Exercise

• STUDY PURPOSE: Examine evidence on the effects of exercise interventions on fatigue, dyspnea, and depression.
• TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: Using PRISMA guidelines, the databases CINAHL, MEDLINE, Embase, and Cochrane were accessed
• YEARS INCLUDED: 2000 to 2017
• INCLUSION CRITERIA: Lung cancer survivors, depression, fatigue, and dyspnea. 
• EXCLUSION CRITERIA: Patients undergoing therapy, duplicate studies, and participants aged 18 years or older, not primary research; fatigue, depression, and fatigue not outcome measures

• TOTAL REFERENCES: N = 852
• EVALUATION METHOD AND COMMENTS ON LITERATURE: Three researchers reviewed looking for dyspnea, fatigue, and depression as primary measures, looking for pre- and post-testing.

• STUDIES INCLUDED: 10  
• TOTAL PATIENTS INCLUDED: 516
• SAMPLE RANGE ACROSS STUDIES: 10 to 162.
• KEY SAMPLE CHARACTERISTICS: 58% were post-treatment for lung cancer

• PHASE OF CARE: Late effects and survivorship     
• APPLICATIONS: Elder care, palliative care 

Dimeo et al. (2004): After three weeks of exercises and relaxation, no significant results were noted for dyspnea, but were significant for fatigue (p = 0.67 and 0.54)

Glattki et al. (2012): In a study with pulmonary rehab measured using modified research council (MRC), the dyspnea scale was significant (p = 0.007, 0.26, SD = 0.61) for improvement in dyspnea.

Peddle-McIntyre et al. (2012): The MRC dyspnea scale was measured after 10 weeks and was not significant (pre = 1.6, SD = 0.6; post = 1.4, SD = 0.8).

Riesenberg and Lubbe (2010): The study showed significant improvements in dyspnea after four weeks of QLQ testing (p < 0.001) and also for fatigue (mean difference = -13.7).

Spruit et al. (2006): Using the BORG scale, no significant difference was found (p = 0.2969)

Overall, six studies reported statistically significant reductions in fatigue, two reported significant improvement in dyspnea, and one had significant reduction in depression.

Although there were some studies that showed that exercise interventions could possibly be effective for relief of symptoms such as dyspnea, the results were mixed, and there are unclear variations between programs and high dropout rates, so no recommendations can be made based on this particular analysis.

• Limited number of studies included
• Mostly low quality/high risk of bias studies

Nurses should be aware that there is the possibility that exercise may benefit some patients, and there is little risk of harm, but nurses should be aware that it is unclear what patients or what programs would be of benefit; therefore, no recommendations can be made at this time.

• STUDY PURPOSE: To conduct a meta-analysis to establish the effect of exercise interventions on multiple physical symptoms, including fatigue, nausea/vomiting, pain, dyspnea, insomnia, loss of appetite, constipation, and diarrhea in patients with cancer
• TYPE OF STUDY: Systematic review

• DATABASES USED: Cochrane Library, the Center for Reviews and Dissemination, PubMed/MEDLINE, CINAHL, Scopus, PEDro, Health and Medical Collection, Psychology Database
• YEARS INCLUDED: Articles published before April 2017
• SEARCH TERMS: MeSH terms of cancer, tumor, randomized controlled trial, training, rehabilitation, and exercise, as well as outcome of physical symptoms
• INCLUSION CRITERIA: Included RCTs that evaluated the effects of exercise intervention by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 or the C15-PAL
• EXCLUSION CRITERIA: Excludes systematic reviews, editorials, cross-sectional studies, case reports, case series, and interventions that were not of high enough intensity (yoga, stretching, Pilates, and education). Also excluded shoulder exercise studies for breast patients and pelvic floor muscle training in gynecologic patients, as well was any trial that did not have a control group that received no major exercise intervention.

