Dropout from exercise trials among cancer survivors-An individual patient data meta-analysis from the POLARIS study.

INTRODUCTION: The number of randomized controlled trials (RCTs) investigating the effects of exercise among cancer survivors has increased in recent years; however, participants dropping out of the trials are rarely described. The objective of the present study was to assess which combinations of participant and exercise program characteristics were associated with dropout from the exercise arms of RCTs among cancer survivors. METHODS: This study used data collected in the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) study, an international database of RCTs investigating the effects of exercise among cancer survivors. Thirty-four exercise trials, with a total of 2467 patients without metastatic disease randomized to an exercise arm were included. Harmonized studies included a pre and a posttest, and participants were classified as dropouts when missing all assessments at the post-intervention test. Subgroups were identified with a conditional inference tree. RESULTS: Overall, 9.6% of the participants dropped out. Five subgroups were identified in the conditional inference tree based on four significant associations with dropout. Most dropout was observed for participants with BMI >28.4 kg/m2 , performing supervised resistance or unsupervised mixed exercise (19.8% dropout) or had low-medium education and performed aerobic or supervised mixed exercise (13.5%). The lowest dropout was found for participants with BMI >28.4 kg/m2 and high education performing aerobic or supervised mixed exercise (5.1%), and participants with BMI ≤28.4 kg/m2 exercising during (5.2%) or post (9.5%) treatment. CONCLUSIONS: There are several systematic differences between cancer survivors completing and dropping out from exercise trials, possibly affecting the external validity of exercise effects.

Moderators of exercise effects on self-reported cognitive functioning in cancer survivors: an individual participant data meta-analysis.

PURPOSE: This individual participant data meta-analysis (IPD-MA) assesses exercise effects on self-reported cognitive functioning (CF) and investigates whether effects differ by patient-, intervention-, and exercise-related characteristics. METHODS: IPD from 16 exercise RCTs, including 1987 patients across multiple types of non-metastatic cancer, was pooled. A one-stage IPD-MA using linear mixed-effect models was performed to assess exercise effects on self-reported CF (z-score) and to identify whether the effect was moderated by sociodemographic, clinical, intervention- and exercise-related characteristics, or fatigue, depression, anxiety, and self-reported CF levels at start of the intervention (i.e., baseline). Models were adjusted for baseline CF and included a random intercept at study level to account for clustering of patients within studies. A sensitivity analysis was performed in patients who reported cognitive problems at baseline. RESULTS: Minimal significant beneficial exercise effects on self-reported CF (ß=-0.09 [-0.16; -0.02]) were observed, with slightly larger effects when the intervention was delivered post-treatment (n=745, ß=-0.13 [-0.24; -0.02]), and no significant effect during cancer treatment (n=1,162, ß=-0.08 [-0.18; 0.02]). Larger effects were observed in interventions of 12 weeks or shorter (ß=-0.14 [-0.25; -0.04]) or 24 weeks or longer (ß=-0.18 [-0.32; -0.02]), whereas no effects were observed in interventions of 12-24 weeks (ß=0.01 [-0.13; 0.15]). Exercise interventions were most beneficial when provided to patients without anxiety symptoms (ß=-0.10 [-0.19; -0.02]) or after completion of treatment in patients with cognitive problems (ß=-0.19 [-0.31; -0.06]). No other significant moderators were identified. CONCLUSIONS: This cross-cancer IPD meta-analysis observed small beneficial exercise effects on self-reported CF when the intervention was delivered post-treatment, especially in patients who reported cognitive problems at baseline. IMPLICATIONS FOR CANCER SURVIVORS: This study provides some evidence to support the prescription of exercise to improve cognitive functioning. Sufficiently powered trials are warranted to make more definitive recommendations and include these in the exercise guidelines for cancer survivors.

The Better By Moving study: A multifaceted intervention to improve physical activity in adults during hospital stay.

