Article

Safety and Feasibility of an Exercise Intervention for Patients Following Lung Resection: A Pilot Randomized Controlled Trial

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Abstract

Purpose: Following surgical lung resection, patients frequently suffer functional decline and reduced activity levels. Despite this exercise interventions are not routinely provided. This study aimed to establish the safety and feasibility of exercise administered following lung resection in an Australian setting. Method: Pilot randomized controlled trial. Fifteen individuals (53% male), mean ± standard deviation age 65.5 ± 16.1 years, undergoing surgery for suspected lung cancer. Randomization occurred postoperatively. Control arm received protocolized inpatient respiratory physiotherapy. Intervention arm additionally received twice daily exercise until discharge home and twice weekly as outpatient for 8 weeks. Outcome measures (safety, feasibility, functional capacity, functional mobility, and health-related quality of life [HRQoL]) were assessed preoperatively and 2 and 12 weeks postoperatively. Results: Fifteen participants (lung cancer n = 10) were assigned to control (n = 8) and intervention (n = 7) groups. Inpatient exercise was delivered on 71% of occasions (35 out of 49 planned sessions). Four participants attended outpatient exercise sessions and these participants attended sessions on 81% of occasions (52 out of 64 planned sessions). No adverse events occurred. There was a significant between group difference in 6-Minute Walk Test (6MWT; P = .024). In both groups the 6MWT declined from baseline to 2 weeks postoperative and then improved up to 12 weeks; improvements were greater in the intervention group. Intervention was associated with positive trends of improvement in some HRQoL domains. Conclusions: Exercise intervention performed in the inpatient and outpatient settings for individuals following lung resection was safe and feasible. The uptake rate for outpatient exercise was 57%, similar to previous trials; however, adherence was excellent within the subgroup of participants who attended. Further research is required to investigate the best setting of exercise delivery and explore ways to improve the uptake rate.

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... The majority of studies [22,23,25,28,34e38] included patients with stage I to IIIA or IIIB disease. Four studies [19,21,27,32] included patients with up to stage IV disease, two studies [30,31] included patients with stage IeII disease and Divisi et al. [33] included patients with stage I disease only, however patients also had to have confirmed COPD. Four studies [20] (study 1 and 2) [24,26], did not report stage of disease however two of these studies [24,26] were post-operative studies and therefore patients would be considered operable stage disease. ...
... The results of the assessment of RCT's revealed that none of the studies were free from risk of bias. All eight studies were described as RCTs, but allocation concealment was only adequate in five studies [19,21,22,24,25]. Other forms of risk of bias included; an uncertainty about the blinding of outcome assessors [19,22e25] and the timing of the outcome assessment after the intervention [20] (study 2); small sample sizes (n < 20) [20] (study 1 and 2) [21] with only two [23,25] reporting a power calculation; and three studies did not adequately report on losses to follow-up [20] (study 1) [21,23]. ...
... All eight studies were described as RCTs, but allocation concealment was only adequate in five studies [19,21,22,24,25]. Other forms of risk of bias included; an uncertainty about the blinding of outcome assessors [19,22e25] and the timing of the outcome assessment after the intervention [20] (study 2); small sample sizes (n < 20) [20] (study 1 and 2) [21] with only two [23,25] reporting a power calculation; and three studies did not adequately report on losses to follow-up [20] (study 1) [21,23]. Also, only three RCT's reported on adverse events [20] (study 1 and 2) [21]. ...
Article
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Background Surgery remains the best curative option for appropriately selected patients with lung cancer. Evidence suggests that improving cardiovascular fitness and functional capacity can accelerate post-surgery recovery and reduce mortality. However, the effect of exercise intervention for patients surgically treated for Non-Small Cell Lung Cancer [NCSLC] has not been fully examined. Purpose This review examines the literature regarding exercise intervention for patients who are surgically treated for NSCLC focussing on three key areas: methodological quality, intervention design (e.g. duration, frequency, type) and outcomes measured. Methods A search of Medline, EMBASE, CINAHL and PsychINFO was undertaken. Randomised Controlled Trials [RCTs] and non-RCTs including exercise training pre or post lung cancer resection were included. Descriptive characteristics were extracted and methodological quality assessed using Downs and Black appraisal checklist. Results Twenty studies (eight RCT's) were included: nine pre-surgical, nine post-surgical and two pre to post-surgical. The quality of evidence is questionable with many limitations (e.g. small samples, inadequate allocation concealment and a lack of clear reporting on timing, adverse events and follow-up). Regarding design of exercise intervention and outcomes measured, there was much variation between studies producing a disparate set of data. An optimal programme is still to be determined; however, suggestions are made relating to type of exercise (i.e. mixing aerobic, resistance and breathing exercises). Preliminary work from this review suggests that exercise intervention compared with usual care both pre and post-surgery is associated with improved cardiopulmonary exercise capacity, increased muscle strength and reduced fatigue, post-operative complications and hospital length of stay. Results concerning pulmonary function, quality of life, and blood gas analysis were variable and inconsistent. Conclusion In order to implement exercise intervention appropriate for patients surgically treated for NCSLC, more high quality randomised controlled trials are required and more work concerning feasibility, acceptability and effectiveness of specific interventions on outcomes is warranted.
... The majority of studies [22,23,25,28,34e38] included patients with stage I to IIIA or IIIB disease. Four studies [19,21,27,32] included patients with up to stage IV disease, two studies [30,31] included patients with stage IeII disease and Divisi et al. [33] included patients with stage I disease only, however patients also had to have confirmed COPD. Four studies [20] (study 1 and 2) [24,26], did not report stage of disease however two of these studies [24,26] were post-operative studies and therefore patients would be considered operable stage disease. ...
... The results of the assessment of RCT's revealed that none of the studies were free from risk of bias. All eight studies were described as RCTs, but allocation concealment was only adequate in five studies [19,21,22,24,25]. Other forms of risk of bias included; an uncertainty about the blinding of outcome assessors [19,22e25] and the timing of the outcome assessment after the intervention [20] (study 2); small sample sizes (n < 20) [20] (study 1 and 2) [21] with only two [23,25] reporting a power calculation; and three studies did not adequately report on losses to follow-up [20] (study 1) [21,23]. ...
... All eight studies were described as RCTs, but allocation concealment was only adequate in five studies [19,21,22,24,25]. Other forms of risk of bias included; an uncertainty about the blinding of outcome assessors [19,22e25] and the timing of the outcome assessment after the intervention [20] (study 2); small sample sizes (n < 20) [20] (study 1 and 2) [21] with only two [23,25] reporting a power calculation; and three studies did not adequately report on losses to follow-up [20] (study 1) [21,23]. Also, only three RCT's reported on adverse events [20] (study 1 and 2) [21]. ...
... Many pilot and feasibility studies examining physical interventions do not have clear a priori criteria for success and often focus on efficacy outcomes of the intervention rather than feasibility [5][6][7][8][9]. Researchers with training in exercise, physical activity, or rehabilitation research may not always have received formal training in the design and conduct of clinical trials nor have expertise in how to design and interpret a pilot study. ...
... Feasibility outcomes could include recruitment rate [5][6][7][8]14], consent rate [6], adherence to the physical activity intervention [5][6][7][8]14], study retention [7,8,14], adverse events [5,6,8,9], and participant experience or satisfaction [5,7,8,14]. The decision to move from a pilot/feasibility study to a full trial should be based on the feasibility objectives and not the secondary outcome measures. ...
... Feasibility outcomes could include recruitment rate [5][6][7][8]14], consent rate [6], adherence to the physical activity intervention [5][6][7][8]14], study retention [7,8,14], adverse events [5,6,8,9], and participant experience or satisfaction [5,7,8,14]. The decision to move from a pilot/feasibility study to a full trial should be based on the feasibility objectives and not the secondary outcome measures. ...
Article
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Background Clinical trials of physical activity and rehabilitation interventions can be challenging. Pilot or feasibility studies can be conducted prior to a definitive randomized controlled trial (RCT), to improve the chances of conducting a high-quality RCT of a physical activity intervention. Main body Physical activity interventions or trials present unique challenges at the population, intervention, comparator and outcome levels. At each level, we present guidance for researchers on the design considerations for pilot or feasibility studies of physical activity interventions. When it comes to defining study population, physical activity trials often exclude participants with certain health conditions or other characteristics (e.g., age, gender) because of uncertainty of the safety of the exercise intervention or presumed differences in responsiveness, at the expense of trial generalizability. A pilot trial could help investigators determine refined inclusion and exclusion criteria to balance safety, adequate recruitment, and generalizability. At the intervention level, because exercise can be a complex intervention, pilot trials allow investigators to evaluate participant adherence and instructor fidelity to the intervention and participant experience. At the comparator level, control group dissatisfaction and post-randomization drop-out can occur, because of the desire to be randomized to the exercise group, and the difficulty with blinding to group allocation; an active control or deception could be used. Finally, at the outcome level, there should be an emphasis on the pilot or feasibility outcomes such as recruitment rate, adherence to exercise, and retention or fidelity, than the efficacy of the exercise intervention. Conclusion Physical activity and rehabilitation researchers can use pilot and feasibility studies to enhance the rigor of future trials, while also publishing the results of their pilot work to move the field forward. Researchers in this field are encouraged to use published reporting guidelines for pilot and feasibility studies and to consider the challenges discussed in this paper.
... there was no heterogeneity (I 2 = 0%) among these studies. While postoperative exercise training also effectively improved exercise capacity in the other 6 studies, 23,28,29,31,36,37 6MWD was increased to 62.83 m (95% CI = 57.94 to 67.72) only after 12 weeks training (P < .00001). ...
... Four studies reported global health score. 23,28,35,36 There was no alteration in patients' global health after exercise training, cumulative MD 2.4 points (95% CI = −2.9 to 7.7, P = .37). ...
... Meanwhile, the other 3 studies reported the dyspnea score. 28,30,37 Exercise training decreased the dyspnea score to −14.3 points (95% CI = −20 to −8.6, P < .00001). There was a low heterogeneity (I 2 = 17%) between these studies ( Figure 6B). ...
Article
Full-text available
Background: This meta-analysis examined the effects of exercise training on length of hospital stay, postoperative complications, exercise capacity, 6-minute walking distance (6MWD), and health-related quality of life (HRQoL) in patients following resection of non-small cell lung cancer (NSCLC). Methods: This review searched PubMed, EMBASE, and the Cochrane Collaboration data base up to August 16, 2015. It includes 15 studies comparing exercise endurance and quality of life before versus after exercise training in patients undergoing lung resection for NSCLC. Results: This review identified 15 studies, 8 of which are randomized controlled trials including 350 patients. Preoperative exercise training shortened length of hospital stay; mean difference (MD): -4.98 days (95% CI = -6.22 to -3.74, P < .00001) and also decreased postoperative complications for which the odds ratio was 0.33 (95% CI = 0.15 to 0.74, P = .007). Four weeks of preoperative exercise training improved exercise capacity; 6MWD was increased to 39.95 m (95% CI = 5.31 to 74.6, P = .02) .While postoperative exercise training can also effectively improve exercise capacity, it required a longer training period; 6MWD was increased to 62.83 m (95% CI = 57.94 to 67.72) after 12 weeks of training ( P < .00001). For HRQoL, on the EORTC-QLQ-30, there were no differences in patients' global health after exercise, but dyspnea score was decreased -14.31 points (95% CI = -20.03 to -8.58, P < .00001). On the SF-36 score, physical health was better after exercise training (MD = 3 points, 95% CI = 0.81 to 5.2, P = .007) while there was no difference with regard to mental health. The I2 statistics of all statistically pooled data were lower than 30%. There was a low amount of heterogeneity among these studies. Conclusions: Evidence from this review suggests that preoperative exercise training may shorten length of hospital stay, decrease postoperative complications and increase 6MWD. Postoperative exercise training can also effectively improve both the 6MWD and quality of life in surgical patients with NSCLC, but requiring a longer training period.
