Nordic Walking as an Exercise Intervention to Reduce Pain in Women With Aromatase Inhibitor-Associated Arthralgia: A Feasibility Study

Nordic Walking as a Non-Pharmacological Intervention for Chronic Pain and Fatigue: Systematic Review

OBJECTIVE

We aimed to analyze and summarize the available scientific evidence on the benefits of Nordic walking for people with chronic pain and fatigue.

LITERATURE SURVEY

This systematic review adhered to PRISMA guidelines and conducted a comprehensive search across five databases using the PICO strategy.

METHODOLOGY

Inclusion criteria encompassed randomized trials evaluating Nordic walking for pain and fatigue. Two authors independently screened studies, extracted data, and assessed methodological quality using the PEDro scale.

SYNTHESIS

A total of 14 studies were included, with sample sizes ranging from 20 to 136 participants. The methodological quality of the included studies varied from fair (five studies) to good (nine studies). The interventions consisted of supervised Nordic walking sessions lasting 6 to 24 weeks, with a frequency of 2 to 4 days per week and duration of 25 to 75 min. The results of this review suggest that Nordic walking had beneficial effects in six of the eight studies that analyzed participant fatigue. However, Nordic walking did not show greater beneficial effects on fatigue than walking (two studies) or than not performing physical activity (one study). Additionally, six of the nine studies that examined the effects of Nordic walking on participants' perceptions of pain showed beneficial results. However, five studies that compared Nordic walking with control groups did not find any significant inter-group differences on pain.

CONCLUSIONS

Based on our findings, Nordic walking exercise programs provide a potentially efficient method for alleviating pain and fatigue in people with chronic conditions. Its straightforwardness and ease of learning make it accessible to a broad spectrum of participants, which can result in higher adherence rates and lasting positive effects.

The role of exercise in aromatase inhibitor-induced arthralgia

Aromatase inhibitors are prescribed in breast cancer due to their associated lower rate of cancer recurrence compared to tamoxifen. However, aromatase inhibitor-induced arthralgia (AIIA) is one of the leading causes of treatment nonadherence, increasing the risk of cancer recurrence. The pathophysiology of AIIA is poorly understood, and although current recommendations for AIIA include lifestyle changes and analgesics depending on the severity of symptoms, there is no established effective treatment. The aim of this study is to explore the presentation and mechanism of AIIA and investigate the feasibility and efficacy of different exercise interventions (aerobic, resistance, aerobic and resistance combined, and yoga or tai chi) in patients with AIIA to guide the development of formal exercise prescription guidelines. Findings indicate that a mixed-modality regimen of aerobic and resistance exercises is feasible and safe and may serve the most benefit in improving joint pain, functionality, and quality of life. More specifically, the weekly regimen should consist of 150 min of aerobic exercise with two sessions of at least six resistance exercises, 8 to 12 repetitions, three sets each. Supplementary yoga and tai chi may be recommended twice a week depending on a patient's target symptoms. Yoga was associated with improved physical functionality, whereas tai chi was related to improvements in mental health. However, the feasibility and impact of combined aerobic and resistance exercise protocols with yoga or tai chi in our target population were not investigated in this review. The use of large, randomized controlled trials is recommended for future studies.

Quantification of the aromatase inhibitor letrozole and its carbinol metabolite in mouse plasma by UHPLC-MS/MS

A liquid chromatography - electrospray ionization-mass spectrometry (LC-ESI-MS) method was developed for the quantification of letrozole, a third-generation aromatase inhibitor, and its main carbinol metabolite (CM) in support of murine pharmacokinetic studies. Using polarity switching, simultaneous ESI-MS measurement of letrozole and CM was achieved in positive and negative mode, respectively. The assay procedure involved a one-step protein precipitation and extraction of all analytes from mouse plasma requiring only 5 μL of sample. Separation was optimized on an Accucore aQ column with gradient elution at a flow rate of 0.4 mL/min in 5 min. Two calibration curves per day over four consecutive measurement days showed satisfactory linear responses (r2 > 0.99) over concentration ranges of 5-1000 ng/mL and 20-2000 ng/mL for letrozole and CM, respectively. No matrix effect was found, and the mean extraction recoveries were 103-108 % for letrozole and 99.8-107 % for CM. Precision and accuracy within a single run and over four consecutive measurement days were verified to be within acceptable limits. Application of the developed method to preclinical pharmacokinetic studies in mice receiving oral letrozole at a dose 1 or 10 mg/kg revealed that the systemic exposure to letrozole was dose-, formulation-, and strain-dependent. These findings may inform the future design of preclinical studies aimed at refining the pharmacological profile of this clinically important drug.

Progressive relaxation training in patients with breast cancer receiving aromatase inhibitor therapy-randomized controlled trial

BACKGROUND

Aromatase inhibitors have positive impacts on the disease-free life of patients with breast cancer. However, their side effects, especially arthralgia, may be experienced by many patients. This study sought to assess the efficacy of Progressive Relaxation Exercises on the prevalent side effects of Aromatase Inhibitors in patients with breast cancer.

MATERIALS AND METHODS

This clinical trial was conducted with single-blind randomization at a physiotherapy department in a local hospital. Patients who received Aromatase Inhibitor were assigned at random to either the study or control group. The study group (n = 22) performed a Progressive Relaxation Exercises program four days a week for six weeks, while the control group (n = 22) received advice on relaxation for daily life. Data was collected before the intervention and after six weeks. The study's primary endpoint was the Brief Pain Inventory, which was used to measure pain severity. Secondary endpoints included assessments of quality of life and emotional status, which were measured using the Functional Assessment of Chronic Illness Therapy and Hospital Anxiety and Depression scales, respectively.

RESULTS

The study group exhibited a significant reduction in Pain Severity (p = 0.001) and Pain Interference (p = 0.012) sub-scores. Reduction in Pain Severity (p<0.001) and Patient Pain Experience (p = 0.003) sub-scores was also noted between the groups. Quality of Life and Emotional Status showed no significant variation both within and between the groups (p>0.05).

CONCLUSION

The study demonstrated that Progressive Relaxation Exercises caused a significant reduction in pain scores among Breast Cancer patients receiving Aromatase Inhibitors. While a decrease in pain during the 6-week period is valuable data, it is necessary to monitor the long-term effects of relaxation techniques.

Efficacy of aerobic and resistance exercises on cancer pain: A meta-analysis of randomised controlled trials

Purpose

To evaluate effects of aerobic and resistance exercises for cancer-related pain in adults with and surviving cancer. Secondary objectives were to a) evaluate the effect of exercise on fatigue, psychological function, physical function, b) assess fidelity to exercise.

Design

A systematic search of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Central Register of Controlled Trials was conducted to identify randomised controlled trials (RCTs) comparing aerobic and/or resistance exercise to control groups. The primary endpoint were changes in cancer-related pain intensity from baseline to post intervention. Meta-regression analysis evaluated predictors for heterogeneity between study findings. Tolerability was defined as reporting of exercise-induced adverse events while fidelity evaluated by reported intervention dropout.