OBJECTIVE: 'Better By Moving' is a multifaceted intervention developed and implemented in collaboration with patients and healthcare professionals to improve physical activity in hospitalized adults. This study aimed to understand if, how and why 'Better By Moving' resulted in higher levels of physical activity by evaluating both outcomes and implementation process. DESIGN: Mixed-methods study informed by the Medical Research Council guidance. SETTING: Tertiary hospital. PARTICIPANTS: Adult patients admitted to surgery, haematology, infectious diseases and cardiology wards, and healthcare professionals. MEASURES: Physical activity was evaluated before and after implementation using the Physical Activity Monitor AM400 on one random day during hospital stay between 8 am and 8 pm. Furthermore, the time spent lying on bed, length of stay and discharge destination was investigated. The implementation process was evaluated using an audit trail, surveys and interviews. RESULTS: There was no significant difference observed in physical activity (median [IQR] 23 [12-51] vs 27 [17-55] minutes, P = 0.107) and secondary outcomes before-after implementation. The intervention components' reach was moderate and adoption was low among patients and healthcare professionals. Patients indicated they perceived more encouragement from the environment and performed exercises more frequently, and healthcare professionals signalled increased awareness and confidence among colleagues. Support (priority, resources and involvement) was perceived a key contextual factor influencing the implementation and outcomes. CONCLUSION: Although implementing 'Better By Moving' did not result in significant improvements in outcomes at our centre, the process evaluation yielded important insights that may improve the effectiveness of implementing multifaceted interventions aiming to improve physical activity during hospital stay.

Physical dependence and urinary catheters both strongly relate to physical inactivity in adults during hospital stay: a cross-sectional, observational study.

PURPOSE: To determine which factors are associated with physical inactivity in hospitalized adults of all ages. METHODS: A cross-sectional sample of 114 adults admitted to a gastrointestinal surgery, internal medicine or cardiology hospital ward (median age 60, length of stay 13 days) were observed during one random day from 8 am to 8 pm using wireless accelerometers and behavioral mapping protocols. Factors (e.g., comorbidities, self-efficacy, independence in mobility, functional restraints) were collected from medical records, surveys, and observations. RESULTS: Patients were physically active for median(IQR) 26 (13-52.3) min and were observed to lie in bed for 67.3%, sit for 25.2%, stand for 2.5%, and walk for 5.0% of the time. Multivariable regression analysis revealed that physical inactivity was 159.87% (CI = 89.84; 255.73) higher in patients dependent in basic mobility, and 58.88% (CI = 10.08; 129.33) higher in patients with a urinary catheter (adjusted R2 = 0.52). The fit of our multivariable regression analysis did not improve after adding hospital ward to the analysis (p > 0.05). CONCLUSIONS: Independence in mobility and urine catheter presence are two important factors associated with physical inactivity in hospitalized adults of all ages, and these associations do not differ between hospital wards. Routine assessments of both factors may therefore help to identify physically inactive patients throughout the hospital.IMPLICATIONS FOR REHABILITATIONHealthcare professionals should be aware that physical inactivity during hospital stay may result into functional decline.Regardless of which hospital ward patients are admitted to, once patients require assistance in basic mobility or have a urinary catheter they are at risk of physical inactivity during hospital stay.Implementing routine assessments on the independence of basic mobility and urine catheter presence may therefore assist healthcare professionals in identifying physically inactive patients before they experience functional decline.

Barriers to and solutions for improving physical activity in adults during hospital stay: a mixed-methods study among healthcare professionals.

PURPOSE: To identify healthcare professionals' perspectives on key barriers to improving physical activity in hospitalized adult patients, and to identify solutions to overcome these barriers. METHODS: We used an explanatory sequential mixed-methods study design in a Dutch university hospital. A survey exploring 39 potential barriers was completed by 15 physicians/physician assistants, 106 nurses, four nursing assistants, and four physical therapists working on surgery, internal medicine, and cardiology wards. Next, three in-depth semi-structured focus groups - comprising 30 healthcare professionals - discussed the survey findings to identify key barriers and solutions. Focus group discussions were analyzed using thematic analysis. RESULTS: Five themes were identified that described both the key barriers and the solutions to overcome these barriers. Healthcare professionals proposed several solutions, including clarifying the definition of physical activity, empowering patients to take responsibility for physical activity, giving physical therapists or physicians a prominent role in encouraging physical activity, and changing the hospital ward to entice patients to become physically active. CONCLUSIONS: Healthcare professionals need clear guidelines, roles, and responsibilities when it comes to physical activity. They also need personalized interventions that empower patients in physical activity. Finally, hospital wards should be designed and furnished so that patients are encouraged to be active.IMPLICATIONS FOR REHABILITATIONMany healthcare professionals want to sustainably improve physical activity in hospitalized adults.For this they need clear guidelines that not only define physical activity, but also describe the roles and responsibilities of all members of the medical team.Healthcare professionals need interventions that help to empower patients to take an active role in physical activity during hospital stay.Hospital wards should be designed and furnished so that patients are encouraged to be physically active.