... A similar number of exercise intervention trials have been conducted in patients with lung cancer who have already undergone surgery (Arbane et al., 2011;Cavalheri et al., 2017;Arbane et al., 2014;Brocki et al., 2014;Edvardsen et al., 2015;Granger et al., 2013;Jones et al., 2010;Messaggi-Sartor et al., 2018;Stigt et al., 2013;Wang et al., 2013;Jonsson et al., 2018). Out of 12 studies, 11 have been completed and one is still ongoing (Jones et al., 2010). ...
... The quality assessment of post-surgery intervention trials is summarized in the Supplementary Table S2. The majority of RCTs (n = 8) had overall good quality (Arbane et al., 2011, [Arbane et al., 2014 2014; Brocki et al., 2014;Edvardsen et al., 2015;Granger et al., 2013;Stigt et al., 2013;Jonsson et al., 2018). Three studies were ranked as poor Messaggi-Sartor et al., 2018;Wang et al., 2013). ...
... Interventions that lasted between 6-and 8-weeks reported contrary results (Cavalheri et al., 2017;Granger et al., 2013;Messaggi-Sartor et al., 2018). While two studies reported improvements in domains of pulmonary and physical function (physical performance, cardiorespiratory fitness, pulmonary capacity) in the intervention groups (Cavalheri et al., 2017;, one study reported only marginal significant differences in lung volume (Messaggi-Sartor et al., 2018). ...
Article
Lung cancer patients undergoing surgery are often left physically deconditioned and/or with functional deficits. Exercise interventions may improve pulmonary and physical function before and after lung resection. We conducted a systematic review of randomized-controlled trials (RCTs) testing the impact of pre-, post-, and combined pre-and-post surgery exercise interventions on physical and pulmonary function in lung cancer patients. Exercise pre-surgery seems to substantially improve physical and pulmonary function, which are factors associated with improved ability to undergo surgery while reducing post-surgery complications. Evidence is inconsistent for post-surgery interventions, reporting no or moderate effects. Results from pre-and-post surgery interventions are limited to one study. In conclusion, pre- and post-surgery exercise interventions, individually, have shown beneficial effects for lung cancer patients undergoing surgery. The impact of interventions combining both pre- and post-surgery exercise programs remains unknown. More evidence is needed on the ideal exercise setting, and timing across the lung cancer care continuum.
... 2014 yılında Crandall ve ark.'ı (37) küçük hücreli olmayan ve ameliyat olan kanser olgularında egzersizin etkilerini sistematik bir derleme ile incelediklerinde 2000 ve 2013 yılları arasında yedi randomize kontrollü çalışma yapıldığını saptamışlardır. Bu çalışmaların üçünde araştırmacılar ameliyat öncesi (38)(39)(40), üçünde ameliyat sonrası (41)(42)(43), birinde ise hem ameliyat öncesi hem sonrası solunum rehabilitasyonu uygulamışlardır (44). Egzersiz programlarında solunum egzersizleri, dirençli egzersizler, aerobik egzersizler (yürüyüş, bisiklet, koşu bandı) verilmiştir. ...
... Ameliyat öncesi eğitim süreleri 1-4 hafta arasında değişmiştir (38)(39)(40)44). Ameliyat sonrası ise taburcu olana kadar (44) ve sonrası 8-12 hafta arasında değişen eğitim verilmiştir (41)(42)(43). Bu randomize çalışmalarda egzersiz sıklığı günde 2-3 (çoğunlukla günde 2) olmak üzere haftada 2-7 (çoğunlukla haftada 5) olarak uygulanmıştır. Çalışmaların birinde ameliyat öncesi 4 hafta kuvvet, endurans ve solunum kas eğitimi verilen grupta kontrol grubuna göre, FVC ve 6 dakika yürüme mesafesinin arttığı, hastanede kalış süresinin ve ameliyat sonrası komplikasyonların azaldığı belirtilmiştir (40). ...
... KOAH'lı kanser hastalarında yapılan randomize egzersiz eğitimi çalışmasının sonucunda hastanede kalış sürelerinde ve ameliyat sonrası göğüs tüpü kalış sürelerinde azalma gözlenmiştir (39). Ameliyat sonrası verilen eğitimin etkisini araştıran bir çalışmada hastalara taburcu olana kadar bir hafta egzersiz eğitimi uygulanmış ve ameliyat sonrası komplikasyon sayısı, hastanede kalış günü azalmış, fonksiyonel kapasite artmış, yaşam kalitesi ise etkilenmemiştir (42). Ameliyat sonrası 12 hafta aerobik ve dirençli egzersizlerle eğitim verilen diğer bir çalışmada hastaların egzersiz kapasitesi artmış, yaşam kalitesi ve solunum fonksiyonları etkilenmemiştir (43). ...
... One multiarm trial included two distinct interventions; thus, a total of 20 interventions are reported and evaluated and herein referred to as trial arms (Table 2). Sixteen trial arms (80%) prescribed combined aerobic plus resistance exercises (Arbane et al., 2011(Arbane et al., , 2014Brocki et al., 2014;Edbrooke et al., 2019;Edvardsen et al., 2015;Granger, Chao, McDonald, Berney, & Denehy, 2013;Henke et al., 2014;Licker et al., 2017;Messaggi-Sartor et al., 2019;Rutkowska et al., 2019;Salhi et al., 2015;Sebio Garcia et al., 2017;Sommer et al., 2016;Stigt et al., 2013), while four (20%) trial arms prescribed aerobic exercise only (Egegaard, Rohold, Lillelund, Persson, & Quist, 2019;Hoffman et al., 2017;Hwang, Yu, Shih, Yang, & Wu, 2012;Morano et al., 2013). No trial arms prescribed resistance training only. ...
... No trial arms prescribed resistance training only. Sixteen (84%) trial arms compared aerobic and/or combined aerobic plus resistance exercise versus usual care (Arbane et al., 2011(Arbane et al., , 2014Brocki et al., 2014;Edbrooke et al., 2019;Edvardsen et al., 2015;Egegaard et al., 2019;Granger et al., 2013;Henke et al., 2014;Hoffman et al., 2017;Hwang et al., 2012;Licker et al., 2017;Messaggi-Sartor et al., 2019;Rutkowska et al., 2019;Sebio Garcia et al., 2017;Stigt et al., 2013), one (5%) trial arm compared aerobic exercise versus standard postoperative chest physiotherapy treatment (Morano et al., 2013), one (5%) trial arm compared exercise versus whole-body vibration training versus usual care (Salhi et al., Median age reported in manuscript. ...
... (Ahead of Print) 2015), and one (5%) multiarmed study was a comparative effectiveness trial comparing timing of exercise (Sommer et al., 2016). Three trial arms (15%) were prehabilitative (i.e., intervention before surgery) (Licker et al., 2017;Morano et al., 2013;Sebio Garcia et al., 2017), 11 (55%) trial arms intervened following surgery (Arbane et al., 2011(Arbane et al., , 2014Brocki et al., 2014;Edvardsen et al., 2015;Granger et al., 2013;Hoffman et al., 2017;Messaggi-Sartor et al., 2019;Salhi et al., 2015;Stigt et al., 2013), one (6%) trial arm was conducted during the perioperative period (i.e., before and following surgery) (Sommer et al., 2016), two trial arms were conducted exclusively during chemotherapy (Henke et al., 2014;Rutkowska et al., 2019), one during targeted therapy after completing various combinations of treatments (Hwang et al., 2012), and one trial arm was conducted during radiation therapy (Egegaard et al., 2019). The length of studies varied from 25 days to 20 weeks, some with postintervention follow-up periods lasting up to 52 weeks. ...
Article
The authors systematically reviewed and summarized exercise trials in persons with lung cancer on (a) attention to the principles of exercise training (specificity, progression, overload, initial values, reversibility, and diminishing returns); (b) methodological reporting of FITT (frequency, intensity, time, and type) components; and (c) reporting on participant adherence to prescribed FITT. Randomized controlled trials of exercise that reported on ≥1 physical fitness, physical function, or body composition outcome in persons with lung cancer were included. Of 20 trial arms, none incorporated all principles of exercise training. Specificity was included by 95%, progression by 45%, overload by 75%, and initial values by 80%, while one trial arm applied reversibility and diminishing returns . Fourteen interventions reported all FITT components; however, none reported adherence to each component. Including the principles of training and reporting FITT components will contribute to better understanding of the efficacy of exercise for persons with lung cancer and inform evidence-based exercise prescriptions.
... In total, 70 trials with 3402 participants (mean age 54.6 years), were included in the data synthesis (Table S1) . These included six trials 18,38,41 in general surgery, three 34,54,59 in bariatric surgery, three 15,17 in breast cancer surgery, eleven 16,23,31,32,47,48,50,65,70,73 in cardiothoracic surgery, fortyone [19][20][21]24,[26][27][28][29][30]33,[35][36][37]39,40,43,45,49,[51][52][53]55,57,58,[60][61][62][63][64][66][67][68][69]71,72 in orthopaedics, three 42,44,46 in transplant surgery, one 56 in urology, one 25 in gynaecological surgery, and one 22 in trauma surgery. Some papers reported results of trial with multiple treatment arms: for the purpose of the meta-analysis, each treatment arm has been considered as a separate trial. ...
... Benedetti et al. 19 Busch et al. 23 Granger et al. 32 Liao et al. 45 Suetta et al. 66 (a) Suetta et al. 66 (b) Tsukagoshi et al. 69 (a) Tsukagoshi et al. 69 (b) Lattanzi et al. 44 ...
... Arbane et al. 16 Do et al. 25 Ghroubi et al. 31 Granger et al. 32 Macchi et al. 47 Morano et al. 50 Stigt et al. 65 Suetta et al. 66 I 2 ¼ 0 per cent). ...