Results

Twenty-three RCTs including 1954 patients (age 58 ± 8.5 years; 78 % women); 1087 (56 %) and 867 (44 %) allocated to aerobic/resistance exercise therapy and control group, respectively. Exercise therapy was associated with small to moderate decreases in cancer-related pain compared to controls (SMD = 0.38, 95 % CI: 0.17, 0.58). Although there was significant heterogeneity between individual and pooled study effects (Q = 205.25, p < 0.0001), there was no publication bias. Meta-regression including supervision, age, duration and exercise type as moderators showed no significant differences in reported outcomes. Analysis of secondary outcomes revealed a moderate effect for improvements in physical function, fatigue and psychological symptoms.

Conclusions

Aerobic and resistance exercises are tolerable and effective adjunct therapies to reduce cancer-related pain while also improving physical function, fatigue and mood. Future RCTs of dose, frequency, compliance and exercise type in specific cancer settings are required.

Physical activity and pain in people with cancer: a systematic review and meta-analysis

PURPOSE

Physical activity can provide analgesic benefit but its effect on cancer-related pain is unclear. This review synthesised and appraised the evidence for the effect of physical activity on pain in people living with or beyond cancer.

METHODS

A systematic search of Ovid Medline and Embase was performed to identify randomised controlled trials (RCTs), randomised cross-over studies (RXTs), and prospective observational studies that examined physical activity and pain outcomes in adults living with or beyond cancer. Meta-analyses were performed to generate effect estimates. Risk of bias was assessed, and the GRADE system was used to assess evidence quality.

RESULTS

One hundred twenty-one studies (n = 13,806), including 102 RCTs, 6 RXTs, and 13 observational studies, met the criteria for inclusion. Meta-analyses of RCTs identified a decrease in pain intensity (n = 3734; standardised mean difference (SMD) - 0.30; 95% confidence interval (CI) - 0.45, - 0.15) and bodily pain (n = 1170; SMD 0.28; 95% CI 0.01, 0.56) but not pain interference (n = 207; SMD - 0.13, 95% CI - 0.42, 0.15) following physical activity interventions. Individual studies also identified a reduction in pain sensitivity but not analgesic use, although meta-analysis was not possible for these outcomes. High heterogeneity between studies, low certainty in some effect estimates, and possible publication bias meant that evidence quality was graded as very low to low.

CONCLUSION

Physical activity may decrease pain in people living with and beyond cancer; however, high heterogeneity limits the ability to generalise this finding to all people with cancer or to specific types of cancer-related pain.

Flexibility and Strength Effects of Adapted Nordic Walking and Myofascial Exercises Practice in Breast Cancer Survivors and Analysis of Differences

Breast cancer treatments can elicit negative kinesiological side effects concerning both the posture and functional status of breast cancer survivors. As our body is functionally organized in myofascial meridians, physical exercise practice should favor a whole-body approach rather than a local one. The aim of the study was to investigate and compare the effects of two whole-body disciplines, i.e., adapted Nordic Walking and myofascial exercise, on the flexibility and strength performances in BCS. One hundred and sixty breast cancer survivors were trained three times per week for 12 weeks through adapted Nordic Walking or myofascial exercise. Handgrip, sit and reach, back scratch, and single leg back bridge tests and body composition were assessed at the beginning and completion of the training period. Linear mixed models showed no significant changes in body composition, whereas flexibility (p < 0.001), strength (p < 0.001), and muscle quality index (p = 0.003) changed independently from the treatment. When data modification has been analyzed according to sub-sample membership, no significant differences have been observed. Age, radiation therapy, and chemotherapy seem to have independent effects on several investigated variables. Twelve weeks of adapted myofascial exercise and Nordic Walking led to significant changes in flexibility, strength, and muscle quality in breast cancer survivors, with no apparent superiority of one approach over the other.

Prehabilitation in Patients With Breast Cancer Receiving Neoadjuvant Therapy to Minimize Musculoskeletal Postoperative Complications and Enhance Recovery (PREOPtimize): A Protocol for a Randomized Controlled Trial

OBJECTIVE

The aim of this study is to assess the effects of a prehabilitation program (PREOPtimize), consisting of Nordic Walking and resistance training exercises plus health education among patients with breast cancer, who are receiving neoadjuvant therapy to enhance postoperative functionality of the affected arm. A secondary aim will be to compare the short-term effects of the intervention on other patient-reported outcome measures.

METHODS

This will be an assessor-blind, randomized controlled trial with a parallel group design conducted at a tertiary hospital. A sample of 64 patients with breast cancer scheduled for surgery and undergoing neoadjuvant chemotherapy will be recruited for the trial and randomly allocated to either (1) a prehabilitation program consisting of 2 weekly sessions of 75 minutes of Nordic Walking, muscle strengthening exercises, and health education sessions conducted between the fourth month of treatment and surgery or (2) usual care. Patients in both groups will be assessed at baseline, before surgery, and at 1 and 3 months after surgery. Assessed outcomes include functionality of the affected arm (QuickDash), arm volume, range of motion, handgrip strength, pain, fatigue, functional capacity, physical activity levels, and health-related quality of life. Adherence to the intervention in the prehabilitation group and adverse events will also be recorded.

IMPACT

Prehabilitation for patients affected by breast cancer is rarely implemented in clinical practice. The results obtained with the PREOPtimize trial could show that prehabilitation is a feasible intervention for patients with breast cancer receiving neoadjuvant therapy that might enhance postoperative recovery of upper arm function as well as improve overall physical performance and health-related quality of life.

The role of exercise for pain management in adults living with and beyond cancer: a systematic review and meta-analysis

BACKGROUND

Pain is a common side effect of cancer or cancer treatment that negatively impacts biopsychosocial wellbeing and quality of life. Exercise is a potential intervention to manage pain that is safe and has multiple benefits. The objective was to determine the role of exercise in cancer pain management.

METHODS

We completed a systematic review and meta-analysis of exercise interventions in adults with any type or stage of cancer by searching Ovid MEDLINE®, Embase, APA PsycInfo, the Cochrane Central Register of Controlled Trials, CINAHL, and SPORTDiscus. We included experimental and quasi-experimental designs where pain was measured as an outcome. Data synthesis included narrative and tabular summary. A meta-analysis was performed on studies powered to detect the effect of exercise on pain. Study quality was evaluated using the Cochrane risk of bias tool and certainty of evidence was evaluated using the GRADE tool.

RESULTS

Seventy-six studies were included. Studies were predominantly conducted in breast cancer and exercise usually included a combination of aerobic and strength training. Ten studies were included in the meta-analysis demonstrating a significant effect for exercise in decreasing pain (estimated average standard mean difference (SMD) was g =  - 0.73 (95% CI: - 1.16 to - 0.30)); however, the overall effect prediction interval was large. Overall risk of bias for most studies was rated as some concerns and the grading of evidence certainty was low.

CONCLUSION

There are limitations in the evidence for exercise to manage cancer-related pain. Further research is needed to understand the role of exercise in a multimodal pain management strategy.

