Ruud H. Knols

Physical Exercise in Cancer Patients During and After Medical Treatment: A Systematic Review of Randomized and Controlled Clinical Trials

PURPOSE To systematically review the methodologic quality of, and summarize the evidence from trials examining the effectiveness of physical exercise in improving the level of physical functioning and psychological well-being of cancer patients during and after medical treatment. METHODS Thirty-four randomized clinical trials (RCTs) and controlled clinical trials were identified, reviewed for substantive results, and assessed for methodologic quality. RESULTS Four of 34 trials met all (seven of seven) methodologic criteria on the Delphi criteria list. Failure to conceal the sequencing of treatment allocation before patient recruitment, failure to blind the outcome assessor, and failure to employ an intention-to-treat analysis strategy were the most prevalent methodologic shortcomings. Various exercise modalities have been applied, differing in content, frequency, intensity, and duration. Positive results have been observed for a diverse set of outcomes, including physiologic measures, objective performance indicators, self-reported functioning and symptoms, psychological well-being, and overall health-related quality of life. CONCLUSION The trials reviewed were of moderate methodologic quality. Together they suggest that cancer patients may benefit from physical exercise both during and after treatment. However, the specific beneficial effects of physical exercise may vary as a function of the stage of disease, the nature of the medical treatment, and the current lifestyle of the patient. Future RCTs should use larger samples, use appropriate comparison groups to rule out the possibility of an attention-placebo effect, use a comparable set of outcome measures, pay greater attention to issues of motivation and adherence of patients participating in exercise programs, and examine the effect of exercise on cancer survival.

Reproducibility of an Isokinetic Strength-Testing Protocol of the Knee and Ankle in Older Adults

Background: Muscle power assessed by isokinetic dynamometers has the potential for playing an important role in investigating functional status in older subjects. Researchers and clinicians are interested in the reliability of isokinetic test protocols for the confidential assessment of status, as this affects the interpretation of the results of an intervention program. Objective: The current study investigated the inter- and intrarater reliability of an isokinetic strength-testing protocol of the knee and ankle preceded by a familiarization session. Methods: Twenty-four independently living elderly subjects (6 males, 18 females, mean age 71.2 ± 5.5 years) were assessed 3 times in two test sessions. The main outcomes were the intraclass correlation coefficient, standard error of measurements (SEM) and ratio of limits of agreement (RLOA) for isokinetic knee and ankle contractions, as measured with the Biodex System 3. Results: The intraclass correlation coefficients of the isokinetic variables varied from 0.81 to 0.99 representing ‘good’ to ‘very good’ reliability. Most SEM and RLOA indexes represented acceptable agreement which varied from 6 to 13 and 18 to 37%, respectively. Nonacceptable agreement was found for ankle plantar flexion with SEMs that varied from 14 to 17% and RLOAs from 39 to 48%. Conclusion: The results of this study demonstrate that the Biodex System 3 is a reliable device when used for elderly living independently. The ability of the device to determine a real change in isokinetic ankle and knee contractions is better on a group level than on an individual level. The Biodex System 3 can be employed with confidence in studies to determine the effect of exercise intervention programs on physical activity.

Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis

BackgroundPrevious studies have shown the beneficial effects of aerobic exercise in chronic stroke. Most motor and functional recovery occurs in the first months after stroke. Improving cardiovascular capacity may have potential to precipitate recovery during early stroke rehabilitation. Currently, little is known about the effects of early cardiovascular exercise in stroke survivors. The aim of this systematic review was to evaluate the effectiveness of cardiovascular exercise early after stroke.MethodsA systematic literature search was performed. For this review, randomized and non-randomized prospective controlled cohort studies using a cardiovascular, cardiopulmonary or aerobic training intervention starting within 6 months post stroke were considered. The PEDro scale was used to detect risk of bias in individual studies. Inter-rater agreement was calculated (kappa). Meta-analysis was performed using a random-effects model.ResultsA total of 11 trials were identified for inclusion. Inter-rater agreement was considered to be “very good” (Kappa: 0.81, Standard Error: 0.06, CI95%: 0.70–0.92), and the methodological quality was “good” (7 studies) to “fair” (4 studies). Peak oxygen uptake data were available for 155 participants. Pooled analysis yielded homogenous effects favouring the intervention group (standardised mean difference (SMD) = 0.83, CI95% = 0.50–1.16, Z = 4.93, P < 0.01). Walking endurance assessed with the 6 Minute Walk Test comprised 278 participants. Pooled analysis revealed homogenous effects favouring the cardiovascular training intervention group (SMD = 0.69, CI95% = 0.45–0.94, Z = 5.58, P < 0.01). Gait speed, measured in 243 participants, did not show significant results (SMD = 0.51, CI95% = −0.25–1.26, Z = 1.31, P = 0.19) in favour of early cardiovascular exercise.ConclusionThis meta-analysis shows that stroke survivors may benefit from cardiovascular exercise during sub-acute stages to improve peak oxygen uptake and walking distance. Thus, cardiovascular exercise should be considered in sub-acute stroke rehabilitation. However, concepts to influence and evaluate aerobic capacity in severely affected individuals with sub-acute stroke, as well as in the very early period after stroke, are lacking.Further research is needed to develop appropriate methods for cardiovascular rehabilitation early after stroke and to evaluate long-term effects of cardiovascular exercise on aerobic capacity, physical functioning, and quality-of-life.

Wearable Systems for Monitoring Mobility-Related Activities in Chronic Disease: A Systematic Review

The use of wearable motion sensing technology offers important advantages over conventional methods for obtaining measures of physical activity and/or physical functioning in individuals with chronic diseases. This review aims to identify the actual state of applying wearable systems for monitoring mobility-related activity in individuals with chronic disease conditions. In this review we focus on technologies and applications, feasibility and adherence aspects, and clinical relevance of wearable motion sensing technology. PubMed (Medline since 1990), PEdro, and reference lists of all relevant articles were searched. Two authors independently reviewed randomised trials systematically. The quality of selected articles was scored and study results were summarised and discussed. 163 abstracts were considered. After application of inclusion criteria and full text reading, 25 articles were taken into account in a full text review. Twelve of these papers evaluated walking with pedometers, seven used uniaxial accelerometers to assess physical activity, six used multiaxial accelerometers, and two papers used a combination approach of a pedometer and a multiaxial accelerometer for obtaining overall activity and energy expenditure measures. Seven studies mentioned feasibility and/or adherence aspects. The number of studies that use movement sensors for monitoring of activity patterns in chronic disease (postural transitions, time spent in certain positions or activities) is nonexistent on the RCT level of study design. Although feasible methods for monitoring human mobility are available, evidence-based clinical applications of these methods in individuals with chronic diseases are in need of further development.

Effects of an outpatient physical exercise program on hematopoietic stem-cell transplantation recipients: a randomized clinical trial

Patients who undergo hematopoietic SCT (HSCT) often experience physical and psychological problems, even long after treatment has been completed. This study was performed to evaluate the effects of a 12-week outpatient physical exercise (PE) program, incorporating aerobic and strength exercises, as compared with a usual care control condition on patients’ physical performance and psychosocial well-being. Patients who had completed HSCT up to 6 months earlier were randomly assigned to a supervised PE program (n=64) or a usual care control group (n=67). Primary outcomes were quantified physical performance and self-reported physical functioning. Secondary outcomes were body composition measurement, quantified walking activity and patient-reported outcomes (physical activity, fatigue and health-related quality of life). Assessments were at baseline, immediately after program completion and at 3-month follow-up. Significant intervention effects were observed at both posttreatment and follow-up on physical performance measures. No other outcomes yielded statistically significant group differences. PE should be considered in the management of HSCT recipients to improve physical performance after discharge from the hospital. Further research is needed to determine how the program can be enhanced so that improved physical performance also translates into improved physical and psychosocial functioning in daily life.

