Exercise

Exercise

PEP Topic 
Chronic Pain
Description 

Exercise is physical activity that involves repetitive bodily movement done to improve or maintain one or more of the components of physical fitness: cardiorespiratory endurance (aerobic fitness), muscular strength, muscular endurance, flexibility, and body composition. Exercise interventions in patients with cancer have been provided as home-based, patient self-managed programs as well as supervised and unsupervised individual or group exercise sessions of varying duration and frequency. They can include combinations of aerobic and resistance activities. Exercise has been studied in patients with cancer for anxiety, chemotherapy-induced nausea and vomiting, depression, hot flashes, lymphedema, sleep/wake disturbance, pain, and fatigue. Users of this information are encouraged to review intervention details in study summaries, as the exercise interventions studied and their timings in the trajectory of cancer care vary and these differences can influence effectiveness.

Effectiveness Not Established

Research Evidence Summaries

Cheville, A.L., Kollasch, J., Vandenberg, J., Shen, T., Grothey, A., Gamble, G., & Basford, J.R. (2013). A home-based exercise program to improve function, fatigue, and sleep quality in patients with stage IV lung and colorectal cancer: A randomized controlled trial. Journal of Pain and Symptom Management, 45, 811–821.

doi: 10.1016/j.jpainsymman.2012.05.006
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Study Purpose:

To report the effects of a strength training and walking program in patients with stage IV lung and colorectal cancer.

Intervention Characteristics/Basic Study Process:

Patients were given usual care or 1.5 hours of training by a physical therapist on rapid, easy, strength training exercises (REST) and pedometer-based walking using an instruction manual, resistance bands, an exertion rating scale, and a study log. They were then followed bimonthly by telephone for eight weeks.

Sample Characteristics:

  • The study reported on a final sample of 56 patients.
  • Mean patient age was 63.8 years in the intervention group and 65.5 years in the control group.
  • The intervention group was 48.5% male and 51.5% female. The control group was 57.6% male and 42.4% female.
  • Patients had stage IV lung or colorectal cancer.

Setting:

  • Single site 
  • Outpatient setting
  • Mayo Clinic

Phase of Care and Clinical Applications:

Patients were undergoing the end of life phase of care.

Study Design:

The study was a single-blinded, randomized, controlled trial.

Measurement Instruments/Methods:

  • Activity Measure for Post-Acute Care Computerized Adaptive Testing (AM-PAC CAT)
  • AM-PAC Mobility
  • Functional Assessment of Cancer Therapy-General (FACT-G)
  • FACT-Fatigue (FACT-F) subscale
  • Numerical rating scale for pain and sleep quality
  • Pedometer step-count logs
  • REST logs
  • Vital sign collection

Results:

Mobility, fatigue, and sleep measures were statistically significant between the intervention and control groups from baseline to week 8 (p = 0.002, p = 0.03, and p = 0.002, respectively), in favor of exercise. Other measures did not show significance. The number of REST sessions and weeks logged with step counts were associated with changes in the mobility score. Survival and withdrawals did not differ significantly between the groups.

Conclusions:

A home-based intervention using walking and strength exercises may improve mobility, fatigue, and sleep quality in patients with stage IV colorectal or lung cancer.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • The study had risks of bias due to no blinding and no appropriate attentional control condition.

Nursing Implications:

The teaching of walking exercises and strength routines may improve functioning in this patient population in terms of mobility, sleep quality, and fatigue. The one-time education session may be appealing to nurses looking for a timely intervention to help improve these symptoms.

