Implementation of a Cancer Rehabilitation Navigation Program: a qualitative analysis of implementation determinants and strategies.

BACKGROUND: Cancer rehabilitation navigation (CRNav) is a care delivery model that expedites identification and management of symptom-related functional morbidity for individuals undergoing cancer treatment. A CRNav program is unique in that it embeds a cancer rehabilitation professional in the cancer center for patient screening and assessment. The implementation of CRNav programs has not been studied and doing so could facilitate greater uptake of these programs. METHODS: Using implementation science frameworks, we conducted a qualitative, post-implementation analysis of a CRNav program that was implemented in 2019. Semi-structured, 1:1 interviews were guided by the Consolidated Framework for Implementation Research (CFIR) and a combination of deductive and inductive analyses, using a priori established codes, was used to assess the implementation context, and identify emergent themes of barriers and facilitators to implementation. Participant described implementation strategies were characterized and defined using the Expert Consensus Recommendations for Implementing Change (ERIC) taxonomy. RESULTS: Eleven stakeholders including physicians, administrators, clinical staff, and patients, involved with program development and the implementation effort, participated in interviews. Predominant barriers to implementation included developing the program infrastructure, and lack of awareness of rehabilitation services among oncology professionals, predominant facilitators of implementation included; physical co-location of the navigator in the cancer center, individual characteristics of the navigator, and unique characteristics of the program. Strategies described that supported implementation included developing stakeholder interrelationships, evaluating and iteratively adapting the program, creating infrastructure, training and education, and supporting clinicians. CONCLUSION: This analysis uses implementation science to methodically analyze and characterize factors that may contribute to successful implementation of a CRNav program. These findings could be used alongside a prospective context-specific analysis to tailor future implementation efforts. IMPLICATIONS FOR CANCER SURVIVORS: Implementing a CRNav program expedites a patient's direct contact with a rehabilitation provider complementing the cancer care delivery team, and providing an additive and often missing service.

Knowledge regarding cancer-related fatigue: a survey of physical therapists and individuals diagnosed with cancer.

BACKGROUND: Cancer-related fatigue (CRF) is a common side effect and remains under-diagnosed. Screening of CRF by physical therapists (PTs) and patient perspectives of their experiences has not been comprehensively examined. PURPOSE: To survey PTs to understand the frequency of CRF screening, and to assess the knowledge and experiences of survivors as it relates to CRF. METHODS: Two separate electronic surveys developed by the authors were distributed. One targeted oncology PTs, the other for adult survivors of cancer. RESULTS: Of the 199 PT respondents, 36% reported screening for CRF at every encounter. Screening included interviews (46%) and/or standardized questionnaires (37%). The most common barriers to receiving treatment for CRF was lack of physician referrals and time constraints. Of patient responses (n = 61), 84% reported CRF as an important ongoing issue; 77% reported that they initiated the discussion about CRF with their provider, and 23% reported being told there were treatment options for CRF. CONCLUSION: CRF is common among cancer survivors. However, consistent screening by PTs is lacking. Patients with CRF frequently initiated the conversation with their providers because of symptoms and many patients were not told of treatment options. These findings represent a substantial gap in clinical practice regarding CRF screening and management.

Current State of Entry-level Physical Therapy Oncology Curricula in the United States: A Faculty Survey.

