Bioimpedance spectroscopy for breast cancer-related lymphedema assessment: clinical practice guidelines.

PURPOSE: Breast cancer-related lymphedema (BCRL) represents a significant concern for patients following breast cancer treatment, and assessment for BCRL represents a key component of survivorship efforts. Growing data has demonstrated the benefits of early detection and treatment of BCRL. Traditional diagnostic modalities are less able to detect reversible subclinical BCRL while newer techniques such as bioimpedance spectroscopy (BIS) have shown the ability to detect subclinical BCRL, allowing for early intervention and low rates of chronic BCRL with level I evidence. We present updated clinical practice guidelines for BIS utilization to assess for BCRL. METHODS AND RESULTS: Review of the literature identified a randomized controlled trial and other published data which form the basis for the recommendations made. The final results of the PREVENT trial, with 3-year follow-up, demonstrated an absolute reduction of 11.3% and relative reduction of 59% in chronic BCRL (through utilization of compression garment therapy) with BIS as compared to tape measurement. This is in keeping with real-world data demonstrating the effectiveness of BIS in a prospective surveillance model. For optimal outcomes patients should receive an initial pre-treatment measurement and subsequently be followed at a minimum quarterly for first 3 years then biannually for years 4-5, then annually as appropriate, consistent with previous guidelines; the target for intervention has been changed from a change in L-Dex of 10 to 6.5. The lack of pre-operative measure does not preclude inclusion in the prospective surveillance model of care. CONCLUSION: The updated clinical practice guidelines present a standardized approach for a prospective model of care using BIS for BCRL assessment and supported by evidence from a randomized controlled trial as well as real-world data.

Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data.

PURPOSE: Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs of care. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects. METHODS: We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention. RESULTS: We identified 12 studies (2907 patients) including 4 randomized trials (1203 patients) and 8 prospective studies (1704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data comes from the randomized PREVENT trial, which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with early intervention with a compression garment applied for 12 h a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement coupled with early intervention. CONCLUSIONS: Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Because level 1 data demonstrate that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed. IMPLICATIONS FOR CANCER SURVIVORS: Breast cancer survivor should undergo prospective BCRL screening with BIS.

Caring for older veterans with chronic low back pain using a geriatric syndrome approach: Rationale and methods for the aging back clinics (ABC) trial.

The purpose of the ongoing trial is to improve care of older Veterans with chronic low back pain (CLBP, i.e., low back pain for ≥6 months on ≥ half the days). Current CLBP care is limited by being either overly spine-focused or non-specifically prescribed and both approaches frequently lead to suboptimal reduction in pain and improvement in function. Through prior studies we have laid the foundation for a patient-centered approach to care for older Veterans with CLBP in which the spine is a source of vulnerability but not the sole treatment target. The approach considers CLBP a geriatric syndrome, a final common pathway for the expression of multiple contributors rather than a disease of the spine. We describe here the rationale and design of a randomized controlled trial to test the efficacy of an older Veteran-centered approach to CLBP care in "Aging Back Clinics (ABCs)" compared with Usual Care (UC). Three hundred thirty Veterans age 65-89 with CLBP will be randomized to ABCs or UC and followed for 12 months after randomization. We will assess the impact of ABCs on our primary outcome of pain-associated disability with the Oswestry Disability Index at 6 and 12 months, and secondary outcomes of pain intensity, health-related quality of life, balance confidence, mobility and healthcare utilization. If shown efficacious, the approach tested in ABCs has the potential to transform the care of older adults with CLBP by improving the quality of life for millions, reducing morbidity and saving substantial healthcare costs.

Electromyographical assessment of passive, active assistive, and active shoulder rehabilitation exercises.

OBJECTIVE: To determine the electromyographical (EMG) activation levels of shoulder musculature during early rehabilitation exercises to regain active range of motion. DESIGN: Descriptive. SETTING: University clinical research laboratory. PARTICIPANTS: Ten asymptomatic volunteers (age, 25 +/- 5 years; height, 171 +/- 7 cm; weight, 78 +/- 15 kg). INTERVENTION: Fine-wire (supraspinatus and infraspinatus) and surface (anterior deltoid, upper trapezius, lower trapezius, and serratus anterior) electrodes recorded EMG activity from each muscle during 12 therapeutic exercises completed during a single testing session in random order. MAIN OUTCOME MEASURE: EMG root mean squared amplitude normalized to a percentage of maximum voluntary contraction (% MVC). RESULTS: Passive exercises generated the lowest mean EMG activity (<10%) for all muscles studied. The standing active shoulder elevation exercises generated the greatest mean EMG activity with an upper boundary of 95% CI (40% MVC). Overall the active-assistive exercises generated a small (<10%) increase in muscle activity compared with the passive exercises for the supraspinatus and infraspinatus muscles, which was not a significant increase (P > .05). CONCLUSION: This electrophysiological data in normal volunteers suggest that many exercises used during the early phase of rehabilitation to regain active elevation do not exceed 20% MVC. Progression from passive to active-assisted can potentially be performed without significantly increasing muscular activation levels exercises. Upright active exercises demonstrated a consistent and often a statistically significant increase in muscular activities supporting that these exercises should be prescribed later in a rehabilitation program.

