Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement.

Background: Fatigue is the most common symptom among cancer survivors. Cancer-related fatigue (CRF) may occur at any point in the cancer care continuum. Multiple factors contribute to CRF development and severity, including cancer type, treatments, presence of other symptoms, comorbidities, and medication side effects. Clinically, increasing physical activity, enhancing sleep quality, and recognizing sleep disorders are integral to managing CRF. Unfortunately, CRF is infrequently recognized, evaluated, or treated in lung cancer survivors despite more frequent and severe symptoms than in other cancers. Therefore, increased awareness and understanding of CRF are needed to improve health-related quality of life in lung cancer survivors. Objectives: 1) To identify and prioritize knowledge and research gaps and 2) to develop and prioritize research questions to evaluate mechanistic, diagnostic, and therapeutic approaches to CRF among lung cancer survivors. Methods: We convened a multidisciplinary panel to review the available literature on CRF, focusing on the impacts of physical activity, rehabilitation, and sleep disturbances in lung cancer. We used a three-round modified Delphi process to prioritize research questions. Results: This statement identifies knowledge gaps in the 1) detection and diagnostic evaluation of CRF in lung cancer survivors; 2) timing, goals, and implementation of physical activity and rehabilitation; and 3) evaluation and treatment of sleep disturbances and disorders to reduce CRF. Finally, we present the panel's initial 32 research questions and seven final prioritized questions. Conclusions: This statement offers a prioritized research agenda to 1) advance clinical and research efforts and 2) increase awareness of CRF in lung cancer survivors.

Health information and resources in hospital outpatient waiting areas may not meet the needs of older adults from culturally and linguistically diverse backgrounds: A cross-cultural qualitative study.

BACKGROUND: Health information and resources are often provided in hospital outpatient waiting areas but may not meet the cultural and health literacy needs of older adults from culturally and linguistically diverse (CALD) backgrounds. OBJECTIVES: To explore the perspectives and experiences of Cantonese- and Vietnamese-speaking patients and carers in this setting. METHODS: This qualitative interview-based study was conducted from December 2019 to March 2020 at a single outpatient rehabilitation service located at a tertiary public hospital. Four adult consumers (two older adult patients, two caregivers) from CALD backgrounds participated in semi-structured interviews with bilingual researchers. Data were transcribed, translated and analysed using reflexive thematic analysis. RESULTS: Five themes were developed which highlighted that older adults' language profiles shaped their health information needs and ability to access resources in waiting areas. Cultural factors such as filial responsibility may also influence health information preferences. DISCUSSION: Older consumers from CALD backgrounds did not have equitable access to health information and resources in the waiting area compared with English-literate older adults. CONCLUSION: Health information and resources in waiting areas warrant improving to better meet the needs of older patients from CALD backgrounds and their caregivers.

Methodological and Clinimetric Evaluation of Inspiratory Respiratory Muscle Ultrasound in the Critical Care Setting: A Systematic Review and Meta-Analysis.

OBJECTIVE: Significant variations exist in the use of respiratory muscle ultrasound in intensive care with no society-level consensus on the optimal methodology. This systematic review aims to evaluate, synthesize, and compare the clinimetric properties of different image acquisition and analysis methodologies. DATA SOURCES: Systematic search of five databases up to November 24, 2021. STUDY SELECTION: Studies were included if they enrolled at least 50 adult ICU patients, reported respiratory muscle (diaphragm or intercostal) ultrasound measuring either echotexture, muscle thickness, thickening fraction, or excursion, and evaluated at least one clinimetric property. Two independent reviewers assessed titles, abstracts, and full text against eligibility. DATA EXTRACTION: Study demographics, ultrasound methodologies, and clinimetric data. DATA SYNTHESIS: Sixty studies, including 5,025 patients, were included with 39 studies contributing to meta-analyses. Most commonly measured was diaphragm thickness (DT) or diaphragm thickening fraction (DTF) using a linear transducer in B-mode, or diaphragm excursion (DE) using a curvilinear transducer in M-mode. There are significant variations in imaging methodology and acquisition across all studies. Inter- and intrarater measurement reliabilities were generally excellent, with the highest reliability reported for DT (ICC, 0.98; 95% CI, 0.94-0.99). Pooled data demonstrated acceptable to excellent accuracy for DT, DTF, and DE to predicting weaning outcome after 48 to 72 hours postextubation (DTF AUC, 0.79; 95% CI, 0.73-0.85). DT imaging was responsive to change over time. Only three eligible studies were available for intercostal muscles. Intercostal thickening fraction was shown to have excellent accuracy of predicting weaning outcome after 48-hour postextubation (AUC, 0.84; 95% CI, 0.78-0.91). CONCLUSIONS: Diaphragm muscle ultrasound is reliable, valid, and responsive in ICU patients, but significant variation exists in the imaging acquisition and analysis methodologies. Future work should focus on developing standardized protocols for ultrasound imaging and consider further research into the role of intercostal muscle imaging.