Self-managed physical activity in breast cancer survivors: A scoping review

OBJECTIVE

Breast cancer survivors (BCS) experience many issues of rehabilitative concern due to the treatments they have undergone. Given the chronicity of these outcomes, the increasing number of survivors, and the positive results obtained by supervised exercise, professionals should consider offering self-managed physical activity (PA) programs to this population. Our aim was to map the currently available evidence about self-care rehabilitation for BCS.

METHODS

Medline, CINAHL, and Cochrane databases were searched for primary literature. Scoping review methodological frameworks were used to tackle the heterogeneity of the topic. Studies investigating self-managed PA interventions prescribed to adult BCS were included.

RESULTS

One hundred-eight studies were included, with sample sizes ranging from 6 to 692 patients. Information was systematically collected in tables displaying study design, type of PA, duration and recommended frequency, professional leading the study, type of supervision, initial training, strategies used to help patients integrate self-care into their daily lives, and self-managed PA efficacy. Tables were produced for every oncological side effect that BCS might experience: lymphedema, arthralgia, cancer-related fatigue, a decline in physical parameters, treatment-related cardiotoxicity, peripheral neurotoxicity, and a possible decline in the quality of life.

CONCLUSIONS

Self-managed PA has the potential to improve BCS oncological issues. Professionals can adopt many strategies to support patients and empower them with long-lasting self-care competencies. This scoping review provided a comprehensive and easy-to-consult overview of self-managed PA interventions for BCS. We also provided recommendations for future primary studies and secondary synthesis.

Comparison of the clinical effectiveness of treatments for aromatase inhibitor-induced arthralgia in breast cancer patients: A systematic review with network meta-analysis

Aromatase inhibitor-induced arthralgia (AIA) contributes to poor adherence of aromatase inhibitor therapies in patients with breast cancer. A systematic review using network meta-analysis (NMA) was conducted to examine the clinical effectiveness of multiple therapies and rank probabilities for the management of AIA. Randomized controlled trials (RCTs) assessing treatments for AIA in postmenopausal women with stage 0-III hormone receptor-positive breast cancer were searched from inception to October 2021. The main NMA involved 1516 participants from 17 RCTs. Acupuncture was the highest ranked intervention to improve pain intensity followed by sham acupuncture, multicomponent herbal medicine, exercise, duloxetine, vitamin D, omega-3 fatty acids, physical therapy, testosterone, and inactive controls. Single natural products were inferior to controls. The current review provides new insights into the management of AIA in breast cancer survivors for increased survival and can be utilized to make evidence-based decisions regarding treatment.

Physical Activity and Health-Related Quality of Life in Women With Breast Cancer: A Meta-Analysis

BACKGROUND

Physical activity (PA) is associated with improved health-related quality of life (HRQoL) among women with breast cancer; however, uncertainty remains regarding PA types and dose (frequency, duration, intensity) and various HRQoL measures. A systematic review and meta-analysis of randomized controlled trials was conducted to clarify whether specific types and doses of physical activity was related to global and specific domains of HRQoL, as part of the Global Cancer Update Programme, formerly known as the World Cancer Research Fund-American Institute for Cancer Research Continuous Update Project.

METHODS

PubMed and CENTRAL databases were searched up to August 31, 2019. Weighted mean differences (WMDs) in HRQoL scores were estimated using random effects models. An independent expert panel graded the evidence.

RESULTS

A total of 79 randomized controlled trials (14 554 breast cancer patients) were included. PA interventions resulted in higher global HRQoL as measured by the Functional Assessment of Cancer Therapy-Breast (WMD = 5.94, 95% confidence intervals [CI] = 2.64 to 9.24; I2 = 59%, n = 12), Functional Assessment of Cancer Therapy-General (WMD = 4.53, 95% CI = 1.94 to 7.13; I2 = 72%, n = 18), and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (WMD = 6.78, 95% CI = 2.61 to 10.95; I2 = 76.3%, n = 17). The likelihood of causality was considered probable that PA improves HRQoL in breast cancer survivors. Effects were weaker for physical function and mental and emotional health. Evidence regarding dose and type of PA remains insufficient for firm conclusions.

CONCLUSION

PA results in improved global HRQoL in breast cancer survivors with weaker effects observed for physical function and mental and emotional health. Additional research is needed to define the impact of types and doses of activity on various domains of HRQoL.

Prevalence and correlates of joint pain among Chinese breast cancer survivors receiving aromatase inhibitor treatment

BACKGROUND

Aromatase inhibitor (AI)-induced joint pain is a common toxicity of AI treatment. Although many studies have been conducted to examine the occurrence and severity of AI-induced joint pain in breast cancer survivors, none of the studies focused on the Chinese population with breast cancer. Given that the differences in cultural background and the genetic structure between Asians and Caucasians may contribute to different phenotypes of joint pain, this cross-sectional study was therefore conducted to examine the prevalence of AI-induced joint pain among Chinese breast cancer survivors receiving AI treatment and the correlates of pain.

METHODS

This cross-sectional study was conducted in a tertiary hospital in China. Breast cancer survivors undergoing AI treatment were recruited to complete the following questionnaires: a self-designed baseline data form, the Nordic Musculoskeletal Questionnaire (NMQ), the Brief Pain Inventory (BPI), the 36-Item Short Form Health Survey (SF-36), and the Functional Assessment of Cancer Therapy-Breast (FACT-B). Based on the assessment results of NMQ (if the participant indicated pain in specific body parts), participants were then invited to complete other questionnaires to specifically assess the joint symptoms, including the Oxford Knee Score (OKS), the Oxford Hip Score (OHS), the Michigan Hand Outcomes Questionnaire (MHQ), and the Manchester Foot Pain Disability Questionnaire (MFPDQ). Descriptive analysis was used to analyse participants' baseline data and the prevalence of pain. Stepwise multiple regression was used to identify the correlates of pain.

RESULTS

Four hundred and ten participants were analysed. According to the NMQ, 71.7% of the participants experienced joint symptoms in at least one joint, and the most frequently mentioned joint was knee (39.0%). The diagram in BPI indicated that 28.0% of the participants had the worst pain around knees. In patients with knee pain, the mean OKS score was 40.46 ± 6.19. The sub-scores of BPI for pain intensity and pain interference were 1.30 ± 1.63 and 1.24 ± 1.79, respectively. Patients' poorer physical well-being/functioning, previous use of AI treatment, presence of osteoarthritis, and receiving of physiotherapy were identified as four common correlates of greater severity of pain and pain interference (p < 0.05).

CONCLUSIONS

Chinese breast cancer survivors can experience joint pain at various locations, particularly knees. In addition to increasing the use of interventions for pain alleviation, a comprehensive assessment of survivors' conditions such as physical functioning, history of AI treatment, and presence of osteoarthritis should be emphasized to identify survivors who need more attention and tailored interventions.

Physical Therapies for Psychosomatic Symptoms and Quality of Life Induced by Aromatase Inhibitors in Breast Cancer Patients: A Systematic Review and Meta-Analysis

Objective

To evaluate the effects of Physical Therapies (PTs) on improvement in psychosomatic symptoms and quality of life (QOL) in breast cancer patients.

