G. Stephen Morris

Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands

BACKGROUND Robotic assisted transaxillary surgery (RATS) is a minimally invasive approach for the removal of the thyroid and/or parathyroid glands through the axilla. This anatomically directed technique, popularized by Chung, eliminates a visible scar and affords excellent high definition optics of the cervical anatomy. We report an initial series of single access RATS in the U.S. METHODS The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent RATS between October 2009 and March 2010. All procedures were performed using a single transaxillary incision. RESULTS Fourteen operations were performed on 13 patients. Indications for RATS were indeterminate thyroid nodules in 11 patients, the need for completion thyroidectomy in 1 patient, and primary hyperparathyroidism in 2 patients. For patients who underwent robotic assisted thyroid lobectomy, the median thyroid nodule size was 2.1 cm (range, 0.8-2.8 cm), and the median body mass index was 25.33 (range, 21.3-34.4). Mean and median total operative times for robotic assisted thyroid lobectomies were 142 minutes and 137 minutes respectively (range, 113-192 minutes). Operative time for the 2 patients who underwent robotic assisted parathyroidectomy was 115 and 102 minutes. Minor complications occurred in 4 patients (28.5%), with no significant perioperative morbidity or mortality. CONCLUSION RATS is feasible. We believe that further study of the RATS technique for removing thyroid lobes and parathyroid glands is warranted. This initial series suggests that careful, continued investigation is necessary prior to routine implementation into clinical practice across the U.S.

Randomized, Controlled Trial of Yoga in Women With Breast Cancer Undergoing Radiotherapy

PURPOSE Previous research incorporating yoga (YG) into radiotherapy (XRT) for women with breast cancer finds improved quality of life (QOL). However, shortcomings in this research limit the findings. PATIENTS AND METHODS Patients with stages 0 to III breast cancer were recruited before starting XRT and were randomly assigned to YG (n = 53) or stretching (ST; n = 56) three times a week for 6 weeks during XRT or waitlist (WL; n = 54) control. Self-report measures of QOL (Medical Outcomes Study 36-item short-form survey; primary outcomes), fatigue, depression, and sleep quality, and five saliva samples per day for 3 consecutive days were collected at baseline, end of treatment, and 1, 3, and 6 months later. RESULTS The YG group had significantly greater increases in physical component scale scores compared with the WL group at 1 and 3 months after XRT (P = .01 and P = .01). At 1, 3, and 6 months, the YG group had greater increases in physical functioning compared with both ST and WL groups (P < .05), with ST and WL differences at only 3 months (P < .02). The group differences were similar for general health reports. By the end of XRT, the YG and ST groups also had a reduction in fatigue (P < .05). There were no group differences for mental health and sleep quality. Cortisol slope was steepest for the YG group compared with the ST and WL groups at the end (P = .023 and P = .008) and 1 month after XRT (P = .05 and P = .04). CONCLUSION YG improved QOL and physiological changes associated with XRT beyond the benefits of simple ST exercises, and these benefits appear to have long-term durability.

A Framework for Assessment in Oncology Rehabilitation

Although the incidence of cancer in the United States is high, improvements in early diagnosis and treatment have significantly increased survival rates in recent years. Many survivors of cancer experience lasting, adverse effects caused by either their disease or its treatment. Physical therapy interventions, both established and new, often can reverse or ameliorate the impairments (body function and structure) found in these patients, improving their ability to carry out daily tasks and actions (activity) and to participate in life situations (participation). Measuring the efficacy of physical therapy interventions in each of these dimensions is challenging but essential for developing and delivering optimal care for these patients. This article describes the acute and long-term effects of cancer and its treatment and the use of the World Health Organizations International Classification of Functioning, Disability and Health (ICF) as a basis for selection of assessment or outcome tools and diagnostic or screening tools in this population.

A randomized control trial of a supervised versus a self‐directed exercise program for allogeneic stem cell transplant patients

Objectives: To determine if therapist supervision of an exercise program produced better functional outcomes in allogeneic stem cell transplant patients than a patient‐directed exercise program.