Do health service waiting areas contribute to the health literacy of consumers? A scoping review.

Health service waiting areas commonly provide health information, resources and supports for consumers; however, the effect on health literacy and related outcomes remains unclear. This scoping review of the literature aimed to explore the use of waiting areas as a place to contribute to the health literacy and related outcomes of consumers attending health appointments. Articles were included if they focussed on health literacy or health literacy responsiveness (concept) in outpatient or primary care health service waiting areas (context) for adult consumers (population) and were published after 2010. Ten bibliographic databases, one full-text archive, dissertation repositories and web sources were searched. The search yielded 5095 records. After duplicate removal, 3942 title/abstract records were screened and 360 full-text records assessed. Data were charted into a standardized data extraction tool. A total of 116 unique articles (published empirical and grey literature) were included. Most articles were set in primary and community care (49%) waiting areas. A diverse range of health topics and resource types were available, but results demonstrated they were not always used by consumers. Outcomes measured in intervention studies were health knowledge, intentions and other psychological factors, self-reported and observed behaviours, clinical outcomes and health service utilization. Intervention studies overall demonstrated positive trends in health literacy-related outcomes, although the benefit declined after 3-6 months. Research on using waiting areas for health literacy purposes is increasing globally. Future research investigating the needs of consumers to inform optimal intervention design is needed.

Health service waiting areas are commonly used to provide health resources (such as health information, resources and supports) for consumers. Health resources which are appropriate and accessible for consumers can improve health literacy by increasing health knowledge, supporting good decision-making or changing behaviours which may result in better health. Although it is common to offer health resources in health service waiting areas, the evidence supporting this practice is unclear. This scoping review of the literature focussed on the use of health service waiting areas as a place to contribute to the health literacy of adult consumers attending outpatient or primary care health appointments. A total of 116 unique articles were included which addressed this issue. Majority of articles were set in primary and community care waiting areas (49%). A range of health topics and resource types were available but these were not always used by consumers. Overall, interventions in waiting areas targeting health literacy-related outcomes resulted in positive outcomes, although the benefit declined after 3­6 months. Research on using waiting areas for health-literacy purposes is increasing worldwide. Future research is needed to identify how to optimize the effectiveness of interventions in waiting areas to benefit consumers.

Exercise in allogeneic bone marrow transplantation: a qualitative representation of the patient perspective.

PURPOSE: Exercise is emerging as a vital aspect of care to alleviate the physical and psychosocial symptom burden associated with allogeneic bone marrow transplantation (BMT). Understanding the patient perspective regarding exercise is important to move towards implementation. This study aimed to characterise experiences and views regarding participation in an exercise program in adults receiving treatment for haematological disease with allogeneic BMT. METHODS: Individual semi-structured interviews were conducted with 35 participants from either an early- or late-commencing supervised group-based exercise program. Using an inductive, conventional approach to qualitative content analysis data were independently analysed by two researchers. RESULTS: Six major themes and 33 sub-themes were identified: this encompassed motivation, physical opportunity and capability to exercise; psychosocial effects of group-based exercise; experienced impact of participation in an exercise program; and intervention design considerations. Key barriers to exercise included symptom severity and fluctuating health and distance or difficult access to an exercise facility or equipment, whilst facilitators included encouragement from staff; peer support in the group-based setting; flexibility; education; and ability to measure change. CONCLUSION: This study highlights the importance of a flexible approach to exercise with consideration of individual symptoms and preferences. The perceived psychological impact of exercise should not be underestimated; future exercise programs should be designed in partnership with patients, with consideration of group-based activities to reduce social isolation if this is feasible in the treatment context. Intervention design should also acknowledge the individual's physical and psychological capability, opportunity and automatic and reflective motivation to direct and sustain exercise behaviours following BMT.