Improving Physical Activity in Adults Admitted to a Hospital With Interventions Developed and Implemented Through Cocreation: Protocol for a Pre-Post Embedded Mixed Methods Study.

BACKGROUND: Admission to a hospital is often related with hospital-associated disabilities. Improving physical activity during hospitalization is considered effective to counteract hospital-associated disabilities, whereas many studies report on very low physical activity levels. Gradually developing and implementing interventions in cocreation with patients and health care professionals rather than implementing predefined interventions may be more effective in creating sustainable changes in everyday clinical practice. However, no studies have reported on the use of cocreation in the development and implementation of interventions aimed at improving physical activity. OBJECTIVE: This protocol presents a study that aims to investigate if interventions, which will be developed and implemented in cocreation, improve physical activity among patients in surgery, internal medicine, and cardiology hospital wards. The secondary aims are to investigate effectiveness in terms of the reduction in the time patients spend in bed, the length of hospital stay, and the proportion of patients going home after discharge. METHODS: The Better By Moving study takes place for 12 months at the following five different wards of a university hospital: two gastrointestinal and oncology surgery wards, one internal medicine hematology ward, one internal medicine infectious diseases ward, and one cardiology ward. The step-by-step implementation model of Grol and Wensing is used, and all interventions are developed and implemented in cocreation with health care professionals and patients. Outcome evaluation is performed across the different hospital wards and for each hospital ward individually. The primary outcome is the amount of physical activity in minutes assessed with the Physical Activity Monitor AM400 accelerometer in two individual groups of patients (preimplementation [n=110], and 13 months after the start of the implementation [n=110]). The secondary outcomes are time spent in bed measured using behavioral mapping protocols, and length of stay and discharge destination assessed using organizational data. A process evaluation using semistructured interviews and surveys is adopted to evaluate the implementation, mechanisms of impact, context, and perceived barriers and enablers. RESULTS: This study is ongoing. The first participant was enrolled in January 2018. The last outcome evaluation and process evaluation are planned for May and June 2020, respectively. Results are expected in April 2021. CONCLUSIONS: This study will provide information about the effectiveness of developing and implementing interventions in cocreation with regard to improving physical activity in different subgroups of hospitalized patients in a university hospital. By following step-by-step implementation and by performing process evaluation, we will identify the barriers and enablers for implementation and describe the effect of new interventions on improving physical activity among hospitalized patients. TRIAL REGISTRATION: Netherlands Trial Register NL8480; https://www.trialregister.nl/trial/8480. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19000.

Moderators of Exercise Effects on Cancer-related Fatigue: A Meta-analysis of Individual Patient Data.

PURPOSE: Fatigue is a common and potentially disabling symptom in patients with cancer. It can often be effectively reduced by exercise. Yet, effects of exercise interventions might differ across subgroups. We conducted a meta-analysis using individual patient data of randomized controlled trials (RCT) to investigate moderators of exercise intervention effects on cancer-related fatigue. METHODS: We used individual patient data from 31 exercise RCT worldwide, representing 4366 patients, of whom 3846 had complete fatigue data. We performed a one-step individual patient data meta-analysis, using linear mixed-effect models to analyze the effects of exercise interventions on fatigue (z score) and to identify demographic, clinical, intervention- and exercise-related moderators. Models were adjusted for baseline fatigue and included a random intercept on study level to account for clustering of patients within studies. We identified potential moderators by testing their interaction with group allocation, using a likelihood ratio test. RESULTS: Exercise interventions had statistically significant beneficial effects on fatigue (ß = -0.17; 95% confidence interval [CI], -0.22 to -0.12). There was no evidence of moderation by demographic or clinical characteristics. Supervised exercise interventions had significantly larger effects on fatigue than unsupervised exercise interventions (ßdifference = -0.18; 95% CI -0.28 to -0.08). Supervised interventions with a duration ≤12 wk showed larger effects on fatigue (ß = -0.29; 95% CI, -0.39 to -0.20) than supervised interventions with a longer duration. CONCLUSIONS: In this individual patient data meta-analysis, we found statistically significant beneficial effects of exercise interventions on fatigue, irrespective of demographic and clinical characteristics. These findings support a role for exercise, preferably supervised exercise interventions, in clinical practice. Reasons for differential effects in duration require further exploration.

Physical activity in patients with cancer: self-report versus accelerometer assessments.

