Evidence in practice: patient examples are designed to illustrate how evidence is gathered and used to guide clinical decision making.

Clinical question: Can a comprehension lymphedema management program decrease limb size and reduce the incidence of infection in a woman with postmastectomy lymphedema?

A 57-year-old woman with a history of breast cancer was referred to our clinic for treatment of lymphedema in the right upper extremity. Cancer was detected originally in her right breast in 1996, and she was treated surgically by lumpectomy at that time. The cancer recurred, however, and she underwent a right radical mastectomy in July 1999. The mastectomy was followed by a series of irradiation treatments to the right axilla, starting in September 1999 and ending in December 1999. She also has been receiving tamoxifen (Nolvadex) continuously since the mastectomy (20 mg administered orally once per day). Over the past year, the patient developed 3 infections in her right upper extremity. She described these infections as "painful, fiery red blotches" that covered various areas of her upper thorax, arm, forearm, and hand. These infections were usually treated by oral administration of penicillin (eg, penicillin V, 250 mg 3 times each day).

I examined this patient and found a noticeable increase in the size of her right upper extremity. Limb girth was measured at 11 standard sites, and, in terms of the total girth difference, the right upper extremity was 51 cm greater than the left upper extremity. The patient also reported feelings of tightness and heaviness in the right upper extremity, and muscle force and joint range of motion were reduced throughout the upper extremity, especially at the shoulder (eg, she could actively flex her shoulder only to 80 degrees).

The increase in limb size was consistent with chronic lymphedema secondary to a radical mastectomy. This lymphedema was very upsetting to the patient, and she stated that she did not want "people staring at my arm all the time." The patient also wanted to reduce the size of her upper extremity to help increase function and, if possible, help prevent infections. Given the degree of swelling and the increased risk of infection, I wanted to initiate an intervention program that would reduce limb size, improve joint mobility, and reduce the incidence of infection. Such a program obviously should combine several interventions that are designed to resolve specific impairments, including some form of external compression to reduce swelling and an exercise program designed to increase range of motion and muscle force. I was aware that this type of program is described in the literature using several terms such as "complex physical therapy," "complex decongestive physical therapy," and "complete decongestive physical therapy." I wanted to find evidence that such a program is successful in reducing these impairments in people with lymphedema following breast cancer treatment. I decided to search for articles that document the effectiveness of comprehensive lymphedema management programs.

* Database used for search: CINAHL

The Cumulative Index to Nursing and Allied Health Literature (CINAHL) is a database that covers approximately 1,200 journals related to nursing, physical therapy, health care administration, and other allied health professions. I selected this database because I wanted to focus on journals that might deal specifically with physical therapy interventions, and CINAHL purportedly covers some physical therapy journals that are not indexed in other databases such as MEDLINE. New citations are usually added to CINAHL 4 to 10 weeks after publication. In addition to providing abstracts for most articles, CINAHL also provides access to the full-text version of some articles. Access to these full-text articles would be helpful because certain journals may not be directly available in my institution's medical library. Access to CINAHL, however, is not free to the public. For a fee, CINAHL can be accessed through the publisher's Web site (www.cinahl.com). Also, many college or health professional libraries provide access directly to CINAHL or enable the user to access CINAHL through another vendor.

At my college's medical library, I accessed CINAHL through ProQuest * (www.il.proquest.com), a vendor that provides access to several databases including CINAHL. Within ProQuest, I clicked on the option Search Professional Research Collections Only (CINAHL) and then clicked on CINAHL. This search was performed on December 1, 2001.

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* Initial keywords: lymphedema AND physical therapy

I started the search with 2 "key terms": lymphedema and physical therapy. As indicated earlier, physical therapy regimens used to manage lymphedema are often identified by different names according to the regimen and the practitioner. Rather than using an arbitrary and ambiguous term such as "complex physical therapy," I decided to use "physical therapy," hoping that this broader term would include various comprehensive regimens. The term "lymphedema" was an obvious choice because it was the primary impairment in this patient. I, therefore, typed lymphedema AND physical therapy in the query box at the top of the search interface. (In CINAHL, operators such as "AND" or "OR" must be capitalized in order to conduct the search properly.)