Inspiratory muscle training in addition to conventional physical rehabilitation in hospitalized patients undergoing hematopoietic stem cell transplantation: a randomized controlled trial.

PURPOSE: To investigate the effect of inspiratory muscle training (IMT) in addition to conventional physical rehabilitation on muscle strength, functional capacity, mobility, hemodynamics, fatigue, and quality of life in hospitalized patients undergoing hematopoietic stem cell transplantation (HSCT). METHODS: We conducted a randomized controlled trial in 57 inpatients with hematological diseases undergoing HSCT. Conventional inpatient physical rehabilitation was delivered to the IMT (n = 27) and control (CON; n = 30) groups according to usual care, and the first group additionally performed IMT. The IMT was prescribed according to clinical and laboratory parameters at 40% of maximal inspiratory pressure (MIP), 5 days/week throughout the hospitalization, in sessions of 10-20 min. The primary outcome was MIP and the secondary outcomes were maximal expiratory pressure (MEP), peripheral muscle strength (handgrip and sit-to-stand tests), functional capacity (6-min step test), mobility (timed up and go test), blood pressure, quality of life (EORTC-QLQ-C30), and fatigue (FACT-F) at admission and hospital discharge. RESULTS: The population was predominately autologous HSCT. The IMT group significantly increased the MIP (P < 0.01) and decreased both fatigue (P = 0.01) and blood pressure (P < 0.01) compared with control. No differences were found between admission and hospital discharge in peripheral and expiratory muscle strength, functional capacity, mobility, and quality of life in both groups (P > 0.05). CONCLUSIONS: Our results support the effectiveness of IMT as part of rehabilitation for HSCT inpatients, improving inspiratory muscle strength, and reducing fatigue and blood pressure. TRIAL REGISTRATION: NCT03373526 (clinicaltrials.gov).

Preoperative exercise training for people with non-small cell lung cancer.

BACKGROUND: Surgical resection for early-stage non-small cell lung cancer (NSCLC) offers the best chance of cure, but it is associated with a risk of postoperative pulmonary complications. It is unclear if preoperative exercise training, and the potential resultant improvement in exercise capacity, may improve postoperative outcomes. This review updates our initial 2017 systematic review. OBJECTIVES: 1. To evaluate the benefits and harm of preoperative exercise training on postoperative outcomes, such as the risk of developing a postoperative pulmonary complication and the postoperative duration of intercostal catheter, in adults scheduled to undergo lung resection for NSCLC. 2. To determine the effect on length of hospital stay (and costs associated with postoperative hospital stay), fatigue, dyspnoea, exercise capacity, lung function and postoperative mortality. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was from 28 November 2016 to 23 November 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which study participants who were scheduled to undergo lung resection for NSCLC were allocated to receive either preoperative exercise training or no exercise training. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. risk of developing a postoperative pulmonary complication; 2. postoperative duration of intercostal catheter and 3. SAFETY: Our secondary outcomes were 1. postoperative length of hospital stay; 2. postintervention fatigue; 3. postintervention dyspnoea; 4. postintervention and postoperative exercise capacity; 5. postintervention lung function and 6. postoperative mortality. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: Along with the five RCTs included in the original version, we identified an additional five RCTs, resulting in 10 RCTs involving 636 participants. Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training (risk ratio (RR) 0.45, 95% CI 0.33 to 0.61; I2 = 0%; 9 studies, 573 participants; high-certainty evidence). The evidence is very uncertain about its effect on postoperative intercostal catheter duration (MD -2.07 days, 95% CI -4.64 to 0.49; I2 = 77%, 3 studies, 111 participants; very low-certainty evidence). Preoperative exercise training is likely safe as studies reported no adverse events. Preoperative exercise training likely results in a reduction in postoperative length of hospital stay (MD -2.24 days, 95% CI -3.64 to -0.85; I2 = 85%; 9 studies, 573 participants; moderate-certainty evidence). Preoperative exercise training likely increases postintervention exercise capacity measured by peak oxygen consumption (MD 3.36 mL/kg/minute, 95% CI 2.70 to 4.02; I2 = 0%; 2 studies, 191 participants; moderate-certainty evidence); but the evidence is very uncertain about its effect on postintervention exercise capacity measured by the 6-minute walk distance (MD 29.55 m, 95% CI 12.05 to 47.04; I2 = 90%; 6 studies, 474 participants; very low-certainty evidence). Preoperative exercise training may result in little to no effect on postintervention lung function (forced expiratory volume in one second: MD 5.87% predicted, 95% CI 4.46 to 7.28; I2 = 0%; 4 studies, 197 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: Preoperative exercise training results in a large reduction in the risk of developing a postoperative pulmonary complication compared to no preoperative exercise training for people with NSCLC. It may also reduce postoperative length of hospital stay, and improve exercise capacity and lung function in people undergoing lung resection for NSCLC. The findings of this review should be interpreted with caution due to risk of bias. Research investigating the cost-effectiveness and long-term outcomes associated with preoperative exercise training in NSCLC is warranted.