Article
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Background The aim of this systematic review was to summarize the results of trials evaluating interventions for the reduction of sarcopenia in patients undergoing surgery. Methods Searches were conducted using the Cochrane Central Register of Controlled Trials, MEDLINE and Embase. RCTs evaluating exercise, dietary or pharmacological interventions to address sarcopenia in the perioperative period were included. Treatment effect estimates were expressed as standardized mean differences (MDs) with confidence intervals, and heterogeneity was expressed as I2 values. Results Seventy trials including 3402 participants were selected for the data synthesis. Exercise interventions significantly increased muscle mass (MD 0.62, 95 per cent c.i. 0.34 to 0.90; P < 0.001), muscle strength (MD 0.55, 0.39 to 0.71; P < 0.001), measures of gait speed (MD 0.42, 0.05 to 0.79; P = 0.03), and reduced time for completion of set exercises (MD −0.76, −1.12 to −0.40; P < 0.001) compared with controls. Subgroup analysis showed that interventions in the early postoperative period were more likely to have a positive effect on muscle mass (MD 0.71, 0.35 to 1.07; P < 0.001) and timed tests (MD −0.70, −1.10 to −0.30; P = 0.005) than preoperative interventions. Treatment effects on muscle mass (MD 0.09, −0.31 to 0.49; P = 0.66) and strength (MD 0.46, −0.01 to 0.92; P = 0.05) were attenuated by the presence of cancer. Results of analyses restricted to nine trials at low risk of allocation concealment bias and fourteen trials at low risk of attrition bias were comparable to those of the primary analysis. Risk-of-bias assessment showed that most trials were at high risk of incomplete outcome and attrition bias, thus reducing the estimate of certainty of the evidence according to the GRADE assessment tool. Conclusion Exercise interventions appear beneficial in reducing the impact of sarcopenia. Because of the high risk of bias and low certainty of the current evidence, large RCTs using standardized measures of muscle mass should be undertaken.
... However, these results are based on small cohort or case studies, mostly performed as inpatient intervention. Likewise, randomized studies of the short-term impact of outpatient exercise training on HRQoL provide no clear evidence: no benefit was found by Arbane et al. [18] while Granger et al. found positive results [19]. Randomized controlled studies with a longer follow-up period are needed to establish the benefits of combined aerobic and muscle strength exercises after LC surgery [8]. ...
... Two previous RCTs have investigated the effects of exercise interventions following LC surgery [18,19]. Arbane et al. [18] included 53 patients, offering exercise training immediately after surgery, followed by unsupervised exercise after discharge; no reports on adherence to home exercising were provided. ...
... They found no evidence of an intervention effect for physical capacity (6MWT) or quality-of-life (EORTC-QLQ30) (European Organization for Research and Treatment of Cancer Quality-of-life Questionnaire). Granger et al. [19] performed a feasibility study including 15 patients, 8 assigned to control and 7 to intervention, and found that both groups improved 6 MWT from 2 weeks to 12 weeks postoperatively by 10%, similarly to the present study' findings. Furthermore, the intervention was favoured in some domains of SF-36 (physical function and mental health) and EORTC-QLQ-30 for fatigue, physical function and pain. ...
... Before starting an exercise programme, a comprehensive evaluation of the exercise capacity and health status is needed to individualize the exercise prescription and explore potential limitations . There is accumulating evidence that exercise in the context of cancer is effective and safe across all stages, although the majority of the research has been conducted in cancer survivors or patients undergoing active treatment (Granger et al., 2013b, Cheema et al., 2014, Jones et al., 2008, Hoffman et al., 2013, Schmitz et al., 2010. Few studies have been undertaken in patients with lung cancer awaiting surgery thus the feasibility and safety of the intervention in this particular context is still not clear (Jones et al., 2007). ...
... The eligibility rate is fundamentally affected by the inclusion and exclusion criteria established by the investigators but also by the designated location from where the participants are picked. For instance, Granger et al. in a pilot randomized trial in patients with NSCLC, reported an eligibility rate of only 18% in a general thoracic clinic, reflecting the heterogeneity of the institution and significantly affecting the potential number of participants eligible for the study (Granger et al., 2013b). The recruitment or consenting rate refers to the number of patients from those eligible who participate in the study and is a reflection of the willingness of the patients to exercise. ...
... The recruitment or consenting rate refers to the number of patients from those eligible who participate in the study and is a reflection of the willingness of the patients to exercise. In our study, we achieved a recruitment rate of 52.2% which although it could be considered as low, it is similar to other feasibility studies conducted in lung cancer patients (Coats V, 2013, Granger et al., 2013b, Jones et al., 2008, Kuehr et al., 2014. In contrast, completion rate was 75%, superior to some other studies including patients with NSCLC (Missel et al., 2015, Temel et al., 2009, Kuehr et al., 2014, Andersen et al., 2013 also reported a 90% completion rate in a preoperative exercise-based intervention and a 95% after a post-operative 14-week training programme (Jones et al., 2008, Jones et al., 2007. ...
... 46 Most interventions were supervised (n=27, 84%), 47,49À58,60À70,72,74À77 and five (16%) interventions were unsupervised (ie, less than half of the prescribed exercise was supervised faceto-face). 46,48,59,71,73 The supervised interventions were most commonly in a hospital setting. Supervision in these trials was from a physiotherapist/physical therapist (n=17), 47 62 or was not specified (n=4). ...
... 52,60,68,76 Four of the interventions categorized as unsupervised involved low levels of supervision from a physiotherapist (n=2) 48,59 or exercise physiologist (n=2). 46,73 Safety: overview of adverse events ...
Article
Background The purpose of this systematic review and meta-analysis was to evaluate the safety (adverse events), feasibility (recruitment, retention, and adherence) and effectiveness of exercise among individuals with lung cancer. Data Sources Electronic databases (CINAHL, Cochrane, Ebscohost, MEDLINE, Pubmed, ProQuest Health and Medical Complete, ProQuest Nursing and Allied Health Source, Science Direct, and SPORTDiscus) were searched for randomized, controlled, exercise trials involving individuals with lung cancer that were published prior to May 1, 2020. The PEDro scale was used to assess risk of bias, and the Common Terminology Criteria for Adverse Events was used to classify adverse event severity. Feasibility was assessed by computing median (range) recruitment, retention, and exercise attendance rates. Meta-analyses were performed to evaluate adverse event risk between exercise and usual care, and effects on health outcomes. Subgroup effects for exercise mode, supervision, intervention duration, diagnosis or treatment-related factors, and trial quality were assessed. Results Thirty-two trials (n=2109) involving interventions ranging between 1 and 20 weeks were included. Interventions comprised of aerobic (n=13, 41%), resistance (n=1, 3%), combined aerobic and resistance (n=16, 50%) and other exercise (n=2, 6%). There was no difference in the risk of an adverse event between exercise and usual care groups (exercise: n=64 events; usual care: n=61 events]; risk difference: -0.01 [91% CI = -0.02, 0.01]; P = .31). Median recruitment rate was 59% (9%–97%), retention rate was 86% (50%–100%), and adherence rate was 80% (44%–100%). Significant effects of exercise compared to usual care were observed for quality of life, aerobic fitness, upper-body strength, lower-body strength, anxiety, depression, forced expiratory volume, and sleep (standardized mean difference range=0.20–0.59). Subgroup analyses showed that safety, feasibility, and effect was similar irrespective of exercise characteristics, stage at diagnosis, treatment (surgery and chemotherapy), and trial quality. Conclusion For individuals with lung cancer (stages I–IV), the risk of an adverse event with exercise is low. Exercise can be feasibly undertaken post-diagnosis and leads to improvements in health-related outcomes. Together, these findings add weight behind the importance of integrating exercise into standard cancer care, including for this specific cancer type. Implications for Nursing Practice Exercise should be considered as part of the treatment for all patients with lung cancer at any stage. Exercise has been shown to be low risk and can be feasibly undertaken by patients. The ideal mode, intensity, frequency, or duration of exercise for all patients with lung cancer is not known. Nonetheless, these findings support endorsement of cancer-specific physical activity guidelines, as well as referral to an exercise professional, such as an exercise physiologist or physiotherapist, for those diagnosed with lung cancer.
... Literature shows the efficacy of exercise in reducing fatigue, improving cardiovascular fitness, quality of life and physical function in patients with breast cancer, lung cancer, Hodgkin's disease and prostate cancer [37][38][39]. In an attempt to demonstrate the efficacy of exercises in improving the immune status in cancer, Hutnick et al. enrolled breast cancer patients post chemotherapy and radiotherapy for an exercise regime. ...
... resection due to malignancy can benefit from resistance training, aerobic exercise and stretching exercise. These exercises also help in reducing post-operative pain and fatigue [39]. ...
... To date, physiotherapy services of hospitals mainly focus on reducing or preventing post-operative pulmonary complications in people who undergo surgical resection for lung cancer [97]. Despite numerous reports on the positive effects of post-operative exercise training on cancerrelated symptoms, lower limb muscle function, exercise performance and quality of life in people with NSCLC [98][99][100][101][102], referral for post-operative pulmonary rehabilitation is ,25% [97]. This may be due to the fact that large, randomised controlled trials and, in turn, robust evidence of the efficacy of pulmonary rehabilitation in people who underwent lung cancer resection are currently lacking [96]. ...
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Dyspnoea, fatigue, reduced exercise tolerance, peripheral muscle dysfunction and mood disorders are common features of many chronic respiratory disorders. Pulmonary rehabilitation successfully treats these manifestations in chronic obstructive pulmonary disease (COPD) and emerging evidence suggests that these benefits could be extended to other chronic respiratory conditions, although adaptations to the standard programme format may be required. Whilst the benefits of exercise training are well established in asthma, pulmonary rehabilitation can also provide evidence-based interventions including breathing techniques and self-management training. In interstitial lung disease, a small number of trials show improved exercise capacity, symptoms and quality of life following pulmonary rehabilitation, which is a positive development for patients who may have few treatment options. In pulmonary arterial hypertension, exercise training is safe and effective if patients are stable on medical therapy and close supervision is provided. Pulmonary rehabilitation for bronchiectasis, including exercise training and airway clearance techniques, improves exercise capacity and quality of life. In nonsmall cell lung cancer, a comprehensive interdisciplinary approach is required to ensure the success of pulmonary rehabilitation following surgery. Pulmonary rehabilitation programmes provide important and underutilised opportunities to improve the integrated care of people with chronic respiratory disorders other than COPD.
... A recent systematic review of the role of exercise programmes in people with lung cancer suggested that such interventions are safe and likely to be effective, but recommended the need for further randomised controlled trials [12]. The National Institute of Health and Clinical Excellence guidance on lung cancer identified the need for further work to examine rehabilitation programmes before and after surgery, and stated that outcomes should include There have been some pilot studies in this area, but these have had significant methodological weaknesses such as lack of a control group and small sample size [13][14][15][16]. One 4-week study reported a reduction in breathlessness after rehabilitation, but the subjects was self-selected and the rehabilitation group was more disabled than the control group at baseline [17]. ...
Article
Objective To evaluate the effect of a combined hospital plus home exercise programme following curative surgery for non-small cell lung cancer (NSCLC). Design Randomised controlled trial. Setting Inpatient hospital. Participants One hundred and thirty-one subjects with NSCLC admitted for curative surgery. Interventions Participants were randomised to usual care or a hospital plus home exercise programme. Outcomes The primary outcome was the between-group difference in physical activity 4 weeks after surgery. Secondary outcomes were the difference in quadriceps strength, exercise tolerance and quality of life [Short Form-36 (SF-36) and European Organisation for Research and Treatment of Cancer (EORTC) QLQ-LC13] from pre-operatively (baseline) to 4 weeks after surgery. Results The participants (n = 131) had a mean age of 68 [standard deviation (SD) 11] years and mean forced expiratory volume in 1 second of 2.4 (1.1) l. There were no significant differences in physical activity between the groups 4 weeks after surgery [mean difference adjusted for baseline 12 minutes/day, 95% confidence interval (CI) -20.2 to 44.1]. In addition, there were no significant differences in total SF-36 or EORTC QLQ-LC13 scores from baseline to 4 weeks after surgery. Both groups had recovered their pre-operative walking distance 4 weeks after surgery, and there were no differences between the groups (mean difference in Incremental Shuttle Walk Test from baseline to 4 weeks after surgery (-26 m, 95% CI -94.2 to 42.3). Conclusions A hospital plus home exercise programme showed little benefit in unselected patients with NSCLC following surgery. Regardless of group allocation, the patients had recovered their pre-operative exercise tolerance levels by 4 weeks after surgery.