• TOTAL REFERENCES RETRIEVED: 743 (only 45 reviewed full-text after exclusion for study design)
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Studies were evaluated for study design (RCT) and for data form, methodologic quality was evaluated with the PEDro scale

• FINAL NUMBER STUDIES INCLUDED: 10
• TOTAL PATIENTS INCLUDED IN REVIEW: 893 (434 in intervention groups)
• SAMPLE RANGE ACROSS STUDIES: Lists patients as having hematological malignancies (largest group), breast, prostate, and mixed cancer. Phases of care were heterogenous, although listed as “mainly postsurgery, posttransplantation (heme), and during chemotherapy
• KEY SAMPLE CHARACTERISTICS: Heme malignancy was most prevalent, states that the largest number of patients with lung cancer was 46 “at most”--total breakdown of cancer types was not provided.

• PHASE OF CARE: Varied
• APPLICATIONS:  Palliative care 

Results showed exercise positively affected the symptoms of fatigue (p = 0.0004), pain (p = 0.02), insomnia (p < 0.0001), dyspnea (p = 0.001), and no significant effect on nausea/vomiting, loss of appetite, constipation, or diarrhea. For dyspnea specifically, only within the mixed exercise program subgroup (as opposed to resistance alone or aerobic exercise alone) was an improvement effect in favor of the intervention group found.

This study concluded that it had confirmed that exercise interventions improve fatigue, pain, and insomnia in cancer, and that it had a novel finding of a benefit of exercise on dyspnea, but showed no effect on nausea/vomiting, loss of appetite, or constipation/diarrhea. The analysis did show significant results in the areas listed previously, although it is difficult to determine generalizability given the unknown sample characteristics. The effect of exercise on dyspnea was only seen with the mixed exercise groups, and it is difficult to understand who was included in that subgroup of patients; unclear, in particular, with cancer type and phase of case. The mechanism of dyspnea in a heme malignancy patient is very different, for example, than for a solid tumor patient, and there was a highly limited number of patients with lung cancer in this study. Not knowing phase of care also limits the ability to understand who this could be applied to. More exploration of the effect of exercise on dyspnea should be undertaken to reach solid conclusions, but this analysis does suggest that the exploration is warranted.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• It can be argued, also, that the search process itself had limitations by using only studies that measured outcomes from the two tools they chose and would limit a  number of high-quality studies using other tools.

With regard to dyspnea specifically, the nurse should be aware that there is a possibility that exercise may have an impact on dyspnea for some patients. It is unclear who these patients are, or what exercise regimens are most affected, so no clear recommendation can be provided to patients at this time based on this particular study.

To test the effects of a specially designed strength and endurance training on the independence and quality of life (QOL) in patients with stages III/IV lung cancer while undergoing chemotherapy

Endurance training and breathing techniques were performed five days per week, and strength training was performed every other day while patients received three cycles of inpatient chemotherapy (platinum based). Endurance training consisted of walking and stair exercises. Strength training consisted of four different endurance exercises (trunk stability, leg, arm, and abdominal musculature), as well as breathing techniques (active cycle of breathing) combined with conventional physiotherapy. Control arm received conventional physiotherapy. Evaluations were conducted at baseline and after three cycles of chemotherapy.

• N = 46; only 29 completed (of the 17 withdrawals, 6 withdrew due to death, 10 from noncompliance, and 1 from switching hospitals). 18 were in the intervention group, 11 in the control.
• AGE: 18 years or older
• MALES (%): Unknown 
• FEMALES (%): Unknown 
• CURRENT TREATMENT: Chemotherapy 
• KEY DISEASE CHARACTERISTICS: Patients with stage IIIA/IIIB or IV lung cancer undergoing platinum-based inpatient chemotherapy regimens 
• OTHER KEY SAMPLE CHARACTERISTICS: Includes patients with non-small cell lung cancer and small cell lung cancer

• SITE: Single Site       
• SETTING TYPE: Hospital (inpatient)   
• LOCATION: Germany

PHASE OF CARE: Active anti-tumor treatment

Randomized controlled trial

6 minute walk test, staircase walking (number of steps), Barthel Index (primary outcome measure), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30, Modified Borg Scale

After intervention, the intervention group had a significantly higher Barthel Index (p = 0.003), indicating higher independence with ADLs. In the single scores of the EORTC QLQ-C30, the intervention group reported higher physical functioning (p = 0.025), lower hemoptysis (p = 0.019), lower pain in the arms/shoulders (p = 0.048), peripheral neuropathy (p = 0.05) and cognitive functioning (p = 0.05). There were significant differences in ability on 6 minute walk test and stair walking as well as strength capacity (all p < 0.05). The level of dyspnea decreased significantly in the intervention group while performing submaximal walking activities.

