A controlled randomized study examining the effects of exercise therapy on patients undergoing haematopoietic stem cell transplantation

Assessment of rehabilitation practices during hematopoietic stem cell transplantation in the United States: a survey

Background

Rehabilitation therapy is important to treat physical and functional impairments that may occur in individuals receiving physically taxing, yet potentially curative hematopoietic stem cell transplants (HSCT). However, there is scarce data on how rehabilitation is delivered during HSCT in real-life setting. Our objective is to assess the rehabilitation practices for adult patients hospitalized for HSCT in the United States.

Methods

A 48-question online survey with cancer centers with the top 10% HSCT volumes (per American registries). We obtained data on patient characteristics, rehabilitation therapy details (timing, indication, administering providers), physical function objective and subjective outcome measures, and therapy activity precautions.

Results

Fourteen (out of 21) institutions were included. Rehabilitation therapy referrals occurred at admission for all patients at 35.7% of the centers for: functional decline (92.9%), fall risk (71.4%), and discharge planning (71.4%). Participating institutions had physical therapists (92.9%), occupational therapists (85.7%), speech language pathologists (64.3%) and therapy aides (35.7%) in their rehabilitation team. Approximately 71% of centers used objective functional measures including sit-to-stand tests (50.0%), balance measures (42.9%), and six-minute walk/gait speed (both 35.7%). Monitoring of blood counts to determine therapy modalities frequently occurred and therapies held for low platelet or hemoglobin values; but absolute neutrophil values were not a barrier to participate in resistance or aerobic therapies (42.9%).

Discussion

Rehabilitation practices during HSCT varied among the largest volume cancer centers in the United States, but most centers provided skilled therapy, utilized objective, clinician and patient reported outcomes, and monitored blood counts for safety of therapy administration.

Effect of non-pharmacological interventions on symptoms and quality of life in patients with hematological malignancies - A systematic review

BACKGROUND

Non-pharmacological interventions have the potential to enhance health-related quality of life (HRQoL) through symptom management. This systematic review aims to identify, collate, and assess randomized controlled trials investigating the effect of non-pharmacological interventions on symptoms and HRQoL within hematology.

METHODS

MEDLINE/PUBMED, EMBASE, CINAHL, PSYCINFO and COCHRANE were searched up to April 2021. Outcomes were changes in symptoms and HRQoL.

RESULTS

Sixty-five studies were categorized into five intervention types: Mind/body (n=9), Web-based (n=9), Music/art (n=6), Consultation-based (n=4), and Physical activity (n=37). We found significantly reduced fatigue (n=12 studies), anxiety (n=8) and depression (n=7), with 11 studies showing significant improvements in HRQoL.

CONCLUSIONS

The evidence for non-pharmacological interventions shows substantial variation in efficacy and methodological quality. While specific symptoms and HRQoL outcomes significantly favored the intervention, no particular intervention can be emphasized as more favorable, given the inability to conduct a meta-analysis.

Effect of exercise interventions on hospital length of stay and admissions during cancer treatment: a systematic review and meta-analysis

OBJECTIVE

To assess the effect of participating in an exercise intervention compared with no exercise during cancer treatment on the duration and frequency of hospital admissions.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, PEDro and Cochrane Central Registry of Randomized Controlled Trials.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised studies published until August 2023 evaluating exercise interventions during chemotherapy, radiotherapy or stem cell transplant regimens, compared with usual care, and which assessed hospital admissions (length of stay and/or frequency of admissions).

STUDY APPRAISAL AND SYNTHESIS

Study quality was assessed using the Cochrane Risk-of-Bias tool and Grading of Recommendations Assessment, Development and Evaluation assessment. Meta-analyses were conducted by pooling the data using random-effects models.

RESULTS

Of 3918 screened abstracts, 20 studies met inclusion criteria, including 2635 participants (1383 intervention and 1252 control). Twelve studies were conducted during haematopoietic stem cell transplantation regimens. There was a small effect size in a pooled analysis that found exercise during treatment reduced hospital length of stay by 1.40 days (95% CI: -2.26 to -0.54 days; low-quality evidence) and lowered the rate of hospital admission by 8% (difference in proportions=-0.08, 95% CI: -0.13 to -0.03, low-quality evidence) compared with usual care.

CONCLUSION

Exercise during cancer treatment can decrease hospital length of stay and admissions, although a small effect size and high heterogeneity limits the certainty. While exercise is factored into some multidisciplinary care plans, it could be included as standard practice for patients as cancer care pathways evolve.

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).

Comparative effects of different types of exercise on health-related quality of life during and after active cancer treatment: A systematic review and network meta-analysis

BACKGROUND

The positive influence of most types of exercise has been reported repeatedly, but what the most effective exercise approaches are for improving health-related quality of life (HRQoL) in people with cancer remains unknown. The aim of this systematic review and network meta-analysis was to synthesize the evidence from intervention studies to assess the effects of different types of exercise on HRQoL during and after cancer treatment.

METHODS

MEDLINE, SPORTDiscus, the Cochrane Library, Web of Science, and Scopus were searched for randomized controlled trials aimed at testing the effects of exercise interventions meant to improve HRQoL in people with cancer. Separate analyses were conducted for HRQoL as measured by general and cancer-specific questionnaires. We also evaluated whether the effects of exercise were different during and after cancer treatment in both the physical and mental HRQoL domains.

RESULTS

In total, 93 studies involving 7435 people with cancer were included. Network effect size estimates comparing exercise intervention vs. usual care were significant for combined exercise (0.35, 95% confidence interval (95%CI): 0.14-0.56) for HRQoL as measured by general questionnaires, and for combined (0.31, 95%CI: 0.13-0.48), mind-body exercise (0.54, 95%CI: 0.18-0.89), and walking (0.39, 95%CI: 0.04-0.74) for HRQoL as measured by cancer-specific questionnaires.

CONCLUSION

Exercise programs combining aerobic and resistance training can be recommended to improve HRQoL during and after cancer treatment. The scarcity and heterogeneity of these studies prevents us from making recommendations about other exercise modalities due to insufficient evidence.

A scoping review of studies exploring physical activity and cognition among persons with cancer

PURPOSE

This scoping review aimed to identify and synthesize published studies on physical activity (PA) and cognition among persons with cancer and elucidate knowledge gaps.

METHODS

Articles were identified through electronic and manual searches (02/21 and 03/22) using the following inclusion criteria: (1) empirical, peer-reviewed publication in English, (2) sample comprised persons with cancer, and (3) reported at least one statistical association between PA and cognition. Multiple reviewers independently performed study selection and data extraction, and results were mapped in tabular and narrative form.

