From Bench to Bedside: The Role of a Multidisciplinary Approach to Treating Patients with Lymphedema.

Background: Lymphedema is a condition characterized by dysfunction of the lymphatic system resulting in chronic, progressive soft tissue edema that can negatively impact individuals' function, self-image, and quality of life. Understanding of the disease process has evolved significantly in the past two decades with advances in diagnostic modalities and surgical techniques revolutionizing prior treatment algorithms. Methods and Results: We reviewed our current approach at the University of Southern California to improving outcomes in lymphedema treatment. Given the complexity of this medical condition, patients are best served by a multidisciplinary approach. At our institution, this involves a collaborative effort between bench researchers, lymphatic therapists, medical physicians, and lymphedema surgeons. Basic science and translational research provide further understanding into the underlying mechanisms of lymphangiogenesis and the possibility for potential therapeutic interventions. Our surgical algorithms require patients to undergo a thorough diagnostic evaluation and consultation with certified lymphatic therapists prior to undergoing either physiologic or debulking operations. Patients are followed clinically following any interventions. Further community outreach and education is carried out in order to improve upon early diagnosis and symptom recognition. Conclusions: Optimizing lymphedema care requires a collaborative interplay between researchers, physicians, and therapists. Additionally, patient and provider education on early disease recognition and treatment options is an equally critical aspect of improving patient outcomes.

Assessment of measurement properties of the Brazilian-Portuguese version of the low back activity confidence scale (LoBACS) in patients with chronic low back pain.

The Low Back Activity Confidence Scale (LoBACS) assesses the self-efficacy to perform activities in individuals with chronic low back pain (CLBP). As self-efficacy appears to directly influence the patient's functional capacity and prognosis, it is important to develop a scale that evaluates this attribute to guide treatment strategy and monitor the clinical course of patients. This study aimed to evaluate the reliability, construct validity, and responsiveness of the Brazilian version of the LoBACS. The scale was applied to 112 male and female patients (age, 18-65 years) with specific and nonspecific CLBP. For evaluating the interobserver reliability, the scale was applied twice on the first evaluation day by two trained evaluators (A and B). Within 48-72 h of the first evaluation, assessor A reapplied the scale to evaluate intraobserver reliability (test-retest), which was analyzed by intraclass correlation coefficient (ICC). The first LoBACS applied in the baseline evaluation was also used to assess the construct validity of the scale by factor analysis. For responsiveness, the scale was applied 5 times at 2-week intervals and the change in scores was analyzed by the repeated measures ANOVA. Although factor analysis indicated three subscales, they did not present acceptable values of convergent and divergent validity. Reliability ranged from good to excellent, with ICC values of .90 (95% CI, .84; .93) and .85 (95% CI, .77; .91) for inter- and intraobserver variability for total score. Moreover, the total score was responsive in all comparisons, with no floor or ceiling effects. Thus, only the total score of the Brazilian version of LoBACS proved to be reliable, valid, and responsive.

Aerobic and Resistance Exercise Improves Shoulder Function in Women Who Are Overweight or Obese and Have Breast Cancer: A Randomized Controlled Trial.

BACKGROUND: Adverse upper limb musculoskeletal effects occur after surgical procedures and radiotherapy for breast cancer and can interfere with activities of daily living. OBJECTIVE: The objective of this study was to examine the effects of a 16-week exercise intervention on shoulder function in women who are overweight or obese and have breast cancer. DESIGN: This study was a randomized controlled trial. SETTING: The study was performed at the Division of Biokinesiology and Physical Therapy at the University of Southern California. PARTICIPANTS: One hundred women with breast cancer were randomly allocated to exercise or usual-care groups. The mean (SD) age of the women was 53.5 (10.4) years, 55% were Hispanic white, and their mean (SD) body mass index was 33.5 (5.5) kg/m2. INTERVENTION: The 16-week exercise intervention consisted of supervised, progressive, moderate to vigorous aerobic and resistance exercise 3 times per week. MEASUREMENTS: Shoulder active range of motion, isometric muscular strength, and patient-reported outcome measures (including Disabilities of the Arm, Shoulder, and Hand and the Penn Shoulder Scale) were assessed at baseline, after the intervention, and at the 3-month follow-up (exercise group only). Differences in mean changes for outcomes were evaluated using mixed-model repeated-measures analysis. RESULTS: Compared with the usual-care group, the exercise group experienced significant increases in shoulder active range of motion (the mean between-group differences and 95% confidence intervals (CIs) were as follows: shoulder flexion = 36.6° [95% CI = 55.2-20.7°], external rotation at 0° = 23.4° [95% CI = 31.1-12.5°], and external rotation at 90° = 34.3° [95% CI = 45.9-26.2°]), improved upper extremity isometric strength, and improved Disabilities of the Arm, Shoulder, and Hand and Penn Shoulder Scale scores. LIMITATIONS: Limitations include a lack of masking of assessors after the intervention, an attention control group, and statistical robustness (shoulder function was a secondary end point). CONCLUSIONS: A 16-week exercise intervention effectively improved shoulder function following breast cancer treatment in women who were overweight or obese, who were ethnically diverse, and who had breast cancer.