INTRODUCTION: The purpose of this study was to determine the extent of oncology rehabilitation education in current physical therapist educational programs in the United States, including oncology rehabilitation content characteristics, delivery, and instructional resources. REVIEW OF LITERATURE: By 2030, more than 21 million survivors of cancer in the United States (US) will be living with multisystem side effects depending on the treatment delivered. In addition, the sociopsychological factors associated with cancer treatment require that physical therapists are equipped with a unique body of knowledge, skills, and abilities. Insufficient cancer rehabilitation education is problematic across the health care spectrum. SUBJECTS: Program directors at 235 US physical therapist educational programs. METHODS: An online survey was developed in REDCap using the American Board of Physical Therapy Specialist's Description of Specialty Practice: Oncology Physical Therapy as a guide. An electronic link to the survey was sent to the email of the chair/program director at 235 Commission for the Accreditation of Physical Therapy Education-accredited programs. RESULTS: The overall response rate was 40.4% (95/235) and represented 36 of the 50 states. Private universities represented 54.3% of the responses, and 65% of the surveys were completed by core faculty. Four programs reported having an independent oncology course, ranging from 1 to 3 credit hours. Integrated content hours averaged 14.8 contact hours (range: 1-60) in the 69 reporting programs. Fifty-four percent of respondents were aware of published rehabilitation cancer guidelines. The majority of respondents (62%) felt their students received adequate instruction related to oncology rehabilitation. Certified lymphedema therapists (68%) were primarily responsible for teaching the oncology content. Goodmans' Pathophysiology text was most reported (87%), whereas 38% used evidence-based research in Rehabilitation Oncology Journal. About half of the respondents (52%) reported offering students full-time clinical experiences in oncology rehabilitation. DISCUSSION AND CONCLUSIONS: This survey demonstrated how oncology rehabilitation education is incorporated into physical therapist educational programs and highlights areas for improvement. The results from this study lay the groundwork for developing core competencies for prelicensure education in oncology rehabilitation.

Screening and Assessment of Cancer-Related Fatigue: A Clinical Practice Guideline for Health Care Providers.

Cancer-related fatigue (CRF) is the most common side effect of cancer treatment. Regular surveillance is recommended, but few clinical practice guidelines transparently assess study bias, quality, and clinical utility in deriving recommendations of screening and assessment methods. The purpose of this clinical practice guideline (CPG) is to provide recommendations for the screening and assessment of CRF for health care professions treating individuals with cancer. Following best practices for development of a CPG using the Appraisal of Guidelines for Research and Evaluation (AGREE) Statement and Emergency Care Research Institute (ECRI) Guidelines Trust Scorecard, this CPG included a systematic search of the literature, quality assessment of included evidence, and stakeholder input from diverse health care fields to derive the final CPG. Ten screening and 15 assessment tools supported by 114 articles were reviewed. One screen (European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire-30 Core Questionnaire) and 3 assessments (Piper Fatigue Scale-Revised, Functional Assessment of Chronic Illness Therapy-Fatigue, and Patient Reported Outcome Measurement Information System [PROMIS] Fatigue-SF) received an A recommendation ("should be used in clinical practice"), and 1 screen and 5 assessments received a B recommendation ("may be used in clinical practice"). Health care providers have choice in determining appropriate screening and assessment tools to be used across the survivorship care continuum. The large number of tools available to screen for or assess CRF may result in a lack of comprehensive research evidence, leaving gaps in the body of evidence for measurement tools. More research into the responsiveness of these tools is needed in order to adopt their use as outcome measures. IMPACT: Health care providers should screen for and assess CRF using one of the tools recommended by this CPG.

Injury and Injury Prevention in United States Para Swimming: A Mixed-Methods Approach.

BACKGROUND: Para swimming has experienced increased participation in recent years. Injury and injury prevention research on Para swimmers is lacking compared to swimmers without impairment. PURPOSE: This study aimed to gather data in Para swimmers on typical injuries, injury prevention programs, and attitudes toward injury and injury prevention in this population. STUDY DESIGN: Cross-sectional, mixed-methods design evaluating injuries, injury management, and injury prevention in elite Para swimmers in United States (U.S.). METHODS: Para swimmers on the U.S. Paralympics Swimming National teams at multiple competition levels were invited to complete an online survey. Qualitative interviews with six U.S. Paralympics National team Para swimmers were conducted to provide detail on athlete experiences with injury and prevention. RESULTS: Twenty-one of 56 surveys were returned: 11 of 21 participants (52.4%) reported experiencing an injury that altered their weekly training. All (21/21) reported participating in strength training and 19 of 21 (90.5%) reported incorporating stretching into their training regimen, although strengthening/stretching regimens included routines that may not have been specifically targeted toward injury prevention. Six of 21 (28.6%) reported participation in an injury prevention program. Qualitative interview themes included the impact of swimmers' compensated body mechanics on injury risk, the value of individualized injury prevention programs, and the importance of knowledgeable coaching and rehabilitation staff. CONCLUSIONS: Injury prevention programs are important components in Para swimming training although they are underutilized based on responses in this study. These programs should be individualized to address swimming biomechanics and athlete-specific impairments. Increasing coaching knowledge and access to individualized programs may reduce injury prevalence among this at-risk population. LEVEL OF EVIDENCE: 3.