RESULTS

Ninety-seven articles were eligible; these were largely published from 2017 to 2022 (54.6%), conducted in high-income countries (96.9%), and presented (quasi-)experimental studies (73.2%). Samples predominantly comprised women with breast cancer (48.5%), and recruitment often occurred post-treatment (63.9%). PA interventions included: aerobic (32.3%), resistance (4.8%), combined aerobic/resistance (38.7%), mind-body (19.4%), or other PA (4.8%). Most (66%) articles reported inconclusive findings; 32% were positive (in support of PA promoting cognition or vice versa), and 2.1% were negative. Diverse samples and studies with long-term follow-up were scarce.

CONCLUSIONS

The state of knowledge is insufficient and more rigorous, large-scale studies are required to provide definitive conclusions about the cognitive benefits of PA among persons with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer-related cognitive impairment (CRCI) thwarts quality of life. This review summarizes what is known about the association between PA and cognition among persons with cancer and concludes that the evidence is currently equivocal. Hence, it remains uncertain if PA interventions can reduce CRCI, and large-scale PA intervention trials explicitly designed to promote cognition are greatly needed.

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.

Effects of continuous bicycle ergometer and step exercises from admission to discharge in a patient with myelodysplastic syndrome undergoing myeloablative conditioning and hematopoietic stem cell transplantation: A case report

BACKGROUND

In myelodysplastic syndromes (MDS), in addition to disease-related symptoms, many adverse events are associated with anticancer agents, myeloablative conditioning (MAC), and allogeneic hematopoietic stem cell transplantation (allo-HSCT). Isolation and bed rest in a clean room severely limit physical activity, resulting in cardiopulmonary and muscle weakness. In addition, post-transplant patients may experience general fatigue, gastrointestinal symptoms, and infections associated with a weakened immune system, as well as graft-versus-host disease, which causes further decline in physical function and activities of daily living (ADL). Most reports on the rehabilitation of patients with hematopoietic tumors involve interventions before and after chemotherapy or transplantation. However, an important issue is to establish effective and feasible exercise programs in a clean room setting, where activity is severely limited and physical function is most likely to decline.

CASE REPORT

This case report describes the treatment progress of a 60-year-old man with MDS and thrombocytopenia scheduled to receive MAC and allo-HSCT, who continued bicycle ergometer and step exercises from admission to discharge. The patient was admitted for allo-HSCT, and on day 4, he started bicycle ergometer and step exercise in a clean room and continued until discharge. As a result, exercise tolerance and lower-extremity muscle strength were maintained at the time of hospital discharge. Furthermore, the patient was able to continue rehabilitation in a restricted environment without adverse events.

CONCLUSIONS

The rehabilitation and treatment course of this case may provide valuable information for patients with MDS and thrombocytopenia.

Monitoring of strength, inflammation and muscle function in allogenic stem-cell transplantation patients - a pilot study for novel biomarker and risk stratification determination

Background

Low aerobic capacity is associated with an increased mortality risk in allogenic stem-cell transplantation (alloSCT) patients, but currently used risk scores in the pre-transplantation workup are still underestimating physical activity as a prognostic factor.

Aim

To examine the physical condition, muscle function, blood inflammation and training adherence of alloSCT patients during inpatient time to identify potential biomarkers associated with development of myopathy and sarcopenia.

Methods

Patients undergoing alloSCT were examined at four time points (T0: before alloSCT; T_ha: hospital admission; T1: engraftment; T2: inpatient discharge). T0 included cardiopulmonary performance, body composition, grip and knee strength, motor skill tests (One-leg stand/Tinetti/Chair-rising), blood sampling (blood cell profiling and inflammation targets (Kynurenin/high sensitivity C-reactive Protein (hsCRP)/Tumor necrosis factor alpha (TNF-alpha)/Musclin/Galectin-3) and quality of life, state of health, fatigue, muscle weakness and physical activity by questionnaires (IPAQ/BSA/SARC-F/Fatigue). At T1 and T2, blood samples, grip strength and motor skill tests were repeated. Glucocorticoid dose and daily physical activity were documented during inpatient stay.

Results

26 of 35 included patients (4 females; age 55.58 ± 12.32 years; BMI 24.70 ± 3.27 kg/m²; VO_2peak 16.55 ± 4.06 ml/min/kg) could proceed to alloSCT. Grip strength and Tinetti decreased from T0 until T2, no difference in Chair-rising test, One-leg and Tandem stand. All patients engrafted after 24.9 days ± 3.9 days. HsCRP and Kynurenine increased from T0 to T1, decreased at T2. TNF-alpha (T0vsT2/T1vsT2) and Musclin (T0vsT1) decreased. At T2, Galectin-3 was higher compared to T0/T1. Correlation analysis of grip strength and inflammatory markers revealed a positive correlation with TNF-alpha at T2. 50% of patients documented physical activity and questionnaire and reported a 50%-reduction of daily endurance and strength training between T1 to T2.

Conclusion

Allogeneic stem-cell transplantation is associated with immune system vulnerability due to conditioning, increased inflammation and fatigue, and loss of muscle strength and function. In addition to hsCRP, Kynurenine seems to be a reliable biomarker to monitor acute and regenerative inflammation status of alloSCT patients, while Musclin and Galectin-3 may be added to physiological assessment regarding myopathy and sarcopenia. Grip strength and daily activity level should be documented by professionals to identify risk patients early and support them with optimal (exercise) therapy.

Harms of exercise training in patients with cancer undergoing systemic treatment: a systematic review and meta-analysis of published and unpublished controlled trials

Background

Exercise is recommended for people with cancer. The aim of this study was to evaluate the harms of exercise in patients with cancer undergoing systemic treatment.

Methods

This systematic review and meta-analysis included published and unpublished controlled trials comparing exercise interventions versus controls in adults with cancer scheduled to undergo systemic treatment. The primary outcomes were adverse events, health-care utilization, and treatment tolerability and response. Eleven electronic databases and trial registries were systematically searched with no date or language restrictions. The latest searches were performed on April 26, 2022. The risk of bias was judged using RoB2 and ROBINS-I, and the certainty of evidence for primary outcomes was assessed using GRADE. Data were statistically synthesised using pre-specified random-effect meta-analyses. The protocol for this study was registered in the PROESPERO database (ID: CRD42021266882).

Findings

129 controlled trials including 12,044 participants were eligible. Primary meta-analyses revealed evidence of a higher risk of some harms, including serious adverse events (risk ratio [95% CI]: 1.87 [1.47-2.39], I2 = 0%, n = 1722, k = 10), thromboses (risk ratio [95% CI]: 1.67 [1.11-2.51], I2 = 0%, n = 934, k = 6), and fractures (risk ratio [95% CI]: 3.07 [3.03-3.11], I2 = 0%, n = 203, k = 2) in intervention versus control. In contrast, we found evidence of a lower risk of fever (risk ratio [95% CI]: 0.69 [0.55-0.87], I2 = 0% n = 1109, k = 7) and a higher relative dose intensity of systemic treatment (difference in means [95% CI]: 1.50% [0.14-2.85], I2 = 0% n = 1110, k = 13) in intervention versus control. For all outcomes, we downgraded the certainty of evidence due to imprecision, risk of bias, and indirectness, resulting in very low certainty of evidence.

