Impaired physiological function and health-related QOL in patients before hematopoietic stem-cell transplantation

Inpatient Rehabilitation of Hematopoietic Stem Cell Transplant Patients: Managing Challenging Impairments and Medical Fragility

ABSTRACT

Hematopoietic stem cell transplants play an important role in the treatment of cancer, particularly hematologic malignancies. These patients can encounter functional impairments unique to hematopoietic stem cell transplant, including deconditioning, cancer-related fatigue, steroid myopathy, graft versus host disease, and capillary leak syndrome. Medical fragility and increased risk of infection may make rehabilitation challenging on the acute care and postacute care settings. Patients admitted to acute inpatient rehabilitation experience a high rate of transfer to the primary acute service and high rate of mortality after transfer back. Physical medicine and rehabilitation physicians can use a number of strategies to mitigate these patients' risk of medical complications including evidence-based predictive models to assist with postacute rehabilitation triage, physiatry-led consult-based rehabilitation, and oncology hospitalist comanagement on inpatient rehabilitation.

Effects of pulmonary rehabilitation in hematopoietic stem cell transplantation recipients: a randomized controlled study

PURPOSE

During hematopoietic stem cell transplantation (HSCT), patients' exercise capacity and quality of life (QOL) are impaired. Exercise training is recommended to preserve cardiorespiratory fitness during the compelling HSCT period. However, studies investigating the effects of pulmonary rehabilitation (PR) in HSCT recipients are limited. Therefore, this study aimed to investigate the effects of two different PR programs on maximal exercise capacity, respiratory muscle strength and endurance, pulmonary function, and QOL.

METHODS

This is a prospective, randomized, controlled, triple-blinded study. Thirty hospitalized patients undergoing HSCT were randomized to the pulmonary rehabilitation plus inspiratory muscle training (PR + IMT) group and the PR group. PR group performed upper extremity aerobic exercise training (AET) and progressive resistance exercise training (PRET), PR + IMT group performed IMT in addition to the upper extremity AET and PRET. Maximal exercise capacity (cardiopulmonary exercise testing), respiratory muscle strength (mouth pressure device, (MIP and MEP)) and respiratory muscle endurance (threshold loading test), pulmonary function (spirometry), and QOL (European Organization for Research and Treatment of Cancer (EORTC QLQ-C30) were evaluated before HSCT and after discharge.

RESULTS

Changes in pulmonary function, respiratory muscle strength and endurance, and QOL were similar within groups (p > 0.05). The MEP, peak oxygen consumption, and oxygen pulse significantly decreased in both groups (p < 0.05).

CONCLUSION

Pulmonary function, inspiratory muscle strength and endurance, and QOL preserved after HSCT. Expiratory muscle strength and maximal exercise capacity decreased even though PR during HSCT. Breathing reserve and restriction improved in the PR + IMT group. In addition, minute ventilation and dyspnea were preserved in the PR + IMT group, while these values were worsened during two structured PR programs. Therefore, PR should be applied in accordance with the patient's current clinical and hematologic status to patients undergoing HSCT.

CLINICALTRIALS

gov (19/07/2018, NCT03625063).

Prehabilitative high-intensity interval training and resistance exercise in patients prior allogeneic stem cell transplantation

Physical capacity prior allogeneic stem cell transplantation (allo-HCT) has been shown as a relevant prognostic factor for survival after transplant. Therefore, we evaluated feasibility and preliminary efficacy of a high-intensity interval training (HIIT) and moderate to high-intensity resistance exercise (RE) to increase physical capacity in patient's prior allo-HCT. In this multicentre single arm pilot study, a supervised exercise program was performed twice weekly for 4-12 weeks prior allo-HCT, depending on the individual time remaining. Outcomes were feasibility (recruitment, adherence, safety), physical capacity (cardiorespiratory fitness [VO2peak], muscle strength) and patient reported outcomes (physical functioning, fatigue). Thirty patients were intended, 16 could be included, and 14 completed post intervention assessment (75% male, 55 ± 11 years). The study was stopped early due to a low recruitment rate. Nine patients (64%) reached the initial minimum planned number of eight exercise sessions. Individual adherence was high with 92% for HIIT and 85% for RE. 87% of all performed exercise sessions were completed without complaints and VO2peak increased significantly from 20.4 to 23.4 ml/kg/min. The low recruitment rate suggests that initiation of the intervention concept immediately before allo-HCT is feasible only in a small number of patients. In particular, the timeframe directly prior allo-HCT seems too short for exercise interventions, although the exercise program was designed to improve outcomes in a very short time frame. HIIT and RE were feasible, effective and well accepted by the included patients.

Minimal important difference of the 6-minute walk test after allogenic hematopoietic stem cell transplantation

PURPOSE

The 6-min walk test (6MWT) of allogenic hematopoietic stem cell transplantation (allo-HSCT) recipients has been gaining attention; however, minimal differences have not been reported. This study aimed to determine the minimal important difference (MID) in the 6MWT among hospitalized patients with allo-HSCT.

MATERIALS AND METHODS

The MID of the 6MWT was calculated using three different methodologies based on an anchor-based method; basic anchor-based methods, linear regression analysis, and receiver operating characteristic (ROC) curve analysis. The decrease in the score of Question 2 of the European Organization for Research and Treatment of Cancer Quality of life questionnaire core-30 was included as an anchor question for calculating the MID. Both actual and percentage changes in 6MWT values from baseline and at discharge were used in the MID calculations. In the actual and percentage change of the 6MWT, the one with the larger the area under the curve in the ROC curve was recommended as the MID.

RESULTS

Among the three methods using actual values, the largest MID of the 6MWT was -37.5 m (sensitivity: 54%, specificity: 88%).

CONCLUSION

More careful follow-up after discharge is necessary for allo-HSCT patients who show a reduction of 37.5 m or more in the acute illness phase.

Effect of rehabilitation in patients undergoing hematopoietic stem cell transplantation

Patients undergoing hematopoietic stem cell transplantation (HSCT) tend to experience decline in physical function, mental function, and quality of life (QOL) after HSCT due to low activity caused by adverse reactions to chemotherapy used in pre-transplantation treatment and post-transplant complications. Rehabilitation for HSCT patients is effective in preventing decline in physical function, reducing fatigue, and improving QOL. A combination of aerobic exercise and strength training is recommended for exercise therapy. Risk management is also important in the implementation of exercise therapy, and the exercise intensity should be determined according to the presence of anemia, low platelet counts, or post-transplant complications. On the other hand, post-transplant complications can decrease the patient's motivation and daily activity level. A multidisciplinary approach, which includes physicians and nurses, is important to achieve early discharge from the hospital and as quick a return to society as possible.

High-dose Chemotherapy Impairs Cardiac Autonomic Control of Hospitalized Cancer Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation

BACKGROUND

Autologous hematopoietic stem cell transplantation (HSCT) patients have intermediary and late cardiac autonomic dysfunction, which is an independent mortality predictor. However, it is unknown when this HSCT-related autonomic dysfunction begins during hospitalization for HSCT and whether cardiac autonomic control (CAC) is related to cardiotoxicity in these patients.

PATIENTS AND METHODS

CAC was assessed in 36 autologous-HSCT inpatients (HSCT group) and 23 cancer-free outpatients (CON group) using heart rate variability analysis. The HSCT group was assessed at five time-points from admission to hospital discharge during hospitalization period. The CON group was assessed once. The severity of cardiotoxicity (CTCAE 5.0) and cardiac troponin I were recorded.

RESULTS

The CAC was significantly reduced after high-dose chemotherapy (HDC) (reduction of MNN, SDNN, RMSSD, LFms² and HFnu, and increase of LFnu and LF/HF; P<0.05). At the onset of neutropenia, pNN50 and HFms² were also reduced (P<0.05) compared to the admission ones. Although both groups were similar regarding CAC at hospital admission, the HSCT patients showed impaired CAC at hospital discharge (P<0.05). The LF/HF was positively associated with cardiac troponin I and RMSSD was inversely associated with the severity of cardiotoxicity (P≤0.05).

