Diving deeper into distress screening implementation in oncology care.

BACKGROUND: Responding to calls for additional research that identifies effective distress screening (DS) processes, including referral practices subsequent to screening and receipt of recommended care, we engaged in qualitative research as part of a larger (mixed methods) study of distress screening. This qualitative inquiry of oncology professionals across different facilities in the United States examined routine DS implementation, facilitators and challenges staff encounter with DS processes, and staff members' perceived value of DS. PARTICIPANTS AND METHODS: We conducted key informant interviews and focus groups with staff in 4 Commission on Cancer (CoC)-accredited oncology facilities (a total of 18 participants) to understand implementation of routine DS within oncology care. We used a rigorous data analysis design, including inductive and deductive approaches. RESULTS: Respondents believe DS enhances patient care and described ways to improve DS processes, including administering DS at multiple points throughout oncology care, using patient-administrated DS methods, and enhancing electronic health records infrastructure to better collect, record, and retrieve DS data. Respondents also identified the need for additional psychosocial staff at their facilities to provide timely psychosocial care. CONCLUSIONS: Results reinforce the value of DS in cancer care, including the importance of follow-up to screening with psychosocial oncology providers. Understanding and resolving the barriers and facilitators to implementing DS are important to ensure appropriate psychosocial care for people with cancer. Insights from oncology staff may be used to enhance the quality of DS and subsequent psychosocial care, which is an essential component of oncology care.

Standing Pelvic Tilt Is Associated With Dynamic Pelvic Tilt During Running When Measured by 3-Dimensional Motion Capture.

Standing pelvic tilt (PT) is related to biomechanics linked with increased risk of injury such as dynamic knee valgus. However, there is limited evidence on how standing PT relates to dynamic PT and whether the palpation meter (PALM), a tool to measure standing PT, is valid against 3-dimensional (3D) motion analysis. The purposes of this study were to (1) determine the criterion validity of the PALM for measuring standing PT and (2) identify the relationship between standing PT and dynamic PT during running. Participants (n = 25; 10 males and 15 females) had their standing PT measured by the PALM and 3D motion analysis. Dynamic PT variables were defined at initial contact and toe off. No relationship between the 2 tools was found. Significant large positive relationships between standing PT and PT at initial contact (r = .751, N = 25, P < .001) and PT at toe off (r = .761, N = 25, P < .001) were found. Since no relationship was found between standing PT measured by the PALM and 3D motion analysis, the PALM is not a valid alternative to 3D motion analysis. Clinicians may be able to measure standing PT and gain valuable information on dynamic PT, allowing clinicians to quickly assess whether further biomechanical testing is needed.

Disparities in Psychosocial Distress Screening and Management of Lung and Ovarian Cancer Survivors.

PURPOSE: Since 2016, the American College of Surgeons' Commission on Cancer (CoC) has required routine distress screening (DS) of cancer survivors treated in their accredited facilities to facilitate early identification of survivors with psychosocial concerns. Lung and ovarian cancer survivors have relatively low 5-year survival rates and may experience high levels of distress. We examined the extent to which ovarian and lung cancer survivors received CoC-mandated DS and whether DS disparities exist on the basis of diagnosis, sociodemographic factors, or facility geography (urban/rural). METHODS: This study included a quantitative review of DS documentation and follow-up services provided using existing electronic health records (EHRs). We worked with 21 CoC-accredited facilities across the United States and examined EHRs of 2,258 survivors from these facilities (1,618 lung cancer survivors and 640 ovarian cancer survivors) diagnosed in 2016 or 2017. RESULTS: Documentation of DS was found in half (54.8%) of the EHRs reviewed. Disparities existed across race/ethnicity, cancer type and stage, and facility characteristics. Hispanic/Latino and Asian/Pacific Islander survivors were screened at lower percentages than other survivors. Patients with ovarian cancer, those diagnosed at earlier stages, and survivors in urban facilities had relatively low percentages of DS. Non-Hispanic Black survivors were more likely than non-Hispanic White survivors to decline further psychosocial services. CONCLUSION: Despite the mandate for routine DS in CoC-accredited oncology programs, gaps remain in how many and which survivors are screened for distress. Improvements in DS processes to enhance access to DS and appropriate psychosocial care could benefit cancer survivors. Collaboration with CoC during this study led to improvement of their processes for collecting DS data for measuring standard adherence.