The search engine also offered several options or fields (located on the left side of the screen) for my search, including the ability to search CINAHL in the basic index field or by another criterion such as the abstract, author, source (eg, journal articles, books), subject, and title. I performed the search in the basic index field because, according to CINAHL's definition, this field "contains all the terms used to index certain database fields" in each citation, including article titles, abstract, main subject headings, and minor subject headings. The basic index field is also useful when it is unclear how terms might be spelled or how they might appear in the database. The basic field index, therefore, seemed to be a comprehensive way to begin this search.

The initial result was 40 articles or "hits." Although this number of articles was not excessive, I noticed that I could click on a small checkbox labeled Limit Search to: Peer Reviewed that was located toward the right side of the search screen. This action presumably would select only those articles that had been published after being reviewed by someone with expertise in this subject. I selected this option by clicking on the checkbox, and I then clicked the Search button located just above the checkbox. At this point, the search retrieved 25 articles. This number of articles was certainly manageable, and a quick look at the titles indicated that many of these articles seemed appropriate to answer my question.

I was curious whether any of these papers focused specifically on the ability of physical therapy to prevent infection in people with lymphedema. I placed the cursor in the query box and added the term AND infection to the original keywords. I then clicked on the Search button. The following message appeared on the screen: "Search Did Not Find Any Records." Obviously, adding the term "infection" was not successful in isolating specific articles; therefore, I removed AND infection from the query box and repeated my original search, retaining the option for only peer-reviewed articles. The citations from the 25 articles are listed in the box on the next page.

* Selection of articles for review: As I scanned the article titles, I was especially interested in finding articles that directly investigated the effects of a comprehensive lymphedema treatment regimen, or that compared the effects of various interventions used separately or in combination, in managing lymphedema. I noticed one recent article with the term "complex physical therapy" in the title, so this article seemed appropriate. I also found 2 review articles that might provide insight into how comprehensive regimens compare with individual interventions. I was able to view the abstracts of these articles by clicking on the small, index card-shaped icon next to the article's title. The abstracts of these articles are reproduced and discussed briefly below. Other articles also seemed appropriate, but, in the interest of time, I decided to start with these 3 papers. I hoped that the review articles would be especially helpful in summarizing information from several studies. If I could not adequately answer my question from these 3 articles, I could always return to the list of search results to read other articles.

   Wozniewski M; Jasinski R; Pilch U; Dabrowska G. Complex physical therapy
   for lymphoedema of the limbs. Physiotherapy 2001 May;87(5): 252-256.

   A total of 208 women aged 17 to 83 years (mean 50.8) were treated for
   lymphoedema with complex physical therapy (CPT)--intermittent pneumatic
   compression, exercise and manual lymph drainage. Of these patients, 188
   (90%) had secondary lymphoedema of the upper limb following radical
   mastectomy; 20 (10%) had lymphoedema of the lower limb, of whom 12 patients
   had secondary lymphoedema following lymphangectomy for malignant melanoma
   and eight patients had lymphoedema of unknown origin.

   The volume of the upper limbs and circumferences at nine levels of the
   lower limbs were measured before and after CPT. Complete resolution of
   lymphoedema of the upper limb was achieved in 32 patients (17%). The
   average decrease in lymphoedema was 43% in patients with minimal oedema,
   33% in those with moderate oedema, and 19% in women with severe oedema.
   Complete resolution of primary lymphoedema of the lower limb was achieved
   in four patients. Average decrease in circumference was 13%. Complete
   resolution of secondary oedema of the lower limb was obtained in four
   patients with an average decrease in circumference of 23%. CPT is an
   effective form of conservative treatment for limb lymphoedema, particularly
   in patients with secondary lymphoedema of the upper limb. Reduction depends
   on the type of lymphoedema and the limb affected, with smaller effects
   demonstrated in lower limbs. The combination of intermittent pneumatic
   compression and manual techniques improves the results of treatment of
   lymphoedema.

   [Abstract reprinted with permission of The Chartered Society of
   Physiotherapy.]

Because the full text of this article was not available through CINAHL directly, I obtained a copy of the article from my institution's medical library. This study lacked a control group; therefore, we cannot say conclusively that these interventions caused the reduction in limb size seen in these patients. Nonetheless, the authors described the use of a comprehensive regimen that included intermittent (mechanical) pneumatic compression, massage techniques, exercises, and the wearing of an elastic garment. This regimen, identified by these authors as complex physical therapy (CPT), was associated with a statistically significant reduction in limb size in this patient cohort. It was not clear, however, exactly how long CPT was administered. The authors indicated that intermittent pneumatic compression was applied "for one hour, five times a week for five weeks," but they also indicated that an elastic sleeve or garment was worn for "about six months."