... Aerobic and resistive exercise interventions lessen the impact of ADT and promote restoration of muscle mass and mitigate bone density loss [92]. Numerous prehabilitation and rehabilitation trials have identified positive benefits of exercise as well as its safety and feasibility in the lung cancer population [93]. Exercise is generally well tolerated and beneficial in controlled clinical settings, and evidence supports moderate-intensity exercise for this population [6,94,95]. ...
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Cancer and its treatments introduce various adverse effects that may affect survivors’ physical, cognitive and psychological functioning. Frequently both tolerance to activity and exercise are affected as well. Rehabilitation providers should have substantive knowledge about the effect of cancer progression and common side effects associated with antineoplastic treatment to safely integrate rehabilitation interventions. Rehabilitation may mitigate loss of function and disability; however, these patients are among the most medically complex that providers treat. This report provides a focused review that synthesizes the current evidence regarding disease progression and oncology-directed treatment side effects within the context of safety considerations for rehabilitation interventions throughout the continuum of cancer care. Descriptive information regarding the evidence for precautions and contraindications is provided so that rehabilitation providers can promote a safe plan of rehabilitation care. It is incumbent upon but also challenging for rehabilitation providers to stay up to date on the many advances in cancer treatment, and there are many gaps in the literature regarding safety issues. Although further research is needed to inform care, this review provides clinicians with a framework to assess patients with the goal of safely initiating rehabilitation interventions. © 2017 American Academy of Physical Medicine and Rehabilitation
... The majority of the trials, as expected, were phase 3 trials (n 5 58). To a lesser degree, the questionnaire was used in phase 2 studies (again, the term "randomized" appeared either in the title or in the description of the methods 25,31,41,76,138,145,147,149,150,157,194,195,223 , in phase 2 and 3 studies, 79,82,113,152 or in pilot studies (ie, authors used the term "pilot study" either in the title or in the method section 83,114 . In 33% of the RCTs, the trial phase was not specified (n 5 32). ...
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The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer 13 (QLQ-LC13) covers 13 typical symptoms of lung cancer patients and was the first module developed in conjunction with the EORTC core quality-of-life (QL) questionnaire. This review investigates how the module has been used and reported in cancer clinical trials in the 20 years since its publication. Thirty-six databases were searched with a prespecified algorithm. This search plus an additional hand search generated 770 hits, 240 of which were clinical studies. Two raters extracted data using a coding scheme. Analyses focused on the randomized controlled trials (RCTs). Of the 240 clinical studies that were identified using the LC13, 109 (45%) were RCTs. More than half of the RCTs were phase 3 trials (n = 58). Twenty RCTs considered QL as the primary endpoint, and 68 considered it as a secondary endpoint. QL results were addressed in the results section of the article (n = 89) or in the abstract (n = 92); and, in half of the articles, QL results were presented in the form of tables (n = 53) or figures (n = 43). Furthermore, QL results had an impact on the evaluation of the therapy that could be clearly demonstrated in the 47 RCTs that yielded QL differences between treatment and control groups. The EORTC QLQ-LC13 fulfilled its mission to be used as a standard instrument in lung cancer clinical trials. An update of the LC13 is underway to keep up with new therapeutic trends and to ensure optimized and relevant QL assessment in future trials. Cancer 2015. © 2015 American Cancer Society.
... Standard care at the institutions was followed and not modified. For surgically treated participants this included post-operative physiotherapy delivered according to a clinical pathway (Supplementary Table 1) which commenced the day after surgery and only continued until patients were able to ambulate safely for discharge home, or they no longer required respiratory management to prevent or treat a physiotherapy amenable post-operative pulmonary complication [20]. In accordance with standard care, participants were not offered pre-operative physiotherapy, formal education regarding physical activity, or referral to pulmonary rehabilitation after surgery. ...
Article
Objectives: To investigate in non-surgically and surgically treated non-small cell lung cancer (NSCLC): (1) changes in physical activity, function, health-related quality of life (HRQoL) and symptoms after diagnosis; and (2) the association between physical activity and outcomes. Design: Prospective observational study. Setting: Three acute tertiary hospitals. Participants: Sixty-nine individuals (43 male, median [IQR] age 68 [61 to 74] years) with stage I-IV NSCLC. Main outcome measures: The primary outcome (Physical Activity Scale for the Elderly) and secondary outcome (six-minute walk test and questionnaires assessing HRQoL, function, symptoms, mood) were measured at diagnosis (pre-treatment), and eight to ten weeks post-diagnosis (post-operative and/or during chemotherapy/radiotherapy). Results: Individuals treated surgically (n=27) experienced a deterioration in physical activity levels (baseline median [IQR]=74 [51 to 135]; follow-up median [IQR]=29 [24 to 73]; median difference=45, effect size=0.3). At follow-up physical activity was inversely related to depression, pain and appetite loss (rho>0.5, p<0.05). In contrast non-surgical individuals (n=42) did not experience a change in physical activity, however did experience deterioration in function, functional capacity, global HRQoL, fatigue and dyspnoea. Physical activity levels were low in this group and at follow-up the strongest relationships with physical activity levels were global HRQoL, function, fatigue and mood (inverse, rho>0.5, p<0.05). Conclusions: Surgically treated individuals experienced a reduction in physical activity levels after diagnosis, which was not seen in the non-surgical group. Lower physical activity levels were associated with poorer outcomes, particularly in non-surgically treated individuals. Further research is required to establish the optimal intervention to improve physical activity levels in these cohorts.
... Nonostante ciò, gli studi su questo argomento non sono molti 73 . Tuttavia, nonostante siano riportati in letteratura significativi effetti sulla tolleranza all'esercizio fisico, sui sintomi, sulla forza muscolare e sulla qualità della vita 74 , solo meno del 25% di questi pazienti viene avviato alla riabilitazione postoperatoria 75 . ...
Article
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This document, produced by a group of experts of "Rehabilitation and Chronic Care Study Group, Italian Association of Hospital Pulmonologists (AIPO)", is not a guideline, not a consensus document and even the Italian version of the statement dismissed in 2013 by the two main scientific societies in the field of pneumology, ATS and ERS, which is still clearly inspired. It represents the update of the previous, product in 2007, and comes from the awareness that in these eight years much progress has been made in various areas of the Pulmonary Rehabilitation. In particular the literature, as well as confirm its effectiveness in improving symptoms, exercise tolerance and quality of life, has shown the ability to reduce exacerbations and hospitalizations and therefore the consumption of health care resources. Furthermore, the improvement of our knowledge on the pathophysiology of chronic respiratory diseases contributed to extend its application also to diseases other than COPD. Considering then that the training exercise is the cornerstone of any rehabilitation program, wide space is given to the methods and strategies helpful to its optimization. In conclusion, our aim is to provide those who began to work on pulmonary rehabilitation and colleagues which already do it, recommendations and advice from experience and from the literature. An updated bibliography will then explore the topics of most interest to each.
... Physiotherapists are involved in the assessment of patients' safety related to mobility for hospital discharge. Most patients following lung resection are able to be discharged directly home; however, a small proportion of patients (2% in an Australian study) 59 do not regain a satisfactory degree of independence required for their social situation and home environment. These patients can be transferred to a sub-acute inpatient rehabilitation facility for a period of intensive physiotherapy/rehabilitation targeting function and mobility. ...
Article
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[Granger CL (2016) Physiotherapy management of lung cancer. Journal of Physiotherapy XX: XX-XX]
... In relation to sex, the current study showed that nearly half of the studied groups were females. This finding was similar to the findings ofHulzebos et.al, (2006) (51) , Benzo et.al, (2011) (52) (45) who reported that nearlyhalf of the studied sample were males . SimilarlyCoats et.al, (2013) (49) andCondessa et.al, (2013) (53) concluded that half of the studied patients were females and the other half was males. ...
... Though likely beneficial, studies increasing PA in lung cancer patients show low adherence in both early and advanced disease. 10,11 Lung cancer patient and survivor surveys reveal preferences for activity guidance 12 and that up to 80% of patients would prefer walking. 13 Two recent randomized trials have shown that Fitbit-based interventions improved PA in postmenopausal women and overweight adults. ...
Article
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Background and objective: Increasing physical activity (PA) is safe and beneficial in lung cancer (LC) patients. Advanced-stage LC patients are under-studied and have worse symptoms and quality of life (QoL). We evaluated the feasibility of monitoring step count in advanced LC as well as potential correlations between PA and QoL. Methods: This is a prospective, observational study of 39 consecutive patients with advanced-stage LC. Daily step count over 1 week (via Fitbit Zip), QoL, dyspnea, and depression scores were collected. Spearman rank testing was used to assess correlations. Correlation coefficients (ρ) >0.3 or <-0.3 (more and less correlated, respectively) were considered potentially clinically significant. Results: Most (83%) of the patients were interested in participating, and 67% of those enrolled were adherent with the device. Of those using the device (n = 30), the average daily step count was 4877 (range = 504-12 118) steps/d. Higher average daily step count correlated with higher QoL (ρ = 0.46), physical (ρ = 0.61), role (ρ = 0.48), and emotional functioning (ρ = 0.40) scores as well as lower depression (ρ = -0.40), dyspnea (ρ = -0.54), and pain (ρ = -0.37) scores. Conclusion: Remote PA monitoring (Fitbit Zip) is feasible in advanced-stage LC patients. Interest in participating in this PA study was high with comparable adherence to other PA studies. In those utilizing the device, higher step count correlates with higher QoL as well as lower dyspnea, pain, and depression scores. PA monitoring with wearable devices in advanced-stage LC deserves further study.
... The anti-inflammatory response induced by regular physical activity is mediated by skeletal muscle contraction through the release of muscle-derived cytokines. Physical activity induces a marked increase in serum levels of cytokines involved in the regulation of inflammation, such as IL-10, the IL-1 receptor antagonist (IL-1ra), and IL-37 [43][44][45][46]. IL-6 is also capable of acting as an anti-inflammatory cytokine for several hours after exercise, as it reduces the production of pro-inflammatory cytokines in different tissues; this action is important against cancer development. ...
Article
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Lung cancer is the most lethal cancer: it has a significant incidence and low survival rates. Lifestyle has an important influence on cancer onset and its progression, indeed environmental factors and smoke are involved in cancer establishment, and in lung cancer. Physical activity is a determinant in inhibiting or slowing lung cancer. Certainly, the inflammation is a major factor responsible for lung cancer establishment. In this scenario, regular physical activity can induce anti-inflammatory effects, reducing ROS production and stimulating immune cell system activity. On lung function, physical activity improves lung muscle strength, FEV1 and forced vital capacity. In lung cancer patients, it reduces dyspnea, fatigue and pain. Data in the literature has shown the effects of physical activity both in in vivo and in vitro studies, reporting that its anti-inflammatory action is determinant in the onset of human diseases such as lung cancer. It has a beneficial effect not only in the prevention of lung cancer, but also on treatment and prognosis. For these reasons, it is retained as an adjuvant in lung cancer treatment both for the administration and prognosis of this type of cancer. The purpose of this review is to analyze the role of physical activity in lung cancer and to recommend regular physical activity and lifestyle changes to prevent or treat this pathology.