REPORT-PFP: a consensus from the International Patellofemoral Research Network to improve REPORTing of quantitative PatelloFemoral Pain studies.

Patellofemoral pain is a common and often debilitating musculoskeletal condition. Clinical translation and evidence synthesis of patellofemoral pain research are compromised by heterogenous and often inadequately reported study details. This consensus statement and associated checklist provides standards for REPORTing of quantitative PatelloFemoral Pain (REPORT-PFP) research to enhance clinical translation and evidence synthesis, and support clinician engagement with research and data collection. A three-stage Delphi process was initiated at the 2015 International Patellofemoral Research Network (iPFRN) retreat. An initial e-Delphi activity (n=24) generated topics and items, which were refined at the 2017 iPFRN retreat, and voted on prior to and following the 2019 iPFRN retreat (n=51 current and past retreat participants). Voting criteria included 'strongly recommended' (essential), 'recommended' (encouraged) and uncertain/unsure. An item was included in the checklist if ≥70% respondents voted 'recommended'. Items receiving ≥70% votes for 'strongly recommended' were labelled as such. The final REPORT-PFP checklist includes 31 items (11 strongly recommended, 20 recommended), covering (i) demographics (n=2,4); (ii) baseline symptoms and previous treatments (n=3,7); (iii) outcome measures (2,4); (iv) outcomes measure description (n=1,2); (v) clinical trial methodology (0,3) and (vi) reporting study results (n=3,0). The REPORT-PFP checklist is ready to be used by researchers and clinicians. Strong stakeholder engagement from clinical academics during development means consistent application by the international patellofemoral pain research community is likely. Checklist adherence will improve research accessibility for clinicians and enhance future evidence synthesis.

Foot joint coupling variability differences between habitual rearfoot and forefoot runners prior to and following an exhaustive run.

As joint coupling variability has been associated with running-related lower extremity injury, the purpose of this study was to identify how variability within the foot may be different between forefoot (FFS) and rearfoot strike (RFS) runners. Identifying typical variability in uninjured runners may contribute to understanding of ideal coordination associated with running foot strike patterns. Fifteen FFS and 15 RFS runners performed a maximal-effort 5 km treadmill run. A 7-segment foot model identified 6 functional articulations (rearfoot, medial and lateral midfoot and forefoot, and 1st metatarsophalangeal) for analysis. Beginning and end of the run motion capture data were analyzed. Vector coding was used to calculate 6 joint couples. Standard deviations of the coupling angles were used to identify variability within subphases of stance (loading, mid-stance, terminal, and pre-swing). Mixed between-within subjects ANOVAs compared differences between the foot strikes, pre and post run. Increased variability was identified within medial foot coupling for FFS and within lateral foot coupling for RFS during loading and mid-stance. The exhaustive run increased variability during mid-stance for both groups. Interpretation. Joint coupling variability profiles for FFS and RFS runners suggest different foot regions have varying coordination needs which should be considered when comparing the strike patterns.

Exploring the Pain in Patellofemoral Pain: A Systematic Review and Meta-Analysis Examining Signs of Central Sensitization.