Influence of pain distribution on gait characteristics in patients with low back pain: Part 1: Vertical ground reaction force

Study Design. In a cross-sectional study, vertical ground reaction force (GRF) during 2 speeds of walking were compared between 3 age- and sex-matched groups: back pain only (BPO) group, back pain with referred leg pain (LGP) group, and a control group. Objective. The purpose was to evaluate the influence of pain distribution on vertical GRF of patients with low back problems during 2 walking speed conditions: preferred and fastest speeds. Summary of Background Data. People with low back pain often have difficulty walking. A better understanding of how pain distribution differentially affects walking will facilitate clinicians’ assessment and enhance treatment in patients with low back pain problems. Methods. All participants walked on a 7.62-m walkway. Vertical GRF parameters were recorded during stance phase using a force platform for each walking speed condition. Multivariate analysis of covariance was used for statistical analysis, with gait velocity as the covariate. Results. The BPO and control groups did not differ significantly in vertical GRF during both walking speed conditions (P ≥ 0.11). All vertical GRF parameters of the LGP group, except the peak loading force (P = 0.374), were significantly less than those of the control group during preferred walking speed condition (P ≤ 0.008). However, there was no significant difference in the vertical GRF components between LGP and control groups during the fastest walking speed condition (P ≥ 0.07). Conclusions. Pain distribution of people with low back problems differentially influences the vertical GRF they experience during walking. When walking at preferred speed, those with referred leg pain seem to use additional strategies besides walking slowly to attenuate the amount of force imposed on their painful leg. When challenged to walk at their fastest speed, people with back pain only walk as fast and withstand comparable amount of force as their pain-free counterparts.

The Influence of Pain Distribution on Walking Velocity and Horizontal Ground Reaction Forces in Patients with Low Back Pain

Objective. The primary purpose of this paper was to evaluate the influence of pain distribution on gait characteristics in subjects with low back problems (LBP) during walking at preferred and fastest speeds. Design. Cross-sectional, observational study. Setting. Gait analysis laboratory in a health professions university. Participants. A convenience age- and gender-matched sample of 20 subjects with back pain only (BPO), 20 with referred leg pain due to back problems (LGP), and 20 pain-free individuals (CON). Methods and Measures. Subjects completed standardized self-reports on pain and disability and were videotaped as they walked at their preferred and fastest speeds along a walkway embedded with a force plate. Temporal and spatial gait characteristics were measured at the midsection of the walkway, and peak medial, lateral, anterior, and posterior components of horizontal ground reaction forces (hGRFs) were measured during the stance phase. Results. Patients with leg pain had higher levels of pain intensity and affect compared to those with back pain only (t = 4.91, P < .001 and t = 5.80, P < 0.001, resp.) and walking had an analgesic effect in the BPO group. Gait velocity was highest in the control group followed by the BPO and LGP group and differed between groups at both walking speeds (F 2.57 = 13.62, P < .001 and F 2.57 = 9.09, P < .001, for preferred and fastest speed condition, resp.). When normalized against gait velocity, the LGP group generated significantly less lateral force at the fastest walking speed (P = .005) and significantly less posterior force at both walking speeds (P ≤ .01) compared to the control group. Conclusions. Pain intensity and distribution differentially influence gait velocity and hGRFs during gait. Those with referred leg pain tend to utilize significantly altered gait strategies that are more apparent at faster walking speeds.

Physical activity among adult survivors of childhood lower-extremity sarcoma.

IntroductionAdult survivors of childhood lower-extremity sarcoma are largely physically inactive, a behavior which potentially compounds their health burden. Altering this behavior requires understanding those factors that contribute to their physical inactivity. Therefore, this investigation sought to identify factors associated with inactivity in this subpopulation of cancer survivors.MethodsDemographic, personal, treatment, and physical activity information from adult survivors of childhood lower-extremity sarcomas was obtained from the Childhood Cancer Survivor Study (CCSS) cohort. Generalized linear models were used to identify variables that best identified those individuals who were physically inactive.ResultsOnly 41% of survivors met Center for Disease Control (CDC) activity guidelines. Survivors were 1.20 (95% confidence intervals (CI) 1.11–1.30) more likely compared to CCSS sibling cohort and 1.12 (95% CI 1.10–1.15) times more likely than the general population to fail to meet CDC guidelines. Significant predictors of physical inactivity included female sex, hemipelvectomy surgery, and platinum and vinca alkaloid chemotherapy.ConclusionsThe primary findings of this study are that survivors of childhood onset lower-extremity sarcoma are (1) highly likely to be physically inactive and (2) less likely than their siblings or the general population to regularly exercise. This study has identified treatment-related risk factors associated with inactivity that will help health and wellness practitioners develop successful exercise interventions to help these survivors achieve recommended levels of physical activity for health.Implications for cancer survivorsThese results suggest that physical activity interventions for adult survivors of childhood lower-extremity sarcomas should be sex specific and responsive to unique physical late effects experienced by these survivors.

