Biologic therapy ice breaking in rheumatology, Case based approach with appli...
Exercise at-rde
1. "Local initiatives developing"Local initiatives developing
exercise programmes forexercise programmes for
cancer patients"cancer patients"
Louise BallagherLouise Ballagher
Senior PhysiotherapistSenior Physiotherapist
Oncology and HaematologyOncology and Haematology
RD&E Foundation TrustRD&E Foundation Trust
July 21July 21stst
20112011
2. Aims
To establish exercise programmes forTo establish exercise programmes for
patients receiving treatment for cancerpatients receiving treatment for cancer
Jones & Courneya 2002Jones & Courneya 2002
To review the use of a PhysiotherapyTo review the use of a Physiotherapy
Technical Instructor in the prescribing andTechnical Instructor in the prescribing and
monitoring of exercise programmes formonitoring of exercise programmes for
Haematology patients in isolationHaematology patients in isolation
3. Common Symptoms ofCommon Symptoms of
cancer treatmentcancer treatment
Fatigue / decreased energy levelsFatigue / decreased energy levels
70%70%
Decreased muscle strengthDecreased muscle strength
Decreased functional statusDecreased functional status
NauseaNausea
PainPain
Body image problemsBody image problems
Sleep disturbancesSleep disturbances
Depression and anxietyDepression and anxiety
20-50%20-50%
4. Positive effects of exercisePositive effects of exercise
Reduces stress on the heart andReduces stress on the heart and
blood vesselsblood vessels
Increases ability of heart and lungsIncreases ability of heart and lungs
to deliver oxygen efficiently to theto deliver oxygen efficiently to the
working tissuesworking tissues
Increases muscular strength andIncreases muscular strength and
enduranceendurance
Improves immune systemImproves immune system
Improves mood, body image andImproves mood, body image and
sleep patternssleep patterns
Improves quality of life bothImproves quality of life both
physically and emotionallyphysically and emotionally
6. ““Evidence is accumulating that exerciseEvidence is accumulating that exercise
is beneficial for cancer sufferersis beneficial for cancer sufferers””
Cancer Level of
Evidence
Strength of
evidence
Colon High Strong
Rectal Medium No effect
Breast High Moderate
Lung Low Moderate
Prostate Medium Equivocal
Overall Medium Moderate
Others Low Equivocal
7. Research - Fatigue
Speck et al (2010)Speck et al (2010)
Meta analysis – Concluded that physicalMeta analysis – Concluded that physical
activity significantly reduced fatigue post Rx.activity significantly reduced fatigue post Rx.
14 studies- 93% positive, 50% statistically14 studies- 93% positive, 50% statistically
significantsignificant
Dimeo et al (2008)Dimeo et al (2008)
32 pts; 3 week programme of endurance32 pts; 3 week programme of endurance
trainingtraining 25%25% in fatigue; 28%in fatigue; 28% inin
exercise capacityexercise capacity
8. ResearchResearch
Quality of LifeQuality of Life
Courneya et al (2005)Courneya et al (2005)
studies concluded that exercise had significantstudies concluded that exercise had significant
positive effects on the QOL of cancer patientspositive effects on the QOL of cancer patients
NauseaNausea
Lee et al (2008)Lee et al (2008)
Moderate aerobic exercise is related to less intenseModerate aerobic exercise is related to less intense
nauseanausea
9. ResearchResearch
Neutropenia / thrombocytopeniaNeutropenia / thrombocytopenia
Dimeo et al (1997)Dimeo et al (1997)
RCT on bone marrow transplant patients undergoingRCT on bone marrow transplant patients undergoing
high-dose chemotherapyhigh-dose chemotherapy
Duration of neutropenia and thrombocytopenia wasDuration of neutropenia and thrombocytopenia was
reduced in the exercise groupreduced in the exercise group
Recurrence / survivalRecurrence / survival
Meyerhardt et al (2006)Meyerhardt et al (2006)
Cancer specific death was 60% lower in women whoCancer specific death was 60% lower in women who
exercised 6 or more hours a week (walking atexercised 6 or more hours a week (walking at
average pace)average pace)
10. If there is oneIf there is one
message from themessage from the
evidence it is:evidence it is:
Rest is NOT alwaysNOT always best
““STAY ACTIVE”STAY ACTIVE”
11. What has been happening at theWhat has been happening at the
RD&E !RD&E !
