Mi-Joung Lee

Assessment of breast cancer-related arm lymphedema--comparison of physical measurement methods and self-report.

ABSTRACT Purpose To determine the relationship between physical methods of measuring lymphedema and self-reported swelling, their reliability, and standard error of measurement. Method: Lymphedema in each arm of women with (n = 33) and without (n = 18) unilateral arm lymphedema, secondary to breast cancer was measured by self-report, bioimpedance spectroscopy (BIS), perometer, and the truncated cone method. Results: The physical measurement tools were highly reliable (ICC(2,1): 0.94 to 1.00) with high concordance (rc: 0.89 to 0.99). Selfreport correlatedmoderately with physical measurements (r = 0.65 to 0.71) and was moderately reliable (ICC(2,1): 0.70). Conclusions: Lymphedema assessment methods are concordant and reliable but not interchangeable.

Comparison of Effect of Aerobic Cycle Training and Progressive Resistance Training on Walking Ability After Stroke: A Randomized Sham Exercise–Controlled Study

OBJECTIVES: To determine whether changes in strength or cardiorespiratory fitness after exercise training improve walking ability in individuals who have had a stroke.

Effect of progressive resistance training on muscle performance after chronic stroke.

PURPOSE This study investigated the effects of high-intensity progressive resistance training (PRT) and high-intensity cycling (cycling) on muscle performance and the time course of strength gains in a chronic stroke population. METHODS Forty-eight individuals with chronic stroke sequelae (mean +/- SD; age = 63 +/- 9 yr, time since stroke = 57 +/- 54 months) were randomly allocated to one of four treatment groups: PRT + cycling, PRT + sham cycling, sham PRT + cycling, or sham PRT + sham cycling groups in a fully factorial clinical trial. Thirty exercise sessions were conducted over a 10- to 12-wk period. The main outcomes investigated were measures of unilateral muscle strength, peak power, and muscle endurance. RESULTS Those undergoing PRT improved their lower limb muscle strength, peak power, and endurance compared with participants receiving sham PRT or cycling only (P < 0.05), and combined exercise was not superior to PRT alone. Strength improvements occurred primarily during the first 6 to 8 wk (98%-100% of total gain) and then reached a plateau during the final 2 to 4 wk. CONCLUSION We have shown for the first time in a direct comparison study that high-intensity PRT, but not cycling or sham exercise, can improve muscle strength, peak power, and muscle endurance in both affected and unaffected lower limbs after chronic stroke by a significant and clinically meaningful amount. Although strength gains plateaued earlier than anticipated, adherence to the intended continuous high-intensity progressive overload protocol was largely achieved (average load of 84% +/- 4% of one repetition maximum).

Pectoral stretching program for women undergoing radiotherapy for breast cancer

Surgery and radiotherapy commonly cause adverse musculoskeletal problems, particularly loss of strength and range of motion, in the upper quadrant of breast cancer patients. Few well-designed studies have investigated whether these impairments can be prevented. Stretching is an effective technique for increasing range of motion, hence the aim of this study was to investigate whether a stretching program reduced acute musculoskeletal impairments in patients undergoing radiotherapy for breast cancer. Sixty-four women were recruited prior to commencement of radiotherapy following breast cancer surgery. Participants were randomised to either a control or stretch group. Participants in both groups were reviewed by the physical therapist on a weekly basis for approximately 6 weeks, and were given general information about skin care and lymphedema. The control group received no advice about exercise. The stretch group received instruction on low-load, prolonged pectoral stretches, which were to be performed daily and were checked at weekly visits. Shoulder range of motion, strength, arm circumference, and quality of life measurements were taken prior to, and at completion of radiotherapy, and at 7 months after radiotherapy. There was no difference in any outcome between groups. Breast symptoms increased for both groups during radiotherapy, without loss of strength or range of movement. The incidence of lymphedema during the study was low for both groups and did not differ between groups. The pectoral stretching program did not influence the outcomes measured because the symptoms reported by patients were not a consequence of contracture.