CONCLUSION

CAC worsened during hospitalization for autologous-HSCT, mainly after HDC. In addition, it seems associated to early signs of cardiotoxicity in these patients.

Impact of the quantity and quality of the skeletal muscle on survival among patients undergoing allogeneic hematopoietic stem cell transplantation

INTRODUCTION

Poor skeletal muscle function is relatively high in patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), leading to various negative health outcomes. This study aimed to investigate the relationship between the quantity and quality of skeletal muscle before transplantation and the short-to long-term survival after transplantation in patients undergoing allo-HSCT.

METHODS

This retrospective cohort study included 156 patients undergoing allo-HSCT (men, 67.3 %; median age, 53 years; interquartile range, 42-61 years). The quantity and quality of the skeletal muscle were measured at the psoas major at the level of the third lumbar vertebrae using a computed tomography (CT) and were defined as psoas muscle index (PMI) and CT values (CTV), respectively. The outcome measure of this study was overall survival (OS) after allo-HSCT, and we examined the relationship between survival at three time points (6, 12, and 24 months) after transplantation, PMI, and CTV.

RESULTS

PMI was significantly associated with survival at all time points in the crude model (P < 0.001), and a significant association was observed in the fully adjusted model (P < 0.01). CTV was significantly associated with survival at all time points in the crude model (P < 0.05), but not in the fully adjusted model (P > 0.05).

CONCLUSIONS

We found that the quantity and quality of the skeletal muscle before transplantation were significantly associated with OS at 6, 12, and 24 months after transplantation, showing a particularly robust association with quantity.

Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant

PURPOSE

Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT.

PATIENTS AND METHODS

In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017.

RESULTS

In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03).

CONCLUSION

A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

Balance Function after Balance Exercise Assist Robot Therapy in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation: A Pilot Study

Objectives

This study compared the balance function in patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT) with their balance function after subsequent training sessions with a Balance Exercise Assist Robot (BEAR).

Methods

In this prospective observational study, inpatients who underwent allo-HSCT from human leukocyte antigen-mismatched relatives were enrolled from December 2015 to October 2017. Patients were allowed to leave their clean room after allo-HSCT and underwent balance exercise training using the BEAR. Sessions (20-40 min) were performed 5 days per week and consisted of three games that were performed four times each. A total of 15 sessions were performed by each patient. Patient balance function was assessed before BEAR therapy according to the mini-balance evaluation systems test (mini-BESTest), and patients were divided into two groups (Low and High) based on a 70% cut-off value for the total mini-BESTest score. Patient balance was also assessed after BEAR therapy.

Results

Fourteen patients providing written informed consent fulfilled the protocol: six patients in the Low group, and eight patients in the High group. In the Low group, there was a statistically significant difference between pre- and post-evaluations in postural response, which a sub-item of the mini-BESTest. In the High group, there was no significant difference between pre- and post-evaluations in the mini-BESTest.

Conclusions

BEAR sessions improve balance function in patients undergoing allo-HSCT.

Weight loss in children undergoing allogeneic hematopoietic stem cell transplantation within the first 100 days: Its influencing factors and impact on clinical outcomes

Purpose/Objective

This study aimed to evaluate the nutritional status of children subjected to allogeneic hematopoietic stem cell transplantation (alloHSCT) in the first 100 days. Objectives were to clarify the effect of weight loss on clinical outcomes, and to analyze factors influencing weight loss.

Methods

Eighty pediatric patients receiving alloHSCT were enrolled in the study. Body mass index (BMI) z-scores and weight for age (WFA) z-scores were collected. A multivariate regression model was set up to investigate factors affecting weight loss. Post-transplant clinical outcomes relative to weight loss on 100 days after transplantation were analyzed.

Results

At admission, eight patients (10%) were underweight, the number had increased to 23 (30.67%) by 100 days post-HSCT. On day + 100, only nutrition screening tool for childhood cancer (SCAN) scores ≥ 3 (OR: 4.474, 95% CI: 1.215, 16.472; P = 0.024) and acute graft versus host disease (aGVHD) (OR: 9.915, 95% CI: 3.302, 29.771; P < 0.001) were regarded as significant influencing factors of weight loss. The Weight loss ≥ 5% group was associated with longer hospital stays (P = 0.001), greater cost of inpatient treatment (P = 0.001), and a higher incidence of 100-day re-admission and intensive care unit (ICU) transfer (P = 0.03 and P = 0.033, respectively). Cumulative number of fever days (P = 0.023) and antibiotic use (P = 0.007) also increased significantly. The Weight loss ≥ 5% group had a significantly lower one-year overall survival rate compared with the Weight loss < 5% group (P = 0.015).

Conclusion

Pediatric patients' nutritional status declined significantly after HSCT. Weight loss within the first 100 days influenced short-term clinical outcomes and one-year overall survival.

Using Wearable Inertial Sensors to Assess Mobility of Patients With Hematologic Cancer and Associations With Chemotherapy-Related Symptoms Before Autologous Hematopoietic Stem Cell Transplant: Cross-sectional Study

BACKGROUND

Wearable sensors could be a simple way to quantify and characterize mobility in patients with hematologic cancer scheduled to receive autologous hematopoietic stem cell transplant (autoHSCT) and how they may be related to common treatment-related symptoms and side effects of induction chemotherapy.

OBJECTIVE

We aimed to conduct a cross-sectional study comparing mobility in patients scheduled to receive autoHSCT with that in healthy, age-matched adult controls and determine the relationships between patient mobility and chemotherapy-related symptoms.

METHODS

Patients scheduled to receive autoHSCT (78/156, 50%) and controls (78/156, 50%) completed the prescribed performance tests using wearable inertial sensors to quantify mobility including turning (turn duration and number of steps), gait (gait speed, stride time, stride time variability, double support time, coronal trunk range of motion, heel strike angle, and distance traveled), and balance (coronal sway, coronal range, coronal velocity, coronal centroidal frequency, sagittal sway, sagittal range, sagittal velocity, and sagittal centroidal frequency). Patients completed the validated patient-reported questionnaires to assess symptoms common to chemotherapy: chemotherapy-induced peripheral neuropathy (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity subscale), nausea and pain (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), fatigue (Patient-Reported Outcomes Measurement Information System Fatigue Short Form 8a), vertigo (Vertigo Symptom Scale-short form), and depression (Center for Epidemiological Studies-Depression). Paired, 2-sided t tests were used to compare mobility between patients and controls. Stepwise multivariable linear regression models were used to evaluate associations between patient mobility and symptoms.

RESULTS

Patients aged 60.3 (SD 10.3) years had significantly worse turning (turn duration; P<.001), gait (gait speed, stride time, stride time variability, double support time, heel strike angle, stride length, and distance traveled; all P<.001), and balance (coronal sway; P<.001, range; P<.001, velocity; P=.02, and frequency; P=.02; and sagittal range; P=.008) than controls. In patients, high nausea was associated with worse stride time variability (ß=.001; P=.005) and heel strike angle (ß=-.088; P=.02). Pain was associated with worse gait speed (ß=-.003; P=.003), stride time variability (ß=.012; P=.02), stride length (ß=-.002; P=.004), and distance traveled (ß=-.786; P=.005). Nausea and pain explained 17% to 33% and 14% to 36% of gait variance measured in patients, respectively.

CONCLUSIONS

Patients scheduled to receive autoHSCT demonstrated worse mobility in multiple turning, gait, and balance domains compared with controls, potentially related in part to nausea and pain. Wearable inertial sensors used in the clinic setting could provide granular information about mobility before further treatment, which may in turn benefit from rehabilitation or symptom management. Future longitudinal studies are needed to better understand temporal changes in mobility and symptoms across the treatment trajectory to optimally time, design, and implement strategies, to preserve functioning in patients with hematologic cancer in the long term.

Rehabilitation in children and adolescents undergoing stem cell transplantation: A pilot study focused on motor performance

OBJECTIVES

The aim of this pilot trial is evaluating the preliminary effectiveness of two in-hospital interventions in the maintenance of motor performance in children/adolescents undergoing hematopoietic stem cell transplantation (HSCT). Secondary objectives investigated the interventions' feasibility, impact on fatigue and to what degree the subjects' maintained their ankle dorsiflexion range of movement (ROM), functional mobility, muscle strength and flexibility.