Systematic Review of Functional Outcomes in Cancer Rehabilitation.

OBJECTIVE: To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains. DATA SOURCES: PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019. STUDY SELECTION: Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion. DATA EXTRACTION: Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV). DATA SYNTHESIS: Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome. CONCLUSIONS: These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

A comparison of treatment signatures of high and low performing physical therapists for patients with lower back pain: analysis of spine care from a physical therapy outcomes registry.

INTRODUCTION: Lower back pain (LBP) is the most common orthopedic complaint in the United States. Physical therapy is recommended as a conservative, non-pharmacological intervention for LBP. While it is thought that skill level and effectiveness of physical therapists differ, there is little understanding regarding characteristics that distinguish high and low performing physical therapists. The purpose of this study was to compare differences in care delivery, termed treatment signatures, between high and low performing physical therapists previously differentiated by a risk-adjusted performance measure. METHODS: Using previously published methodology, 1,240 physical therapists were classified as "outperforming", "meeting expectations", or "underperforming" relative to predicted change in Modified Low Back Pain Disability Questionnaire (MDQ) across patients receiving care for LBP. Patients were divided into quartiles of baseline disability per initial MDQ. Two-way analyses of variance were used to compare billed (1) active, exercise-based units per visit (UPV), (2) manual therapy UPV, (3) modality UPV, and (4) the combination of active and manual therapy UPV (broadly termed skilled UPV) by performance cohort and baseline patient disability quartile among physical therapists deemed "outperforming" and "underperforming". Tukey's post hoc tests established mean differences with 95% confidence intervals. RESULTS: Physical therapists that "outperformed" (n=120; 17,404 patients) used more active UPV (mean difference (diff) = 0.1, p<.001), manual therapy UPV (mean diff = 0.2, p<.001), and skilled UPV (mean diff = 0.3, p<.001), and less modality UPV (mean diff = 0.1, P < 0.001) than those that "underperformed" (n=139; 21,800 patients). Tukey's post hoc tests showed that while differences in care were negligible in patients with low baseline disability, the highest performing PT cohort delivered skilled (0.4 UPV), active (0.2 UPV), and manual therapy (0.2 UPV) UPV at a significantly higher mean rate in patients with the highest baseline disability. CONCLUSIONS: Clinically effective physical therapists incorporated a treatment signature that included a consistent blend of skilled active and manual therapy interventions that was distinct from lower performing physical therapists. While group mean differences were relatively small, a consistent pattern emerged in which high performing physical therapists maintained a high level of skilled, one-on-one interventions across their entire caseload-while their lower performing counterparts significantly decreased use of the same interventions as baseline disability increased. These differences highlighted a treatment signature that was associated with clinically important improvements for patients with greater baseline disability. Future guideline recommendations should consider the importance of baseline disability and the consistent application of skilled active and manual therapy interventions.

We Don't Know Our Own Strength: A Survey of Strength Training Attitudes, Behaviors, and Knowledge in Physical Therapists and Physical Therapist Students.