Reliability and Concurrent Validity of the Perometer for Measuring Hand Volume in Women With and Without Lymphedema

BACKGROUND Lymphedema of hand after breast cancer treatment causes significant loss of hand function. Although there are several ways of assessing limb volume, measuring hand volume has been problematic due to technical difficulties associated with assessment of finger volumes. The aim of this study was to investigate the criterion validity and reliability of Perometer™ for measuring hand volume in woman with and without lymphedema. METHODS AND RESULTS Hand volume of forty women with (n = 20) and without lymphedema (n = 20) was assessed twice by one rater and once by another rater using the Perometer, and once by one rater using the water volumetry method. Intra- and inter-rater reliability was determined from the intraclass correlation coefficients and Percent Close Agreement. Agreement between the Perometer and water volumetry was determined using a limit of agreement and Lins concordance correlation. The Perometer had high intra [ICC(2,1) = 0.989 (95% CI: 0.98-0.99)] and inter-rater reliability [ICC(2,1) = 0.993 (95% CI: 0.99-1.0)]. Percent close agreement revealed that 80% of the measures were within 9 ml for inter-rater reliability and within 15 ml for intra-rater reliability. In addition, there was high concordance between hand volumes obtained with the Perometer and water volumetry method (R(c) = 0.88). However, the Perometer overestimated the volume of hand compared to water volumetry method (bias: 7.5%). CONCLUSIONS The Perometer can be used with high reliability to measure hand volume but caution should be exercised when data are compared with measures derived from the water volumetry method.

Prospective transcriptomic pathway analysis of human lymphatic vascular insufficiency: identification and validation of a circulating biomarker panel.

Background In our previous transcriptional profiling of a murine model, we have identified a remarkably small number of specific pathways with altered expression in lymphedema. In this investigation, we utilized microarray-based transcriptomics of human skin for an unbiased a priori prospective candidate identification, with subsequent validation of these candidates through direct serum assay. The resulting multi-analyte biomarker panel sensitively should sensitively discriminate human lymphedema subjects from normal individuals. Methods and Findings We enrolled 63 lymphedema subjects and 27 normals in our attempt to discover protein analytes that can distinguish diseased individuals from controls. To minimize technical and biologically irrelevant variation, we first identified potential candidates by performing transcriptional microarray analysis on paired diseased and normal skin specimens sampled from the same individuals. We focused our attention on genes with corresponding protein products that are secreted and took these candidates forward to a protein multiplex assay applied to diseased and normal subjects. We developed a logistic regression-based model on an eventual group of six proteins and validated our system on a separate cohort of study subjects. The area under the receiver operating characteristic curve was calculated to be 0.87 (95% CI : 0.75 to 0.97). Conclusions We have developed an accurate bioassay utilizing proteins representing four central pathogenetic modalities of the disease: lymphangiogenesis, inflammation, fibrosis, and lipid metabolism, suggesting that these proteins are directly related to the pathogenesis of the tissue pathology in lymphatic vascular insufficiency. Further studies are warranted to determine whether this newly-identified biomarker panel will possess utility as an instrument for in vitro diagnosis of early and latent disease; the ultimate applicability to risk stratification, quantitation of disease burden, and response to therapy can easily be envisioned.

Movement detection at the ankle following stroke is poor

This study assessed whether sense of movement is impaired at the ankle in persons post-stroke who are able to walk independently. Eleven chronic post-stroke subjects (> 4 months post stroke) who were ambulatory with or without walking aids and living within the community, and 10 healthy age-matched control subjects volunteered to participate. Proprioceptive acuity at the ankle, measured by sense of movement, was tested at three velocities, 0.1, 0.5, and 2.5 deg/sec, in random order. In addition, ankle range of motion and the distance that subjects walked in 6 minutes were assessed. Stroke subjects were significantly poorer (p < 0.001) at detecting movement at the affected ankle compared with either the unaffected ankle or with the control group at each of the velocities tested. Six out of 11 stroke subjects demonstrated significant impairment in movement detection compared to controls. The usual primary impairments following stroke are loss of strength and loss of co-ordination. However, reduced proprioceptive acuity at the affected ankle may also contribute to a persons ability to position and load the foot during walking. This could explain the moderate relationship found between proprioceptive acuity and walking endurance in persons following stroke (Spearmans rho = 0.63 to 0.77).