Maximising Abilities, Negotiating and Generating Exercise options (MANAGE) in people with multiple sclerosis: A feasibility randomised controlled trial.

OBJECTIVE: To investigate the feasibility and preliminary efficacy of a group self-management exercise and education program in people with multiple sclerosis. DESIGN: Feasibility randomised controlled trial. SETTING: Outpatient rehabilitation facility. SUBJECTS: Twenty-three adults (age 48.6 (11.7) years) recruited from a Multiple Sclerosis Clinic register. INTERVENTIONS: The intervention group undertook a 12-week group program incorporating behaviour change education, exercise and community integration. This was compared with a waitlist control group. MAIN MEASURES: Feasibility was measured by recruitment, adherence and safety. Efficacy outcomes included measures of physical function (6-metre and 6-min walk, Functional Reach) and self-report questionnaires (fatigue, quality of life, exercise benefits and barriers) at baseline, 6, 12 and 24 weeks. RESULTS: Of 74 individuals identified through the register, 48 (65%) were contacted and deemed eligible, and 23 (48%) agreed to participate. There was high adherence for attendance at education (57 of 72, 79%) and exercise (135 of 174, 78%) sessions. No adverse safety events occurred within the intervention sessions. Missed attendances at assessment sessions was high (5 to 8 participants missed at each time point) predominately due to health issues. The intervention group demonstrated positive changes in walking endurance, Functional Reach and fatigue, whereas the control had some reductions in walking speed and more perceived exercise barriers. CONCLUSIONS: The MANAGE program appears feasible and safe for people with mild-to-moderate multiple sclerosis, with high adherence to exercise and education sessions. Future trials should consider strategies such as flexible scheduling or alternative methods of data collection to improve follow-up assessment attendance.

Seeking Choice to Fulfill Health Literacy Needs: Health Literacy Opportunities for Consumers in Hospital Waiting Areas.

In this research, we explore and theorize on the potential of hospital outpatient rehabilitation waiting areas to respond and contribute to the health literacy needs of consumers. Constructivist grounded theory informed the sampling and analytical procedures. Thirty-three consumers attending outpatient rehabilitation for a range of health conditions were recruited to this multi-site study. Semi-structured interview and participant observation data were collected and analyzed concurrently using the constant comparison method. The substantive theory of "seeking choice to fulfill health literacy needs" and five interdependent categories were developed. Results indicated that consumers sought choice reflective of their needs; however, the waiting area offered limited choice. Consumers shared ideas to address the lack of choice. Results provide insight into the health literacy needs of consumers in hospital outpatient waiting areas and how health services can appropriately respond to these needs. Future research should investigate the effect of health service environments on health outcomes.

Patient acceptance of prehabilitation for major surgery: an exploratory survey.

