Priorities for women with lymphoedema after treatment for breast cancer: population based cohort study

Objective To explore the perceived unmet needs among women treated for breast cancer and in whom symptoms and signs indicate the presence of lymphoedema

Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial

BACKGROUND: Currently 1 in 11 women over the age of 60 in Australia are diagnosed with breast cancer. Following treatment, most breast cancer patients are left with shoulder and arm impairments which can impact significantly on quality of life and interfere substantially with activities of daily living. The primary aim of the proposed study is to determine whether upper limb impairments can be prevented by undertaking an exercise program of prolonged stretching and resistance training, commencing soon after surgery. METHODS/DESIGN: We will recruit 180 women who have had surgery for early stage breast cancer to a multicenter single-blind randomized controlled trial. At 4 weeks post surgery, women will be randomly assigned to either an exercise group or a usual care (control) group. Women allocated to the exercise group will perform exercises daily, and will be supervised once a week for 8 weeks. At the end of the 8 weeks, women will be given a home-based training program to continue indefinitely. Women in the usual care group will receive the same care as is now typically provided, i.e. a visit by the physiotherapist and occupational therapist while an inpatient, and receipt of pamphlets. All subjects will be assessed at baseline, 8 weeks, and 6 months later. The primary measure is arm symptoms, derived from a breast cancer specific questionnaire (BR23). In addition, range of motion, strength, swelling, pain and quality of life will be assessed. DISCUSSION: This study will determine whether exercise commencing soon after surgery can prevent secondary problems associated with treatment of breast cancer, and will thus provide the basis for successful rehabilitation and reduction in ongoing problems and health care use. Additionally, it will identify whether strengthening exercises reduce the incidence of arm swelling. TRIAL REGISTRATION: The protocol for this study is registered with the Australian Clinical Trials Registry (ACTRN012606000050550)

Reliability of two goniometric methods of measuring active inversion and eversion range of motion at the ankle

BACKGROUND: Active inversion and eversion ankle range of motion (ROM) is widely used to evaluate treatment effect, however the error associated with the available measurement protocols is unknown. This study aimed to establish the reliability of goniometry as used in clinical practice. METHODS: 30 subjects (60 ankles) with a wide variety of ankle conditions participated in this study. Three observers, with different skill levels, measured active inversion and eversion ankle ROM three times on each of two days. Measurements were performed with subjects positioned (a) sitting and (b) prone. Intra-class correlation coefficients (ICC([2,1])) were calculated to determine intra- and inter-observer reliability. RESULTS: Within session intra-observer reliability ranged from ICC([2,1] )0.82 to 0.96 and between session intra-observer reliability ranged from ICC([2,1] )0.42 to 0.80. Reliability was similar for the sitting and the prone positions, however, between sessions, inversion measurements were more reliable than eversion measurements. Within session inter-observer measurements in sitting were more reliable than in prone and inversion measurements were more reliable than eversion measurements. CONCLUSION: Our findings show that ankle inversion and eversion ROM can be measured with high to very high reliability by the same observer within sessions and with low to moderate reliability by different observers within a session. The reliability of measures made by the same observer between sessions varies depending on the direction, being low to moderate for eversion measurements and moderate to high for inversion measurements in both positions

A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study proto

© Article author(s). Introduction Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended-release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-Arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD. Methods and analysis The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0-10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used. Ethics and dissemination Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness. Trial registration number NCT02720822; Pre-results

Assessment of breast cancer-related lymphedema : A comparison of moisture meter and spot bioimpedance measurement

Background: Tissue dielectric constant (TDC) and spot bioimpedance measurement (BIA) have a role in the assessment of tissue composition changes in breast cancer-related lymphedema (BCRL). Our aims were to determine whether TDC and spot BIA measures could detect inter-limb differences in BCRL, explore the relationship between methods, and establish the intra-rater reliability and technical error of measurement for TDC. Methods and Results: Women with (n=20) and without (n=4) unilateral BCRL participated. Circumference, TDC, and spot BIA measures were completed on the most affected region of the arm for BCRL participants and at a standardized forearm point in women without lymphedema. All measures were compared to measurements from an identical location on the contralateral arm. The affected arm differed significantly to the unaffected arm of women with BCRL for TDC and spot BIA measures. The median (IQR) differences were: extra-small probe 5.75 (3.10–8.21), small probe 3.50 (1.16–6.89), medium probe 5.08 (0.88–10.91), and for spot BIA measurement (−35.20 Ω; −59.75 to −14.85 Ω). The small and medium TDC probe measures were moderately correlated to spot bioimpedance measurements (r=−0.54 and r=−0.43, respectively). Intra-rater reliability coefficients (ICC2,1) of TDC measures ranged from 0.50 (95% CI: 0.12–0.75) to 0.92 (0.82–0.96). TDC technical error of measurement for women with lymphedema varied from 10.5% to 13.3%. Conclusions: Both TDC and spot bioimpedance may have a role in clinical assessment of tissue compositional change in BCRL. Their relationship with tissue composition, assessed by imaging, is now required

