Mary Lou Galantino

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.

Iyengar Yoga versus Enhanced Usual Care on Blood Pressure in Patients with Prehypertension to Stage I Hypertension: a Randomized Controlled Trial.

The prevalence of prehypertension and Stage 1 hypertension continues to increase despite being amenable to non-pharmacologic interventions. Iyengar yoga (IY) has been purported to reduce blood pressure (BP) though evidence from randomized trials is lacking. We conducted a randomized controlled trial to assess the effects of 12 weeks of IY versus enhanced usual care (EUC) (based on individual dietary adjustment) on 24-h ambulatory BP in yoga-naïve adults with untreated prehypertension or Stage 1 hypertension. In total, 26 and 31 subjects in the IY and EUC arms, respectively, completed the study. There were no differences in BP between the groups at 6 and 12 weeks. In the EUC group, 24-h systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) significantly decreased by 5, 3 and 3 mmHg, respectively, from baseline at 6 weeks (P < .05), but were no longer significant at 12 weeks. In the IY group, 24 h SBP was reduced by 6 mmHg at 12 weeks compared to baseline (P = .05). 24 h DBP (P < .01) and MAP (P < .05) decreased significantly each by 5 mmHg. No differences were observed in catecholamine or cortisol metabolism to explain the decrease in BP in the IY group at 12 weeks. Twelve weeks of IY produces clinically meaningful improvements in 24 h SBP and DBP. Larger studies are needed to establish the long term efficacy, acceptability, utility and potential mechanisms of IY to control BP.

Impact of Yoga on Functional Outcomes in Breast Cancer Survivors With Aromatase Inhibitor–Associated Arthralgias

Arthralgia affects postmenopausal breast cancer survivors (BCSs) receiving aromatase inhibitors (AIs). This study aims to establish the feasibility of studying the impact of yoga on objective functional outcomes, pain, and health-related quality of life (HR-QOL) for AI-associated arthralgia (AIAA). Postmenopausal women with stage I to III breast cancer who reported AIAA were enrolled in a single-arm pilot trial. A yoga program was provided twice a week for 8 weeks. The Functional Reach (FR) and Sit and Reach (SR) were evaluated as primary outcomes. Pain, as measured by the Brief Pain Inventory (BPI), self-reported Patient Specific Functional Scale (PSFS), and Functional Assessment of Cancer Therapy–Breast (FACT-B) were secondary outcomes. Paired t tests were used for analysis, and 90% provided data for assessment at the end of the intervention. Participants experienced significant improvement in balance, as measured by FR, and flexibility, as measured by SR. The PSFS improved from 4.55 to 7.21, and HR-QOL measured by FACT-B also improved; both P < .05. The score for the Pain Severity subscale of the BPI reduced. No adverse events nor development or worsening of lymphedema was observed. In all, 80% of participants adhered to the home program. Preliminary data suggest that yoga may reduce pain and improve balance and flexibility in BCSs with AIAA. A randomized controlled trial is needed to establish the definitive efficacy of yoga for objective functional improvement in BCSs related to AIAA.

The Effect of Iyengar Yoga and Strengthening Exercises for People Living with Osteoarthritis of the Knee: A Case Series

This case series describes the impact of various forms of exercise on symptoms associated with osteoarthritis of the knee. A group of 15 women and men performed one of the following: traditional stretching and strengthening exercises, Iyengar yoga, or no structured group exercise. Low back and hamstring flexibility and quadriceps strength and function were monitored before and after the program. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was used to assess subjective change after the six-week intervention period. A global assessment questionnaire was also completed by each participant and each instructor at the exit sessions to measure perceived changes in improvements since the initiation of the intervention. This study found functional changes and improvement in quality of life in traditional exercise and a yoga based approach that should encourage further comprehensive and carefully designed studies of yoga in osteoarthritis.