OBJECTIVE: Strength training is frequently utilized by physical therapists; however, there has been discussion about whether physical therapists utilize strength training adequately. The purpose of this study was to describe and compare the strength training attitudes, behaviors, and knowledge of physical therapists and physical therapy students and to determine how participant characteristics influenced knowledge scores. METHODS: An anonymous survey was created in 3 rounds. For round 1, researchers used textbooks to create items assessing demographics, attitudes, behaviors, and knowledge regarding strength training. Rounds 2 and 3 consisted of feedback from 7 content experts until 80% consensus was reached; items were added, removed, or edited based on feedback. The final survey was distributed through social media, list servs, and email targeting physical therapists and students based in the United States. Response frequencies for all items were reported. Overall knowledge scores were calculated by summing correct responses for each item, with a maximum score of 13; scores <70% were considered low. Binomial logistic regression determined which characteristics (demographics, attitudes, or behaviors) influenced whether participants adequately utilized strength training principles (scored ≥70% on knowledge items). RESULTS: There were 777 physical therapist and 648 student participants. Nearly 90% of therapists and students reported frequently prescribing strength training. Over 48% of therapists felt their professional education did not prepare them to apply strength training (compared with 24% of students), and 68% believed that strength training is inadequately applied in physical therapy (compared with 40% of students). Sixty-two percent of therapists and 55% of students scored ≥70% for knowledge items. Additional strength training education and regular participation in strength training increased the odds of scoring ≥70% on knowledge items. CONCLUSION: Physical therapists and physical therapy students frequently prescribe strength training despite similarly low knowledge scores. To increase knowledge, greater emphasis on strength training in professional education, continuing education, participation in strength training, or all 3 is warranted. IMPACT: Strength training is an important intervention used in physical therapy and must be used appropriately to improve the health of patients. According to these findings, strength training education may not currently be optimal, as demonstrated by low knowledge scores by both therapists and students. Further work is needed to determine how knowledge of strength training relates to patient outcomes and also how best to implement strength training in physical therapy education and practice.

Understanding Injury and Injury Prevention in Para Sport Athletes.

CONTEXT: Training loads, injury, and injury prevention in the Para sports population has not been well established. OBJECTIVE: The purpose of this study was to survey elite-level swimming, cycling, and athletic Para sport athletes in the United States who were competing in the 2016 US Paralympic trials to better understand common injuries among athletes in each sport and to determine whether injury prevention programs were being utilized. DESIGN: Cross-sectional, survey study. SETTING: The 2016 US Paralympic trials for swimming, cycling, and athletics. PARTICIPANTS: Athletes who competed in swimming, cycling, and/or athletics at the 2016 US Paralympic trials (N = 144; 83 males and 61 females). MAIN OUTCOME MEASURES: Participants completed electronic survey using Qualtrics XM (Qualtrics, Provo, UT) with questions pertaining to average number of hours trained per week, number of cross-training hours performed each week, descriptive information regarding sport-related injuries, pain, whether athletes received treatment for injuries, and descriptive information regarding whether the athletes had participated in an injury prevention program. RESULTS: Over 64% of respondents reported training greater than or equal to 11 hours per week, and 45% of athletes reported spending greater than or equal to 6 hours per week cross-training. Forty-two percent of athletes reported currently having pain with 34% reporting missing a competition because of injury. Only 24% of respondents reported having participated in an injury prevention program. CONCLUSIONS: Many Para sport athletes train at similar durations as able-bodied counterparts and have pain that interferes with their ability to train and compete, however, only a small percentage consistently perform injury prevention programs.

An interdisciplinary intensive outpatient pain program is associated with improved patient activation and key outcomes.

Aim: To examine the change in the Patient Activation Measure and physical and psychosocial outcome measures in a military interdisciplinary intensive outpatient program for persistent pain. Materials & methods: Pre- and post-intervention measures, which were also stratified by gender and baseline activation, included patient-reported outcomes and physical function assessment, obtained from 2017 to 2018 program database. Results: The majority of the participants were male (70.9%), with an average age of 29.18 years and pain duration of 4.78 years (n = 103). Patient activation, majority of the patient reported outcomes and functional assessments improved in the overall sample with fewer changes in females on the Defense and Veterans Pain Rating Scale. Conclusion: Improvements were noted on the Patient Activation Measure and majority of the other outcome measures suggesting that service members with persistent pain at any level of patient activation or baseline function, may benefit from an intensive outpatient program.

Measurement of Pectoralis Minor Muscle Length in Women Diagnosed With Breast Cancer: Reliability, Validity, and Clinical Application.

