Chen, H.M., Tsai, C.M., Wu, Y.C., Lin, K.C., & Lin, C.C. (2014). Randomised controlled trial on the effectiveness of home-based walking exercise on anxiety, depression and cancer-related symptoms in patients with lung cancer. British Journal of Cancer, 112, 438–445. 

To determine the effectiveness of a 12-week, home-based walking exercise program in managing anxiety, depression, and the severity of cancer-related symptoms while investigating the psychological effects of home-based walking exercises on patients with lung cancer

116 patients were randomly assigned to the walking-exercise group (58) or the usual-care group (58). The exercise program consisted of a 12-week, home-based, moderate-intensity walking exercise of 40 minutes per session with three sessions per week and weekly exercise counseling. Patients were given a booklet and instructions on the mode intensity and frequency of exercise, pulse rate measurement, Borg’s rating of perceived exertion scale (RPE), prevention of sports injuries, and the time point of terminating the exercise. The participant was to achieve a target heart rate of 50%–80% based on the Korvonen method and a score of 13–15 on the RPE scale. Measurements were recorded at three time points: baseline, three months, and six months.

• N = 116  
• AGE RANGE = 37–88 years
• MALES: 54, FEMALES: 62
• KEY DISEASE CHARACTERISTICS: Primary lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Excluded if patient participated in regular exercise or received cognitive behavior therapy in the past six months

• SITE: Single site    
• SETTING TYPE: Outpatient    
• LOCATION: Taiwan

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care, palliative care 

Parallel, randomized, controlled, single-center trial

• Hospital Anxiety and Depression Scale (HADS)
• Taiwanese MD Anderson Symptom Inventory (MDASI)
• Statistical analysis: Intention-to-treat (ITT) approach

There were no statistically significant differences in the baseline demographic data, disease characteristics, or baseline physical activity between the two groups. 44.8% of the exercise group completed the intervention. The exercise adherence rate was 59.7%. No exercise-related adverse effects were observed during the study period. The mean anxiety score of the walking exercise group declined by 1.04 points between baseline and the six-month completion. This was not statistically significant. The mean anxiety score of the usual care group at the third month increased significantly (mean difference = 1.72, P = 0.012) and remained stable until the sixth month. The anxiety scores of the walking exercise group declined by 0.63 points at the third month and by 1.03 points at the sixth month. A significant interaction term of the model at the third month and sixth month verified that the walking exercise reduced anxiety over time. The mean depression scores of the walking exercise group gradually declined, but there was no statistical significance. The mean depression scores for the usual care group significantly increased by the sixth month (mean difference = 1.35, P = 0.071). Participants engaging in walking exhibited additional reductions in depression over time. The mean symptom scores of the walking exercise group declined from baseline to the third month and remained stable. The mean symptom scores of the usual care group remained unchanged from baseline. A marginally significant difference between both groups was seen at the third month (1.50 versus 2.08, P = 0.053).

The authors concluded that the walking exercise program effectively reduced anxiety and depression over time. The benefits of exercise demonstrated in other cancer populations applied to patients with lung cancer as well. No substantial reduction was observed regarding the effect of the exercise program on symptom relief. However, the symptom scores of the exercise group were marginally lower over time. Adherence and dropout rates suggested that regular follow-up calls and encouragement to continue exercise would be beneficial.

• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results 
• Selective outcomes reporting 
• Measurement validity/reliability questionable
• Other limitations/explanation: Generalized symptom improvements in a large subset of symptoms (i.e., pain, fatigue, nausea, sleep disturbance, sadness, shortness of breath, difficulty remembering, poor appetite, drowsiness, dry mouth, distress, vomiting, numbness) instead of measuring the outcomes of a targeted symptom

Exercise is a valuable intervention for anxiety and depression in patients with cancer. Nurses should consider education and training for patients to establish regular exercise programs as a supportive care intervention.