Background: In order to counteract fatigue, physical activity (PA) is recommended for all stages of cancer. However, only few advanced cancer patients (ACP) are physically active. Quantitative data with high numbers of ACP reporting barriers to PA are missing. This study aimed to identify barriers to PA in ACP with tiredness/weakness and investigate their motivation towards it.
Methods: Outpatients with metastatic cancer receiving cancer care at a German Cancer Center reporting moderate/severe tiredness/weakness during self-assessment (MIDOS II) were enrolled. We assessed Fatigue-(FACF-F) and Depression (PHQ8) Scores, demographics, cancer-specific parameters, motivation for PA, physical, psychological and social barriers.
Results: 141 of 440 eligible patients (32.0%) with different diagnoses agreed to participate. Patients frequently reported “I feel weakened due to my tumor therapy” (n = 108; 76.6%), physical symptoms (tiredness, weakness, dyspnea, joint-problems, pain, nausea [n = 107; 75.9%]) and fatigue (n = 99; 70.2%) as barriers to PA. However, no significant group differences regarding these barriers were found between physically active and inactive patients. Social barriers were rarely chosen. Motivated patients were 5.6 times more likely to be physically active (p < 0.001), also motivation turned out to be the strongest predictor for a physically active behavior (ß = 1.044; p = 0.005). Motivated attitude towards PA was predicted by fatigue (ß = - 2.301; p = 0.008), clinically relevant depression (ß = - 1.390, p = 0.039), knowledge about PA and quality of life (QoL) (ß = 0.929; p = 0.002), PA before diagnosis (ß = 0.688; p = 0.005 and Interest in exercise program (ß = 0.635; p = 0.008).
Conclusion: “I feel weakened due to my tumor therapy” is the most reported barrier to PA among both, physically and inactive patients. Motivation for PA is the strongest predictor of performing PA. Interest in PA, knowledge about PA/QoL and PA before diagnosis are main predictors of a motivated attitude. Absence/presence of social barriers did not associate with motivation, fatigue and depression proved to be a negative predictor. Programs including information, motivational counseling and individualized training should be offered for ACP to overcome barriers and reduce fatigue.
Trial registration: German Register of Clinical Trials DRKS00012514, registration date: 30.5.2017.
Physical activity has increasingly gained attention within palliative care. This article aims to explore how the idea of physical activity influences patients with advanced cancer and health-care professionals’ interactions. The empirical material was gathered as part of an anthropological field study about palliative care needs among 16 patients with advanced cancer, consisting of observations and interviews with patients, relatives, and professionals. Two of the patient cases were analyzed, inspired by Goffman’s theory, showing how patients and health-care professionals interact in relation to physical activity. The findings show that patients played roles either embracing physical activity or distancing it by postponement. Professionals played expert roles of duty and attachment, stressing the importance of physical activity. Thus, they accepted a minimum of physical activity when patients were close to death. Professionals regarded patients’ absence of physical activity as a lack of desire to live; patients regard it as a way to live.
Purpose: Tai Chi is increasingly being used as a complimentary therapy in hospice care to help patients self-manage multiple and complex health needs. However, currently there is limited understanding of Tai Chi from patients’ perspective, including what participation in this mindfulness based movement (MBM) exercise means to their experiences of living with an advanced, incurable disease. The purpose of this study was to explore outpatients’ lived experiences of hospice-based Tai Chi in relation to mindfulness.
Methods: 19 participants (15 females; 4 males, aged between 50 and 91 years old) with a range of advanced, incurable diseases (cancer, COPD, pulmonary fibrosis, pulmonary arterial hypertension) who attended day therapy at a local hospice took part in Tai Chi sessions. Using a focused ethnographic approach, multi-methods including 17 semi-structured interviews (averaging 40 min), participant observations (equating to 200 h spent in the day therapy unit), and informal conversations were used to collect data over a 6 month period. Data was analysed using a thematic framework approach.
