Racial disparity in breast cancer survivorship: themes from a series of four national healthcare provider live virtual forums.

PURPOSE: Significant disparity exists in the diagnosis, treatment, and survivorship outcomes among Black breast cancer (BC) survivors. Black BC survivors have more significant survivorship issues and a greater burden of illness than White counterparts. Barriers to rehabilitation exist for all BC survivors but are magnified in Black BC survivors. The purpose of this qualitative research was to document patient, clinician, and researchers' perceptions surrounding contributing factors, lived experiences, and potential solutions to racial disparity in BC survivorship. METHODS: A narrative approach was utilized to identify themes from a series of four virtual healthcare provider forums that explored lived personal and professional experiences, issues, and potential solutions surrounding racial disparity in BC survivorship. Forums included perspectives of patients, healthcare providers, researchers, and stakeholders in the BC field. An independent thematic analysis was performed by the investigators, all of whom have emic perspectives with respect to race and/or BC. RESULTS: Three main themes were identified related to racial disparity in BC survivorship: (1) societal and cultural contributing factors, (2) contribution of healthcare providers and systems, and (3) models of care and research considerations. CONCLUSIONS: The findings provide compelling documentation of lived personal and professional experiences of racial disparity in BC survivorship. Potential solutions exist and must be enacted immediately to ensure equitable survivorship outcomes for Black individuals following a BC diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Increased awareness related to racial disparity in BC survivorship among survivors, healthcare providers, and researchers will contribute to health equity and improved outcomes for Black individuals.

The prevalence of wound management physical therapist practice in the state of Texas.

INTRODUCTION: Wound management has become one of the ten physical therapy (PT) certification specialty areas. With this advanced clinical designation opportunity, more PT specialists and residencies with integumentary and wound management expertise will be needed for the educational and practice training of future specialists. PURPOSE: The purpose of this study was to characterize wound management practice by licensed physical therapists in Texas. METHODS: A Qualtrics survey was distributed to 19,159 licensed physical therapists. The questionnaire contained 23 questions that inquired into the subject's professional background, clinical experience, and opinions of wound care practice. RESULTS: The response rate was 9.6% (n = 1,839) and 1,643 respondents indicated that they were currently practicing. Although 69.1% of active physical therapists (n = 1,136) stated that they had practiced wound care at some point of their career, most of them do not practice wound care anymore and their reasons were discussed. Of those active physical therapists, 41.3% (n = 679) of them reported wound care was being practiced in their facilities, but only 18.3% (n = 311) directly practiced wound care. The respondents felt that the prevalence of wound management physical therapists practice over the last five years has been decreasing. CONCLUSION: The current prevalence of wound management practice is low and a decreasing trend of PT practice in wound care was observed in Texas. A limitation of this study is the low response rate. Future studies across different regions of the country are warranted.

Justice in Educational Content: A Guide to Racial and Cultural Representation in Academic and Clinical Teaching and Assessment.

BACKGROUND AND PURPOSE: Case-based instruction is broadly used in health professions education, including physical therapy education. Case-based instruction can support achievement of higher-order, applied, learning objectives and clinical reasoning. Instructors strive to represent the diversity of the clinical population in case studies and may have explicit intercultural competency objectives. The inclusion of cultural, racial, and ethnic characteristics in cases or assessments can potentially reinforce stereotypes or inaccurately emphasize these characteristics as direct predictors of health profile. Furthermore, as most physical therapy faculty creating cases are from a White majority stance, there is a risk that inclusion of cultural elements risks inappropriate and biased representation. POSITION AND RATIONALE: Well-intentioned instructors risk substituting cultural, racial, and ethnic characteristics for social and structural determinants of health. Race is a social, not biologic construction and should not be confused. Informed instructors guided by evidence-based strategies can achieve rich case depictions that do not convey inaccurate risk or alienate learners. DISCUSSION AND CONCLUSION: A curriculum design strategy is offered for case development that brings explicit attention to representation of race and culture. This tool serves as a self-reflective and improvement tool. Continued community and student engagement is necessary to achieve high-quality and instructive case studies.