Lymphedema Following Taxane-Based Chemotherapy in Women with Early Breast Cancer

BACKGROUND Taxanes can cause fluid accumulation by increasing extracellular fluid (ECF). Taxane-based regimens are standard of care for early breast cancer, but it is unknown whether they increase the risk of lymphedema. The aim of this study was to describe the incidence of lymphedema, generalized limb edema, and associated symptoms in women receiving adjuvant taxane-based chemotherapy. METHODS AND RESULTS Women (n=63) recruited after axillary surgery for early breast cancer were assessed prior to anthracycline-based, prior to taxane-based chemotherapy, and 3 weeks and 6 months after completing taxane-based chemotherapy. At each assessment, the inter-limb ECF ratios and intra-limb intracellular fluid to ECF ratios were determined using bioimpedance spectroscopy. Inter-limb arm volume ratios were calculated from arm circumferences measurements. Self-rated symptoms of swelling and pain in the arm on the side of surgery were recorded. In the 53 women who completed assessments, taxane-based chemotherapy increased the ECF volume in both upper and lower limbs, which was not observed after anthracycline-based chemotherapy. The arm on the side of surgery was preferentially affected, indicated by elevated ECF ratios at 3 weeks and 6 months after completing taxane-based chemotherapy with 32% and 23% meeting the criteria for lymphedema at these time-points, respectively. Edema resolved by 6 months following completion of chemotherapy except in the arm on the side of surgery. CONCLUSION The incidence of lymphedema in the arm on the side of surgery following taxane-based chemotherapy was increased persisting at least 6 months after ceasing chemotherapy. However, generalized swelling in the legs and opposite arm resolved by 6 months after chemotherapy.

Inter-limb coordination in bimanual reach-to-grasp following stroke

Purpose. To determine the extent to which inter-limb coordination in the execution of unimanual and bimanual tasks was impaired following stroke. Methods. Thirteen stroke survivors aged 55 – 77 years and 13 healthy, neurologically intact participants aged 57 – 86 years performed a unimanual and two bimanual tasks involving the relocation of single and paired objects. Movements were recorded using electromagnetic sensors attached to the wrists and a series of micro switches placed under the objects. Main outcome measures included time to complete components of the tasks; comparison between sides; deviation of the hands from a linear trajectory; coordination of the two sides as indicated by relative phase angle. Results. Stroke survivors took longer to complete the bimanual tasks, but did not deviate from the optimal trajectories more than the healthy participants. Both groups performed unimanual tasks faster than bimanual and stroke participants were only slightly less synchronised when performing bimanual tasks. Conclusions. In conclusion, in a group of stroke patients with reasonable strength, inter-limb coordination was mildly impaired. This impairment in coordination was not due to lateral deviation of the impaired limb.

Sedentary versus active behavior in people after stroke

Abstract Background: The detrimental effect of sedentary behavior has been acknowledged and the benefit of interrupting sedentary behavior is being explored. Objectives: The aim of this review was to examine sedentary and active behavior of stroke survivors, how these behaviors are accumulated and to explore energy expenditure to understand how much physical activity is required following stroke. Method: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EMBASE were searched for studies involving community-dwelling stroke survivors and healthy adults, and using objective measures of sedentary/active behavior or energy expenditure during active tasks. Data were extracted independently by two reviewers. Results: After being assessed against the inclusion criteria, 12 studies were included. The mean ratio (stroke∶controls) of sitting behavior was 1·2∶1 suggesting that stroke survivors are more sedentary than healthy individuals. The ratio of standing and walking time was 0·7∶1 and steps per day was 0·5∶1 suggesting that stroke survivors are less active than healthy individuals. The ratio of bouts of activity/day was 0·7∶1 suggesting that stroke survivors do not interrupt their sedentary time as often as healthy individuals. The ratio of energy expenditure ranged from 1·1 to 2·5∶1 suggesting that stroke survivors expend more energy than healthy individuals for the same activity. Conclusions: Stroke survivors have less bouts of activity than their age-matched counterparts suggesting that they are at risk of health issues. However, stroke survivors expend more energy for the same activity, and this may go some way toward balancing out their reduced amount of physical activity.