Interpretation

The harms of exercise in patients with cancer undergoing systemic treatment are uncertain, and there is currently insufficient data on harms to make evidence-based risk-benefits assessments of the application of structured exercise in this population.

Funding

There was no funding for this study.

An 8-step approach for the systematic development of an evidence-based exercise program for patients undergoing hematopoietic stem cell transplantation

Background

A tailored and reliable intervention program developed based on evidence is necessary for patients with serious health conditions.

Objective

We describe the development of an exercise program for HSCT patients based on evidence from a systematic process.

Methods

We developed the exercise program for HSCT patients using eight systematic steps: (1) a literature review, (2) understanding patient characteristics, (3) first expert group discussion, (4) development of the first draft of the exercise program, (5) a pre-test, (6) second expert group discussion, (7) a pilot randomized controlled trial (n=21), and (8) a focus group interview.

Results

The developed exercise program was unsupervised and consisted of different exercises and intensities according to the patients' hospital room and health condition. Participants were provided with instructions for the exercise program, exercise videos via smartphone, and prior education sessions. In the pilot trial, the adherence to the exercise program was only 44.7%, however, some changes in physical functioning and body composition favored the exercise group despite the small sample size.

Conclusion

Strategies to improve adherence to this exercise program and larger sample sizes are needed to adequately test if the developed exercise program may help patients improve physical and hematologic recovery after HSCT. This study may help researchers develop a safe and effective evidence-based exercise program for their intervention studies. Moreover, the developed program may benefit the physical and hematological recovery in patients undergoing HSCT in larger trials, if exercise adherence is improved.

Clinical trial registration

https://cris.nih.go.kr/cris/search/detailSearch.do?seq=24233&search_page=L, identifier KCT 0008269.

Effects of Exercise Programs on Psychoemotional and Quality-of-Life Factors in Adult Patients with Cancer and Hematopoietic Stem Cell Transplantation or Bone Marrow Transplantation: A Systematic Review

This review analyzed the effects of an exercise program on psychoemotional and quality-of-life (QoL) factors in adult patients with cancer and hematopoietic stem cell transplantation (HSCT) or bone marrow transplantation (BMT). Studies were identified from the PubMed and Web of Science databases (from inception to 24 August 2022), according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. The methodological quality of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale, based in turn on the Delphi list. A total of 20 randomized controlled studies were included with 1219 participants. The main result of this systematic review is that exercise program interventions produce improvements on psychoemotional and QoL factors in adult patients with cancer and HSCT or BMT. Moreover, exercise programs may have a beneficial effect on health, maintaining or increasing the patient's QoL. Further, it has a positive effect on the prevention and control of transplant complications in combination with medical treatment.

Alestad J, Santali EY, Arshad S, Ahmed N, Afolabi HA. Effectiveness of physical activity on immunity markers and quality of life in cancer patient: a systematic review

Background

Cancer is a huge group of diseases that can affect various body parts of humans but also has a psychological, societal, and economic impact. Physical activity can improve the quality of life (QOL) and immunity, while moderate intensity exercise can reduce the probability of this lethal disease. The current study aimed to determine the effect of physical activity on immune markers and QOL in cancer patients as well as to evaluate cancer-related fatigue (CRF) and its association with physical activity.

Methodology

Before starting the study, the study protocol was registered in PROSPERO (registration number CRD42021273292). An electronic literature search was performed by combining MeSH terminology and keywords used with the Boolean operators "OR" and "AND" to find relevant published studies on PubMed, Scopus, Cochrane, and ScienceDirect databases. The Joanna Briggs Institute (JBI) critical evaluation checklist was used to assess the quality of selected studies, while the GRADE approach was used to see the quality of evidence.

Results

A total of 13,931 studies were retrieved after the search on databases. After the scrutiny of studies by reading the title of articles and the inclusion/exclusion criteria, a total of 54 studies were selected for further screening by reading the full texts. In the final, a total of nine studies were selected for the current systematic review and proceeded for data extraction. The patients who were doing different exercises showed improvements in immunity, QOL, and reduction in CRF. A significant reduction in tumour necrosis factor-α (TNF-α), C reactive protein (CRP), interleukin-8 (IL-8), IL-6, and an increase in natural killer (NK) cells levels was also observed.

Conclusions

The exercise program is safe and beneficial to improve the quality of life and immunity markers before, during, and after cancer treatment. Physical exercise may also help patients to overcome the adverse effects of the treatment and to reduce the chance of developing new tumours in the future.

A Scoping Review on Outcomes and Outcome Measurement Instruments in Rehabilitative Interventions for Patients with Haematological Malignancies Treated with Allogeneic Stem Cell Transplantation

Rationale: Allogeneic hematopoietic stem cell transplantation (HSCT) is associated with increased treatment-related mortality, loss of physical vitality, and impaired quality of life. Future research will investigate the effects of multidisciplinary rehabilitative interventions in alleviating these problems. Nevertheless, published studies in this field show considerable heterogeneity in selected outcomes and the outcome measurement instruments used. The purpose of this scoping review is to provide an overview of the outcomes and outcome measurement instruments used in studies examining the effects of rehabilitative interventions for patients treated with allogeneic HSCT. Methods: We conducted a scoping review that included randomized controlled trials, pilot studies, and feasibility studies published up to 28 February 2022. Results: We included n = 39 studies, in which n = 84 different outcomes were used 227 times and n = 125 different instruments were used for the measurements. Conclusions: Research in the field of rehabilitation for patients with haematological malignancies treated with allogeneic HSCT is hampered by the excess outcomes used, the inconsistent outcome terminology, and the inconsistent use of measurement instruments in terms of setting and timing. Researchers in this field should reach a consensus with regard to the use of a common terminology for the outcomes of interest and a homogeneity when selecting measurement instruments and measurement timing methods.

Effects of physical exercise on the quality-of-life of patients with haematological malignancies and thrombocytopenia: A systematic review and meta-analysis

BACKGROUND

Annually, there are an estimated 1187000 new patients worldwide diagnosed with haematological malignancies. Effective strategies are needed to alleviate side effects and prevent the physical and psychosocial degeneration of patients in active treatment for haematological malignancies.

AIM

To explore the effects of physical exercise on quality of life (QoL) of patients with haematological malignancies and thrombocytopenia.

METHODS

Cochrane Library, PubMed and Embase were searched for all relevant articles reporting randomized controlled trials (RCTs) that were published up to 31 July 2021. Two authors independently selected articles in accordance with the inclusion criteria, evaluated their quality, and collected information. Any controversy was resolved through discussion with a third senior author. The PRISMA 2009 checklist was followed.