BACKGROUND: Patellofemoral pain (PFP) has high recurrence rates and minimal long-term treatment success. Central sensitization refers to dysfunctional pain modulation that occurs when nociceptive neurons become hyperresponsive. Researchers in this area of PFP have been increasingly productive in the past decade. OBJECTIVE: To determine whether evidence supports manifestations of central sensitization in individuals with PFP. DATA SOURCES: We searched MeSH terms for quantitative sensory testing (QST) pressure pain thresholds (PPTs), conditioned pain modulation (CPM), temporal summation, sensitization, hyperalgesia, and anterior knee pain or PFP in PubMed, SPORTDiscus, CINAHL, Academic Search Complete, and EBSCOhost. STUDY SELECTION: Peer-reviewed studies that were written in English and published between 2005 and 2020 and investigated QST or pain mapping in a sample with PFP were included in this review. DATA EXTRACTION: The initial search yielded 140 articles. After duplicates were removed, 78 abstracts were reviewed. The full text of 21 studies was examined, and we included 15 studies in our evaluation: 6 in the meta-analysis, 4 in the systematic review, and 5 in both the meta-analysis and systematic review. DATA SYNTHESIS: A random-effects meta-analysis was conducted for 4 QST variables (local PPTs, remote PPTs, CPM, temporal summation). Strong evidence supported lower local and remote PPTs, impaired CPM, and facilitated temporal summation in individuals with PFP compared with pain-free individuals. Evidence for heat and cold pain thresholds was conflicting. Pain mapping demonstrated expanding pain patterns associated with long duration of PFP symptoms. CONCLUSIONS: Signs of central sensitization were present in individuals with PFP, indicating altered pain modulation. The etiologic and treatment models of PFP should reflect the current body of evidence regarding central sensitization. Signs of central sensitization should be monitored clinically, and treatments with central effects should be considered as part of a multimodal plan of care.

The effects of military style ruck marching on lower extremity loading and muscular, physiological and perceived exertion in ROTC cadets.

Military ruck marching with load carriage increases ground reaction forces, which are related to bone stress injuries (BSI). This study's purpose was to examine whether a ruck march increases impact loading and to describe muscular, physiological and perceived exertion in Army Reserve Officer Training Corps (ROTC) cadets. Secondary purposes examined relationships among loading changes after the ruck march and baseline characteristics. Fifteen Army ROTC cadets performed a 4-mile march. Lower extremity loading and muscular, physiological and perceived exertion were measured pre- and post-march. Results indicated significant increases in peak impact force and loading rate and decreases in ankle dorsiflexion and plantarflexion strength. Factors that might have been related to changes seen in lower extremity loading did not yield any compelling relationships to explain those changes. In conclusion, the ruck march led to increased peak impact force and loading rate, which have been shown to be related to the risk of BSI. Practitioner summary: This study examined ROTC cadets ankle strength and lower extremity loading before and after a ruck march. We found that lower extremity loading increased after the march, and ankle dorsiflexion (DF) strength decreased, despite the cadets not feeling fatigued. These changes are consistent with risk factors for bone stress injuries. Abbreviations: BSI: bone stress injury; ROTC: Reserve Officer Training Corps; PIF: peak impact force; LR: loading rate; RPE: rate of perceived exertion; APFT: Army physical fitness test; DF: dorsiflexors; PF: plantar-flexors; INV: invertors; EV: evertors; HHD: handheld dynamometer; %HRmax: percentage of maximum heart rate.

Quantitative and qualitative assessment of frontal plane knee motion in males and females: A reliability and validity study.

BACKGROUND: The aim was to determine reliability and validity of frontal plane projection angle (FPPA) and visual assessments (VA) in both males and females. METHODS: Fifty-four participants (30 females) performed lateral step-downs while kinematics were recorded by two-dimensional and three-dimensional analyses. Two raters viewed the videos, extracted images, and measured the FPPA (quantitative). Using the videos, the raters also categorized (qualitative VA) each participant's motion as demonstrating dynamic valgus (>10° valgus), dynamic varus (>10° varus), or no change. Reliability was assessed for FPPA and VA using intraclass correlation coefficients and Kappa, respectively. Validity was determined by comparing the FPPA to three-dimensional measures (Pearson correlations) and comparing the VA to both FPPA and standard reference 3D kinematics (Kappa). RESULTS: FPPA showed good-excellent reliability (ICC = 0.850-0.998). VA showed minimal-moderate reliability (κ = 0.370-0.766). The FPPA showed large correlations (r = -0.514-0.531) with hip adduction in both sexes but only a moderate relationship with knee abduction in males (r = 0.427-0.445). VA showed no-weak (κ = 0.153-0.475) and weak-moderate (κ = 0.455-0.698) agreement compared to FPPA and no-weak (κ = -0.300-0.183) and no-minimal (κ = -0.078-0.027) disagreement compared to the reference standard 3D kinematics in males and females, respectively. CONCLUSION: The quantitative FPPA is more reliable and valid than qualitative VA of frontal knee plane motion.

