A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course

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1 2014 Annual Breast Cancer Rehabilitation Healthcare Provider Event A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course November 7 th and 8 th, 2014 Mercer University, Atlanta, GA Sponsored By: TurningPoint s Edith Van Riper-Haase Breast Cancer Rehabiltation Advocacy Fund Presentations are Available on TurningPoint s Website: myturningpoint.org Click on Course Link itsthejourney.org thevisualab.com

2 A Manual Therapy and Exercise Approach to Breast Cancer Rehabilitation Course Functional Outcome Measures in Breast Cancer Rehabilitation Jill Binkley, PT, MSc, FAAOMPT, CLT This Presentation is available on TurningPoint s Website: myturningpoint.org From Homepage Click on Course Link

3 Generic Health Status Condition/Region Specific Patient Specific does not refer to a specific disease or problem taps a spectrum of health concepts permits comparison among groups with different health problems (e.g. cancer, kidney disease, OA, stroke) Example: SF-36 Functional Assessment of Cancer Therapy Breast Cancer Quality of Life Instrument (FACT-B) EORTC-C30 and BR23 Scales Classification of Self-Report Outcome Measures assesses characteristic or activities most relevant to the condition or intervention Examples: Upper Extremity Functional Index (UEFI), Disabilities of Arm, Shoulder and Hand (DASH) Hybrid Measures a spectrum of health concepts, including physical, social and emotional Characteristics of both generic health status and condition-specific assesses characteristic or activities that are most relevant to the individual Example: PSFS

4 Comparison of Types of Measures Sensitivity to change: Patient Specific > Condition > Generic Generic measures Tend to be influenced to a greater extent by co-morbid conditions Take longer to complete, often require a computer to score Patient and condition/region specific measures Tend to be more efficient to administer and score Meaningful between-patient comparisons are difficult with patient specific measures Clinical efficiency and sensitivity to change make patient-specific and condition specific measures appropriate choices for clinical application. More generic health status measures important for measuring overall well-being.

5 Common Self-Report Measures of Upper Extremity Function DASH = Disabilities of the Arm, Shoulder and Hand (Hudak, 1996) UEFI = Upper Extremity Functional Index (Binkley, 2001) ULDQ = Upper Limb Disability Questionnaire (Springer, 2010) KAPS = Kwan Arm Problem Scale (Kwan, 2002) * Developed for Breast Cancer Population

6 Breast Cancer EDGE Tool to Evaluate Physical Therapy Outcome Measures for Breast Cancer: 5= highly recommended; the outcome measure has excellent psychometric properties and clinical utility. 4 = recommended; lacking psychometric properties, but the measure was specifically designed for use in Breast Cancer population. 3= recommended; the outcome measure has good psychometric properties and good clinical utility. 2= unable to recommend at this time; there is insufficient information to support a recommendation of this outcome measure. 1= not recommended; the outcome measure has poor psychometric properties and/or poor clinical utility. Evaluation Database to Guide Effectiveness (EDGE) Task Force on Outcome Measures

7 Recommended Upper Extremity Functional Outcome Measures for Breast Cancer Population Edge Task Force of the APTA Oncology Section Reviewed scales that had been used in breast cancer population Ranking level 5: DASH, SPADI, PENN, SRQ Ranking level 4: ULDQ Noted lack of validation in breast cancer population of all scales reviewed Harrington et al, Arch Phys Med, 2013

8 DASH and QuickDASH (Hudak, 1996; Gummerson, 2006; Mintken, 2009; SooHoo, 2002) DASH is 30 items, 2 pages + optional work and sports modules QuickDASH is 11 items, 1 page + work/sports modules Low score no disability, high score (100) high disability Requires a calculator to score DASH and Quick DASH have been show to be reliable, valid and sensitive to change in an orthopaedic population (Roy, 2009; Poison, 2010; Lebman 2010) Multi-dimensional includes impairments such as pain and numbness and tingling in addition to function Not validated in BC population, but are the scales most widely in assessing function in this population in research studies