Longitudinal Impact of Yoga on Chemotherapy-Related Cognitive Impairment and Quality of Life in Women with Early Stage Breast Cancer: A Case Series

PURPOSE Adjuvant chemotherapy for women with breast cancer has significantly improved the cure rate; however, it has been associated with chemotherapy-related cognitive impact (CRCI). The literature provides preliminary support for the feasibility and efficacy of yoga interventions for the general cancer population, however, controlled trials are scarce and no studies have examined the effect of yoga on cognition for women with breast cancer during chemotherapy. This case series aims to identify the impact of yoga on measures of cognition, functional outcomes, and quality of life (QOL) for breast cancer survivors (BCS). METHODS Four women with a diagnosis of early-stage breast cancer prior to chemotherapy treatment were administered the following physiologic measures at baseline, 6, and 12 weeks during chemotherapy, and at one and three months after the conclusion of the study: Functional Reach test (balance) and Sit and Reach test (flexibility), and QOL, POMS (Mood) and FACT-B (QOL), at baseline. Primary outcomes of cognition were measured with the Perceived Cognition Questionnaire (PCQ) and CogState, a computerized measurement of cognition. Women attended an Iyengar-inspired yoga program twice a week for 12 weeks. Qualitative questionnaires were administered after the completion of the study to determine perceived benefits and challenges of the yoga program. RESULTS Four women with Stage II breast cancer ranged in age from 44-65 years. CogState computerized testing showed changes in varying domains of cognition through treatment and follow-up. Improved balance, flexibility, and QOL were also noted over time. No adverse events were observed. Analysis of qualitative data revealed the yoga classes were helpful and subjects continued the practice elements of yoga including relaxation, breathing, and stretching. The most challenging aspect of the study was physical limitations due to various medical complications and included fatigue, decreased range of motion, and pain. CONCLUSION This case series suggests that yoga may impact various aspects of cognition during and after chemotherapy administration as noted through quantitative measures. Women describe yoga as improving various domains of QOL through the treatment trajectory. This mind-body intervention may stave off CRCI; however, further investigation is needed for additional randomized controlled trials on the effects of yoga on cognition for women with breast cancer undergoing adjuvant chemotherapy treatment.

A qualitative exploration of the impact of yoga on breast cancer survivors with aromatase inhibitor-associated arthralgias.

RESEARCH QUESTION Arthralgia affects postmenopausal breast cancer survivors (BCS) receiving aromatase inhibitors (AI), which may result in reduced function and long-term well-being. This is an exploratory, qualitative investigation of BCS who participated in a yoga-based program to understand impact on joint pain and various aspects of quality of life (QOL) through a yoga program. THEORETICAL FRAMEWORK Social cognitive theory was used and provided the foundation for developing a yoga intervention through sources of efficacy information: (1) performance accomplishment, (2) structured experience, (3) verbal support from instructor and group, and (4) physical feedback. METHODOLOGY Ten postmenopausal women with stage I-III breast cancer and AI associated arthralgia (AIAA) received yoga twice a week for eight weeks for 90 minutes and were instructed to continue in a home-based yoga program. We used social cognitive theory (SCT) to structure a yoga intervention as an ongoing physical activity to manage joint pain and function. Participants completed journal reflections on their experience and received weekly phone calls. ANALYSIS Data was collected and analyzed using qualitative methods. Member checks were completed and emergent themes were explored and agreed upon by the research team to ensure reliability and validity of data. Several emergent themes were discovered: Empowerment: Importance of Camaraderie, Community, and Sharing; Pain Relief; Increased Physical Fitness (Energy, Flexibility, and Function); Relieved Stress/Anxiety and Transferability of Yoga through Breathing. These themes were identified through instructor observation, participant observation, and weekly phone call documentation. INTERPRETATION Participants experienced an eight-week yoga intervention as an effective physical activity and support group that fostered various improvements in quality of life (QOL) and reduction in AIAA. Participants were highly motivated to improve physical fitness levels and reduce pain. This study revealed benefits from alternative forms of exercise such as yoga to provide a structure, which is transferable in other situations. Information, structured physical guidance in yoga postures, support, and feedback are necessary to foster physical activity for BCS experiencing pain. IMPLICATIONS FOR CANCER SURVIVORS Results of this qualitative analysis indicate that interventions to support BCS with AIAA are warranted. Yoga appears to positively impact these side effects of hormonal therapies. Additional research would aid in the development of other interventions.

