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Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial

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Purpose: Cancer-related fatigue (CRF) is a common and relevant symptom in patients with advanced cancer that significantly decreases their quality of life. The aim of this study was to evaluate the effect of a physiotherapy programme on CRF and other symptoms in patients diagnosed with advanced cancer. Methods: The study was designed as a randomized controlled trial. Sixty patients diagnosed with advanced cancer receiving palliative care were randomized into two groups: the treatment group (n = 30) and the control group (n = 30). The therapy took place three times a week for 2 weeks. The 30-min physiotherapy session included active exercises, myofascial release and proprioceptive neuromuscular facilitation (PNF) techniques. The control group did not exercise. The outcomes included Brief Fatigue Inventory (BFI), Edmonton Symptom Assessment Scale (ESAS) and satisfaction scores. Results: The exercise programme caused a significant reduction in fatigue scores (BFI) in terms of severity of fatigue and its impact on daily functioning. In the control group, no significant changes in the BFI were observed. Moreover, the physiotherapy programme improved patients' general well-being and reduced the intensity of coexisting symptoms such as pain, drowsiness, lack of appetite and depression. The analysis of satisfaction scores showed that it was also positively evaluated by patients. Conclusion: The physiotherapy programme, which included active exercises, myofascial release and PNF techniques, had beneficial effects on CRF and other symptoms in patients with advanced cancer who received palliative care. The results of the study suggest that physiotherapy is a safe and effective method of CRF management.
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ORIGINAL ARTICLE
Physiotherapy programme reduces fatigue in patients
with advanced cancer receiving palliative care: randomized
controlled trial
Anna Pyszora
1
&Jacek Budzyński
2
&Agnieszka Wójcik
3
&Anna Prokop
4
&
Małgorzata Krajnik
1
Received: 18 October 2016 /Accepted: 4 May 2017 /Published online: 16 May 2017
#The Author(s) 2017. This article is an open access publication
Abstract
Purpose Cancer-related fatigue (CRF) is a common and rele-
vant symptom in patients with advanced cancer that signifi-
cantly decreases their quality of life. The aim of this study was
to evaluate the effect of a physiotherapy programme on CRF
and other symptoms in patients diagnosed with advanced
cancer.
Methods The study was designed as a randomized controlled
trial. Sixty patients diagnosed with advanced cancer receiving
palliative care were randomized into two groups: the treatment
group (n= 30) and the control group (n= 30). The therapy
took place three times a week for 2 weeks. The 30-min
physiotherapy session included active exercises, myofascial
release and proprioceptive neuromuscular facilitation (PNF)
techniques. The control group did not exercise. The outcomes
included Brief Fatigue Inventory (BFI), Edmonton Symptom
Assessment Scale (ESAS) and satisfaction scores.
Results The exercise programme caused a significant reduc-
tion in fatigue scores (BFI) in terms of severity of fatigue and
its impact on daily functioning. In the control group, no sig-
nificant changes in the BFI were observed. Moreover, the
physiotherapy programme improved patientsgeneral well-
being and reduced the intensity of coexisting symptoms such
as pain, drowsiness, lack of appetite and depression. The anal-
ysis of satisfaction scores showed that it was also positively
evaluated by patients.
Conclusion The physiotherapy programme, which included
active exercises, myofascial release and PNF techniques, had
beneficial effects on CRF and other symptoms in patients with
advanced cancer who received palliative care. The results of
the study suggest that physiotherapy is a safe and effective
method of CRF management.
Keywords Physiotherapy .Cancer-related fatigue .
Exercises .Palliative care
Background
Cancer-related fatigue (CRF) is one of the most common and
complex symptoms experienced by patients diagnosed with
cancer. The National Comprehensive Cancer Network
(NCCN) defines CRF as Ba distressing, persistent, subjective
sense of physical, emotional, and/or cognitive tiredness or
exhaustion related to cancer or cancer treatment that is not
proportional to recent activity and interferes with usual
functioning^[1]. Fatigue associated with cancer has a
*Anna Pyszora
aniap30@wp.pl
Jacek Budzyński
budz@cps.pl
Agnieszka Wójcik
maw5@tlen.pl
Anna Prokop
agajewska@vp.pl
Małgorzata Krajnik
malgorzata.krajnik@wp.pl
1
Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus
Copernicus University in Toruń,Skłodowskiej Curie 9,
85-094 Bydgoszcz, Poland
2
Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus
Copernicus University in Toruń, Ujejskiego 75,
85-168 Bydgoszcz, Poland
3
Faculty of Rehabilitation, Józef Piłsudski University of Physical
Education in Warsaw, Marymoncka 34, 00-968 Warszawa, Poland
4
The Blessed Father Jerzy Popiełuszko Hospice in Bydgoszcz, Ks.
Prałata Biniaka 3, 85-862 Bydgoszcz, Poland
Support Care Cancer (2017) 25:28992908
DOI 10.1007/s00520-017-3742-4
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
complex aetiology. It results from the interaction of two fac-
tors: those related to the disease itself or its treatment, and
reduced physical activity [2,3]. For this reason, the treatment
of CRF should be multi-faceted and include, among others,
physiotherapy [1]. The maintenance of physical activity plays
an important role in the treatment of fatigue. The application
of selected physiotherapy methods enables patients to increase
their physical activity, reduce fatigue and improve their func-
tional status, which has a direct positive impact on their qual-
ity of life [427]. The issues of evaluating the effectiveness of
physiotherapy programmes in the treatment of CRF have been
the subject of interest for numerous researchers. Most studies
were conducted in patient populations undergoing an inten-
sive anticancer regime (i.e. chemotherapy or radiation thera-
py) or those successfully treated [422]. Much less interest
was devoted to the merits of inclusion of physiotherapy in
the treatment of CRF in patients with advanced cancer who
are not given causal treatment anymore and receive palliative
care [2327]. The following study constitutes an attempt to
assess the advisability of including physiotherapy as a treat-
ment for CRF in patients with advanced cancer who were
receiving palliative care. The aims of the study were to assess
the effect of authorial physiotherapy programme on the inten-
sity of CRF and comorbid symptoms and to evaluate whether
the patients were satisfied with such kind of treatment.
Methods
Participants
The study was designed as a randomized, controlled trial. The
study protocol was approved by the Bioethics Committee of
the L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus
Copernicus University in Torun (KB 156/2009). Participants
were recruited from the Palliative Care Department,
Bydgoszcz University Hospital No. 1 and from the in-
patient and home care provided by the Blessed Father
Popieluszko Hospice in Bydgoszcz between January 2010
and May 2011. Eligible patients admitted to the palliative care
service were identified by their physicians and informed about
the study. After giving their preliminary consent to participat-
ing in the study, patientswere offered detailed information and
had the opportunity to ask questions. Patients had 2 days to
decide whether to participate, which was confirmed by their
submission of written consent. The inclusion criteria were
diagnosis of advanced cancer, intensity of fatigue 4 in a 10-
point NRS (Numerical Rating Scale) obtained during the first
visit, survival expectancy of a month at the very least, func-
tional status allowing the patient to participate in the proposed
therapy, 18 years old and written consent to participate in the
study. The exclusion criteria were anaemia (haemoglobin
8 g/dl), the existence of comorbidities causing fatigue (e.g.
multiple sclerosis, Parkinsons disease, heart failure), infection
requiring antibiotics, age <18 and inability to understand writ-
ten and spoken Polish.
Randomization
Patients were randomized into the therapy group and the con-
trol group at the ratio of 1:1. Patients were assigned to respec-
tive groups using a list of numbers ranked in no particular
order, with each new patient assigned a subsequent available
number from the list. Even numbers designated the therapy
group, while odd ones the control group.