BACKGROUND: Decreased pectoralis minor muscle length is common after primary breast cancer treatment and can result in an abnormal position of the scapula. This position can contribute to shoulder pain and pathomechanics and can lead to problems such as impingement syndrome, rotator cuff tears, and frozen shoulder. Currently, there are limited reliable methods for measuring pectoralis minor length. OBJECTIVE: The objective of this study was to examine the reliability and validity of measuring pectoralis minor length in women diagnosed with breast cancer. DESIGN: This was a cross-sectional reliability and validity study. METHODS: Bilateral pectoralis minor length (in centimeters) was assessed using a palpation meter in women (N = 29) diagnosed with breast cancer by 2 licensed physical therapists who were masked to the measures. Bilateral pectoralis minor length was also measured using a motion capture system to assess validity. RESULTS: Intratester reliability (intraclass correlation coefficient, ICC [3,k] = 0.971; 95% confidence interval [CI] = 0.939-0.986; standard error of measurement [SEM] = 0.16 cm) and intertester reliability (ICC[3,k] = 0.915; 95% CI = 0.81-0.962; SEM = 0.31 cm) were excellent for the palpation meter on the affected side and the unaffected side (intratester reliability: ICC[3,k] = 0.951; 95% CI = 0.897-0.977; SEM = 0.19 cm; intertester reliability: ICC[3,k] = 0.945; 95% CI = 0.877-0.975; SEM = 0.22 cm). Significant correlations were found between the motion capture system and the palpation meter on the affected side (r = 0.87) and the unaffected side (r = 0.81). Bland-Altman plots between the palpation meter and the motion capture system demonstrated that all the measures fell within the limits of agreement. LIMITATIONS: This study encountered possible errors with the accuracy of the motion capture system tracking because of the proximity of the markers and inherent volumetric restrictions. CONCLUSIONS: The palpation meter is a reliable, valid, easily administered, and cost-effective tool for assessing pectoralis minor length in women with breast cancer.

Cancer Rehabilitation Publications (2008-2018) With a Focus on Physical Function: A Scoping Review.

BACKGROUND: Cancer rehabilitation research has accelerated over the last decade. However, closer examination of the published literature reveals that the majority of this work has focused on psychological interventions and cognitive and behavioral therapies. Recent initiatives have aggregated expert consensus around research priorities, highlighting a dearth in research regarding measurement of and interventions for physical function. Increasingly loud calls for the need to address the myriad of physical functional impairments that develop in people living with and beyond cancer have been published in the literature. A detailed survey of the landscape of published research has not been reported to our knowledge. PURPOSE: This scoping review systematically identified literature published between 2008 and 2018 related to the screening, assessment, and interventions associated with physical function in people living with and beyond cancer. DATA SOURCES: PubMed and CINAHL were searched up to September 2018. STUDY SELECTION: Study selection included articles of all levels of evidence on any disease stage and population. A total of 11,483 articles were screened for eligibility, 2507 full-text articles were reviewed, and 1055 articles were selected for final inclusion and extraction. DATA EXTRACTION: Seven reviewers recorded type of cancer, disease stage, age of participants, phase of treatment, time since diagnosis, application to physical function, study design, impairments related to physical function, and measurement instruments used. DATA SYNTHESIS: Approximately one-third of the articles included patients with various cancer diagnoses (30.3%), whereas the rest focused on a single cancer, most commonly breast (24.8%). Most articles (77%) measured physical function following the completion of active cancer treatment with 64% representing the assessment domain. The most commonly used measures of physical function were the Medical Outcomes Study 36-Item Health Survey Questionnaire (29%) and the European Organization for Research and Treatment of cancer Quality of Life Questionnaire-Cancer 30 (21.5%). LIMITATIONS: Studies not written in English, study protocols, conference abstracts, and unpublished data were excluded. CONCLUSIONS: This review elucidated significant inconsistencies in the literature regarding language used to define physical function, measurement tools used to characterize function, and the use of those tools across the cancer treatment and survivorship trajectory. The findings suggested that physical function in cancer research is predominantly measured using general health-related quality-of-life tools rather than more precise functional assessment tools. Interdisciplinary and clinician-researcher collaborative efforts should be directed toward a unified definition and assessment of physical function.