... Treatment efficacy will be determined by changes in the primary outcome 6MWD from baseline to nineweeks. This is a commonly used submaximal test of functional exercise capacity [48] that has been found to predict outcomes [49,50] in patients with lung cancer. The test is being performed according to the American Thoracic Society (ATS) guidelines [50], including duplicate tests to account for the learning effect. ...
Article
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Background Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC. Methods This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference. Discussion There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting. Trial registration This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614001268639: (4/12/14). Electronic supplementary material The online version of this article (10.1186/s12885-017-3651-4) contains supplementary material, which is available to authorized users.
... Moreover, during treatment, a gain in both psychological and physical variables was observed, whereas after completion of therapies an improvement in only the physical aspects was evident [41]. Focusing on studies including only patients with lung cancer, no clear advantage in terms of QoL after applying a physical exercise program is evident [29,31,32,[42][43][44][45][46][47][48][49]. A randomized controlled trial attempted to assess the impact of EX intervention on QoL in 81 patients undergoing thoracotomy. ...
Article
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Lung cancer remains the leading cause of cancer-related death worldwide. Affected patients frequently experience debilitating disease-related symptoms, including dyspnea, cough, fatigue, anxiety, depression, insomnia, and pain, despite the progresses achieved in term of treatment efficacy. Physical activity and exercise are nonpharmacological interventions that have been shown to improve fatigue, quality of life, cardiorespiratory fitness, pulmonary function , muscle mass and strength, and psychological status in patients with lung cancer. Moreover, physical fitness levels, especially cardiorespiratory endurance and muscular strength, are demonstrated to be independent predic-tors of survival. Nevertheless, patients with lung cancer frequently present insufficient levels of physical activity and exercise, and these may contribute to quality of life impairment, reduction in functional capacity with skeletal muscle atrophy or weakness, and worsening of symptoms, particularly dyspnea. The molecular bases underlying the potential impact of exercise on the fitness and treatment outcome of patients with lung cancer are still elusive. Counteracting specific cancer cells' acquired capabilities (hallmarks of cancer), together with preventing treatment-induced adverse events, represent main candidate mechanisms. To date, the potential impact of physical activity and exercise in lung cancer remains to be fully appreciated, and no specific exercise guidelines for patients with lung cancer are available. In this article, we perform an in-depth review of the evidence supporting physical activity and exercise in lung cancer and suggest that integrating this kind of intervention within the framework of a global, multidimensional approach, taking into account also nutritional and psychological aspects, might be the most effective strategy. The Oncologist 2019;24:1-15 Implications for Practice: Although growing evidence supports the safety and efficacy of exercise in lung cancer, both after surgery and during and after medical treatments, most patients are insufficiently active or sedentary. Engaging in exercise programs is particularly arduous for patients with lung cancer, mainly because of a series of physical and psychosocial disease-related barriers (including the smoking stigma). A continuous collaboration among oncologists and cancer exercise specialists is urgently needed in order to develop tailored programs based on patients' needs, preferences, and physical and psychological status. In this regard, benefit of exercise appears to be potentially enhanced when administered as a multi-dimensional, comprehensive approach to patients' well-being.
... There were 58 (54%) studies conducted among adults diagnosed with solid tumours [24,, 25 (23%) studies in haematological cancers [25, and 24 (22%) studies including patients with mixed cancer diagnoses [26,38,. For the studies in solid tumours, exercise interventions were delivered during cancer treatment in 20 (34%) studies [34-37, 39-49, 87, 134-137], during and after treatment in 12 (21%) studies [24,[50][51][52][53][54][55][56][57][58][59][60], and entirely after treatment in 26 (45%) studies . The most common solid tumour groups investigated were cancers of colon or rectum (n = 15, 26%), lung (n = 12, 21%), and head and neck (n = 10, 17%). ...
Article
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Background: The primary objective of this systematic review was to update our previous review on randomized controlled trials (RCTs) of exercise in cancers other than breast or prostate, evaluating: 1) the application of principles of exercise training within the exercise prescription; 2) reporting of the exercise prescription components (i.e., frequency, intensity, time, and type (FITT)); and 3) reporting of participant adherence to FITT. A secondary objective was to examine whether reporting of these interventions had improved over time. Methods: MEDLINE, EMBASE, CINAHL and SPORTDiscus databases were searched from 2012 to 2020. Eligible studies were RCTs of at least 4 weeks of aerobic and/or resistance exercise that reported on physiological outcomes relating to exercise (e.g., aerobic capacity, muscular strength) in people with cancer other than breast or prostate. Results: Eighty-six new studies were identified in the updated search, for a total of 107 studies included in this review. The principle of specificity was applied by 91%, progression by 32%, overload by 46%, initial values by 72%, reversibility by 7% and diminishing returns by 5%. A significant increase in the percentage of studies that appropriately reported initial values (46 to 80%, p < 0.001) and progression (15 to 37%, p = 0.039) was found for studies published after 2011 compared to older studies. All four FITT prescription components were fully reported in the methods in 58% of all studies, which was higher than the proportion that fully reported adherence to the FITT prescription components in the results (7% of studies). Reporting of the FITT exercise prescription components and FITT adherence did not improve in studies published after 2011 compared to older studies. Conclusion: Full reporting of exercise prescription and adherence still needs improvement within exercise oncology RCTs. Some aspects of exercise intervention reporting have improved since 2011, including the reporting of the principles of progression and initial values. Enhancing the reporting of exercise prescriptions, particularly FITT adherence, may provide better context for interpreting study results and improve research to practice translation.
... Indeed, in chronic lung diseases such as COPD and Cystic Fibrosis, physical activity has proven consistent beneficial effects in terms of respiratory function (FEV1%, FVC, decreased dyspnea and fatigue, improvement in shortness of breath) as well as in terms of quality of life (cognitive functions) [111][112][113][114] Respect to lung cancer, physical activity has been described as a preventive factor able to reduce the risk as well as a non-pharmacological approach to manage the disease ameliorating the carcinogenesis risk, the chemotherapy response and finally prognosis and survival [115][116][117][118]. Indeed, home-based exercise is a beneficial approach to improve symptoms and quality of life of patients with lung cancer [119]. On the other hand, the risk of an adverse event with exercise is low, reinforcing the necessity for lung cancer patients to perform physical activity and keep active [120,121]. Increased physical activity and resistance exercise is a cornerstone of the management of sarcopenia [122] while physical inactivity represents a major risk for loss of functional capacities. Exercise and physical activity can reduce inflammation [123] as well as can induce molecular signaling pathways that support building muscle mass, and stimulate beneficial metabolic adaptations [124]. ...
Article
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Lung cancer still represents the leading cause of cancer-related death, globally. Likewise, malnutrition and inactivity represent a major risk for loss of functional pulmonary capacities influencing overall lung cancer severity. Therefore, the adhesion to an appropriate health lifestyle is crucial in the management of lung cancer patients despite the subtype of cancer. This review aims to summarize the available knowledge about dietary approaches as well as physical activity as the major factors that decrease the risk towards lung cancer, and improve the response to therapies. We discuss the most significant dietary schemes positively associated to body composition and prognosis of lung cancer and the main molecular processes regulated by specific diet schemes, functional foods and physical activity, i.e., inflammation and oxidative stress. Finally, we report evidence demonstrating that dysbiosis of lung and/or gut microbiome, as well as their interconnection (the gut–lung axis), are strictly related to dietary patterns and regular physical activity playing a key role in lung cancer formation and progression, opening to the avenue of modulating the microbiome as coadjuvant therapy. Altogether, the evidence reported in this review highlights the necessity to consider non-pharmacological interventions (nutrition and physical activity) as effective adjunctive strategies in the management of lung cancer.
... 폐암도 이러한 목적으로 운동이 많이 활용되고 있다 11) . ⑤ Mean difference in EQ-5D-5L score from baseline to 2 weeks between two groups ⑤ -0.016 13,17,20,25,26) . 메타 분석 결 과에서도 유사한 결과가 나타났다 (Fig. 4a). ...
... There have been a small number of studies investigating the role of post-operative exercise commencing whilst patients are still in hospital after surgery, 38,39 although the majority of studies commence exercise training once patients are discharged from hospital. 40 It is currently unknown whether early commencement provides added benefits. ...
Article
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Exercise training is playing an increasing role in lung cancer care. Lung cancer is associated with significant burden to the individual and healthcare system. There is now substantial evidence that exercise training is safe, feasible and effective at improving several outcomes in people with lung cancer, especially in those with NSCLC. Exercise is beneficial across the lung cancer disease and treatment pathway, including in patients with early stage disease before and after surgery, and in patients with advanced disease. This review describes the impact of lung cancer and lung cancer treatment on patient health outcomes and summarizes the aims, safety, feasibility and effects of exercise training in the context of both early stage and advanced stage lung cancer. The paper also includes a discussion of current topical discussion areas including the use of exercise in people with bone metastases and the potential effect of exercise on suppression of tumour growth. Finally, seven clinical questions are included, which are a priority to be addressed by future research over the next decade as we strive to progress the field of lung cancer and improve patient outcomes.
... 프로그램 참여로 얻을 수 있는 건강 증진의 효과에도 불구하고, 폐 절제술 후 신체활동 증진 프로그램에 대한 참여도는 48.0~62.0%로 낮았고 [15,16] ...
Article
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Purpose: This study aims to examine the effects of nursing interventions based on the Extended Theory of Planned Behavior (ETPB) regarding self-efficacy for exercise (SEE), physical activity (PA), physical function (PF), and quality of life (QOL) in patients with lung cancer who have undergone pulmonary resection. Methods: This quasi-experimental study was conducted between July 2015 and June 2018 in two university-affiliated hospitals. The intervention included pre-operative patient education, goal setting (action and coping planning), and feedback (behavior intention and perceived behavioral control). The intervention group (IG) (n=51) received nursing interventions from the day before surgery to 12 months after lung resection, while the comparison group (CG) (n=36) received usual care. SEE, PA, PF (dyspnea, functional status, and 6-minute walking distance [6MWD]), and QOL were measured before surgery and at one, three, six, and 12 months after surgery. Data were analyzed using the χ² test, Fisher's exact test, Mann-Whitney U test, t-test, and generalized estimation equations (GEE). Results: There were significant differences between the two groups regarding SEE (χ²=13.53, p=.009), PA (χ²=9.51, p=.049), functional status (χ²=10.55, p=.032), and 6MWD (χ²=15.62, p=.004). Although there were no time or group effects, the QOL mental component (Z=-2.78, p=.005) of the IG was higher than that of the CG one month after surgery. Interventions did not affect dyspnea or the QOL physical component. Conclusion: The intervention of this study was effective in improving SEE, PA, functional status, and 6MWD of lung cancer patients after lung resection. Further extended investigations that utilize ETPB are warranted to confirm these results.