METHODS

This trial included 5- to 18-year-old participants, affected by oncological and non-oncological diseases during hospitalisation for autologous/allogenic HSCT. The subjects were assigned to an exercise group (EG), or a counselling group based on a cluster model based on inpatient timeframe. The EG subjects performed strengthening, stretching and aerobic exercises for 30 min/5 days a week. Both groups followed rehabilitation counselling indications (RCI), 7 days a week.

RESULTS

Forty-nine participants were enrolled (median age = 12.9 years) (EG n = 36). In both groups the participants maintained their baseline motor performance and ankle ROM, and the children/adolescents and parents reduced their levels of fatigue. However, the interventions were not effective in maintaining strength.

CONCLUSION

In maintaining the subjects' motor performance, the RCI results are significant because they pave the way for the application in clinical practice contexts where there are poor rehabilitation resources. Clinical Trials registration NCT03842735.

Allogeneic haematopoietic stem cell transplantation and patient falls: impact of lower extremity muscle strength

OBJECTIVES

Patients undergoing allogeneic haematopoietic stem cell transplantation (allo-HSCT) have a higher risk of falls than those receiving other therapies for haematological disorders. This study aimed to investigate the impact of pretransplant lower extremity muscle strength (LEMS) on post-transplant falls.

METHODS

In this retrospective cohort study, patients aged ≥18 years who underwent allo-HSCT were included. All data were extracted from medical records. LEMS was defined as the knee extension force measured by a handheld dynamometer divided by the patient's weight. The receiver operating characteristic (ROC) curve was used to calculate the optimal LEMS cut-off value for prediction of falls. Patients were categorised into low and normal LEMS groups based on the cut-off value. The impact of pretransplant LEMS on post-transplant falls was analysed using a Cox proportional hazards model.

RESULTS

In total, 101 patients were analysed. During the observation period, falls occurred in 32 patients (31.7%). The ROC curve analysis results showed that the optimal LEMS cut-off value for prediction of falls was 45.4% per body weight. In multivariate analysis, pretransplant low LEMS was a significant predictor of falls in model 1 with patient characteristics as a confounding factor and model 2 with medications-inducing falls as a confounding factor, respectively (model 1: HR 3.23, 95% CI 1.37 to 7.64; model 2: HR 2.82, 95% CI 1.20 to 6.59).

CONCLUSIONS

Pretransplant LEMS was a significant predictor of post-transplant falls. The results of this study may help to prevent falls in patients undergoing allo-HSCT.

Rehabilitation Needs for Patients Undergoing CAR T-Cell Therapy

PURPOSE OF REVIEW

Chimeric antigen receptor (CAR) T-cell therapy is a relatively new, innovative treatment strategy to manage refractory hematological cancers, including some types of leukemia, lymphoma, and multiple myeloma. This article outlines the CAR T-cell therapy process, toxicity, and complications, along with an overview of the currently known short- and long-term physical and functional sequelae that will be helpful for general or oncology rehabilitation specialists caring for these patients.

RECENT FINDINGS

There is a dearth of literature on the topic of rehabilitation of patients receiving CAR T-cell therapy. Rehabilitation practices can be extrapolated from the limited functional information on patients who have completed treatment for lymphoma and multiple myeloma. Patients present with cognitive impairment, muscle weakness, reduced exercise capacity, neuropathy, and cancer-related fatigue. Physical activity and rehabilitation programs may be beneficial to address fatigue, psychological symptoms, and quality of life. There is limited rehabilitation research in patients receiving CAR T-cell therapy. These patients may present with general deconditioning and neurological complications which translate to neuromuscular and cognitive impairment that benefit from multidisciplinary rehabilitation intervention prior to, during, and after treatment. Studies measuring the impairments at baseline and evaluation of the impact of rehabilitation practices are much needed to support this.

Exercise in allogeneic bone marrow transplantation: a qualitative representation of the patient perspective

PURPOSE

Exercise is emerging as a vital aspect of care to alleviate the physical and psychosocial symptom burden associated with allogeneic bone marrow transplantation (BMT). Understanding the patient perspective regarding exercise is important to move towards implementation. This study aimed to characterise experiences and views regarding participation in an exercise program in adults receiving treatment for haematological disease with allogeneic BMT.

METHODS

Individual semi-structured interviews were conducted with 35 participants from either an early- or late-commencing supervised group-based exercise program. Using an inductive, conventional approach to qualitative content analysis data were independently analysed by two researchers.

RESULTS

Six major themes and 33 sub-themes were identified: this encompassed motivation, physical opportunity and capability to exercise; psychosocial effects of group-based exercise; experienced impact of participation in an exercise program; and intervention design considerations. Key barriers to exercise included symptom severity and fluctuating health and distance or difficult access to an exercise facility or equipment, whilst facilitators included encouragement from staff; peer support in the group-based setting; flexibility; education; and ability to measure change.

CONCLUSION

This study highlights the importance of a flexible approach to exercise with consideration of individual symptoms and preferences. The perceived psychological impact of exercise should not be underestimated; future exercise programs should be designed in partnership with patients, with consideration of group-based activities to reduce social isolation if this is feasible in the treatment context. Intervention design should also acknowledge the individual's physical and psychological capability, opportunity and automatic and reflective motivation to direct and sustain exercise behaviours following BMT.

Allogeneic haematopoietic stem cell transplantation-clinical outcomes: impact of leg muscle strength

OBJECTIVES

Muscle strength decline is reported to predict mortality in many cancers. However, there is little knowledge of the relation between muscle strength decline and clinical outcomes of allogeneic haematopoietic stem cell transplantation (allo-HSCT). This study aimed to determine the impact of pre-transplant lower extremity muscle strength (LEMS) on post-transplant overall survival (OS) and non-relapse mortality (NRM).

METHODS

In this retrospective cohort study, 97 adult patients underwent allo-HSCT during 2012-2020. LEMS was defined as knee extension force divided by patient's body weight. The patients were divided into low and high LEMS groups based on pre-transplant LEMS. OS was measured using the Kaplan-Meier method and the Cox proportional hazards model. The cumulative incidence of NRM was evaluated using the Fine and Gray method, with relapse considered as a competing risk event.

RESULTS

Probability of OS was significantly lower in the low LEMS groups (HR 2.48, 95% CI 1.20 to 5.12, p=0.014) than in the high LEMS group on multivariate analysis. Five-year OS was 25.8% and 66.4% in the low and high LEMS groups, respectively. Risk of NRM was significantly higher in the low LEMS group (HR 4.49, 95% CI 1.28 to 15.68, p=0.019) than in the high LEMS group. The cumulative incidence of NRM was 41.4% and 11.1% in the low and high LEMS groups, respectively.

CONCLUSIONS

Pre-transplant LEMS was a significant factor in predicting OS and NRM.

People With Hematological Malignancies Treated With Bone Marrow Transplantation Have Improved Function, Quality of Life, and Fatigue Following Exercise Intervention: A Systematic Review and Meta-Analysis

OBJECTIVE

For people with hematological malignancies treated with bone marrow transplantation (BMT), this systematic review aimed to identify, evaluate, and synthesize the evidence examining the effect of exercise training on the outcomes of exercise capacity, health-related quality of life (HRQoL), and hospital length of stay (LOS) and to identify any difference in the effect on people treated with allogeneic versus autologous transplantation.