Data Sources

Seven databases (MEDLINE, EMBASE, Cochrane CENTRAL, China National Knowledge Infrastructure, Wangfang, VIP, and China Biology Medicine disc databases) were systematically searched from the database inception through May 18, 2021.

Study Selection

Randomized controlled trials (RCTs) which compared acupuncture or exercise with a sham control or usual care for the treatment of aromatase inhibitors (AIs)-related psychosomatic symptoms and QOL.

Data Extraction and Synthesis

Data were screened and extracted independently using predesigned forms. The quality of RCTs was assessed with the Cochrane Handbook for Systematic Reviews of Interventions. The effect size was calculated via random-effects modeling. The quality of evidence was evaluated with the Grading of Recommendations Assessment, Development and Evaluation approach.

Main Outcomes and Measures

The score of pain was measured with BPI scale and Western Ontario and the McMaster Universities Index (WOMAC) scale. Emotional state was measured with Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS-A), and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue). The QOL score was measured by self-reported measurements, including the Functional Assessment of Cancer Therapy-General (FACT-G) scale and 36-Item Short Form Survey (SF-36) scale.

Results

Eleven RCTs (with 830 patients) were included in the systematic review, and data from 10 RCTs (with 798 patients) were used in the meta-analysis. Results showed acupuncture significantly reduced worst pain scores (P < 0.00001, I² = 83.5%) [SMD = −0.81, 95% CI (−1.51, −0.11)], but the effect of exercise therapies was not significant in overall change in worst pain scores (P =0.006, I² = 72.3%) [SMD = −0.30, 95% CI (−0.76, 0.16)]. Both acupuncture and exercise resulted in little to no difference in overall change in HADS-A subscale (P = 0.026<0.05, I² = 79.8%) [WMD = −0.21, 95% CI (−3.44, 3.03)], PSQI subscale (P = 0.488, I² = 0%) [WMD = 0.98, 95% CI (−0.57, 2.53)], and FACIT-Fatigue subscale (P = 0.022<0.05, I² = 81.0%) [WMD = 1.6, 95% CI (−5.75, 8.94)]. Exercise (compared with usual care) was associated with improving overall change in health-related QOL (subscales of SF-36 tool) (P = 0, I² = 72.1%) [WMD = 7.97, 95% CI (5.68, 10.25)] and cancer-specific QOL (subscales of FACT-G tool) (P = 0.304, I² = 16%) [WMD = 1.16, 95% CI (0.34, 1.97)].

Conclusions and Relevance

This systematic review and meta-analysis suggested that based on moderate-level evidence, acupuncture was associated with significant reductions in pain intensity, and exercise might improve QOL in breast cancer patients treated with AIs. However, in psychosomatic symptoms such as anxiety, sleep disturbance, and fatigue, acupuncture and exercise training did not result in significant improvements.

Yoga versus massage in the treatment of aromatase inhibitor-associated knee joint pain in breast cancer survivors: a randomized controlled trial

Aromatase inhibitors (AIs) are standard adjuvant therapy for postmenopausal women with oestrogen receptor-positive, early-stage, and metastatic breast cancer. Although effective, the risk of falls due to AI-associated knee joint pain significantly increased. The aim of this study was to evaluate the therapeutic effects of yoga and massage on AI-associated knee joint pain. Breast cancer survivors were randomly assigned to a 6-week yoga intervention-2-week rest-6-week massage exposure (Yoga first, n = 30) or a 6-week massage intervention-2-week rest-6-week yoga exposure (Massage first, n = 30). Evaluations of the treatment efficacy were made at baseline, post-intervention, and post-exposure using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale, plasma cytokine levels, and changes in meridian energy. The results showed that yoga, superior to massage intervention, significantly reduced AI-associated knee joint pain, as demonstrated by the WOMAC pain score. The yoga intervention improvements were also associated with changes in plasma cytokine levels and meridian energy changes. In conclusion, this study provides scientific evidence that yoga was more effective than massage for reducing AI-associated knee joint pain. Meridian energy changes may provide another scientific, objective, non-invasive way to monitor the therapeutic effects of yoga and investigate another alternative, complementary medicine.

Effectiveness of Pilates and circuit-based exercise in reducing arthralgia in women during hormone therapy for breast cancer: a randomized, controlled trial

OBJECTIVE

To investigate the effect of Pilates compared with circuit-based exercise in reducing arthralgia in women during hormone therapy for breast cancer.

DESIGN

Single-blind randomized controlled trial, parallel.

SETTING

University hospital of Brasilia and Brazilian Association for Assistance to People with Cancer.

PARTICIPANTS

Sixty women with arthralgia were recruited. Eligibility criteria included women complaining of arthralgia during hormone therapy for breast cancer. The exclusion criteria were women with active cancer, lymphedema, limitations to physical exercise, or limitation to answer some questionnaires.

MAIN OUTCOME MEASURES

Primary: Pain. Secondary: Function, flexibility, and sleep quality. Outcomes were assessed at baseline and the end of the intervention (8 weeks) by the same blinded evaluator.

INTERVENTION

Sixty participants were randomly assigned 20 to each of the three groups: Pilates, circuit-based exercise, and control groups. Exercise was performed twice per week for 75 min, over a period of 8 weeks. Participants in the control group were instructed to continue their usual activities. The Kolmogorov-Smirnov test was used to verify the normality of the outcomes. Intergroup differences were calculated using Kruskal-Wallis test with post hoc Mann Whitney U testing and the parametric data between the three groups with ANOVA of repeated measures with Bonferroni post hoc.

RESULTS

The Pilates group demonstrated a significant difference in pain reduction compared to the circuit group (mean difference: -1.95 points, p = 0.020).

CONCLUSION

Pilates was more effective than circuit-based exercise in reducing arthralgia in women during hormone therapy for breast cancer.

TRIAL REGISTRATION

http://www.ensaiosclinicos.gov.br/rg/RBR-3wsdhs/ Registered on Octob 16th 2017.

Managing Menopausal Symptoms in Young Women With Breast Cancer: When Medicine Is Not All. The Take Care Project

In the last decade, endocrine therapy strategies in perimenopausal women with hormone-responsive early breast cancer (BC) have changed and now ovarian function suppression (OFS) is recommended for the majority of patients. Side effects of OFS mimic menopausal symptoms, including hot flushes, sweats, weight gain, and sexual dysfunction, which may negatively impact quality of life (QoL). Aims of the Take Care Project are the education of physicians and patients to have all the information (medical and nonmedical) they need to manage menopausal symptoms by distributing educational materials useful to face menopause. Four different areas have been identified by surveys conducted among physicians and young patients: for each area, interventions and tools have been elaborated by a doctor and nonphysician professionals of these identified areas, to offer the widest information available. Clinical and practical suggestions have been provided. Based on the evidence given, we strongly suggest setting up a multidisciplinary team for the treatment planning of young patients with BC, which could help patients to face and manage their new menopause condition. The reduction of side effects and the improvement in QoL should be the best ally to treat young patients with BC.

The influence of 12-week dance intervention on sleep quality and pain among women with breast cancer - Pilot study of a non-randomized clinical trial

BACKGROUND

Analyze the effects of a 12-week dance intervention on the sleep quality and the level of pain among women with breast cancer.

