Pain in the Cancer Survivor.

Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.

Neuromodulation techniques for cancer pain management.

PURPOSE OF REVIEW: Advanced pain management techniques may be indicated in 5-15% of cancer patients. Despite this, a recent review identified that, over the course of 1 year in England, only 458 patients received a procedure intended to provide analgesia and only 30 patients had intrathecal drug delivery (ITDD) devices implanted. This article describes the emerging evidence for ITDD in cancer pain and provides a narrative review of other neuromodulatory techniques (including spinal cord stimulation, peripheral nerve stimulation and acupuncture), approaches that might be employed to address this area of significant unmet clinical need. RECENT FINDINGS: Numerous studies have been published within the last year reporting positive outcomes associated with ITDD in cancer pain management. Neuromodulation represents an important strategy in the management of persistent pain. Whilst the nonmalignant pain evidence-base is rapidly growing, it remains sparse for cancer pain management. The growing cohort of cancer survivors may significantly benefit from neuromodulatory techniques. SUMMARY: ITDD and other neuromodulatory techniques for cancer pain management appear underutilised in the UK and offer the prospect of better treatment for cancer patients with refractory pain or intolerable side-effects from systemic analgesics.

Metabolic Fingerprinting Links Oncogenic PIK3CA with Enhanced Arachidonic Acid-Derived Eicosanoids.

Oncogenic transformation is associated with profound changes in cellular metabolism, but whether tracking these can improve disease stratification or influence therapy decision-making is largely unknown. Using the iKnife to sample the aerosol of cauterized specimens, we demonstrate a new mode of real-time diagnosis, coupling metabolic phenotype to mutant PIK3CA genotype. Oncogenic PIK3CA results in an increase in arachidonic acid and a concomitant overproduction of eicosanoids, acting to promote cell proliferation beyond a cell-autonomous manner. Mechanistically, mutant PIK3CA drives a multimodal signaling network involving mTORC2-PKCζ-mediated activation of the calcium-dependent phospholipase A2 (cPLA2). Notably, inhibiting cPLA2 synergizes with fatty acid-free diet to restore immunogenicity and selectively reduce mutant PIK3CA-induced tumorigenicity. Besides highlighting the potential for metabolic phenotyping in stratified medicine, this study reveals an important role for activated PI3K signaling in regulating arachidonic acid metabolism, uncovering a targetable metabolic vulnerability that largely depends on dietary fat restriction. VIDEO ABSTRACT.

Sustainability of outcomes after a randomized crossover trial of resistance exercise for shoulder dysfunction in survivors of head and neck cancer.

PURPOSE: Shoulder pain and dysfunction may occur after surgery for head and neck cancer (HNC) as a result of damage to or resection of the spinal accessory nerve. Previous research found that 12 weeks of upper extremity progressive resistance exercise training (PRET) improved shoulder outcomes in survivors of HNC; the purpose of this study was to determine whether benefits persisted over the longer term. METHODS: Survivors of HNC were assigned at random to PRET (n=27) or a standard therapeutic protocol (TP; n=25), with an opportunity for crossover in the TP group after 12 weeks. At 12-month follow-up, participants were mailed a questionnaire that assessed quality of life (QOL), shoulder outcomes, and exercise behaviour. RESULTS: Of the 52 participants enrolled in the study, 44 were eligible at 12-month follow-up, and 37 (71%) completed the questionnaires. Overall, self-reported outcomes were largely sustained over the follow-up period. After 12 months, regardless of original group allocation, participants who continued resistance exercise training during the follow-up period reported better neck dissection-related functioning (p=0.021) and better QOL (p=0.011) than those who did not. CONCLUSIONS: Benefits of PRET were sustained at 12-month follow-up. Ongoing participation in resistance exercise training may prove valuable as a supportive care intervention for survivors of HNC.

