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1 CRITICALLY APPRAISED PAPER (CAP) Lengacher, C. A., Reich, R. R., Paterson, C. L., Ramesar, S., Park, J. Y., Alinat, C., &... Kip, K. E. (2016). Examination of broad symptom improvement resulting from mindfulness-based stress reduction in breast cancer survivors: A randomized controlled trial. Journal of Clinical Oncology, 34(24), CLINICAL BOTTOM LINE This study assessed the effectiveness of mindfulness-based stress reduction (MBSR) to reduce both physical symptoms (e.g., pain and fatigue) and psychological symptoms (e.g., anxiety, depression, fear of recurrence, and perceived stress) for breast cancer survivors. In addition, this study focused on the impact of MBSR on quality of life. MBSR has been shown to reduce pain, fatigue, stress, anxiety, depression, and fear of recurrence among breast cancer survivors. This intervention has widespread implications for both clinical and community-based occupational therapy practice, because improved quality of life and posttraumatic growth can influence engagement in activities of daily living. RESEARCH OBJECTIVE(S) Evaluate the efficacy of MBSR on physical symptoms (pain and fatigue) of breast cancer survivors Evaluate the efficacy of MBSR on psychological symptoms (anxiety, depression, fear of recurrence) and perceived stress of breast cancer survivors Evaluate the impact of MBSR on the quality of life of breast cancer survivors Evaluate whether breast cancer survivors with higher levels of baseline stress yield the greatest benefits from MBSR practice DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION 1
2 How were participants recruited and selected to participate? Enrollment occurred over a 4-year period (April 2009 to March 2013). Participants were recruited from three treatment facilities in Tampa, Florida: Carol and Frank Morsani Center for Advanced Healthcare, Life Hope Medical Group, and Moffit Cancer Center. Inclusion criteria: Age 21 years or older Diagnosis of Stage 0 to Stage III breast cancer Treatment completion from 2 weeks to 2 years prior to the start of the study Exclusion criteria: Diagnosis of Stage IV cancer Recurring breast cancer Severe mental disorder PARTICIPANT CHARACTERISTICS N= 322 #/ % Male: 0/0% #/ % Female: 322/100% Ethnicity: Disease/disability diagnosis: n = 222 White non-hispanic n = 37 Black non-hispanic n = 33 Hispanic n = 12 other single race or ethnicity n = 16 more than one race or ethnicity reported Breast cancer Stage 0 to Stage III INTERVENTION AND CONTROL GROUPS Group 1: MBSR intervention group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? MBSR intervention sessions included educational materials (CD and training manual), practice sessions of four meditative techniques (walking meditation, sitting meditation, body scan, and Hatha yoga), and supportive group interaction focused on identifying barriers to practice and applying practice to daily routine. 155 Clinic sessions and home practice Clinical psychologist One 2-hour session weekly 2
3 For how long? 6 weeks Group 2: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Participants in the control group received standard posttreatment follow-up care. They were offered an opportunity to participate in MBSR after study completion. 167 Follow-up clinic Not specified Not reported 6 weeks INTERVENTION BIASES Contamination: YES NO Co-intervention: Explanation: The control group was not introduced to the intervention during the study. Explanation: Cointervention might have occurred for both the MBSR group and the control group, because they were also undergoing standard-of-care treatment for breast cancer. Timing of intervention: Site of intervention: Explanation: Because this study was conducted over a 4-year period, timing of the intervention might have been influenced by changes in cancer treatment protocols or disease progression, remission, or recurrence of the disease among participants. Explanation: Sites did vary between the MBSR practice group and the control group, which might have contributed to higher levels of satisfaction in the intervention group. Use of different therapists to provide intervention: Explanation: The medical providers varied for the control group on the basis of medical needs. 3
4 Baseline equality: YES NO Explanation: Baseline equality was noted. MEASURES AND OUTCOMES Measure 1: Brief Pain Inventory What outcome is reliable (as reported in the article)? valid (as reported in the article)? Brief Pain Inventory Pain and impact on daily living YES Not Reported YES Not Reported Measure 2: Fatigue Symptom Inventory What outcome is reliable as reported in the article? valid as reported in the article? Fatigue Symptom Inventory Perceived impact of fatigue on quality of life YES Not Reported YES Not Reported Measure 3: Center for Epidemiologic Studies Depression Scale Center for Epidemiologic Studies Depression Scale What outcome is Depression YES Not Reported reliable as reported in the article? valid YES Not Reported 4