PURPOSE: The level of daily physical activity in patients with cancer is frequently assessed by questionnaires, such as the Physical Activity Scale for the Elderly (PASE). Objective assessments, with for example accelerometers, may be a good alternative. The aim of this study was to investigate the agreement between the PASE questionnaire and accelerometer-assessed physical activity in a large group of patients with different types of cancer. METHODS: Baseline accelerometer and PASE questionnaire data of 403 participants from the REACT (Resistance and Endurance Exercise After Chemotherapy, n = 227), the EXIST (Exercise Intervention After Stem-Cell Transplantation, n = 74), and NET-QUBIC (NEtherlands QUality of Life And Biomedical Cohort Studies In Cancer, n = 102) studies were available for the current analyses. Physical activity was assessed by the PASE questionnaire (total score) and accelerometers (total minutes per day > 100 counts). Linear mixed models regression analysis was used to assess the agreement between the PASE questionnaire and accelerometer-assessed physical activity. RESULTS: The mean (SD) PASE score was 95.9 (75.1) points and mean (SD) time in physical activity measured with the accelerometer was 256.6 (78.8) min per day. The agreement between the PASE score and the accelerometer data was significant, but poor (standardized regression coefficient (B) = 0.36, 95%CI = 0.27; 0.44, p < 0.01). CONCLUSION: Agreement between the PASE questionnaire and accelerometer-assessed physical activity was poor. The poor agreement indicates that they measure different physical activity constructs and cannot be used interchangeably to assess the level of daily physical activity in patients with cancer.

Long-term effectiveness and cost-effectiveness of an 18-week supervised exercise program in patients treated with autologous stem cell transplantation: results from the EXIST study.

PURPOSE: To evaluate the long-term effectiveness and cost-effectiveness of a supervised 18-week high-intensity exercise program compared with usual care in patients treated with autologous stem cell transplantation. METHODS: One hundred nine patients were randomly assigned to the exercise intervention (n = 54) or the usual care control group (n = 55). Data on cardiorespiratory fitness (VO2peak), handgrip strength, general fatigue, and health-related quality of life (quality-adjusted life years [QALYs]) were collected at baseline (T0), after completion of the exercise intervention or at a similar time point in the control group (T1) and 12 months later (T2). Cost questionnaires were used to assess societal costs. Long-term effectiveness (at T2) was evaluated using linear mixed model analyses. For the economic evaluation, missing data were imputed using multiple imputation, and data were analyzed using linear mixed models. RESULTS: At T2, no statistically significant differences were found between the intervention and control group for VO2peak (0.12; 95%CI - 1.89; 2.14 ml/min/kg), handgrip strength (- 1.08; 95%CI- 2.47; 2.31), and general fatigue (- 0.69; 95%CI - 2.52; 1.14). During 12-months follow-up, no significant between-group differences in QALYs and societal costs were found (QALYs - 0.07; 95%CI - 0.17; 0.04; costs 529; 95%CI - 3205;4452). Intervention costs were €1340 per patient. For all outcomes, the probability of the intervention being cost-effective was low at reasonable values of willingness-to-pay. CONCLUSION: We found no evidence for the exercise intervention being effective on physical fitness and fatigue, nor cost-effective from a societal perspective. TRIAL REGISTRATION: The study was prospectively registered on 27 May 2010 at the Netherlands Trial Register ( NTR2341 ). IMPLICATIONS FOR CANCER SURVIVORS: The current exercise intervention should not be recommended to patients recently treated with autologous stem cell transplantation.

Effects and moderators of exercise on muscle strength, muscle function and aerobic fitness in patients with cancer: a meta-analysis of individual patient data.

OBJECTIVE: To optimally target exercise interventions for patients with cancer, it is important to identify which patients benefit from which interventions. DESIGN: We conducted an individual patient data meta-analysis to investigate demographic, clinical, intervention-related and exercise-related moderators of exercise intervention effects on physical fitness in patients with cancer. DATA SOURCES: We identified relevant studies via systematic searches in electronic databases (PubMed, Embase, PsycINFO and CINAHL). ELIGIBILITY CRITERIA: We analysed data from 28 randomised controlled trials investigating the effects of exercise on upper body muscle strength (UBMS) and lower body muscle strength (LBMS), lower body muscle function (LBMF) and aerobic fitness in adult patients with cancer. RESULTS: Exercise significantly improved UBMS (ß=0.20, 95% Confidence Interval (CI) 0.14 to 0.26), LBMS (ß=0.29, 95% CI 0.23 to 0.35), LBMF (ß=0.16, 95% CI 0.08 to 0.24) and aerobic fitness (ß=0.28, 95% CI 0.23 to 0.34), with larger effects for supervised interventions. Exercise effects on UBMS were larger during treatment, when supervised interventions included ≥3 sessions per week, when resistance exercises were included and when session duration was >60 min. Exercise effects on LBMS were larger for patients who were living alone, for supervised interventions including resistance exercise and when session duration was >60 min. Exercise effects on aerobic fitness were larger for younger patients and when supervised interventions included aerobic exercise. CONCLUSION: Exercise interventions during and following cancer treatment had small effects on UBMS, LBMS, LBMF and aerobic fitness. Demographic, intervention-related and exercise-related characteristics including age, marital status, intervention timing, delivery mode and frequency and type and time of exercise sessions moderated the exercise effect on UBMS, LBMS and aerobic fitness.