Objet : Une douleur à l'épaule et une dysfonction peuvent faire leur apparition après une intervention chirurgicale pour un cancer de la tête et du cou (CTC) parce que le nerf spinal accessoire a été endommagé ou réséqué. Des recherches antérieures ont révélé que 12 semaines d'exercice contre résistance progressive (ERP) des membres supérieurs amélioraient le résultat pour l'épaule chez les survivants d'un CTC. Cette étude visait à déterminer si les bienfaits persistaient à long terme. Méthodes : Les survivants d'un CTC ont été répartis au hasard pour suivre un programme d'ERP (n=27) ou un protocole thérapeutique habituel (PT; n=25) et ont pu passer au groupe PT après 12 semaines. Au suivi à 12 mois, on a envoyé par la poste aux participants un questionnaire d'évaluation de la qualité de vie (QDV), des résultats pour l'épaule et du comportement lié à l'exercice. Résultats : Sur les 52 participants inscrits à l'étude, 44 étaient admissibles au suivi à 12 mois et 37 (71 %) ont répondu aux questionnaires. Dans l'ensemble, les résultats autodéclarés ont été maintenus en grande partie au cours de la période de suivi. Après 12 mois, sans égard à leur affectation au groupe original, les participants qui ont poursuivi leur entraînement par l'exercice à résistance au cours de la période de suivi ont signalé un meilleur fonctionnement lié à la dissection subie au cou (p=0,021) et une meilleure QDV (p=0,011) que ceux qui ne l'ont pas fait. Conclusions : Les bienfaits de l'ERP persistaient au suivi à 12 mois. La participation continue à un programme d'exercice contre résistance peut se révéler utile comme soins de soutien pour les survivants d'un CTC.

Predictors of adherence to an exercise program for shoulder pain and dysfunction in head and neck cancer survivors.

PURPOSE: Achieving acceptable levels of adherence to exercise may be a challenge with head and neck cancer (HNC) survivors given the high morbidity associated with treatment. The purpose of the present trial was to identify the key predictors of adherence during our shoulder exercise rehabilitation trial. METHODS: Fifty-two HNC survivors were randomly assigned to a 12-week progressive resistance exercise training protocol (n = 27) or a standardized therapeutic exercise protocol (n = 25) that was prescribed to address shoulder pain and dysfunction. Baseline data were collected on standard demographic, medical, behavioral, symptom, psychosocial, and motivational variables from the theory of planned behavior. RESULTS: The exercise adherence rate for the trial was 91%. In multivariate analysis, the independent predictors of reduced adherence were undergoing a more extensive neck dissection procedure (ß = -0.361; P = 0.007) and reporting daily alcohol consumption (ß = -0.298; P = 0.031). Higher exercise adherence was achieved by HNC participants who had undergone nerve sparing neck dissection procedures and who were not regular drinkers. CONCLUSION: Excellent adherence to exercise was achieved in the trial despite high morbidity associated with HNC treatment. The high adherence achieved was likely due to the select and highly motivated sample of HNC survivors as well as to factors associated with trial design such as the support offered to participants. The findings of this trial need to be further explored and confirmed in a larger study that includes a more diverse sample of HNC survivors.

Effects of exercise therapy on endogenous pain-relieving peptides in musculoskeletal pain: a systematic review.

OBJECTIVE: To review the literature regarding the effects of exercise in patients with musculoskeletal pain on modifying: (1) the plasma or cerebral spinal fluid concentrations of pain-relieving peptides and (2) changing the cerebral activity of areas linked with pain processing and modulation systematically. METHODS: An extensive search of bibliographic databases including MEDLINE, EMBASE, EBM Reviews-Cochrane Central Register of Controlled Trials, ISI Web of Science, Scopus, PeDro, AMED, and CINAHL was made. Two independent investigators screened the titles of publications and completed quality assessment of the selected studies. RESULTS: The search of the literature resulted in a total of 1819 published studies. Of these only 1 study of low methodological quality was considered to be relevant. The agreement between reviewers to select the articles was κ=1. The agreement for the methodological quality evaluation was κ=0.9. DISCUSSION: Given the small number of studies identified and the low quality of research, no firm conclusions could be reached about the impact of therapeutic exercise on modifying concentrations of pain-relieving peptides or its effect on changing the cerebral activity of areas linked with pain processing in patients with musculoskeletal pain. There is a clear need for well-designed trials examining exercise therapy interventions and their effect on both pain-relieving peptides and cerebral activity in patients with musculoskeletal pain.

Avaliação musculoesquelética / Musculoskeletal assessment

Esta 5ª edição totalmente colorida oferece uma abordagem clara e sistemática para a realização de avaliações neuromusculoesqueléticas, desvendando a lógica por trás de seus vários aspectos. Nesta obra, cada articulação do corpo é tratada em capítulos exclusivos, que abrangem tópicos como: os princípios da avaliação, marcha, postura, os amputados, avaliação primária e de emergências do esporte, cabeça e face. O leitor também encontrará: ilustrações e fotos que mostram claramente os métodos de avaliação, testes, etiologia etc. ; um novo capítulo sobre avaliação primária, que aborda o papel cada vez mais relevante dos fisioterapeutas ; uma completa revisão da avaliação ortopédica baseada em evidências, com informações e detalhes necessários para entender e aplicar métodos de avaliação neuromuscular ; informações sobre ciências fundamentais, aplicações clínicas e testes especiais, que incorporam as últimas pesquisas e as práticas mais utilizadas ; estudos de caso que auxiliam no desenvolvimento de técnicas de avaliação, com exemplos reais ; tabelas e quadros, que organizam e resumem as informações importantes, além de destacar pontos-chave de fácil aprendizagem e memorização.

Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: a randomized controlled trial.

BACKGROUND: Shoulder pain and disability are well recognized complications associated with surgery for head and neck cancer. This study was designed to examine the effects of progressive resistance exercise training (PRET) on upper extremity pain and dysfunction in postsurgical head and neck cancer survivors. METHODS: Fifty-two head and neck cancer survivors were assigned randomly to PRET (n = 27) or a standardized therapeutic exercise protocol (TP) (n = 25) for 12 weeks. The primary endpoint was change in patient-rated shoulder pain and disability from baseline to postintervention. Secondary endpoints were upper extremity strength and endurance, range of motion, fatigue, and quality of life. RESULTS: Follow-up assessment for the primary outcome was 92%, and adherence to the supervised PRET and TP programs were 95% and 87%, respectively. On the basis of intention-to-treat analyses, PRET was superior to TP for improving shoulder pain and disability (-9.6; 95% confidence interval [95% CI], -16.4 to -4.5; P = .001), upper extremity strength (+10.8 kg; 95% CI, 5.4-16.2 kg; P < .001), and upper extremity endurance (+194 repetitions x kg; 95% CI, 10-378 repetitions x kg; P = .039). Changes in neck dissection impairment, fatigue, and quality of life favored the PRET group but did not reach statistical significance. CONCLUSIONS: The PRET program significantly reduced shoulder pain and disability and improved upper extremity muscular strength and endurance in head and neck cancer survivors who had shoulder dysfunction because of spinal accessory nerve damage. Clinicians should consider the addition of PRET in the rehabilitation of postsurgical head and neck cancer survivors.

A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders.

BACKGROUND AND PURPOSE: The purpose of this qualitative systematic review was to assess the evidence concerning the effectiveness of physical therapy interventions in the management of temporomandibular disorders. METHODS: A literature search of published and unpublished articles resulted in the retrieval of 36 potential articles. RESULTS: Twelve studies met all selection criteria for inclusion in the review: 4 studies addressed the use of therapeutic exercise interventions, 2 studies examined the use of acupuncture, and 6 studies examined electrophysical modalities. Two studies provided evidence in support of postural exercises to reduce pain and to improve function and oral opening. One study provided evidence for the use of manual therapy in combination with active exercises to reduce pain and to improve oral opening. One study provided evidence in support of acupuncture to reduce pain when compared with no treatment; however, in another study no significant differences in pain outcomes were found between acupuncture and sham acupuncture. Significant improvements in oral opening were found with muscular awareness relaxation therapy, biofeedback training, and low-level laser therapy treatment. DISCUSSION AND CONCLUSION: Most of the studies included in this review were of very poor methodological quality; therefore, the findings should be interpreted with caution.

The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trial.

PURPOSE: The purpose of this investigation was to compare the reduction in arm lymphedema volume achieved from manual lymph drainage massage (MLD) in combination with multi-layered compression bandaging (CB) to that achieved by CB alone. METHODS AND MATERIALS: Fifty women with lymphedema (mean age of 59 years +/- 13 years) were randomly assigned to 4 weeks of combined MLD/CB or CB alone. The primary study endpoint was the reduction in arm lymphedema volume, which was determined by water displacement volumetry and measurement of circumference. Independent assessors, blinded to subject treatment assignment, performed the outcome measurements. RESULTS: Arm lymphedema volume decreased significantly after 4 weeks irrespective of treatment assignment (p < 0.001). Individuals with mild lymphedema receiving combined MLD/CB had a significantly larger percentage reduction in volume compared to individuals with mild lymphedema receiving CB alone, and compared to individuals with moderate or severe lymphedema receiving either treatment. CONCLUSION: These findings indicate that CB, with or without MLD, is an effective intervention in reducing arm lymphedema volume. The findings suggest that CB on its own should be considered as a primary treatment option in reducing arm lymphedema volume. There may be an additional benefit from the application of MLD for women with mild lymphedema; however, this finding will need to be further examined in the research setting.