Sample size calculation
At the planning stage of the research protocol, the number of
patients required to meet the objectives of the study was spec-
ified. The following assumptions were adopted for the calcu-
lation of the number of sub-groups: normal distribution of
obtained values in the sample, target test power >90% and
the value of statistical significance for the differencealpha
<0.05 (type I error), beta (type II error) <10%, combined stan-
dard deviation (sigma) of 10% of the average and a two-way
test of the null hypothesis assuming no differences in mean
values of the studied parametres between the two groups.
Moreover, the following effectiveness criteria of the therapeu-
tic methods (differences in mean values of the evaluated
parametres) were applied:
&Comparison of two dependent meanseffective final
treatment effect was defined as a 25% reduction in fatigue
after 2 weeks of physiotherapy [2830]
&Comparison of two independent means (therapeutic and
control groups)the final difference in fatigue severity
between the therapy group and the control group was set
at 25%
The required numbers were similar and totalled respective-
ly 21 and 23. Due to the specifics of the population studied
the severity of the disease and the high risk of discontinuation
of the study due to deterioration in the general condition of the
patient or death, the target number of patients in each group
(therapy and control) was set at 30.
Main outcome measures
The primary outcomes were use to measure the severity of
fatigue and its impact on daily functioning and well-being
(Brief Fatigue InventoryBFI) and intensity of other symp-
toms associated with the disease (Edmonton Symptom
Assessment ScaleESAS).
The BFI has nine items, with the items measured on 010
numeric rating scales. Three items ask patients to rate the
2900 Support Care Cancer (2017) 25:28992908
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severity of their fatigue at its Bworst^,Busual^and Bnow^
during normal waking hours, with 0 being Bno fatigue^and
10 being Bfatigue asbad as you can imagine^. Six items assess
the extent to which fatigue interfered with different aspects of
the patients life during the past 24 h. The interference items
include general activity, mood, walking ability, normal work
(includes both work outside the home and housework), rela-
tions with other people and enjoyment of life. The interference
items are measured on a 010 scale, with 0 being Bdoes not
interfere^and 10 being Bcompletely interferes^[31]. The se-
lection of this particular tool was dictated by its concise and
simple form as well as the capacity to assess both the fatigue
severity and its impact on patients daily activities.
ESAS assists in the assessment of nine symptoms common
in patients diagnosed with cancer: pain, fatigue, nausea, de-
pression, anxiety, drowsiness, appetite, well-being and breath-
lessness. The severity at the time of assessment of each symp-
tom is rated from 0 to 10 on a numerical scale, 0 meaning that
the symptom is absent and 10 that it is of the worst possible
severity [32].
Additionally, patient satisfaction was also evaluated in the
treatment group (satisfaction scores, SS). To that end, points
of satisfaction were used ranging from 3to+3(where3
means complete dissatisfaction, 0 no change and +3 complete
satisfaction).
Additionally, data were collected on the following
variables:
&Demographic details such as gender, age and primary
diagnosis
&Karnofsky Performance Scale Index
Interventions
Patients in the therapy group were included into the physio-
therapy program. During the 2-week study period, there were
six therapy sessions in total (three per week). Each individual
session lasted 30 min. The physiotherapy programme includ-
ed active exercises of the upper and lower limbs, selected
techniques of myofascial release (MFR) and selected tech-
niques of proprioceptive neuromuscular facilitation (PNF).
Physiotherapy sessions were always conducted by the same
therapist, licensed in PNF method and trained in the applica-
tion of myofascial release techniques.
For the study design, see Fig. 1.
Parallel treatment
In line with the research protocol, no restrictions were im-
posed on parallel pharmacological treatment. Patients re-
ceived their previous medications, which were entered in the
clinical outcomes record. In the event that during the study a
patient was started on a new regimen that might affect fatigue
severity, it was decided that the patient should be excluded
from the statistical analysis evaluating the effect of physiother-
apy on CRF.
Additionally, throughout the study, the intensity of symp-
toms was monitored using ESAS.
The study protocol assumed that any increase in the sever-
ity of symptoms such as pain, nausea, depression, anxiety and
breathlessness by at least two points on a 010 scale (observed
during two consecutive visits) excluded a patient from the
statistical analysis that assessed the effect of physiotherapy
on CRF. Such an assumption was based on observations from
the study by Yennu et al. and Yennurajalingam et al. [33,34]
in an advanced cancer population, which showed that the in-
tensity of these symptoms strongly correlated with fatigue
severity.
Statistical analysis
The statistical analysis of the study results was performed
using Statistica 9.1 for Windows.
DAY 0, VISIT 1
- qualification for the study (inclusion/exclusion criteria)
- Karnofsky Performance Scale Index
- obtaining patient consent
- randomization
Randomized patients
(n=60)
THERAPY GROUP
(n=30)
DAY 1
BFI, ESAS, THERAPY
DAY 3
BFI, ESAS, THERAPY
DAY 5
BFI, ESAS, THERAPY
DAY 8
BFI, ESAS, THERAPY
DAY 10
BFI, ESAS, THERAPY
DAY 12
BFI, ESAS, THERAPY
CONTROL GROUP
(n=30)
DAY 1
BFI, ESAS
DAY 3
BFI, ESAS
DAY 5
BFI, ESAS
DAY 8
BFI, ESAS
DAY 10
BFI, ESAS
DAY 12
BFI, ESAS
Withdrawn (n=1).
Death
Withdrawn (n=1).
Death
Completed trial (n=29)
Excluded from analysis
(n=1)
Completed trial (n=29)
Excluded from analys is
(n=1)
Fig. 1 Study design
Support Care Cancer (2017) 25:28992908 2901
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The obtained data are presented as mean or median
values ± SD (standard deviation) or 95% CI (confidence in-
terval). The distribution of variables was verified using the
Shapiro-Wilk test. Comparisons of statistical significance of
differences between the median values of parametres on suc-
cessive observation days and between groups were performed
using one- and two-way ANOVA (analysis of variance) with
an appropriate number of repeats. In order to assess the sig-
nificance of differences in the tested parametres at individual
measurement points, a post hoc LSD (least significant differ-
ence) test was used. The significance of differences between
mean values in the treatment and control groups was assessed
using Studentsttest for independent samples (normal vari-
able distribution) or the Mann-Whitney Utest. The power of
the statistical analysis was 90%; the differences between
groups or the analysed time points were considered statistical-
ly significant at P<0.05.
Results
Characteristics of study participants
The study included 60 patients (n= 60). Participants were
randomized into the therapy group and the control group at
the ratio of 1:1. Study groups (therapy and control) did not
differ significantly with respect to age, tumour location and
the study site. However, a significant gender difference was
observed with respect to the assignment to the control or ther-
apy groups, respectively (P= 0.03). Demographic and clinical
characteristics of the patients qualified for the study are shown
in Table 1.
Parallel treatment
In the course of the study, drug regimen was modified in two
patients (one in each group) whose general condition had de-
teriorated, which excluded them from the study. These pa-
tients were also excluded from the statistical analysis of the
impact of physiotherapy on the fatigue level. None out of the
60 patients in the study sample was on the anticancer therapy.
Discontinuation of the study
The study was discontinued for two patients (n=1,therapy
group and n= 1, control group). The cause of their death was
advanced cancer. Those patients were excluded from the sta-
tistical analysis of the impact of physiotherapy on the severity
of fatigue. They were the same patients who needed modified
pharmacological treatment.
