Integrating Function‐Directed Treatments into Palliative Care

The growing acceptance of palliative care has created opportunities to increase the use of rehabilitation services among populations with advanced disease, particularly those with cancer. Broader delivery has been impeded by the lack of a shared definition for palliative rehabilitation and a mismatch between patient needs and established rehabilitation service delivery models. We propose the definition that, in the advanced cancer population, palliative rehabilitation is function‐directed care delivered in partnership with other clinical disciplines and aligned with the values of patients who have serious and often incurable illnesses in contexts marked by intense and dynamic symptoms, psychological stress, and medical morbidity to realize potentially time‐limited goals. Although palliative rehabilitation is most often delivered by inpatient physical medicine and rehabilitation consultation/liaison services and by physical therapists in skilled nursing facilities, outcomes in these settings have received little scrutiny. In contrast, outpatient cancer rehabilitation programs have gained robust evidentiary support attesting to their benefits across diverse settings. Advancing palliative rehabilitation will require attention to historical barriers to the uptake of cancer rehabilitation services, which include the following: patient and referring physicians’ expectation that effective cancer treatment will reverse disablement; breakdown of linear models of disablement due to presence of concurrent symptoms and psychological distress; tension between reflexive palliation and impairment‐directed treatment; palliative clinicians’ limited familiarity with manual interventions and rehabilitation services; and challenges in identifying receptive patients with the capacity to benefit from rehabilitation services. The effort to address these admittedly complex issues is warranted, as consideration of function in efforts to control symptoms and mood is vital to optimize patients’ autonomy and quality of life. In addition, manual rehabilitation modalities are effective and drug sparing in the alleviation of adverse symptoms but are markedly underused. Realizing the potential synergism of integrating rehabilitation services in palliative care will require intensification of interdisciplinary dialogue.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146938/1/pmr2s335.pd

The effects of Pilates training on flexibility and body composition: an observational study”. Arch Phys Med Rehabil,

ABSTRACT. Segal NA, Hein J, Basford JR. The effects of Pilates training on flexibility and body composition: an observational study. Arch Phys Med Rehabil 2004;85:1977-81. Objective: To assess claims regarding the effects of Pilates training on flexibility, body composition, and health status. Design: An observational prospective study. Setting: A community athletic club. Participants: A sample of 47 adults (45 women, 2 men) who presented for Pilates training. Interventions: Not applicable. Main Outcome Measures: Fingertip-to-floor distance, truncal lean body mass by bioelectric impedance, health status by questionnaire and visual analog scale were assessed at baseline, 2, 4, and 6 months (Ϯ1wk). Results: Thirty-two of 47 enrolled subjects met the protocol requirements of missing no more than 1 weekly 1-hour session Pilates mat class during each 2-month period. Investigators were blinded to measurements from previous time points. Median (interquartile range [IQR]) fingertip-to-floor distance improved from baseline by 3.4cm (1.3-5.7cm), 3.3cm (0.3-7.8cm), and 4.3cm (1.5-7.6cm) at 2, 4, and 6 months, respectively (paired nonparametric analysis, all PϽ.01). There were no statistically significant changes in truncal lean body mass, height, weight, or other body composition parameters. Selfassessment of health also did not change in a statistically significant manner from its baseline median (IQR) value of 77mm (69 -85mm). Conclusions: Pilates training may result in improved flexibility. However, its effects on body composition, health status, and posture are more limited and may be difficult to establish. Further study might involve larger sample sizes, comparison with an appropriate control group, and assessment of motor unit recruitment as well as strength of truncal stabilizers

Low level laser treatment of tendinopathy: a systematic review with meta-analysis