Treatment Success of Hip and Core or Knee Strengthening for Patellofemoral Pain: Development of Clinical Prediction Rules.

CONTEXT: Patellofemoral pain (PFP) is a common injury that interferes with quality of life and physical activity. Clinical subgroups of patients may exist, one of which is caused by proximal muscle dysfunction. OBJECTIVES: To develop clinical prediction rules that predict a positive outcome after either a hip and core- or knee-focused strengthening program for individuals with PFP. DESIGN: Secondary analysis of data from a randomized control trial. SETTING: Four university laboratories. PATIENTS OR OTHER PARTICIPANTS: A total of 199 participants with PFP. INTERVENTION(S): Participants were randomly allocated to either a hip and core-focused (n = 111) or knee-focused (n = 88) rehabilitation group for a 6-week program. MAIN OUTCOME MEASURE(S): Demographics, self-reported knee pain (visual analog scale) and function (Anterior Knee Pain Scale), hip strength, abdominal muscle endurance, and hip range of motion were evaluated at baseline. Treatment success was defined as a decrease in visual analog scale score by ≥2 cm or an increase in the Anterior Knee Pain Scale score by ≥8 points or both. Bivariate relationships between the outcome (treatment success) and the predictor variables were explored, followed by a forward stepwise logistic regression to predict a successful outcome. RESULTS: Patients with more pain, better function, greater lateral core endurance, and less anterior core endurance were more likely to have a successful outcome after hip and core strengthening (88% sensitivity and 54% specificity). Patients with lower weight, weaker hip internal rotation, stronger hip extension, and greater trunk-extension endurance were more likely to have success after knee strengthening (82% sensitivity and 58% specificity). CONCLUSION: The patients with PFP who have more baseline pain and yet maintain a high level of function may experience additional benefit from hip and core strengthening. The clinical prediction rules from this study remain in the developmental phase and should be applied with caution until externally validated.

Acute Responses of Strength and Running Mechanics to Increasing and Decreasing Pain in Patients With Patellofemoral Pain.

CONTEXT: Patellofemoral pain (PFP) is typically exacerbated by repetitive activities that load the patellofemoral joint, such as running. Understanding the mediating effects of changes in pain in individuals with PFP might inform injury progression, rehabilitation, or both. OBJECTIVE: To investigate the effects of changing pain on muscular strength and running biomechanics in those with PFP. DESIGN: Crossover study. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Seventeen participants (10 men, 7 women) with PFP. INTERVENTION(S): Each participant completed knee pain-reducing and pain-inducing protocols in random order. The pain-reducing protocol consisted of 15 minutes of transcutaneous electric nerve stimulation (TENS) around the patella. The pain-inducing protocol was sets of 20 repeated single-legged squats (RSLS). Participants completed RSLS sets until either their pain was within at least 1 cm of their pain during an exhaustive run or they reached 10 sets. MAIN OUTCOME MEASURE(S): Pain, isometric hip and trunk strength, and running mechanics were assessed before and after the protocols. Dependent variables were pain, normalized strength (abduction, extension, external rotation, lateral trunk flexion), and peak lower extremity kinematics and kinetics in all planes. Pain scores were analyzed using a Friedman test. Strength and mechanical variables were analyzed using repeated-measures analyses of variance. The α level was set at P < .05. RESULTS: Pain was decreased after the TENS (pretest: 3.10 ± 1.95, posttest: 1.89 ± 2.33) and increased after the RSLS (baseline: 3.10 ± 1.95, posttest: 4.38 ± 2.40) protocols (each P < .05). The RSLS protocol resulted in a decrease in hip-extension strength (baseline: 0.355 ± 0.08 kg/kg, posttest: 0.309 ± 0.09 kg/kg; P < .001). Peak plantar-flexion angle was decreased after RSLS (baseline: -13.97° ± 6.41°, posttest: -12.84° ± 6.45°; P = .003). Peak hip-extension (pretest: -2.31 ± 0.46) and hip-abduction (pretest: -2.02 ± 0.35) moments decreased after both the TENS (extension: -2.15 ± 0.48 Nm/kg, P = .015; abduction: -1.91 ± 0.33 Nm/kg, P = .015) and RSLS (extension: -2.18 ± 0.52 Nm/kg, P = .003; abduction: -1.87 ± 0.36 Nm/kg, P = .039) protocols. CONCLUSIONS: This study presents a novel and effective method of increasing pain in persons with PFP. Functionally increased pain after RSLS coincides with reduced hip-extensor muscle strength and decreased plantar-flexion angle during running. The TENS treatment decreased pain during running in those with PFP but failed to influence strength. Hip moments were reduced by both protocols, which may demonstrate that acute increases or decreases in pain cause runners to change their mechanics.