Operational equivalence of bioimpedance indices and perometry for the assessment of unilateral arm lymphedema

The aim was to assess the agreement between bioimpedance indices and inter-limb volume differences, as assessed by perometry, for assessment of unilateral arm lymphedema.Impedance was measured in the arms of 45 women with lymphedema and a separate control group without lymphedema (n = 21). Arm volume was measured at the same time by perometry. The impedance indices, (ratio of impedances between limbs and the L-dex scores) were compared to the inter-limb volume differences using concordance correlation analysis.Impedance indices were highly correlated (r = 0.926) with the difference in arm volume measured by perometry.Bioelectrical impedance analysis, although not providing a quantitative volume measurement of lymphedema, provides a measurement index that is highly correlated with quantitative measurements of the volume increase in limb size seen in lymphedema. The speed and ease of the impedance technique renders it a suitable alternative to perometry for the assessment of lymphedema

Breast cancer-related arm lymphedema: fluctuation over six months and the effect of the weather

Background: An understanding of normal fluctuation of lymphedema over time is important to identify real change, whether it is from response to treatment or worsening of the condition. The weather is another factor that possibly influences lymphedema but has had minimal investigation to date. The purpose of this study was to determine the extent to which breast cancer-related lymphedema (BCRL) fluctuated over a 6-month period and the influence of temperature, humidity, and barometric pressure. Method and Results: Women with unilateral BCRL (n = 26) and without BCRL (n = 17) were measured on nine occasions over 6 months using a standardized protocol. Measures included self-reported arm swelling, arm volume, and extracellular fluid with bioimpedance. Daily weather data were obtained for analysis of effects on lymphedema. Neither arm volume nor extracellular fluid varied significantly for women with lymphedema; coefficients of variation were 2.3% and 3.7%, respectively. Women without lymphedema had even less fluctuation, with coefficient of variation of 1.9% for arm volume and 2.9% for ECF. Correlation of weather and lymphedema data showed that temperature was the only aspect of the weather to have any effect on BCRL, with the maximum temperature on the day before measurement slightly affecting ECF (r = 0.27, p < 0.001), arm volume (r = 0.23, p < 0.001), and self-reported swelling (r = 0.26, p < 0.001). For women without lymphedema, the weather did not affect any measure. Conclusions: Established BCRL is relatively stable over a 6-month period. Temperature was the only aspect of the weather found to impact lymphedema

Reliability and concurrent validity of the perometer for measuring hand volume in women with and without lymphedema

Background: Lymphedema of hand after breast cancer treatment causes significant loss of hand function. Although there are several ways of assessing limb volume, measuring hand volume has been problematic due to technical difficulties associated with assessment of finger volumes. The aim of this study was to investigate the criterion validity and reliability of Perometer™ for measuring hand volume in woman with and without lymphedema. Methods and Results: Hand volume of forty women with (n = 20) and without lymphedema (n = 20) was assessed twice by one rater and once by another rater using the Perometer, and once by one rater using the water volumetry method. Intra- and inter-rater reliability was determined from the intraclass correlation coefficients and Percent Close Agreement. Agreement between the Perometer and water volumetry was determined using a limit of agreement and Lin's concordance correlation. The Perometer had high intra [ICC2,1 = 0.989 (95% CI: 0.98–0.99)] and inter-rater reliability [ICC2,1 = 0.993 (95% CI: 0.99–1.0)]. Percent close agreement revealed that 80% of the measures were within 9 ml for inter-rater reliability and within 15 ml for intra-rater reliability. In addition, there was high concordance between hand volumes obtained with the Perometer and water volumetry method (Rc = 0.88). However, the Perometer overestimated the volume of hand compared to water volumetry method (bias: 7.5%). Conclusions: The Perometer can be used with high reliability to measure hand volume but caution should be exercised when data are compared with measures derived from the water volumetry method