Nevertheless, this study lends insight into the use of a combination of interventions in people with lymphedema. Most of the patients in this study (90%) had lymphedema that occurred following a radical mastectomy, and this patient subgroup had a mean age of 54 years. Therefore, the people in this subgroup were reasonably similar to my patient in terms of age and the cause of lymphedema. This study, however, did not compare CPT with another intervention or one of the components of the CPT program. The article's lack of a comparison concerned me. For example, I could not be sure that CPT would produce a greater decrease in limb size than using only one component of the CPT program such as intermittent pneumatic compression. Likewise, the authors measured limb size, but they did not assess any other outcomes such as a reduction in the incidence of infection after undergoing this CPT regimen. I, therefore, was interested in what results might be found in other articles obtained from this search.

   Harris SR; Hugi MR; Olivotto IA; Levine M, et al. Clinical practice
   guidelines for the care and treatment of breast cancer: 11. Lymphedema
   CMAJ: Canadian Medical Association Journal 2001 Jan; 164(2):191-199

   Objective: To provide information and recommendations for women and their
   physicians when making decisions about the management of lymphedema related
   to breast cancer. Options: Compression garments, pneumatic compression
   pumps, massage and physical therapies, other physical therapy modalities,
   pharmaceutical treatments. Outcomes: Symptom control, quality of life,
   cosmetic results. Evidence: Systematic review of English-language
   literature retrieved primarily from MEDLINE (1966 to April 2000) and
   CANCERLIT (1985 to April 2000). Nonsystematic review of breast cancer
   literature published to October 2000.

   Recommendations:

   * Pre- and postoperative measurements of both arms are useful in the
   assessment and diagnosis of lymphedema. Circumferential measurements should
   be taken at 4 points: the metacarpal-phalangeal joints, the wrists, 10 cm
   distal to the lateral epicondyles and 15 cm proximal to the lateral
   epicondyles.

   * Clinicians should elicit symptoms of heaviness, tightness or swelling in
   the affected arm. A difference of more than 2.0 cm at any of the 4
   measurement points may warrant treatment of the lymphedema, provided that
   tumour involvement of the axilla or brachial plexus, infection and axillary
   vein thrombosis have been ruled out.

   * Practitioners may want to encourage long-term and consistent use of
   compression garments by women with lymphedema.

   * One randomized trial has demonstrated a trend in favour of pneumatic
   compression pumps compared with no treatment. Further randomized trials are
   required to determine whether pneumatic compression provides additional
   benefit over compression garments alone.

   * Complex physical therapy, also called complex decongestive physiotherapy,
   requires further evaluation in randomized trials. In one randomized trial
   no difference in outcomes was detected between compression garments plus
   manual lymph drainage versus compression garments alone.

   * Clinical experience supports encouraging patients to consider some
   practical advice regarding skin care, exercise and body weight.

   [A patient version of these guidelines appears in Appendix 2.]

   Validation: An initial draft of this document was developed by a task force
   sponsored by the BC Cancer Agency. It was updated and revised substantially
   by a writing committee and then submitted for further review, revision and
   approval by the Steering Committee for Clinical Practice Guidelines for the
   Care and Treatment of Breast Cancer. Sponsor: The steering committee was
   convened by Health Canada. Completion date: October 2000.

   [Abstract reprinted with permission of the Canadian Medical Association.]

A full-text version of this review article was available through CINAHL, and I accessed the complete article by clicking on the article title on the search screen. This review dealt with many issues concerning the treatment of lymphedema that can occur in women treated for breast cancer. The authors systematically reviewed the literature and briefly summarized the results of relevant studies. From these summaries, they developed recommendations and guidelines for treating various aspects of lymphedema in these patients. They based these guidelines on the design and scientific rigor of the articles retrieved from their search, and they used the rules of evidence developed by Sackett (1) to grade experimental studies according to the strength of evidence. These grades ranged from studies presenting strong evidence (level I studies: large randomized controlled trials with low false-positive or false-negative errors) to studies where evidence was weakest because extraneous variables were not controlled (level V studies: case series without controls).