Pulmonary Rehabilitation Improves Functional Status in Oncology Patients

OBJECTIVE To determine if participation in a pulmonary rehabilitation (PR) program improved the functional and physiologic status of oncology patients with chronic symptoms of shortness of breath, fatigue, and/or exercise intolerance. DESIGN Retrospective chart review. SETTING Comprehensive cancer center. PATIENTS Oncology patients (N=30) (either a solid or a hematologic malignancy) with chronic dyspnea, exercise intolerance, and/or decreased functional status who had participated in an outpatient PR program. INTERVENTIONS The PR program used an individualized, progressive aerobic exercise program (2-3 sessions/wk for 8-12 weeks) that consisted of treadmill walking, riding on a bicycle ergometer and exercising on a sliding board. This program also included a didactic educational and psychosocial component. MAIN OUTCOME MEASURES Functional status and exercise tolerance was assessed by the 6-minute walk test (6MWT) conducted at the beginning and end of the program. Self reports of perceived exertion and dyspnea were collected during and after these tests. Physiologic status was assessed by calculating 6-minute walk work (body mass x 6-minute walk distance). RESULTS Participation in the outpatient PR program significantly increased the 6-minute walk distance (21%, P<.05) and 6-minute walk work (17%, P<.05). Dyspnea and perceived exertion scores were similar at the pre- and postrehabilitation 6MWT despite the greater physiologic demand of the post-rehabilitation 6-minute walk. No adverse events occurred during the study. CONCLUSIONS The current study, although limited in size, suggests that participation in a comprehensive outpatient PR program is safe and of benefit in a heterogeneous population of oncology patients with pulmonary symptoms.

Defining Core Faculty for Physical Therapist Education

Background and Purpose. With the rapid transition in professional (entrylevel) educational preparation from the masters degree to the doctoral degree in physical therapist education, the need for doctorally trained faculty is likely to increase substantially. Several different doctoral degrees that may meet the academic qualifications expected of core faculty members currently are offered; however, these doctoral degrees vary widely in their educational focus, rigor, and philosophy. Such differences in doctoral preparation, combined with faculty shortages, have increased the debate over the necessary academic qualifications for people who serve as core faculty members in physical therapist education programs. The purpose of this article is to suggest that the ideal faculty team in professional physical therapist education should include a balance of people possessing terminal academic degrees in physical therapy or a closely related field, people possessing terminal professional clinical degrees with documented clinical specialization, and people possessing terminal academic degrees in foundational sciences with or without physical therapy degrees. Position and Rationale. A diverse core faculty with a balance of academic training in complementary fields will benefit an education program in many ways, such as providing breadth of expertise, serving to maintain academic standards in doctoral education, and meeting requirements established by accrediting agencies and home institutions. Discussion and Conclusion. For programs providing professional physical therapist education, a variety of doctorally prepared people should be actively recruited for core faculty positions. Once hired, these faculty members should be vigorously supported and mentored so as to ensure their success in meeting the faculty expectations established by their academic institutions and pertinent accrediting bodies.

Oncologic Emergencies: Implications for Rehabilitation

Many oncology patients are at risk for emergent medical conditions brought on by either their disease itself or its treatment. Such conditions typically arise from structural/mechanical defects, metabolic derangements, and/or hematological deficits. Although rehabilitation staff members do not treat these emergent conditions, they are uniquely positioned to recognize changes in patient status that may signal an emergent condition. By alerting medical staff to these changes, appropriate and potentially life-saving medical care can be initiated. The purpose of this manuscript, therefore, is to identify the signs and symptoms of the more frequent emergent conditions seen in the oncology environment and to describe the implications for rehabilitation staff.