Effect of physiotherapy program on fatigue (BFI)
The analysis of the impact of physiotherapy program on the
severity of fatigue included 29 patients from the treatment
group and 29 patients from the control group. It was found
that physiotherapy program significantly reduced fatigue se-
verity in patients evaluated using the BFI. After 12 days, the
results demonstrated a significant decrease in fatigue scores
(BFI) compared with baseline (Wilcoxon test):
&In the treatment group on all the questions, mean score
6.4 ± 1.0 vs. 4.4 ± 1.4, P<0.01
&In the control group on questions 1 and 3, mean score
6.13 ± 1.4 vs. 5.9 ± 1.44, P<0.01
As compared with the control group, the treated individuals
had significantly lower scores on the BFI on questions 1, 2, 3,
4a, 4b, 4e and 4f. Significant differences were observed on
average as of day 8 of physiotherapy (Figs. 2and 3).
Impact of physiotherapy program on the severity
of fatigue and other symptoms (ESAS)
Throughout the study, the severity of symptoms was evaluated
using ESAS both in the treatment and in the control groups. At
baseline, no significant differences were observed regarding
ESAS parametre values between the groups (Table 2).
However, the comparison of scores for individual symptoms
between baseline and the evaluation at the end of the study
revealed a statistically significant beneficial effect of therapy
in terms of reduced severity of the following: pain, fatigue,
depression, anxiety, drowsiness, well-being and improved ap-
petite (P< 0.01) (Table 3). Similar effects were not observed
in the control group (Table 4). After 14 days of physiotherapy,
the therapy group compared with the control group reported a
statistically significant reduced severity of fatigue and drows-
iness; moreover, patients in the therapy group rated their well-
being higher (Table 2, Fig. 4).
Satisfaction with physiotherapy program
At the end of physiotherapy program, the mean level of patient
satisfaction was 1.6 ± 0.8 (min. = 0, max. = 3). Of the 29
patients under observation, 26 rated the therapy as positive
(+3, n=3;+2,n= 14; +1, n= 9), whereas three patients rated
it as neither positive nor negative.
Discussion
One of the elements of multifaceted symptom management in
palliative care is physiotherapy. The main aim of physiother-
apy in this patient population is to improve quality of life by
2902 Support Care Cancer (2017) 25:28992908
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way of alleviating troublesome symptoms and allowing the
patients to function at an optimal level [35]. The effectiveness
of physiotherapy in the treatment of selected symptoms in
patients with advanced cancer has been confirmed on numer-
ous occasions. These symptoms include, among others,
myofascial pain, lymphoedema, breathlessness, constipation
or motor deficits secondary to neurological disorders [3641].
CRF is rarely recognized as an indication for physiothera-
py. The effect of physiotherapy programs on CRF in patients
with advanced cancer had not been extensively studied. So far,
the issue of physical exercises used for relieving fatigue in
patients with advanced cancer was analysed only by Porock
et al., Buss et al., Oldervoll et al., Van den Dungen et al. and
Cheville et al. [2428]. In their study, Porock et al. [24]
Fig. 2 Mean change in BFI score
from baseline (questions 13).
Legend: rate your (1) level of fa-
tigue right now, (2) level of fa-
tigue during the past 24 h, and (3)
the worst level of fatigue during
the past 24 h
Tabl e 1 Demographic and
clinical characteristics of patients
qualified for the study
Data Therapy group Control group P
Age (mean ± SD) 72.4 ± 9.5 69.3 ± 13.7 0.32
Gender F = 15 (50%) F = 24 (80%) 0.03
M = 15 (50%) M = 6 (20%)
Tumour location Alimentary system, n= 7 Alimentary system, n= 8 0.33
Urogenital system, n= 8 Urogenital system, n=5
Lung, n=2 Lung,n=3
CNS, n= 4 CNS, n=1
Mammary gland, n= 2 Mammary gland, n=6
Haematological, n= 2 Haematological, n=4
Indefinite origin, n= 4 Indefinite origin, n=2
Mouth, n= 1 Skin, n=1
Study site Home care, n=24 Homecare,n=21 0.54
Hospice, n= 3 Hospice, n=6
PCD, n= 3 PCD, n=3
KPSI 46.0 ± 7.2 48.0 ± 11.0 0.41
Fatigue
NRS, 010
6.8 ± 1.1 6.5 ± 1.4 0.41
Pborderline level of statistical significance, SD standard deviation, Mmale, Ffemale, CNS central nervous
system, PCD palliative care department, KPSI Karnofsky Performance Scale Index, NRS numeric rating scale
Support Care Cancer (2017) 25:28992908 2903
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included only 11 patients with advanced cancer, suffering
from fatigue. The study lasted 28 days and patients did not
follow a single exercise therapy. The therapy involved exer-
cises in bed, exercises in a sitting position, treadmill walking,
cycle-ergometer exercises and dancing to the rhythm of
favourite music. The exercise programs were tailored to the
needs and physical capacity of individual patients. Therefore,
individual interventions differed significantly in duration
(ranging from 22 to 180 min per week). Although the authors
did not observe any significant reduction in fatigue levels
within the studied group, they pointed to the fact that the
therapy regimens patients received did not increase their
Fig. 3 Mean change inBFI score from baseline(questions 4a4f). Legend: rate how fatiguehas interfered with the following: 4ageneral activity, 4b
mood, 4cwalking ability, 4dnormal work, 4erelations with other people and 4fenjoyment of life).
Tabl e 2 Scores representing the
severity of symptoms evaluated
using ESAS in both subsets at
baseline and after 12 days of
physiotherapy
Symptoms (ESAS) Treatment group (n= 29) Control group (n=29) P
pain_1 1.5 ± 1.9 1.7 ± 2.1 0.6
fatigue_1 6.8 ± 1.1 6.5 ± 1.4 0.4
nausea_1 0.4 ± 1.0 1.1 ± 2.2 0.1
depression_1 2.9 ± 2.3 2.9 ± 2.5 0.9
anxiety_1 2.7 ± 2.3 2.7 ± 2.5 1.0
drowsiness_1 3.6 ± 2.9 4.0 ± 2.7 0.6
appetite_1 4.3 ± 2.9 4.0 ± 3.0 0.7
well-being_1 4.8 ± 0.9 5.3 ± 1.3 0.1
breathlessness_1 1.0 ± 1.8 0.9 ± 1.6 0.9
pain_12 1.2 ± 1.5 1.7 ± 2.0 0.2
fatigue_12 4.6 ± 1.6 6.3 ± 1.2 <0.01
nausea_12 0.3 ± 0.8 0.9 ± 2.0 0.1
depression_12 2.7 ± 2.1 2.8 ± 2.6 0.8
anxiety_12 2.5 ± 2.1 2.5 ± 2.5 0.9
drowsiness_12 2.3 ± 2.1 3.8 ± 2.7 <0.05
appetite_12 3.1 ± 2.5 3.8 ± 2.8 0.4
well-being_12 3.0 ± 1.2 5.0 ± 1.3 <0.01
breathlessness_12 0.8 ± 1.5 0.9 ± 1.6 0.7
ESAS Edmonton Symptom Assessment Scale, Pborderline level of significance
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fatigue levels. Furthermore, the applied therapy regimens
were positively evaluated by the patients, as they tangibly
increased patientsdaily physical activity. Buss et al. also
attempted to assess the effectiveness of exercise interventions
in reducing fatigue in the terminal hospice cancer patients
[25]. They assessed the effect of a single, well-defined, repro-
ducible across the entire group of patientsexercise program
on quality of life and fatigue in the hospice terminal cancer
patients. The study group comprised 38 patients. Their analy-
sis showed that, on average, after 3 weeks of a physical ther-
apy exercise program, a significant decrease in fatigue levels
was observed, while in the control group, it increased after
2 weeks of observation. It should be noted, however, that
patients with short life expectancy (approx. 12 months) were
among those admitted into the study by Buss et al. A similar
criterion was used in the present study, i.e. approx. 1
3 months. For that reason, a timeline for the study was set at
2 weeks. Extending time frames of interventions in the case of
short life expectancy patients increases a risk of their non-
completion of a study. This is usually associated with deteri-
oration of general condition, disease progression or death.