METHODS

Five electronic databases were systematically searched from inception to December 5, 2020. Prospective studies with a comparator group, with or without randomization, were included if they investigated the effects of an exercise intervention compared with usual care or another intervention in adults who had a hematological malignancy and were undergoing BMT. Primary outcomes of interest were functional exercise capacity and HRQoL; secondary outcomes included strength, fatigue, hospital LOS, and feasibility. Only randomized controlled trials were included in the meta-analyses. Risk of bias was evaluated using the Physiotherapy Evidence Database or Newcastle-Ottawa Scale; the quality of evidence for meta-analyses was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Twenty-four randomized controlled trials and 3 prospective nonrandomized experimental trials were included (n = 2432). There was moderate-quality evidence that exercise improves functional exercise capacity (mean difference [MD] = 29 m; 95% CI = 12.59 to 45.4), global HRQoL (MD = 3.38 points; 95% CI = 0.37 to 6.39), and fatigue (MD = 2.52 points; 95% CI = 0.42 to 4.63) and low-quality evidence for reduced hospital LOS (MD = 2.07 days; 95% CI = 0.43 to 3.72). These effects were more pronounced in recipients of allogeneic transplantation. No serious adverse events were associated directly with exercise in the included studies.

CONCLUSION

Exercise is safe and improves outcomes, including functional exercise capacity, HRQoL, and hospital LOS in adults undergoing BMT.

IMPACT

The results of this systematic review support the implementation of exercise programs in adults undergoing BMT, particularly recipients of allogeneic transplantation.

Analysis of factors associated with patient-reported physical functioning scores at discharge of allogeneic hematopoietic stem cell transplantation patients: a cross-sectional study

PURPOSE

The purpose of this study was to clarify the independent factors related to patient-reported physical functioning (PF) scores at discharge of patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

A total of 103 patients who underwent allo-HSCT were included in this cross-sectional study. As a screening method, a single regression analysis was conducted with the PF domain in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 at discharge as the dependent variable, and body mass index, adverse events related to HSCT, and objective physical functions as independent variables. Multiple regression analysis was performed with PF as the dependent variable and variables that passed the screening by single regression analysis and confounders as independent variables.

RESULTS

The mean PF score at discharge of the patients was 76.5 (standard deviation: 15.2). Based on the results of screening by the single regression analysis, length of stay, infections (+ / -), acute graft-versus-host disease grade, brief fatigue inventory score (BFI), knee extensor strength, and 6-min walk distance (6MWD) were included in the multiple regression analysis. BFI (B =  - 11.94, p < 0.001) and 6MWD (per 10 m) (B = 0.56, p = 0.001) were extracted as significant independent variables governing the PF at discharge in the multiple regression model (adjusted R² = 0.59).

CONCLUSION

Higher exercise tolerance and lower fatigue in patients who underwent allo-HSCT were associated independently with patient-reported better PF scores at discharge.

An Exploratory Study on Physical Function in Stem Cell Transplant Patients Undergoing Corticosteroid Treatment for Acute Graft-Versus-Host-Disease

ABSTRACT

Acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation is treated with corticosteroids, placing patients at risk for steroid myopathy. In this single-arm cohort study, 23 patients who were started on high-dose corticosteroids for acute graft-versus-host disease underwent a series of functional tests (baseline and days 14, 28, and 56): 6-min walk test, hip flexor and knee extensor strength via dynamometry, five times sit-to-stand, Brooke scale for myopathy, modified Adult Myopathy Assessment Tool, and manual muscle testing. Participants were prescribed home exercises including walking and resistance exercises, with low adherence. Fifteen (63%) participants were male and median (range) age was 60 (36-70) yrs. Median (range) corticosteroid duration and cumulative equivalent methylprednisolone dose were 66 (22-165) days and 3625 (1020-11720) mg, respectively. At day 14, there was a significant decline in five times sit-to-stand (P = 0.0132), knee extensor (P = 0.0182), and manual muscle testing (P = 0.0466). Functional tests negatively associated with cumulative corticosteroid dose included 6-min walk test distance (P = 0.0103), hip flexor strength (P = 0.0262), knee extensor strength (P = 0.0369), and manual muscle testing strength (P = 0.0319). Five times sit-to-stand was positively associated with corticosteroid dose (P = 0.0003). In conclusion, stem cell transplant patients receiving high-dose corticosteroids for acute graft-versus-host disease are at risk for weakness detected as early as day 14. Increasing adherence to exercise may mitigate these changes.

Pre-transplant Rehabilitation to Decrease the Post-transplant Length of Stay for Hematological Malignancy Patients Undergoing Allo-HSCT

Objectives:

Pre-transplant rehabilitation for hematological malignancy patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) helps improve physical capacity. However, its benefit with respect to post-transplant hospital length of stay (LOS) is unclear. Consequently, the aim of this study was to investigate the effect of pre-transplant rehabilitation on post-transplant LOS for hematological malignancy patients undergoing allo-HSCT.

Methods:

Data on patients diagnosed between April 2014 and March 2017 were collected from the Japanese Diagnosis Procedure Combination database. The patients were identified using the ICD-10 codes C81–85, C90–94, C96, and D46. Multilevel linear regression analyses were conducted to identify the effects of pre-transplant rehabilitation on post-transplant LOS (log transformed).

Results:

In total, 3614 patients were included in the study. Pre-transplant rehabilitation was associated with a significant reduction in post-transplant hospital LOS (β=–0.134, P<0.001).

Conclusions:

Pre-transplant rehabilitation may be an effective strategy for shortening the post-transplant hospital LOS in hematological malignancy patients undergoing allo-HSCT. Consequently, it may be necessary to consider starting rehabilitation before transplantation.

Efficacy of physical exercise using the balance board game on physical and psychological function in patients with hematological malignancies confined to a bioclean room

OBJECTIVE

This study aimed to define the efficacy and features of physical therapy (PT) using the Nintendo Wii Fit U (Nintendo Inc., Kyoto, Japan) in patients with hematological malignancies confined to a bioclean room.

METHOD

A total of 33 patients with hematological malignancies confined to a bioclean room were enrolled in this study. This study was designed as a randomized crossover test between two weeklong interventions: PT program (Therapist PT) and Wii Fit U program (Wii PT). We compared the efficacy of Wii PT and Therapist PT with regard to physical and psychological function test scores.

RESULTS

Of the 33 patients, 22 were analyzed. The validity of the crossover design was demonstrated, as there were no significant differences in period and carryover effects between the two groups. Therapist PT resulted in significantly better improvements in fatigue scores and total mood disturbance (TMD) scores in the Profile of Mood States short-form Japanese version compared to Wii PT (fatigue score, -5.2±8.3 vs 2.7±8.2; TMD score, -22.5±32.8 vs -2.6±20.5; p<0.05). Physical function improved post-Wii PT and post-Therapist PT interventions (p<0.05), and there was no difference in treatment effect.

CONCLUSION

Improvements in physical function were clearly observed following the use of Wii PT in patients confined to a bioclean room. However, compared to Therapist PT, Wii PT was less effective in improving the psychological function of patients.

Exacerbated hemodynamic response during exercise in cancer patients prior to autologous hematopoietic stem cell transplantation

PURPOSE

Chemotherapy treatment can lead to cardiovascular toxicity and physical impairment prior to autologous hematopoietic stem cell transplantation (auto-HSCT). Cardiovascular adjustments during exercise and the exercise capacity remain unknown in patients prior to auto-HSCT. Thus, the hemodynamic responses during exercise and exercise capacity were evaluated using a novel effort test in patients prior to auto-HSCT.

METHODS

Thirty patients prior to auto-HSCT (BMT group: 44.6 ± 14.1 years) and 23 control participants (CON group: 43.9 ± 16.6 years) performed the 6-Minute Step Test (6MST) to assess their exercise capacity and the hemodynamic responses during exercise. Systolic and diastolic blood pressure (SBP and DBP), heart rate (HR), and oxygen saturation (SpO₂) were measured during the test. Rate-pressure product (RPP) was calculated multiplying SBP by HR. The highest HR value recorded during the test was compared with the maximum HR predicted by age and was used as % of maximum HR (%HRmax).

RESULTS

The number of steps up and down performed by the BMT group was lower than CON (108.8 ± 25.3 vs. 127.5 ± 34.4 steps, P = 0.02). The BMT group showed a higher magnitude of increase in SBP and RPP during the 6MST when compared to CON (ΔSBP: 18.5 ± 11.45 vs. 8.30 ± 18.46 mmHg, P = 0.01; and ΔRPP: 8197.3 ± 3829.1 vs. 6170.9 ± 3568.9 mmHg beats min^-1, P = 0.05). The BMT group exhibited higher SpO2 and HR values throughout the protocol (P < 0.05), reaching a higher %HRmax than CON group (76.9 ± 9.6 vs. 66.4 ± 8.9%, P < 0.01).