METHODS

Non-randomized clinical trial including 21 breast cancer survivors allocated in intervention group (n = 11) or control group (n = 10). Intervention group received a 12-week mix dance intervention and the control group maintained their routine activities. Data collection was realized through the application of a questionnaire before and after 12 weeks, involving pain (VAS) and sleep quality (Pittsburgh Sleep Quality Index). The Two-way ANOVA with repeated measures and Šidák correction, and multiple linear regression was used.

RESULTS

No significant effects were found on sleep quality and pain after the 12-week intervention with a mix dance protocol. Also, no significant difference was found between intervention and control group during post-intervention. The multiple linear regression analysis, controlled by stage of treatment, did not present a significant relationship between sleep quality and pain. Additionally, some spontaneous reports provided by the participants demonstrated a subjective improvement in their social life and general well-being.

CONCLUSION

The 12-week mix dance intervention did not seem to directly influence the sleep quality and pain of breast cancer survivors in this study; however, no adverse events were reported. Perhaps, a dance protocol focusing only in one modality of dance may be more effective for breast cancer survivors on sleep quality and pain.

The Effect of Exercise on the Alleviation of Side Effects Induced by Aromatase Inhibitors in Postmenopausal Breast Cancer Patients

PURPOSE OF REVIEW

Aromatase inhibitors (AIs) are effective in treating postmenopausal women suffering from estrogen receptor-positive breast cancer (BC). However, AIs are also commonly associated with a number of side effects which decrease the quality of life (QoL) of the patients. This review focuses on the effects of exercise interventions on reducing the side effects commonly experienced by BC patients on AI treatment.

RECENT FINDINGS

Recent studies in the literature support that exercise interventions are feasible and improve body composition, aromatase inhibitor-induced Arthralgia (AIIA), and the overall QoL of BC patients. Successful implementation of longitudinal exercise interventions is expected to improve the QoL of BC patients on AI treatment. Future studies should therefore be carried out with a larger number of postmenopausal BC patients on AI treatment to (a) investigate the effects of exercise interventions on depression, cognitive decline, and cardiotoxicity and (b) address the motivation that should be used to keep BC survivors engaged in exercise intervention programs.

Management of Aromatase Inhibitor-Induced Musculoskeletal Symptoms

Aromatase inhibitor-induced musculoskeletal symptoms (AIMSS) were first recognized as a distinct entity in 2001, 5 years after the approval of the first aromatase inhibitor, anastrozole. Musculoskeletal symptoms can severely affect patients' quality of life and also lead to premature discontinuation of aromatase inhibitor therapy. Several interventions for managing AIMSS have been investigated in the last decade, with some demonstrating promise. This article provides an evidence-based summary to guide practicing oncologists in regard to the epidemiology, prevention, and treatment of AIMSS.

Aromatase Inhibitors-Induced Musculoskeletal Disorders: Current Knowledge on Clinical and Molecular Aspects

Aromatase inhibitors (AIs) have radically changed the prognosis of hormone receptor positive breast cancer (BC) in post-menopausal women, and are a mainstay of the adjuvant therapy for BC after surgery in place of, or following, Tamoxifen. However, AIs aren't side effect-free; frequent adverse events involve the musculoskeletal system, in the form of bone loss, AI-associated arthralgia (AIA) syndrome and autoimmune rheumatic diseases. In this narrative review, we reported the main clinical features of these three detrimental conditions, their influence on therapy adherence, the possible underlying molecular mechanisms and the available pharmacological and non-pharmacological treatments. The best-known form is the AIs-induced osteoporosis, whose molecular pathway and therapeutic possibilities were extensively investigated in the last decade. AIA syndrome is a high prevalent joint pain disorder which often determines a premature discontinuation of the therapy. Several points still need to be clarified, as a universally accepted diagnostic definition, the pathogenetic mechanisms and satisfactory management strategies. The association of AIs therapy with autoimmune diseases is of the utmost interest. The related literature has been recently expanded, but many issues remain to be explored, the first being the molecular mechanisms.

Effects of exercise on physical outcomes of breast cancer survivors receiving hormone therapy - A systematic review and meta-analysis

BACKGROUND

Side-effects of hormone therapy can impair the physical health of breast cancer survivors. Exercise has been clearly shown to improve the quality of life of breast cancer survivors. Less is known about the effects of exercise on physical outcomes for breast cancer survivors receiving hormone therapy.

OBJECTIVE

To investigate the effects of exercise on physical outcomes of breast cancer survivors receiving hormone therapy.

METHODS

Five electronic databases were searched by two authors using the terms "Breast Neoplasms" [MeSH] and "Tamoxifen" [MeSH] and "Aromatase Inhibitors" [MeSH] and "Exercise" [MeSH]. Randomized and non-randomized clinical trials were included. Risk of bias was assessed by the Cochrane Collaboration tool and ROBINS-I, and the quality of evidence was evaluated using GRADE. Pooled effects were reported as standardized mean differences (SMDs) and 95 % confidence intervals (CIs) using a random effects model.

RESULTS

Eleven studies were included in the meta-analysis. Two hundred and fourteen breast cancer survivors receiving hormone therapy, tamoxifen, or aromatase inhibitors participated in interventions based on aerobic plus resistance exercise or walking activity. The physical outcomes reported in the articles were: cardiorespiratory fitness, pain, bone mineral density, grip strength, and body fat percentage. Exercise effects were found only for cardiorespiratory fitness (SMD = 0.37; 95 % CI: 0.11; 0.63; I² = 93 %) and pain (SMD = -0.55; IC95 % -1.11; -0.00; I² = 80 %), with low quality of evidence. No effects were observed for the other variables.

CONCLUSIONS

Aerobic plus resistance exercise had positive effects on cardiorespiratory fitness and pain in breast cancer survivors receiving hormone therapy. However, high-quality randomized clinical trials are required to confirm this finding.

Effects of Exercise on Brain and Cognition Across Age Groups and Health States

Exercise has been shown to benefit brain structure and function, particularly in aging populations. However, the mechanisms by which exercise exerts its effects, especially in humans, are not fully understood. This review argues that one reason for this knowledge gap is that exercise likely operates through multiple levels of mechanisms. Furthermore, the mechanisms of exercise may vary depending on factors such as age and health state. We discuss the state of evidence at each of three levels of analysis (molecular/cellular, brain structure/function, and mental states and higher-order behaviors) and highlight consistencies across these levels, inconsistencies within them, and knowledge gaps. Lastly, based on these, we speculate about which mechanisms of exercise may be universal across age groups and populations versus those that might be distinct to specific age ranges or populations.

The effect of exercise on aromatase inhibitor-induced musculoskeletal symptoms in breast cancer survivors :a systematic review and meta-analysis

BACKGROUND

Evidence is mixed regarding the effect of exercise programs on improving musculoskeletal symptoms and quality of life. Previous meta-analyses have not focused specifically on the musculoskeletal symptoms. Therefore, this meta-analysis aimed to evaluate the effect of exercise on these outcomes in breast cancer survivors taking aromatase inhibitors.