Functional Movement Screen Factorial Validity and Measurement Invariance Across Sex Among Collegiate Student-Athletes.

Gnacinski, SL, Cornell, DJ, Meyer, BB, Arvinen-Barrow, M, and Earl-Boehm, JE. Functional Movement Screen factorial validity and measurement invariance across sex among collegiate student-athletes. J Strength Cond Res 30(12): 3388-3395, 2016-The Functional Movement Screen (FMS) is a screening tool used to evaluate functional movement quality and subsequent musculoskeletal injury risk. Despite recent research on the factorial validity of the FMS, no confirmatory factor analysis (CFA) has been conducted to examine measurement invariance across sex among student-athletes. The primary purpose of the current study was to confirm the factor structure of the FMS measurement model in a collegiate student-athlete population. It was hypothesized that the 1-factor model would demonstrate better model fit than the recently proposed 2-factor model. The secondary purpose of the study was to examine FMS measurement invariance across sex using the previously identified measurement model. It was hypothesized that FMS measurement invariance would hold across sex. Male (n = 88) and female (n = 88) collegiate student-athletes completed FMS screening during the off-season. Factorial validity was examined using CFA procedures, and model parameters were estimated using maximum likelihood estimation. Measurement invariance was examined by comparison of fit indices between hierarchically constrained models. Results revealed support for both the 1- and the 2-factor models; however, the 2-factor model failed to fit the data significantly better than the 1-factor model. Results also indicated that measurement invariance did not hold across sex, indicating that the FMS sum score construct is not measured equivalently in male and female populations. Collectively, results provide evidence for the use of the unidimensional FMS sum score among collegiate student-athletes, yet prompt caution because it relates to the evaluation of sex differences in sum or movement pattern scores.

Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial.