CONCLUSIONS

Patients with indication for auto-HSCT have exacerbated chronotropic and pressor responses during exercise and reduced exercise capacity in the 6MST.

Influencing factors of cardiorespiratory fitness in allogeneic stem cell transplant candidates prior to transplantation

PURPOSE

Cardiorespiratory fitness (CRF) seems to be prognostic prior to allogeneic stem cell transplantation (allo-HSCT). Influencing factors of CRF in allo-HSCT candidates have not been studied so far. Aim was to identify potentially influencing factors on CRF.

METHODS

To assess CRF, a maximal cardiopulmonary exercise test (CPET) was performed on average 2.6 ± 7.2 days prior to admission. A regression analysis was conducted, with the following predictors: gender, age, body mass index (BMI), time between last therapy and allo-HSCT (t_Therapies), number of cardiotoxic therapies (n_Cardiotox), number of transplantations (n_Transplantations), comorbidity index (HCT-CI), hemoglobin level of the last 3 months (area under the curve), and physical activity.

RESULTS

A total of 194 patients performed a CPET. VO_2peak was significantly reduced compared with reference data. In total, VO_2peak was 21.4 ml/min/kg (- 27.5%, p < 0.05). Men showed a significant larger percentage difference from reference value (- 29.1%, p < 0.05) than women (- 24.4%). VO_2peak was significantly (p < 0.05) influenced by age (β = - 0.11), female gender (β = - 3.01), BMI (β = - 0.44), n_Cardiotox (β = - 0.73), hemoglobin level (β = 0.56), and physical activity prior to diagnosis (β = 0.10).

CONCLUSIONS

Our study demonstrates a decreased CRF indicating the potential need of prehabilitative exercise. We revealed some influencing factors on CRF. Those patients could benefit the most from exercise.

Relationship Between Muscle Oxygen Saturation and Exercise Load in Patients with Malignant Hematopoietic Disease

Our previous research confirmed that patients with malignant hematopoietic disease already had a low hemoglobin level before allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, no study has determined whether a correlation exists between exercise load, hemoglobin level, and muscle oxygen saturation (SmO₂), during exercise. Therefore, the purpose of this study was to investigate whether near-infrared spectroscopy (NIRS)-derived SmO₂ is associated with exercise load, as determined by a dynamometer, before allo-HSCT. This study included 19 male patients who received allo-HSCT in Hyogo College of Medicine Hospital (Japan) between November 2009 and October 2012. Patients performed isometric repeated dorsiflexion at 50% maximum voluntary contraction for 180 s to determine exercise load, and SmO₂ was evaluated during exercise at the same time using NIRS (BOM-L1TRW, Omega Wave, Inc., Japan). The hemoglobin level was also evaluated before allo-HSCT. Patients with hematopoietic disease before allo-HSCT already had a low hemoglobin level. There was a significant correlation between exercise load and ∆SmO₂; however, the hemoglobin level was not correlated with exercise load. In these patients, exercise load might be affected by muscle oxygen consumption rather than by the hemoglobin level. This finding shows that NIRS can used to assess fatigue in patients with malignant hematopoietic disease.

Relationship Between Exercise Capacity and Muscle O2Hb Saturation in Patients Before Hematopoietic Stem-Cell Transplantation

Patients with hematological malignancy might already have decreased muscle oxygen saturation at rest and exercise capacity before undergoing hematopoietic stem cell transplantation (HSCT). However, to date, no studies have investigated the relationship between exercise capacity and muscle oxygen saturation at rest in these patients. Therefore, purpose of this study was to investigate the relationship between exercise capacity and muscle oxygen-hemoglobin (O2Hb) saturation (SmO2) at rest and patients' hemoglobin level before undergoing HSCT.

METHODS

This study included 60 men with hematologic disease who underwent allo-HSCT. Patients performed a 6-minute walk test (6MWT) to determine exercise capacity, and muscle O2Hb saturation at rest was evaluatabed using near-infrared spectroscopy (BOM-L1TRW, Omegawave Inc., Japan); hemoglobin levels in hematological malignancy patients before undergoing HSCT were also evaluated.

RESULTS

There was a significant correlation between the 6MWT and muscle O2Hb saturation at rest in hematological malignancy patients (p < 0.05). Additionally, the 6MWT was significantly correlated to the hemoglobin level (p < 0.05). Furthermore, muscle O2Hb saturation at rest was significantly related to hemoglobin level (p < 0.05).

CONCLUSION

In patients with hematological malignancy, a relationship exists between exercise capacity, muscle O2Hb saturation, and hemoglobin level before they undergo HSCT. Therefore, rehabilitation staff, nurses, and physicians should recognize these relationships in patients who undergo allo-HSCT. Moreover, physiotherapists may need to promote muscle oxidative metabolism through exercise to increase exercise capacity in these patients.

The benefit of exercise in patients who undergo allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) is increasingly used in the treatment of hematologic cancers such as leukemias, lymphomas, and myeloma, and for other hematologic disorders such as primary immunodeficiency, aplastic anemia, and myelodysplasia. Allo-HSCT entails a conditioning regimen of frequent high-dose chemotherapy in combination with total body irradiation, followed by infusion of donor-harvested bone marrow or peripheral blood stem cells. As an aggressive and demanding medical therapy that profoundly impacts patient quality of life (QOL), allo-HSCT is associated with numerous treatment-related physical, psychological, and psychosocial side effects. The procedure can result in decreased respiratory and balance function, skeletal muscle strength, and exercise capacity. Thus, as physical exercise has been shown to positively effect physical and psychosocial function and QOL in allo-HSCT patients, it is a recommended intervention for improving essential functions and offsetting lost exercise capacity after the procedure. Furthermore, recent evidence has shown that physical exercise can influence survival rate and mortality in allo-HSCT patients. This review provides an overview of the current research on the effectiveness of physical exercise for allo-HSCT patients.

Social determinants associated with the quality of life of baccalaureate nursing students: A cross-sectional study

BACKGROUND

There is a paucity of studies that have explored the quality of life (QoL) of nursing students in the Philippines.

OBJECTIVES

The study assessed the QoL and identified the social determinants associated with the four domains of QoL among nursing students.

METHODS

This cross-sectional study was conducted among 444 randomly selected baccalaureate nursing students in a university in the Philippines. The QoL was determined using an adapted WHOQOL-BREF questionnaire (∝ = 0.89). Multiple linear regression determined the association between the variables of the study.

RESULTS

The students exhibited better scores in social relationships and environment than psychological and physical health domains of QoL. Physical health was significantly correlated to sex, hours of sleep, and medical condition, whereas sex, year level, academic load, hours of sleep, and medical condition were correlated to psychological domain. However, no significant association was noted between the factors and social relationships, but monthly allowance was positively correlated with the environment domain.

CONCLUSIONS

Various social determinants influence the QoL; thus, it is essential to be considered as a critical element in planning the curriculum to improve the QoL among baccalaureate students.

