Physiotherapy management of cancer-related fatigue: a survey of UK current practice

Canadian oncology physiotherapists' perspectives of physical activity in people with advanced cancer: a mixed-methods study

BACKGROUND

Individuals with advanced cancer can benefit from physical activity (PA), but face barriers to PA participation. Physiotherapists can be well-positioned to support this patient population.

OBJECTIVE

Our objective was to describe the perspectives, practices, knowledge, and skills of oncology physiotherapists related to PA in people with advanced cancer.

METHODS

In this mixed-methods study, we recruited Canadian physiotherapists with current or recent clinical experience with advanced cancer. Phase I consisted of an online survey about views toward PA in advanced cancer and activity-related recommendations and concerns for two case scenarios. Phase II involved individual, semi-structured interviews about perspectives related to working with advanced cancer.

RESULTS

Sixty-two physiotherapists participated in the survey, of which 13 participated in interviews. Most respondents (> 85%) agreed or strongly agreed PA is important and safe for individuals with advanced cancer. Case responses highlighted cancer-related considerations (e.g. bone metastases) tailored activity recommendations, and patient-centered, interprofessional care. Interview themes included: 1) situating PA within individually meaningful goals; 2) tailored strategies to promote PA; 3) overarching roles in functional optimization and symptom management; and 4) generalized lack of awareness regarding physiotherapy.

CONCLUSION

Our findings indicate Canadian oncology physiotherapists describe knowledge of the safety and importance of PA, as well as key considerations in advanced cancer. Moreover, they highlight the importance of a patient-centered approach to support this population, particularly in facilitating safe and meaningful PA, as well as optimizing function and alleviating symptom burden. Further efforts are needed to investigate the development and integration of physiotherapy within cancer care.

Physical activity and life-limiting conditions

BACKGROUND

Physical activity can assist people with life-limiting conditions to maintain their wellbeing and quality of life.

AIMS

To explore the views of clinical nurse specialists (CNS) working in community palliative care towards the role of physical activity for people with life-limiting conditions, and to explore the physical activity needs of patients with life-limiting conditions identified by CNSs.

METHODS

A purposive sample of CNSs working in community palliative care received an anonymous online survey via email.

FINDINGS

The response rate was 66% (n=20). Most respondents were practicing for over 20 years (60%, n=12). All respondents (100%, n=20) reported they would like further information on the role of exercise for palliative populations. The main perceived benefit of physical activity was to improve quality of life (95%, n=18). A lack of physical activity guidelines for people living with life-limiting conditions was the most commonly reported barrier to engaging in discussions around physical activity (74%, n=14).

CONCLUSION

Further education opportunities on the role of physical activity for patients living with life-limiting conditions are needed.

Non-Parametric Functional Muscle Network as a Robust Biomarker of Fatigue

Characterization of fatigue using surface electromyography (sEMG) data has been motivated for rehabilitation and injury-preventative technologies. Current sEMG-based models of fatigue are limited due to (a) linear and parametric assumptions, (b) lack of a holistic neurophysiological view, and (c) complex and heterogeneous responses. This paper proposes and validates a data-driven non-parametric functional muscle network analysis to reliably characterize fatigue-related changes in synergistic muscle coordination and distribution of neural drive at the peripheral level. The proposed approach was tested on data collected in this study from the lower extremities of 26 asymptomatic volunteers (13 subjects were assigned to the fatigue intervention group, and 13 age/gender-matched subjects were assigned to the control group). Volitional fatigue was induced in the intervention group by moderate-intensity unilateral leg press exercises. The proposed non-parametric functional muscle network demonstrated a consistent decrease in connectivity after the fatigue intervention, as indicated by network degree, weighted clustering coefficient (WCC), and global efficiency. The graph metrics displayed consistent and significant decreases at the group level, individual subject level, and individual muscle level. For the first time, this paper proposed a non-parametric functional muscle network and highlighted the corresponding potential as a sensitive biomarker of fatigue with superior performance to conventional spectrotemporal measures.

Physical Therapists in Oncology Settings: Experiences in Delivering Cancer Rehabilitation Services, Barriers to Care, and Service Development Needs

OBJECTIVE

Physical therapist-delivered rehabilitation aims to manage the side effects of cancer and its treatments. Although access to cancer rehabilitation is not yet a standard of care in many countries, physical therapists practice in many types of cancer services with different cancer populations. The purpose of this study was to explore the experiences of physical therapists in cancer care practice with regard to their role, the factors influencing service delivery and development, and physical therapists' professional development needs.