12. Problems facing haematologyProblems facing haematology
patientspatients
Intensive and lengthyIntensive and lengthy
chemotherapy regimes,chemotherapy regimes,
often HSCT.often HSCT.
Frequent hospitalFrequent hospital
admissions often inadmissions often in
isolationisolation
Side effects of RxSide effects of Rx
De-conditioningDe-conditioning
Reduced QOLReduced QOL
Low morale / lowLow morale / low
motivationmotivation
14. The Wii!
““ There is growing evidenceThere is growing evidence
of the benefits of the Wii,of the benefits of the Wii,
and physiotherapists areand physiotherapists are
looking into outcomeslooking into outcomes
with their patients. Therewith their patients. There
is definitely evidence thatis definitely evidence that
they are of benefit”they are of benefit”
Professional Adviser
Chartered Society of
Physiotherapy 2008
15. The introduction of the Wii
ELF donationELF donation
Wii sport and Wii fitWii sport and Wii fit
Study Jan 09- July 09Study Jan 09- July 09
Patient SatisfactionPatient Satisfaction
SurveySurvey
Initial assessmentInitial assessment
Goal settingGoal setting
Exercise diaryExercise diary
Follow up questionnaireFollow up questionnaire
GuidelinesGuidelines
21. Results
85% study reported85% study reported
average of 30 minsaverage of 30 mins
accumulated exerciseaccumulated exercise
Positive feedback !Positive feedback !
Difficulties!Difficulties!
Access to equipmentAccess to equipment
StaffingStaffing
Availability of staffAvailability of staff
Increased referralsIncreased referrals
22. What happened next!What happened next!
• Proposal for fundingProposal for funding
of Physiotherapyof Physiotherapy
Technical instructorTechnical instructor
postpost
• 6 month pilot agreed6 month pilot agreed
8 Hrs/week8 Hrs/week
23. Evaluation of PilotEvaluation of Pilot
Patients identified byPatients identified by
MDTMDT
New diagnosis, newNew diagnosis, new
physio referralphysio referral
QuestionnaireQuestionnaire
completed.completed.
24. ““Was it useful having a Technical InstructorWas it useful having a Technical Instructor
monitor your exercise programme?”monitor your exercise programme?”
0
20
40
60
80
100
Yes No
26. How would you rate theHow would you rate the
improvement ?improvement ?
0
2
4
6
8
10
Mood
Motivation
Energy Levels
Physical levels
Overall Well
Being
27. ‘‘Are there any other comments you wouldAre there any other comments you would
like to make?’like to make?’
““Feel good factor andFeel good factor and
gets you motivated togets you motivated to
push yourself”push yourself”
““Without technicalWithout technical
instructor I wouldn’t haveinstructor I wouldn’t have
been able to do it !been able to do it !
““Great motivation by aGreat motivation by a
smiley instructor ! ”smiley instructor ! ”
““Exercises to suitExercises to suit
personal needs”personal needs”
““An excellent programme”An excellent programme”
““This should be regardedThis should be regarded
as an essential serviceas an essential service
28. What is going well ?What is going well ?
Many Thanks to ELFMany Thanks to ELF
• Permanent TechnicalPermanent Technical
Instructor PostInstructor Post
• Increased to 12Increased to 12
hrs/weekhrs/week
““ The Way Forward ”The Way Forward ”
GroupGroup
Advice and informationAdvice and information
LeafletsLeaflets
Out-patients/ DaycareOut-patients/ Daycare
unitunit
Cancer RehabilitationCancer Rehabilitation
ProgrammesProgrammes
Campbell 2007Campbell 2007
29. Cancer Rehabilitation ProgrammesCancer Rehabilitation Programmes
Pilot agreed !Pilot agreed !