Whole-Body Electromyostimulation Combined With Individualized Nutritional Support Improves Body Composition in Patients With Hematological Malignancies - A Pilot Study

Patients undergoing the complex treatment for hematological malignancies are exposed to a high physiological and psychological distress inducing fatigue and physical inactivity. In line with cancer-related metabolic changes patients are predisposed for skeletal muscle mass loss that leads to a functional decline, affects therapeutic success, and quality of life. Benefits of physical exercise and nutritional interventions on muscle maintenance are observed in solid cancer patients, but marginally investigated in patients with hematological cancer. We here studied the effects of a combined supportive exercise and nutrition intervention using whole-body electromyostimulation (WB-EMS) training and individualized nutritional support in patients actively treated for hematological malignancy. In a controlled pilot trial, 31 patients (67.7% male; 58.0 ± 16.7 years) with various hematological cancers were allocated to a control group (n = 9) receiving nutritional support of usual care regarding a high protein intake (>1.0 g/kg/d) or to a physical exercise group (n = 22) additionally performing WB-EMS training twice weekly for 12 weeks. Bodyweight and body composition assessed by bioelectrical impedance analysis were measured every 4 weeks. Physical function, blood parameters, quality of life and fatigue were assessed at baseline and after 12 weeks. No WB-EMS-related adverse effects occurred. Patients attending the exercise program presented a higher skeletal muscle mass than controls after 12-weeks (1.51 kg [0.41, 2.60]; p = 0.008). In contrast, patients of the control group showed a higher fat mass percentage than patients of the WB-EMS group (-4.46% [-7.15, -1.77]; p = 0.001) that was accompanied by an increase in serum triglycerides in contrast to a decrease in the WB-EMS group (change ± SD, control 36.3 ± 50.6 mg/dl; WB-EMS -31.8 ± 68.7 mg/dl; p = 0.064). No significant group differences for lower limb strength, quality of life, and fatigue were detected. However, compared to controls the WB-EMS group significantly improved in physical functioning indicated by a higher increase in the 6-min-walking distance (p = 0.046). A combined therapeutic intervention of WB-EMS and protein-rich nutritional support seems to be safe and effective in improving skeletal muscle mass and body composition in hematological cancer patients during active oncological treatment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02293239.

Differences in pulmonary and extra-pulmonary characteristics in severely versus non-severely fatigued recipients of allogeneic hematopoietic stem cell transplantation: a cross-sectional, comparative study

OBJECTIVES

Fatigue is a common symptom in allogeneic-hematopoietic stem cell transplantation (allogeneic-HSCT) recipients. However, effects of severe fatigue on pulmonary functions, blood cells, dyspnea, muscle strength, exercise capacity, depression and quality of life (QOL) in allogeneic-HSCT recipients are still unknown. Therefore, to compare pulmonary functions, blood levels, dyspnea, muscle strength, exercise capacity, depression, and QOL between allogeneic-HSCT recipients according to fatigue severity and to determine predictors of severe fatigue were aimed in the current study.

METHODS

Twenty-four severe-fatigued (Fatigue Severity Scale score ≥36) (40.08 ± 12.44years) and 25 non-severe-fatigued (36.20 ± 13.73years) allogeneic-HSCT recipients were compared. Blood levels, pulmonary functions (spirometer), dyspnea (Modified Medical Research Council Dyspnea scale), exercise capacity (6-minute walk test), depression (Beck Depression Inventory-II), QOL (European Organization for Research and Treatment of Cancer QOL Questionnaire), respiratory (mouth pressure device) and peripheral muscle strength (dynamometer) were evaluated.

RESULTS

Symptom QOL-subscale and depression scores were significantly higher; peripheral muscle strength, global health status, and functional QOL-subscales scores were lower in severe-fatigued recipients (p < 0.05) whose exercise capacity was clinically (28.85 m) decreased. Blood levels, pulmonary functions, dyspnea, and respiratory muscle strength were similar in groups (p > 0.05). 42.4% of the variance in severe fatigue was explained by symptom QOL-subscale score and corticosteroid use after HSCT (p < 0.001).

CONCLUSIONS

Impairments in peripheral muscle strength, QOL, exercise capacity, and depression are more prevalent among severe-fatigued recipients. Moreover, poorer QOL and corticosteroid use after HSCT are most important predictors of severe fatigue. Effects of comprehensive exercise programs and psychosocial support for severe-fatigued recipients in late post-engraftment period should be investigated.

Factors affecting lower limb muscle strength and cardiopulmonary fitness after allogeneic hematopoietic stem cell transplantation

Purpose

The aim of this study is to clarify the factors affecting physical function after allogeneic hematopoietic stem cell transplantation (HSCT).

Methods

We retrospectively analyzed 88 patients (median age, 44.5 years) who received allogeneic HSCT. Leg extension torque and peak oxygen consumption (VO₂) were evaluated before and after HSCT. Patient factors (age, sex, underlying diseases, hemoglobin, serum albumin, and Karnofsky performance status score before transplant) and transplant factors (conditioning regimen, days to neutrophil engraftment, grades of acute graft-versus-host disease [GVHD], infections, and the interval between pre- and post-evaluation) were collected via chart review, and were used for correlational and comparison analyses in order to identify the variables associated with reduced post-HSCT leg extension torque and peak VO₂. Stepwise multiple regression analyses for post-HSCT leg extension torque and post-HSCT peak VO₂ were performed using age, sex, and the related variables with a p value < 0.2 in the correlational and comparison analyses.

Results

Leg extension torque and peak VO₂ were significantly reduced after HSCT (p < 0.001). Pre-HSCT leg extension torque, grades of acute GVHD, age, and the interval between pre- and post-evaluation were identified as significant factors associated with reduced post-HSCT leg extension torque. However, none of these factors were significantly associated with reduced post-HSCT peak VO₂, and only its pre-transplant value was identified as a significant factor.

Conclusions

These findings suggest that improvements in muscle strength and cardiopulmonary fitness before HSCT are crucial for maintaining post-treatment physical function, especially in elderly individuals with acute GVHD requiring a long-term stay in a protective environment.

Changes in Borg scale for resistance training and test of exercise tolerance in patients undergoing allogeneic hematopoietic stem cell transplantation

PURPOSE

We aimed to investigate the relationship between Borg scale and intensity of resistance training in patients who had undergone allogeneic hematopoietic stem cell transplantation (allo-HSCT). Furthermore, the relationship between Borg scale, heart rate (HR), and intensity of exercise tolerance test was also studied.

METHODS

The study included 28 patients (19 men and 9 women) who had undergone allo-HSCT between June 2015 and February 2017. Their knee extension strengths and exercise tolerances were evaluated. Patients were asked to grade between 0 and 10 on Borg scale based on the level of difficulty experienced during exercising, after 10 repetitions in randomized 20, 40, and 60% resistance training for knee extension. Additionally, we evaluated Borg scale, HR, and load intensity during exercise tolerance test, every minute of the exercise for 2 weeks before and 3 weeks after HSCT.

RESULTS

Knee extension strength and exercise tolerance were significantly decreased 3 weeks after HSCT from those before HSCT (p < 0.01). Additionally, rise in Borg scale with increase in load intensity during knee extension resistance training, both before and after HSCT (p < 0.01), was noted. Furthermore, Borg scale was found to be associated with HR and load intensity during exercise tolerance test in patients both before and after HSCT (p < 0.01).

CONCLUSIONS

A correlation was found between Borg scale with intensity of resistance training and exercise tolerance in patients who had undergone allo-HSCT. Therefore, Borg scale could be useful to determine the intensity of physical exercise in patients who have undergone allo-HSCT.

Quality of life trajectories during the first year following hematopoietic cell transplantation: an inception cohort study

BACKGROUND

Allogeneic hematopoietic cell transplantation (HCT) affects quality of life (QOL). Patient-reported outcomes examine symptoms, side effects, distress, and physical and social problems, but positive outcomes have been ignored. This inception cohort study followed people over the first year following HCT to document positive and negative outcomes.

METHODS

People with hematologic cancers treated by HCT completed complementary self-report instruments at four milestones: (a) pre-transplant (N = 88); (b) engraftment (N = 80); (c) short-term post-discharge (N = 60); and (d) long-term post-discharge (N = 45). We examined symptoms, side effects, illness intrusiveness, depressive symptoms, positive and negative affect, and self-esteem. We compared QOL in HCT with diverse published values.

RESULTS

QOL deteriorated following HCT. Most variables returned to baseline by short-term post-discharge, but self-esteem and illness intrusiveness required more time. Illness intrusiveness at 1 year post-discharge was higher in HCT than other cancer groups; negative affect, too, was higher, but HCT survivors also reported higher positive affect. HCT and other cancer survivors reported similar depressive symptom levels. Compared to healthy people, HCT survivors reported more severe depressive symptoms, but similar positive and negative affect.