5 as reported in the article? Measure 4: State Trait Anxiety Inventory State Trait Anxiety Inventory Situational anxiety YES NR YES NR Measure 5: Perceived Stress Scale Perceived Stress Scale Stress YES NR YES NR Measure 6: Concerns About Recurrence Scale Concerns About Recurrence Scale Fear of recurrence YES NR YES NR 5
6 Measure 7: Demographic data and clinical history Demographic data and clinical history Updated demographic data and clinical history YES NR YES NR MEASUREMENT BIASES Were the evaluators blind to treatment status? YES NO Was there recall or memory bias? Other measurement biases: Explanation: Blinding was not possible after baseline assessment because of the use of a wait-list control design. Explanation: Given the short duration of the study from baseline to final testing (12 weeks), recall bias is possible, because participants and evaluators might have recalled ratings and potentially thus inflated scores. RESULTS List key findings based on study objectives: Results demonstrated that the MBSR intervention improved both psychological symptoms anxiety (p =.007), overall fear of recurrence (p <.1), and depression (p =.06) and physical symptoms fatigue severity and interference (p <.01) as compared with standard care for breast cancer survivors. Overall effect sizes were largest for fear of recurrence problems (d = 0.35) and fatigue severity (d = 0.27). Moderate effect sizes showed that breast cancer survivors with the highest levels of stress at baseline experienced the greatest benefit from MBSR. The MBSR program significantly improved a broad range of symptoms among breast cancer survivors up to 6 weeks after MBSR training, with generally small to moderate overall effect sizes. Was this study adequately powered (large enough to show a difference)? Explanation: A total of 322 participants were involved in this study. 6
7 Were the analysis methods appropriate? Explanation: The authors used linear mixed models to assess the effectiveness of MBSR over the duration of the study. Were statistics appropriately reported (in written or table format)? Explanation: Statistics were clearly presented in table format. Was participant dropout less than 20% in total sample and balanced between groups? Explanation: 7.14% (n = 23) What are the overall study limitations? The authors stated that the study had a 9% rate of attrition. Lack of diversity among program participants limits generalizability to a broader population. Participants were primarily White, married, well-educated women with a mean age of 56.6 years. An active-attention comparison treatment trial design would have allowed greater control for time, attention, and expectancy efforts. CONCLUSIONS The authors concluded that this study provides evidence to promote the use of MBSR as an effective clinical intervention for breast cancer survivors experiencing physical or emotional distress. Benefits of MBSR included the ability to improve outcomes for those breast cancer survivors experiencing the most distress and to simultaneously address multiple physical and psychological symptoms of distress. The authors recommended additional research and development of technology-based intervention strategies for efficacious use. This work is based on the evidence-based literature review completed by Marit A. Watson, OTR/L, and Sarah L. Smith, DSc, OTR/L, faculty advisor, Creighton University. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 7
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CRITICALLY APPRAISED PAPER (CAP) Shin, J., Bog Park, S., & Ho Jang, S. (2015). Effects of game-based virtual reality on healthrelated quality of life in chronic stroke patients: A randomized, controlled
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CRITICALLY APPRAISED PAPER (CAP) Yasukawa, A., Patel, P., & Sisung, C. (2006). Pilot study: Investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. American Journal of
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CRITICALLY APPRAISED PAPER (CAP) Smania, N., Gandolfi, M., Paolucci, S., Iosa, M., Ianes, P., Recchia, S., & Farina, S. (2012). Reduced-intensity modified constraint-induced movement therapy versus conventional
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For patients with acute cerebral vascular accident, is virtual reality gaming more effective than standard recreational therapy for the improvement of
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CRITICALLY APPRAISED PAPER (CAP) Kim, E. S., Berkovits, L. D., Bernier, E. P., Leyzberg, D., Shic, F., Paul, R., & Scassellati, B. (2013). Social robots as embedded reinforcers of social behavior in children
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION: For adults who have an acquired brain injury, what is the effect of personal assistant devices on memory, compared with standard occupational therapy?