Application of principles of exercise training in sub-acute and chronic stroke survivors: a systematic review

BackgroundThere is increasing evidence for the beneficial effects of exercise training in stroke survivors. In order to reach the desired training effects, exercise training principles must be considered as this ensures the prescription of adequate exercises at an adequate dose. Moreover, exercise training interventions must be designed in a way that maximizes patients’ adherence to the prescribed exercise regimen. The objectives of this systematic review were (1) to investigate whether training principles for physical exercise interventions are reported in RCTs for sub-acute and chronic stroke survivors, (2) to evaluate whether the RCTs reported the prescription of the FITT components of the exercise interventions as well as (3) patients’ adherence to this prescription, and (4) to assess the risk of bias of the included studies.MethodsWe performed a systematic review of RCTs with exercise training as the primary intervention and muscular strength and/or endurance as primary outcomes. The Cochrane library’s risk of bias (ROB) tool was used to judge the methodological quality of RCTs.ResultsThirty-seven RCTs were included in this systematic review. Eighteen studies (48.7%) focused on aerobic, 8 (21.6%) on resistance and 11 (29.7%) on combined interventions of aerobic and resistive strength exercise. Twenty-nine studies (78.4%) included only chronic stroke survivors, 5 studies (13.5%) only sub-acute stroke survivors whilst 3 studies (8.1%) included both. In terms of principle of exercise training, 89% reported specificity, 75.7% progression, 48.7% overload, 37.8% initial values, 32.4% reversibility and 13.5% diminishing returns. One RCT described all principles of physical exercise training and 19 (51.4%) all FITT components. Patients’ adherence to exercise prescription was accounted for in 3 studies (8.1%). Failure to report blinding in patients and participants and failure to report allocation concealment were the most prevalent methodological shortcomings.ConclusionsIncomplete and inconsistent reporting of (1) training components, (2) underlying exercise training principles and (3) patient adherence together with (4) a broad variation in the methodological quality of the included RCTs limit both the utility and reproducibility of physical exercise programs in stroke patients.

Treatment of Knee Osteoarthritis with Oral Chondroitin Sulfate

Publisher Summary Knee osteoarthritis (OA) is a frequent chronic musculoskeletal condition, encountered mostly in elderly people. The therapeutic approaches of knee OA is based on both nonpharmacological and pharmacological therapies. Regarding the pharmacological therapies, there is now a large panel of evidence to support the use of symptomatic slow‐acting drugs for OA (SYSADOA) that is a generic term used for those medications for OA acting on the symptoms of the disease with delayed onset, reducing pain, improving both the joint function and the overall mobility of the patients, and having, in addition, a remanent effect when the administration is stopped. Among them, orally administered chondroitin sulfate (CS) is of special interest in the indication of knee OA, a condition in which a couple of randomized controlled trials (RCTs) have been performed in the last 20 years. Based upon a survey of 11 RCTs, the data available from three published meta‐analyses and the latest European League against Rheumatism (EULAR) recommendations for the management of knee OA, it can be concluded that the long‐term administration of oral CS is safe, well tolerated, and well indicated to control the symptoms of pain and increase the overall mobility of patients suffering from knee OA.

Reliability of Ambulatory Walking Activity in Patients With Hematologic Malignancies