Oldevoll et al. [26] pursued their study for 8 weeks. Patients
with advanced cancer with a life expectancy <2 years were
included in the study. Out of 231 patients, 68 (29%) were lost
as a result of disease progression. The study evaluated the
effects of a group exercise intervention, supervised by a phys-
iotherapist. The exercise group had two exercise sessions per
week over an 8-week period. Each session lasted 5060 min
and included a warm-up (1015 min), circuit training with six
stations (30 min) and stretching/relaxation (1015 min). The
analysis showed no significant reduction in fatigue levels in
the study group. The applied intervention enhanced physical
performance. The gait and muscle strength test results were
significantly improved after 8 weeks of physical exercise.
Improvement in physical fitness was also noted by van den
Dungen et al. [27]. Their non-randomized pilot study com-
prised 26 palliative care patients with advanced cancer.
Participants followed an individually graded group exercise
program, consisting of resistance training and aerobic exer-
cise, twice a week during 6 weeks. Apart from improved
physical fitness, the authors observed improved quality of life
and reduced fatigue in patients. Cheville et al. [28] assessed
the effectiveness of a home-based physiotherapy. Sixty-six
adults with stage IV lung or colorectal cancer were admitted
into the study. They were randomized, in an 8-week trial, to
usual care or incremental walking and home-based strength
training. The exercising participants were instructed during a
single physiotherapy visit and subsequently exercised 4 days
or more per week; training and step-count goals were ad-
vanced during bimonthly telephone calls. A home-based ex-
ercise program seems capable of improving the mobility, fa-
tigue and sleep quality of patients with stage IV lung and
colorectal cancer.
Much more research on the evaluation of physiotherapy
treatment in terms of CRF reduction was conducted in popu-
lations of patients undergoing an intensive oncological regi-
men and those who have been successfully treated. Results of
research in this area show that the treatment groups achieve a
statistically more effective fatigue reduction compared with
controls. The authors have identified exercise as a beneficial
and valuable form of treatment for fatigue among patients
undergoing intensive anticancer therapy and patients with
chronic fatigue that persists despite completed oncological
treatment. At the same time, they signalled the need for re-
search aimed at optimizing the type, intensity and duration of
specific therapeutic interventions. The need to develop clear
guidelines on the use of physiotherapy in the treatment of
fatigue was also confirmed by a survey conducted among
British physiotherapists working with cancer patients and
Tabl e 3 Scores representing the severity of symptoms evaluated using
ESAS in the treatment group at baseline and after 12 days of
physiotherapy
Symptoms (ESAS) symptom_1 symptom_12 P
Pain 1.5 ± 1.9 1.2 ± 1.5 <0.01
Fatigue 6.8 ± 1.1 4.6 ± 1.6 <0.01
Nausea 0.4 ± 1.0 0.3 ± 0.8 0.08
Depression 2.9 ± 2.3 2.7 ± 2.1 <0.01
Anxiety 2.7 ± 2.3 2.5 ± 2.1 <0.01
Drowsiness 3.6 ± 2.9 2.3 ± 2.1 <0.01
Appetite 4.3 ± 2.9 3.1 ± 2.5 <0.01
Well-being 4.8 ± 0.9 3.0 ± 1.2 <0.01
Breathlessness 1.0 ± 1.8 0.8 ± 1.5 0.18
symptom_1 intensity of a particular symptom on day 1 of observation,
symptom_12 intensity of a particular symptom on day 12 of observation,
ESAS Edmonton Symptom Assessment Scale, Pborderline level of
significance
Tabl e 4 Scores representing the severity of symptoms evaluated using
ESAS in the control group at baseline and after 12 days of physiotherapy
Symptoms (ESAS) symptom_1 symptom_12 P
Pain 1.7 ± 2.1 1.7 ± 2.0 0.16
Fatigue 6.5 ± 1.4 6.3 ± 1.2 0.031
Nausea 1.1 ± 2.2 0.9 ± 2.0 0.33
Depression 2.9 ± 2.5 2.8 ± 2.6 0.33
Anxiety 2.7 ± 2.5 2.5 ± 2.5 0.16
Drowsiness 4.0 ± 2.7 3.8 ± 2.7 0.08
Appetite 4.0 ± 3.0 3.8 ± 2.8 0.057
Well-being 5.3 ± 1.3 5.0 ± 1.3 0.022
Breathlessness 0.9 ± 1.6 0.9 ± 1.6 1.0
symptom_1 intensity of a particular symptom on day 1 of observation,
symptom_12 intensity of a particular symptom on day 12 of observation,
ESAS Edmonton Symptom Assessment Scale, Pborderline level of
significance
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members of the Association of Chartered Physiotherapists in
Oncology and Palliative Care (ACPOPC) [42].
Studies evaluating the effectiveness of selected physiother-
apy methods in the treatment of fatigue support the use of this
form of therapy among patients diagnosed with cancer.
However, there are substantial differences among individual
researchers concerning the duration of the therapy and its fre-
quency. The authors of the publications studied, among
others, the effectiveness of an exercise regimen carried out
individually or in groups 27timesaweekfor28weeks.
The duration of a single therapy session ranged from 20 to
90 min. The protocol adopted for the present study included
30-min physiotherapy sessions three times a week for 2 weeks.
The planned follow-up period proved to be long enough to
observe changes in fatigue severity due to physiotherapy,
since statistically significant differences were already ob-
served on average as of day 8 of the intervention.
Simultaneously, in the vast majority of patients (n=58),there
was no disease progression or increased severity of symp-
toms; hence, they did not require additional pharmacological
treatment. The comparison of ESAS scores between baseline
and the day the observation ended showed statistically signif-
icant beneficial effects of the physiotherapy. It may have had a
significant impact on the high level of treatment satisfaction.
The proposed physiotherapy program, including active ex-
ercises of upper and lower extremities, selected techniques of
myofascial relaxation and PNF, was devised by the author of
the study. The selection of individual components of the treat-
ment program reflected the desire to devise a treatment plan
specially tailored to the condition of the patients participating
in the study. However, the formulation of specific guidelines
on physical therapy programs used as part of fatigue treatment
requires more research. In most published studies, the selec-
tion of specific physiotherapy techniques is quite varied.
Therapies include, among others, active exercises (resisted
and unresisted), balance exercises, breathing and relaxation
and ergometer training [427]. The selection of specific ther-
apies should be based on a careful individual analysis of the
potential and limitations of particular patients. This is espe-
cially important in a population of patients diagnosed with
advanced cancer receiving palliative care. They tend to be
reluctant to undertake physical activity giving reasons such
as limited fitness and functional capacity [43]. Moreover, in
this population, fatigue is often accompanied by the anorexia-
cachexia syndrome. The patient who notes a progressive loss
of body mass and suffers from anorexia, whose fatigue in-
creases with each movement, may at first refuse to participate
in any treatment proposed by a physiotherapist for fear that
his/her exhaustion may increase. Hence, the physiotherapy
program should include both the treatment elements that do
not require large expenditures of energy on the part of the
patients and methods that actively engage them. For this rea-
son, the proposed program included relaxation techniques
(myofascial relaxation, breathing stimulation) and more active
methods (active exercises, selected PNF techniques).
