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"Local initiatives developing "Local initiatives developing exercise programmes for exercise programmes for
cancer patients"cancer patients"
Louise BallagherLouise BallagherSenior PhysiotherapistSenior Physiotherapist
Oncology and HaematologyOncology and HaematologyRD&E Foundation TrustRD&E Foundation Trust
July 21July 21stst 2011 2011
Aims
To establish exercise programmes for To establish exercise programmes for patients receiving treatment for cancerpatients receiving treatment for cancer Jones & Courneya 2002Jones & Courneya 2002
To review the use of a Physiotherapy To review the use of a Physiotherapy Technical Instructor in the prescribing and Technical Instructor in the prescribing and monitoring of exercise programmes for monitoring of exercise programmes for Haematology patients in isolationHaematology patients in isolation
Common Symptoms of Common Symptoms of cancer treatmentcancer treatment
Fatigue / decreased energy levelsFatigue / decreased energy levels 70%70%
Decreased muscle strengthDecreased muscle strength Decreased functional statusDecreased functional status NauseaNausea PainPain Body image problemsBody image problems Sleep disturbancesSleep disturbances Depression and anxiety Depression and anxiety
20-50%20-50%
Positive effects of exercisePositive effects of exercise
Reduces stress on the heart and Reduces stress on the heart and blood vesselsblood vessels
Increases ability of heart and lungs Increases ability of heart and lungs to deliver oxygen efficiently to the to deliver oxygen efficiently to the working tissuesworking tissues
Increases muscular strength and Increases muscular strength and enduranceendurance
Improves immune systemImproves immune system Improves mood, body image and Improves mood, body image and
sleep patternssleep patterns Improves quality of life both Improves quality of life both
physically and emotionallyphysically and emotionally
““Evidence is accumulating that exercise Evidence is accumulating that exercise is beneficial for cancer sufferersis beneficial for cancer sufferers””
Cancer Level of Evidence
Strength of evidence
Colon High Strong
Rectal Medium No effect
Breast High Moderate
Lung Low Moderate
Prostate Medium Equivocal
Overall Medium Moderate
Others Low Equivocal
Research - Fatigue
Speck et al (2010)Speck et al (2010) Meta analysis – Concluded that physical Meta analysis – Concluded that physical
activity significantly reduced fatigue post Rx.activity significantly reduced fatigue post Rx. 14 studies- 93% positive, 50% statistically 14 studies- 93% positive, 50% statistically
significantsignificant
Dimeo et al (2008)Dimeo et al (2008) 32 pts; 3 week programme of endurance 32 pts; 3 week programme of endurance
training training 25% 25% in fatigue; 28% in fatigue; 28% in in exercise capacityexercise capacity
ResearchResearch
Quality of LifeQuality of Life Courneya et al (2005)Courneya et al (2005)
studies concluded that exercise had significant studies concluded that exercise had significant positive effects on the QOL of cancer patientspositive effects on the QOL of cancer patients
NauseaNausea Lee et al (2008) Lee et al (2008)
Moderate aerobic exercise is related to less intense Moderate aerobic exercise is related to less intense nauseanausea
ResearchResearch
Neutropenia / thrombocytopeniaNeutropenia / thrombocytopenia Dimeo et al (1997) Dimeo et al (1997)
RCT on bone marrow transplant patients undergoing RCT on bone marrow transplant patients undergoing high-dose chemotherapyhigh-dose chemotherapy
Duration of neutropenia and thrombocytopenia was Duration of neutropenia and thrombocytopenia was reduced in the exercise groupreduced in the exercise group
Recurrence / survivalRecurrence / survival Meyerhardt et al (2006)Meyerhardt et al (2006)
Cancer specific death was 60% lower in women who Cancer specific death was 60% lower in women who exercised 6 or more hours a week (walking at exercised 6 or more hours a week (walking at average pace)average pace)
If there is one If there is one message from the message from the evidence it is:evidence it is:
Rest is NOT alwaysNOT always best
““STAY ACTIVE”STAY ACTIVE”
Problems facing haematology Problems facing haematology patientspatients
Intensive and lengthy Intensive and lengthy chemotherapy regimes, chemotherapy regimes, often HSCT.often HSCT.
Frequent hospital Frequent hospital admissions often in admissions often in isolationisolation
Side effects of RxSide effects of Rx
De-conditioningDe-conditioning
Reduced QOLReduced QOL
Low morale / low Low morale / low motivationmotivation
The Wii!
“ “ There is growing evidence There is growing evidence of the benefits of the Wii, of the benefits of the Wii, and physiotherapists are and physiotherapists are looking into outcomes looking into outcomes with their patients. There with their patients. There is definitely evidence that is definitely evidence that they are of benefit” they are of benefit”
Professional Adviser
Chartered Society of Physiotherapy 2008
The introduction of the Wii
ELF donationELF donation Wii sport and Wii fitWii sport and Wii fit Study Jan 09- July 09Study Jan 09- July 09 Patient Satisfaction Patient Satisfaction
SurveySurvey Initial assessmentInitial assessment Goal settingGoal setting Exercise diaryExercise diary Follow up questionnaire Follow up questionnaire GuidelinesGuidelines
Initial AssessmentInitial AssessmentType of Type of exerciseexercise
% of patients% of patients
No exerciseNo exercise 40 %40 %
Bed Bed exercisesexercises
15%15%
Seated Seated exercisesexercises
31%31%
Static bikeStatic bike 15%15%
Resistance Resistance exerciseexercise
0%0%
0
0.5
1
1.52
2.5
3
Patients
1 2 3 4 5 6 7 8 9 10
1=Very Happy 10=Very Depressed
Mood
Start Patients Follow up Patients
012345
1 2 3 4 5 6 7 8 9 10
1=Very Motivate 10=V.De-motivated
Motivation
Start Patients Follow up Patients
0
1
2
3
4
1 2 3 4 5 6 7 8 9 10
1=Very Active 10=Very Inactive
Physical Activity
Start Patients Follow up Patients
Results
85% study reported 85% study reported average of 30 mins average of 30 mins accumulated exerciseaccumulated exercise
Positive feedback !Positive feedback !