OBJECTIVES To determine the relative and absolute reliability of the assessment of ambulatory walking activity during 2 consecutive weeks in patients with hematologic malignancies recovering at home from their medical treatment and to compare the physical activity level of hematologic cancer patients after high-dose chemotherapy with healthy subjects. DESIGN Test-retest study of 2 consecutive 7-day recordings using the microprocessor-based step accelerometer 3 (SAM3). SETTING Home and community. PARTICIPANTS Patients (n=23) with hematologic malignancies recovering from high-dose chemotherapy and healthy controls (n=30). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The intraclass correlation coefficient (ICC(3,1)) and its 95% confidence interval (CI), SE of measurement procedure and its 95% CI, the smallest detectable difference (SDD), the coefficient of variation (CV), and t tests for the variables total steps and peak activity. RESULTS The day-to-day and week-to-week CVs for walking activity and peak activity were 35.17% and 13.17% and 18.61% and 6.90%, respectively. For relative reliability, the ICCs for 2 consecutive 7-day recordings including the 95% CI for total steps and peak activity were 0.90 (95% CI, 0.75-0.98) and 0.85 (95% CI, 0.66-0.94), respectively. The absolute reliability for total steps and peak activity including the SE of measurement procedure and the 95% CI were 564 (95% CI, +/-1106) and 2.42 steps (95% CI, +/-4.74), respectively, for 2 consecutive 7-day recordings. The week-to-week SDD was 1564 for total steps and 6.70 for peak activity. The 7-day mean for total step activity was 5355 for the patients with hematologic malignancies and 6364 for healthy subjects (P<0.05). CONCLUSIONS The results of this study indicate that there is good relative reliability for the assessment of 2 consecutive 7-day recordings of ambulatory walking activity, and it showed that the SDD derived from this sample may be useful in detecting changes in daily walking activity in hematologic cancer patients who are recovering from intensive medical treatment. The study also documented compromised levels of ambulatory walking activity among hematologic cancer patients recovering from high-dose chemotherapy as compared with healthy controls.

Chondroitin sulfate as a structure-modifying agent.

Publisher Summary The disease‐ or structure‐modifying effects of chondroitin sulfate (CS) have been the focus of only a small number of studies performed in vitro or in vivo in animal models of osteoarthritis (OA) or joint degradation in the last decades. Some randomized controlled trials (RCTs) conducted on humans have integrated this feature as a primary or secondary evaluation outcome. The results of the survey conducted allowed the identification of six RCTs performed in both knee OA and finger‐joint OA. Only two groups, one in Belgium and one in Switzerland, have conducted these human studies. Based upon the results of these trials, it may be concluded that the daily oral administration of 800–1200 mg of chondroitin 4‐ and 6‐sulfate appears to be able to limit or even stop the radiological progression of both femoro‐tibial knee OA and interphalangeal finger OA in a time frame of a minimum of 1 year to up to 3 years of continuous or intermittent administration of the compound.

Exercise and other non-pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis

Aim To assess the relative effects of different types of exercise and other non-pharmaceutical interventions on cancer-related fatigue (CRF) in patients during and after cancer treatment. Design Systematic review and indirect-comparisons meta-analysis. Data sources Articles were searched in PubMed, Cochrane CENTRAL and published meta-analyses. Eligibility criteria for selecting studies Randomised studies published up to January 2017 evaluating different types of exercise or other non-pharmaceutical interventions to reduce CRF in any cancer type during or after treatment. Study appraisal and synthesis Risk of bias assessment with PEDro criteria and random effects Bayesian network meta-analysis. Results We included 245 studies. Comparing the treatments with usual care during cancer treatment, relaxation exercise was the highest ranked intervention with a standardisedmean difference (SMD) of −0.77 (95% Credible Interval (CrI) −1.22 to −0.31), while massage (−0.78; −1.55 to −0.01), cognitive–behavioural therapy combined with physical activity (combined CBT, −0.72; −1.34 to −0.09), combined aerobic and resistance training (−0.67; −1.01 to −0.34), resistance training (−0.53; −1.02 to −0.03), aerobic (−0.53; −0.80 to −0.26) and yoga (−0.51; −1.01 to 0.00) all had moderate-to-large SMDs. After cancer treatment, yoga showed the highest effect (−0.68; −0.93 to −0.43). Combined aerobic and resistance training (−0.50; −0.66 to −0.34), combined CBT (−0.45; −0.70 to −0.21), Tai-Chi (−0.45; −0.84 to −0.06), CBT (−0.42; −0.58 to −0.25), resistance training (−0.35; −0.62 to −0.08) and aerobic (−0.33; −0.51 to −0.16) showed all small-to-moderate SMDs. Conclusions Patients can choose among different effective types of exercise and non-pharmaceutical interventions to reduce CRF.