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CRITICALLY APPRAISED PAPER (CAP) Dahl, A., Askim, T., Stock, R., Langørgen, E., Lydersen, S., & Indredavik, B. (2008). Short- and long-term outcome of constraint-induced movement therapy after stroke:
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CRITICALLY APPRAISED PAPER (CAP) De Brito Brandao, M., Gordon, A. M., & Mancini, M. C. (2012). Functional impact of constraint therapy and bimanual training in children with cerebral palsy: A randomized
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION What is the effectiveness of a 12-week family-centered evaluation and intervention program for children with attention deficit hyperactivity disorder (ADHD)
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CRITICALLY APPRAISED PAPER (CAP) Kwon, J., Park, M., Yoon, I., & Park, S. (2012). Effects of virtual reality on upper extremity function and activities of daily living performance in acute stroke: A double-blind
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CRITICALLY APPRAISED PAPER (CAP) Prosser, R., Hancock, M. J., Nicholson, L., Merry, C., Thorley, F., & Wheen, D. (2014). Rigid versus semi-rigid orthotic use following TMC arthroplasty: A randomized controlled
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1 CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For patients with De Quervain's tenosynovitis, how does kinesiotaping compare with a thumb spica splint on reducing pain and increasing strength? Jongprasitkul,
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CRITICALLY APPRAISED PAPER (CAP) Gitlin, L. N., Winter, L., Dennis, M. P., Corcoran, M., Schinfeld, S., & Hauck, W. W. (2006). A randomized trial of a multicomponent home intervention to reduce functional
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CRITICALLY APPRAISED PAPER (CAP) Focused Question Is greater progress with contracture resolution made with participants who utilized a splint wearing schedule of 6 12 hours/day or 12 16 hours/day? Glasgow,
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CRITICALLY APPRAISED PAPER (CAP) Wu, C., Huang, P., Chen, Y., Lin, K., & Yang, H. (2013). Effects of mirror therapy on motor and sensory recovery in chronic stroke: A randomized controlled trial. Archives
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION Is the combination of occupational therapy (OT) and mental practice (MP), from either an internal or an external perspective, an effective intervention
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION For stroke patients, in what ways does robot-assisted therapy improve upper extremity performance in the areas of motor impairment, muscle power, and strength?
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CRITICALLY APPRAISED PAPER (CAP) Wu, C. Y., Wang, T. N., Chen, Y. T., Lin, K. C., Chen, Y. A., Li, H. T., & Tsai, P. L. (2013). Effects of constraint-induced therapy combined with eye patching on functional
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CRITICALLY APPRAISED PAPER (CAP) FOCUSED QUESTION: Will use of low-level functional electrical stimulation improve accuracy of active reaching with the upper extremity better than traditional occupational
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CRITICALLY APPRAISED PAPER (CAP) Gabriels, R. L., Pan, Z., Dechant, B., Agnew, J. A., Brim, N., & Mesibov, G. (2015). Randomized controlled trial of therapeutic horseback riding in children and adolescents
More informationRESEARCH OBJECTIVE(S) List study objectives. To evaluate effectiveness of an intensive day-treatment program on the dietary diversity and
CRITICALLY APPRAISED PAPER (CAP) Sharp, W. G., Jaquess, D. L., Morton, J. F., & Miles, A. G. (2011). A retrospective chart review of dietary diversity and feeding behavior of children with autism spectrum
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