The Changing Landscape of Intercultural Mindset in 616 Doctor of Physical Therapy Students Over the Past 7 Years and the Implications for Doctor of Physical Therapy Cultural Competence Education.

INTRODUCTION: This prospective longitudinal study will report the results of a quantitative analysis of the change in Intercultural Development Inventory (IDI) scores and the distribution of students in 5 orientations along the Intercultural Developmental Continuum (IDC) in 8 cohorts of Doctor of Physical Therapy (DPT) students during their academic preparation. REVIEW OF LITERATURE: The expanding interest in developing intercultural sensitivity in an increasingly more complex and diverse health care environment calls for the dissemination of research on the effectiveness of innovative curricular models that include psychometrically strong outcome measures. Research suggests that health care providers can develop intercultural sensitivity when provided with didactic knowledge, experiential learning, self-reflection, mentoring, and a systematic individualized development plan. SUBJECTS: The participants were from a sample of convenience of 616 DPT students from the graduating classes of 2015-2022. METHODS: The study is a repeated-measure design. The IDI was selected to guide targeted intervention and assessment of intercultural sensitivity at an individual level and group level and was administered in semesters 3 and 8 as part of the DPT program course requirements. RESULTS: There was significant improvement in the IDI Perceived and Developmental Orientation (DO; P < .001) scores between semesters 3 and 8. There was a significant change (P = .0001) in the distribution of students along the 5 DOs of the IDC with 10% of students regressing 1 orientation, 51.7% of students remaining the same, 33.3% of students advancing 1 orientation, and 5% of students advancing 2 orientations along the IDC. Nearly 40% of participants had a positive shift along the IDC. DISCUSSION AND CONCLUSION: The results of this study suggest that intercultural sensitivity or mindset, as measured by the IDI, can be developed in DPT students who participate in a targeted intercultural development curriculum based on the Process Model of Cultural Competence by Deardorff and the Developmental Model of Intercultural Sensitivity by Bennett.

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.

Crises as the Crucible for Change in Physical Therapist Education.

This Perspective issues a challenge to physical therapists to reorient physical therapist education in ways that directly address the crises of COVID-19 and systemic racism. We advocate that professional education obligates us to embrace the role of trusteeship that demands working to meet society's needs by producing graduates who accept their social and moral responsibilities as agents and advocates who act to improve health and health care. To achieve this, we must adopt a curriculum philosophy of social reconstruction and think more deeply about the why and how of learning. Currently, health professions education places strong emphasis on habits of head (cognitive knowledge) and hand (clinical skills) and less focus on habits of heart (professional formation). We believe that habits of heart are the essential foundations of the humanistic practice needed to address health inequities, find the moral courage to change the status quo, and address imbalances of power, privilege, and access. A social reconstruction orientation in physical therapist education not only places habits of heart at the center of curricula, but it also requires intentional planning to create pathways into the profession for individuals from underrepresented groups. Adopting social reconstructionism begins with a faculty paradigm shift emphasizing the learning sciences, facilitating learning, metacognition, and development of a lifelong master adaptive learner. Achieving this vision depends not only on our ability to meet the physical therapy needs of persons with COVID-19 and its sequalae but also on our collective courage to address injustice and systemic racism. It is imperative that the physical therapy community find the moral courage to act quickly and boldly to transform DPT education in ways that enable graduates to address the social determinants of health and their systemic and structural causes that result in health disparities. To succeed in this transformation, we are inspired and strengthened by the example set by Geneva R. Johnson, who has never wavered in recognizing the power of physical therapy to meet the needs of society.

Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study.