Objectives: To assess the clinical effectiveness of Low Level Laser Therapy (LLLT) in the treatment of tendinopathy. Secondary objectives were to determine the relevance of irradiation parameters to outcomes, and the validity of current dosage recommendations for the treatment of tendinopathy. Background: LLLT is proposed as a possible treatment for tendon injuries. However, the clinical effectiveness of this modality remains controversial, with limited agreement on the most efficacious dosage and parameter choices. Method: The following databases were searched from inception to 1st August 2008: MEDLINE, PubMed, CINAHL, AMED, EMBASE, All EBM reviews, PEDro (Physiotherapy Evidence Database), SCOPUS. Controlled clinical trials evaluating LLLT as a primary intervention for any tendinopathy were included in the review. Methodological quality was classified as: high (≥6 out of 10 on the PEDro scale) or low (\u3c6) to grade the strength of evidence. Accuracy and clinical appropriateness of treatment parameters were assessed using established recommendations and guidelines. Results: Twenty-five controlled clinical trials met the inclusion criteria. There were conflicting findings from multiple trials: 12 showed positive effects and 13 were inconclusive or showed no effect. Dosages used in the 12 positive studies would support the existence of an effective dosage window that closely resembled current recommended guidelines. In two instances where pooling of data was possible, LLLT showed a positive effect size; in studies of lateral epicondylitis that scored ≥6 on the PEDro scale, participants\u27 grip strength was 9.59 kg higher than that of the control group; for participants with Achilles tendinopathy, the effect was 13.6 mm less pain on a 100 mm visual analogue scale. Conclusion: LLLT can potentially be effective in treating tendinopathy when recommended dosages are used. The 12 positive studies provide strong evidence that positive outcomes are associated with the use of current dosage recommendations for the treatment of tendinopathy

The Effect of Seat Position on Wheelchair Propulsion Biomechanics

This study examined the effect of seat position on handrim biomechanics. Thirteen experienced users propelled a wheelchair over a smooth level floor at a self-selected speed. Kinetic and temporal-distance data were collected with the use of an instrumented rim and a motion analysis system. A custom-designed axle was used to change the seat position. We used repeated measures analysis of variance to evaluate if differences existed in the temporal-distance and kinetic data with change in seat position. Results showed that a shorter distance between the axle and shoulder (low seat height) improved the push time and push angle temporal variables (p \u3c 0.0001). Tangential force output did not change with seat position. Axial and radial forces were highest in the lowest seat position (p \u3c 0.001). Propulsion efficiency as measured by the fraction of effective force did not significantly change with seat position

Comparison of the effects of flexion and extension of the thumb and fingers on the position and cross-sectional area of the median nerve.

OBJECTIVE: To assess the separate effects of thumb and finger extension/flexion on median nerve position and cross-sectional area. METHODS: Ultrasonography was used to assess median nerve transverse position and cross-sectional area within the carpal tunnel at rest and its movement during volitional flexion of the individual digits of the hand. Both wrists of 165 normal subjects (11 men, 4 women, mean age, 28.6, range, 22 to 38) were studied. RESULTS: Thumb flexion resulted in transverse movement of the median nerve in radial direction (1.2 ± 0.6 mm), whereas flexion of the fingers produced transverse movement in ulnar direction, which was most pronounced during flexion of the index and middle fingers (3.2 ± 0.9 and 3.1 ± 1.0 mm, respectively). Lesser but still statistically significant movements were noted with flexion of the ring finger (2.0 ± 0.8 mm) and little finger (1.2 ± 0.5 mm). Flexion of the thumb or individual fingers did not change median nerve cross-sectional area (8.5 ± 1.1 mm(2)). CONCLUSIONS: Volitional flexion of the thumb and individual fingers, particularly the index and middle fingers, produced significant transverse movement of the median nerve within the carpal tunnel but did not alter the cross-sectional area of the nerve. The importance of these findings on the understanding of the pathogenesis of the carpal tunnel syndrome and its treatment remains to be investigated

The Cancer Rehabilitation Medicine Metrics Consortium: A Path to Enhanced, Multi-Site Outcome Assessment to Enhance Care and Demonstrate Value.

Purpose: A primary objective stated at the Cancer Rehabilitation Symposium at the National Institutes of Health was to improve outcome measurement. The purpose of this project was for the Cancer Rehabilitation Medicine Metrics Consortium (CRMMC) to develop an assessment tool to evaluate function in cancer patients via a data-driven and methodologically sound process. There is no agreed-upon measure of physical and cognitive function for cancer patients, making it difficult to demonstrate the value of rehabilitation interventions. Cancer patients are a particularly challenging population, with many tumor- and treatment-related variables impacting function. Methods: Investigators from nine different cancer rehabilitation programs participated in a modified-Delphi process to delineate necessary aspects of an ideal patient assessment tool, including instrument type, domains evaluated, applicability across a range of patient traits, clinical feasibility, and item response characteristics. This involved numerous meetings, data review, and analysis of items involved in patient assessment. Results: The CRMMC developed a 21-item patient-reported outcome measure based on item response theory. The process by which the short form was developed was documented and provides a framework for other clinicians to follow. Conclusion: This document provides a framework for rehabilitation providers to follow when developing an assessment tool. This process is described in a stepwise fashion for reproducibility even in different, non-cancer populations