METHODS

PubMed, CINAHL, EMBASE, Web of Science, Wan Fang, CNKI, VIP, and CBM were searched for randomized control trials or quasi-experimental studies from the establishment of the database to May 2019. Studies comparing exercise programs with usual care among breast cancer survivors taking aromatase inhibitors were included. The primary outcome was the degree of musculoskeletal symptoms, as assessed by scores of pain, stiffness, and grip strength. The secondary outcome was the total quality of life score.

RESULTS

A total of 9 studies involving 743 participants were included. Exercise programs were more effective than usual care in improving musculoskeletal symptoms among breast cancer patients taking AIs. The subgroup scores of pain (SMD = -0.46, 95% CI -0.79 to -0.13, P = 0.006), stiffness (SMD = -0.40, 95% CI -0.71 to -0.08, P = 0.01), and grip strength (SMD = 0.43, 95% CI 0.16 to 0.71, P = 0.002) benefited from exercise interventions. Similar effects were found for the quality of life scores (SMD = 2.24, 95% CI 0.28 to 4.21, P = 0.03).

CONCLUSIONS

Results indicate that exercise relieves musculoskeletal symptoms and improves quality of life, which can be used to motivate patients to exercise actively under professional guidance. Due to a small sample size, further research is required to ensure the effectiveness of exercise on musculoskeletal symptoms and quality of life.

Original Research: Arthritis-Related Functional Limitations and Inadequate Physical Activity Among Female Adult Cancer Survivors

BACKGROUND

The American Cancer Society (ACS) Guidelines on Nutrition and Physical Activity for Cancer Prevention recommend an adequate level of physical activity for cancer prevention and survivorship. Many adults have been diagnosed with arthritis, with a significantly higher rate in women. People with arthritis tend to be less physically active than those without arthritis, and are less likely to engage in moderate or vigorous activity. The proportion of adults meeting ACS physical activity guidelines is especially low among those with arthritis.

OBJECTIVE

We wanted to explore the extent to which arthritis-related functional limitations are predictive of inadequate physical activity in female adult cancer survivors after accounting for other known predictors.

METHODS

Data included in the analyses were from a sample of 729 adult women diagnosed with cancer who participated in the U.S. National Health and Nutrition Examination Survey between 2011 and 2016. Inadequate physical activity was defined as not meeting ACS physical activity guidelines. Bivariate and multivariate logistic regression analyses were conducted to identify correlates of inadequate physical activity.

RESULTS

Being age 65 years or older, having no more than a high school education, being overweight or obese, being clinically depressed, and having arthritis-related functional limitations were found to be significant correlates of inadequate physical activity in the study population.

CONCLUSIONS

Our results indicate that, in addition to previously identified predictors of inadequate physical activity in cancer survivors, having arthritis-related functional limitations is a significant predictor of inadequate physical activity in female adult cancer survivors. Assessment and management of arthritis-related functional limitations by health care providers are needed to facilitate successful adherence to physical activity guidelines.

Exercise therapies for preventing or treating aromatase inhibitor-induced musculoskeletal symptoms in early breast cancer

BACKGROUND

Survival for stage I to III, hormone receptor-positive, breast cancer has substantially improved over time due to advances in screening, surgery and adjuvant therapy. However many adjuvant therapies have significant treatment-related toxicities, which worsen quality of life for breast cancer survivors. Postmenopausal women with hormone receptor-positive breast cancer are now prescribed aromatase inhibitors (AI) as standard, with longer durations of therapy, up to 10 years, being considered for certain women. AI treatment is associated with a high incidence of AI-induced musculoskeletal symptoms (AIMSS), often described as symmetrical pain and soreness in the joints, musculoskeletal pain and joint stiffness. AIMSS reduces compliance with AI therapy in up to one half of women undergoing adjuvant AI therapy, potentially compromising breast cancer outcomes. Exercise has been investigated for the prevention and treatment of AIMSS but the effect of this intervention remains unclear.

OBJECTIVES

To assess the effects of exercise therapies on the prevention or management of aromatase inhibitor-induced musculoskeletal symptoms (AIMSS) in women with stage I to III hormone receptor-positive breast cancer.

SEARCH METHODS

We searched Cochrane Breast Cancer's Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases up to 13 December 2018. We also searched two conference proceedings portals and two clinical trials registries for ongoing studies or unpublished trials, or both, in August 2019. We also reviewed reference lists of the included studies.

SELECTION CRITERIA

We included randomised controlled trials that compared exercise versus a comparator arm. We did not impose any restriction on the comparator arm, which could include an alternative type of exercise, no exercise or a waiting list control. Both published and non-peer-reviewed studies were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed risk of bias and certainty of the evidence using the GRADE approach. The outcomes investigated were pain, joint stiffness, grip strength, health-related quality of life, cancer-specific quality of life, adherence to AI therapy, adverse events, incidence of AIMSS, breast cancer-specific survival and overall survival. For continuous outcomes that were assessed with the same instrument, we used the mean difference (MD); for those outcomes that used different instruments, we used the standardised mean difference (SMD) for the analysis. For dichotomous outcomes, we reported outcomes as an odds ratio (OR).

MAIN RESULTS

We included seven studies with 400 randomised participants; one study assessed exercise for preventing AIMSS and six studies assessed treating AIMSS. For preventing AIMSS, the single study reported no difference in pain scores, grip strength or compliance to taking AI medication between groups. Data values were not provided in the study and no other outcomes were reported. For managing AIMSS, we found that the evidence for the effect of exercise therapies on overall change in worst pain scores was very uncertain (SMD -0.23, 95% confidence interval (CI) -0.78 to 0.32; 4 studies, 284 women; very low-certainty evidence). The evidence suggested that exercise therapies result in little to no difference in overall change in stiffness scores (Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) stiffness score MD -0.76, 95% CI -1.67 to 0.15 and Visual Analogues Scale (VAS) stiffness score MD -0.42, 95% CI -2.10 to 1.26; 1 study, 53 women; low-certainty evidence). The evidence was very uncertain for the outcomes of overall change in grip strength (MD 0.30, 95% CI -0.55 to 1.15; 1 study, 83 women; very low-certainty evidence); overall change in health-related quality of life (subscales of SF-36 tool ranged from least benefit of MD 1.88, 95% CI -2.69 to 6.45 to most benefit of MD 9.70, 95% CI 1.67 to 17.73; 2 studies, 123 women, very low-certainty evidence); overall change in cancer-specific quality of life (MD 4.58, 95% CI -0.61 to 9.78; 2 studies, 136 women; very low-certainty evidence); and adherence to aromatase inhibitors (OR 2.43, 95% CI 0.41 to 14.63; 2 studies, 224 women; very low-certainty evidence). There were no adverse events identified across four studies in either arm (0 events reported; 4 studies; 331 participants; low-certainty evidence). There were no data reported on incidence of AIMSS, breast cancer-specific survival or overall survival.