PURPOSE: Axillary web syndrome (AWS) presents as a common postsurgical complication in individuals with breast cancer. Breast cancer-related lymphedema (BCRL) contributes to the shoulder and arm morbidity common in breast cancer survivors and often associated to cancer treatment. A paucity of literature exists evaluating the risk factors for developing AWS and the association between AWS and BCRL. The purposes of this study were (1) to identify risk factors for AWS in individuals with breast cancer, (2) to examine the association between BCRL and AWS, and (3) to determine if AWS increases the risk for developing BCRL. METHODS: A retrospective study of 354 women who underwent breast cancer treatment and received physical therapy was included. RESULTS: Axillary web syndrome developed in a third of women and predominately occurred in the first 8 postoperative weeks. The odds of AWS development were 73% greater for participants over the age of 60 (OR = 1.73, CI 95% 1.05-2.84). Women with AWS had 44% greater risk to develop lymphedema during the first postoperative year (RR = 1.44, CI 95% 1.12-1.84, p = 0.002). If AWS developed within the first postoperative month, women were almost 3 times more likely to develop lymphedema within the first 3 postoperative months compared with other women with AWS (RR = 2.75, CI 95% 1.199-6.310, p = 0.007). CONCLUSIONS: Our findings suggest that 30% of breast cancer survivors will have AWS during the first year of survivorship. As institutions prioritize screening efforts, early postoperative prospective surveillance is needed for women over 60 due to high risk for AWS development and any women with AWS for increased risk of lymphedema development based on our findings.

Examining Factors That Contribute to Delayed Wound Healing in Children with Tracheostomy Wounds.

OBJECTIVE: To identify variables that may contribute to delayed wound healing times in pediatric patients with tracheostomy wounds. DESIGN: Researchers identified 134 charts spanning January 2013 to June 2017; 95 charts met the inclusion criteria. The study examined Pressure Ulcer Scale for Healing (PUSH) scores, pressure injury staging, and albumin levels. SETTING: Arkansas Children's Hospital. PATIENTS: Patients (birth to 18 years) who developed or were admitted with a wound caused by a tracheostomy device. MAIN OUTCOME MEASURE: Time in days to wound closure. MAIN RESULTS: There was a moderate positive correlation between albumin and days to healing (r = 0.432, n = 22, P = .045) with higher albumin levels associated with shorter healing times. The PUSH scores and pressure injury stage were significant in explaining 14.1% of variance in days to healing (F77,2 = 7.458; P < .001). CONCLUSIONS: Wound healing appears to be multifactorial in nature in the pediatric population; albumin levels, pressure injury stage, and PUSH scores are all positively correlated with healing times. Further research is needed to investigate the contribution of race to healing time predication for the pediatric population.

Pediatric Tracheostomy Wound Healing: A Retrospective Cohort Study.

OBJECTIVE: To compare wound products by measuring time to granulation tissue and time to complete wound healing for tracheostomy wounds in the pediatric population. METHODS: Investigators identified 134 charts of patients treated January 2013 and June 2017; 93 charts met the inclusion criteria. This study compared the use of a foam dressing (n = 34) to the foam dressing plus a wound filler (n = 59) in patients who developed or were admitted with a wound caused by a tracheostomy device. PRIMARY OUTCOME MEASURES: Time in days to granulation tissue and to wound closure. RESULTS: The average time to complete wound closure for participants in this study was 14 days. There was no statistically significant difference in time to granulation tissue or wound closure formation between the wound care products (F2,34 = 1.11, P = .34). Cluster analysis (10 splits) revealed that pressure injury stage was the best predictor, accounting for 41% of the variance in the high treatment response group (those healing in <14 days). Patients who were African American with a stage 2 pressure injury, had a PUSH score of 5 or more, and were using a foam plus a wound filler dressing were 86% more likely to be in the high-response group. CONCLUSIONS: All wounds reviewed healed with current wound care practices without surgical intervention. Best practice for healing tracheostomy wounds in pediatric patients should include the wound filler in the first 14 days based on variable interaction.

Current Wound Care Education in Entry-Level Doctor of Physical Therapy Curricula.

OBJECTIVE: To investigate how wound care instruction is currently delivered within entry-level doctor of physical therapy (DPT) educational curricula. METHODS: An electronic survey was distributed to 226 DPT programs in the US. The questionnaire contained 27 questions about the characteristics of the wound care instruction as well as the credentials, clinical experience, and teaching experience of the instructors. Descriptive statistics were analyzed for each questionnaire item response. MAIN RESULTS: The response rate was 22.1% (n = 50). The majority of respondents reported 10 to 29 contact hours of wound care instruction throughout the curriculum. More than half of the programs reported that their students completed a wound care observation in clinical settings. Forty-four percent of programs stated that their students had the opportunity to participate in a clinical rotation focused solely on wound care. All respondents reported that their wound care instructors were physical therapists. Of those instructors, most were seasoned clinicians, and 46% held a wound care-related certification. CONCLUSIONS: Current entry-level DPT curricula provide physical therapy students with adequate contact hours in wound care and the opportunity for clinical experiences. The instructors are seasoned physical therapists, and nearly half of them hold advanced certification in the content area. Further studies are warranted to investigate how physical therapists practice in wound management in various clinical settings.