Targeting Exercise Interventions to Patients With Cancer in Need: An Individual Patient Data Meta-Analysis.

Background: Exercise effects in cancer patients often appear modest, possibly because interventions rarely target patients most in need. This study investigated the moderator effects of baseline values on the exercise outcomes of fatigue, aerobic fitness, muscle strength, quality of life (QoL), and self-reported physical function (PF) in cancer patients during and post-treatment. Methods: Individual patient data from 34 randomized exercise trials (n = 4519) were pooled. Linear mixed-effect models were used to study moderator effects of baseline values on exercise intervention outcomes and to determine whether these moderator effects differed by intervention timing (during vs post-treatment). All statistical tests were two-sided. Results: Moderator effects of baseline fatigue and PF were consistent across intervention timing, with greater effects in patients with worse fatigue (Pinteraction = .05) and worse PF (Pinteraction = .003). Moderator effects of baseline aerobic fitness, muscle strength, and QoL differed by intervention timing. During treatment, effects on aerobic fitness were greater for patients with better baseline aerobic fitness (Pinteraction = .002). Post-treatment, effects on upper (Pinteraction < .001) and lower (Pinteraction = .01) body muscle strength and QoL (Pinteraction < .001) were greater in patients with worse baseline values. Conclusion: Although exercise should be encouraged for most cancer patients during and post-treatments, targeting specific subgroups may be especially beneficial and cost effective. For fatigue and PF, interventions during and post-treatment should target patients with high fatigue and low PF. During treatment, patients experience benefit for muscle strength and QoL regardless of baseline values; however, only patients with low baseline values benefit post-treatment. For aerobic fitness, patients with low baseline values do not appear to benefit from exercise during treatment.

Effects of Upper-Extremity Surgery on Manual Performance of Children and Adolescents with Cerebral Palsy: A Multidisciplinary Approach Using Shared Decision-Making.

BACKGROUND: Little is known about the effects of upper-extremity surgery on the manual performance of children and adolescents with cerebral palsy (CP). This clinical cohort study describes our experience with patient selection based on multidisciplinary assessment and shared decision-making and the effects of upper-extremity surgery on manual performance and patient-relevant outcomes. METHODS: All patients (up to 20 years of age) with CP referred to our multidisciplinary team for evaluation for upper-extremity surgery between July 2011 and May 2017 were included. Suitability for upper-extremity surgery was assessed with comprehensive, multidisciplinary screening, and the decision to proceed with surgery was made together with the patient. Individual patient-relevant goals were identified with the Canadian Occupational Performance Measure (COPM); perceived independence in performing bimanual activities at home was assessed with the ABILHAND-Kids tool, and perceived quality of use of the affected hand during daily activities was assessed with a visual analog scale (VAS). The quality of use of the affected hand during bimanual performance was measured with the Assisting Hand Assessment (AHA), and gross manual dexterity was evaluated with the Box and Block Test (BBT). All baseline assessments were repeated at an average of 9 months after the surgery. RESULTS: Of 66 patients assessed by the multidisciplinary upper-extremity-surgery team, 44 were considered eligible for upper-extremity surgery. Of these patients, 39 (mean age and standard deviation [SD], 14.9 ± 2.10 years, 87% with unilateral CP, and 72% at Manual Ability Classification System [MACS] level II) underwent upper-extremity surgery and were evaluated in the pre-post study. All outcomes improved significantly after upper-extremity surgery, with average improvements of 3.1 ± 1.6 points in the COPM-Performance (COPM-P) score (p < 0.001), 3.3 ± 2.1 points in the COPM-Satisfaction (COPM-S) score (p < 0.001), 1.5 ± 1.2 logits in the ABILHAND score (p < 0.001), 2.4 ± 1.9 cm in the VAS score (p < 0.001), 6.7 ± 4.2 units in the AHA score (p < 0.001), and 2.2 ± 5.0 blocks/minute on the BBT (p = 0.021). The improvement in the COPM-P, COPM-S, ABILHAND, VAS, AHA, and BBT scores was clinically meaningful in 80%, 77%, 55%, 62%, 71%, and 31% of the patients, respectively. CONCLUSIONS: Careful assessment of eligibility for upper-extremity surgery, based on multidisciplinary screening and shared decision-making, resulted in a clinically relevant improvement in patient-specific functional and/or cosmetic goals and manual performance after upper-extremity surgery in most patients with CP. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Randomized controlled trial on the effects of a supervised high intensity exercise program in patients with a hematologic malignancy treated with autologous stem cell transplantation: Results from the EXIST study.