Two 8 week programmesTwo 8 week programmes
The programme format :The programme format :
Pre assessment /Pre assessment /
screeningscreening
Exercise programme –Exercise programme –
warm-up, aerobics,warm-up, aerobics,
relaxation/cool downrelaxation/cool down
Educational componentEducational component
One meeting to takeOne meeting to take
place at Fitness Firstplace at Fitness First
Leisure CentreLeisure Centre
30. The FutureThe Future
More Promotion of InformationMore Promotion of Information
Fly fishing / Dragon Boat racing!Fly fishing / Dragon Boat racing!
More ResearchMore Research
More Hannahs !More Hannahs !
32. ReferencesReferences
Campbell, A.Campbell, A. (2007)(2007) Exercise after cancerExercise after cancer
diagnosis. Available at:diagnosis. Available at: www.canrehab.co.ukwww.canrehab.co.uk
Courneya, K. (2005)Courneya, K. (2005) Exercise can improveExercise can improve
breast cancer survival.breast cancer survival. CA: A Cancer JournalCA: A Cancer Journal
for Cliniciansfor Clinicians 55:5: 265-26655:5: 265-266
Dimeo, F., Bertz, H., Finke, S., Mertlesmann,Dimeo, F., Bertz, H., Finke, S., Mertlesmann,
R., Keul, J. (1996)R., Keul, J. (1996) An Aerobic ExerciseAn Aerobic Exercise
Programme for patients with haematologicalProgramme for patients with haematological
malignancies after bone marrow Transplant.malignancies after bone marrow Transplant.
Bone Marrow TransplantBone Marrow Transplant, 18:1157-60, 18:1157-60
33. Jones, L and Courneya, K. (2002)Jones, L and Courneya, K. (2002)
Exercise discussions during cancerExercise discussions during cancer
treatment consultations.treatment consultations. Cancer PracticeCancer Practice
10(2):66-7410(2):66-74
Lee, J., Dodd, S., Dibbles, D., Abrams, D.Lee, J., Dodd, S., Dibbles, D., Abrams, D.
(2008)(2008) Nausea at the end of adjuvantNausea at the end of adjuvant
cancer treatment in relation to exercisecancer treatment in relation to exercise
during treatment in patients with breastduring treatment in patients with breast
cancer.cancer. Oncology Nursing ForumOncology Nursing Forum 35(5):35(5):
830-835830-835
34. Meyerhardt, J., Giovannucci, E., Holmes,Meyerhardt, J., Giovannucci, E., Holmes,
M. (2006)M. (2006) Physical activity and survivalPhysical activity and survival
after colorectal cancer diagnosis.after colorectal cancer diagnosis. JournalJournal
of Clinical Oncologyof Clinical Oncology 24(22): 3527-353424(22): 3527-3534
Winningham, M. (1992)Winningham, M. (1992) The Role ofThe Role of
Exercise in Cancer TherapyExercise in Cancer Therapy. In: Watson,. In: Watson,
R., Eisinger, M. (eds)R., Eisinger, M. (eds) Exercise andExercise and
Disease.Disease. Boca Raton: CRC PressBoca Raton: CRC Press
Hinweis der Redaktion
Our work at the RD&E has been to ………. So as to help overcome or reduce many of the side effects of cancer and it’s Rx. And to ………
Cancer pts tend to decrease ttheir physical activity levels after diagnosis and during and after Rx, and many do not return to their pre Rx activity levels.This trend is enforced as pts are often advised to limit activity and get plenty of rest.
. A study by Jones and Courneya 2002 of 311 cancer survivors found that 82% felt that their oncologist should initiate discussion of ecercise and physical activity as part of their oncology consultation and the study concluded that exercise should be recommended both during and after Rx to pts with early stage cancer.
So why should pts undergoing Rx consider exercise to help them? The reason is the benefit of exercise to the human system.
Regular exercise reduces the risk of heart disease, improves lung function, increases mm strength and endurance, helps mood, the immune system and generally increases QOL both physically and emotionally.
The message be active ,Stay active applies as much to cancer and Haematology pts as to anyone else, perhaps even more.