Results: Four main themes were constructed that demonstrated participants’ lived experiences of mindfulness during participation in hospice-based Tai Chi sessions. Main themes included: (1) mind-body respite; (2) being present with others; (3) tranquil and therapeutic atmosphere and; (4) physical limitations.
Conclusion: Tai Chi may be an important therapeutic strategy for helping patients with advanced, incurable disease experience mindfulness. The findings of this study support the use of MBM exercises such as Tai Chi as a non-pharmacological adjunct to conventional treatments within palliative care settings.
Purpose: Physical activity (PA) is increasingly being used in hospice care as a rehabilitation strategy to help patients manage symptoms and improve quality of life. However, little is known about how to design and deliver interventions that promote uptake and maintenance of PA in this population. Single-level approaches (i.e., psychological models) have primarily been used to study factors that influence PA engagement among patients with advanced, incurable disease and therefore offer a limited perspective on strategies that target changes beyond the individual level. This study explored perspectives on factors perceived important for influencing PA participation in hospice care using a social-ecological framework.
Method: Patients (n = 27) and health providers (n = 5) from multiple hospices (n = 5) across the UK were involved in this study. Data were collected using focus group and individual semi-structured interviews and analyzed using a thematic framework approach.
Results: Eight main themes were perceived to be important for influencing PA engagement at the individual, interpersonal, physical environment, community, and policy levels including: (1) PA as therapy; (2) apprehension about PA-induced harm; (3) group-based PA with peers; (4) supervised PA sessions; (5) limited facilities and access; (6) patient-centered approach; (7) lack of a strong PA culture and; (8) absence of a policy and guidance for PA provision.
onclusion: Hospice-based PA interventions that target multiple levels simultaneously may be more effective at successfully changing and sustaining patients' PA behavior. Study findings provide evidence-based recommendations that may facilitate the effective delivery of PA interventions in hospice care.
BACKGROUND: Cancer-related fatigue and loss of physical functioning are distressing symptoms which negatively impact the quality of life of people with advanced cancer. Physical activity has been shown to have positive effects on these symptoms in early-stage cancer, but previous research demonstrated an incongruence between people with advanced cancer's expressed interest and actual participation in a physical activity intervention.
AIM: To gain an in-depth understanding of the experience of activity and quality of life in people with advanced cancer, using a classic grounded theory approach.
DESIGN: Through the post-positivist lens of subtle realism, and informed by classic grounded theory methods, a two-phase, cross-sectional, qualitative study was conducted. For 7 days duration, participants wore an activPAL™ activity monitor and completed a daily record sheet, which were then used as qualitative probes for face-to-face, semi-structured interviews.
SETTING/PARTICIPANTS: A total of 15 people with advanced cancer, aged 18 years or older, and with a median survival of 100 days from time of study consent, were recruited from an outpatient department of a tertiary cancer centre in Alberta, Canada.
FINDINGS: Maintaining their responsibilities, no matter how small, was the prime motive for participants' behaviour. For people with advanced cancer, the minimum level of responsibility was dynamic and unique. It was achieved through a multifaceted interaction between the perceived benefits, prevailing conditions and mechanisms.
CONCLUSION: This grounded theory enables understanding of activity as a mechanism through which responsibility is managed and may inform future behavioural interventions in people with advanced cancer.
In literature, obituaries from different cultures and languages have been studied on different levels and from different perspectives. One of the popular research topics is the use of metaphors, since metaphors help to cope with death, which in modern society is still a taboo. This article presents a bottom-up, primarily qualitative analysis of the metaphors in 150 obituaries of sportspeople, published in online versions of newspapers/magazines and on the Internet. As expected, the obituaries contain the traditional metaphors of death. Also more original, creative metaphors are introduced to describe death in a euphemistic way. Some of those have a link to sports but not systematically to the sport practiced by the deceased.
BACKGROUND: Fatigue is a common symptom experienced by people with cancer and other long-term, non-malignant conditions. It can be disease-related or caused by treatments such as chemotherapy or radiotherapy. Patients frequently report this as a distressing symptom and, while some international guidelines for its management exist, evidence suggests that these are not always implemented.