9 Upper Extremity Functional Index (UEFI) (Stratford, Binkley, Stratford, 2001, Chesworth, 2009; Razmjou, 2006) 20 item self-report functional status measure Items scored on a 5 point scale (0 to 4) Total score value 0 (low function) to 80 (high) < 15 seconds to score without computational aids Reliable and valid in orthopaedic population (Stratford, 2001; Chesworth, 2009; Razmjou, 2006) Unidimensional only contains items related to function Not validated in BC population Companion Scale to the Lower Extremity Functional Scale (LEFS) which is widely used both were designed to be efficient clinically for patients to complete and clinicians to score

10

11 Comparison of Measurement Properties of Upper Extremity Functional Index (UEFI) with Disabilities of the Arm, Shoulder, Hand (DASH) Self-Report Measures for Women with Breast Cancer UEFI (/80) Reliability Validity including Sensitivity to Change Clinical Utility and Application to BC Internal consistency a=.96 Test-retest: ICC.86 to.95 (Stratford, Binkley, 2001; Chesworth, 2009) Discriminates between subjects by work status (Stratford, Binkley, 2001) Convergent cross-sectional validity with UEFS (Stratford, Binkley, 2001; Chesworth, 2009) 1 page, easy to complete and score MDC = 10 scale points (Stratford, Binkley, 2001) Sensitivity to Change Correlation of UEFI and Pooled Rating of Change (UEFS change, prognostic rating, pain severity change): r=.7 ( ) (Stratford, Binkley, 2001) SRM UEFI 1.54 (superior RC-QOL, WORC Index, ASES) (Razmjou, 2006) UEFI superior compared to UEFS, RC-QOL, WORC Index and ASES standard shoulder form using global rating of change and SRM calculation (Chesworth, 2009; Razmjou, 2006 DASH And QuickDASH (/100) Poor Function=100 No disability = 0 DASH And QuickDASH (subjects with breast cancer) Test-retest : ICC = (Roy, 2009) MDC = 11 (Roy, 2009; Polson, 2010) (DASH and QuickDASH) MID = 19 (QuickDASH) Not available Convergent Validity and Sensitivity to Change well established (Roy, 2009; Beaton, 2006, Slobogean, 2010) SRM DASH (Roy, 2009) No significant difference in sensitivity to change between DASH and UEFI using GRC and area under ROC curve (Lehman, 2010) DASH correlates with UE strength, ROM, grip strength (Hayes, 2005) DASH appears to have adequate construct validity and responsiveness in breast cancer patients (Harrington, 2013) UEFI shorter to complete than DASH (3-5 minutes versus 5-7 minutes) (Lehman, 2010) UEFI faster to score (20 s versus 5 minutes) (Lehman, 2010) UEFS = Upper Extremity Functional Scale; RC-QOL = Rotator Cuff-Quality of Life; WORC = Western Ontario Rotator Cuff Index; ASES = American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form

12 Patient Specific Functional Scale (Stratford & Binkley, 1995; Chatman, Binkley et al, 1997; Westaway, Stratford, Binkley 1998) Patient specific measures assess functional status activities that are most relevant to the individual patient Initial Assessment Script I m going to ask you to identify up to 3 important activities that you are unable to do or have difficulty with as a result of your breast cancer Unable to perform activity Able to at perform activity fully

13 Patient Specific Functional Scale Measurement properties of the PSFS have been reported for patients with low back pain, knee, neck and upper limb dysfunction (Stratford, Binkley 95; Chatham, Binkley 97; Westaway, 98; Stewart, 07, Hefford, 2012) The Patient Specific Functional Scale (PSFS) has been shown to be highly reliable and valid and sensitivity to change is superior than relevant condition-specific or generic health status measures Minimal Detectable Change (MDC) = 1 scale point (average); 2 scale points (individual items) MCID = 2 (upper extremity problems) Takes approximately 4 minutes to complete with patient