BACKGROUND: This single blind, multicenter randomized controlled trial aimed to evaluate the effectiveness of a supervised high intensity exercise program on physical fitness and fatigue in patients with multiple myeloma or lymphoma recently treated with autologous stem cell transplantation. METHODS: 109 patients were randomly assigned to the 18-week exercise intervention or the usual care control group. The primary outcomes included physical fitness (VO2peak and Wpeak determined using a cardiopulmonary exercise test; grip strength and the 30s chair stand test) and fatigue (Multidimensional Fatigue Inventory) and were assessed prior to randomization and after completion of the intervention or at similar time points for the control group. Multivariable multilevel linear regression analyses were performed to assess intervention effects. RESULTS: Patients in the intervention group attended 86% of the prescribed exercise sessions. Of the patients in the control group, 47% reported ≥10 physiotherapy sessions, which most likely included supervised exercise, suggesting a high rate of contamination. Median improvements in physical fitness ranged between 16 and 25% in the intervention group and between 12 and 19% in the control group. Fatigue decreased in both groups. There were no significant differences between the intervention and control group. CONCLUSION: We found no significant beneficial effects of the supervised high intensity exercise program on physical fitness and fatigue when compared to usual care. We hypothesized that the lack of significant intervention effects may relate to suboptimal timing of intervention delivery, contamination in the control group and/or suboptimal compliance to the prescribed exercise intervention. TRIAL REGISTRATION: Netherlands Trial Register-NTR2341.

Validation and Refinement of Prediction Models to Estimate Exercise Capacity in Cancer Survivors Using the Steep Ramp Test.

OBJECTIVE: To further test the validity and clinical usefulness of the steep ramp test (SRT) in estimating exercise tolerance in cancer survivors by external validation and extension of previously published prediction models for peak oxygen consumption (Vo2peak) and peak power output (Wpeak). DESIGN: Cross-sectional study. SETTING: Multicenter. PARTICIPANTS: Cancer survivors (N=283) in 2 randomized controlled exercise trials. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prediction model accuracy was assessed by intraclass correlation coefficients (ICCs) and limits of agreement (LOA). Multiple linear regression was used for model extension. Clinical performance was judged by the percentage of accurate endurance exercise prescriptions. RESULTS: ICCs of SRT-predicted Vo2peak and Wpeak with these values as obtained by the cardiopulmonary exercise test were .61 and .73, respectively, using the previously published prediction models. 95% LOA were ±705mL/min with a bias of 190mL/min for Vo2peak and ±59W with a bias of 5W for Wpeak. Modest improvements were obtained by adding body weight and sex to the regression equation for the prediction of Vo2peak (ICC, .73; 95% LOA, ±608mL/min) and by adding age, height, and sex for the prediction of Wpeak (ICC, .81; 95% LOA, ±48W). Accuracy of endurance exercise prescription improved from 57% accurate prescriptions to 68% accurate prescriptions with the new prediction model for Wpeak. CONCLUSIONS: Predictions of Vo2peak and Wpeak based on the SRT are adequate at the group level, but insufficiently accurate in individual patients. The multivariable prediction model for Wpeak can be used cautiously (eg, supplemented with a Borg score) to aid endurance exercise prescription.

Health-related physical fitness in patients with multiple myeloma or lymphoma recently treated with autologous stem cell transplantation.