DPT Student Perceptions of the Physical Therapist Assistant's Role: Effect of Collaborative Case-Based Learning Compared to Traditional Content Delivery and Clinical Experience.

INTRODUCTION: Doctor of physical therapy (DPT) student learning about role delineation of physical therapist assistants (PTAs) is essential to ethical and legal practice. METHODS: Survey assessment of three DPT student cohorts compared collaborative interprofessional case-based learning with PTA students to traditional curriculum delivery strategies. Control cohorts were assessed one time. The intervention group was assessed pre-intervention, immediately post-intervention, and after completing a full-time clinical experience. The case-based learning covered 46% of survey content, allowing for the assessment of content-specific material and potential learning through collaboration. RESULTS: Following the educational intervention, the intervention group improved significantly in areas inside and outside the case-based study content, outscoring both control groups on 25-34% of the survey items. Following the clinical experience, the intervention group declined answer accuracy for patient evaluation and treatment implementation, suggesting unlearning. Improvement in the administrative section was observed after the clinical experience. Perceptions of the tasks within the PTA role were diminished while tasks outside the scope of practice appeared clarified following the clinical experience. CONCLUSION: While case-based collaborative intraprofessional learning proves effective in student learning about the PTA role, changes following the clinical experience raise questions about the influence of the clinical environment on learning and the practical application of recently learned knowledge.

Significance of Nonphysical Predictors of Distress in Cancer Survivors.

BACKGROUND: The Distress Thermometer (DT) is a well-validated tool that is frequently used in patients with cancer to screen for general distress and to generate referrals. However, a majority of the DT problem list items relate to physical concerns; this may lead to psychosocial issues being overshadowed. OBJECTIVES: The purpose of the current study is to examine the endorsement rates for nonphysical items, as well as the relationship between these items and overall DT scores. METHODS: A multiple logistic regression analysis of the first-time distress rating scale of 1,209 patients from 2005-2009 was conducted to determine whether nonphysical items on the DT significantly contributed to a patient falling into one of two categories. FINDINGS: This study provides evidence that emotional variables are particularly significant for patients who are at risk for distress and, consequently, should be prioritized for intervention when endorsed on the DT problem list.

The Relationship Between Perceived Racism/Discrimination and Health Among Black American Women: a Review of the Literature from 2003 to 2013.

OBJECTIVES: The purpose of this paper was to systematically review the literature investigating the relationship between perceived racism/discrimination and health among black American women. METHODS: Searches for empirical studies published from January 2003 to December 2013 were conducted using PubMed and PsycInfo. Articles were assessed for possible inclusion using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 framework. In addition, the Agency for Healthcare Research and Quality (AHRQ) system for rating the strength of scientific evidence was used to assess the quality of studies included in the review. RESULTS: Nineteen studies met criteria for review. There was mixed evidence for general relationships between perceived racism/discrimination and health. Consistent evidence was found for the relationship between adverse birth outcomes, illness incidence, and cancer or tumor risk and perceived racism/discrimination. Inconsistent findings were found for the relationship between perceived racism/discrimination and heart disease risk factors. There was no evidence to support the relationship between perceived racism/discrimination and high blood pressure. CONCLUSIONS: There is mixed evidence to support the association between perceived racism/discrimination and overall objective health outcomes among black American women. The strongest relationship was seen between perceived racism/discrimination and adverse birth outcomes. Better understanding of the relationship between health and racism/discrimination can aid in identifying race-based risk factors developing primary prevention strategies. Future studies should aim to investigate the role of perceived racism/discrimination as a specific chronic stressor within discrete pathogenesis models.

