An individualised group based exercise intervention is associated with improvements in functional performance, quality of life, and fatigue in adults with cancer

Introduction Cancer and its treatment are frequently associated >with impaired physical fitness which often persists into survivorship.

Functional impairments such as cancer related fatigue, >muscle atrophy, excessive weight gain or weight loss with associated deconditioning, reduced aerobic capacity, pain, nausea, neuropathy and reduced joint range of motion are commonly reported side effects of cancer therapy1.

Side effects not only impact on the physical wellbeing >of the patient but often affect activities of daily living which can significantly impact on social and psychological wellbeing and affect quality of life1,2,4.

To our knowledge, no published studies have evaluated >the effectiveness of a clinical non disease specific group based exercise program for cancer patients.

Methods We developed a multimodal group exercise intervention >for cancer patients who were either undergoing or had recently completed therapy for cancer. This program was supervised by exercise physiologists, with participants attending 2–3 sessions per week for 10 weeks at our hospital gymnasium.

Patients underwent a baseline assessment which included >past and present medical history, measurement of functional performance and self reported quality of life3 and fatigue4.

Battery testing was determined by the Exercise >Physiologist during assessment. Tests included Fullarton’s Functional Assessment for Older Adults5 and Australian functional fitness norms6.

Exercise goals were set using SMART principles > 7.

Individualised exercise programs were developed utilising >information gathered from the baseline assessment and specific patient goals.

Exercise programs comprised of cardiovascular, resistance, >flexibility and core stability exercises.

Exercise intensity was monitored using heart rate and >Borg’s Rate of Perceived Exertion (RPE) scale. Aerobic intensity was set at 75% of predicted maximum heart rate, and a RPE of 13 (somewhat hard).

Assessment of one repetition maximum (1RM) was >assessed at baseline to enable prescription of the intensity for the resistance exercises (at an initial 60% 1RM). When a 1RM assessment was not appropriate, intensity was set using a 10-RM protocol.

Patients were closely supervised throughout the 10 week >intervention to ensure progression, monitor intensity and ensure safety.

Further, patients were encouraged to perform physical >activity outside of gym sessions.

Paired t-tests were used to compare results prior to >commencing and after completing the 10 week program.

Results296 cancer patients were enrolled between 2008 and >2012.

153 were male and 143 female, with a range of cancer >diagnoses. The median age was 57 years.

186 (63%) completed the program. >

The mean body mass pre-intervention was 75.8 (±17.7) >and post intervention 74.5 (±17.1), while the mean BMI pre intervention was 26.2(±6.3) and post-intervention 26.2 (± 6.3).

Highly significant improvements were observed in quality >of life scores (mean (± SD) = 20.5 (± 4.2) pre-intervention versus 22.8 (±3.7) post-intervention, p<0.0001),

Piper fatigue scores decreased by 11% (5.0 (± 1.9) pre- >intervention vs 3.2 (± 2.0) post-intervention; p<0.0001)

Significant improvements were seen in 11 of the 12 >functional assessment measures (Table 1). Figure 1 and 2 demonstrate the mean percentage improvements for each functional measure.

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Mean percentage improvement Australian functional fitness norms

0%

10%

20%

30%

40%

50%

60%

70%

80%

Outcome measure

Sit and reach (32%)

Back scratch right arm raised (67%)

Back scratch left arm raised (23%)

Max grip strength right arm (4%)

Max grip strength left arm (7%)

Max back and leg strength (9%)

Max push ups (44%)

Max sit ups (18%)

Pred Vo2max (17%)

Figure 1

Mean percentage improvement Fullartons Functional Assessment

0%

5%

10%

15%

20%

25%

30%

Outcome measure

30 sec chair stands (25%)

30 sec arm curls right arm (20%)

30 sec arm curls left arm (23%)

Self selected gait speed (10%)

Max gait speed (10%)

Six Minute Walk Test (13%)

Figure 2

M. Atkinson1, Michael Osborn2

1Centre for Physical Activity in Ageing Hampstead Rehabilitation Centre, Northfield, Australia.2 Department of Clinical Haematology and Oncology, Women’s and Children’s Hospital, North Adelaide, AustraliaCorrespondence: morgan.atkinson@health.sa.gov.au

AcknowledgementsI would like to acknowledge Robert Barnard, Adam Zerner, Ross Gray, Kerri Frahn, Stephen Bateman, Jack Kaleta and Amanda Foley-Gooding from the Centre for Physical Activity in Ageing at the Hampstead Rehabilitation Centre for their ongoing support.

References1. Schmitz, K.H., Courneya, K.H., Mathews, C.M., Demark-Wahnefried, W., Gavao, D.D., Pinto,B.M., Et Al. (2010). American College of Sports Medicine Round Table on Exercise Guidelines for Cancer Patients.

Medicine and Science in Sport and Exercise, 42(7), 1409-1426. 2. Pentheroudakis, G., & Pavlidis, N. (2007). Late Toxicity in survivors from Adolescent cancers. Cancer Treatment Reviews, 33, 656-6633. Schreier, A.M., & Williams, S.A. (2004). Anxiety and quality of life of women who receive radiation or chemotherapy for breast cancer. Oncology Nursing Forum, 31(1), 127-130.4. Piper, B.F., Dibble, S.L., Dodd, M.J. et al: The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum 25,4: 677-84.5. Riki, R.& Jones, C.J. (2001) Senior fitness test manual. Champaign, IL: Human Kinetics.6. Gore, C.J. & Edwards, D.A. Australian Fitness Norms: A Manual for Assessors. Adelaide Aust: The Health Development Foundation.7. Doran, G. T. (1981). There's a S.M.A.R.T. way to write management's goals and objectives. Management Review, Volume 70, Issue 11(AMA FORUM), pp. 35-36.

Centre for Physical Activity in Ageing

Outcome measure nMean

pre-intervention

Mean post-

interventionP-Value

Maximum grip strength (kg) 95 R 38.6 L 35.74 R 40.37 L 38.56 R<0.0001 L<0.0001

30 sec arm curls

(number of repetitions))148 R 16.60 L 16.30 R 20.81 L 21.05 R<0.0001 L<0.0001

Back scratch

(shoulder flexibility, cm)101 R -2.67 L -7.08 R -0.88 L -5.44 R=0.0100 L=0.1031

Sit and reach (hamstring flexibility, cm)

54 -9.24 -6.23 <0.0145

Maximum back and leg strength

(kg)51 113.65 124.54 <0.0001

30 sec chair stands

(number of repetitions))148 11.79 15.66 <0.0001

Max push ups

(number of repetitions))39 14.4 25.74 <0.0001

Max sit ups

(number of repetitions)45 21.85 26.80 <0.0001

Self selected gait speed

(ms-1)141 1.24 1.38 <0.0001

Max gait speed (ms-1) 140 1.69 1.88 <0.0001

Six Minute Walk Test (m) 140 495.81 569.66 <0.0001

Pred Vo2max (ml/kg/min) 45 32.74 39.35 <0.0001

Table 1

ConclusionsIn conclusion, the improvement in functional >assessment measures indicates that the program improves physical fitness, at least in the short-term, in a group at risk of persisting impaired fitness.

Furthermore, the improvements in fatigue levels and >quality of life suggest that the benefits of an exercise program extend beyond just physical fitness for cancer patients.