OBJECTIVES: We aimed to examine health-related physical fitness and its demographic and clinical correlates in patients recently treated with autologous stem cell transplantation. DESIGN: Cross-sectional study. METHODS: In 109 patients (multiple myeloma: n=58, lymphoma: n=51, median age: 55, range: 19-67 years) maximal exercise testing was conducted to assess cardiorespiratory fitness (VO2peak). Upper and lower extremity muscle strength were assessed with hand grip- and fixed dynamometry and body composition with whole body DXA scans. In addition, we assessed the patients' demographic and clinical characteristics and examined whether they were associated with health-related physical fitness. RESULTS: VO2peak was 21.7 (5.5) mL/min/kg, 26% below reference values. Muscle strength was also reduced when compared with reference values (upper extremity: 90%, lower extremity: 80%) and 73% of our population was classified as overweight or obese. Being female and being older were significantly associated with a lower cardiorespiratory fitness (gender: ß=-2.7, 95%CI=-4.6;-0.7mL/min/kg; age: ß=-0.2, 95%CI=-0.3;-0.1mL/min/kg), upper (gender: ß=-17.7, 95%CI=-20.1;-15.3kg; age: ß=-0.2, 95%CI=-0.3;-0.1kg) and lower (gender: ß=-58.3, 95%CI=-73.5;- 43.0Nm; age: ß=-1.7, 95%CI=-2.4;-1.1Nm) extremity muscle strength. Patients who were non-smoking (ß=-5.3, 95%CI=-8.7;-1.9), women (ß=7.2, 95%CI=4.8;9.6) and diagnosed with multiple myeloma (ß=4.6, 95%CI=2.2;6.9) had a higher percentage body fat. CONCLUSIONS: The physical fitness deficits in this population indicate the need for targeted interventions. TRIAL REGISTRATION: Netherlands Trial Register - NTR2341.

Effects and moderators of exercise on quality of life and physical function in patients with cancer: An individual patient data meta-analysis of 34 RCTs.

This individual patient data meta-analysis aimed to evaluate the effects of exercise on quality of life (QoL) and physical function (PF) in patients with cancer, and to identify moderator effects of demographic (age, sex, marital status, education), clinical (body mass index, cancer type, presence of metastasis), intervention-related (intervention timing, delivery mode and duration, and type of control group), and exercise-related (exercise frequency, intensity, type, time) characteristics. Relevant published and unpublished studies were identified in September 2012 via PubMed, EMBASE, PsycINFO, and CINAHL, reference checking and personal communications. Principle investigators of all 69 eligible trials were requested to share IPD from their study. IPD from 34 randomised controlled trials (n=4519 patients) that evaluated the effects of exercise compared to a usual care, wait-list or attention control group on QoL and PF in adult patients with cancer were retrieved and pooled. Linear mixed-effect models were used to evaluate the effects of the exercise on post-intervention outcome values (z-score) adjusting for baseline values. Moderator effects were studies by testing interactions. Exercise significantly improved QoL (ß=0.15, 95%CI=0.10;0.20) and PF (ß=0.18, 95%CI=0.13;0.23). The effects were not moderated by demographic, clinical or exercise characteristics. Effects on QoL (ßdifference_in_effect=0.13, 95%CI=0.03;0.22) and PF (ßdifference_in_effect=0.10, 95%CI=0.01;0.20) were significantly larger for supervised than unsupervised interventions. In conclusion, exercise, and particularly supervised exercise, effectively improves QoL and PF in patients with cancer with different demographic and clinical characteristics during and following treatment. Although effect sizes are small, there is consistent empirical evidence to support implementation of exercise as part of cancer care.

Effects of exercise in patients treated with stem cell transplantation for a hematologic malignancy: a systematic review and meta-analysis.

We performed a systematic review and meta-analysis evaluating the effectiveness of exercise interventions compared with usual care on physical fitness, fatigue and health-related quality of life in patients with hematologic malignancies treated with stem cell transplantation. Electronic databases were searched up to June 2012. We included randomized controlled trials comparing exercise with usual care, in which at least 75% of the patients had a hematologic malignancy. Standard mean differences were calculated and pooled to generate summary effect sizes (ES) and 95% confidence intervals (CI). The Cochrane Collaboration Risk of Bias Tool was used to assess the methodological quality of the studies. Eight studies met our inclusion criteria. Exercise had a statistically significant moderately favourable effect on cardiorespiratory fitness (ES=0.53, 95% CI=0.13-0.94), lower extremity muscle strength (ES=0.56, 95% CI=0.18-0.94) and fatigue (ES=0.53, 95% CI=0.27-0.79). Significant small positive effects were found for upper extremity muscle strength, global quality of life, and physical, emotional and cognitive functioning. In conclusion, exercise seems to have beneficial effects in patients treated with stem cell transplantation. However, all studies had at least some risk of bias, and for cardiorespiratory fitness and lower extremity muscle strength substantial heterogeneity in effect sizes were observed. Further high quality research is needed to determine the optimal exercise intervention and clinical implications.

Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: a pilot study.

BACKGROUND: Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections. Recently, physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay. The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training (IMT) on the incidence of pneumonia in patients undergoing oesophagectomy. METHODS: A pragmatic non-randomized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010. Patients in the intervention group received IMT prior to surgery. Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction. Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure (MIP) and endurance, the incidence of post-operative pneumonia and length of hospital stay. RESULTS: Eighty-three patients were included, of which 44 received pre-operative IMT. No adverse effects were observed. IMT was well tolerated and appreciated. In the intervention group, the median MIP and endurance improved significantly after IMT by 32% and 41%, respectively (p < 0.001). The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups (pneumonia, 25% vs. 23% [p = 0.84]; hospitalization, 13.5 vs. 12 days [p = 0.08]). CONCLUSIONS: Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function. This, however, did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy.

The infant behavioral assessment and intervention program in very low birth weight infants; outcome on executive functioning, behaviour and cognition at preschool age.

BACKGROUND: The Infant Behavioral Assessment and Intervention Program (IBAIP©) improved motor function at 24 months, and mental and behavioural development in high risk subgroups of very low birth weight (VLBW) infants. AIM: To determine IBAIP's effects on executive functioning, behaviour and cognition at preschool age. STUDY DESIGN: Follow-up of a randomised controlled trial (RCT). SUBJECTS: At 44 months corrected age, all 176 VLBW infants were invited for follow-up. Forty-one term born children were assessed for comparison. OUTCOME MEASURES: Visual Attention Task (VAT), Gift delay, Peabody Picture Vocabulary Test III-NL (PPVT), Visual motor integration tests and Miller assessment for preschoolers. Parents completed Behavior Rating Inventory of Executive Function-Preschool (BRIEF-P) and Child Behavior Checklist (CBCL). RESULTS: At preschool age, 76 (88%) children of the intervention group and 75 (83%) children of the control group participated. There were no significant differences between the intervention and the control group. However, positive interaction effects between intervention and infants with bronchopulmonary dysplasia, infants born at gestational age<28 weeks, and infants of low educated mothers were found on CBCL, CBCL and BRIEF-P, and PPVT respectively. Most interaction effects exceeded 1 standard deviation in favour of the intervention children. The 151 VLBW children performed significantly worse than the term born children on the VAT, BRIEF-P and CBCL. CONCLUSION: IBAIP effects in VLBW children did not sustain until preschool age on executive functioning, behaviour and cognition. However, the most vulnerable children had a clinical relevant profit from IBAIP. VLBW children performed worse than the term born children. This study is a follow-up at preschool age of the multi-centre RCT of IBAIP versus usual care in VLBW infants. The RCT was performed in Amsterdam, The Netherlands (IBAIP).

Alpe d'HuZes cancer rehabilitation (A-CaRe) research: four randomized controlled exercise trials and economic evaluations in cancer patients and survivors.

BACKGROUND: Previous studies showed that exercise in cancer patients is feasible and may reduce fatigue and improve physical fitness and quality of life. However, many previous studies had methodological weaknesses related to trial design, sample size, comparison group, outcome measures, short follow-up durations and programme content. PURPOSE: This paper aims to present the rationale and design of the clinical research subprogramme of the Alpe d'HuZes Cancer Rehabilitation (A-CaRe) programme. METHOD: A-CaRe Clinical Research includes four randomized controlled trials in patients: (a) after chemotherapy, (b) during chemotherapy, (c) after stem cell transplantation and (d) during childhood cancer. These trials compare high-intensity resistance and endurance exercise interventions with usual care or a waiting list control group. In two studies, a second intervention arm consisting of low-to-moderate intensity exercise is included. All four A-CaRe trials use similar methods. RESULTS: Outcome measures are carefully chosen based on the International Classification of Functioning Disability and Health model. Measurements will be performed prior to randomization (T0), after completion of the intervention (T1) and at follow-up (T2). The primary outcome measures are cardiorespiratory fitness, muscle strength and fatigue. Secondary outcome measures include health-related quality of life and psychosocial functioning. Furthermore, cost-effectiveness and cost-utility analyses are performed from a societal perspective. CONCLUSION: We hypothesize that exercise is more effective at improving physical fitness and thereby reducing fatigue and more cost-effective compared with usual care or a waiting list control group. If so, the programmes will be implemented in the Dutch clinical practice.