The rationale for the use of this kind of fatigue treatment
programs was evaluated in studies conducted by Fernández-
Lao et al. [44,45] among patients with breast cancer once they
completed their anticancer treatment. The proposed physio-
therapy regime included core stability exercises and elements
Fig. 4 Self-rated severity of
symptoms on consecutive
observation days (ESAS)
2906 Support Care Cancer (2017) 25:28992908
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
of myofascial release. Results of the study indicate a high
effectiveness of the proposed physiotherapy program in re-
lieving fatigue and other symptoms associated with anxiety
and depression. Moreover, the treatments improved the pa-
tientsmuscle strength and their overall fitness. Similar posi-
tive therapeutic effects were not observed in the control group.
In devising physiotherapy programs for the treatment of
fatigue, it is very important to include simple exercises easy
to remember by the patient. The inclusion of such therapy
forms is of great importance since they can be used as part
of movement activation exercises to be performed by each
patient individually.
The results of the present study clearly demonstrate that
cancer-related fatigue in patients with advanced cancer consti-
tutes an indication for the inclusion of physiotherapy in their
non-pharmacological treatment. However, the issue requires
more detailed research involving large groups of advanced
cancer patients receiving palliative, hospice and home care,
respectively.
The main limitation of the study was the fact that despite
the randomization, the process of group assignment itself
showed a significant association with gender (P=0.03).Itis
worth noting, however, that there was no significant correla-
tion between gender and the effect of physiotherapy on the
severity of fatigue.
Conclusions
The proposed physiotherapy program significantly reduces
the severity of fatigue in patients diagnosed with advanced
cancer receiving palliative care. Additionally, this program
improves the general well-being of patients and reduces the
severity of their comorbid symptoms, especially pain, drows-
iness, loss of appetite and depression. The proposed physio-
therapy program was positively rated by patients who com-
pleted treatment satisfaction questionnaire. Non-
pharmacological treatment of fatigue in advanced cancer pa-
tients receiving palliative care should include an appropriate
selection of physiotherapy methods.
ANOVA, analysis of variance; BFI, Brief Fatigue
Inventory; CI, confidence interval; CRF, cancer-related fa-
tigue; ESAS, Edmonton Symptom Assessment Scale; LSD,
least significant difference; MFR, myofascial release; NCCN,
National Comprehensive Cancer Network; NRS, Numerical
Rating Scale; P, borderline level of statistical significance;
PNF, proprioceptive neuromuscular facilitation; SD, standard
deviation; SS, satisfaction scores
Acknowledgments The authors thank all medical and nursing staff of
the Blessed Father Jerzy Popieluszko Hospice in Bydgoszcz and of the
Palliative Care Department, University Hospital No. 1 in Bydgoszcz,
where patients were recruited. Finally, the authors wish to thank all the
participating patients.
Authorscontributions AP conceived the idea for the study. AP, MK,
JB and AW contributed to the design of the research. AP and APr were
involved in data collection. AP, MK and JB analysed the data. MK coor-
dinated funding for the project (institutional funding). All authors edited
and approved the final version of manuscript.
Compliance with ethical standards
Competing interests The authors declare that they have no competing
interests.
Funding Funding for this study was provided by the Nicolaus
Copernicus University Collegium Medicum, Bydgoszcz, Poland (institu-
tional funding).
Consent for publication Not applicable.
Ethical approval and consent to participate Written informed con-
sent was obtained from all participants. Confidentiality and anonymity
were guaranteed. The study protocol was approved by the Bioethics
Committee of the L. Rydygier Collegium Medicum in Bydgoszcz,
Nicolaus Copernicus University in Torun (KB 156/2009).
Open Access This article is distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International License (http://
creativecommons.org/licenses/by-nc/4.0/), which permits any noncom-
mercial use, distribution, and reproduction in any medium, provided
you give appropriate credit to the original author(s) and the source, pro-
vide a link to the Creative Commons license, and indicate if changes were
made.
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... CRF is a persistent and subjective sense of fatigue and activity intolerance caused by cancer itself and surgery, which cannot be alleviated by sleep and rest, and is the most intolerable adverse reaction in patients with cancer [3]. The National Comprehensive Cancer Network believes that anemia, depression, pain, sleep disorders, and nutrition may all be related to CRF based on research on CRF symptoms [4]. Thus, CRF has a significantly negative impact on patients' quality of life, and comprehensive research has found that the influencing factors of CRF mainly include the following aspects: cancer type and treatment pathways, psychological factors, socioeconomic factors, and cancer complications [4]. ...
... The National Comprehensive Cancer Network believes that anemia, depression, pain, sleep disorders, and nutrition may all be related to CRF based on research on CRF symptoms [4]. Thus, CRF has a significantly negative impact on patients' quality of life, and comprehensive research has found that the influencing factors of CRF mainly include the following aspects: cancer type and treatment pathways, psychological factors, socioeconomic factors, and cancer complications [4]. CRF is an ever-changing subjective feeling. ...
Article
Background: Scientific and effective nursing methods can effectively mitigate negative emotions in patients. Related studies have shown that systematic nursing interventions are beneficial in enhancing the self-efficacy and self-care abilities of patients and improving their physical and mental state, thereby alleviating their fatigue and improving their quality of life. Aim: To explore the effects of systematic nursing intervention on cancer-related fatigue, self-efficacy, self-nursing ability, and quality of life in gastric cancer (GC) patients during the perioperative period. Methods: In this study, sample size was based on the multivariable scale. The sample size was 10 times the acceptable variable, with an additional 20% added to account for an expected loss of patients in follow-up for a final sample size of 168 patients. Conventional nursing measures were used in the control group, while the systematic nursing intervention Adopted Cancer Fatigue Scale (CFS), General Self-Efficacy Scale-Schwarzer (GSES), Self-Care Agency Scale (ESCA), and simple health scale (SF-36) were used in the observation group. The questionnaires were administered on admission and discharge. Results: At admission, there was no statistically significant difference in the scores on each scale between the groups. At discharge, the CFS and GSES scores in the observation group were 21.56 ± 2.24 and 51.16 ± 11.71, while those in the control group were 29.61 ± 3.48 and 41.58 ± 8.54, respectively, with statistically significant differences. The ESCA score in the observation and control groups was 112.09 ± 11.72 and 97.87 ± 9.26, respectively. Moreover, the scores in all dimensions (self-concept, self-responsibility, health knowledge level, and self-care skills) in the observation group were higher than those in the control group, with statistically significant differences. The SF-36 score in the observation and control groups was 75.51 ± 3.63 and 63.24 ± 3.41, respectively, with statistically significant differences. The scores in all dimensions (mental health, vitality, physical function, physical pain, social function, emotional function, and overall health level) in the observation group were higher than those in the control group, with statistically significant differences. Conclusion: Systemic nursing intervention for GC patients during the perioperative period could alleviate cancer-related fatigue, improve self-efficacy and self-nursing ability, and improve quality of life, which all have clinical value.
... Web-based selfmanagement is considered as an important route for improving fatigue and HRQOL significantly more than the routine care among patient with cancer. Pyszora A et al (2017) concluded that physiotherapy program that includes 1) active exercise, 2) MFR, and 3) PNF facilitates a considerable reduction of CRF in post palliative care of cancer patients. [52] Similar study was done by Villanueva et al (2012) on 78 patients between the agegroup of 25-65 years for a period of 8 weeks. ...