CONCLUSIONS

QOL changes dramatically following HCT. People report more interference with valued activities and interests after 1 year than survivors of other cancers, but depressive symptoms are not higher. Positive and negative affect are equivalent to healthy community residents. Continued involvement in psychologically meaningful activities may preserve QOL.

Impact of the initial fitness level on the effects of a structured exercise therapy during pediatric stem cell transplantation

BACKGROUND

Before and after hematopoietic stem cell transplantation (HSCT), most patients suffer from psychophysical limitations due to the treatment. Exercise interventions demonstrate beneficial effects on, for example, strength, endurance, or health-related quality of life during and after HSCT, but with a great variation among patients concerning the response to exercise. This study examines the influence of the initial fitness on the effects of an exercise therapy in pediatric HSCT.

PROCEDURE

Fifty-three children and adolescents (10.9 ± 3.5 years) scheduled for HSCT were randomized into an exercise intervention group (IG) or a control group (CG). During hospitalization, the IG performed endurance, strength, and flexibility training three times per week. The CG included a nonexercise program. A 6-min walk test was completed before and after the inpatient period. Baseline results (6-min walking distance [6MWD]) were used to split both groups into the following: IG_UNFIT , n = 14; IG_FIT , n = 12; CG_UNFIT , n = 16; CG_FIT , n = 11. Differences in outcome changes between groups were analyzed with H-test.

RESULT

Intergroup comparison revealed significant differences between IG_UNFIT and CG_UNFIT (P < 0.05). The IG_UNFIT increased their 6MWD by +8% (vs. IG_FIT , +1%); both CGs presented a decline in 6MWD (CG_UNFIT , -14%; CG_FIT , -16%). At discharge, the IG_FIT achieved 85.5 ± 10.3% of healthy reference values.

CONCLUSIONS

The current results indicate that exercise during pediatric HSCT is feasible and contributes to prevention of treatment-related loss of physical function. As seen in healthy persons, patients' benefits might depend on their initial fitness level. As a diminished physical capability may result in higher training effects, impaired especially patients should engage in exercise.

A hospital and home-based exercise program to address functional decline in people following allogeneic stem cell transplantation

PURPOSE

The aims of this study are to investigate the feasibility of an exercise program commencing 60 days following allogeneic stem cell transplantation (alloSCT), to investigate changes in physical function and health-related quality of life (HRQoL) in patients from pre- to post-alloSCT and to explore changes in patient outcomes before and after the program.

METHODS

This study is a single site, prospective case series including 43 adults undergoing alloSCT. The intervention was an 8-week outpatient and home-based exercise and education program. Outcomes included feasibility (consent, attendance, compliance and completion rates), functional exercise capacity (incremental shuttle walk test), muscle strength (hand-held dynamometry), self-efficacy for physical activity (Physical Activity Assessment Inventory) and HRQoL (Functional Assessment of Cancer Therapy-Bone Marrow Transplant). Outcomes were measured pre-alloSCT, 60 days post-alloSCT (pre-intervention) and 100 days post-alloSCT (post-intervention).

RESULTS

The consent rate was 93%. From baseline to 60 days post-alloSCT, there was significant decline in functional exercise capacity (mean difference 224 m, 95% CI 153-295, p < 0.0005), self-efficacy for physical activity (294 points, 95% CI 136-452, p = 0.001) and HRQoL (15 points, 95% CI 8-21, p < 0.0005). Ten participants did not commence the exercise program due to death (n = 5), illness (n = 1) or cancellation of alloSCT (n = 4). The intervention was feasible in those not affected by major medical complications or death. No adverse events occurred. From pre- to post-intervention, there was significant improvement in functional exercise capacity (p = 0.001) and HRQoL (p = 0.001).

CONCLUSIONS

AlloSCT results in significant decline in functional exercise capacity, self-efficacy for physical activity and HRQoL, which may be improved through an exercise program. This pilot demonstrated safety, feasibility and high patient interest. Further randomised research is required.

Cardiorespiratory fitness and muscle strength in pancreatic cancer patients

PURPOSE

Cancer patients frequently experience reduced physical fitness due to the disease itself as well as treatment-related side effects. However, studies on physical fitness in pancreatic cancer patients are missing. Therefore, we assessed cardiorespiratory fitness and muscle strength of pancreatic cancer patients.

METHODS

We included 65 pancreatic cancer patients, mostly after surgical resection. Cardiorespiratory fitness was assessed using cardiopulmonary exercise testing (CPET) and 6-min walk test (6MWT). Hand-held dynamometry was used to evaluate isometric muscle strength. Physical fitness values were compared to reference values of a healthy population. Associations between sociodemographic and clinical variables with patients' physical fitness were analyzed using multiple regression models.

RESULTS

Cardiorespiratory fitness (VO₂peak, 20.5 ± 6.9 ml/min/kg) was significantly lower (-24%) compared to healthy reference values. In the 6MWT pancreatic cancer patients nearly reached predicted values (555 vs. 562 m). Maximal voluntary isometric contraction (MVIC) of the upper (-4.3%) and lower extremities (-13.8%) were significantly lower compared to reference values. Overall differences were larger in men than those in women. Participating in regular exercise in the year before diagnosis was associated with greater VO₂peak (p < .05) and MVIC of the knee extensors (p < .05).

CONCLUSIONS

Pancreatic cancer patients had significantly impaired physical fitness with regard to both cardiorespiratory function and isometric muscle strength, already in the early treatment phase (median 95 days after surgical resection). Our findings underline the need to investigate exercise training in pancreatic cancer patients to counteract the loss of physical fitness.

Clinical impact of sarcopenia and relevance of nutritional intake in patients before and after allogeneic hematopoietic stem cell transplantation

PURPOSE

We conducted a retrospective study to evaluate the effect of rehabilitation on minimizing sarcopenia during hematopoietic stem cell transplantation (HSCT) therapy.

METHODS

We developed a protocol to test for retention of physical function during HSCT. Muscle strength, muscle circumference, and muscle function before and after HSCT were measured. Consecutive patients with hematological malignancies who underwent HSCT treatment were recruited in this research.

RESULTS

We included 34 patients (16 females, 18 males; median age, 51.5 years). Bodyweight significantly decreased after HSCT (p < 0.001). Nine females and three males had sarcopenia prior to allogeneic HSCT. After HSCT, bilateral hand grip strength and bilateral knee extensor strength decreased significantly. The total caloric intakes for pre-conditioning, during preparation regimen, and after transplant were 1709, 1024, and 1445 kcal, respectively, and were significantly attenuated in the post-transplant period. Serum albumin was significantly decreased in the final period. Conversely, C-reactive protein was slightly but significantly increased across the transplantation process. Multivariate regression analysis revealed that oral caloric intake after the transplantation period and sex were significantly related to muscle weakness (p = 0.033 and 0.036, respectively).

CONCLUSIONS

Sarcopenia during HSCT was affected by oral caloric intake during the preparation regimen and after transplantation. Physical therapy in conjunction with nutritional therapy may help prevent weakness in HSCT recipients.

Physical Exercise Training versus Relaxation in Allogeneic stem cell transplantation (PETRA Study) - Rationale and design of a randomized trial to evaluate a yearlong exercise intervention on overall survival and side-effects after allogeneic stem cell transplantation

Background

Allogeneic stem cell transplantation (allo-HCT) is associated with high treatment-related mortality and innumerable physical and psychosocial complications and side-effects, such as high fatigue levels, loss of physical performance, infections, graft-versus-host disease (GvHD) and distress. This leads to a reduced quality of life, not only during and after transplantation, but also in the long term. Exercise interventions have been shown to be beneficial in allo-HCT patients. However, to date, no study has focused on long-term effects and survival. Previous exercise studies used ‘usual care’ control groups, leaving it unclear to what extent the observed effects are based on the physical effects of exercise itself, or rather on psychosocial factors such as personal attention. Furthermore, effects of exercise on and severity of GvHD have not been examined so far. We therefore aim to investigate the effects and biological mechanisms of exercise on side-effects, complications and survival in allo-HCT patients during and after transplantation.