METHODS

In this qualitative study with semistructured interviews, physical therapists in cancer care settings in the Republic of Ireland were interviewed via telephone. Participants (n = 17) represented a variety of clinical settings and roles. Two researchers performed thematic analysis of transcriptions using a semantic, inductive approach. Key themes and codes were identified and illustrative quotes were selected.

RESULTS

Six main themes were found: the need for more services, barriers to service development and delivery, a lack of awareness of the role of physical therapy, facilitators to service development, goals for the future of oncology physical therapy, and training needs of staff.

CONCLUSIONS

Physical therapists provide valuable interventions across the spectrum of cancer care but experience barriers to the delivery and development of services. Investment in oncology physical therapy and developing international standards of care will allow physical therapists to meet the rehabilitation needs of survivors of cancer.

IMPACT

As international guidelines increasingly recommend development of cancer rehabilitation programs, it is important to understand physical therapists' experiences of working in cancer care to assist in the development of effective oncology physical therapy services. This study demonstrates that physical therapist-led cancer rehabilitation services need investment and public promotion to enable the provision of optimal services to all patients with cancer and to meet standards of care.

Perceptions and work-readiness of Australian physiotherapists in cancer care: a national evaluation

OBJECTIVES

Physiotherapy interventions can improve health outcomes for people across the cancer continuum yet little is known of the work-readiness and perceptions of physiotherapists working in cancer care. This study described perceptions of Australian physiotherapists.

DESIGN

Electronic, national cross-sectional survey.

SETTING

One hundred nineteen Australian hospitals and 35 rehabilitation programmes in July 2019 were invited.

PARTICIPANTS

Clinical physiotherapists responsible for the provision of cancer care.

MAIN OUTCOME MEASURES

Custom-designed survey targeted clinical knowledge, physiotherapy management, physical activity/exercise, and learning/preparedness. Relationships between domains and demographic characteristics eg: clinical experience and work setting, were analysed.

RESULTS

One hundred twenty eight surveys were completed. Median [IQR] experience was 8 [4 to 19] years (2 [0.5 to 5] years specifically in oncology). Most participants (99/128, 77%) felt poorly prepared to commence work in oncology. Confidence was consistently lower among physiotherapists in their first year compared to others. Confidence and knowledge was rated high for people with early stage cancers (median 4 [3 to 5]) and lower for prescribing exercise for patients with cardiotoxicity and knowledge of precautions/contraindications regarding hormone and targeted therapies (median 2 [1 to 3]). High importance ratings (Likert scores 4 or 5) were reported for exercise (115/127, 91%) and physical activity (120/126, 95%). Learning needs were identified for medical management, treatment side-effects/precautions and management of cancer-related pain and fatigue.

CONCLUSION

Australian physiotherapists feel underprepared to work in cancer care, but report good confidence and knowledge. Professional development opportunities appear indicated.

Current physical therapy care of patients undergoing breast reconstruction for breast cancer: a survey of practice in the United Kingdom and Brazil

BACKGROUND

In both the United Kingdom (UK) and Brazil, women undergoing mastectomy should be offered breast reconstruction. Patients may benefit from physical therapy to prevent and treat muscular deficits. However, there are uncertainties regarding which physical therapy program to recommend.

OBJECTIVE

The aim was to investigate the clinical practice of physical therapists for patients undergoing breast reconstruction for breast cancer. A secondary aim was to compare physical therapy practice between UK and Brazil.

METHODS

Online survey with physical therapists in both countries. We asked about physical therapists' clinical practice.

RESULTS

181 physical therapists completed the survey, the majority were from Brazil (77%). Respondents reported that only half of women having breast reconstruction were routinely referred to physical therapy postoperatively. Contact with patients varied widely between countries, the mean number of postoperative sessions was 5.7 in the UK and 15.1 in Brazil. The exercise programs were similar for different reconstruction operations. Therapists described a progressive loading structure over time: range of motion (ROM) was restricted to 90° of arm elevation in the first two postoperative weeks; by 2-4 weeks ROM was unrestricted; at 1-3 months muscle strengthening was initiated, and after three months the focus was on sports-specific activities.

CONCLUSION

Only half of patients having a breast reconstruction are routinely referred to physical therapy. Patients in Brazil have more intensive follow-up, with up to three times more face-to-face contact with a physical therapist than in the UK. Current practice broadly follows programs for mastectomy care rather than being specific to reconstruction surgery.

Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial

Purpose

Cancer-related fatigue (CRF) is a common and relevant symptom in patients with advanced cancer that significantly decreases their quality of life. The aim of this study was to evaluate the effect of a physiotherapy programme on CRF and other symptoms in patients diagnosed with advanced cancer.

Methods

The study was designed as a randomized controlled trial. Sixty patients diagnosed with advanced cancer receiving palliative care were randomized into two groups: the treatment group (n = 30) and the control group (n = 30). The therapy took place three times a week for 2 weeks. The 30-min physiotherapy session included active exercises, myofascial release and proprioceptive neuromuscular facilitation (PNF) techniques. The control group did not exercise. The outcomes included Brief Fatigue Inventory (BFI), Edmonton Symptom Assessment Scale (ESAS) and satisfaction scores.

Results

The exercise programme caused a significant reduction in fatigue scores (BFI) in terms of severity of fatigue and its impact on daily functioning. In the control group, no significant changes in the BFI were observed. Moreover, the physiotherapy programme improved patients’ general well-being and reduced the intensity of coexisting symptoms such as pain, drowsiness, lack of appetite and depression. The analysis of satisfaction scores showed that it was also positively evaluated by patients.

Conclusion

The physiotherapy programme, which included active exercises, myofascial release and PNF techniques, had beneficial effects on CRF and other symptoms in patients with advanced cancer who received palliative care. The results of the study suggest that physiotherapy is a safe and effective method of CRF management.

Relationship between patterns of daily physical activity and fatigue in cancer survivors

PURPOSE

This study investigated: (1) physical activity behaviour of cancer survivors throughout the day, (2) the relationship between objective and subjective measures of physical activity, and (3) the relationship between daily physical activity and fatigue.

METHOD

Physical activity was measured objectively using 3D-accelerometry (expressed in counts per minute (cpm)), and subjectively using a Visual Analogue Scale (VAS; 0-10) implemented on a smartphone in 18 cancer survivors (6 male; age 55.7 ± 10.2 yrs; free from cancer, last treatment ≥three months previously), and matched controls. Fatigue was scored thrice daily on a smartphone (0-10 VAS).

RESULTS

Mean daily physical activity of cancer survivors did not deviate from controls (1108 ± 287 cpm versus 1223 ± 371 cpm, p = .305). However, in cancer survivors physical activity significantly decreased from morning to evening (p < .01) and increased levels of fatigue throughout the day were reported (p < .01). Furthermore, a positive correlation was found between levels of fatigue and the magnitude of the decline in physical activity from afternoon to evening (p < .05). Objective and subjective measured physical activity showed low correlations.

CONCLUSIONS

This study demonstrated imbalanced activity patterns in cancer survivors. Also, the more a survivor felt fatigued, the greater the decline in activity behaviour throughout the day. The low correlation between objective and subjective physical activity suggests low awareness in cancer survivors about their daily physical activity performed. Ambulatory monitoring provides new insights in both patterns of physical activity and fatigue, which might be a valuable tool to provide activity management more efficiently during treatment of fatigue.

An evaluation of the St Christopher's Hospice rehabilitation gym circuits classes: Patient uptake, outcomes, and feedback

Background

Evidence suggests exercise may benefit patients with advanced progressive illness and some hospice day services now provide dedicated gym space. However, supporting data for such a service development are limited. We describe patient referrals, interventions, feedback, and potential impact of a nine-session, outpatient, hospice-based, circuit exercise programme.

Methods

Consecutive referrals to physiotherapy over a 6-month period commencing March 2013 were followed prospectively. Physical function (short physical performance battery (SPPB), grip strength), fatigue (Functional Assessment of Chronic Illness Therapy), psychological well-being (General Health Questionnaire), and patient satisfaction (FACIT-PS) were assessed pre- and post-programme.

Results

Of 212 referrals, 61 (29%) with a range of cancer and non-cancer diagnoses (median [inter-quartile range] survival 67 [50–137] days) were considered appropriate for the circuits of whom 54 (89%) started. There were no statistical differences between those completing and not-completing with regards to age, diagnosis, social status, or survival. In completers (n = 28), 4-m gait speed (mean Δ [95% confidence intervals] 0.23 [0.03, 0.44] m/seconds), five sit-to-stand time (mean Δ −5.44 [−10.43, −0.46] seconds) and overall SPPB score changed statistically, while grip strength did not (mean Δ 0.65 [−1.39, 2.96] kg). Psychological well-being, quality of life, and fatigue remained unchanged. Patients felt the physiotherapists gave clear explanations, understood their needs, and would recommend the service to others.