METHOD: This article reviews the evidence basis for fatigue management, looking at exercise, education, psychological interventions, complementary therapies and pharmacological therapy, and finds that a one-size fits all approach to fatigue management is unrealistic.
FINDINGS: Research appears to support different interventions at various points in the disease trajectory and this is of importance for service design as palliative care is increasingly introduced earlier in the patient's pathway.
CONCLUSION: Although the body of research is growing, management of fatigue caused by non-malignant conditions remains poorly evidenced, making comprehensive recommendations for these patient groups even more challenging.
BACKGROUND: People with metastatic cancers experience poor quality of life (QoL), fatigue, and decreased physical function. Exercise improves these symptoms in the curative setting, but the efficacy and safety of exercise in the metastatic setting is uncertain.
METHODS: Prospective, randomized trials of moderate/high intensity aerobic exercise or resistance training versus control in patients with advanced / metastatic solid cancers were identified from prior reviews and updated using a search of PubMed. The mean and standard deviation (SD) for validated outcome measures (QoL, physical function, and fatigue) were extracted for intervention and control groups at baseline and post-intervention. The Mann Whitney test was used to evaluate the effect of exercise on the pooled change between baseline and post-intervention. Safety was evaluated qualitatively.
RESULTS: Sixteen trials were analysed. Among patients with scores at the mean or 2SD above, exercise was not associated with significant or clinical difference in QoL or fatigue. In patients with baseline scores 2SD below mean, exercise was associated with non-significant difference meeting minimal clinical important difference in QoL (-2.8 vs 4.6, p=0.28). For function, patients at the mean had non-statistically significant, but clinically meaningful improvement in the 6-minute walk test (6-MWT) (14.7 vs 29.0 meters, p=0.44). In patients 2 SD below the mean, there was a clinically meaningful difference in two patient-reported functional subscales (0.1 vs 5.3, p=0.076 and 0.44 vs 8.5, p=0.465) and a clinically meaningful difference in the 6-MWT (-7.5 vs 27.0 meters, p=0.34), although none of these associations met statistical significance. There were no differences in falls, fractures, or pain.
DISCUSSION: Exercise is associated with clinically meaningful improvements in QoL, function, and 6-MWT in some patients with metastatic cancer. Despite poor reporting of safety, there was no signal of increased harm from exercise in this setting.
PURPOSE: Patients with advanced cancer can experience debilitating physical symptoms, making participation in exercise programs difficult. This systematic review investigated the recruitment, adherence, and attrition rates of patients with advanced cancer participating in exercise interventions and examined components of exercise programs that may affect these rates.
METHODS: Relevant studies were identified in a systematic search of CINAHL, PubMed, PsycINFO, and EMBASE to December 2017. Two quality assessment tools were used, and levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine (CEBM) guidelines.
RESULTS: The search identified 18 studies published between 2004 and 2017. Recruitment, adherence, and attrition rates varied widely among the studies reviewed. The mean recruitment rate was 49% (standard deviation [SD] = 17; range 15-74%). Patient-reported barriers to recruitment included time constraints and difficulties in traveling to exercise centers. Levels of adherence ranged from 44% to 95%; however, the definition of adherence varied substantially among trials. The average attrition rate was 24% (SD = 8; range 10-42%), with progression of disease status reported as the main cause for dropout during exercise interventions.
SIGNIFICANCE OF RESULTS: Concentrated efforts are needed to increase the numbers of patients with advanced disease recruited to exercise programs. Broadening the eligibility criteria for exercise interventions may improve accrual numbers of patients with advanced cancer to exercise trials and ensure patients recruited are representative of clinical practice.
OBJECTIVES: Cardiac rehabilitation (CR) programmes are standard of care for patients following a coronary event. While such exercise-based secondary prevention programme do offer benefits, they are used by less than 30% of eligible patients and attrition within these programmes is high. This project is a nested qualitative assessment of a pilot programme considering Tai Chi (TC) as an alternative to CR. We hypothesised that TC may overcome several key barriers to CR.