... Pyszora A et al (2017) concluded that physiotherapy program that includes 1) active exercise, 2) MFR, and 3) PNF facilitates a considerable reduction of CRF in post palliative care of cancer patients. [52] Similar study was done by Villanueva et al (2012) on 78 patients between the agegroup of 25-65 years for a period of 8 weeks. [53] The experimental group receives physical training (core stability exercises) for 4 hours followed by 12 hours of recovery procedures (MFR) 3 times/week for a period of 90 min each. ...
Article
Full-text available
Globally, breast cancer is considered one of the most common types of cancer among women. The National Institute of Health in collaboration with the National Coalition for Cancer Survivorship defines cancer survivors as an individual from the time of cancer diagnosis, through the balance of his or her life. Cancer-related Fatigue (CRF) is described as the distressing side effects of cancer and its treatment associated with physical, mental, and emotional manifestations including generalized weakness, diminished concentration, or attention, decreased motivation or interest to engage in normal activities and emotional lability. There are several validated tools for measuring cancer-related fatigue. The search for the relevant journal was carried out referring through many databases: PubMed, PubMed Central, Cochrane, and PEDro and mainly focuses on the RCTs, clinical trials, and systemic reviews. There are varieties of physical therapy interventions that play a beneficial role in reducing Cancer-related Fatigue followed by improvement in the physical activities, functional status thereby enhancing the lifestyle & quality of life among breast cancer survivors. These interventional programs will only be effective if the patient strictly adheres and follow the pre-designed exercise protocols referring through many guidelines for an effective outcome. The purpose of this research is to identify various effective assessment and physiotherapeutic interventions according to evidence-based studies on cancer-related fatigue among breast cancer survivors.
... In particular, the focus is on the care of cancer patients to take place in nearby hospitals or at home. This form of rehabilitation is an extension of hospice care for end-of-life patients [25][26][27]. ...
... While in 50% of the trial's outcome assessment, blinding had a high risk of bias 22, 25, 28-30, 32, 34, 35 . The risk of bias could not be ensured from the method defined for other bias from some studies 27,33,35 . ...
Article
Full-text available
Background: Cancer is ranked as the 2nd common deadliest disorder worldwide, and the growing incidence demands updating and optimizing the treatment strategies for cancer survivors. However, evidence regarding this area is scarce; therefore, this systematic review aimed to evaluate the effects of Physiotherapy (PT) in managing cancer-related pain and fatigue. Methodology: Electronic search conducted utilizing Google Scholar, Embase.com, Cochrane CENTRAL via Wiley, Web of Science Core Collection, MEDLINE via Ovid, PEDro, and PubMed. Randomized controlled trials published from 2014 to April 2021 analyzing the effects of PT approaches for cancer-related pain and/or fatigue management in adult cancer patients were included in the review. Sixteen eligible trials were evaluated, of which eight trials addressed Cancer-Related Pain (CRP) while others addressed Cancer-Related Fatigue (CRF). The risks of bias and trials credibility were analyzed via the Cochrane tool to assess bias risk. Results: Strong evidence favors the effectiveness of various PT approaches mainly, aerobic and resistance exercises for CRF and CRP management. However, endurance exercises, high-intensity interval training, and myofascial release were effective in CRF management. In contrast, Xbox Kinect-based games, stretching, lymphatic drainage, and passive mobilization effectively reduced CRF. Conclusion: Large body of evidence supports the effectiveness of PT exercises mainly, aerobic and resistance exercises, in cancer-associated pain and fatigue management. Hence exercises prescriptions should be implemented in the treatment plan of cancer patients.
Article
There are a large number of publications confirming the clinical safety of the of physiotherapy application in patients with malignant neoplasms of the breast, but scientific studies on the physical factors complex use in medical rehabilitation of this group of patients in the early postoperative period have not been published yet. Aim. To determine the effectiveness of fluctuating currents in combination with pneumocompression, general magnetotherapy, local magnetotherapy, low-temperature argon plasma applied for patients after radical surgical treatment of breast cancer in the early postoperative period. Material and methods. A prospective, simple, randomized study involving 190 women diagnosed with breast cancer in the early postoperative period after radical Madden mastectomy or radical breast resection (2–4 days) was performed, the average age was 58±10.61 years. The control group consisted of patients included in the course of rehabilitation (exercise therapy, balance therapy and classes with a medical psychologist) fluctuating currents. Low-temperature argon plasma, intermittent pneumocompression, general and local magnetotherapy were added to fluctuations for patients in the main groups. Results and discussion. The analysis of the clinical and functional data showed that in the early postoperative period for breast cancer against the background of the standard drug therapy and the course of medical rehabilitation, the combination of fluctuating currents with intermittent pneumocompression, general and local magnetotherapy significantly reduced the degree of the upper limb edema and the volume of lymphorrhea. The addition of general and local magnetotherapy affects the decrease in the indicators of the shoulder girdle and forearm muscles electrical excitability. Low temperature argon plasma improves the regeneration of the postoperative suture and reduces swelling and inflammation in this area. The dynamics of the decrease in the level of anxiety and depression, pain syndrome and the general condition of cancer patients are most pronounced in the groups that additionally received magnetotherapy. The volume and quality of movements, muscle strength significantly increased in all groups without differences in results. The action of magnetic fields contributes to the increase of tissue oxygenation, due to which an anti-inflammatory and decongestant effect is realized. Fluctuation of the shoulder girdle and forearm muscles leads to normalization of the functional electrical excitability of the muscles by surgical treatment, which allows to restore the motor stereotype of the limb in a short time, and intermittent pneumocompression affecting the skin and tissue structures of the lower extremities and trunk improves the overall lymph flow, which does not lead to stagnation of lymph in the operated area. Conclusion. Thus, the combined application of physical factors against the background of the standard drug therapy and the course of medical rehabilitation significantly improves the result and recovery time after surgical treatment of the breast cancer in the early postoperative period. A comprehensive approach to medical rehabilitation at the I stage led to the preservation of results in the long-term period 1.5 and 6 months after the operation without adverse events.
Article
Objectives This study was aimed to analyse the effect of a patient-oriented modality of physical exercise (programmed and directed physical exercise (PDPE)) on cancer-related fatigue (CRF) and quality of life (QoL). The secondary aim was to evaluate changes in body composition and skeletal muscle function during the study in patients with and without PDPE. Methods A prospective randomised study was conducted to analyse the impact of PDPE on CRF and QoL. Patients were selected before the development of CRF to set the intervention before its appearance. A high probability CRF population was chosen: patients with advanced gastrointestinal cancer undergoing chemotherapy with weight loss (≥5%) over the last 6 months. PDPE consisted of a programme of exercise delivered weekly and adjusted to patients’ medical conditions. Four visits were planned (weeks 0, 4, 8 and 12). QoL, CRF, body composition and skeletal muscle function were evaluated in each visit. Results From 101 patients recruited, 64 were considered evaluable, with three or four visits completed (n=30 control, n=34 PDPE group). Satisfactory compliance of ≥50% to the PDPE programme was seen in 47%. A reduction in the severity of fatigue was detected in the PDPE group (p=0.019), being higher in the subgroup of satisfactory compliance (p<0.001). This latter group showed better results of QoL in comparison with the control group (p=0.0279). A significant increase in endurance was found in the PDPE group (p<0.001). Conclusion PDPE reduced the severity of fatigue and improved QoL. The difference in endurance would explain the results seen in the severity of fatigue.