CONTEXT: Patellofemoral pain (PFP) is the most common injury in running and jumping athletes. Randomized controlled trials suggest that incorporating hip and core strengthening (HIP) with knee-focused rehabilitation (KNEE) improves PFP outcomes. However, no randomized controlled trials have, to our knowledge, directly compared HIP and KNEE programs. OBJECTIVE: To compare PFP pain, function, hip- and knee-muscle strength, and core endurance between KNEE and HIP protocols after 6 weeks of rehabilitation. We hypothesized greater improvements in (1) pain and function, (2) hip strength and core endurance for patients with PFP involved in the HIP protocol, and (3) knee strength for patients involved in the KNEE protocol. DESIGN: Randomized controlled clinical trial. SETTING: Four clinical research laboratories in Calgary, Alberta; Chicago, Illinois; Milwaukee, Wisconsin; and Augusta, Georgia. PATIENTS OR OTHER PARTICIPANTS: Of 721 patients with PFP screened, 199 (27.6%) met the inclusion criteria (66 men [31.2%], 133 women [66.8%], age = 29.0 ± 7.1 years, height = 170.4 ± 9.4 cm, weight = 67.6 ± 13.5 kg). INTERVENTION(S): Patients with PFP were randomly assigned to a 6-week KNEE or HIP protocol. MAIN OUTCOME MEASURE(S): Primary variables were self-reported visual analog scale and Anterior Knee Pain Scale measures, which were conducted weekly. Secondary variables were muscle strength and core endurance measured at baseline and at 6 weeks. RESULTS: Compared with baseline, both the visual analog scale and the Anterior Knee Pain Scale improved for patients with PFP in both the HIP and KNEE protocols (P < .001), but the visual analog scale scores for those in the HIP protocol were reduced 1 week earlier than in the KNEE group. Both groups increased in strength (P < .001), but those in the HIP protocol gained more in hip-abductor (P = .01) and -extensor (P = .01) strength and posterior core endurance (P = .05) compared with the KNEE group. CONCLUSIONS: Both the HIP and KNEE rehabilitation protocols produced improvements in PFP, function, and strength over 6 weeks. Although outcomes were similar, the HIP protocol resulted in earlier resolution of pain and greater overall gains in strength compared with the KNEE protocol.

Reduced hamstring strength increases anterior cruciate ligament loading during anticipated sidestep cutting.

BACKGROUND: Dynamic knee stability is considered a critical factor in reducing anterior cruciate ligament loads. While the relationships between hamstring force production and anterior cruciate ligament loading are well known in vitro, the influence of hamstring strength to anterior cruciate ligament loading during athletic maneuvers remains unknown. Therefore, the purpose of this study was to determine the influence of hamstring strength on anterior cruciate ligament loading during anticipated sidestep cut. METHODS: Seventeen recreationally active females were recruited to perform sidestep cutting maneuvers pre/post an acute hamstring strength reduction protocol. Kinematics and kinetics were calculated during the cut and a musculoskeletal model was used to estimate muscle, joint, and anterior cruciate ligament loads. Dependent t-tests were conducted to investigate differences between the two cutting conditions. FINDINGS: Anterior cruciate ligament loading increased by 36% due to reduced hamstring strength. This was mostly due to a 44% increase in sagittal plane loading and a 24% increase in frontal plane loading. Post strength reduction sidestep cuts were also performed with decreased anterior tibiofemoral shear force, an outcome that would theoretically reduce anterior cruciate ligament loading. However, the overall decrease in hamstring force production coupled with a more axial hamstring line of action yielded a net increase in anterior cruciate ligament loading. INTERPRETATION: These results suggest that decreased hamstring strength significantly increases anterior cruciate ligament loading during anticipated sidestep cutting. Additionally, these results support the premise that preseason screening programs should monitor hamstring strength to identify female athletes with potential deficits and increased injury risk.

Age and cancer risk: a potentially modifiable relationship.

This article challenges the idea that cancer cannot be prevented among older adults by examining different aspects of the relationship between age and cancer. Although the sequential patterns of aging cannot be changed, several age-related factors that contribute to disease risk can be. For most adults, age is coincidentally associated with preventable chronic conditions, avoidable exposures, and modifiable risk behaviors that are causally associated with cancer. Midlife is a period of life when the prevalence of multiple cancer risk factors is high and incidence rates begin to increase for many types of cancer. However, current evidence suggests that for most adults, cancer does not have to be an inevitable consequence of growing older. Interventions that support healthy environments, help people manage chronic conditions, and promote healthy behaviors may help people make a healthier transition from midlife to older age and reduce the likelihood of developing cancer. Because the number of adults reaching older ages is increasing rapidly, the number of new cancer cases will also increase if current incidence rates remain unchanged. Thus, the need to translate the available research into practice to promote cancer prevention, especially for adults at midlife, has never been greater.

The relationship among foot posture, core and lower extremity muscle function, and postural stability.