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.

INTEGRATING ACUPUNCTURE WITH EXERCISE-BASED PHYSICAL THERAPY FOR KNEE OSTEOARTHRITIS: A RANDOMIZED CONTROLLED TRIAL

Background Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study. Objective The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT). Methods This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray–confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese “Bi” syndrome approach to knee pain, using either standard needles or Streitberger non–skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks. Results Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age. Conclusions Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.

Predictors of Yoga Use Among Patients With Breast Cancer

OBJECTIVE Emerging research suggests that yoga may be beneficial for reducing symptoms and improving quality of life among breast cancer patients. However, very little is known about the characteristics of breast cancer patients who use yoga; thus, this study seeks to identify the sociodemographic and clinical characteristics of yoga users among this population. DESIGN A cross-sectional survey study was conducted. SETTING The study was conducted at an outpatient breast oncology clinic at a large university hospital. PARTICIPANTS Three hundred postmenopausal breast cancer patients currently receiving aromatase inhibitors were included in this study. MAIN OUTCOME MEASUREMENT Self-reported use of yoga following the cancer diagnosis was collected along with sociodemographic and clinical data. Multivariate logistic regression was used to identify independent predictors of yoga use among breast cancer patients. RESULTS Of 300 participants, 53 (17.7%) reported having used yoga following cancer diagnosis. White patients were significantly more likely to use yoga than nonwhite patients (P = .02). Higher education level, lower BMI (body mass index), part-time employment status, previous chemotherapy, and radiation therapy were all associated with greater yoga use (all P < .05). Controlling for other factors, greater yoga use was independently associated with higher education level (adjusted odds ratio [AOR] 2.72, 95% confidence interval [CI], 1.15-6.46), and lower BMI (AOR 0.25, 95% CI, 0.09-0.66). CONCLUSION Yoga use following breast cancer diagnosis was substantially higher for white patients and those with lower BMI and higher education levels. Considering its potential benefits for symptom management in cancer, more research is needed to understand the attitudes and barriers to yoga use among individuals with nonwhite race, lower education, and higher BMI level. Such investigation will help design yoga programs that are aligned to the needs of these populations.

Safety and feasibility of modified chair-yoga on functional outcome among elderly at risk for falls

Falls are among the most common problems affecting older adults. At least 50% of those over the age of 80 fall annually. The goal of this pilot study was to assess the safety and feasibility of structured yoga in an elderly population with fall risk. Seniors at risk for falls were identified and enrolled in a single arm pilot trial. A chair based yoga program was provided twice a week for 8 weeks. The program was designed from previously published pilot data. A battery of validated instruments was administered at baseline and week eight and was used to identify which instruments may be sensitive to change as a result of a yoga program. Among sixteen seniors (median age of 88) with a previous history of falls, 87% provided data for assessment at the end of the intervention. Two patients withdrew, one due to a fall outside the institution and the other due to lack of time and interest. There were no adverse events during the yoga sessions. Paired-t tests compared pre-post changes and gains were noted in Fear of Falling (5.27 to 2.60; P = 0.029) and SPPB sit to stand subscale (0.31 to 1.00; P =.022). Improved trends were noted in anxiety and the timed up and go assessments. We found the modified chair-yoga program is safe and recruitment is feasible. Our data suggests that yoga may be beneficial in improving mobility and reducing fear of falling which warrants additional research via randomized controlled trial.