Methods/design

The PETRA study is a randomized, controlled intervention trial investigating the effects of a yearlong partly supervised mixed exercise intervention (endurance and resistance exercises, 3–5 times per week) in 256 patients during and after allogeneic stem cell transplantation. Patients in the control group perform progressive muscle relaxation training (Jacobsen method) with the same frequency. Main inclusion criterion is planned allo-HCT. Main exclusion criteria are increased fracture risk, no walking capability or severe cardiorespiratory problems. Primary endpoint is overall survival after two years; secondary endpoints are non-relapse mortality, median survival, patient reported outcomes including cancer related fatigue and quality of life, physical performance, body composition, haematological/immunological reconstitution, inflammatory parameters, severity of complications and side-effects (e.g. GvHD and infections), and cognitive capacity.

Discussion

The PETRA study will contribute to a better understanding of the physiological and psychological effects of exercise training and their biological mechanisms in cancer patients after allo-HCT. The ultimate goal is the implementation of optimized intervention programs to reduce side-effects and improve quality of life and potentially prognosis after allogeneic stem cell transplantation.

Trial registration

ClinicalTrials.gov Identifier: NCT01374399.

Balance function in patients who had undergone allogeneic hematopoietic stem cell transplantation

A previous study reported a 45% incidence of falling among allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients during hospitalisation. We investigated balance and physical function in allo-HSCT patients. Thirty patients (18 men and 12 women) who underwent allo-HSCT between February 2013 and September 2014 were included in this study. Patients were evaluated for up to 3 weeks before and 7 weeks after transplantation. Balance was evaluated using the Timed Up and Go test (TUG) and length of centre of pressure (CoP). Physical function was assessed using hand-grip strength, knee-extensor strength tests, and the 6 min walk test (6MWT). TUG and length of CoP were significantly increased following HSCT (P<0.01). Hand-grip strength, knee-extensor strength, and the 6MWT score decreased significantly after allo-HSCT (P<0.01). TUG and length of CoP were negatively correlated with hand grip and knee-extensor strength (P≤0.05). The allo-HSCT patients in this study had worsened dynamic and static movements of the CoP after transplantation as well as decline of physical function. Rehabilitation staff, nurses, and physicians should recognize the decreased balance function of patients who have undergone allo-HSCT.

Early-phase differences in health-related quality of life, psychological status, and physical function between human leucocyte antigen-haploidentical and other allogeneic haematopoietic stem cell transplantation recipients

PURPOSE

This study investigated the differences between allogeneic haematopoietic stem cell transplantation (allo-HSCT) patients receiving HSC from human leucocyte antigen (HLA)-haploidentical donors (HID) and other donors that included HLA-matched sibling, matched unrelated, and unrelated umbilical cord blood donors in the 6 weeks after HSCT with respect to quality of life (QOL), psychological status, and physical function.

METHODS

The study included 126 patients (HID group, n = 100; other donor group, n = 26) who underwent allo-HSCT between July 2007 and December 2012. Patients were evaluated for health-related QOL using the Medical Outcome Study 36-item Short Form Health Survey. Psychological status was measured by Hospital Anxiety and Depression Scale. Physical function was assessed using tests for handgrip strength, knee extensor strength, and the 6-min walk test.

RESULTS

After HSCT, the HID group showed significantly greater improvements in the general health subscale and Mental Component Summary (MCS) of QOL than the other donor group (P < 0.01). Multivariate analysis confirmed that complete remission and age were associated with changes in the general health subscale before and after HSCT (P < 0.05). With regard to physical function, the HID group showed significantly more decline than the other donor group with respect to handgrip strength and knee extensor muscle strength after HSCT (P < 0.05). Total corticosteroid dose was associated with decreased handgrip strength before and after HSCT (P < 0.05).

CONCLUSIONS

The donor type affects QOL, psychological status, and physical function in allo-HSCT recipients; these findings may provide insights for customised rehabilitation strategies for HSCT recipients.

Physical performance and psychosocial status in lung cancer patients: results from a pilot study

BACKGROUND

The aim of this study was to assess the physical performance and psychosocial status of lung cancer patients.

PATIENTS AND METHODS

Patients with predominantly advanced-stage non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) were recruited. Muscle strength was assessed via hand-held dynamometry (HHD) and endurance capacity via the 6-minute walk test (6MWT), and results were compared to healthy reference values. Psychosocial status, lung cancer-specific symptoms, and quality of life (QoL) outcomes were evaluated.

RESULTS

39 patients (NSCLC n = 22, SCLC n = 17) with predominantly advanced-stage disease and a median age of 62 years (range 44-83 years) were enrolled. Compared to a healthy reference population, mean muscle strength values of upper (elbow flexion -28.2% (±17.5), elbow extension -12.4% (±11.1)) and lower (knee extension -47.6% (±19.3), hip abduction -44.9% (±14.9), hip flexion -13% (±24.2)) extremities, and 6MWT were lower (male/female: 434/411 m vs. 597/514 m). Lung cancer-specific symptoms and QoL were comparable to published data.

CONCLUSION

Our results indicate that lung cancer patients experience muscular weakness, lower endurance performance, and decreased QoL compared to a healthy reference population. The feasibility and benefit of a structured exercise intervention in this specific population need to be evaluated, in particular its effect on psychosocial well-being.

Cardiopulmonary fitness in patients undergoing hematopoietic SCT: a pilot study

Hematopoietic cell transplantation (HCT) is a life-saving treatment for patients with high-risk hematological malignancies. Prognostic measures to determine fitness for HCT are needed to inform decision-making and interventions. VO(2peak) is obtained by measuring gas exchange during cycle ergometry and has not been studied as a prognostic factor in HCT. Thirty-two autologous and allogeneic HCT patients underwent VO(2peak) and 6 Minute Walk (6MW) testing before HCT, and provided weekly symptom and health-related quality of life (HRQOL) assessments before HCT and concluding at Day 100. Twenty-nine patients completed pre-HCT testing. Pre-HCT VO(2peak) was positively correlated with pre-HCT 6MW (r=0.65, P<0.001) and negatively correlated with number of chemotherapy regimens and months of chemotherapy. Patients with lower VO(2peak) reported higher symptom burden and inferior HRQOL at baseline and during early post-HCT period. Patients with pre-HCT VO(2peak) <16 mL/kg/min had higher risk of mortality post HCT (entire cohort: hazard ratio (HR) 9.1 (1.75-47.0), P=0.01; allogeneic HCT patients only: HR 6.70 (1.29-34.75), P=0.02) and more hospitalized days before Day 100 (entire cohort: median 33 vs 19, P=0.003; allogeneic HCT patients only: median 33 vs 21, P=0.004). VO(2peak) pre-HCT is feasible and might predict symptom severity, HRQOL and mortality. Additional studies are warranted.

Exercise in the setting of hematopoietic stem cell transplantation

The procedure of hematopoietic stem cell transplantation (HSCT) is an intense treatment approach to cure patients from leukemia or lymphoma. Prior, during, and after HSCT, patients experience considerable physical and psychosocial distress. In light of the increasing number of successfully treated patients, the need is growing for evidence-based adjuvant therapy options, which are able to reduce treatment-related side effects and enhance the rehabilitation process. Exercise constitutes to be a promising intervention in this setting due to its multidimensional effectiveness. The purpose of this article was to review the current knowledge in the field of exercise and HSCT. Therefore, an electronic literature search in PubMed on the topic was performed. Twenty-nine articles could be identified and classified as relevant for this paper. Reviewed studies suggest that exercise training is an important therapeutic approach in the supportive care for transplant patients. Significant benefits from the exercise interventions have been reported for physical performance, quality of life (QoL), and fatigue status. Several other benefits, such as a more rapid immune recovery or alleviation of therapy-related side effects have been reported in some studies. Future studies should address existing methodological problems, identify further effect levels of exercise and integrate a long-term perspective for the participants in the context of hematopoietic stem cell transplantation. Furthermore, potential biological pathways of exercise in HSCT patients should be investigated.