CONTEXT: Identification of impaired balance as a risk factor for lower extremity injury regardless of injury history has led to subsequent investigation of variables that may adversely affect balance in healthy individuals. OBJECTIVES: To investigate the relationship among core and lower extremity muscle function, foot posture, and balance. DESIGN: Descriptive laboratory study. SETTING: Musculoskeletal injury biomechanics laboratory. PATIENTS OR OTHER PARTICIPANTS: A total of 108 individuals (40 men, 68 women; age = 22.8 ± 4.7 years, height = 168.5 ± 10.4 cm, mass = 69.9 ± 13.3 kg) participated in the study. MAIN OUTCOME MEASURE(S): Core endurance was assessed during 1 time-to-failure trial, and isometric hip and ankle strength were assessed using a handheld dynamometer and isokinetic dynamometer, respectively. Foot structure was quantified using the digital photographic measurement method. Single-limb-stance time to boundary was assessed using a force plate during an eyes-closed condition. Hierarchical multiple regression analyses were performed to predict balance using lower extremity strength, foot posture, and core endurance. RESULTS: Foot posture (ß = -0.22, P = .03) and ankle-inversion strength (ß = -0.29, P = .006) predicted mediolateral balance. Increasing arch posture and ankle-inversion strength were associated with decreased mediolateral single-limb-stance balance. CONCLUSIONS: Increasing arch height was associated with decreased mediolateral control of single-limb stance. The relationship between time to boundary and injury risk, however, has not been explored. Therefore, the relationship between increasing arch height and injury due to postural instability cannot be determined from this study. If authors of future prospective studies identify a relationship between decreased time to boundary and increased injury risk, foot structure may be an important variable to assess during preparticipation physical examinations. The relationship between increasing ankle-inversion strength and decreased balance may require additional study to further elucidate the relationship between ankle strength and balance.

Clinical outcomes from the CDC's Colorectal Cancer Screening Demonstration Program.

BACKGROUND: Colorectal cancer remains the second leading cause of cancer-related deaths among US men and women. Screening rates have been slow to increase, and disparities in screening remain. METHODS: To address the disparity in screening for this high burden but largely preventable disease, the Centers for Disease Control and Prevention (CDC) designed and established a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 for low-income, under-insured or uninsured men and women aged 50 to 64 years in 5 participating US program sites. In this report, the authors describe the design of the CRCSDP and the overall clinical findings and screening test performance characteristics, including the positive fecal occult blood testing (FOBT) rate; the rates of polyp, adenoma, and cancer detection with FOBTs and colonoscopies; and the positive predicative value for polyps, adenomas, and cancers. RESULTS: In total, 5233 individuals at average risk and increased risk were screened for colorectal cancer across all 5 sites, including 44% who underwent screening FOBT and 56% who underwent screening colonoscopy. Overall, 77% of all individuals screened were women. The FOBT positivity rate was 10%. Results from all screening or diagnostic colonoscopies indicated that 75% had negative results and required a repeat screening colonoscopy in 10 years, 16% had low-risk adenomas and required surveillance colonoscopy in 5 to 10 years, 8% had high-risk adenomas and required surveillance colonoscopy in 3 years, and 0.6% had invasive cancers. CONCLUSIONS: This report documents the successes and challenges in implementing the CDC's CRCSDP and describes the clinical outcomes of this 4-year initiative, the patterns in program uptake and test choice, and the comparative test performance characteristics of FOBT versus colonoscopy. Patterns in final outcomes from the follow-up of positive screening tests were consistent with national registry data.

Implementing the CDC's Colorectal Cancer Screening Demonstration Program: wisdom from the field.