An analysis of the distress thermometer problem list and distress in patients with cancer.

PURPOSE: Patients with a cancer diagnosis experience complex issues that can cause distress. The purpose of this study is to identify factors associated with overall distress for a diverse population of cancer survivors. METHODS: Researchers conducted a secondary data analysis of distress ratings (n = 1205) for people receiving outpatient care at a Midwestern US cancer center from 2005 to 2009 to describe the relationships between distress factors and need for assessment of distress. The screening tool was based on the distress thermometer (DT) scale and a modified problem list. Odds ratios and 95 % confidence intervals from this multivariable model were computed. RESULTS: Statistical analysis revealed that the items on the problem list that most contribute to being at risk for distress include financial, worry, nervousness, getting around, and sleep. The most highly associated risk factor for distress was worry. Those that were at risk for high distress were 5.57 times more likely to endorse problems related to worry. CONCLUSIONS: This research identifies which factors may be especially salient to the patient's perception of distress and help guide clinicians in developing targeted screening strategies and specific interventions based on patient response to the DT. It also points to the need for future research to more clearly characterize distress from the patient perspective and determine when interventions may be indicated.

Time-dependent alterations in rat macrovessels with type 1 diabetes.

Vascular complications are associated with the progressive severity of diabetes, resulting in significant morbidity and mortality. This study quantifies functional vascular parameters and macrovascular structure in a rat model of type 1 diabetes. While there was no difference in the systemic arterial elastance (Ea) with 50 days of diabetes, changes were noted in the aorta and femoral artery including increased tunica media extracellular matrix content, decreased width of both the media and individual smooth muscle cell layers, and increased incidence of damaged mitochondria. Extracellular matrix proteins and elastin levels were significantly greater in the aorta of diabetic animals. These differences correlated with diminished matrix metalloprotease activity in the aorta of the diabetic animals. In conclusion, diabetes significantly altered the structure and ultrastructure of the aorta and femoral artery before systemic changes in arterial elastance could be detected.

Electrocardiographic changes with the onset of diabetes and the impact of aerobic exercise training in the Zucker Diabetic Fatty (ZDF) rat.

BACKGROUND: Early markers of diabetic autonomic neuropathy (DAN) in an electrocardiogram (ECG) include elevated R wave amplitudes, widening of QTc intervals and decreased heart rate variability (HRV). The severity of DAN has a direct relationship with mortality risk. Aerobic exercise training is a common recommendation for the delay and possible reversal of cardiac dysfunction. Limited research exists on ECG measures for the evaluation of aerobic exercise training in Zucker Diabetic Fatty (ZDF) rat, a model of type 2 diabetes. The objective of this study was to assess whether aerobic exercise training may attenuate diabetes induced ECG changes. METHODS: Male ZDF (obese fa/fa) and control Zucker (lean fa/+) rats were assigned to 4 groups: sedentary control (SC), sedentary diabetic (SD), exercised control (EC) and exercised diabetic (ED). The exercised groups began 7 weeks of treadmill training after the development of diabetes in the ED group. Baseline (prior to the training) and termination measurements included body weight, heart weight, blood glucose and glycated hemoglobin levels and ECG parameters. One way repeated measures ANOVA (group) analyzed within and between subject differences and interactions. Pearson coefficients and descriptive statistics described variable relationships and animal characteristics. RESULTS: Diabetes caused crucial changes in R wave amplitudes (p < 0.001), heart rate variability (p < 0.01), QT intervals (p < 0.001) and QTc intervals (p < 0.001). R wave amplitude augmentation in SD rats from baseline to termination was ameliorated by exercise, resulting in R wave amplitude changes in ED animals similar to control rats. Aerobic exercise training neither attenuated QT or QTc interval prolongation nor restored decreases in HRV in diabetic rats. CONCLUSION: This study revealed alterations in R wave amplitudes, HRV, QT and QTc intervals in ZDF rats. Of these changes, aerobic exercise training was able to correct R wave amplitude changes. In addition, exercise has beneficial effect in this diabetic rat model in regards to ECG correlates of left ventricular mass.