... Так, С. Prokakis и соавт. [30] указывают на отсутствие преимуществ активной аспирации после лобэктомий по сравнению с пассивным дренированием по Бюлау [33]. Ряд авторов [31] считают, что активная аспирация ускоряет заживление паренхимы легкого за счет сопоставления париетальной и висцеральной плевры, другие -что продленное разрежение в плевральной полости поддерживает дефекты паренхимы и замедляет выздоровление. ...
Article
Objective: To assess standardized protocol for fast track recovery after lung cancer surgery. Material and methods: There were 201 patients. Patients underwent VATS lung resection, VATS lobectomy and various open resections of lungs. Patients had either primary lung cancer or metastatic lung lesion with indications for surgical treatment. Management of patients was divided into 3 periods: preoperative, intraoperative and postoperative. The protocol of fast track recovery was developed considering literature data and own experience. Requirements of this protocol were applied in perioperative management. Results: Application of the protocol was successful in all patients. Minimum number of complications (6%) and length of postoperative hospital-stay of 4 days were observed after VATS resection of lung. VATS lobectomy was followed by complication rate 25% and postoperative hospital-stay of 6 days. In the group of open resections these values were 29% and 7 days.
Article
Abstract Integrative oncology uses non-pharmacological adjuncts to mainstream care to manage physical, emotional, and psychological symptoms experienced by cancer survivors. Depression, anxiety, fatigue and pain are among the common, often burdensome symptoms that can occur in clusters, deplete patient morale, interfere with treatment plans, and hamper recovery. Patients already seek various modalities on their own to address a broad range of problems. Legitimate complementary therapies offered at major cancer institutions improve quality of life, speed recovery, and optimize patient support. They also augment the benefits of psychiatric interventions, due to their ability to increase self-awareness and improve physical and psychological conditioning. Further, these integrated therapies provide lifelong tools and develop skills that patients use well after treatment to develop self-care regimens. The active referral of patients to integrative therapies achieves three important objectives: complementary care is received from therapists experienced in working with cancer patients, visits become part of the medical record, allowing treatment teams to guide individuals in maximizing benefit, and patients are diverted from useless or harmful 'alternatives.' We review the reciprocal physical and psychiatric benefits of exercise, mind-body practices, massage, acupuncture, and music therapy for cancer survivors, and suggest how their use can augment mainstream psychiatric interventions.
Article
Lung cancer continues to be a difficult disease frequently diagnosed in late stages with a high mortality and symptom burden. In part due to frequent lung comorbidity, even lung cancer survivors often remain symptomatic and functionally-limited. Though targeted therapy continues to increase treatment options for advanced-stage disease, symptom burden remains high with few therapeutic options. In the last several decades, exercise and physical activity have arisen as therapeutic options for obstructive lung disease and lung cancer. To date, exercise has been shown to reduce symptoms, increase exercise tolerance, improve quality of life, and potentially reduce length of stay and post-operative complications. Multiple small trials have been performed in perioperative NSCLC patients, while fewer studies are available for patients with advanced-stage disease. Despite the increased interest in this subject over the last few years, a validated exercise regimen has not been established for perioperative or advanced-stage disease. Clinicians underutilize exercise and pulmonary rehabilitation as a therapy, in part due to the lack of evidence-based consensus as to how and when to implement increasing physical activity. This review summarizes the existing evidence on exercise in lung cancer patients.
Article
Problem identification: Improving quality of life (QOL) is a key issue for patients with lung cancer. Exercise interventions could positively affect patients' QOL; however, there is no clear-cut understanding of the role of exercise in improving QOL in patients with lung cancer. Literature search: The PubMed®, Embase®, Cochrane Library, and Web of Science electronic databases were searched from inception to September 6, 2019. Data evaluation: 16 randomized controlled trials met the inclusion criteria. A qualitative synthesis method was used to identify the effect of exercise interventions on QOL in patients with lung cancer. Synthesis: This review indicates that exercise interventions may have beneficial effects on the QOL of patients with lung cancer. The effectiveness seems to be affected by the duration of the intervention, as well as exercise frequency, intensity, and adherence. Implications for practice: Exercise interventions can be integrated into management plans for patients with lung cancer to improve their QOL. Healthcare providers should consider developing optimal exercise prescriptions to maximize the results for this population.
Article
Introduction: Pulmonary rehabilitation (PR) for patients undergoing lung resection for cancer remains controversial. We studied the effects of PR, its impact on quality of life and the level of anxiety and depression. Methods: In 2011 and 2012, PR was offered to all patients referred to our institution after lung resection for cancer. Patients were evaluated between admission and discharge by a 6minutes walking test (6MWD), a Visual Analogue Pain Intensity Scale, a quality of life questionnaire (EORTC QLQ C30) and by the Hospital Anxiety and Depression Scale (HAD). The same questionnaires were mailed 6months after completing PR. Results: Between early 2011 and late 2012, 133 patients were admitted to our institution following lung resection for cancer. Of these, 59 (44%) patients completed PR and returned their questionnaires 6months after discharge. During PR of these 59 patients, the mean quality of life score increased from 56.3 to 65.9 (P<0.05), the median anxiety score decreased from 5.5 to 4 (P<0.05) and that of depression from 3 to 2 (P<0.05). At 6months post-discharge, the mean quality of life score remained stable at 66.3 (P=0.8), the median anxiety score reverted to 6 (P<0.05) and the median depression score reverted to 4.5 (P<0.05). Conclusion: This observational study during PR, showed that quality of life and the levels of anxiety and depression were improved at the end of the course. After returning home, the average quality of life score remained stable but the level of anxiety and depression increased.
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Rationale: Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients. Objectives: The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide. Methods: Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS. Main results: This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR. Conclusions: The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.
Article
Purpose To evaluate whether postoperative exercise training is effective in improving clinical outcomes such as the quality of life (QoL), exercise capacity and respiratory function of patients receiving pulmonary resection. Data sources The PubMed, EMBASE, Web of Science and PEDro electronic databases were comprehensively searched to identify eligible randomized controlled trials (RCTs). Methods The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The primary outcome was postoperative QoL and secondary outcomes were exercise capacity and respiratory function. Results A total of eight studies involving 691 participants were enrolled in this systematic review and meta-analysis. For the postoperative QoL measured by 36-Item Short Form Health Survey (SF-36), the pooled results demonstrated that postoperative exercise training could significantly improve the SF-36 physical domain score [weighted mean difference (WMD)=5.87, 95% confidence interval (CI): 3.96 to 7.78, P<0.001] and SF-36 mental domain score (WMD=8.15, 95% CI: 0.13 to 16.16, P=0.05). The results of further analysis for the eight dimensions of SF-36 were similar to the overall results. However, for secondary outcomes, no significant effects of postoperative exercise training on exercise capacity and respiratory function were observed. Conclusion Postoperative exercise training could significantly improve the QoL of patients undergoing lung surgery. However, more RCTs with large samples are still needed to verify the effects of postoperative exercise rehabilitation on clinical outcomes of patients who receive pulmonary resection.
Article
Background: Early mobilization is considered an important element of postoperative care; however, how best to implement this intervention in clinical practice is unknown. This systematic review summarizes the evidence regarding the impact of specific early mobilization protocols on postoperative outcomes after abdominal and thoracic surgery. Method: The review was performed according to PRISMA guidelines. We searched 8 electronic databases to identify studies comparing patients receiving a specific protocol of early mobilization to a control group. Methodologic quality was assessed using the Downs and Black tool. Results: Four studies in abdominal surgery (3 randomized controlled trials [RCTs] and 1 observational prospective study) and 4 studies in thoracic surgery (3 RCTs and 1 observational retrospective study) were identified. None of the 5 studies evaluating postoperative complications reported differences between groups. One of 4 studies evaluating duration of stay reported a significant decrease in the intervention group. One of 3 studies evaluating gastrointestinal function reported differences in favor of the intervention group. One of 4 studies evaluating performance-based outcomes reported differences in favor of the intervention group. One of 5 studies evaluating patient-reported outcomes reported differences in favor of the intervention group. Overall methodologic quality was poor. Conclusion: Few comparative studies have evaluated the impact of early mobilization protocols on outcomes after abdominal and thoracic surgery. The quality of these studies was poor and results were conflicting. Although bed rest is harmful, there is little available evidence to guide clinicians in effective early mobilization protocols that increase mobilization and improve outcomes.
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Background: Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review. Objectives: The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality. Search methods: We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019). Selection criteria: We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training. Data collection and analysis: Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria. Main results: Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO2peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO2peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL (MD 5.0 points, 95% CI 2.3 to 7.7 points, 4 studies, 208 participants, low-certainty evidence); improved force-generating capacity of the quadriceps muscle (SMD 0.75, 95% CI 0.4 to 1.1, 4 studies, 133 participants, moderate-certainty evidence); and less dyspnoea (SMD -0.43, 95% CI -0.81 to -0.05, 3 studies, 110 participants, very low-certainty evidence). We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies. Authors' conclusions: Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.
Article
Purpose: The purpose of this review was to investigate the effect of respiratory physiotherapy after lung resection on mortality, postoperative pulmonary complications (PPC), length of stay, lung volumes, and adverse events. Material and methods: Randomized or quasi-randomized controlled trials were searched in CENTRAL, PubMed, EMBASE, Cinahl, PEDro, and hand searching of related studies. Various respiratory physiotherapy interventions were compared to standard care, sham treatment, or no treatment. Two reviewers assessed eligibility and quality of studies using Cochrane guidelines. Meta-analyses were undertaken on subgroups of intervention. Results: Various types of positive pressure breathing, deep breathing exercises, and strength and aerobic exercises as a supplement to standard care did not show any significant effect over standard care in preventing mortality or PPC, reducing length of stay, or improving lung volumes. Conclusion: Prophylactic continuous positive airway pressure does not seem to affect rate of mortality and PPC, when compared with standard care embodying respiratory physiotherapy such as airway clearance techniques and assistance with early ambulation. However, further research is still needed to make a final conclusion. The effect of standard respiratory physiotherapy as a package is still unknown, and may or may not be effective in preventing PPC among patients undergoing lung resection.
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Introduction Lung cancer is a significant burden on societies worldwide, and the most common cause of death in patients with cancer overall. Exercise intervention studies in patients with lung cancer have consistently shown benefits with respect to physical and emotional functioning. However, to date, exercise training has not been consistently implemented into clinical practice given that interventions have been costly and not aligned with clinical care. Methods/design The Precision-Exercise-Prescription (PEP) study is a prospective randomised controlled trial comparing the effectiveness and feasibility of a personalised intervention exercise programme among patients with lung cancer undergoing surgery. Two-hundred patients who are diagnosed with stage primary or secondary lung cancer and are eligible to undergo surgical treatment at Huntsman Cancer Institute comprise the target population. Patients are randomised to either the (1) outpatient precision-exercise intervention group or (2) delayed intervention group. The intervention approach uses Motivation and Problem Solving, a hybrid behavioural treatment based on motivational interviewing and practical problem solving. The dosage of the exercise intervention is personalised based on the individual’s Activity Measure for Post-Acute-Care outpatient basic mobility score, and incorporates four exercise modes: mobility, callisthenics, aerobic and resistance. Exercise is implemented by physical therapists at study visits from presurgery until 6 months postsurgery. The primary endpoint is the level of physical function assessed by 6 min walk distance at 2 months postsurgery. Secondary outcomes include patient-reported outcomes (eg, quality of life, fatigue and self-efficacy) and other clinical outcomes, including length of stay, complications, readmission, pulmonary function and treatment-related costs up to 6 months postsurgery. Ethics/dissemination The PEP study will test the clinical effectiveness and feasibility of a personalised exercise intervention in patients with lung cancer undergoing surgery. Outcomes of this clinical trial will be presented at national and international conferences and symposia and will be published in international, peer-reviewed journals. Ethics approval was obtained at the University of Utah (IRB 00104671). Trial registration number NCT03306992 .