Fernandez-Lao, C., Cantarero-Villanueva, I., Fernandez-de-Las-Penas, C., del Moral-Avila, R., Castro-Sanchez, A.M., & Arroyo-Morales, M. (2012). Effectiveness of a multidimensional physical therapy program on pain, pressure hypersensitivity, and trigger points in breast cancer survivors: A randomized controlled clinical trial. Clinical Journal of Pain, 28, 113–121.

doi: 10.1097/AJP.0b013e318225dc02
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Study Purpose:

To evaluate the effects of an eight-week multidimensional physical therapy program, including strengthening exercises and recovery massage, on neck and shoulder pain, pressure hypersensitivity, and the presence of active trigger points (TrPs) in breast cancer survivors

Intervention Characteristics/Basic Study Process:

Forty-four breast cancer survivors were randomly assigned to one of two groups: the CUIDATE group, which received a multidimensional physical therapy program, or the control group, which received usual care treatment for breast cancer. The CUIDATE program consisted of 24 hours of individual physical training (aerobic, mobility, stretching, and strengthening exercises) and 12 hours of physical therapy recovery interventions (stretching, massage) three times per week for 90 minutes. The program was supervised by two physical therapists with clinical experience in the management of patients with different cancer conditions. Each group had approximately six to eight patients. Outcomes were assessed at baseline and after the eight-week program by a blinded assessor. Control group patients followed usual care recommended by the oncologist in relation to a healthy lifestyle. They received a printable dossier from the oncologist that outlined recommendations related to nutrition, lifestyle behaviors, and exercise.

Sample Characteristics:

  • The study reported on 44 breast cancer survivors.
  • Mean patient age was 49 years in the CUIDATE group and 47 years in the control group (p = 0.482).
  • The sample was 100% female.
  • Patients were eligible if they had a diagnosis of breast cancer (stage I–IIIA); had received a simple mastectomy or quadrantectomy, including those with breast reconstruction at the time of initial surgery or subsequent breast reconstruction; were between the ages of 25 and 65; had completed coadjuvant treatment except for hormone therapy; did not have active cancer; and had neck and shoulder pain that began after their breast cancer surgery.
  • All patients underwent axillary lymph node dissection during their surgery. The mean time from breast surgery was 10 months (SD = 2 months).
  • Patients were excluded if they were receiving chemotherapy or radiotherapy at the time of the study, suffered from chronic or orthopedic diseases that would not allow them to participate in physical therapy, had uncontrolled hypertension with diastolic blood pressures greater than 95 mmHg, had lymphedema, had recurrent cancer, or had previous diagnosis of fibromyalgia syndrome.

Setting:

  • Breast oncology unit of the Virgen de las Nieves Hospital
  • Outpatient setting
  • Granada, Spain

Phase of Care and Clinical Applications:

  • Patients were undergoing the survivorship phase of care.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study was a randomized, controlled, clinical trial.

Measurement Instruments/Methods:

  • Visual analog scale (0–100) to measure neck and shoulder pain: pressure pain thresholds over the C5–C6 zygaphophyseal joints, deltoid muscles, and second metacarpal and tibialis anterior muscles, and the presence of active TrPs in shoulder muscles
  • Minnesota Leisure Time Physical Activity Questionnaire

Results:

The CUIDATE group demonstrated an estimated improvement for neck pain of –56 mm [95% confidence interval (CI), –71 –40, p < 0.001; effect size 2.72, 1.94–3.44] and for shoulder/axillary pain of –56 mm [95% CI, –74 –38, p < 0.001; effect size 2.45, 1.66–3.23]. Improvements also were noted for pressure pain thresholds levels: Patients within the CUIDATE program showed a greater reduction of active muscle TrPs compared with the control group (p < 0.01).

Conclusions:

An eight-week supervised multidimensional program including strengthening and endurance exercises, relaxation, and massage as major components was effective for improving neck and shoulder pain and reducing widespread pressure hyperalgesia in breast cancer survivors compared with usual care treatment.

Limitations:

  • The study had a small sample size, with less than 100 participants.
  • Investigators only assessed the short-term effects of the CUIDATE program.
  • Program adherence was not evaluated.
  • Control group patients were also allowed to freely exercise, but no information on their use of exercise was provided.
  • Physical therapy sessions were done in small groups, but no appropriate attentional control was used.

Nursing Implications:

Almost all cancer survivors experience one or more cancer-related symptoms that impact their quality of life. Among these symptoms, localized pain is the most frequent impairment after breast cancer treatment (20%–65%). There is evidence that breast cancer survivors may present with changes in nociceptive pain from damage to the small nerve fibers during surgery.