PURPOSE: Prehabilitation programs are effective in optimising patient's functional reserve prior to surgery and increasingly associated with reduced postoperative complications. However, acceptability of programs among patients is largely unknown. This study set out to explore the acceptability of prehabilitation from the perspective of patients awaiting major cancer surgery. METHODS: Adult patients awaiting major gastrointestinal and urological cancer surgeries were surveyed. Patients were excluded if they were unable to complete the survey due to language, intellectual impairment and/or visual/hearing deficit. The survey was designed to explore categories related to patient demographics, level of physical activity and perceived enablers and barriers to prehabilitation. RESULTS: One hundred and three participants presenting to a pre-anaesthesia clinic completed the survey over a 5-month period, with 83% response rate. Approximately, half of the respondents were female (55%) and were currently physically active (53%). Fewer than one third (30%) felt they completed 'enough exercise'. The majority of participants (83%) were unfamiliar with the concept of prehabilitation but two thirds (68%) were interested in such a program after explanation. The majority of participants (72%) indicated a strong preference to exercise in a home-based environment. Medical recommendation increased willingness to participate (p < 0.001), while program costs (p = 0.01) were potential barriers to participation. CONCLUSION: Patients are willing to participate in prehabilitation prior to major cancer surgery but practical barriers and facilitators should be considered when designing prehabilitation programs to maximise patient commitment to facilitate improved postoperative outcomes.

Location and Patterns of Persistent Pain Following Cardiac Surgery.

OBJECTIVES: To investigate the specific clinical features of pain following cardiac surgery and evaluate the information derived from different pain measurement tools used to quantify and describe pain in this population. METHODS: A prospective observational study was undertaken at two tertiary care hospitals in Australia. Seventy-two (72) adults (mean age, 63±11 years) were included following cardiac surgery via a median sternotomy. Participants completed the Patient Identified Cardiac Pain using numeric and visual prompts (PICP), the McGill Pain Questionnaire-Short Form version 2 (MPQ-2) and the Medical Outcome Study 36-item version 2 (SF-36v2) Bodily Pain domain (BP), which were administered prior to hospital discharge, 4 weeks and 3 months postoperatively. RESULTS: Participants experienced a high incidence of mild (n=45, 63%) to moderate (n=22, 31%) pain prior to discharge, which reduced at 4 weeks postoperatively: mild (n=28, 41%) and moderate (n=5, 7%) pain; at 3 months participants reported mild (n=14, 20%) and moderate (n=2, 3%) pain. The most frequent location of pain was the anterior chest wall, consistent with the location of the surgical incision and graft harvest. Most participants equated "pressure/weight" to "aching" or a "heaviness" in the chest region (based on descriptor of pain in the PICP) and the pain topography was persistent at 4 weeks and 3 months postoperatively. Each pain measurement tool provided different information on pain location, severity and description, with significant change (p<0.005) over time. CONCLUSION: Mild-to-moderate pain was frequent after sternotomy, improved over time and was mostly located over the incision and mammary (internal thoracic) artery harvest site. Persistent pain at 3 months remained a significant problem in the community within this surgical population.

Evaluating Physical Functioning in Survivors of Critical Illness: Development of a New Continuum Measure for Acute Care.

OBJECTIVES: Evaluation of physical functioning is central to patient recovery from critical illness-it may enable the ability to determine recovery trajectories, evaluate rehabilitation efficacy, and predict individuals at highest risk of ongoing disability. The Physical Function in ICU Test-scored is one of four recommended physical functioning tools for use within the ICU; however, its utility outside the ICU is poorly understood. The De Morton Mobility Index is a common geriatric mobility tool, which has had limited evaluation in the ICU population. For the field to be able to track physical functioning recovery, we need a measurement tool that can be used in the ICU and post-ICU setting to accurately measure physical recovery. Therefore, this study sought to: 1) examine the clinimetric properties of two measures (Physical Function in ICU Test-scored and De Morton Mobility Index) and 2) transform these measures into a single measure for use across the acute care continuum. DESIGN: Clinimetric analysis. SETTING: Multicenter study across four hospitals in three countries (Australia, Singapore, and Brazil). PATIENTS: One hundred fifty-one ICU patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Physical function tests (Physical Function in ICU Test-scored and De Morton Mobility Index) were assessed at ICU awakening, ICU, and hospital discharge. A significant floor effect was observed for the De Morton Mobility Index at awakening (23%) and minimal ceiling effects across all time points (5-12%). Minimal floor effects were observed for the Physical Function in ICU Test-scored across all time points (1-7%) and a significant ceiling effect for Physical Function in ICU Test-scored at hospital discharge (27%). Both measures had strong concurrent validity, responsiveness, and were predictive of home discharge. A new measure was developed using Rasch analytical principles, which involves 10 items (scored out of 19) with minimal floor/ceiling effects. CONCLUSIONS: Limitations exist for Physical Function in ICU Test-scored and De Morton Mobility Index when used in isolation. A new single measure was developed for use across the acute care continuum.