In this review article, the authors specifically addressed the issue of CPT. They described CPT as "a treatment regimen that includes meticulous skin hygiene, manual lymph drainage, bandaging, exercises, and support garments." As indicated in the abstract, the authors retrieved only one study (2) that met the level I criteria (ie, randomized controlled trial). This study did not find any additional benefit to adding manual lymph drainage and self-massage to a standard regimen that included custom-made compression garments, instruction in exercises, and patient education about skin care and other issues related to lymphedema. Harris et al also identified several other studies that investigated various aspects of CPT, and they categorized each study as having evidence between level II and level V according to each study's design. They stated, however, that "interpretation of the results is limited by the methodology of these studies." In other words, these studies differed from each other in how they manipulated the independent variables. For example, one study compared compression bandaging plus manual drainage versus compression bandaging alone, whereas another study compared manual lymph drainage plus compression garment use versus pneumatic compression plus compression garment use.

This review article did not recommend conclusively that CPT should be used instead of other interventions nor did it conclude that CPT was more effective than individual components of the CPT regimen (eg, use of compression garments alone). In addition, the ability of these interventions to reduce the risk of infection was not addressed in this review. The results from individual studies described in this review were based mostly on a reduction of limb size and other symptoms (eg, decreased pain, increased range of motion). I considered a second review article.

   Megens A; Harris SR. Physical therapist management of lymphedema following
   treatment for breast cancer: a critical review of its effectiveness.
   Physical Therapy 1998 Dec; 78(12): 1302-1311.

   The purpose of this review is to analyze the research literature that has
   examined the effectiveness of physical therapy in the management of
   lymphedema following treatment for breast cancer. Thirteen studies met the
   criteria for experimental research, which were then categorized according
   to Sackett's levels of evidence. One study was graded at level II, 5
   studies were graded at level III, and the remaining 7 studies were graded
   at level V. One grade B recommendation and 6 grade C recommendations were
   developed from the levels of evidence. The 13 selected studies were also
   graded according to 6 criteria to evaluate scientific rigor. Clinical
   recommendations and future research directions are provided.

   [Abstract reprinted with permission of the American Physical Therapy
   Association.]

As member of APTA, I have a subscription to Physical Therapy, and I retrieved a copy from the back issues that I keep in my office. A full-text version of this article was also available through CINAHL. This review article, published in 1998, had a purpose and format that was similar to the more recent review described above. The coauthor of this review, in fact, was the lead author of the previous review article. As this abstract indicates, the authors retrieved 13 articles from the literature, categorized these articles from level II to level V according to Sackett's rules, (1) and made recommendations based on the scientific merit of these articles. These recommendations were graded according to criteria that were also developed by Sackett. (1) A grade A recommendation was based on evidence from at least one level I study, a grade B recommendation was based on at least one level II study, and a grade C recommendation was based on evidence from level III, IV, or V studies.

The authors could not make any grade A recommendations because none of the 13 studies produced level I evidence. The single grade B recommendation from these studies did not pertain directly to CPT, but indicated that long-term (6 months) use of compression garments can reduce limb size and that adding electrical stimulation to this intervention' offered no additional benefits. The authors indicated, however, that a grade C recommendation could be made for using CPT. That is, CPT consisting of exercise, massage techniques, compression bandaging or garments, and skin care was successful in reducing limb size according to the results of 2 level V studies. It is worth noting, however, that one of these level V studies, (3) which I obtained from my college library, indicated that a fairly intensive program of CPT (daily treatments of massage and compression bandaging, lasting at least 1 hour each day, for 5 days each week for 4 weeks) seemed as effective as a modified program that was performed twice each week and used compression garments in place of bandaging. Similarly, another grade C recommendation from this review article suggested that combining other interventions such as massage, pneumatic pumps, and compression garments may also "show promising results in the treatment of people with lymphedema."

This review article nicely characterized the ability, of CPT and other treatment combinations to reduce limb size in people with lymphedema. This review article, however, did not specifically address the issue of infection because the studies it examined apparently did not use incidence of infection as one of the primary outcome measures.