Article
Background: This is an updated version of the original Cochrane Review published in the Cochrane Liibrary 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps. Objectives: To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions? Search methods: We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews. Selection criteria: We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis. Data collection and analysis: In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler. Main results: We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence). Authors' conclusions: Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.
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Currently, only 10–20 % of patients diagnosed with lung cancer are eligible for curative surgical resection. Reasons to dismiss surgical treatment are not only related to advanced oncologic disease but also to severe comorbid conditions and poor functional capacity. Indeed, aerobic fitness has been associated with clinical outcome in lung cancer patients beyond staging. Low peak oxygen consumption (VO2peak) or poor exercise tolerance has been identified as a strong predictor of perioperative complications and postoperative short-term mortality. Therefore implementation of pre- and postoperative muscle training to improve fitness, as best estimated by cardiopulmonary exercise test measuring VO2peak, should be considered to downgrade high-risk patient into a lower-risk profile. Over these last two decades, numerous studies have been published, supporting the safety and feasibility of implementing physical training programs. However, we urgently need high-quality research studies in order to more precisely tailor these rehabilitation programs to each specific group of patients.
Chapter
The respiratory system is particularly susceptible to complications of cancer and cancer therapy. This vulnerability arises from the stringent architectural requirements for gas exchange, the continuous exposure of the respiratory tract to the external environment, and the severe symptoms that can accompany respiratory compromise. Gas exchange requires patent airways, an effective musculoskeletal ventilatory pump, a thin alveolocapillary membrane, and adequate blood flow through the pulmonary circulation. In cancer patients, primary and metastatic tumors of the chest compromise major airways; pleural effusions externally compress the lungs and impair diaphragmatic function; direct, hematogenous, or lymphangitic spread of tumor replaces functioning lung parenchyma; resectional surgery reduces parenchymal volume; nonresectional surgery can transiently impair lung function; radiotherapy, chemotherapy, stem cell therapy, and infection injure the vulnerable alveolocapillary membrane; tumors directly or indirectly compromise the musculoskeletal pump; and venous thromboembolism (VTE) and pulmonary vasculopathy obstruct pulmonary blood flow. The normal respiratory system contains considerable physiologic reserve, such that surgical loss of one lung is generally well tolerated. However, in cancer patients, insults to multiple components of the respiratory system may result in progressive loss of physiologic reserve and increasing dyspnea. Dyspnea, cough, wheezing, stridor, chest pain, and hemoptysis are common symptoms in the cancer setting that lead to pulmonary consultation. In this chapter, we will discuss the pathophysiology, diagnosis, and management of the major respiratory complications of cancer and its therapy. We begin with the direct effects of cancer and cancer therapies on the lungs, review major indirect effects of cancer on the lungs, and end with respiratory failure in the cancer patient.
Chapter
Pulmonary rehabilitation is an important component in the management of lung cancer. It aims to minimise physical and psychological impairments which commonly occur in patients following a diagnosis of lung cancer. There are well-established clinical guidelines regarding exercise for patients with cancer. These recommend at least 150 min of moderate intensity physical activity and two to three resistance training sessions per week, and avoidance of sedentary time. The evidence for exercise specifically in lung cancer is growing rapidly. It shows that pulmonary rehabilitation is associated with improvements in exercise capacity, muscle strength and symptoms, especially when delivered after surgery. Pulmonary rehabilitation before surgery (prehabilitation) is also associated with reduced post-operative complications and hospital length of stay. Pulmonary rehabilitation during chemotherapy or radiotherapy, and for patients with advanced palliative disease appears to be effective at reducing symptoms and improving and/or maintaining exercise capacity and muscle strength. This chapter begins by providing an overview to the topic of thoracic oncology and specifically focuses on lung cancer. The chapter summarises the symptoms of lung cancer, medical treatment and side-effects, common impairments, and the evidence for physical activity and exercise training. It also outlines a number of specific considerations for delivery of pulmonary rehabilitation in the lung cancer setting including patient assessment, exercise prescription, safety, and timing of delivery across the cancer disease trajectory.
Article
This systematic review aimed to examine physical fitness, adherence, treatment tolerance, and recovery for (p)rehabilitation including a home-based component for patients with non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. Studies describing (home-based) prehabilitation or rehabilitation in patients with NSCLC were included from four databases (January 2000-April 2016, N = 11). Nine of ten rehabilitation studies and one prehabilitation study (437 NSCLC patients, mean age 59-72 years) showed significantly or clinically relevant improved physical fitness. Three (27%) assessed home-based training and eight (73%) combined training at home, inhospital (intramural) and/or at the physiotherapy practice/department (extramural). Six (55%) applied supervision of home-based components, and four (36%) a personalized training program. Adherence varied strongly (9-125% for exercises, 50-100% for patients). Treatment tolerance and recovery were heterogeneously reported. Although promising results of (p)rehabilitation for improving physical fitness were found (especially in case of supervision and personalization), adequately powered studies for home-based (p)rehabilitation are needed.
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Background: Little is known about rehabilitation for postthoracotomy non-small cell lung cancer (NSCLC) patients. This research uses a perceived self-efficacy-enhancing light-intensity exercise intervention targeting a priority symptom, cancer-related fatigue (CRF), for postthoracotomy NSCLC patients. This article reports on phase II of a 2-phase study. Phase I focused on initiation and tolerance of exercise during the 6 weeks immediately after thoracotomy, whereas phase II addressed maintenance of exercise for an additional 10 weeks including participants initiating and completing chemotherapy and/or radiation therapy. Objective: The objective of this study was to investigate the feasibility, acceptability, and preliminary efficacy of an exercise intervention for postthoracotomy NSCLC patients to include those initiating and completing adjuvant therapy. Interventions/methods: A single-arm design composed of 7 participants postthoracotomy for NSCLC performed light-intensity exercises using an efficacy-enhancing virtual-reality approach using the Nintendo Wii Fit Plus. Results: Despite most participants undergoing chemotherapy and/or radiation therapy, participants adhered to the intervention at a rate of 88% with no adverse events while giving the intervention high acceptability scores on conclusion. Likewise, participants' CRF scores improved from initiation through the conclusion of the intervention with perceived self-efficacy for walking at a light intensity continuously for 60 minutes, improving significantly upon conclusion over presurgery values. Conclusions: Postthoracotomy NSCLC patients maintained exercise for an additional 10 weeks while undergoing adjuvant therapy showing rehabilitation potential because the exercise intervention was feasible, safe, well tolerated, and highly acceptable showing positive changes in CRF self-management. Implications for practice: A randomized controlled trial is needed to further investigate these relationships.
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In 1995 the American College of Sports Medicine and the Centers for Disease Control and Prevention published national guidelines on Physical Activity and Public Health. The Committee on Exercise and Cardiac Rehabilitation of the American Heart Association endorsed and supported these recommendations. The purpose of the present report is to update and clarify the 1995 recommendations on the types and amounts of physical activity needed by healthy adults to improve and maintain health. Development of this document was by an expert panel of scientists, including physicians, epidemiologists, exercise scientists, and public health specialists. This panel reviewed advances in pertinent physiologic, epidemiologic, and clinical scientific data, including primary research articles and reviews published since the original recommendation was issued in 1995. Issues considered by the panel included new scientific evidence relating physical activity to health, physical activity recommendations by various organizations in the interim, and communications issues. Key points related to updating the physical activity recommendation were outlined and writing groups were formed. A draft manuscript was prepared and circulated for review to the expert panel as well as to outside experts. Comments were integrated into the final recommendation. Primary recommendation: To promote and maintain health, all healthy adults aged 18 to 65 yr need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 min on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 min on three days each week. [I (A)] Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. [IIa (B)] For example, a person can meet the recommendation by walking briskly for 30 min twice during the week and then jogging for 20 min on two other days. Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-min minimum by performing bouts each lasting 10 or more minutes. [I (B)] Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate. In addition, every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week. [IIa (A)] Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. [I (A)]
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Introduction: Intensive care (ICU) survivors have poor quality of life (QoL) and physical outcomes compared to people of the same age and sex [1]. Although rehabilitation of patients in ICU is now advocated as routine clinical prac-tice [2] there are few randomised controlled trials (RCTs) examining patient outcomes. The primary aim of this single blind randomised controlled trial is to investigate the efficacy of a comprehensive rehabilitation intervention begun in ICU compared to standard care on health related quality of life (HRQoL) and physical function. Method: Participants who have been in one tertiary ICU for 5 days, aged 18 years, who can understand written and spoken English, will be randomly allocated to receive either standard care or a comprehensive physiotherapy rehabilita-tion program beginning in ICU and continuing upon discharge to the ward and as an out patient (OP). Blinded assessment of the primary outcome measures physical function, health status and HRQoL will be performed at baseline, 3, 6 and 12 months after discharge. Physical function measures will be obtained at ICU and hospital discharge and for the intervention group, pre and post OP classes. The intervention will include individualised exercises prescribed by physiotherapists in ICU and on the ward and given by an exercise physiologist and physiotherapist in OP. Results: We aim to enrol 200 participants over two years. The study will determine whether comprehensive physiotherapy rehabilitation from ICU to discharge and OP attendance will improve physical functioning, health status and quality of life in critical care survivors. The cost utility (CUA) and cost effectiveness of such a program will also be evaluated using util-ity scores and a purpose designed economics questionnaire. Secondary outcomes related to proxy and subject HRQoL comparisons, mechanical ventilation, critical illness neuromyopathy, ICU readmission and discharge destination will also be examined. Conclusion: The outcomes measured are of significance to critical care patients. The CUA of the intervention will be of interest to health service providers. The results will enable development of clinical practice guidelines for the appropriate exercises in survivors of ICU. Registered with the Australian and New Zealand Clinical Trials Network [ACTRN 12605000776606].
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The CONSORT (Consolidated Standards of Reporting Trials) statement is used worldwide to improve the reporting of randomized, controlled trials. Schulz and colleagues describe the latest version, CONSORT 2010, which updates the reporting guideline based on new methodological evidence and accumulating experience.