METHODS: A semistructured focus group agenda was used to assess three key domains of feasibility: (1) patients' experiences, (2) reasons/barriers for not having attended CR and (3) any improvements in physical activity and other secondary outcomes (quality of life, weight, sleep). A thematic analysis was used to better understand the key concepts.
RESULTS: This high-risk group of patients reported that they enjoyed TC exercise, and felt confident and safe doing it. TC practice was reported to support other types of physical activity allowing for a generalisation of positive effects.
DISCUSSION: This analysis is consistent with published reports of TC practice improving mood and psychological well-being. Qualitative methods allowed us to find emergent experiential reports of behaviour change factors found in established behaviour change theories.
BACKGROUND: Physical activity in palliative care patients is closely linked to independence, function, carer burden, prognosis, and quality of life. Changes in physical activity can also be related to service provision needs, including requirements for support and prognosis. However, the objective measurement of physical activity is challenging, with options, including self-report, invasive and intensive measures such as calorimetry, or newer options such as pedometers and accelerometers. This latter option is also becoming more viable with the advent of consumer technology driven by the health and exercise industry.
OBJECTIVE: In this article, we highlight our experiences of activity monitoring in palliative care patients as part of telehealth trial. We also highlight the strengths and limitations of activity monitoring in the palliative care population and potential applications.
CONCLUSIONS: Although the advent of consumer technology for activity measurement makes their use seem attractive in clinical settings for palliative care patients, there are a number of issues that must be considered, in particular the reason for the activity monitoring and associated limitations in the technology.
Background: The aim of the study was to assess four evidence-based assessments utilising exercise challenges that induce breathlessness, each with progressively less demanding levels of exertion, which can be tailored to people with a range of functional capabilities in the setting of advanced cancer for research studies. Functional cut off points for these assessments have not previously been defined.
Methods: A cross sectional study of four exercise tests attempted by all participants: 6 min walk test (6MWT); (derived) 2 min walk test (2MWT); arm exercises; and reading numbers aloud. Performance status (Australia-modified Karnofsky Performance Status (AKPS)), baseline breathlessness using the modified Medical Research Council (mMRC) breathlessness scale, and a visual analogue scale of intensity and unpleasantness of breathlessness were measured. Co-morbidity was codified using the Charlson Co-morbidity Index. Percentage of people completing each test by AKPS level of function and baseline mMRC breathlessness scores were quantified.
Results: In the 68 participants, poorer function decreased the proportion of people able to complete the exercise tests. For completion rates =80%, of 6MWT and 2MWT, only people with an AKPS 70–90 had completion. For arm exercises, this included people with an AKPS as low as =50; and for reading numbers, it included people with an AKPS of 40 but not below.
Conclusions: Walking tests have poor utility in people with high levels of functional impairment. For people with high levels of dependence, reading numbers should be used in evaluating exercise-induced breathlessness in research studies. These data also suggest that people’s exertional limitations have been under-estimated as cancer progresses.
Objective: Physical activity (PA) may improve the quality of life (QOL) of cancer survivors. However, the impact on patients with advanced cancer with high cachectic potential is unknown. We analyzed the feasibility of PA intervention using the multimodal program Nutrition and Exercise Treatment for Advanced Cancer (NEXTAC) and the impact on QOL in elderly patients with advanced cancer.
Methods: We recruited 30 patients aged =70 years who were scheduled to receive the first-line chemotherapy for newly diagnosed advanced pancreatic or non-small-cell lung cancer. The QOL was assessed using the European Organization for Research and Treatment of Cancer QOL Questionnaire version 3.0, while the PA was measured using a pedometer/accelerometer. Instructors counseled patients to increase daily activity in an 8-week educational intervention. We assessed patient attendance, compliance, and intervention efficacy.
Results: The median patients' age was 75 years (range, 70-84 years). Twelve patients (40%) were cachectic at baseline. Twenty-eight (93%) patients attended all sessions. Six (21%) and 15 (52%) patients increased their indoor and outdoor activity, respectively. There were significant differences in measured PA, global QOL, and role and emotional functioning between the patients who increased outdoor activity and those who did not.