Clinical decision: I decided to implement a comprehensive treatment regimen that included massage, compression bandaging, exercise, and a skin care and hygiene education program to reduce lymphedema in this patient. The reviews by Harris et al and Megens and Harris certainly support the use of certain interventions such as compression garments in reducing limb size in people with lymphedema. Some evidence also exists indicating that a more comprehensive regimen that combines compression garments with other interventions can reduce limb size in this patient population. Exactly which combination of treatments will provide optimal results remains in question. I felt it was reasonable, however, to choose interventions that have a complementary effect on each other and that address all possible aspects of the patient's impairments, functional limitations, and disabilities.

I selected massage techniques and compression bandaging as the crux of the plan of care. Massage techniques (also called manual lymph drainage or Foldi massage by some therapists) are intended to help reduce limb size before compression bandaging. Given this patient's tendency toward infection, I felt that massage offered some degree of control and safety over a pneumatic compression pump because I could carefully observe the patient's response to this treatment while I was administering the massage. I likewise elected to use compression bandaging at the beginning of treatment rather than a commercial compression garment. I thought that using bandaging as an initial method to reduce limb size would allow a custom-fit garment to be ordered when limb size was successfully reduced (ie, when this regimen produced no further decrease in limb size).

I decided to schedule this regimen of massage and bandaging twice each week for the first 4 weeks. I based this decision on the results of Matthews and Smith (3) (an article addressed in the Megens and Harris review), where twice weekly treatments were found to be as effective as daily treatments. The patient also would be instructed in how to massage and bandage her upper extremity on the days that I did not see her.

I planned to develop a home exercise program that included active range-of-motion and isometric exercises to maintain joint mobility and to facilitate lymph drainage via the muscle pump. The patient likewise would be educated about skin care and hygiene and safety precautions to prevent injury to the affected limb.

The issue of infection was never really addressed by the literature. I could not find any information that directly supported the use of physical therapy as a means to reduce the incidence of infection in people with lymphedema. However, I believe that we can reasonably assume that a reduction in lymphedema (as indicated by a reduction in limb size) would have beneficial effects on tissue perfusion. Edema that collects in the interstitium between the tissues and vasculature impedes the delivery of oxygen and nutrients, retards the removal of waste products, and serves as a protein-rich medium for the growth of the bacteria that lead to infection. Consequently, a logical outcome of reducing lymphedema would be improved tissue perfusion and a better chance of resisting a local infection. In my opinion, a comprehensive treatment program that reduces limb volume and helps the patient protect her arm seems to be a logical way to reduce the risk of local infection. I will examine this patient carefully at each visit to see if there are fewer episodes of infection.

* ProQuest Information and Learning Co, 300 N Zeeb Rd, Ann Arbor, MI 48106-1346.

References

(1) Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1989;95 (2 suppl):2S-4S.

(2) Anderson L, Hojris I, Erlandsen M, Anderson J. Treatment of breast-cancer related lymphedema with or without manual lymphatic drainage: a randomized study. Acta Oncol. 2000;39:399-405.

(3) Matthews K, Smith J. Effectiveness of modified complex physical therapy for lymphoedema treatment. Australian Journal of Physiotherapy. 1996;42:323-328.

RELATED ARTICLE: Citations retrieved by search using the keywords "Lymphedema" and "Physical Therapy"

1. Management and prevention of venous leg ulcers: a literature-guided approach; Kunimoto BT; Ostomy/ Wound Management; 2001 Jun; 47(6), p.36-8, 40-2, 44-9

2. Physiotherapists can help lymphoedema patients ...; Wozniewski M, Jasinski R, Pilch U, Dabrowska G (2001). Complex physical therapy for lymphoedema of the limbs, Physiotherapy, 87, 5, 252-256; Bessant N; Physiotherapy; 2001 Jul; 87(7), p. 389

3. Complex physical therapy for lymphoedema of the limbs; Wozniewski M; Jasinski R; Pilch U; Dabrowska G; Physiotherapy; 2001 May; 87(5), p. 252-6

4. Development and validation of a telephone questionnaire to characterize lymphedema in women treated for breast cancer; Norman SA; Miller LT; Erikson HB; Norman MF; McCorkle R; Physical Therapy; 2001 Jun; 81(6), p. 1192-205

5. Arm edema in breast cancer patients; Erickson VS; Pearson ML; Ganz PA; Adams J; Kahn KL; Journal of the National Cancer Institute; 2001 Jan 17; 93(2), p. 96-111