The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis.

Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.

Oncology Section EDGE Task Force on Urogenital Cancer: A Systematic Review of Clinical Measures for Incontinence.

BACKGROUND: Compared to the general population, women and men with urogenital and colorectal cancer experience higher rates of urinary and fecal incontinence. Although a variety of measures exist to assess these areas, currently, there are no guidelines recommending which outcomes rehabilitation professionals should administer to examine these impairments in those with cancer. PURPOSE: To identify outcome measures for assessing urinary and fecal incontinence and evaluate their psychometric data and applicability to the cancer population. METHODS: Multiple electronic databases (CINAHL, Medline, PsycInfo) were reviewed using specific search terms to locate articles that identify outcome measures assessing urinary and fecal incontinence. As part of a larger effort to identify outcome measures for both incontinence and sexual dysfunction, 1118 articles were initially identified, 228 articles were reviewed, and 37 outcome measures were selected for analysis, 13 of which were related to urinary and fecal incontinence. Each incontinence outcome measure was independently reviewed and rated by two reviewers using the Cancer EDGE Task Force Outcome Measure Rating Form. Any discrepancies between reviewers were discussed and an overall recommendation for each outcome measure was made using the 4-point Cancer EDGE Task Force Rating Scale. RESULTS: The Task Force was able to highly recommend 1 measure addressing urinary incontinence (American Urological Association Symptom Index) and 2 measures assessing both urinary and fecal incontinence (Pelvic Floor Distress Inventory - Short Form, Pelvic Floor Impact Questionnaire - Short Form). The Task Force also recommended two measures of urinary incontinence that demonstrated strong psychometric properties, but had not yet been evaluated in the cancer population (Incontinence Quality of Life Questionnaire, International Consultation on Incontinence Questionnaire - Short Form). The Task Force was unable to recommend any measures that solely addressed fecal incontinence. CONCLUSIONS: Five of the 13 outcome measures assessing urinary incontinence and two of the 13 measures assessing both urinary and fecal incontinence demonstrated satisfactory psychometric properties and application to the urogenital cancer population and are thereby recommended for use by the Task Force.

Oncology Section EDGE Task Force on Cancer: A systematic review of patient-reported measures for sexual dysfunction.

BACKGROUND: Sexual dysfunction is an important and infrequently addressed issue in patients with cancer. PURPOSE: To identify self-report measures for assessing sexual dysfunction and to evaluate their psychometric properties and relevance to patients with cancer. METHODS: Multiple electronic databases (CINAHL, Medline, PsycInfo) were reviewed using specific search terms to locate articles that identify self-report measures assessing sexual dysfunction. From the 1118 articles reviewed, 21 measures were selected for analysis. Each measure was independently reviewed and rated by two reviewers using the Cancer EDGE Task Force Outcome Measure Rating Form. Any discrepancies between reviewers were discussed and an overall recommendation for each measure was made using the 4-point Cancer EDGE Task Force Rating Scale. RESULTS: Based on the psychometric properties and relevance to patients with cancers, we highly recommend the following four measures: Sexual Function - Vaginal Changes Questionnaire; International Index of Erectile Function; Erection Hardness Score; Sexual Health Inventory for Men (aka International Index of Erectile Function-5). We recommend one measure, the Sexual Interest and Desire Inventory. We are unable to recommend eight measures based on limited psychometric information and/or clinical utility. Finally, we do not recommend an additional eight measures. CONCLUSIONS: Five of the 21 sexual dysfunction measures demonstrated satisfactory psychometric properties and application to the cancer population and are thereby recommended for clinical use in patients with cancer.

Oncology Section EDGE Task Force on Prostate Cancer: A Systematic Review of Outcome Measures for Health-Related Quality of Life.