Home-based rehabilitation in inoperable non-small cell lung cancer-the patient experience.

PURPOSE: Exercise is important in lung cancer, yet most people do not meet the physical activity guidelines. The aim of this study was to characterise the views and experiences of participants with inoperable lung cancer who completed a home-based rehabilitation program. METHODS: Ninety-two participants were recruited (45 intervention group [IG], 47 usual care). Individual semi-structured interviews were conducted with participants randomised to the IG of a trial of home-based exercise, behaviour change and symptom management. Data were independently coded by two researchers, cross-checked and analysed using content analysis with a summary of arising themes. RESULTS: Of the IG (25/45), 55% were interviewed: mean (SD) age 67 (13) years; male 52%; disease stage n (%) III = 9 (36), IV = 11 (44); radical treatment intent n (%) 13 (52). The majority of participants reported program benefits, both in the physical domain (reduced sedentary time and improved strength, fitness and function) and the mental domain (motivation to keep healthy, preventing boredom). Support to self-manage symptoms was well received and many participants reported increased confidence in managing their symptoms. Exercise enablers included having expert health professional support; motivation to be stronger and better prepared for future challenges; and having an achievable and familiar program that was monitored. Treatment side-effects, pain from comorbidities and the weather were exercise barriers. For the majority of participants the use of a Fitbit™ activity tracker, text message exercise reminders and an exercise diary helped to promote adherence. CONCLUSIONS: This home-based rehabilitation program was acceptable to most participants with multiple benefits reported including improved fitness, motivation and ability to manage symptoms.

An allied health rehabilitation program for patients following surgery for abdomino-pelvic cancer: a feasibility and pilot clinical study.

PURPOSE: To investigate the feasibility of conducting a rehabilitation program for patients following surgery for abdomino-pelvic cancer. METHODS: A non-randomised controlled before-and-after study. Patients who had undergone surgery for stage I-III abdomino-pelvic cancer (colorectal, gynaecological or prostate cancer) were recruited. The rehabilitation group (n = 84) received an 8-week, bi-weekly education and exercise program conducted by a physiotherapist, exercise physiologist, health psychologist and dietician, supplemented by exercise diaries and telephone coaching sessions. The comparator group (n = 104) completed postal questionnaires only. Feasibility measures, functional exercise capacity, muscle strength, physical activity levels, pelvic floor symptoms, anxiety and depression, health-related quality of life (HRQoL) and self-efficacy were measured at baseline (time 1), immediately post-intervention (time 2) and at 6 months post-baseline (time 3) and compared within- and between-groups. RESULTS: The consent rate to the rehabilitation program was 24%. Eighty-one percent of the rehabilitation group attended 85-100% of 16 scheduled sessions. Overall satisfaction with the program was 96%. Functional exercise capacity, handgrip strength in males, bowel symptoms, physical activity levels, depression and HRQoL were significantly improved in the rehabilitation group (p < 0.05) at time 2. The improvements in all these outcomes were sustained at time 3. The rehabilitation group had significantly improved physical activity levels, depression and HRQoL compared with the comparator group at times 2 and 3 (p < 0.05). CONCLUSION: Recruitment to this oncology rehabilitation program was more difficult than expected; however, attendance and patient satisfaction were high. This program had positive effects on several important clinical outcomes in patients following abdomino-pelvic cancer treatment. TRIAL REGISTRATION: ANZCTR 12614000580673.

Exercise training as part of lung cancer therapy.