Tarlov Cysts in a Woman With Lumbar Pain.

A 25-year-old woman presented to her primary care physician with thoracic spine pain; two weeks later, she returned to her primary care physician with lumbar spine pain that limited exercise and sitting for 30 minutes or less. The patient was referred to physical therapy for examination, then referred back to her primary care physician after complaints raised concern for a mass or other source of neurologic compression. Magnetic resonance imaging was performed and revealed 4 sacral perineural (Tarlov) cysts. J Orthop Sports Phys Ther 2018;48(2):121. doi:10.2519/jospt.2018.7644.

Measurement Properties of the Low Back Activity Confidence Scale (LoBACS).

The purpose of this study was to determine the measurement properties of the Low Back Activity Confidence Scale (LoBACS) in individuals with post-acute low back pain (LBP) receiving nonsurgical intervention, including construct validity, factorial validity, and internal consistency reliability. Data were analyzed from an existing randomized clinical trial involving 112 patients with LBP. Evidence for convergent validity was observed through significant correlations between LoBACS subscale scores and other function, pain, and psychobehavioral measures. LoBACS subscales accounted for 36% of the unique variance in dependent variable measurements, suggesting a satisfactory level of statistical divergence between the LoBACS and other psychobehavioral measurements in this study. Cronbach's α ranged from .88 to .92 for LoBACS subscales, and item-total correlations exceeded .6, indicating high internal consistency reliability. Principal axis factoring confirmed the hypothesized three-subscale structure by correctly classifying 14 of the 15 items. These findings indicate the LoBACS is valid and internally consistent to measure domain-specific self-efficacy beliefs.

The Low Back Activity Confidence Scale (LoBACS): preliminary validity and reliability.

BACKGROUND: Low back pain affects a substantial number of adults each year and is persistent or recurrent for many. Self-efficacy is an important predictor of functional recovery. OBJECTIVE: The purpose of this investigation was to assess the preliminary reliability and validity of the Low Back Activity Confidence Scale (LoBACS) for individuals with histories of low back pain or lumbar surgery. DESIGN: Two overlapping samples of patients who had undergone a microdiskectomy participated: a test-retest sample of 21 individuals and a validity sample of 53 individuals. METHODS: Low Back Activity Confidence Scale items pertaining to self-efficacy for functional activities (FnSE subscale), self-regulation of back health (Self-RegSE subscale), and regular exercise (ExSE subscale) were generated from existing literature and clinical observations. The test-retest sample completed the LoBACS twice, approximately 10 days apart. The validity sample completed the LoBACS and measures of functional performance, self-reported leisure and occupational physical activity, pain, fear beliefs, disability, and quality of life. RESULTS: The FnSE, Self-RegSE, and ExSE subscale scores and LoBACS total score had excellent to acceptable test-retest reliability (intraclass correlation coefficients of .924, .634, .710, and .850, respectively) and internal consistency (Cronbach α coefficients of .924, .804, .941, and .911, respectively). The LoBACS subscales were correlated in expected directions with physical performance, physical activity, pain, fear beliefs, disability, and quality of life, providing initial evidence of concurrent validity. CONCLUSIONS: The findings provide preliminary content and concurrent validity and interrater and internal consistency reliability for the LoBACS measure of self-efficacy for individuals with histories of low back pain and lumbar microdiskectomy.

