Ellen van Weert

The development of an evidence-based physical self-management rehabilitation programme for cancer survivors

OBJECTIVE This paper describes the development of a physical training programme for cancer patients. Four related but conceptually and empirically distinct physical problems are described: decreased aerobic capacity, decreased muscle strength, fatigue and impaired role physical functioning. The study aimed to identify the optimal content for an exercise programme that addresses these four physical problems, based on the highest level of evidence available. The study further aimed to review the evidence available on the delivery of the programmes. The final goal was to develop a programme in which content and delivery are based on the best available evidence. METHODS Literature searches (PUBMED and MEDLINE, to July 2006) on content looked for evidence about the efficacy of exercise on aerobic capacity, muscle strength, fatigue and impaired role physical functioning. Literature searches on delivery looked for self-management and/or self-efficacy enhancing techniques in relation to outcome, adherence to and/or adoption of a physically active lifestyle. RESULTS Evidence on the effectiveness of exercise in cancer patients varies and increases when moving from muscle strength (RCT level), fatigue and physical role functioning to aerobic capacity (all at the meta-analysis level). Effect sizes for aerobic capacity were moderate, while effect sizes for fatigue and physical role functioning were zero and/or small. Many of the studies have significant methodological shortcomings. There was some evidence (meta-analyses) that self-management programmes and self-efficacy enhancing programmes have beneficial effects on health outcomes in a variety of chronic diseases, on the quality of life in cancer patients, and on exercise adherence and later exercise behaviour. CONCLUSION Limited data are available on the effectiveness of exercise for cancer patients. Although evidence supports the positive effects of exercise on exercise capacity during and after completion of cancer treatment, the effects for fatigue and role functioning are ambiguous. Evidence on the effectiveness of progressive exercise training on muscle strength is promising. In addition, some evidence supports the positive effects of self-management programmes and self-efficacy enhancing programmes on health outcomes, exercise adherence and later exercise behaviour. PRACTICE IMPLICATIONS The resulting programme was developed on the basis of the highest quality of evidence available regarding content and delivery. The content is based on information obtained from the present review, and on the recommendations of the American College of Sports Medicine. Potential advantages of the programme include: (a) tailored physical training towards focusing on the patients established problems and (b) delivery of the training as a self-management programme that might have beneficial effects on health outcome, exercise adherence and a long-term physically active lifestyle.

Quality of Life After Self-Management Cancer Rehabilitation: A Randomized Controlled Trial Comparing Physical and Cognitive-Behavioral Training Versus Physical Training

Objective: To conduct a randomized controlled trial and compare the effects on cancer survivors’ quality of life in a 12-week group-based multidisciplinary self-management rehabilitation program, combining physical training (twice weekly) and cognitive-behavioral training (once weekly) with those of a 12-week group-based physical training (twice weekly). In addition, both interventions were compared with no intervention. Methods: Participants (all cancer types, medical treatment completed ≥3 months ago) were randomly assigned to multidisciplinary rehabilitation (n = 76) or physical training (n = 71). The nonintervention comparison group consisted of 62 patients on a waiting list. Quality of life was measured using the RAND-36. The rehabilitation groups were measured at baseline, after rehabilitation, and 3-month follow-up, and the nonintervention group was measured at baseline and 12 weeks later. Results: The effects of multidisciplinary rehabilitation did not outperform those of physical training in role limitations due to emotional problem (primary outcome) or any other domains of quality of life (all p > .05). Compared with no intervention, participants in both rehabilitation groups showed significant and clinically relevant improvements in role limitations due to physical problem (primary outcome; effect size (ES) = 0.66), and in physical functioning (ES = 0.48), vitality (ES = 0.54), and health change (ES = 0.76) (all p < .01). Conclusions: Adding a cognitive-behavioral training to group-based self-management physical training did not have additional beneficial effects on cancer survivors’ quality of life. Compared with the nonintervention group, the group-based self-management rehabilitation improved cancer survivors’ quality of life. PT = physical training; CBT = cognitive-behavioral training; PT+CBT = physical training plus cognitive-behavioral training; WLC = waiting-list comparison; QoL = quality of life; ANOVA = analysis of variance; ES = effect size.

Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs

This individual patient data meta-analysis aimed to evaluate the effects of exercise on quality of life (QoL) and physical function (PF) in patients with cancer, and to identify moderator effects of demographic (age, sex, marital status, education), clinical (body mass index, cancer type, presence of metastasis), intervention-related (intervention timing, delivery mode and duration, and type of control group), and exercise-related (exercise frequency, intensity, type, time) characteristics. Relevant published and unpublished studies were identified in September 2012 via PubMed, EMBASE, PsycINFO, and CINAHL, reference checking and personal communications. Principle investigators of all 69 eligible trials were requested to share IPD from their study. IPD from 34 randomised controlled trials (n=4519 patients) that evaluated the effects of exercise compared to a usual care, wait-list or attention control group on QoL and PF in adult patients with cancer were retrieved and pooled. Linear mixed-effect models were used to evaluate the effects of the exercise on post-intervention outcome values (z-score) adjusting for baseline values. Moderator effects were studies by testing interactions. Exercise significantly improved QoL (β=0.15, 95%CI=0.10;0.20) and PF (β=0.18, 95%CI=0.13;0.23). The effects were not moderated by demographic, clinical or exercise characteristics. Effects on QoL (βdifference_in_effect=0.13, 95%CI=0.03;0.22) and PF (βdifference_in_effect=0.10, 95%CI=0.01;0.20) were significantly larger for supervised than unsupervised interventions. In conclusion, exercise, and particularly supervised exercise, effectively improves QoL and PF in patients with cancer with different demographic and clinical characteristics during and following treatment. Although effect sizes are small, there is consistent empirical evidence to support implementation of exercise as part of cancer care.

Improved physical fitness of cancer survivors: A randomised controlled trial comparing physical training with physical and cognitive-behavioural training

We compared the effect of a group-based 12-week supervised exercise programme, i.e. aerobic and resistance exercise, and group sports, with that of the same programme combined with cognitive-behavioural training on physical fitness and activity of cancer survivors. One hundred and forty seven cancer survivors (all cancer types, medical treatment ≥3 months ago) were randomly assigned to physical training (PT, n=71) or PT plus cognitive-behavioural training (PT+CBT, n=76). Maximal aerobic capacity, muscle strength and physical activity were assessed at baseline and post-intervention. Analyses using multilevel linear mixed-effects models showed that cancer survivors’ physical fitness increased significantly in PT and PT+CBT from baseline to post-intervention. Changes did not differ between PT and PT+CBT. Physical fitness of cancer survivors was improved following an intensive physical training programme. Adding a structured cognitive-behavioural intervention did not enhance the effect.

Cancer-Related Fatigue and Rehabilitation: A Randomized Controlled Multicenter Trial Comparing Physical Training Combined With Cognitive-Behavioral Therapy With Physical Training Only and With No Intervention

Background Research suggests that cancer rehabilitation reduces fatigue in survivors of cancer. To date, it is unclear what type of rehabilitation is most beneficial. Objective This randomized controlled trial compared the effect on cancer-related fatigue of physical training combined with cognitive behavioral therapy with physical training alone and with no intervention. Design In this multicenter randomized controlled trial, 147 survivors of cancer were randomly assigned to a group that received physical training combined with cognitive-behavioral therapy (PT+CBT group, n=76) or to a group that received physical training alone (PT group, n=71). In addition, a nonintervention control group (WLC group) consisting of 62 survivors of cancer who were on the waiting lists of rehabilitation centers elsewhere was included. Setting The study was conducted at 4 rehabilitation centers in the Netherlands. Patients All patients were survivors of cancer. Intervention Physical training consisting of 2 hours of individual training and group sports took place twice weekly, and cognitive-behavioral therapy took place once weekly for 2 hours. Measurements Fatigue was assessed with the Multidimensional Fatigue Inventory before and immediately after intervention (12 weeks after enrollment). The WLC group completed questionnaires at the same time points. Results Baseline fatigue did not differ significantly among the 3 groups. Over time, levels of fatigue significantly decreased in all domains in all groups, except in mental fatigue in the WLC group. Analyses of variance of postintervention fatigue showed statistically significant group effects on general fatigue, on physical and mental fatigue, and on reduced activation but not on reduced motivation. Compared with the WLC group, the PT group reported significantly greater decline in 4 domains of fatigue, whereas the PT+CBT group reported significantly greater decline in physical fatigue only. No significant differences in decline in fatigue were found between the PT+CBT and PT groups. Conclusions Physical training combined with cognitive-behavioral therapy and physical training alone had significant and beneficial effects on fatigue compared with no intervention. Physical training was equally effective as or more effective than physical training combined with cognitive-behavioral therapy in reducing cancer-related fatigue, suggesting that cognitive-behavioral therapy did not have additional beneficial effects beyond the benefits of physical training.

Promoting physical activity in children with juvenile idiopathic arthritis through an internet-based program: results of a pilot randomized controlled trial

Patients with juvenile idiopathic arthritis (JIA) are less physically active than healthy peers. Therefore, we developed an Internet‐based intervention to improve physical activity (PA). The aim of this study was to examine the effectiveness of the program in improving PA.

