Measurement of physical activity in clinical practice and research: advances in cancer and chronic respiratory disease

Pain management in advanced cancer: physical activity as an outcome - accelerometer feasibility study

OBJECTIVE

Cancer pain is a common distressing symptom. Numerical Pain Scales (NPS) assess pain but lack information about function and quality of life. This feasibility study assesses the use of triaxial accelerometers to measure function as an outcome measure in pain studies in advanced cancer.

METHODS

Advanced cancer participants were recruited from two palliative care services, with an average pain score of ≥3 on NPS. ActiGraph wGT3X-BT Accelerometers were worn for 1 week on the wrist. Patients recorded daily pain scores, Edmonton Symptom Assessment Scale (ESAS) scores, and their daily opioid use.

RESULTS

24 participants were recruited. A total of 142 days of accelerometer data was collected (5.9 days/participant). The average daily step count was 5723.7. The average acceleration was 14.4 milligravity units/day. An average of 93 min/day total activity across all intensities was recorded. No correlation was seen between acceleration or average daily minutes in activity and total daily oral morphine equivalent, ESAS, 'average pain' score or 'worst pain' scores using spearman's correlation coefficients. Overall, participants were satisfied with the study.

CONCLUSIONS

Accelerometers are a feasible method to measure activity as an outcome measure in advanced cancer. Further study is required to assess the impact of pain management strategies on function.

Physical function endpoints in cancer cachexia clinical trials: Systematic Review 1 of the cachexia endpoints series

In cancer cachexia trials, measures of physical function are commonly used as endpoints. For drug trials to obtain regulatory approval, efficacy in physical function endpoints may be needed alongside other measures. However, it is not clear which physical function endpoints should be used. The aim of this systematic review was to assess the frequency and diversity of physical function endpoints in cancer cachexia trials. Following a comprehensive electronic literature search of MEDLINE, Embase and Cochrane (1990-2021), records were retrieved. Eligible trials met the following criteria: adults (≥18 years), controlled design, more than 40 participants, use of a cachexia intervention for more than 14 days and use of a physical function endpoint. Physical function measures were classified as an objective measure (hand grip strength [HGS], stair climb power [SCP], timed up and go [TUG] test, 6-min walking test [6MWT] and short physical performance battery [SPPB]), clinician assessment of function (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group-Performance Status [ECOG-PS]) or patient-reported outcomes (physical function subscale of the European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaires [EORTC QLQ-C30 or C15]). Data extraction was performed using Covidence and followed PRISMA guidance (PROSPERO registration: CRD42022276710). A total of 5975 potential studies were examined and 71 were eligible. Pharmacological interventions were assessed in 38 trials (54%). Of these, 11 (29%, n = 1184) examined megestrol and 5 (13%, n = 1928) examined anamorelin; nutritional interventions were assessed in 21 trials (30%); and exercise-based interventions were assessed in 6 trials (8%). The remaining six trials (8%) assessed multimodal interventions. Among the objective measures of physical function (assessed as primary or secondary endpoints), HGS was most commonly examined (33 trials, n = 5081) and demonstrated a statistically significant finding in 12 (36%) trials (n = 2091). The 6MWT was assessed in 12 trials (n = 1074) and was statistically significant in 4 (33%) trials (n = 403), whereas SCP, TUG and SPPB were each assessed in 3 trials. KPS was more commonly assessed than the newer ECOG-PS (16 vs. 9 trials), and patient-reported EORTC QLQ-C30 physical function was reported in 25 trials. HGS is the most commonly used physical function endpoint in cancer cachexia clinical trials. However, heterogeneity in study design, populations, intervention and endpoint selection make it difficult to comment on the optimal endpoint and how to measure this. We offer several recommendations/considerations to improve the design of future clinical trials in cancer cachexia.

Dietary Patterns and Their Associations with Symptom Levels Among People with Multiple Sclerosis: A Real-World Digital Study

INTRODUCTION

The objective of the study was to investigate long-term food intake patterns and establish possible associations between the inferred dietary habits and levels of reported symptoms among people with multiple sclerosis (MS) in Denmark.