RESULTS

Seven RCTs were selected in the systematic review and three were included in the final meta-analysis. There were significant differences in QoL between physical exercise groups [mean score difference = 8.81; 95% confidence interval (CI): 1.81-15.81, P = 0.01], especially in emotional functioning (mean score difference = 12.34; 95%CI: 4.64-20.04, P = 0.002) and pain (mean score difference = –12.77; 95%CI: -3.91 to -21.63, P = 0.005).

CONCLUSION

Physical exercise has clinical effects on QoL and improves emotional function and pain indices of patients with haematological malignancies and thrombocytopenia.

Effects of Exercise Programs on Physical Factors and Safety in Adult Patients with Cancer and Haematopoietic Stem Cell Transplantation: A Systematic Review

This study looks at the effects of exercise programs on physical factors and safety in adult patients with cancer and hematopoietic stem cell transplantation (HSCT) or bone marrow transplantation (BMT). A systematic search was performed in the PubMed and Web of Science databases (from inception to 26 August 2021). A review was carried out following the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) checklist. The methodological quality of the included studies was assessed with the Physiotherapy Evidence Database (PEDro) scale, based, in turn, on the Delphi list. A total of 25 randomized controlled trials studies were included, comprising 1434 patients. The most significant result of this systematic review is that exercise program interventions are safe and produce positive changes in cardiorespiratory fitness, muscle strength, and the functional mobility-state in adult patients with cancer and HSCT or BMT. Only 3 patients from the 711 participants in the exercise interventions (i.e., 0.42%) reported adverse events related to exercise interventions. Moreover, exercise training programs may have a cardiological and muscular protective effect, as well as a healthy effect on the prevention and control of transplant complications, improving health outcomes.

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.

Attention to principles of exercise training: an updated systematic review of randomized controlled trials in cancers other than breast and prostate

BACKGROUND

The primary objective of this systematic review was to update our previous review on randomized controlled trials (RCTs) of exercise in cancers other than breast or prostate, evaluating: 1) the application of principles of exercise training within the exercise prescription; 2) reporting of the exercise prescription components (i.e., frequency, intensity, time, and type (FITT)); and 3) reporting of participant adherence to FITT. A secondary objective was to examine whether reporting of these interventions had improved over time.

METHODS

MEDLINE, EMBASE, CINAHL and SPORTDiscus databases were searched from 2012 to 2020. Eligible studies were RCTs of at least 4 weeks of aerobic and/or resistance exercise that reported on physiological outcomes relating to exercise (e.g., aerobic capacity, muscular strength) in people with cancer other than breast or prostate.

RESULTS

Eighty-six new studies were identified in the updated search, for a total of 107 studies included in this review. The principle of specificity was applied by 91%, progression by 32%, overload by 46%, initial values by 72%, reversibility by 7% and diminishing returns by 5%. A significant increase in the percentage of studies that appropriately reported initial values (46 to 80%, p < 0.001) and progression (15 to 37%, p = 0.039) was found for studies published after 2011 compared to older studies. All four FITT prescription components were fully reported in the methods in 58% of all studies, which was higher than the proportion that fully reported adherence to the FITT prescription components in the results (7% of studies). Reporting of the FITT exercise prescription components and FITT adherence did not improve in studies published after 2011 compared to older studies.

CONCLUSION

Full reporting of exercise prescription and adherence still needs improvement within exercise oncology RCTs. Some aspects of exercise intervention reporting have improved since 2011, including the reporting of the principles of progression and initial values. Enhancing the reporting of exercise prescriptions, particularly FITT adherence, may provide better context for interpreting study results and improve research to practice translation.

The effect of a single session of 30-min mindful breathing in reducing fatigue among patients with haematological cancer - a randomised controlled trial

BACKGROUND

Patients with haematological cancer had considerable symptom burden, in which fatigue was the most prevalent. Almost 70% of haematological cancer patients reported fatigue.

METHODS

We conducted a parallel-group, non-blinded, randomised control trial at the haemato-oncology unit of University Malaya Medical Centre, from 1st October 2019 to 31st May 2020. Patients included were ≥ 18 years, had histopathological diagnosis of haematological cancer, and fatigue score of ≥4 based on the fatigue subscale of Edmonton Symptom Assessment System (ESAS). Patients allocated to the intervention group received standard care plus a guided 30-min mindful breathing session, while those in control group received standard care. The study outcomes include fatigue severity according to the fatigue subscale of ESAS, visual analogue scale of 0 - 10, and Functional Assessment of Chronic Illness Therapy Fatigue Scale Version 4, at minute 0 and minute 30.

RESULTS

Of 197 patients screened, 80 were eligible and they were equally randomised into 30-min mindful breathing versus standard care. Lymphoma (58.9%) was the commonest haematological malignancy, followed by multiple myeloma (13.8%), acute leukaemia (11.3%), myeloproliferative neoplasm (6.3%), chronic leukaemia (5.0%) and myelodysplastic syndrome (5.0%). There was no difference in the demographic and clinical characteristics between the 2 groups. At minute 0, both arms of patients had similar ESAS-fatigue score (median, 5) and FACIT-fatigue score (mean ± SD, 24.7 ± 10.6 for intervention group versus 24.7 ± 9.7 for control group). At minute 30, intervention group had lower ESAS-fatigue score (median, 3 versus 5) and FACIT-fatigue score (mean ± SD, 17.1 ± 10.5 versus 24.8 ± 11.3) compared to control group. Both the ESAS-fatigue score reduction (median, - 2 versus 0, p = 0.002) and FACIT-fatigue score reduction (mean ± SD, - 6.7 versus + 0.8; p < 0.001) for the intervention group were statistically significant. The calculated effect size Cohen's d was 1.4 for between-group comparison of differences in total FACIT-fatigue score.

CONCLUSIONS

Our results provide evidence that a single session of 30-min mindful breathing was effective in reducing fatigue in haematological cancer patients. On top of all the currently available methods, 30-min mindful breathing can prove a valuable addition.

TRIAL REGISTRATION

NCT05029024 , date of registration 15th August 2021. (Retrospectively registered).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPACT

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

Feasibility of early-commencing group-based exercise in allogeneic bone marrow transplantation: the BOOST study

Increasing evidence supports that individualised exercise is safe and beneficial for adults treated with allogeneic bone marrow transplantation (alloBMT), although this is not part of standard care and no research has investigated group-based interventions. This study aimed to determine safety, feasibility and exploratory effects of a supervised group-based inpatient and subsequent home-based exercise programme in alloBMT. This single-site prospective cohort study included consecutive adults treated with alloBMT for haematological disease. All participants received usual care in addition to the protocolised exercise programme pre-transplant until 60 days post transplant. The primary outcome was feasibility; secondary outcomes included exercise capacity, frailty, health-related quality of life and strength. Consent rate was 100% (n = 42); 83% (n = 35) completed all aspects of the intervention and outcome testing; of those, 83% (n = 29) attended ≥2 group-exercise sessions per week; no adverse events occurred. Emotional well-being significantly improved over time, which may highlight benefits of group-based intervention. Other outcomes significantly declined from pre-BMT to hospital discharge, with some improvement at 60 days post-BMT. Participants with early signs of frailty demonstrated the greatest decline in outcomes. Group-based exercise was safe and feasible; observations from this study highlight the importance of baseline identification of frailty to target intervention at those who need it most.