6. Clinical practice guidelines for the care and treatment of breast cancer: 11. Lymphedema; Harris SR; Hugi MR; Olivotto IA; Levine M; CMAJ: Canadian Medical Association Journal; 2001 Jan 23; 164(2), p. 191-9

7. Lymphedema after breast cancer treatment; Davis BS; American Journal of Nursing; 2001 Apr; 101(4), p. 24AAAA-DDDD

8. Lymphedema: current issues in research and management; Petrek JA; Pressman PI; Smith RA; Ca--A Cancer Journal for Clinicians; 2000 Sep-Oct; 50(5), p. 292-311

9. Assessment of limb volume by manual and automated methods in patients with limb edema or lymphedema; Mayrovitz NH; Sims N; Macdonald J; Advances in Skin & Wound Care; 2000 Nov-Dec; 13(6), p. 272-6

10. Management of lymphedema; Neese PY; Lippincott's Primary Care Practice; 2000 Jul-Aug; 4(4), p. 390-9

11. Oncologic rehabilitation -- the role of physiotherapy; Lee M; Physiotherapy Singapore; 1999 Sep; 2(3), p. 110-2

12. Case in point. Case study: management of lymphedema; Keller AM; Pillion M; Oncology Nursing Forum; 1999 Apr; 26(3), p. 507-9

13. Effectiveness of the treatment of upper limb lymphedema by multicompartmental sequential pneumatic pressure therapy [Spanish]; Viejo MAG; Huerta MJC; Navea ML; Marticorena TE; Arzoz MAR; Panos MA; Rehabilitacion; 1998; 32(4), p. 234-40

14. Physical therapist management of lymphedema following treatment for breast cancer: a critical review of its effectiveness; Megens A; Harris SR; Physical Therapy; 1998 Dec; 78(12), p. 1302-11

15. Effectiveness of modified complex physical therapy for lymphoedema treatment; Matthews K; Smith J; Australian Journal of Physiotherapy; 1996 Dec; 42(4), p. 323-8

16. Lower limb lymphedema in a patient with idiopathic retroperitoneal fibrosis [Spanish]; Alcoba MJ; Lafuente G; Rehabilitacion; 1997 Jul-Aug; 31(4), p. 318-20

17. Physical therapists play an important role in treating lymphedema; Augustine E; Humble CA; Oncology Nursing Forum; 1996 Apr; 23(3), p. 421-218. Minimising lymphoedema; Todd JE; Tribe K; Physiotherapy; 1995 Jun; 81(6), p. 359-60

19. Treatment of lymphoedema: the central importance of manual lymph drainage; Tribe K; Physiotherapy; 1995 Mar; 81(3), p. 154-6

20. Psychosocial benefits of postmastectomy lymphedema therapy; Mirolo BR; Bunce IH; Chapman M; Olsen T; Eliadis P; Hennessy JM; Ward LC; Jones LC; Cancer Nursing; 1995 Jun; 18(3), p. 197-205

21. Lymphoedema and physiotherapists: control not cure; Gillham L; Physiotherapy; 1994 Dec; 80(12), p. 835-43

22. Complex physical therapy -- a treatment note; Ross C; New Zealand Journal of Physiotherapy; 1994 Dec; 22(3), p. 19-21

23. Effects of electrical stimulation on lymphatic flow and limb volume in the rat; Cook HA; Morales M; La Rosa EM; Dean J; Donnelly MK; McHugh P; Otradovec A; Wright KS; Kula T; Tepper SH; Physical Therapy; 1994 Nov; 74(11), p. 1040-6

24. The treatment of lymphoedema by Complex Physical Therapy; Mason M; Australian Journal of Physiotherapy; 1993 Mar; 39(1), p. 41-5

25. A clinical report on the use of three external pneumatic compression devices in the management of lymphedema in a paediatric population; McLeod A; Brooks D; Hale J; Lindsay WK; Zuker RM; Thomson HG; Physiotherapy Canada; 1991 Summer; 43(3), p. 28-32

In the next Evidence in Practice: Julie Fritz, PT, PhD, ATC, will seek answers to the question "What signs and symptoms might indicate a non-musculoskeletal origin for low back pain in a 12-year-old girl?" (Coming in May 2002)

Charles D Ciccone, PT, PhD, is Professor, Department of Physical Therapy, Ithaca College, Ithaca, NY.