the OV limb after 5-months of emphysema (mean 0.92 vs. 1.55 cap/fiber). Muscle overload prevented emphysema-associated changes in fiber type composition, but not in CFR. Peripheral muscle is affected early in the course of emphysema and chronic overload may play an important role in preserving normal muscle composition.

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 nondisabled 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 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 posttest 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

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

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 wellreceived 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.