Difficulties!Difficulties!
Access to equipmentAccess to equipment StaffingStaffing
Availability of staffAvailability of staff Increased referralsIncreased referrals
What happened next!What happened next!
• Proposal for funding Proposal for funding of Physiotherapy of Physiotherapy Technical instructor Technical instructor postpost
• 6 month pilot agreed6 month pilot agreed
8 Hrs/week8 Hrs/week
Evaluation of PilotEvaluation of Pilot
Patients identified by Patients identified by MDT MDT
New diagnosis, new New diagnosis, new physio referralphysio referral
Questionnaire Questionnaire completed.completed.
““Was it useful having a Technical Instructor Was it useful having a Technical Instructor monitor your exercise programme?”monitor your exercise programme?”
0
20
40
60
80
100
Yes No
How would you rate the How would you rate the improvement ?improvement ?
0
2
4
6
8
10Mood
Motivation
Energy Levels
Physical levels
Overall WellBeing
‘‘Are there any other comments you would Are there any other comments you would like to make?’like to make?’
““Feel good factor and Feel good factor and gets you motivated to gets you motivated to push yourself”push yourself”
“ “Without technical Without technical instructor I wouldn’t have instructor I wouldn’t have been able to do it ! been able to do it !
““Great motivation by a Great motivation by a smiley instructor ! ”smiley instructor ! ”
““Exercises to suit Exercises to suit personal needs”personal needs”
““An excellent programme”An excellent programme” “ “This should be regarded This should be regarded
as an essential serviceas an essential service
What is going well ?What is going well ?
Many Thanks to ELF Many Thanks to ELF
• Permanent Technical Permanent Technical Instructor Post Instructor Post
• Increased to 12 Increased to 12 hrs/weekhrs/week
“ “ The Way Forward ” The Way Forward ” GroupGroup
Advice and informationAdvice and information LeafletsLeaflets Out-patients/ Daycare Out-patients/ Daycare
unitunit
Cancer Rehabilitation Cancer Rehabilitation ProgrammesProgrammes Campbell 2007Campbell 2007
Cancer Rehabilitation ProgrammesCancer Rehabilitation Programmes
Pilot agreed !Pilot agreed ! Two 8 week programmes Two 8 week programmes The programme format :The programme format :
Pre assessment / Pre assessment / screeningscreening
Exercise programme –Exercise programme –warm-up, aerobics, warm-up, aerobics, relaxation/cool down relaxation/cool down
Educational component Educational component
One meeting to take One meeting to take place at Fitness First place at Fitness First Leisure Centre Leisure Centre
The Future The Future
More Promotion of InformationMore Promotion of Information
Fly fishing / Dragon Boat racing!Fly fishing / Dragon Boat racing!
More Research More Research
More Hannahs !More Hannahs !
ReferencesReferences
Campbell, A.Campbell, A. (2007)(2007) Exercise after cancer Exercise after cancer diagnosis. Available at: diagnosis. Available at: www.canrehab.co.uk
Courneya, K. (2005)Courneya, K. (2005) Exercise can improve Exercise can improve breast cancer survival. breast cancer survival. CA: A Cancer Journal CA: A Cancer Journal for Cliniciansfor Clinicians 55:5: 265-266 55:5: 265-266
Dimeo, F., Bertz, H., Finke, S., Mertlesmann, Dimeo, F., Bertz, H., Finke, S., Mertlesmann, R., Keul, J. (1996)R., Keul, J. (1996) An Aerobic Exercise An Aerobic Exercise Programme for patients with haematological Programme for patients with haematological malignancies after bone marrow Transplant. malignancies after bone marrow Transplant. Bone Marrow TransplantBone Marrow Transplant, 18:1157-60, 18:1157-60
Jones, L and Courneya, K. (2002)Jones, L and Courneya, K. (2002) Exercise discussions during cancer Exercise discussions during cancer treatment consultations. treatment consultations. Cancer PracticeCancer Practice 10(2):66-7410(2):66-74
Lee, J., Dodd, S., Dibbles, D., Abrams, D. Lee, J., Dodd, S., Dibbles, D., Abrams, D. (2008)(2008) Nausea at the end of adjuvant Nausea at the end of adjuvant cancer treatment in relation to exercise cancer treatment in relation to exercise during treatment in patients with breast during treatment in patients with breast cancer. cancer. Oncology Nursing ForumOncology Nursing Forum 35(5): 35(5): 830-835830-835
Meyerhardt, J., Giovannucci, E., Holmes, Meyerhardt, J., Giovannucci, E., Holmes, M. (2006)M. (2006) Physical activity and survival Physical activity and survival after colorectal cancer diagnosis. after colorectal cancer diagnosis. Journal Journal of Clinical Oncologyof Clinical Oncology 24(22): 3527-3534 24(22): 3527-3534
Winningham, M. (1992)Winningham, M. (1992) The Role of The Role of Exercise in Cancer TherapyExercise in Cancer Therapy. In: Watson, . In: Watson, R., Eisinger, M. (eds) R., Eisinger, M. (eds) Exercise and Exercise and Disease.Disease. Boca Raton: CRC Press Boca Raton: CRC Press