Efficacy of face-to-face behavior change counseling interventions on physical activity behavior in cancer survivors - a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis of randomized controlled trials determines the efficacy of face-to-face behavior change counseling (BCC) interventions on physical activity (PA) behavior in adult cancer survivors at least pre-and immediately post-intervention compared to usual care. Additionally, this review aims to answer the question which behavior change techniques (BCTs) are most effective.

MATERIALS AND METHODS

A structured search of the databases Medline, OTseeker, PEDro, the Cochrane Library, and article reference lists was conducted. All trials were critically appraised for methodological quality using the PEDro scale. The BCC interventions were coded using the BCT Taxonomy (v1). Random effect meta-analysis explored between group differences in PA behavior post intervention. Standardized mean differences (SMD) describe effect sizes.

RESULTS

Fourteen studies were included, 12 effect sizes within 11 trials were pooled in meta-analysis. The SMD between groups favored the intervention group with a small effect (SMD 0.22; 95% CI 0.11, 0.33; p < 0.0001). The BCTs "graded tasks", "self-monitoring of behavior", "action planning" and "habit reversal" were more frequently coded in more efficacious interventions.

CONCLUSION

BCC interventions are effective in increasing PA behavior in cancer survivors. Further research is needed providing details of fidelity assessment and structuring the intervention description by using a BCT taxonomy. Health care professionals should consider our results while awaiting further trial evaluation.Implications for RehabilitationFace-to-face behavior change counseling interventions can significantly increase physical activity behavior in cancer survivors.Although small differences are evident, included trials presented with a broad variety of study components, and characteristics, which limits the interpretation of effective components.The behavior change techniques "Graded tasks", "Action planning", "Habit reversal", and "Credible Source" were used in the trials with a positive effect, but not in the ineffective ones.

Wearable Monitors Facilitate Exercise in Adult and Pediatric Stem Cell Transplant

Hematopoietic stem cell transplant (HSCT) is a potentially curative treatment for hematopoietic malignancies, complicated by decreased performance status and quality of life. Exercise therapy improves outcomes in HSCT, but several barriers have prevented exercise from becoming routine clinical practice. Based on existing data that wearable technologies facilitate exercise participation in other sedentary and chronic illness populations, we propose the novel hypothesis that wearable technologies are a valuable tool in transcending barriers and developing exercise therapy programs for HSCT patients.

The effect of exercise and nutrition interventions on physical functioning in patients undergoing haematopoietic stem cell transplantation: a systematic review and meta-analysis

PURPOSE

Haematopoietic stem cell transplantation (HSCT) is potentially lifesaving. However, it comes with negative consequences such as impaired physical functioning, fatigue and poor quality of life. The aim of this systematic review and meta-analysis is to determine the effect of exercise and nutrition interventions to counteract negative consequences of treatment and improve physical functioning in patients receiving HSCT.

METHODS

This systematic review and meta-analysis included randomised controlled trials from three electronic databases between 2009 and 2020. The trials included adult patients receiving HSCT and an exercise or nutrition intervention. Study selection, bias assessment and data extraction were independently performed by two reviewers. Physical functioning outcomes were meta-analysed with a random-effects model.

RESULTS

Thirteen studies were included using exercise interventions (n = 11) and nutrition interventions (n = 2); no study used a combined intervention. Meta-analysis of the trials using exercise intervention showed statistically significant effects on 6-min walking distance (standardised mean difference (SMD) 0.41, 95% CI: 0.14-0.68), lower extremity strength (SMD 0.37, 95% CI 0.12-0.62) and global quality of life (SMD 0.27, 95% CI: 0.08-0.46).

CONCLUSION

Our physical functioning outcomes indicate positive effects of exercise interventions for patients receiving HSCT. Heterogeneity of the exercise interventions and absence of high-quality nutrition studies call for new studies comparing different types of exercise studies and high quality studies on nutrition in patients with HSCT.

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

Objectives:

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

Methods:

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

Results:

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

Conclusions:

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

Role of Physical Activity and Cardiac Rehabilitation in Patients Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is a standard treatment for several malignancies, and >50,000 HSCT are performed annually worldwide. As survival after HSCT improves, cardiovascular disease and associated risk factors have gained importance as a significant cause of morbidity and mortality in this cohort. In this article, we detail the risk factors for cardiovascular disease and their impact in patients undergoing HSCT. Additionally, we critically review the data on the impact of physical exercise in patients undergoing HSCT. Although limited by significant heterogeneity in methodologies, small sample sizes, attrition, and lack of long-term cardiovascular follow-up, most of these studies reinforce the beneficial effects of physical activity and exercise in this patient population. Cardiac rehabilitation (CR) is a structured exercise and lifestyle modification program that is typically instituted in patients who experience acute cardiovascular events. We review the data on CR in the oncologic and nononcologic populations with an aim of building a framework for use of CR in HSCT patients.

•

Patients surviving HSCT have a higher incidence of cardiovascular risk factors and cardiovascular disease than the general population.

•

Physical activity can improve cardiovascular fitness, strength, and quality of life and decrease fatigue in HSCT patients and survivors.

•

In addition to physical exercise, cardiac rehabilitation also involves dietary and smoking cessation counseling, medication management, and psychosocial support, and it may therefore offer a unique framework to mitigate cardiovascular risk in HSCT.

•

Early referral, cardiovascular risk stratification, monitoring for complications, and multimodal lifestyle interventions should form the backbone of cardiac rehabilitation in this population.

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Outcome data on quality of life indices and survival as potential benefits of cardiac rehabilitation in HSCT are needed.

Multidirectional Walking in Hematopoietic Stem Cell Transplant Patients

BACKGROUND

The effect of a peritransplant multidirectional walking intervention to target losses in physical function and quality of life (QOL) has not been investigated.

PURPOSE

This study examined the effects of a novel multidirectional walking program on physical function and QOL in adults receiving a hematopoietic stem cell transplant (HSCT).

METHODS

Thirty-five adults receiving an autologous or allogeneic HSCT were randomized to a multidirectional walking (WALK) or usual care (CONT) group. The WALK group received supervised training during hospitalization; the CONT group received usual care. Patients were assessed at admission (t0), 3 to 5 d post-HSCT (t1), and 30 d post-HSCT (t2). Physical function measures included the 6-min walk test (6MWT), the Physical Performance Test, and the Timed Up and Go test. Health-related QOL was collected using the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) questionnaire.