There is also evidence showing that physical therapy, including exercise and massage interventions, may be beneficial for improving physical function in breast cancer survivors. Nurses can provide patient education regarding the use of a multidimensional physical therapy program to activate exercise-induced hypoalgesia in breast cancer survivors. Physical therapy interventions may be clinically useful in minimizing pain and persistent hypersensitivity after medical treatment in this cancer population.

Litterini, A.J., Fieler, V.K., Cavanaugh, J.T., & Lee, J.Q. (2013). Differential effects of cardiovascular and resistance exercise on functional mobility in individuals with advanced cancer: A randomized trial. Archives of Physical Medicine and Rehabilitation, 94, 2329–2335. 

doi: 10.1016/j.apmr.2013.06.008
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Study Purpose:

To compare effects of cardiovascular and resistance exercise on functional mobility in people with advanced cancer

Intervention Characteristics/Basic Study Process:

Individuals were randomly assigned to either resistance or cardiovascular exercise groups. Exercise sessions were held in a hospital-based fitness facility twice weekly for 10 weeks. Both groups  participated in flexibility exercises. Sessions lasted 30–60 minutes and were supervised by oncology-trained exercise specialists. Participants completed the study assessments at baseline and one week after study completion.

Sample Characteristics:

  • N = 52    
  • MEAN AGE = 62.35 years (SD = 13.49)
  • MALES: 45%, FEMALES: 55%
  • KEY DISEASE CHARACTERISTICS: Multiple tumor types. All had advanced cancer determined by an oncologist to be in a terminal stage.
  • OTHER KEY SAMPLE CHARACTERISTICS: More than 90% of the patients were currently receiving chemotherapy, radiation therapy, or a combination of these. Baseline mean fatigue was 37.02 on a 0–100 scale.

Setting:

  • SITE: Single site
  • SETTING TYPE: Outpatient
  • LOCATION: New England

Phase of Care and Clinical Applications:

  • PHASE OF CARE: End-of-life care
  • APPLICATIONS: Palliative care

Study Design:

  • Randomized, parallel group trial

Measurement Instruments/Methods:

  • Short Physical Performance Battery (SPPB)
  • 100 mm visual analog scale for fatigue and pain

Results:

On average, participants attended 70% of exercise sessions. SPPB scores improved in all over time (p < .001), but improved slightly more in the cardiovascular group (p = .045). Intent-to-treat analysis did not confirm this difference between groups. Fatigue declined over time in all (p = .05), with no difference between groups. There were no significant changes in pain by group or by time.

Conclusions:

Findings show improved functional mobility and reduced fatigue over time. This study did not show a difference associated with the type of exercise provided.

Limitations:

  • Small sample (< 100)
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Measurement validity/reliability questionable
  • Other limitations/explanation: VAS score was only for fatigue. There was a 21% dropout rate and reasons for this are not described. Relatively low levels of fatigue at baseline, suggesting possible measurement floor effect.

Nursing Implications:

This study suggests that both cardiovascular and resistance exercise can be used in appropriate patients with advanced disease, and findings showed that there were no significant changes in pain or fatigue with these interventions.

McNeely, M.L., Parliament, M.B., Seikaly, H., Jha, N., Magee, D.J., Haykowsky, M.J., & Courneya, K.S. (2008). Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: A randomized controlled trial. Cancer, 113, 214–222.

doi: 10.1002/cncr.23536
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Study Purpose:

To examine the effects of progressive resistance exercise training on upper extremity pain and dysfunction in postsurgical head and neck cancer survivors

Intervention Characteristics/Basic Study Process:

Participants were randomly assigned to either standard therapeutic exercise or progressive resistance exercise training (PRET). All were asked to attend at least two supervised sessions per week for 12 weeks. Standard exercise involved active and passive range of motion and stretching, postural exercise, and strengthening with light weights (1–5 kg) and elastic resistance bands targeting specific muscle groups. The PRET group received the same exercises except that the strengthening was replaced with individualized exercise on the same muscle groups designed with the intent to provide progressive overload to those muscles. Outcomes were assessed at baseline and postintervention.