An intensive, progressive exercise program reduces disability and improves functional performance in patients after single-level lumbar microdiskectomy.

BACKGROUND: Restoration of physical function following lumbar microdiskectomy may be influenced by the postoperative care provided. OBJECTIVE: The purpose of this study was to examine the effectiveness of a new interventional protocol to improve functional performance in patients who have undergone a single-level lumbar microdiskectomy. SETTING: The study was conducted in physical therapy outpatient clinics. DESIGN AND PARTICIPANTS: Ninety-eight participants (53 male, 45 female) who had undergone a single-level lumbar microdiskectomy were randomly allocated to receive education only or exercise and education. INTERVENTION AND MEASUREMENTS: The exercise intervention consisted of a 12-week periodized program of back extensor strength (force-generating capacity) and endurance training and mat and upright therapeutic exercises. The Oswestry Disability Index (ODI) and physical measures of functional performance were tested 4 to 6 weeks postsurgery and 12 weeks later, following completion of the intervention program. Because some participants sought physical therapy outside of the study, postintervention scores were analyzed for both an as-randomized (2-group) design and an as-treated (3-group) design. RESULTS: In the 2-group analyses, exercise and education resulted in a greater reduction in ODI scores and a greater improvement in distance walked. In the 3-group analyses, post hoc comparisons showed a significantly greater reduction in ODI scores following exercise and education compared with the education-only and usual physical therapy groups. LIMITATIONS: The limitations of this study include a lack of adherence to group assignment, disproportionate therapist contact time among treatment groups, and multiple use of univariate analyses. CONCLUSIONS: An intensive, progressive exercise program combined with education reduces disability and improves function in patients who have undergone a single-level lumbar microdiskectomy.

The immediate and long-term effects of exercise and patient education on physical, functional, and quality-of-life outcome measures after single-level lumbar microdiscectomy: a randomized controlled trial protocol.

BACKGROUND: Low back pain remains a costly quality-of-life-related health problem. Microdiscectomy is often the surgical procedure of choice for a symptomatic, single-level, lumbar disc herniation in younger and middle-aged adults. The question of whether a post-microdiscectomy exercise program enhances function, quality of life, and disability status has not been systematically explored. Thus, the overall purpose of this study is to assess immediate and long-term outcomes of an exercise program, developed at University of Southern California (USC), targeting the trunk and lower extremities (USC Spine Exercise Program) for persons who have undergone a single-level microdiscectomy for the first time. METHODS/DESIGN: One hundred individuals between the ages of 18 and 60 who consent to undergo lumbar microdiscectomy will be recruited to participate in this study. Subjects will be randomly assigned to one of two groups: 1) one session of back care education, or 2) a back care education session followed by the 12-week USC Spine Exercise Program. The outcome examiners (evaluators), as well as the data managers, will be blinded to group allocation. Education will consist of a one-hour "one-on-one" session with the intervention therapist, guided by an educational booklet specifically designed for post-microdiscectomy care. This session will occur four to six weeks after surgery. The USC Spine Exercise Program consists of two parts: back extensor strength and endurance, and mat and upright therapeutic exercises. This exercise program is goal-oriented, performance-based, and periodized. It will begin two to three days after the education session, and will occur three times a week for 12 weeks. Primary outcome measures include the Oswestry Disability Questionnaire, Roland-Morris Disability Questionnaire, SF-36 quality of life assessment, Subjective Quality of Life Scale, 50-foot Walk, Repeated Sit-to-Stand, and a modified Sorensen test. The outcome measures in the study will be assessed before and after the 12-week post-surgical intervention program. Long-term follow up assessments will occur every six months beginning one year after surgery and ending five years after surgery. Immediate and long-term effects will be assessed using repeated measures multivariate analysis of variance (MANOVA). If significant interactions are found, one-way ANOVAs will be performed followed by post-hoc testing to determine statistically significant pairwise comparisons. DISCUSSION: We have presented the rationale and design for a randomized controlled trial evaluating the effectiveness of a treatment regimen for people who have undergone a single-level lumbar microdiscectomy.