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

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.

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.

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.

Belt Electrode-Skeletal Muscle Electrical Stimulation During Early Hematopoietic Post-Transplantation To Prevent Skeletal Muscle Atrophy and Weakness

A decline in physical functions at the early stage of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a serious issue. Belt electrode-skeletal muscle electrical stimulation (B-SES) can induce significant muscle contractions with electrical stimulation and reduce muscle weakness. However, this approach has not been used in allo-HSCT patients. This study aimed to examine the effect of B-SES on physical function, and safety in patients during the early post-transplantation period. Forty-three adult patients who underwent B-SES after allo-HSCT were stratified into 2 groups based on the intensity of electrical stimulation (high versus low). B-SES was performed in combination with exercise therapy for 4 post-transplantation weeks. Knee extensor strength (KES) in the low B-SES group decreased significantly, whereas no change was observed in the high-intervention group. A significant positive correlation was observed between total intensity and ΔKES. A reduction in the 6-minute walking distance in the high B-SES group patients was lower than that of historical data. Two patients had B-SES-related complications including muscle pain. This study is the first to propose a new rehabilitation intervention strategy for allo-HSCT. Combined use of B-SES may be a new approach to reducing the decline of physical function in the early post-transplantation period.

American Society for Transplantation and Cellular Therapy Return to Work Guidance Committee Recommendations for Health Care Providers Who Take Care of Hematopoietic Cell Transplantation Patients

Hematopoietic cell transplantation (HCT) health care providers report a desire to improve long-term outcomes and quality of life for their patients. One of the items frequently cited by patients in terms of transitioning from being a patient back to pre-HCT life is return to work (RTW). However, these patients report little support from their health care providers in facilitating this process, and only 50% to 60% achieve RTW, at a median of 3 years post-HCT. Barriers are physical, psychological, and logistical, as well as poor communication between the patient and their employer. We convened a group of experts in survivorship, rehabilitation, social work, and psychology to draft an evidence-based document to assist health care providers in guiding their patients' RTW journey. Guidance is drawn from the existing literature for HCT and general cancer patients and is divided into pre-HCT, peri-HCT, and post-HCT categories. Collaboration among health care providers, patients, and their employers is key to this transition. Suggested referrals and evaluations also are provided. The goal is for this guidance to be continually updated as we advance the field with more HCT-specific literature.

Preventing the adverse cardiovascular consequences of allogeneic stem cell transplantation with a multi-faceted exercise intervention: the ALLO-Active trial protocol

BACKGROUND

Allogeneic stem cell transplantation (allo-SCT) is a potentially lifesaving treatment for high-risk hematological malignancy, but survivors experience markedly elevated rates of cardiovascular disease and associated functional impairment. Mounting evidence suggests regular exercise, combined with a reduction in sedentary time through replacement with light exercise may be a useful therapeutic strategy for the prevention of cardiovascular comorbidities. However, this type of intervention has yet to be evaluated in patients undergoing allo-SCT. The ALLO-Active study will evaluate the efficacy of a ~ 4 month multi-faceted exercise intervention, commenced upon admission for allo-SCT, to preserve peak oxygen uptake (VO2peak) and peak cardiac output, compared with usual care. The study will also evaluate the effect of the intervention on functional independence, quality of life, and symptoms of fatigue.

METHODS

Sixty adults with hematological malignancy scheduled for allo-SCT will be randomly assigned to usual care (n = 30) or the exercise and sedentary behaviour intervention (n = 30). Participants assigned to the intervention will complete a thrice weekly aerobic and progressive resistance training program and concomitantly aim to reduce daily sedentary time by 30 min with short, frequent, light-intensity exercise bouts. Participants will undergo testing prior to, immediately after inpatient discharge, and 12 weeks after discharge. To address aim 1, VO2peak and peak cardiac output (multiple primary outcomes, p < 0.025) will be assessed via cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, respectively. Secondary outcomes include functional independence (defined as VO2peak ≥ 18.mL.kg-1.min-1), quality of life, and fatigue (assessed via validated questionnaire). Exploratory outcomes will include indices of resting cardiac, vascular, and skeletal muscle structure and function, cardiovascular biomarkers, anxiety and depression, transplant outcomes (e.g., engraftment, graft-versus-host disease), and habitual physical activity, sedentary time, and sleep.

DISCUSSION

Multi-faceted exercise programs are a promising approach for ameliorating the cardiovascular consequences of allo-SCT. If this intervention proves to be effective, it will contribute to the development of evidence-based exercise guidelines for patients undergoing allo-SCT and assist with optimising the balance between acute cancer management and long-term health.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ID: 12619000741189 . Registered 17 May 2019.