Sample Characteristics:

  • The study reported on 52 head and neck cancer survivors.
  • Mean participant age was 52 years (range = 32–76 years).
  • The sample was 71% male and 29% female.
  • To be eligible, participants had to have undergone surgical treatment, including radical neck dissection, modified radical neck dissection, or other variants of selective neck dissection; have a Karnofsky Performance Status score greater than 60%; have no evidence of residual cancer in the neck and no distant metastases; and have completed adjuvant treatment for head and neck cancer.
  • All participants were required to present with symptoms of shoulder dysfunction attributed to spinal accessory nerve damage.

Setting:

  • Multisite
  • Outpatient setting
  • Cross Cancer Institute and University of Alberta in Edmonton, Canada

Study Design:

The study was a prospective randomized controlled trial.

Measurement Instruments/Methods:

  • A block permutation procedure to generate the allocation sequence with each stratum Borg scale for rating of perceived exertion
  • Training log
  • Shoulder Pain and Disability Index (SPADI)
  • Functional Assessment of Cancer Therapy–Anemia (FACT-An) scale for quality-of-life and fatigue assessment
  • Neck Dissection Impairment Index (NDII)

Results:

The PRET program significantly reduced shoulder pain and disability (p = 0.001) and improved upper extremity muscular strength and endurance. Patients participating in the PRET program had a 52% reduction in pain. The effect size for change in pain was d = 0.84. PRET was better than the standard exercise for all strength endpoints measured, and endurance was more improved with PRET (p = 0.039).

Conclusions:

Findings show that a program of individualized progressive resistance exercise in patients with specific shoulder dysfunction postsurgery for head and neck cancer as provided here can reduce pain and disability.

Limitations:

  • Range of time from surgery varied widely among participants.
  • Study results may have been limited by long-term survivors with deficits refractory to the exercise protocol that focused primarily on active and passive range-of-motion and basic strengthening exercises.
  • The study did not differentiate between the location and type of pain in participants, nor did it differentiate involvement of the upper, middle, and lower trapezius, which may affect head and neck cancer survivors’ clinical presentation and response to treatment.

Nursing Implications:

Survivors of head and neck cancer can be burdened with pain and loss of strength and function associated with damage to the spinal accessory nerve. It is important that nurses consider means that will help to minimize these residual effects. Exercise is a noninvasive tool that enables patients to actively participate in their recovery. This study shows that a PRET program had a beneficial effect, with reduction in pain of 52% in the PRET group. Improvement in pain was also associated with increases in upper extremity strength and endurance.

Guideline/Expert Opinion

Qaseem, A., Snow, V., Shekelle, P., Casey, D.E., Jr., Cross, J.T., Jr, Owens, D.K., . . . Shekelle, P. (2008). Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148, 141–146.

doi: 10.7326/0003-4819-148-2-200801150-00009
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Purpose & Patient Population:

Objectives were to

  • Present evidence that will contribute to the improvement of palliative care at the end of life.
  • Answer questions regarding critical elements.
  • Identify patients who could benefit from palliative approaches.
  • Identify treatment strategies that work for pain, dyspnea, and depression.
  • Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

Type of Resource/Evidence-Based Process:

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

Results Provided in the Reference:

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

  • Pain
    • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
    • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
    • Palliative care teams may be moderately beneficial in providing pain management.
  • Dyspnea
    • Evidence shows a valuable effect of morphine.
    • Nebulized opioids show no additional benefit over oral opioids.
    • Evidence regarding the use of oxygen is equivocal.
    • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
  • Depression
    • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
    • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
    • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

Guidelines & Recommendations:

The following were graded as strong recommendations with moderate quality of evidence.

  • Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
  • For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
  • Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
  • Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
  • Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

Limitations:

  • Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
  • Financial support for this guideline was entirely from the American College of Physicians.

Nursing Implications:

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.


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