The effect of anchor modality on the reliability of vocal severity ratings.

The purpose of this study was (1) to confirm if anchors (ie, perceptual references) and training affect the inter- and intrarater reliability of perceptual analysis of various voice types and severities compared to receiving training alone, and (2) to determine whether the modality in which the anchor is presented affects rater reliability. In this study, modality refers to whether the anchor is presented auditorily, visually via a written definition (a textual anchor), or a combination of both anchor types. A randomized multigroup comparison was performed. Forty inexperienced judges were selected to rate 36 sustained vowel voice samples of various voice types (ie, normal, breathy, hoarse, and rough) in terms of perceived vocal severity using four different methods (No Anchor, Textual Anchor, Auditory Anchor, and Combined Textual/Auditory Anchors). Subjects were randomly assigned to one of the four conditions. Before the rating task, all subject groups received a brief training sessions (15-20 minutes in duration) in which voice quality type and severity definitions were provided and representative voice samples were listened to. A computer program was developed to present anchors in the form of an auditory sample, written definition, or both. A no anchor condition was also presented. Results indicated that the combination of training and anchors significantly improves the interrater reliability of perceptual voice ratings. In addition, the use of auditory anchors resulted in 95% confidence intervals that were significantly smaller for rating mild voice disorders, and both breathy and hoarse voice qualities. Textual anchors did appear to show some improvement over training alone (ie, no anchors), but were generally not as strong as the use of auditory anchors. However, the combination of textual and auditory anchors resulted in the greatest degree of interrater reliability as assessed via mean correlations. The ratings produced by the Auditory and Combined Anchor groups were also observed to have significantly smaller 95% confidence intervals for the rating of mildly dysphonic voice than the No Anchor or Textual Anchor groups, indicating greater consistency and increased precision of ratings for this level of severity. Anchors were not only useful in improving measures of reliability among judges, but were also able to do so without significantly increasing the amount of time that the judges had to spend on the rating tasks. No significant effect of anchors was observed for measures of intrarater reliability. The use of perceptual anchors (in particular, auditory anchors), in conjunction with training and computerized rating procedures, may provide the consistent methodology necessary to improve the reliability of perceptual judgments. Although textual anchors were not as effective as auditory anchors, the combination of auditory and textual information may result in overall improvements in interrater reliability.

Preoperative lymphoscintigraphy and internal mammary sentinel lymph node biopsy do not enhance the accuracy of lymphatic mapping for breast cancer.

Lymphoscintigraphy (LS) may identify sentinel lymph nodes (SLNs) outside the axilla. Biopsy of these nodes could improve the accuracy of lymphatic mapping (LM) for breast cancer (BC) if a significant number of tumor-positive extra-axillary sentinel nodes are identified. To address this, we evaluated the impact of the use of preoperative LS and biopsy of axillary and internal mammary SLNs in women with BC. From October 1997 to July 2003, 175 women with breast cancer received technetium sulfur colloid, and images were obtained. Isosulfan blue dye was injected intraoperatively, and LM of the axillary and internal mammary lymph node basins was performed with a hand-held gamma probe. The anatomic location and histologic status of all SLNs identified with LS and LM was recorded, and the impact of the findings on LS and internal mammary LM were evaluated. LS showed SLN in 127/175 (73%) women and "hot spots" were found with the gamma probe in 142/175 (81%). At least one SLN was identified by LM in 168/175 (96%) patients, and 48/168 (29%) had metastases. One hundred sixty-two of 168 (96%) patients had SLN exclusively in the axilla. Only 10 of 175 (6%) women had internal mammary (IM) SLNs seen on LS. LM identified IM sentinel nodes in 6 of these 10 patients, but none were involved with tumor. Preoperative lymphoscintigraphy and biopsy of internal mammary sentinel nodes do not enhance the accuracy of lymphatic mapping for breast cancer. Omitting lymphoscintigraphy reduces the complexity and cost of lymphatic mapping without compromising the identification of tumor-positive sentinel nodes.