Conclusions: The PA intervention of the NEXTAC program was feasible as the elderly patients with advanced cancer in this study were highly compliant. The majority of patients demonstrated behavioral changes that were associated with the improvement in global QOL. We conduct a randomized phase II study to measure the impact of the NEXTAC program on QOL and functional prognosis.
Maintaining physical independence is important to terminally ill patients; rehabilitation can improve both functional status and quality of life (QOL) during palliative care. In this prospective pilot study, we evaluated changes in physical function, symptoms, and QOL among 19 hospitalized patients receiving palliative or terminal care for cancer (7 men and 12 women; mean age, 66.8 years, range, 44–84 years). Assessments were performed at admission and after 2 weeks, primarily using the Functional Independence Measure (FIM) and the McGill Quality of Life Questionnaire (MQOL), and a follow-up evaluation was performed 4 weeks after admission if possible. The study was from April to September 2013. In 19 patients, FIM responses were obtained from 17 and 7 patients at 2 and 4 weeks, respectively. MQOL responses were obtained from 11 and 5 patients at 2 and 4 weeks, respectively. A comparison of FIM scores at admission and 2 weeks revealed nonsignificant reductions in the total, motor, and cognitive elements (P = 0.46, 0.70, and 0.20, respectively), which remained nonsignificant at 4 weeks (P = 0.51, 0.65, and 0.27, respectively). There was no significant decline in the total MQOL between admission and 2 and 4 weeks. Although QOL was correlated with physical symptoms, it was not correlated with function. In conclusion, we showed that patient function did not significantly decline and that self-efficacy was maintained with our intervention. A multidisciplinary palliative care approach may reduce symptoms, thereby improving patient QOL. Achieving symptom control is still the mainstay of palliative care.
Background & aims: Cancer cachexia is multifactorial and should be targeted using a multimodal form of intervention. The purpose of the present trial was to test the effects of a combined nutrition and physical exercise program on cancer patients with metastatic or locally advanced tumors of the gastrointestinal and lung tracts.
Methods: Patients were randomized into two groups: One group received a minimum of three standardized individual nutritional counselling sessions and participated in a 60-min exercise program twice a week. The second group received their usual care. The intervention spanned a period of three months. Quality of life (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0), physical performance (hand-grip strength, 6-min walk test, timed sit-to-stand test and 1 repetition maximum leg press), nutritional status (body weight, bioelectrical impedance analysis), dietary intake (three-day dietary record) and clinical data (unexpected hospital days, performance status) were tested at baseline and after three and six months.
Results: In total, 18 women and 40 men (mean age 63, range 32–81) with metastatic or locally advanced tumors of the gastrointestinal (n = 38) and lung (n = 20) tracts were included. Median adherence to the supervised exercise program was 75%. The median number of individual nutritional counselling sessions was 3.0 (range 0–7 sessions). Post intervention, no difference in global health status/quality of life (overall QoL) was observed. Intervention was superior to UC for the patient-rated symptom scale regarding nausea and vomiting (p = 0.023) and protein intake (p = 0.01). No statistical differences were observed for energy intake, nutritional status and physical performance.
Conclusions: The results show good adherence to a combined nutrition and exercise program. The multimodal intervention did not improve overall QoL, but contributed to an adequate protein intake and to the general well-being of the patient by reducing nausea and vomiting.
OBJECTIVES: To investigate Irish chartered physiotherapists' views on physical activity for patients with advanced cancer.
METHODS: A mixed methods study design was used. Eligibility criteria included Irish physiotherapists treating patients with advanced cancer. An online survey instrument was created, which included: (1) A quantitative section that explored physiotherapists' views on the role of physical activity for patients with advanced cancer; and (2) A qualitative section that explored physiotherapists' prescription of physical activity for two patient case studies. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using content analysis.