RESULTS

There were no significant between-group changes for physical function or QOL. However, after the intervention (t1 to t2), the WALK group showed significant improvement in aerobic capacity (6MWT, P = 0.01), physical (P < 0.01) and functional well-being (P = 0.04), and overall QOL scores (P < 0.01). The CONT group saw no significant changes in physical function or QOL. Effect sizes showed the WALK group had a larger positive effect on physical function and QOL. Minimal clinically important differences in the 6MWT and FACT-BMT were exceeded in the WALK group.

CONCLUSION

A multidirectional walking program during the transplant period may be effective at increasing aerobic capacity and QOL for patients receiving HSCT compared with no structured exercise.

Rehabilitation Before and After Autologous Haematopoietic Stem Cell Transplantation (AHSCT) for Patients With Multiple Sclerosis (MS): Consensus Guidelines and Recommendations for Best Clinical Practice on Behalf of the Autoimmune Diseases Working Party, Nurses Group, and Patient Advocacy Committee of the European Society for Blood and Marrow Transplantation (EBMT)

Autologous haematopoietic stem cell transplantation (AHSCT) is increasingly used to treat people with multiple sclerosis (MS). Supported by an evolving evidence base, AHSCT can suppress active inflammation in the central nervous system and induce long-term changes in immune cell populations, thereby stabilizing, and, in some cases, reversing disability in carefully selected MS patients. However, AHSCT is an intensive chemotherapy-based procedure associated with intrinsic risks, including profound cytopenia, infection, and organ toxicity, accompanied by an on-going degree of immuno-compromise and general deconditioning, which can be associated with a transient increase in functional impairment in the early stages after transplantation. Although international guidelines and recommendations have been published for clinical and technical aspects of AHSCT in MS, there has been no detailed appraisal of the rehabilitation needed following treatment nor any specific guidelines as to how this is best delivered by hospital and community-based therapists and wider multidisciplinary teams in order to maximize functional recovery and quality of life. These expert consensus guidelines aim to address this unmet need by summarizing the evidence-base for AHSCT in MS and providing recommendations for current rehabilitation practice along with identifying areas for future research and development.

Therapeutic Education and Physical Activity to Support Self-management of Cancer-related Fatigue in Hematologic Cancer Patients: Protocol of a Feasibility Randomized Controlled Trial

Introduction

Hematologic malignancies account for nearly 8% of new cancer diagnosis in Italy. Cancer-related fatigue (CRF) is one of the most distressing symptoms reported by patients with cancer. As CRF has a multifactorial etiology, physical activity and therapeutic education may be beneficial for managing CRF, both during and after cancer treatment. However, there is a lack of evidence specific to hematologic malignancies. This paper describes the protocol of a feasibility study on Therapeutic Education and Physical Activity (TEPA) intervention to support self-management of CRF in patients with hematologic malignancies.

Methods

TEPA was addressed to newly diagnosed adult individuals with hematologic malignancy able to take part in a rehabilitation programme at the AUSL-IRCCS of Reggio Emilia. The protocol was developed in 2 phases. Phase I was an observational cohort study involving a convenience sample of 10 participants with the aim to evaluate the feasibility of the assessment schedule and to register longitudinal clinical data regarding CRF (FACIT-F), psychologic distress (NCCN Distress Thermometer), QoL (EORTC QLQ-C30), physical performance (TUG and 6MWT) and habitual level of physical activity during first months after diagnosis. Phase II (underway) is a feasibility randomized controlled trial (TEPA) involving a convenience sample of 40 participants and comparing 2 parallel active interventions (Therapeutic Education versus Therapeutic Education and Physical Activity) on top of usual care. The primary aim is to estimate the feasibility of TEPA, measured by the adherence rate to the intervention. Secondary aims are: to estimate the effect size of TEPA in terms of changes in CRF, psychological distress, QoL, physical performance and habitual level of physical activity (measured as in Phase I); to collect patient satisfaction, perception of usefulness of the TEPA intervention and data on long-term adherence to an active lifestyle. Data are collected in both phases at the time of diagnosis and then at 1-, 3- (completion of intervention) and 7-month follow-up.

Discussion

Data on feasibility and effect size of TEPA will be analyzed upon completion of Phase II, allowing us to design a large, adequately powered RCT to verify the effectiveness of this intervention on CRF management in patients with hematologic cancer. Trial registration: clinicaltrials.gov; Trial registration number: NCT03403075

Functional Capacity Change Impacts the Quality of Life of Hospitalized Patients Undergoing Hematopoietic Stem Cell Transplantation

OBJECTIVE

The aim of the study was to compare the quality of life (QOL) of patients undergoing hematopoietic stem cell transplantation who improved their functional capacity during hospitalization (increased functional capacity group) with that of patients who maintained or decreased functional capacity during hospitalization (decreased functional capacity group).

DESIGN

This observational, longitudinal study included 27 hospitalized patients undergoing hematopoietic stem cell transplantation. Patients were divided into increased functional capacity group (16 patients) and decreased functional capacity group (11 patients). Functional capacity (6-min step test), peripheral muscle strength (sit-to-stand test and handgrip strength), and QOL (European Organization for Research and Treatment of Cancer) were assessed at admission and at hospital discharge.

RESULTS

Increased functional capacity patients had increased functional capacity and peripheral muscle strength of the lower and upper limbs at hospital discharge (P < 0.01, <0.01, and 0.02, respectively). The patients in the increased functional capacity group demonstrated an increase in global health and reduced symptoms at discharge (P = 0.02 and 0.03, respectively). No significant differences were observed between groups in the functional domain.

CONCLUSIONS

Patients undergoing hematopoietic stem cell transplantation, who have improved functional capacity at discharge, also experience an improved QOL, with no such improvement noted among patients who have stable or reduced functional capacity. We recommend that the treatment protocol for hospitalized patients undergoing hematopoietic stem cell transplantation include an exercise program aimed at improving functional capacity.

The Effect of Exercise on Cancer-Related Cognitive Impairment and Applications for Physical Therapy: Systematic Review of Randomized Controlled Trials

BACKGROUND

Cancer-related cognitive impairment (CRCI), often called "chemo-brain" or "chemo-fog," is a common side effect among adults with cancer, which can persist well after treatment completion. Accumulating evidence demonstrates exercise can improve cognitive function in healthy older adults and adults with cognitive impairments, suggesting exercise may play a role in managing CRCI.

PURPOSE

The purpose was to perform a systematic review of randomized controlled trials (RCTs) to understand the effect of exercise on CRCI.

DATA SOURCES

Relevant literature was retrieved from CINAHL, Medline (Ovid), and EMBASE.