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.

Evaluation of indices for predicting recovery of exercise tolerance in patients surviving allogenic hematopoietic stem cell transplantation

PURPOSE

Decline in physical function in the early stage after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a major challenge. Exercise tolerance tests, such as the 6-min walk test, are useful markers for predicting exercise tolerance and various other traits, including cardiometabolic risk and non-relapse mortality. This retrospective cohort study aimed to investigate and identify predictors of recovery of exercise tolerance in the early stage after allo-HSCT.

METHODS

Ninety-eight patients were classified into recovery and non-recovery groups according to the median 6-min walk distance (6MWD) at discharge.

RESULTS

Logistic regression analysis revealed that pre-post change in knee extensor strength (ΔKES) and hematopoietic cell transplantation comorbidity index were useful predictors of recovery of exercise tolerance at discharge and moderate predictors of 6MWD recovery in the early post-transplant period. Receiver operating characteristic analysis showed that pre-transplant ΔKES was an accurate predictor of 6MWD recovery in the early post-transplant period. The cutoff point for ΔKES calculated using the Youden index was - 1.17 Nm/kg.

CONCLUSIONS

The results of this study emphasize the importance of the need for programs designed to prevent muscle weakness in the early period after allo-HSCT. The results from markers of recovery of exercise tolerance are promising and can be used for patient education in rehabilitation programs after allo-HSCT.

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.

Muscle oxygen extraction and lung function are related to exercise tolerance after allogeneic hematopoietic stem cell transplantation

PURPOSE

This study aimed to investigate the relationship between exercise intolerance, muscle oxidative metabolism, and cardiopulmonary function following allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a sterile isolation room setting.

METHODS

This was a prospective observational cohort study conducted in a single center. Fourteen patients with hematopoietic malignancies who had undergone allo-HSCT were included in this study from June 2015 to April 2020. Patients received donor HSCT after high dose-chemotherapy and total-body irradiation. Physical activity was limited during treatments. Outcome measures included body anthropometric measurements, exercise tolerance tests using the ramp protocol, pulmonary function tests, and near-infrared spectroscopy (NIRS) measurements. Data of pre- and posttransplant measurements were compared using the paired t test or nonparametric Wilcoxon U test. Associations were assessed using the Pearson or nonparametric Spearman correlations.

RESULTS

NIRS showed reduced muscle consumption and extraction of oxygen in the posttransplant period compared to the pretransplant period (ΔStO_{2 min} pre: -18.6% vs. post: -13.0%, P = 0.04; ΔHHb _max pre: 4.21μmol/l vs. post: 3.31μmol/l: P = 0.048). Exercise tolerance had reduced following allo-HSCT (Peak workload pre: 70.3 W vs. post: 58.0 W: P = 0.014). Furthermore, exercise intolerance was associated with pulmonary function, muscle oxygen consumption, and muscle oxygen extraction (all P <0.05).

CONCLUSION

This analysis revealed that exercise intolerance following allo-HSCT was associated with pulmonary dysfunction and muscle oxidative dysfunction. These findings could help identify the physical function associated with impaired tissue oxygen transport leading to exercise intolerance following allo-HSCT.

Screening supportive care needs, compliance with exercise program, quality of life, and anxiety level during the COVID-19 pandemic in individuals treated with hematopoietic stem cell transplantation

Purpose

The primary aim was to assess supportive care needs, compliance with home exercise program, quality of life level (QOL), and anxiety level during the COVID-19 pandemic in individuals treated with hematopoietic stem cell transplantation (HSCT). The secondary aim was to investigate demographic and medical factors associated with the recorded outcomes.

Methods

The present study included individuals treated with HSCT and previously referred to physical therapy. The data were collected by interviews with the participants on the phone. Supportive care needs were assessed using the Supportive Care Needs Survey-Short Form 29^TR. Compliance with the exercise program was recorded as the number of patients regularly performed strengthening and stretching exercises and the ratio of the walking duration to the recommended duration. The European Cancer Research and Treatment Organization Quality of Life Questionnaire-Cancer30 was used to assess the QOL. The State-Trait Anxiety Inventory-I and the Visual Analogue Scale were used to assess anxiety level.