BACKGROUND: Health-related quality of life (HRQOL) is multidimensional and subjective, encompassing occupational and physical function, psychological state, social interaction, and somatic sensation. Because of the wide scope of HRQOL and its implications for the medical management of prostate cancer survivors, clinicians and researchers need to know the most reliable and valid measures currently available for addressing this clinical construct in men diagnosed with prostate cancer. PURPOSE: To identify and evaluate patient-reported outcome measures used to assess HRQOL in men diagnosed with prostate cancer and make recommendations for the use of these patient-reported outcome measures in both the research and clinic settings. METHODS: The literature was systematically reviewed for patient-reported outcome measures used in peer-reviewed, published research to assess HRQOL in men diagnosed with prostate cancer. The goals were to examine the psychometric properties of commonly used HRQOL measures in order to determine their clinical utility. RESULTS: The following patient-reported outcome measures are highly recommended by the Task Force to assess HRQOL in men diagnosed with prostate cancer: EORTC QLQ-P25 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Prostate 25), EPIC (Expanded Prostate Cancer Index Composite), FACT-P (Functional Assessment of Cancer Therapy-Prostate), UCLA-PCI (UCLA-Prostate Cancer Index), EORTC QLQ-C30 (EORTC Quality of Life Questionnaire-Cancer 30), FACT-G (Functional Assessment of Cancer Therapy-General), and SF (Short-Form) 36, 12, and 8. CONCLUSIONS: A variety of patient-reported outcome measures have been reported in the literature to assess HRQOL in men diagnosed with prostate cancer. Seven measures were found to have satisfactory psychometric properties, as well as good clinical utility, and are recommended for use by the researchers on this Task Force.

Investigation of In-Water and Dry-Land Training Programs for Competitive Swimmers in the United States.

CONTEXT: Youth- through masters-level competitive swimmers incur significant shoulder pain. Risk factors associated with shoulder pain include high swimming yardage, a lack of cross-training, decreased shoulder strength and reduced core endurance, and limited posterior shoulder and pectoral length. Since training, swimming exposure, and physical-performance measures have all been associated with shoulder pain, the methods used to train swimmers may influence the development of shoulder pain, yet studies delineating training methods are lacking. OBJECTIVES: To identify in-water and dry-land practices among youth- through masters-level swimmers in the United States (US) and describe the potential effects of training practices on swimmers' shoulders. DESIGN: A Web-based survey was developed to identify common training practices in 5 areas: quantification of swimming and dry-land training and in-water techniques such as kicking drills, upper-body stretching, shoulder and core strengthening, and cross-training. PARTICIPANTS: 156 swim-team coaches or captains of youth, high school, and college swim teams and 196 masters swimmers participated (N = 352). There was geographic representation from across the US. RESULTS: Responses indicated diverse training practices. However, most respondents used kicking drills, which may provoke shoulder pain due to prolonged poor positioning. High yardage swum by high school and college teams increases their risk of shoulder tendinopathy. Stretching and strengthening exercises and dosages commonly used were inconsistent with current research recommendations and lacked specificity in terms of addressing typical mobility restrictions and muscle weaknesses described in the swimming literature. Core strengthening and cross-training are frequently performed. CONCLUSIONS: Several areas of in-water and dry-land practice were identified that may put swimmers' shoulders at risk for injury. Further research regarding the safety and efficacy of training programs is recommended to determine optimal methods of injury prevention and performance enhancement.

Breast Cancer EDGE Task Force Outcomes: Clinical Measures of Pain.