STUDY SELECTION

Eligible articles were RCTs that prescribed aerobic, resistance, combined aerobic/resistance, or mind-body (eg, yoga or Qigong) exercise during or following cancer treatment and included cognitive function outcome measures.

DATA EXTRACTION

Descriptive information and Cohen d effect sizes were directly extracted or calculated for included trials.

DATA SYNTHESIS

Twenty-nine trials were included in the final analysis. A statistically significant effect of exercise on self-reported cognitive function, both during and postadjuvant treatment, was reported in 12 trials (41%) (Cohen d range: 0.24-1.14), most commonly using the EORTC QLQ-C30. Ten trials (34%) performed neuropsychological testing to evaluate cognitive function; however, only 3 trials in women with breast cancer reported a significant effect of exercise (Cohen d range: 0.41-1.47).

LIMITATIONS

Few RCTs to date have evaluated the effect of exercise on CRCI as a primary outcome. Twenty-six trials (90%) in this review evaluated CRCI as secondary analyses.

CONCLUSIONS

Evidence supporting exercise as a strategy to address CRCI is limited. Future research evaluating CRCI as a primary outcome, including self-reported and objective measures, is needed to confirm the possible role of exercise in preventing and managing cognitive impairments in adults with cancer.

Whole body vibration training during allogeneic hematopoietic cell transplantation-the effects on patients' physical capacity

Patients undergoing allogeneic hematopoietic cell transplantation (alloHCT) experience a considerable decline in physical and psycho-social capacity. Since whole body vibration (WBV) is known to efficiently stimulate the neuromuscular system and enhance cardiorespiratory fitness and muscle strength in frail individuals, we hypothesized that WBV would maintain various physical and psychological capacities in patients during alloHCT. Seventy-one patients were randomly allocated to either an intervention group (IG) doing WBV or an active control group (CG) doing mobilization exercises five times per week. We determined peak oxygen consumption (VO_2peak) and maximum power, maximum strength, functional performance, body composition, quality of life (QoL), and fatigue. Tests were carried out before conditioning therapy, at hospital discharge and at day ± 180 (follow-up). As 18 patients did not participate in post-intervention assessment and follow-up data from 9 patients was not collectible, per-protocol (PP) analysis of 44 patients is presented. During hospitalization, WBV maintained maximum strength, height, and power output during jumping, as well as reported QoL, physical functioning, and fatigue level compared with mobilization. At follow-up, relative VO_2peak (p = 0.035) and maximum power (p = 0.011), time and power performing chair-rising test (p = 0.022; p = 0.009), and reported physical functioning (p = 0.035) significantly increased in the IG, while fatigue decreased (p = 0.005). CG’s body cell mass and phase angle had significantly decreased at follow-up (p = 0.002; p = 0.004). Thus, WBV might maintain maximum strength, functional performance, QoL, and fatigue during alloHCT, while cardiorespiratory fitness might benefit from accelerated recovery afterwards.

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.

Psychophysical effects of an exercise therapy during pediatric stem cell transplantation: a randomized controlled trial

This study evaluates the physical and psychosocial effects of an inpatient exercise program for children and adolescents undergoing hematopoietic stem cell transplantation (HSCT). Participants (n = 70) were randomized to an exercise intervention (IG: resistance, endurance, and flexibility training) or a non-exercise control group (CG: mental and relaxation training). Pre- (prior hospital admission; T0) and post- (day of discharge; T1) measurements included maximal isometric knee extension strength (KES; strain gauge force transducer), hand grip strength (HGS; JAMAR dynamometer), distance walked in 6 min (6MWD; 6-minute walk test), quality of life (QoL; KINDL-R) and medical parameters. Fifty-seven patients (IG: n = 28; 11.0 (5-17) years; CG: n = 29; 12.0 (6-18) years) completed the study. During hospitalization the IG and CG attended on average 3.1 (2-4) or 2.9 (0.3-4) training sessions weekly. KES, 6MWD, and HGS significantly decreased (p < 0.05) in the CG, while there were no changes in the IG. Pre- to post-changes in 6MWD and HGS differed significantly between groups (p < 0.05). QoL declined in both groups (p < 0.05). Our results indicate that a moderate exercise program is feasible and might counteract a treatment-associated decline of physical performance.

Exercise prescription and tailored physical activity intervention in onco-hematology inpatients, a personalized bedside approach to improve clinical best practice

Therapy of hematological malignancies lasts for long periods implicating various complications. The chemotherapy induces fatigue and forces bed rest. These features strongly contribute to a general impairment of the physical efficiency. Oppositely, an increase of physical exercise can prevent or reduce this weakening. Few trials examined the efficacy of an exercise in onco-hematological inpatients, during their hospitalization. Therefore, this study aimed to determine the feasibility of an inter-hospital intervention and the beneficial role of a tailored exercise program in the maintenance of the physical function in onco-hematological inpatients. The study included 42 patients, which were allocated in two groups. In the intervention group (IG) a tailored exercise protocol during patient's hospitalization was administered. Exercise protocol was focused on development of strength, balance control, and flexibility; sessions were directly performed in the patient's hospital room everyday for 15 to 30 minutes. Exercise was supervised by an exercise specialist and driven by a multimedia support. Control group (CG) remained physically inactive for all period of hospitalization. To examine the interaction between the two situations (T₀ and T₁ ) and the two groups (IG and CG) for all dependent variables, a 2 × 2 within-subjects contrasts model analysis of variance was applied. Within groups analysis displayed significant differences in grip and leg strength and in static balance control (P < 0.05) with medium to very large effect size. Results from this investigation showed that a tailored exercise protocol administered to hospitalized onco-hematological patients was feasible and efficient to promote the maintenance of their physical function, improving clinical best practice including exercise to the traditional treatment. Moreover, the magnitude of the difference between the IG and the CG underlined the importance to invite and stimulate patients to workout to preserve the physical function, counteracting side effects of chemotherapy treatments with a concurrent reduction in bed rest syndrome.

Aerobic physical exercise for adult patients with haematological malignancies

BACKGROUND

Although people with haematological malignancies have to endure long phases of therapy and immobility, which is known to diminish their physical performance level, the advice to rest and avoid intensive exercises is still common practice. This recommendation is partly due to the severe anaemia and thrombocytopenia from which many patients suffer. The inability to perform activities of daily living restricts them, diminishes their quality of life and can influence medical therapy.