Results

The present study included 101 individuals treated with HSCT. The psychological and physical supportive care needs were predominant in participants. Compliance with exercise program was low. General anxiety level was low, yet anxiety about COVID-19 was moderate level in participants. Supportive care needs were related to female gender, performance level, time since HSCT, and QOL level (p ˂ 0.05). Anxiety level was correlated with supportive care needs, COVID-19-related anxiety, and QOL (p ˂ 0.05). Compliance with exercise program was associated with age, performance level, and QOL (p ˂ 0.05).

Conclusion

Our results offer that supportive telehealth interventions should be considered during the COVID-19 pandemic for individuals treated with HSCT to decrease unmet supportive care needs and isolation-related physical inactivity.

Relationship Between Corticosteroid Dose and Muscle Oxygen Consumption in Recipients of Hematopoietic Stem-Cell Transplantation

INTRODUCTION

After hematopoietic stem-cell transplantation (HSCT), patients exhibit decreased muscle strength and muscle oxygen consumption. Furthermore, total corticosteroid dose affects the reduction in muscle strength after HSCT. However, to date, no studies have investigated the relationship between corticosteroid dose and muscle oxygen consumption and saturation in these patients. The purpose of this study was to investigate the relationship between steroid dose and deoxyhemoglobin (ΔHHb) and muscle oxyhemoglobin saturation (ΔSmO₂) in patients undergoing HSCT.

METHODS

This study included 17 men with hematologic disease who underwent allogeneic HSCT. We evaluated ankle dorsiflexor muscle force, ΔHHb, and ΔSmO₂ in skeletal muscles by near-infrared spectroscopy (NIRS) in patients before and after HSCT.

RESULTS

Peak ankle dorsiflexion, ΔHHb, and ΔSmO₂ decreased significantly after transplantation as compared to measurements taken before transplantation (p < 0.01). The change in peak ankle dorsiflexion from before to after HSCT was not significantly correlated with total steroid dose. However, ΔHHb and ΔSmO₂ from before to after HSCT were significantly correlated with total steroid dose (p < 0.01).

CONCLUSION

This study showed that higher corticosteroid doses are associated with diminished skeletal muscle O₂ consumption and skeletal muscle O₂ demand relative to supply. Therefore, rehabilitation staff, nurses, and physicians should take note of these findings in patients undergoing HSCT. Moreover, physiotherapists should be carefully measuring muscle oxidative metabolism on skeletal muscle when planning physical exercise in such patients.

Exercise before, during, and after Hospitalization for Allogeneic Hematological Stem Cell Transplant: A Feasibility Randomized Controlled Trial

People with cancer who undergo allogeneic hematological stem cell transplant (allo-HSCT) experience significant deconditioning that can compromise quality of life. Exercise has shown to be beneficial before or after allo-HSCT; however, little is known about exercise therapy delivered across the continuum of care. We conducted a feasibility randomized controlled trial of exercise delivered prior to admission, during the inpatient stay, and after discharge versus control in people with planned allo-HSCT. Feasibility was assessed via recruitment and retention rates, the incidence of adverse events, and adherence to the exercise prescription. Estimates of efficacy were measured at baseline, one week prior to hospital admission, and 100 days and one year after transplant. The recruitment and retention rates were 20% and 33%, respectively. One serious adverse event occurred during the baseline six-minute walk test that precluded participation in the study and no adverse events were associated with the intervention. From baseline to pre-transplant, the intervention group improved six-minute walk test distances by 45 m (95% CI: −18.0 to 108.7)—a finding that warrants further investigation with an adequately powered trial. Our study contributes important feasibility considerations and pilot data for future exercise intervention research in allo-HSCT recipients.

Effect of the severity of acute graft-versus-host disease on physical function after allogeneic hematopoietic stem cell transplantation

PURPOSE

The purpose of this study was to retrospectively investigate the effect of the severity of acute graft-versus-host disease (GVHD) on physical function after allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

76 patients were included as subjects of this study. Severity of acute GVHD was classified according to the method defined by Grucksberg. To evaluate physical function, the knee extensor strength and six-minute walk distance (6MWD) were performed.

RESULTS

Among these patients, 54% developed acute GVHD; of these, 32%, 54%, and 15% of patients had grade I, grade II, and grades III-IV GVHD, respectively. In the grade I-II groups, mild acute GVHD following allo-HSCT resulted in a gradual decline in physical function, which improved at discharge. However, in cases of severe acute GVHD, physical function deteriorated, implementation of rehabilitation became difficult, and the decline in physical function persisted even at discharge.

CONCLUSION

These results indicate that severe acute GVHD negatively affects physical function leading to longer hospital days because of inadequate rehabilitation interventions.

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.