"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

Benefits of exercise for cancer Benefits of exercise for cancer patientspatients

““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”

What has been happening at the What has been happening at the RD&E !RD&E !

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

RD&E Haematology UnitRD&E Haematology Unit

PastPast

PresentPresent

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

The ResultsThe Results

Wii Study 2009Wii Study 2009

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

0

20

40

60

80

100Mood

Motivation

Energy Levels

PhysicalActivity

Overall WellBeing

ResultsResults

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 !

Any Any Questions?Questions?

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