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Does a postoperative physiotherapy exercise program incorporating shoulder exercises improve shoulder function, pain, range of motion, muscle strength, and health-related quality of life in patients undergoing elective pulmonary resection via open thoracotomy? Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis. 76 patients who underwent pulmonary resection via open thoracotomy. All participants received standard medical and nursing care involving a clinical pathway. The experimental group also received physiotherapy interventions that included daily supervised, progressive exercises until discharge and a postoperative exercise booklet on discharge. Preoperatively and up to 3 months postoperatively pain was measured with a numerical rating scale, shoulder function with the Shoulder Pain and Disability Index, and quality of life with the Short Form-36. Shoulder range of motion and muscle strength were measured in a subgroup. The experimental group had 1.3 units (95% CI 0.3 to 2.2) less shoulder pain (scored /10) and 2.2 units (95% CI 0.2 to 4.3) less total pain (scored /30) at discharge, and 7.6% (95% CI 1.7 to 13.6) better function at 3 months. The Short Form-36 physical component score was 4.8 points (95% CI -0.3 to 10.0) better for the experimental group than the control group at 3 months. Differences between groups in all range of motion and strength measures were small and statistically non-significant. A physiotherapist-directed postoperative exercise program resulted in significant benefits in pain and shoulder function over usual care for patients following open thoracotomy. ANZCTRN 12605000201673.
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Postoperative pulmonary complications (PPC) are the most frequently observed complications following lung resection, of which pneumonia and atelectasis are the most common. PPCs have a significant clinical and economic impact associated with increased observed number of deaths, morbidity, length of stay and associated cost. The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors. A prospective observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months. PPC was assessed using a scoring system based on chest x-ray, raised white cell count, fever, microbiology, purulent sputum and oxygen saturations. Thirty-four of 234 subjects (14.5%) had clinical evidence of PPC. The PPC patient group had a significantly longer length of stay (LOS) in hospital, high dependency unit (HDU) LOS, higher frequency of intensive care unit (ITU) admission and a higher number of hospital deaths. Older patients, body mass index (BMI) > or =30 kg/m(2), preoperative activity <400 m, American Society of Anesthesiologists (ASA) score > or =3, smoking history, chronic obstructive pulmonary disease (COPD), lower preoperative forced expiratory volume in 1 s (FEV(1)) and predicted postoperative (PPO) FEV(1) were all significantly (p<0.05) associated with PPC on univariate analysis. Multivariate analysis confirmed that age >75 years, BMI > or =30 kg/m(2), ASA > or =3, smoking history and COPD were significant independent risk factors in the development of PPC (p<0.05). The clinical impact of PPCs is marked. Significant independent preoperative risk factors have been identified in current clinical practice. Potentially modifiable risk factors include BMI, smoking status and COPD. The impact of targeted therapy requires further evaluation.
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Regular physical activity may offer benefits to lung cancer survivors, many of whom experience quality-of-life (QOL) impairments. However, little is know about lung cancer survivors' engagement in physical activity across the cancer trajectory. The current study addressed this research gap and also examined the association between lung cancer survivors' physical activity and their QOL. The study participants were 175 individuals who completed surgical treatment for early-stage non-small cell lung cancer 1 to 6 years previously. Participants completed a one-time survey regarding their current QOL and their engagement in physical activities currently, during the 6 months after treatment, and during the 6 months before diagnosis. Participants' reported engagement in both moderate and strenuous intensity activities was lower during the post-treatment period compared with before diagnosis and at the current time. Engagement in light intensity activities did not differ for the three time points. Almost two-thirds of participants did not engage in sufficient activity to meet national physical activity guidelines for any of the three time points. Lung cancer survivors who currently met physical activity guidelines reported better QOL in multiple domains than less active individuals. Engagement in physical activity among lung cancer survivors is particularly low during the early post-treatment period. Current engagement in physical activity is associated with better QOL. However, most lung cancer survivors do not meet physical activity guidelines and may benefit from interventions to promote engagement in regular physical activities.
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This study was undertaken in people with chronic obstructive pulmonary disease to determine differences in incremental shuttle walk test distance and endurance shuttle walk test time when two of each shuttle test were performed before (n = 53 participants) and after an exercise training program (n = 31 participants) and whether the results altered program outcomes. There was a significant increase in incremental shuttle walk test distance between the two incremental shuttle walk tests before (P < 0.001) and after training (P < 0.01). There was no significant difference in the endurance shuttle walk test time between the two endurance shuttle walk tests before (P = 0.95) or after training (P = 0.07). There was a significant increase in both incremental shuttle walk test distance and endurance shuttle walk test time after training (all P < 0.01); however, the increase was greater if the better of the two tests was reported at both time points. The incremental shuttle walk test should be performed twice before and after an exercise training program. This does not seem to be necessary for the endurance shuttle walk test; however, improvement after training was greater if the better of two endurance shuttle walk tests were used to evaluate program outcomes.
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Severe impairment in quality of life (QoL) is one of the major patients' fears about lung surgery. Its prediction can be valuable information for both patients and physicians. The objective of this study was to identify predictors of clinically relevant decline of the physical and emotional components of QoL after lung resection. This is a prospective observational study on 172 consecutive patients submitted to lobectomy or pneumonectomy (2007-2008). QoL was assessed before and 3 months after operation through the administration of the Short Form 36v2 survey. The relevance of the perioperative changes in physical component summary (PCS) and mental component summary (MCS) scales was measured by the Cohen's effect size (mean change of the variable divided by its baseline standard deviation). An effect size >0.8 is regarded as large and clinically relevant. QoL changes were dichotomized according to this threshold. Logistic regression and bootstrap analyses were used to identify reliable predictors of large decline in PCS and MCS. A total of 48 patients (28%) had a large decline in the PCS scale and 26 (15%) in the MCS scale. Patients with a better preoperative physical functioning (p=0.0008) and bodily pain (p=0.048) scores and those with worse mental health (p=0.0007) scores were those at higher risk of a relevant physical deterioration. Patients with a lower predicted postoperative forced expiratory volume in 1s (ppoFEV1; p=0.04), higher preoperative scores of social functioning (p=0.02) and mental health (p=0.06) were those at higher risk of a relevant emotional deterioration. The following logistic equations were derived to calculate the risk of decline in physical or emotional components of QoL, respectively: risk of physical decline: lnR/(1+R): -11.6+0.19XPF, physical functioning+0.05XBP, bodily pain-0.05XMH, mental health; risk of emotional decline: ln R₁/(1+R₁): -8.06-0.03XppoFEV1+0.11XSF+0.055XMH. A consistent proportion of patients undergoing lung resection exhibit an important postoperative worsening in their QoL. We were able to identify reliable risk factors and predictive equations estimating this decline. These findings may be used as selection criteria for efficacy trials on perioperative physical rehabilitation or psychological treatments, during preoperative counseling, in the surgical decision-making process and for selecting those patients who would benefit from physical and emotional supportive programs.
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Early detection and improved treatments for cancer have resulted in roughly 12 million survivors alive in the United States today. This growing population faces unique challenges from their disease and treatments, including risk for recurrent cancer, other chronic diseases, and persistent adverse effects on physical functioning and quality of life. Historically, clinicians advised cancer patients to rest and to avoid activity; however, emerging research on exercise has challenged this recommendation. To this end, a roundtable was convened by American College of Sports Medicine to distill the literature on the safety and efficacy of exercise training during and after adjuvant cancer therapy and to provide guidelines. The roundtable concluded that exercise training is safe during and after cancer treatments and results in improvements in physical functioning, quality of life, and cancer-related fatigue in several cancer survivor groups. Implications for disease outcomes and survival are still unknown. Nevertheless, the benefits to physical functioning and quality of life are sufficient for the recommendation that cancer survivors follow the 2008 Physical Activity Guidelines for Americans, with specific exercise programming adaptations based on disease and treatment-related adverse effects. The advice to "avoid inactivity," even in cancer patients with existing disease or undergoing difficult treatments, is likely helpful.
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Deterioration in exercise tolerance and impairment in quality of life (QoL) are common consequences of lobectomy. This study evaluates additional exercise and strength training after lung resection on QoL, exercise tolerance and muscle strength. Fifty-three (28 male) patients attending thoracotomy for lung cancer, mean age, range 64 (32-82) years; mean pack years (SD) 31.9 (26.8); BMI 25.6 (4.2); FEV1 2.0 (0.7) l were randomised to control (usual care) or intervention (twice daily training plus usual care). After discharge the intervention group received monthly home visits and weekly telephone calls, the control group received monthly telephone calls up to 12 weeks. Assessment pre-operatively, 5 day and 12 weeks post-operatively consisted of quadriceps strength using magnetic stimulation, 6 Minute Walking Distance (6MWD) and QoL-EORTC-QLQ-LC13. QoL was unchanged over 12 weeks; 6MWD showed significant deterioration at 5 days post-operatively compared with pre-operatively, mean difference (SD)-131.6 (101.8) m and -128.0 (90.7) m in active and control groups respectively (p=0.89 between groups) which returned to pre-operative levels by 12 weeks in both groups. Quadriceps strength over the 5 day in-patient period showed a decrease of -8.3 (11.3) kg in the control group compared to increase of 4.0 (21.2) kg in the intervention group (p=0.04 between groups). Strength training after thoracotomy successfully prevented the fall in quadriceps strength seen in controls, however, there was no effect on 6MWD or QoL. 6MWD returned to pre-operative levels by 12 weeks regardless of additional support offered.
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To establish the minimal important difference (MID) for the six-minute walk distance (6MWD) in persons with chronic obstructive pulmonary disease (COPD). Analysis of data from an observational study using distribution- and anchor-based methods to determine the MID in 6MWD. Outpatient pulmonary rehabilitation program at 2 teaching hospitals. Seventy-five patients with COPD (44 men) in a stable clinical state with mean age 70 years (SD 9 y), forced expiratory volume in one second 52% (SD 21%) predicted and baseline walking distance 359 meters (SD 104 m). Not applicable. Participants completed the six-minute walk test before and after a 7-week pulmonary rehabilitation program. Participants and clinicians completed a global rating of change score while blinded to the change in 6MWD. The mean change in 6MWD in participants who reported themselves to be unchanged was 17.7 meters, compared with 60.2 meters in those who reported small change and 78.4 meters in those who reported substantial change (P=.004). Anchor-based methods identified an MID of 25 meters (95% confidence interval 20-61 m). There was excellent agreement with distribution-based methods (25.5-26.5m, kappa=.95). A change in 6MWD of 14% compared with baseline also represented a clinically important effect; this threshold was less sensitive than for absolute change (sensitivity .70 vs .85). The MID for 6MWD in COPD is 25 meters. Absolute change in 6MWD is a more sensitive indicator than percentage change from baseline. These data support the use of 6MWD as a patient-important outcome in research and clinical practice.
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This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy. Seventy-six patients participated in a prospective, single-blind, parallel-group, randomised trial with concealed allocation, assessor blinding and intention-to-treat analysis. Treatment group participants received daily respiratory physiotherapy interventions until discharge. Control group participants received standard medical/nursing care involving a clinical pathway. The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a standardised diagnostic tool. Length of stay was recorded. Postoperative pulmonary complications developed in two participants (4.8%) in the treatment group and in one participant (2.9%) in the control group; the difference (treatment minus control) was 1.8% (95% confidence interval (CI) -10.6% to 13.1%) (p=1.00). No significant difference was found between groups for length of stay (treatment group, median 6.0 days; control group 6.0 days) (p=0.87). A preoperative forced expiratory volume in 1s of 1.5l or less (p=0.005) and a history of chronic obstructive pulmonary disease (p=0.008) were associated with a greater number of criteria for a postoperative pulmonary complication being met. In this patient population, given the low incidence of postoperative pulmonary complications, targeted respiratory physiotherapy may not be required in addition to standard care involving a clinical pathway following pulmonary resection via open thoracotomy. These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function.