This study shows both feasibility and effects of a strength and endurance program during chemotherapy for lung cancer. The effects were significantly positive for the intervention group in every area (strength, endurance, QOL, independence). There were many issues with the study, however, making it difficult to apply to other populations. One huge issue is that it is unclear how many of the patients were SCLC versus NSCLC. These populations would have a wide difference in the natural history of disease on platinum regimen for the first few cycles; therefore, not knowing the content of each group is problematic. There were also large differences at baseline, so the effects are harder to evaluate. There was a very small sample size and large dropout rate. The intervention was feasible, but only given inpatient, so it is unclear if it is feasible for an outpatient population and these regimens are currently most typically administered outpatient in the United States. Although promising, it would need to be repeated to be generalizable.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Findings not generalizable
• Subject withdrawals 10% or greater  
• Other limitations/explanation: This study was conducted on an inpatient basis. At least in the United States, current chemotherapy for these diseases even at this stage would be outpatient, so feasibility not applicable. Also, there was a large difference between groups at baseline in physical capacity and strength. The dropout rate was high, but also different between groups. The study was conducted as inpatient for what is an outpatient regimen in the United States.

Nurses should take away from this study that there is the possibility that endurance, strength, and QOL are improved by a program of strength and endurance training during chemotherapy. The results are not generalizable and would need further studies to confirm. There was no harm, but it cannot be recommended based solely on this study at this time.

To evaluate the effects of a supervised outpatient physical therapy strengthening and conditioning program on symptoms and quality of life

The program included aerobic exercise and strength training. The first two sessions were individualized under the supervision of a physical therapist. Patients who needed additional assistance walking, transferring, or using equipment continued to attend one-hour individual sessions. Patients were placed into 90-minute group sessions. The program consisted of intensive work for eight weeks, then six months of maintenance training was offered for those who were interested. Study assessments were done at baseline and after eight weeks.

• N = 75
• MEAN AGE = 62.6 years (SD = 11.9 years)
• MALES: 34.7%, FEMALES: 65.3%
• KEY DISEASE CHARACTERISTICS: Various tumor types (breast and lung were most prevalent)
• OTHER KEY SAMPLE CHARACTERISTICS: 34.7% metastatic disease; 15.3% in active treatment; 26.7% working full- or part-time

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Minnesota, United States

• PHASE OF CARE: Multiple phases of care

Quasi-experimental

• Short Form 36 (SF-36)
• Six-Minute Walk Test (6MWT)
• MD Anderson Symptom Inventory (MDASI)

The results of the 6MWt were better on average at the end of eight weeks (p < 0.0001). Physical component scores on the SF-36 improved (p < 0.001) as did mental component scores after eight weeks (p < 0.005). At the end of six months, only physical component scores remained higher than reported at baseline. Fatigue (p = 0.003) and dyspnea (p = 0.007) were improved at eight weeks. After six months, fatigue (p = 0.0077), shortness of breath (p = 0.0005), and disturbed sleep (p = 0.045) were improved from baseline. Patients still in active treatment showed significantly less improvement. Those who showed the worst performance at baseline showed the greatest improvement.

The eight-week strengthening and conditioning program improved physical function, fatigue, dyspnea, and sleep disturbance in this study. Improvement was greatest among those who had the worst symptoms and physical performance statuses at baseline and among those who were not in active treatment.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: Greater than 30% of participants withdrew from the study. There were significant differences for individuals still in treatment; however, the sample was too small to adequately analyze study sample subgroups. No information was provided about other relevant interventions that may have occurred during the six months of follow-up.

The findings of this study demonstrated the effectiveness of an exercise program on symptoms of fatigue, shortness of breath, and sleep disturbance among a variety of patients with cancer. These findings add to the large body of evidence about the efficacy of exercise.