14 Prospective Surveillance Model Feasibility Study Prospective observational study conducted at the Avon Breast Cancer Center at Grady Memorial Hospital, Atlanta, GA Subjects: Patients undergoing surgical interventions for breast cancer. Stage 0-III breast cancer Breast conserving surgery (BCS) or mastectomy, with or without reconstruction Willing to complete surveys and consent

15 Demographics 120 patients enrolled Age: 58, sd 11 years of age (range 26-95) Race: 87% African-American 7% Black/Caribbean 4% Caucasian/white (non-latino) 2 % other Employment: 42% Homemaker 20% Employed Full Time 16% Unemployed 10% Employed Part Time 8% Retired/Students Insurance: 44% Medicaid and/or Medicare/Medicaid 30% Medicare 8% Public Insurance (VA, etc) 11% Private Insurance 7% No Insurance

16 Validity of Quick DASH and UEFI in Breast Cancer Population Convergent Construct Validity: Reasonable correlation of scales with Fact B Physical subscales: UEFI r=.74 DASH r= -.75 Reasonable correlation of both scales with Shoulder Range of Motion at Single Point in Time: UEFI r=.55 DASH r= -.48

17 T=2.55, df=32, p=.02 Validity Construct: Subjects with mastectomy versus breast conserving surgery will have lower functional measures. T=0.40, df=32, p=.70

18 Sensitivity to Change of Quick DASH and UEFI in Breast Cancer Population Correlation of Change in Quick DASH and UEFI with Change in Patient-Rated Quality of Life and Change in Flexion between Early Post-op and 6 week Post-op Period Change in QOL (95% CI) Change in Flexion (95% CI) UEFI 0.55 (0.17, 0.79) 0.41 (0, 0.71) Quick DASH 0.49 (0.09, 0.46) 0 (-0.42, 0.42) FACT-B Physical 0.39 (-0.04, 0.70) 0.28 (-0.16, 0.63)

19 Model of Evaluation of Pain, Function and Health-Related Quality of Life in Women with Breast Cancer Admission (Pre-Operative or Early Post-Op) Pain, Patient Specific Functional Scale, Condition Specific Scale and Multi-Dimensional Health Status Measure Pain Scale, PSFS, UEFI/DASH FACT-B Intermittent (e.g. weekly) Re-evaluation of Functional Status and Goals Pain Scale, PSFS, UEFI/DASH Discharge from PT Pain Scale, PSFS, UEFI FACT-B

20 Goal Setting Using Self-Report Functional Scales Select relevant measure Select measures that are expected to change related to your intervention Make goals measureable goals of change should be greater than MDC for given scale and ideally greater than MCID if known Final anticipated functional level based on factors that impact expectations of change, including treatment factors (e.g. radiation), age, severity, chronicity Setting goals requires clinical experience with measures Individual PSFS items can be used to set goals or as PSFS average Examples: Initial UEFI = 45: 2 week goal to UEFI >? 4 week goal >? Initial Average PSFS = 3: 2 week goal PSFS >? 4 week goal PSFS >?

21 FUNCTIONAL GOAL AND OUTCOME WORKSHEET PATIENT SPECIFIC FUNCTIONAL SCALE ACTIVITIES (10 = full function) Initial 1. Driving 5 2. Lifting Baby 3 3. Playing tennis 0 Average PSFS: 2.7 PAIN SCORE: 3 (0 = no pain) Upper Extremity Functional Index (N=80) 53 FACT-B Physical Well-Being ( /28) 12 Social/Family Well-Being ( /28) 10 Emotional Well-Being ( /24) 6 Functional Well-Being ( /28) 15 Additional Concerns ( /40) 18 KEY IMPAIRMENT MEASURES: 1. Shoulder Flexion R/L (deg) 145/ GOALS: 1. Increase UEFI >75/80 2. Increase PSFS > 8/10 3. Increase Tennis > 7/10 4. Decrease Pain < 1/10

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