Article
Background: Persons with hematologic malignancies have a high symptom burden throughout the illness journey. Coping skills interventions effectively reduce fatigue for other cancer patients. The purpose of this systematic review is to identify if coping interventions can reduce fatigue in patients with hematologic malignancies. Methods: A search of PubMed, Embase, CINAHL, APA Psych INFO, Scopus, Cochrane, and non-traditional publications was performed in June 2021 for studies introducing coping interventions for adults with hematological cancers within the past 20 years. The Transactional Model of Stress and Coping was used as a framework with fatigue as the primary outcome. The Johns Hopkins Nursing Evidence Based Practice Appraisal tool was used for quality appraisal. Results: Twelve interventional studies met criteria for inclusion. Four studies significantly reduced fatigue, with an additional 3 showing a reduction in fatigue. Interventions that utilized both problem and emotion-focused coping were more effective at reducing fatigue compared to interventions that only used emotion or problem-focused coping. Conclusion: This systematic review found moderate-strength evidence to support that coping interventions can reduce fatigue, with mixed, but mostly beneficial results. Clinicians caring for patients with hematologic malignancies should consider using coping interventions to reduce fatigue.
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Background: Early access to rehabilitation can improve quality of life for those with life-limiting illnesses and is highlighted as a core component of the Adult Palliative Care Services Model of Care for Ireland. Despite this, palliative rehabilitation remains under-utilised and under-developed. In 2020, the Sláintecare Integration Fund provided opportunity to pilot a novel rehabilitative palliative care service, “Palliat Rehab”. This protocol proposes a case study, which aims to advance understanding of the form, content, and delivery of the pilot service. Methods: A prospective, longitudinal, mixed-methods, case study design will be used to describe the service and to explore the experiences of patients, informal carers and clinicians. Additionally, data collection instruments will be tested and the utility of outcome measures will be examined. Data will be collected from documentary, survey, and interview sources. Quantitative data will be analysed using descriptive statistics, including chi-square tests for categorical variables, Mann-Whitney U tests for ordinal data, and t-tests/ ANOVA for continuous data. Qualitative data will be analysed using thematic analysis. Conclusions: New pathways are required to advance service provision to ensure that patients receive the ‘right care, in the right place, at the right time’. This protocol outlines a case study which will aim to develop current understanding of the implementation and delivery of a novel rehabilitative palliative care service in Ireland and will consider its potential contribution to the achievement of Sláintecare goals. Investigating the service within its environmental context will lead to a better understanding of ‘how’ and ‘why’ things happen. Findings will be used to inform efforts to further develop and tailor the intervention.
Thesis
Einleitung: Die Datenlage zu klinischer Symptomatik und therapeutischem Vorgehen am Lebensende von Kindern ist begrenzt. Ziel dieser Analyse ist eine systematische Erfassung von Symptomatik und Management palliativ betreuter, unheilbar kranker Kinder, Jugendlicher und junger Erwachsener in der Terminalphase in Abhängigkeit von der jeweiligen Grunderkrankung. Patienten und Methoden: Die Ergebnisse basieren auf einer 4,5-jährigen retrospektiven Studie von 89 Kindern und Jugendlichen, die sich vor ihrem Tod in pädiatrischer Palliativversorgung befanden. Dabei wurden Symptome und Methoden der Symptomkontrolle am Lebensende bzw. zwei Wochen vor dem Tod untersucht. Ergebnisse: Häufige klinische Symptome bei Kindern in der Sterbebegleitung waren Schmerzen (56%, n=50), Atemnot (55%, n=49), Angst (57,3%, n=51), Übelkeit/Erbrechen (32,5%, n=29) und Obstipation (40%, n=36). Von 89 in diese Studie eingeschlossenen Patienten litten 47% an einer onkologischen Erkrankung. Onkologische Patienten hatten im Vergleich mit Anderen eine signifikant höhere Symptomlast am Lebensende (p<0,05), zusätzlich nahm die Symptomintensität mit Fortschreiten der Grunderkrankung zu. Auch die Wahrscheinlichkeit von Schmerzen und Übelkeit/Erbrechen war bei onkologischen Patienten signifikant höher (p<0,05). Patienten erhielten im Median drei Medikamente. Die am häufigsten zur Symptomkontrolle verwendeten Medikamente waren starke Opioide (66 % der Fälle). Für die Gesamtgruppe konnte eine angemessene Symptomkontrolle in einer häuslichen Umgebung gut implementiert werden; 58 % der Patienten starben zu Hause mit Unterstützung unserer spezialisierten häuslichen Palliativversorgung. Schlussfolgerung: In dieser Untersuchung ging die jeweilige Grunderkrankung mit deutlichen Unterschieden der klinischen Leitsymptomatik einher. Folglich sollte das Symptommanagement entsprechend der Grunderkrankung angepasst werden, da die Grunderkrankung einen Einfluss auf die Schwere der Symptome und damit auf die Behandlung zu haben scheint. Diese Analyse kann als Informationsbasis für ein grunderkrankungsspezifische Symptommanagement in der Sterbebegleitung von Kindern, Jugendlichen und jungen Erwachsenen dienen, wobei der Schwerpunkt auf der häuslichen Sterbebegleitung liegt.
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Are soft tissue therapies and Kinesio Taping useful for symptom management in palliative care? Three case reports. Abstract Physiotherapy may improve the quality of life of patients provided with palliative care. In this article the authors present three cases of advanced cancer patients whose symptoms were successfully treated with various methods of physiotherapy, such as soft tissue therapy and Kinesio Taping. The authors show that a physiotherapist, as part of a multidisciplinary team, plays an important role in the care of patients with progressive diseases. Physiotherapy can minimize the complications and effects of a disease and optimize patients' condition.
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Purpose: Fatigue is a frequently reported symptom by patients with advanced cancer, but hardly any prospective information is available about fatigue while on treatment in the palliative setting. In a previous cross-sectional study, we found several factors contributing to fatigue in these patients. In this study, we investigated the course of fatigue over time and if psychosocial factors were associated with fatigue over time. Methods: Patients on cancer treatment for incurable solid tumors were observed over 6 months. Patients filled in the Checklist Individual Strength monthly to measure the course of fatigue. Baseline questionnaires were used to measure disease acceptance, anxiety, depressive mood, fatigue catastrophizing, sleeping problems, discrepancies in social support, and self-reported physical activity for their relation with fatigue over time. Results: At baseline 137 patients and after 6 months 89 patients participated. The mean duration of participation was 4.9 months. At most time points, fatigue scores were significantly higher in the group dropouts in comparison with the group participating 6 months (completers). Overall fatigue levels remained stable over time for the majority of participants. In the completers, 42 % never experienced severe fatigue, 29 % persisted being severely fatigued, and others had either an increasing or decreasing level. Of the investigated factors, low reported physical activity and non-acceptance of cancer were associated significantly to fatigue. Conclusion: A substantial number of participants never experienced severe fatigue and fatigue levels remained stable over time. For those who do experience severe fatigue, non-acceptance of having incurable cancer and low self-reported physical activity may be fatigue-perpetuating factors.