Exercise training is playing an increasing role in lung cancer care. Lung cancer is associated with significant burden to the individual and healthcare system. There is now substantial evidence that exercise training is safe, feasible and effective at improving several outcomes in people with lung cancer, especially in those with NSCLC. Exercise is beneficial across the lung cancer disease and treatment pathway, including in patients with early stage disease before and after surgery, and in patients with advanced disease. This review describes the impact of lung cancer and lung cancer treatment on patient health outcomes and summarizes the aims, safety, feasibility and effects of exercise training in the context of both early stage and advanced stage lung cancer. The paper also includes a discussion of current topical discussion areas including the use of exercise in people with bone metastases and the potential effect of exercise on suppression of tumour growth. Finally, seven clinical questions are included, which are a priority to be addressed by future research over the next decade as we strive to progress the field of lung cancer and improve patient outcomes.

Psychometric evaluation of the shortened version of the Functional Difficulties Questionnaire to assess thoracic physical function.

OBJECTIVE: The aim of this study was to investigate the psychometric properties of the shortened version of the Functional Difficulties Questionnaire (FDQ). DESIGN: This is a multisite observational study. SETTING: The study was conducted in four tertiary care hospitals in Australia. SUBJECTS: A total of 225 participants, following cardiac surgery, were involved in the study. INTERVENTION: Participants completed the original 13-item FDQ and other measures of physical function, pain and health-related quality of life. METHOD: Item reduction was utilized to develop the shortened version. Reliability was evaluated using intraclass correlation coefficients (ICCs), the smallest detectable change and Bland-Altman plots. The validity and responsiveness were evaluated using correlation. Anchor and distribution-based calculation was used to calculate the minimal clinical important difference (MCID). RESULTS: Item reduction resulted in the creation of a 10-item shortened version of the questionnaire (FDQ-s). Within the cohort of cardiac surgery patient, the mean (SD) for the FDQ-s was 38.7 (19.61) at baseline; 15.5 (14.01) at four weeks and 7.9 (12.01) at three months. Validity: excellent internal consistency (Cronbach's α > 0.90) and fair-to-excellent construct validity (>0.4). Reliability: internal consistency was excellent (Cronbach's α > 0.8). The FDQ-s had excellent test-retest reliability (ICC = 0.89-0.92). Strong responsiveness overtime was demonstrated with large effect sizes (Cohen's d > 1.0). The MCID of the FDQ-s was calculated between 4 and 10 out of 100 (in cm). CONCLUSION: The FDQ-s demonstrated robust psychometric properties as a measurement tool of physical function of the thoracic region following cardiac surgery.

The fear and risk of community falls in patients following an intensive care admission: An exploratory cohort study.

BACKGROUND: Muscle weakness and impairments in physical functioning are well-recognised sequelae after critical illness. Whether individuals have a higher risk of community falls and a fear of falling has not been examined amongst individuals after critical illness. OBJECTIVES: The objective of this study was to explore the prevalence of falls, fear of falling, and fall risk in intensive care unit (ICU) survivors over a 6-month period after hospital discharge. METHODS: This was a nested exploratory study within a medical ICU. Fall prevalence was measured in line with established guidelines over 6 months after ICU discharge. Fear of falling and prediction of fall risk were assessed at 2, 4, and 6 months after discharge. RESULTS: Twelve individuals were included. Half of the cohort (n = 6) had at least one fall, with one-third sustaining more than one fall. There were 17 falls reported across the six individuals. Injuries requiring medical intervention were reported with five falls. Almost one-third were classified as 'moderate' to 'severe' injurious falls. Loss of balance and fatigue were reported as the main contributors to the falls. All individuals who had a fall reported a severe fear of falling at 2 months. Individuals classified as having 'moderate' to 'high' risk of falls at 2 months were more likely to have at least one fall. CONCLUSIONS: This study suggests that ICU survivors may have a high fall risk, fear of falling, and fall prevalence, which can result in significant injury.

Multidisciplinary home-based rehabilitation in inoperable lung cancer: a randomised controlled trial.