Effects of a group-based exercise and educational program on physical performance and disease self-management in rheumatoid arthritis : a randomized controlled study

Background Evidence supports the use of educational and physical training programs for people with rheumatoid arthritis (RA). Objective The purpose of this study was to evaluate the effects of a group-based exercise and educational program on the physical performance and disease self-management of people with RA. Design This was a randomized controlled trial. Setting The study was conducted at a rehabilitation center in the Netherlands. Participants Thirty-four people diagnosed with RA participated in the study. Participants were randomly assigned to either an intervention group (n=19) or a waiting list control group (n=15). Intervention The intervention in this study was an 8-week, multidisciplinary, group therapy program for people with RA, consisting of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) together with an educational program to improve health status and self-efficacy for disease-self-management. Measurements The main outcome measures were maximum oxygen uptake (V̇o2max), muscle strength of the elbow and knee flexors and extensors, health status, and perceived self-efficacy. All data were recorded before intervention in week 1, after intervention in week 9, and at follow-up in week 22. Results The intervention group showed significant improvement (12.1%) in V̇o2max at week 9 compared with the control group (−1.7%). Although significant within-group changes were found over time for muscle strength of the upper and lower extremities and health status that favored the intervention group, no between-group changes were found regarding these outcomes. Limitations An important limitation was the small number of participants included in our study, which may have resulted in a lack of power. Conclusions The present group-based exercise and educational program for people with RA had a beneficial effect on aerobic capacity but not on muscle strength, health status, or self-efficacy.

Health-Related Physical Fitness in Dutch Children With Developmental Coordination Disorder

Objective: To compare components of health-related physical fitness between Dutch children with clinically diagnosed developmental coordination disorder (DCD) and typically developing children (TDC), and to examine associations between motor performance problems and components of health-related fitness in children with DCD. Methods: A multicenter case-control study was used to compare health-related physical fitness in children with DCD (N = 38; age, 7–12 years; 10 girls and 28 boys) with that in age- and gender-matched TDC. Motor coordination problems (manual dexterity, ball and balance skills) were assessed using the Movement Assessment Battery for Children. Health-related physical fitness was indicated by (1) cardiorespiratory fitness, (2) muscle strength, and (3) body mass index. Results: Significantly lower values of cardiorespiratory fitness (6.7% lower maximal cardiorespiratory fitness) were found in children with DCD compared with TDC. Extension and flexion of the elbow and flexion of the knee were also significantly lower (by 15.3%, 16.7%, and 18.4%, respectively) in DCD children compared with TDC. A significant negative and large association was found between cardiorespiratory fitness and balance performance. Conclusion: Lower cardiorespiratory fitness and muscle strength in children with clinically diagnosed DCD compared with TDC support the importance of examining and training cardiorespiratory fitness and muscle strength, besides the regular attention for motor coordination problems.

Effects of cancer rehabilitation on problem-solving, anxiety and depression: A RCT comparing physical and cognitive-behavioural training versus physical training

We tested the effects on problem-solving, anxiety and depression of 12-week group-based self-management cancer rehabilitation, combining comprehensive physical training (PT) and cognitive-behavioural problem-solving training (CBT), compared with PT. We expected that PT + CBT would outperform PT in improvements in problem-solving (Social Problem-Solving Inventory-Revised (SPSI-R)), anxiety and depression (Hospital Anxiety and Depression Scale (HADS)), and that more anxious and/or depressed participants would benefit most from adding CBT to PT. Cancer survivors (aged 48.8 ± 10.9 years, all cancer types, medical treatment completed) were randomly assigned to PT + CBT (n = 76) or PT (n = 71). Measurement occasions were: before and post-rehabilitation (12 weeks), 3- and 9-month follow-up. A non-randomised usual care comparison group (UCC) (n = 62) was measured at baseline and after 12 weeks. Longitudinal intention-to-treat analyses showed no differential pattern in change between PT + CBT and PT. Post-rehabilitation, participants in PT and PT + CBT reported within-group improvements in problem-solving (negative problem orientation; p < 0.01), anxiety (p < 0.001) and depression (p < 0.001), which were maintained at 3- and 9-month follow-up (p < 0.05). Compared with UCC post-rehabilitation, PT and PT + CBT only improved in anxiety (p < 0.05). CBT did not add to the effects of PT and had no extra benefits for higher distressed participants. PT was feasible and sufficient for durably reducing cancer survivors’ anxiety.

Relationship Between Participation in Leisure Time Physical Activities and Aerobic Fitness in Children With DCD

Purpose: (1) To explore participation in leisure time physical activities (LTPAs) in children with developmental coordination disorder (DCD) compared with children developing typically. (2) To examine the association between participation in LTPA and aerobic fitness. Methods: Thirty-eight children with DCD (aged 7–12 years) were age and gender matched with 38 children developing typically. Participation in LTPA was self-administered by using an activity questionnaire, and aerobic fitness was estimated using a Shuttle Run Test. Results: Children with DCD spent significantly less time in overall, nonorganized, and vigorous LTPA compared with children developing typically. Aerobic fitness was significantly lower for children with DCD. The best model, including age, group, and overall LTPA, explained 46.2% of the variance in aerobic fitness. Conclusions: Suitable physical activities should be fostered in children with DCD, who have a low participation rate and aerobic fitness level.