METHODS

The present study was designed as a prospective cohort study. Participants were invited to register daily food intake and MS symptoms and were observed during a period of 100 days. Dropout and inclusion probabilities were addressed using generalized linear models. Dietary clusters were identified among 163 participants using hierarchical clustering on principal component scores. Associations between the dietary clusters and the levels of self-assessed MS symptoms were estimated using inverse probability weighting. Furthermore, the effect of a person's position on the first and second principal dietary component axis on symptom burden was investigated.

RESULTS

Three dietary clusters were identified: a Western dietary cluster, a plant-rich dietary cluster and a varied dietary cluster. Analyses further indicated a vegetables-fish-fruit-whole grain axis and a red-meat-processed-meat axis. The plant-rich dietary cluster showed reduction in symptom burden in nine pre-defined MS symptoms compared to the Western dietary cluster (between 19 and 90% reduction). This reduction was significant for pain and bladder dysfunction as well as across all nine symptoms (pooled p value = 0.012). Related to the two dietary axes, high intake of vegetables resulted in 32-74% reduction in symptom burden compared to low levels of vegetable intake. Across symptoms, this was significant (pooled p value = 0.015), also regarding walking difficulty and fatigue.

CONCLUSIONS

Three dietary clusters were identified. Compared to levels of self-assessed MS-related symptoms, and adjusted for potential confounders, the results suggested less symptom burden with increased intake of vegetables. Although the research design limits the possibilities of establishing causal inference, the results indicate that general guidelines for healthy diet may be relevant as a tool in coping with MS symptoms.

Potentials and barriers of using digital tools for collecting daily measurements in multiple sclerosis research

Objective

Digital tools offer new ways of collecting outcome data in intervention research. Little is known about the potentials and barriers of using such tools for outcome measurement in multiple sclerosis trials. This study aimed to examine reporting adherence and barriers experienced by people with multiple sclerosis in an intervention study using three different digital tools for outcome measurement.

Methods

This was a mixed-methods study conducted in the context of a randomized controlled trial. Data collected during the randomized controlled trial were analysed to assess reporting adherence. Twenty-three semi-structured, in-depth interviews were conducted to investigate randomized controlled trial participants’ experiences.

Results

Reporting adherence was high for all three measurement tools, but lower in the control group. Four main barriers were defined: (1) the self-monitoring aspect and repeated tests imbedded in the digital tools affected participants’ behavior during the randomized controlled trial. (2) Self-monitoring caused some participants to worry more about their health. (3) Passively collected data did not always correspond with participants’ own experiences, which caused them to question the validity of the collected data. (4) Daily reporting using different digital tools placed a significant burden on participants.

Conclusion

The study indicates a high reporting adherence using digital tools among people with multiple sclerosis. However, future studies should carefully consider the overall burden imposed on participants when taking this approach. Measures should be taken to avoid the potential unintended effects of the self-monitoring and gamification aspects of using digital tools. These measures could include passive monitoring, reducing the frequency of reporting and blinding participants to their own data.

Combined exercise and nutritional rehabilitation in outpatients with incurable cancer: a systematic review

PURPOSE

The optimal components for rehabilitation in patients with incurable cancer are unclear. However, principles of exercise and nutrition-based interventions used in cancer cachexia may be applied usefully to this population of cancer patients. This systematic review examines current evidence for rehabilitation combining exercise and nutritional support in patients with incurable cancer.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched. Eligible studies included patients with incurable cancer and rehabilitation programmes combining exercise and nutritional interventions. Studies of cancer survivors, curative treatments, reviews, case note reviews, protocols and abstracts were excluded. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied to patient-important outcomes.

RESULTS

Of the 2424 search results, 67 abstracts were reviewed and 24 full texts examined. Eight studies (n = 685) were included comprising two randomised control trials, three prospective, one exploratory and two secondary analyses. All examined multi-modal outpatient programmes. GRADE analysis revealed moderate evidence (B) for improvements in depression and physical endurance, low-quality evidence (C) for quality of life and fatigue and very low-quality evidence (D) for overall function and nutritional status.

CONCLUSION

There are limited data for multi-modal rehabilitation programmes combining exercise and nutritional interventions in patients with incurable cancer. However, studies to date report improvements in multiple domains, most notably physical endurance and depression scores. This supports the concept that multi-modal rehabilitation incorporating principles of cachexia management may be appropriate for the wider group of patients with incurable cancer. Further, high-quality studies are needed to define the optimal approach and outcome measures.