Conclusion

A hospice-based programme is one way to offer exercise to a range of patients with advanced progressive illness. Despite excellent feedback, only half of patients completed the nine-session programme in full and evidence of benefit was limited. Future work should explore the broader benefits of participation and whether delivering programmes or elements of them in shorter time frames is more beneficial.

Oncology Rehabilitation Provision and Practice Patterns across Canada

PURPOSE

Rehabilitation is increasingly recognized as an important therapeutic intervention for people with cancer. The main objective of this study was to explore the current practice pattern and provision of oncology rehabilitation in Canada.

METHODS

A descriptive cross-sectional online survey was administered to Canadian facilities offering cancer treatment and/or listed as offering rehabilitation services during or after cancer treatment (cancer centres, rehabilitation hospitals, community centres, and private clinics).

RESULTS

Of the 116 sites contacted, 62 completed the questionnaire, 20 of which reported having an oncology rehabilitation programme. The majority of respondents indicated that they are not meeting their clients' rehabilitation needs. Rehabilitation programmes were provided by multidisciplinary health care teams, the majority of which included a physiotherapist. Funding and availability of resources were identified as the main barriers to the development of oncology rehabilitation programmes.

CONCLUSIONS

Formal oncology rehabilitation programmes appear to be scarce, despite growing evidence that rehabilitation offers benefits across the cancer survivorship continuum.

Cancer survivors' exercise barriers, facilitators and preferences in the context of fatigue, quality of life and physical activity participation: a questionnaire-survey

OBJECTIVE

To investigate the exercise barriers, facilitators and preferences of a mixed sample of cancer survivors as well as fatigue levels, quality of life (QoL) and the frequency and intensity of exercise that cancer survivors typically engage in.

METHODS

An anonymous, postal questionnaire-survey with a convenience sample of 975 cancer survivors was used. Standardised measures were used to establish fatigue (Multidimensional Fatigue Symptom Inventory-Short Form), QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30), exercise frequency and intensity (Leisure Score Index).

RESULTS

A 52.3% response rate (n = 456) was achieved. A total of 76.0% were female, with stage I (18.3%) or stage II (21.0%) breast cancer (64.4%), and 62.3% were ≥ 3 years post treatment. A total of 73.5% reported fatigue with 57.2% experiencing fatigue on a daily basis. A total of 68.1% had never been given any advice on how to manage fatigue. A total of 9.4% reported to engage in strenuous physical activity, 43.5% in moderate physical activity and 65.5% in mild physical activity. Respondents experienced difficulties with emotional, cognitive and social functioning and the symptoms of fatigue, insomnia and pain. Barriers that interfered with exercise 'often/very often' were mainly related to respondents' health and environmental factors. A total of 50.2% were interested in exercise and 52.5% felt able to exercise. Exercise facilitators, preferences and motivators provide some insight into cancer survivors' needs in terms of becoming more physically active.

CONCLUSIONS

Although cancer survivors continue to experience fatigue and QoL issues long after treatment completion, over half are willing and feel able to participate in exercise. Exercise barriers were mainly health related or environmental issues, however, the main barriers reported were those that had the potential to be alleviated by exercise.

Effectiveness of core stability exercises and recovery myofascial release massage on fatigue in breast cancer survivors: a randomized controlled clinical trial

The purpose of the present paper was to evaluate the effects of an 8-week multimodal program focused on core stability exercises and recovery massage with DVD support for a 6-month period in physical and psychological outcomes in breast cancer survivors. A randomized controlled clinical trial was performed. Seventy-eight (n = 78) breast cancer survivors were assigned to experimental (core stability exercises plus massage-myofascial release) and control (usual health care) groups. The intervention period was 8 weeks. Mood state, fatigue, trunk curl endurance, and leg strength were determined at baseline, after the last treatment session, and at 6 months of followup. Immediately after treatment and at 6 months, fatigue, mood state, trunk curl endurance, and leg strength exhibited greater improvement within the experimental group compared to placebo group. This paper showed that a multimodal program focused on core stability exercises and massage reduced fatigue, tension, depression, and improved vigor and muscle strength after intervention and 6 months after discharge.