AUTHORS' CONCLUSIONS

Given the wide-ranging benefits of exercise for people affected by cancer, it was surprising that this review provided no clear evidence of benefit for exercise therapies in women with early breast cancer with AIMSS. This review only yielded seven eligible studies with 400 participants, which is likely to have underpowered the findings. The meta-analysis was challenging due to the considerable heterogeneity amongst the trials, with a wide range of exercise regimens and follow-up periods. Despite these inconclusive findings, exercise needs to be part of routine care for women with breast cancer due to its wide-ranging benefits. Future research in this area would be enhanced with further understanding of the mechanism of AIMSS, a single clear definition of the condition, and phase III randomised controlled trials that are adequately powered to test targeted exercise interventions on the key clinical outcomes in this condition.

Nordic walking for women with breast cancer: A systematic review

Nordic walking (NW) seems to be an interesting rehabilitation strategy for women with breast cancer (BC). No review article that has synthesised and summarised the existing scientific evidence about the effect of NW on BC survivors has been published so far. A systematic review was conducted aimed at identifying the characteristics and methodological quality of the studies that have analysed the effects of NW on women with BC. The critical appraisal of the randomised controlled trials (RCTs) was retrieved from the Physiotherapy Evidence Database (PEDro). The methodological quality of the uncontrolled studies was evaluated by means of the Quality Assessment Tool for Before-After Studies with No Control Group. Nine investigations (four RCTs and five quasi-experimental studies) were included in the final analysis. The RCTs showed a fair methodological quality, while the quasi-experimental studies obtained a score ranging from "fair" to "poor". Judging from the findings of the analysed studies, NW had a significant and positive impact on a number of BC symptoms, including lymphedema, physical fitness, disability and morbid perceptions. No adverse effects were reported. However, due to the methodological limitations observed, further research is needed to confirm such findings.

Interventions for promoting habitual exercise in people living with and beyond cancer

BACKGROUND

This is an updated version of the original Cochrane Review published in the Cochrane Library 2013, Issue 9. Despite good evidence for the health benefits of regular exercise for people living with or beyond cancer, understanding how to promote sustainable exercise behaviour change in sedentary cancer survivors, particularly over the long term, is not as well understood. A large majority of people living with or recovering from cancer do not meet current exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important for understanding the most effective strategies to ensure benefit in the patient population and identify research gaps.

OBJECTIVES

To assess the effects of interventions designed to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following secondary questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals and/or healthcare professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with better behavioural outcomes? What behaviour change techniques (BCTs) are most often associated with increased exercise behaviour? What adverse effects are attributed to different exercise interventions?

SEARCH METHODS

We used standard methodological procedures expected by Cochrane. We updated our 2013 Cochrane systematic review by updating the searches of the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, Embase, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro up to May 2018. We also searched the grey literature, trial registries, wrote to leading experts in the field and searched reference lists of included studies and other related recent systematic reviews.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs) that compared an exercise intervention with usual care or 'waiting list' control in sedentary people over the age of 18 with a homogenous primary cancer diagnosis.

DATA COLLECTION AND ANALYSIS

In the update, review authors independently screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that could not be safely excluded without assessment of the full text (e.g. when no abstract is available). We extracted data from all eligible papers with at least two members of the author team working independently (RT, LS and RG). We coded BCTs according to the CALO-RE taxonomy. Risk of bias was assessed using the Cochrane's tool for assessing risk of bias. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. If statistical heterogeneity was noted, a meta-analysis was performed using a random-effects model. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation (SD) of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate the standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we narratively synthesised studies. The quality of the evidence was assessed using the GRADE approach with the GRADE profiler.

MAIN RESULTS

We included 23 studies in this review, involving a total of 1372 participants (an addition of 10 studies, 724 participants from the original review); 227 full texts were screened in the update and 377 full texts were screened in the original review leaving 35 publications from a total of 23 unique studies included in the review. We planned to include all cancers, but only studies involving breast, prostate, colorectal and lung cancer met the inclusion criteria. Thirteen studies incorporated a target level of exercise that could meet current recommendations for moderate-intensity aerobic exercise (i.e.150 minutes per week); or resistance exercise (i.e. strength training exercises at least two days per week).Adherence to exercise interventions, which is crucial for understanding treatment dose, is still reported inconsistently. Eight studies reported intervention adherence of 75% or greater to an exercise prescription that met current guidelines. These studies all included a component of supervision: in our analysis of BCTs we designated these studies as 'Tier 1 trials'. Six studies reported intervention adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendations: in our analysis of BCTs we designated these studies as 'Tier 2 trials.' A hierarchy of BCTs was developed for Tier 1 and Tier 2 trials, with programme goal setting, setting of graded tasks and instruction of how to perform behaviour being amongst the most frequent BCTs. Despite the uncertainty surrounding adherence in some of the included studies, interventions resulted in improvements in aerobic exercise tolerance at eight to 12 weeks (SMD 0.54, 95% CI 0.37 to 0.70; 604 participants, 10 studies; low-quality evidence) versus usual care. At six months, aerobic exercise tolerance was also improved (SMD 0.56, 95% CI 0.39 to 0.72; 591 participants; 7 studies; low-quality evidence).

AUTHORS' CONCLUSIONS

Since the last version of this review, none of the new relevant studies have provided additional information to change the conclusions. We have found some improved understanding of how to encourage previously inactive cancer survivors to achieve international physical activity guidelines. Goal setting, setting of graded tasks and instruction of how to perform behaviour, feature in interventions that meet recommendations targets and report adherence of 75% or more. However, long-term follow-up data are still limited, and the majority of studies are in white women with breast cancer. There are still a considerable number of published studies with numerous and varied issues related to high risk of bias and poor reporting standards. Additionally, the meta-analyses were often graded as consisting of low- to very low-certainty evidence. A very small number of serious adverse effects were reported amongst the studies, providing reassurance exercise is safe for this population.

A randomized phase II trial of MOVING ON: An intervention to increase exercise outcome expectations among breast cancer survivors

OBJECTIVE

The objective of the study is to test theoretical intervention fidelity and feasibility of MOVING ON, a self-directed, home-based, randomized controlled trial to increase exercise outcome expectations (OEs) (what one expects to obtain or avoid as a result of a behavior or lack thereof), among breast cancer survivors.

METHOD

Stage Ia to IIb survivors (n = 60) were given the MOVING ON intervention or control booklet. Data were collected through online surveys and an accelerometer at baseline, 4, 8, and 12 weeks postintervention. Fidelity was measured by questions assessing participant perceptions of MOVING ON (score ≥2) and direction of intervention effects. Feasibility was measured by recruitment rate (target of 60 participants in 6 months), retention (total attrition <17%), and acquisition of accelerometer data (% ≥subjective exercise data obtained). Analyses consisted of descriptive statistics, mixed models, and content analysis.

RESULTS

Fidelity met a priori criteria (mean = 3.31, SD = 0.87). Outcome expectations increased 0.01 points, and weekly steps increased by 970 every 4 weeks in the intervention arm compared to the control arm. All effect sizes were small, ranging from 0.01 to 0.09. Target enrollment, achieved in 17 weeks, met a priori feasibility criteria. Retention (66%) and accelerometer data acquisition (60%) (compared to 73% of subjective exercise data) did not.