BACKGROUND: Colorectal cancer, as the second leading cause of cancer-related deaths among men and women in the United States, represents an important area for public health intervention. Although colorectal cancer screening can prevent cancer and detect disease early when treatment is most effective, few organized public health screening programs have been implemented and evaluated. From 2005 to 2009, the Centers for Disease Control and Prevention funded 5 sites to participate in the Colorectal Cancer Screening Demonstration Program (CRCSDP), which was designed to reach medically underserved populations. METHODS: The authors conducted a longitudinal, multiple case study to analyze program implementation processes. Qualitative methods included interviews with 100 stakeholders, 125 observations, and review of 19 documents. Data were analyzed within and across cases. RESULTS: Several themes related to CRCSDP implementation emerged from the cross-case analysis: the complexity of colorectal cancer screening, the need for teamwork and collaboration, integration of the program into existing systems, the ability of programs to use wisdom at the local level, and the influence of social norms. Although these themes were explored independently from 1 another, interaction across themes was evident. CONCLUSIONS: Colorectal cancer screening is clinically complex, and its screening methods are not well accepted by the general public; both of these circumstances have implications for program implementation. Using patient navigation, engaging in transdisciplinary teamwork, assimilating new programs into existing clinical settings, and deferring to local-level wisdom together helped to address complexity and enhance program implementation. In addition, public health efforts must confront negative social norms around colorectal cancer screening.

Recruiting patients into the CDC's Colorectal Cancer Screening Demonstration Program: strategies and challenges across 5 sites.

BACKGROUND: In 2005, the Centers for Disease Control and Prevention (CDC) funded 5 sites as part of the Colorectal Cancer Screening Demonstration Program (CRCSDP) to provide colorectal cancer screening to low-income, uninsured, and underinsured individuals. Funded sites experienced unexpected challenges in recruiting patients for services. METHODS: The authors conducted a longitudinal, qualitative case study of all 5 sites to document program implementation, including recruitment. Data were collected during 3 periods over the 4-year program and included interviews, document review, and observations. After coding and analyzing the data, themes were identified and triangulated across the research team. Patterns were confirmed through member checking, further validating the analytic interpretation. RESULTS: During early implementation, patient enrollment was low at 4 of the 5 CRCSDP sites. Evaluators found 3 primary challenges to patient recruitment: overreliance on in-reach to National Breast and Cervical Cancer Early Detection Program patients, difficulty keeping colorectal cancer screening and the program a priority among staff at partnering primary care clinics responsible for patient recruitment, and a lack of public knowledge about the need for colorectal cancer screening among patients. To address these challenges, site staff expanded partnerships with additional primary care networks for greater reach, enhanced technical support to primary care providers to ensure more consistent patient enrollment, and developed tailored outreach and education. CONCLUSIONS: Removing financial barriers to colorectal cancer screening was necessary but not sufficient to reach the priority population. To optimize colorectal cancer screening, public health practitioners must work closely with the health care sector to implement evidence-based, comprehensive strategies across individual, environmental, and systems levels of society.

Developmental milestones across the programmatic life cycle: implementing the CDC's Colorectal Cancer Screening Demonstration Program.

BACKGROUND: In 2005 through 2009, the Centers for Disease Control and Prevention (CDC) funded 5 sites to implement a colorectal cancer screening program for uninsured, low-income populations. These 5 sites composed a demonstration project intended to explore the feasibility of establishing a national colorectal cancer screening program through various service delivery models. METHODS: A longitudinal, multiple case study was conducted to understand and document program implementation processes. Using metaphor as a qualitative analytic technique, evaluators identified stages of maturation across the programmatic life cycle. RESULTS: Analysis rendered a working theory of program development during screening implementation. In early stages, program staff built relationships with CDC and local partners around screening readiness, faced real-world challenges putting program policies into practice, revised initial program designs, and developed new professional skills. Midterm implementation was defined by establishing program cohesiveness and expanding programmatic reach. In later stages of implementation, staff focused on sustainability and formal program closeout, which prompted reflection about personal and programmatic accomplishments. CONCLUSIONS: Demonstration sites evolved through common developmental stages during screening implementation. Findings elucidate ways to target technical assistance to more efficiently move programs along their maturation trajectory. In practical terms, the time and cost associated with guiding a program to maturity may be potentially shortened to maximize return on investment for both organizations and clients receiving service benefits.