RESULTS: A total of 38 physiotherapists completed the study. In all, 94% (n = 36) of physiotherapists agreed with the statement "being physically active is important for patients with advanced cancer" and 80% (n = 30) stated a need for further information on prescribing physical activity to patients with advanced cancer. A content analysis of case study responses demonstrated physiotherapists have a number of concerns regarding the prescription of physical activity to patients with bone metastasis. Concerns center on patients' increased fracture risk, the presence of osteoporosis and the risk of falls in this patient group.
CONCLUSION: The majority of physiotherapists perceived physical activity to be of benefit for patients living with advanced cancer. There is a need for more education and training around the prescription of physical activity programs to advanced cancer populations. Physiotherapists' responses suggest patients with advanced cancer have limited exposure to factors that may prompt increased physical activity levels post diagnosis.
In 2016, five Hospices supported by a local University, formed a collaborative to become ‘research active’. Rehabilitative services in Specialist Palliative Care were a common interest, with an emphasis on exercise and its impact on patients’ lives. As a first step towards research activity, a service evaluation of the Hospices’ exercise groups was conducted to evaluate their impact on patients.Key findings: 86% (37, n = 42) believed that exercise helped them cope with their illness ‘completely’ or to ‘a large extent’. Patients agreed classes had a positive effect on the management of their disease although there may be variations over time. They gained confidence in exercising independently and continuing activity outside the group, although 38% (16, n = 42) had no/limited access to resources to facilitate independent exercise. Group interactions were also beneficial.Key recommendations included the implementation of regular reviews to ensure patients are supported effectively over time; provision of an individualized programme and resource advice to support independent exercise and the maintenance of group ‘drop-out’ records to inform future evaluations. The collaborative intends to use these results, in conjunction with a literature review, to inform a feasibility study on physical activity and self-management in palliative care.
Background: Patients with advanced cancer frequently experience functional impairment and reduced quality of life. Therapeutic exercise can provide benefit and be made accessible through the use of tailored programmes. Most studies examining exercise programmes for people with advanced cancer have used quantitative outcome measures and focussed on objective physical function, therefore offer a limited perspective on the experience of exercise participation.Methods: This qualitative study explored patients' experiences of an exercise programme within a palliative care setting. The interviews focussed on the perceived impact on all aspects of quality of life.Results: Nine people with advanced cancer, attending a hospice-based exercise programme, completed a one-to-one interview with a senior physiotherapist to explore the physical, emotional, and social impacts of their participation. Interviews were audiotaped, transcribed verbatim and analysed using interpretive phenomenological analysis. Patients reported an awareness of the positive physical, psychological, and social consequences of exercising. Their experiences reflected on all dimensions of quality of life, the impact of others and the sense of meaning gained through participation in exercise.Conclusion: Our findings highlight that exercise in palliative care should not be viewed solely a physical intervention, but one that has potential to enhance many aspects of patients' quality of life.
BACKGROUND: Physical activity (PA) levels play an important role in maintaining the quality of life and enhancing the physical function of advanced cancer patients. A brief exercise prompt by physicians can increase PA levels of patients diagnosed with cancer.
AIMS: This study explores the views of Irish oncology and palliative care physicians towards PA for patients with advanced cancer.
METHODS: A web-based survey with closed- and open-ended questions was used to explore physicians' views. The survey presented a Likert-style questionnaire and open text responses to two patient case studies. Quantitative data were analysed using descriptive statistics, and qualitative data were analysed using content analysis.
RESULTS: Forty participants completed the study, a response rate of 41%. Responding physicians acknowledged the importance of physical activity for patients with advanced cancer. Twenty-six physicians (67%) agreed that patients look to them for PA recommendations and 30 physicians (77%) indicated a need for more information on providing PA recommendations. Case study responses highlighted concerns relating to PA prescription for patients with bone metastases including the aggravation of symptom control and increased fracture risk.
CONCLUSIONS: The results of this study identify a need for physician education on providing PA recommendations for patients with advanced cancer. Concerns over the prescription of PA to patients with bone metastases highlight the need to disseminate the evidence on the benefits of PA for patients with metastatic cancer to healthcare professionals.
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