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Objective: Our aim was to investigate the feasibility of completing an exercise program in patients with advanced cancer and to obtain preliminary data of its impact on physical and quality of life (QoL) outcomes. Methods: We conducted a nonrandomized pilot study. Participants were 26 palliative care patients with advanced cancer (mean age=54.5 years; standard deviation [SD] 8.9 years) of the outpatient clinic of the medical oncology and the urology departments of a medical center in The Netherlands. Participants followed an individually graded group exercise program, consisting of resistance training and aerobic exercise, twice a week during 6 weeks. Feasibility of the training program, muscle strength, aerobic fitness, body composition, QoL, fatigue, and physical role, social, and activities of daily living (ADL) functioning were assessed at baseline and immediately after the intervention. Results: Dropout rate during the training period was 35% due to disease progression. After the training period, based on intention to treat analysis, muscle strength and aerobic functional fitness had increased significantly (p≤0.01). A significant decrease in fat percentage (p≤0.02) was observed. QoL had increased significantly (p≤0.02), as well as social (p≤0.04), physical role (p≤0.01), and ADL functioning (p≤0.05). Fatigue decreased significantly on the Checklist Individual Strength (CIS) and RAND-36 questionnaires (p≤0.02), however not on the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (p=0.48). No change in physical functioning was observed with the EORTC QLQ-C30 and RAND-36 (respectively, p=0.33 and p=0.09). Conclusions: These preliminary results show that physical exercise in patients with advanced cancer is feasible. A significant impact was observed on physical and QoL outcomes. These findings need to be confirmed with a larger-scale, randomized controlled trial.
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Background The aim of this study was to determine factors associated with the severity of cancer related fatigue (CRF) and predictors of improvement of CRF at the first follow-up visit in patients with advanced cancer referred to outpatient palliative care clinic (OPC). Methods We reviewed the records of consecutive patients with advanced cancer presenting to OPC. Edmonton Symptom Assessment System (ESAS) scores were obtained at the initial and subsequent visits between January 2003 and December 2008. All patients received interdisciplinary care led by palliative medicine specialists following an institutional protocol. Fatigue improvement was defined as a reduction of ≥2 points in ESAS score relative to the baseline. Descriptive statistics were used to summarize patient characterstics. Univariate analyses were performed and only significant variables were included in multivariate regression analysis to determine factors associated with severity and improvement in CRF. Results A total of 1778 evaluable patients were analyzed (median age, 59 years; 52% male). The median time between visits was 15 days. Median fatigue scores on the ESAS were 6 at baseline and 5 at follow-up. Severity of all ESAS items and low serum albumin were associated with fatigue at baseline (p < 0.0001). The improvement of fatigue was observed in 586 patients (33%). The hierarchical model showed that fatigue improved over time (b = −0.009; p = 0.0009). low appetite (odds ratio [OR] = 1.09 per point; p = 0.0113) and genitourinary cancer (OR = 1.74 per point; p = 0.0458) were significantly associated with improvement of fatigue. Conclusions CRF is strongly associated with physical and emotional symptoms. Genitourinary cancer and low appetite at baseline were associated with successful improvement of fatigue.
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BACKGROUND Fatigue is a major disease and treatment burden for cancer patients. Several scales have been created to measure fatigue, but many are long and difficult for very ill patients to complete, or they are not easy to translate for non-English speaking patients. The Brief Fatigue Inventory was developed for the rapid assessment of fatigue severity for use in both clinical screening and clinical trials.METHODS The study enrolled 305 consecutive, consenting adult inpatients and outpatients with cancer who could understand and complete the self-report measures used in the study. The same instruments also were administered to 290 community-dwelling adults to obtain a comparison sample. Research staff completed a form that indicated the primary site and stage of the cancer, rated the Eastern Cooperative Oncology Group performance status of the patient, described the characteristics of the pain, and described the current pain treatment being provided to the patients.RESULTSThe BFI was shown to be an internally stable (reliable) measure that tapped a single dimension, best interpreted as severity of fatigue. It correlated highly with similar fatigue measures. Greater than 98% of patients were able to complete it. A range of scores defining severe fatigue was identified.CONCLUSIONS The BFI is a reliable instrument that allows for the rapid assessment of fatigue level in cancer patients and identifies those patients with severe fatigue. Cancer 1999;85:1186–96. © 1999 American Cancer Society.
Article
We describe a simple method for the assessment of symptoms twice a day in patients admitted to a palliative care unit. Eight visual analog scales (VAS) 0–100 mm are completed either by the patient alone, by the patient with nurse's assistance, or by the nurses or relatives at 10:00 and 18:00 hours, in order to indicate the levels of pain, activity, nausea, depression, anxiety, drowsiness, appetite, and sensation of well-being. The information is then transferred to a graph that contains the assessments of up to 21 days on each page. The sum of the scores for all symptoms is defined as the symptom distress score. The Edmonton Symptom Assessment System (ESAS) was carried out for 101 consecutive patients for the length of their admission to our unit. Of these, 84% were able to make their own assessment sometime during their admission. However, before death 83% of assessments were completed by a nurse or relative. Mean symptom distress score was 410±95 during day 1 of the admission, versus 362±83 during day 5 (p<0.01). Mean symptom distress scores throughout the hospitalization were 359±105, 374±93, 359±91 and 406±81 when the ESAS was completed by the patient alone, patient with nurse's assistance (p=N.S.), nurse alone (p=N.S.), or relative (p<0.01) respectively. We conclude that this is a simple and useful method for the regular assessment of symptom distress in the palliative care setting.
Article
Context: Exercise benefits patients with cancer, but studies of home-based approaches, particularly among those with Stage IV disease, remain small and exploratory. Objectives: To conduct an adequately powered trial of a home-based exercise intervention that can be facilely integrated into established delivery and reimbursement structures. Methods: Sixty-six adults with Stage IV lung or colorectal cancer were randomized, in an eight-week trial, to usual care or incremental walking and home-based strength training. The exercising participants were instructed during a single physiotherapy visit and subsequently exercised four days or more per week; training and step-count goals were advanced during bimonthly telephone calls. The primary outcome measure was mobility assessed with the Ambulatory Post Acute Care Basic Mobility Short Form. Secondary outcomes included ratings of pain and sleep quality as well as the ability to perform daily activities (Ambulatory Post Acute Care Daily Activities Short Form), quality of life (Functional Assessment of Cancer Therapy-General), and fatigue (Functional Assessment of Cancer Therapy-Fatigue). Results: Three participants dropped out and seven died (five in the intervention and two in the control group, P=0.28). At Week 8, the intervention group reported improved mobility (P=0.01), fatigue (P=0.02), and sleep quality (P=0.05) compared with the usual care group, but did not differ on the other measures. Conclusion: A home-based exercise program seems capable of improving the mobility, fatigue, and sleep quality of patients with Stage IV lung and colorectal cancer.
Article
BACKGROUND Advice to rest and take things easy if patients become fatigued during radiotherapy may be detrimental. Aerobic walking improves physical functioning and has been an intervention for chemotherapy-related fatigue. A prospective, randomized, controlled trial was performed to determine whether aerobic exercise would reduce the incidence of fatigue and prevent deterioration in physical functioning during radiotherapy for localized prostate carcinoma.METHODS Sixty-six men were randomized before they received radical radiotherapy for localized prostate carcinoma, with 33 men randomized to an exercise group and 33 men randomized to a control group. Outcome measures were fatigue and distance walked in a modified shuttle test before and after radiotherapy.RESULTSThere were no significant between group differences noted with regard to fatigue scores at baseline (P = 0.55) or after 4 weeks of radiotherapy (P = 0.18). Men in the control group had significant increases in fatigue scores from baseline to the end of radiotherapy (P = 0.013), with no significant increases observed in the exercise group (P = 0.203). A nonsignificant reduction (2.4%) in shuttle test distance at the end of radiotherapy was observed in the control group; however, in the exercise group, there was a significant increase (13.2%) in distance walked (P = 0.0003).CONCLUSIONS Men who followed advice to rest and take things easy if they became fatigued demonstrated a slight deterioration in physical functioning and a significant increase in fatigue at the end of radiotherapy. Home-based, moderate-intensity walking produced a significant improvement in physical functioning with no significant increase in fatigue. Improved physical functioning may be necessary to combat radiation fatigue. Cancer 2004. © 2004 American Cancer Society.