BACKGROUND: Pain is one of the most commonly reported impairments after breast cancer treatment affecting anywhere from 16-73% of breast cancer survivors Despite the high reported incidence of pain from cancer and its treatments, the ability to evaluate cancer pain continues to be difficult due to the complexity of the disease and the subjective experience of pain. The Oncology Section Breast Cancer EDGE Task Force was created to evaluate the evidence behind clinical outcome measures of pain in women diagnosed with breast cancer. METHODS: The authors systematically reviewed the literature for pain outcome measures published in the research involving women diagnosed with breast cancer. The goal was to examine the reported psychometric properties that are reported in the literature in order to determine clinical utility. RESULTS: Visual Analog Scale, Numeric Rating Scale, Pressure Pain Threshold, McGill Pain Questionnaire, McGill Pain Questionnaire - Short Form, Brief Pain Inventory and Brief Pain Inventory - Short Form were highly recommended by the Task Force. The Task Force was unable to recommend two measures for use in the breast cancer population at the present time. CONCLUSIONS: A variety of outcome measures were used to measure pain in women diagnosed with breast cancer. When assessing pain in women with breast cancer, researchers and clinicians need to determine whether a unidimensional or multidimensional tool is most appropriate as well as whether the tool has strong psychometric properties.

Physical therapy students' perceptions of team-based learning in gross anatomy using the Team-Based Learning Student Assessment Instrument.

PURPOSE: The objective of this study was to assess physical therapy student perceptions of team-based learning (TBL) in a graduate level gross anatomy course using the TBL Student Assessment Instrument (TBL-SAI). METHODS: The TBL-SAI was administered to 85 doctor of physical therapy (DPT) students, comprising three cohorts (classes of 2013, 2014, and 2015), who successfully completed a gross anatomy course where TBL was implemented. The TBL-SAI surveys 33 items, each rated from one (strongly disagree) to five (strongly agree) and measures three subscales: students' perceptions of accountability, preference for lecture or TBL, and student satisfaction. RESULTS: The means for each subscale and the total TBL-SAI score for each cohort fell above the neutral score. The 2015 group (mean, 37.97; 95% confidence interval [CI], 35.67 to 40.26) reported significantly higher satisfaction than that of the 2013 group (mean, 32.71; 95% CI, 30.31 to 35.05) and the 2014 group (mean, 33.11; 95% CI, 30.69 to 35.53). The 2015 group (mean, 125.3; 95% CI, 120.6 to 130.3) also had a significantly higher total score than that of the 2013 group (mean, 115.6; 95% CI, 110.5 to 120.5). CONCLUSION: The physical therapy students reported an overall positive experience in using TBL to learn gross anatomy in terms of accountability, preference for learning mode, and satisfaction. This positive experience with TBL was accompanied by their successful academic performance. Given the traits and learning preferences in this generation of graduate students, TBL could be a teaching method that is received positively elsewhere and results in successful academic performance and learning.

A cross-sectional study examining shoulder pain and disability in Division I female swimmers.

CONTEXT: The prevalence of shoulder pain in the competitive swimming population has been reported to be as high as 91%. Female collegiate swimmers have a reported shoulder-injury rate 3 times greater than their male counterparts. There has been little information on how to best prevent shoulder pain in this population. The purpose of this study was to examine if differences exist in shoulder range of motion, upper-extremity strength, core endurance, and pectoralis minor length in NCAA Division I female swimmers with and without shoulder pain and disability. METHODS: NCAA Division I females (N = 37) currently swimming completed a brief survey that included the pain subscale of the Penn Shoulder Score (PSS) and the sports/performing arts module of the Disabilities of the Arm, Shoulder, and Hand (DASH) Outcome Measure. Passive range of motion for shoulder internal rotation (IR) and external rotation (ER) at 90° abduction was measured using a digital inclinometer. Strength was measured using a handheld dynamometer for scapular depression and adduction, scapular adduction, IR, and ER. Core endurance was assessed using the side-bridge and prone-bridge tests. Pectoralis minor muscle length was assessed in both a resting and a stretched position using the PALM palpation meter. All measures were taken on the dominant and nondominant arms. RESULTS: Participants were classified as positive for pain and disability if the following 2 criteria were met: The DASH sports module score was >6/20 points and the PSS strenuous pain score was ≥4/10. If these criteria were not met, participants were classified as negative for pain and disability. Significant differences were found between the 2 groups on the dominant side for pectoralis muscle length at rest (P = .003) and stretch (P = .029). CONCLUSIONS: The results provide preliminary evidence regarding an association between a decrease in pectoralis minor length and shoulder pain and disability in Division I female swimmers.