BACKGROUND: Lung cancer is associated with poor health-related quality of life (HRQoL) and high symptom burden. This trial aimed to assess the efficacy of home-based rehabilitation versus usual care in inoperable lung cancer. METHODS: A parallel-group, assessor-blinded, allocation-concealed, randomised controlled trial. Eligible participants were allocated (1:1) to usual care (UC) plus 8 weeks of aerobic and resistance exercise with behaviour change strategies and symptom support (intervention group (IG)) or UC alone. Assessments occurred at baseline, 9 weeks and 6 months. The primary outcome, change in between-group 6 min walk distance (6MWD), was analysed using intention-to-treat (ITT). Subsequent analyses involved modified ITT (mITT) and included participants with at least one follow-up outcome measure. Secondary outcomes included HRQoL and symptoms. RESULTS: Ninety-two participants were recruited. Characteristics of participants (UC=47, IG=45): mean (SD) age 64 (12) years; men 55%; disease stage n (%) III=35 (38) and IV=48 (52); radical treatment 46%. There were no significant between-group differences for the 6MWD (n=92) at 9 weeks (p=0.308) or 6 months (p=0.979). The mITT analyses of 6MWD between-group differences were again non-significant (mean difference (95% CI): 9 weeks: -25.4 m (-64.0 to 13.3), p=0.198 and 6 months: 41.3 m (-26.7 to 109.4), p=0.232). Significant 6-month differences, favouring the IG, were found for HRQoL (Functional Assessment of Cancer Therapy-Lung: 13.0 (3.9 to 22.1), p=0.005) and symptom severity (MD Anderson Symptom Inventory-Lung Cancer: -2.2 (-3.6 to -0.9), p=0.001). CONCLUSIONS: Home-based rehabilitation did not improve functional exercise capacity but there were improvements in patient-reported exploratory secondary outcomes measures observed at 6 months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614001268639).

Practical approach to establishing pulmonary rehabilitation for people with non-COPD diagnoses.

Pulmonary rehabilitation is a core aspect in the management of patients with chronic respiratory diseases. This paper describes a practical approach to establishing pulmonary rehabilitation for patients with non-COPD diagnoses using examples from the interstitial lung disease (ILD), pulmonary hypertension (PH), bronchiectasis and lung cancer patient populations. Aspects of pulmonary rehabilitation, including the rationale, patient selection, setting of programmes, patient assessment and training components (both exercise and non-exercise aspects), are discussed for these patient groups. Whilst there are many similarities in the rationale and application of pulmonary rehabilitation across these non-COPD populations, there are also many subtle differences, which are discussed in detail in this paper. With consideration of these factors, pulmonary rehabilitation programmes can be adapted to facilitate the inclusion of respiratory patients with non-COPD diagnoses.

Commencing Out-of-Bed Rehabilitation in Critical Care-What Influences Clinical Decision-Making?

OBJECTIVES: To develop a decision tree that objectively identifies the most discriminative variables in the decision to provide out-of-bed rehabilitation, measure the effect of this decision and to identify the factors that intensive care unit (ICU) practitioners think most influential in that clinical decision. DESIGN: A prospective 3-part study: (1) consensus identification of influential factors in mobilization via survey; (2) development of an early rehabilitation decision tree; (3) measurement of practitioner mobilization decision-making. Treating practitioners of patients expected to stay >96 hours were asked if they would provide out-of-bed rehabilitation and rank factors that influenced this decision from an a priori defined list developed from a literature review and expert consultation. SETTING: Four tertiary metropolitan ICUs. PARTICIPANTS: Practitioners (ICU medical, nursing, and physiotherapy staff) (N=507). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A decision tree was constructed using binary recursive partitioning to determine the factor that best classified patients suitable for out-of-bed rehabilitation. Descriptive statistics were used to describe practitioner and patient samples as well as patient adverse events associated with out-of-bed rehabilitation and the factors prioritized by ICU practitioners. RESULTS: There were 1520 practitioner decisions representing 472 individual patient decisions. Practitioners classified patients suitable for out-of-bed rehabilitation on 149 occasions and not suitable on 323 occasions. Decision tree analysis showed the presence of an endotracheal tube (ETT) and sedation state were the only discriminative variables that predicted patient suitability for rehabilitation. In contrast, medical staff and nurses reported that ventilator status was the most influential factor in their decision not to provide rehabilitation while physiotherapists ranked sedation most highly. The presence of muscle weakness did not inform the decision to provide rehabilitation. CONCLUSION: These results confirm previous observational reports that the presence of an ETT remains a major obstacle to the provision of rehabilitation for critically ill patients. Despite rehabilitation being effective for improving muscle strength, the presence of muscle weakness did not influence the decision to provide rehabilitation.