CONCLUSION

MOVING ON influenced OEs as intended and was well received by participants. A fully powered study, of this low-cost, easy-to-implement intervention, is warranted. Intervention and measurement strategies used in MOVING ON can be incorporated in any study targeting OEs as a mediator of exercise or collecting exercise data with an accelerometer.

Estrogen: The necessary evil for human health, and ways to tame it

Estrogen is a pivotal enzyme for survival and health in both genders, though their quantum, tropism, tissue-specific distribution, and receptor affinity varies with different phases of life. Converted from androgen via aromatase enzyme, this hormone is indispensable to glucose homeostasis, immune robustness, bone health, cardiovascular health, fertility, and neural functions. However, estrogen is at the center of almost all human pathologies as well-infectious, autoimmune, metabolic to degenerative. Both hypo and hyper level of estrogen has been linked to chronic and acute diseases. While normal aging is supposed to lower its level, leading to tissue degeneration (bone, muscle, neural etc.), and metabolite imbalance (glucose, lipid etc.), the increment in inflammatory agents in day-to-day life are enhancing the estrogen (or estrogen mimic) level, fueling 'estrogen dominance'. The resultant excess estrogen is inducing an overexpression of estrogen receptors (ERα and ERβ), harming tissues, leading to autoimmune diseases, and neoplasms. The unprecedented escalation in the polycystic ovary syndrome, infertility, breast cancer, ovary cancer, and gynecomastia cases are indicating that this sensitive hormone is getting exacerbated. This critical review is an effort to analyze the dual, and opposing facets of estrogen, via understanding its crosstalk with other hormones, enzymes, metabolites, and drugs. Why estrogen level correction is no trivial task, and how it can be restored to normalcy by a disciplined lifestyle with wise dietary and selective chemical usage choices has been discussed. Overall, our current state of knowledge does not disclose the full picture of estrogen's pleiotropic importance. Hence, this review should be a resource for general public as well as researchers to work in that direction.

Protocol for Moving On: a randomized controlled trial to increase outcome expectations and exercise among breast cancer survivors

Aim

The aim of this study was to test the feasibility and fidelity of an intervention, Moving On, aimed to increase outcome expectations OEs (i.e. what one expects to obtain or avoid as a result of a behaviour) and exercise among breast cancer survivors.

Design

Randomized controlled trial.

Methods

Intervention arm participants will be given a theory-guided booklet that was co-created by the research team and three physically active breast cancer survivors who exercise to manage late and long-term treatment effects. Attention control arm participants will be given a similar booklet focused on diet. Participants will have 1 week to complete reading, writing and reflecting activities in the booklets. Study outcomes will be measured through online surveys; exercise will also be measured objectively with a Fitbit®. Four weeks postintervention, participants' thoughts about the usefulness, strengths and weakness of the intervention booklet will be assessed. OEs and exercise will be measured at baseline, 4-, 8- and 12-week postintervention.

Breast cancer: Lesser-known facets and hypotheses

Breast cancer is the most common cancer in females. The deteriorating environment, and lifestyle flaws are raising the frequency of this cancer. Existing therapies are not universally-effective, and they cause side effects, relapses, and high mortality rate. Alternative medications may be milder, but are less effective or are inadequate for a complex disease like the breast cancer. So, it requires the understanding that drugs are not the solution of this cancer, but prevention is the sustainable solution. In the past decades, an enormous quantum of insights on this disease has been obtained. A lifestyle based on the template of estrogenic compounds and, the resultant endocrine disruption, and acidosis, is elevating aromatase level, promoting the deleterious forms of estrogen, and inducing epithelial proliferation. This review provids a holistic account of breast cancer as a inflammatory endocrinopathy, and how it can be curbed by discipline, and awareness.

Randomized Controlled Trial of a Home-Based Walking Program to Reduce Moderate to Severe Aromatase Inhibitor-Associated Arthralgia in Breast Cancer Survivors

BACKGROUND

In postmenopausal women diagnosed with breast cancer (BC), most BC tumors are hormone receptor positive and guidelines recommend adjuvant endocrine therapy that includes an aromatase inhibitor (AI). This study investigates the impact of a 6-week, home-based, self-directed walking program on the commonly reported side effect of AI-associated arthralgia (AIAA).

MATERIALS AND METHODS

In this phase II trial, consented BC patients were randomized to walking Intervention (n = 31) or Wait List Control (WLC; n = 31). Eligibility criteria included: stage 0-III BC, on AI for at least 4 weeks, ≥3 on a 5-point scale inquiring about joint symptom intensity "at its worst," and exercising ≤150 minutes per week. Outcomes were self-reported joint symptoms and psychosocial measures. Analyses comparing Intervention and WLC groups were conducted on an intention-to-treat basis to assess intervention impact at 6 weeks (postintervention) and at 6-months follow-up. Adjusted means were calculated to assess differences in two groups.

RESULTS

In our final sample (n = 62), mean age was 64 years, 74% were white, and 63% had a body mass index of 30 or higher. At postintervention, Intervention group participants reported significantly increased walking minutes per week, reduced stiffness, less difficulty with activities of daily living (ADL), and less perceived helplessness in managing joint symptoms. At 6-months follow-up (postwalking period in both Intervention and WLC), walking minutes per week had decreased significantly; however, improvements in stiffness and difficulty with ADLs were maintained.

CONCLUSION

This study adds to the growing evidence base suggesting exercise as a safe alternative or adjunct to medications for the management of AIAA.

IMPLICATIONS FOR PRACTICE

Breast cancer survivors whose adjuvant endocrine treatment includes an aromatase inhibitor (AI) often experience the side effect of AI-associated arthralgia (AIAA). This study investigates the impact of a 6-week, home-based, self-directed walking program in the management of AIAA. Compared with Wait List Control, women in the Intervention group reported significantly increased walking minutes per week, reduced stiffness, less difficulty with activities of daily living, and less perceived helplessness in managing joint symptoms. This study adds to the growing evidence base suggesting exercise as a safe alternative or adjunct to medications for the management of AIAA.

Disruption of aromatase homeostasis as the cause of a multiplicity of ailments: A comprehensive review

Human health is beset with a legion of ailments, which is exacerbated by lifestyle errors. Out of the numerous enzymes in human body, aromatase, a cytochrome P450 enzyme is particularly very critical. Occurring at the crossroads of multiple signalling pathways, its homeostasis is vital for optimal health. Unfortunately, medications, hormone therapy, chemical additives in food, and endocrine-disrupting personal care products are oscillating the aromatase concentration beyond the permissible level. As this enzyme converts androgens (C19) into estrogens (C18), its agitation has different outcomes in different genders and age groups. Some common pathologies associated with aromatase disruption include breast cancer, prostate cancer, polycystic ovary syndrome (PCOS), endometriosis, osteoporosis, ovarian cancer, gastric cancer, pituitary cancer, Alzheimer's disease, schizophrenia, male hypogonadism, and transgender issues. Several drugs, cosmetics and pesticides act as the activators and suppressors of this enzyme. This carefully-compiled critical review is expected to increase public awareness regarding the threats resultant of the perturbations of this enzyme and to motivate researchers for further investigation of this field.