Fatigue is among the most frequently reported side effects of chemotherapy and results in impaired or diminished physical activity. Fatigue during cancer therapy may result from extreme muscular decon¬ditioning caused by disease and treatment as well as a sedentary lifestyle. Prevention and treat¬ment of fatigue in patients undergoing chemotherapy are complicated and often ineffective. Exercise training has been introduced to improve physical capacity and quality of life and to reduce fatigue; however, few intervention studies have included patients who were undergoing chemotherapy and the evidence to support exercise training during chemotherapy is modest. A 2006 Cochrane meta-analysis found the asso¬ciation between exercise and fatigue to be insignificant and inconclusive in patients with breast cancer undergoing adjuvant chemotherapy owing to lack of evaluable studies.1
Adamsen and colleagues2 conducted a randomized controlled trial of 269 patients with cancer who were undergoing adjuvant chemotherapy or treatment for advanced disease at two university hospitals in Copenhagen, Denmark. The participants included 73 men, 196 women, mean age 47 years (range 20-65) and represented 21 cancer diagnoses. Patients with brain or bone metastases were excluded from the trial.
Purpose
The trial was designed to assess the effect of a multimodal group exercise intervention, as an adjunct to conventional care, on fatigue, physical capacity, general wellbeing, physical activity, and quality of life in patients with cancer who were undergoing adjuvant chemotherapy or treatment for advanced disease.
Outcome Measures
Participants’ quality of life was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). Physical effects were measured by the Medical Outcomes Study Short Form (MOS SF-36), Leisure Time Physical Activity Questionnaire, muscular strength (one repetition maximum), and maximum oxygen consumption (VO2max).
Intervention Group
Participants assigned to the intervention group received standard medical care while participating in a group based multimodal high and low intensity exercise intervention. The intervention consisted of three 90 min high intensity physical training sessions followed by 30 min relaxation training, plus one 90 min session of body awareness training followed by 30 min of relaxation training each week. The intervention was undertaken over a six week period for nine hours per week, equal to 43 metabolic equivalent of task (MET) hours per week. The high intensity physical training sessions comprised three components: 30 min warm-up exer¬cises, 45 min resistance training, and 15 min cardio¬vascular training. Low intensity physical training comprised three psy¬chosocial components: relaxation, body awareness and restorative training, and massage.
Control Group
Participants assigned to the control group received standard medical care and were allowed to increase physical activity as desired.
Results
The intervention group showed an estimated improvement at six weeks for the primary outcome, fatigue, of estimated mean difference of -6.6 points (95% confidence interval -12.3 to -0.9, P=0.02)
Other significant effects (estimated mean differences):
- Vitality scores = 8.8 (95% CI 4.4 to 13.1), P <0.0001
- Physical functioning scores = 4.4 (95% CI 1.1 to 7.7) P = 0.01
- Role physical scores = 12.4 (95% CI 3.4 to 21.5) P = 0.0007
- Role emotional scores = 12.0 (95% CI 1.9 to 22.0) P = 0.02
- Mental health scores = 3.3 (95% CI 0.2 to 6.4) P = 0.04
Participants assigned to the control group received standard medical care and were allowed to increase physical activity as desired.
Improvement was noted in physical capacity. Estimated mean difference between groups:
- VO2max was 0.16 l/min (95% CI 0.1 to 0.2, P<0.0001)
- Muscular strength (leg press) was 29.7 kg (95% CI 23.4 to 34.9, P<0.0001)
No significant effect was seen on global health status/quality of life. The effect size of the improvement in fatigue (0.33) sug¬gests a small to medium clinically important change.
Discussion & Implications for Nursing Practice
Men and women with a broad range of ages, cancer diagnoses, disease statuses, and chemotherapy regimens participated in this study and showed broad effects of participating in multimodal high intensity exercise, relaxation, body awareness training, and massage. Significant effects on fatigue, vitality, physical functioning, role functioning, role emotional, mental health, physical component scale, and mental component scale, and physical capacity were noted by the investigators, while global health status/quality of life and symptom scales did not show improvement. The primary outcome, fatigue, was the most fre¬quently reported symptom; 65% of the study popula¬tion reported a fatigue level greater than that of the general population at baseline and 29% reported severe fatigue.
Limitations of this study included an adherence rate of 70.8% and a dropout rate of 12.7%. Self selection of participants may have resulted in a population who were overly motivated to engage in group based physical activity.
The authors concluded that high intensity exercise can be undertaken safely by such patients and is associated with physiological, functional, and emotional benefits. This intervention, however, does not improve overall health status or quality of life. Nurses who advise patients to increase self-directed exercise during cancer chemotherapy should be aware that this study used a multidisciplinary team to monitor patients during group exercise and that unsupervised exercise may not be as safe as the program outlined in this study.
References
- Markes M, Brockow T, Resch KL. Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database Syst Rev. 2006;4:CD005001. Available at http://www.cochrane.org/reviews/en/ab005001.html
- Adamsen L, Quist M, Andersen C, et al. Effect of a multimodal high intensity exercise intervention in cancer patients undergoing chemotherapy: Randomized controlled trial. BMJ. 2009;339:b3410. Full text available without charge at http://www.bmj.com/cgi/reprint/339/oct13_1/b3410