OBJECTIVES

In this update of the original review (published in 2014) our main objective was to re-evaluate the efficacy, safety and feasibility of aerobic physical exercise for adults suffering from haematological malignancies considering the current state of knowledge.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2018, Issue 7) and MEDLINE (1950 to July 2018) trials registries (ISRCTN, EU clinical trials register and clinicaltrials.gov) and conference proceedings. We did not apply any language restrictions. Two review authors independently screened search results, disagreements were solved by discussion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing an aerobic physical exercise intervention, intending to improve the oxygen system, in addition to standard care with standard care only for adults suffering from haematological malignancies. We also included studies that evaluated aerobic exercise in addition to strength training. We excluded studies that investigated the effect of training programmes that were composed of yoga, tai chi chuan, qigong or similar types of exercise. We also excluded studies exploring the influence of strength training without additive aerobic exercise as well as studies assessing outcomes without any clinical impact.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed the quality of trials. We used risk ratios (RRs) for adverse events, mortality and 100-day survival, standardised mean differences (SMD) for quality of life (QoL), fatigue, and physical performance, and mean differences (MD) for anthropometric measurements.

MAIN RESULTS

In this update, nine trials could be added to the nine trials of the first version of the review, thus we included eighteen RCTs involving 1892 participants. Two of these studies (65 participants) did not provide data for our key outcomes (they analysed laboratory values only) and one study (40 patients) could not be included in the meta-analyses, as results were presented as changes scores only and not as endpoint scores. One trial (17 patients) did not report standard errors and could also not be included in meta-analyses. The overall potential risk of bias in the included trials is unclear, due to poor reporting.The majority of participants suffered from acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), malignant lymphoma and multiple myeloma, and eight trials randomised people receiving stem cell transplantation. Mostly, the exercise intervention consisted of various walking intervention programmes with different duration and intensity levels.Our primary endpoint overall survival (OS) was only reported in one of these studies. The study authors found no evidence for a difference between both arms (RR = 0.67; P = 0.112). Six trials (one trial with four arms, analysed as two sub-studies) reported numbers of deceased participants during the course of the study or during the first 100 to 180 days. For the outcome mortality, there is no evidence for a difference between participants exercising and those in the control group (RR 1.10; 95% CI 0.79 to 1.52; P = 0.59; 1172 participants, low-certainty evidence).For the following outcomes, higher numbers indicate better outcomes, with 1 being the best result for the standardised mean differences. Eight studies analysed the influence of exercise intervention on QoL. It remains unclear, whether physical exercise improves QoL (SMD 0.11; 95% CI -0.03 to 0.24; 1259 participants, low-certainty evidence). There is also no evidence for a difference for the subscales physical functioning (SMD 0.15; 95% CI -0.01 to 0.32; 8 trials, 1329 participants, low-certainty evidence) and anxiety (SMD 0.03; 95% CI -0.30 to 0.36; 6 trials, 445 participants, very low-certainty evidence). Depression might slightly be improved by exercising (SMD 0.19; 95% CI 0.0 to 0.38; 6 trials, 445 participants, low-certainty evidence). There is moderate-certainty evidence that exercise probably improves fatigue (SMD 0.31; 95% CI 0.13 to 0.48; 9 trials, 826 patients).Six trials (435 participants) investigated serious adverse events. We are very uncertain, whether additional exercise leads to more serious adverse events (RR 1.39; 95% CI 0.94 to 2.06), based on very low-certainty evidence.In addition, we are aware of four ongoing trials. However, none of these trials stated, how many patients they will recruit and when the studies will be completed, thus, potential influence of these trials for the current analyses remains unclear.

AUTHORS' CONCLUSIONS

Eighteen, mostly small RCTs did not identify evidence for a difference in terms of mortality. Physical exercise added to standard care might improve fatigue and depression. Currently, there is inconclusive evidence regarding QoL, physical functioning, anxiety and SAEs .We need further trials with more participants and longer follow-up periods to evaluate the effects of exercise intervention for people suffering from haematological malignancies. To enhance comparability of study data, development and implementation of core sets of measuring devices would be helpful.

Physical therapy pathway and protocol for patients undergoing hematopoietic stem cell transplantation: Recommendations from The Eastern Mediterranean Blood and Marrow Transplantation (EMBMT) Group

BACKGROUND

Patients undergoing hematopoietic stem cell transplantation (HSCT) are often referred for physical therapy (PT) to help improve their quality of life. However, to our knowledge there is no clear PT pathway to guide therapists and patients before, during, and after HSCT.

METHODS

A comprehensive literature review was carried out exploring the role and benefits of PT in HSCT patients. The current evidence was comlimented with recommendations and opinions from the experts in the field, which included PT's and hematology consultants from PTAGVHD and the EMBMT group.

RESULT

A clear pathway and protocol as a working guide for rehabilitation professionals working with the HSCT patient's was developed.

CONCLUSION

This paper not only reviews the current evidence on safe PT practice but also puts forward a protocol and pathway for HSCT rehabilitation, highlights the importance of individualized exercise intervention for HSCT patients, and outlines safe practice guidelines for the physical therapists working in this field.

[Stem cell transplantation unit: Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]

Allogeneic hematopoietic cell transplantation (HCT) is part of the standard of care for many hematological diseases. Over the last decades, significant advances in patient and donor selection, conditioning regimens as well as supportive care of patients undergoing allogeneic HCT leading to improved overall survival have been made. In view of many new treatment options in cellular and molecular targeted therapies, the place of allogeneic transplantation in therapy concepts must be reviewed. Most aspects of HCT are well standardized by national guidelines or laws as well as by certification labels such as FACT-JACIE. However, the requirements for human resources, construction and layout of a unit treating patients during the transplantation procedure and for different complications are not well defined. Here, we describe the process of planning a transplant unit in order to open a discussion that could lead to more precise guidelines in the field of personnel and infrastructural requirements for hospitals caring for people with severe immunosuppression.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

A systematic review of the safety and efficacy of aerobic exercise during cytotoxic chemotherapy treatment

PURPOSE

Aerobic exercise improves prognosis and quality of life (QoL) following completion of chemotherapy. However, the safety and efficacy of aerobic exercise during chemotherapy is less certain. A systematic review was performed of randomised trials of adult patients undergoing chemotherapy, comparing an exercise intervention with standard care.

METHOD

From 253 abstracts screened, 33 unique trials were appraised in accordance with PRISMA guidance, including 3257 patients. Interventions included walking, jogging or cycling, and 23 were of moderate intensity (50-80% maximum heart rate).

RESULTS

Aerobic exercise improved, or at least maintained fitness during chemotherapy. Moderately intense exercise, up to 70-80% of maximum heart rate, was safe. Any reported adverse effects of exercise were mild and self-limiting, but reporting was inconsistent. Adherence was good (median 72%). Exercise improved QoL and physical functioning, with earlier return to work. Two out of four studies reported improved chemotherapy completion rates. Four out of six studies reported reduced chemotherapy toxicity. There was no evidence that exercise reduced myelosuppression or improved response rate or survival.

CONCLUSIONS

Exercise during chemotherapy is safe and should be encouraged because of beneficial effects on QoL and physical functioning. More research is required to determine the impact on chemotherapy completion rates and prognosis.