So should we be encouraging pts to run or cycle marathons during their Rx like Jane Tomlinson and Lance Armstrong
Thankfully not
The majority of studies of exercise and cancer have been conducted with women with early stage breast cancer, which then limits the generalizability of these studies to other cancers. However there is still a convincing amount of research that has been performed in most cancer areas , looking at specific cancer treatment side effects that benefit from exercise.
Dimeo 1996 About 30 days after bone marrow transplant and followed 6 week treadmill walking program
Quality of Life
Courneya & colleagues (2001) reviewed studies and concluded that exercise had significant positive effects on the QOL of cancer patients. The studies include self reported exercise prorammes and supervised interventions, studies of a variety of cancers and studies of the effects of aerobic exercise and mm strengh programmes. ( The exercise interventions ranged from 2- 20 weeks but most about 12 ).
The Qol improvements included enhanced functional capacity , increased mm strength, reduced fatigue , improved self image, improved energy and reduced anxiety and depression
Nausea
Lee et al 2008 in a study of 112 women with breast cancer receiving adjuvant cancer Rx found that those who exercised for the equivalent of 20 mins moderate intensity aerobic exercise 3 x’s a week experienced less intense nausea at the end of their Rx
Haematology pts often face problems that other cancer pts do not. Their treatment usually involves intensive and lengthy chemo regimes, often with HSCT.
This means frequent hospital admissions often in protective isolation.
The Rx often brings horrible side effects. The isolation in a small room leads to deconditioning.
And not surprisingly this all leads to reduced QOL for the pt and low morale and lack of motivation.
Treatment regimes – including stem cell transplants (Auto ) and continuing the care of patients of pts following allogenic SCT and the common disabilitating condition GVHD
The Wii Nintendo has caused an explosion of interest in the physiotherapy world as an adjunct to treatment and is beginning to be used in more specialised areas of rehabilitation.
The Exeter Leukaemia Fund in dec 2008 kindly donated the money for the Haematology Unit to purchase two Wii consoles with Wii sport and 2 wii fit balance boards..
We began our 6 month study in Jan 09
Pts referred where assessed by myself and then invited to complete an initial assessment form. Here they reported how much exercise they were currently doing and then scored their mood, motivation, energy levels, physical activity and overall well being.
A goal of 30 mins accumulated exercise of any sort on a roughly daily basis was set, dependent on chemo regimes. This is as per government and WCRF guidelines and now the 2010 American ACSM guidelines.
A follow up questionairre was completed by the pt on discharge or end of intervention
Pts were monitored and given advice as much as possible throughout.
And as for the goal set. 85% of pts reported that they had achieved the goal of 30 mins accumulated exercise on most of their days.
But best of all was probably the positive feedback from pts.
Read out :
Many pts commented on how great it was that they could hve fun and be interactive with their family- children and grandchildren. They were exercising but also the children were being entertained during visits where they often got bored!
So what happened next?
Well following the study’s success and seeing that limited staffing was a primary difficulty , I put in a proposal to ELF forr funding of a 6 month Physio Technical Instructor post. The role would be prescribing and monitoring of exercise plans for pts whilst in isolation on Yarty.
ELF very kindly agreed to fund a 6 month pilot and lovely Hannah was appointed as the successful candidate , contracted for 8 hours a week
So the pilot began in April 2010
Pts were referred by MDT and then assessed and invited onto the study by Hannah.An individual exercise folder would be given to the pt which included our information leaflet on the importance of exercise through Rx as well as a copy of bed and seated exercises. Pts also had an exercise diary to complete.
An individual exercise programme would then be prescribed which could include the Wii, static bike and therabands for resistance work.
Hannahs 8 hours were split over 3 mornings where she would spend time with each pt discussing their programme – monitoring and motivating and often working out with them! You can often tell which pt Hannah is with by the laughter coming from the room!
On discharge the pt would be asked to complete the questionairre to see if there had been any change in mood/ motivation etc as in the initial study and invited to answer a few questions about the physio tech role.
As to the results! Pts were asked if it was useful
The results coud not have been better – All responded yes
100% of pts felt there had been a change in mood, energy levels and physical activity with 92% in motivation and overall well being
And when asked to rate this improvement, 100% scored 7 or 8 , where in this study, just to confuse you , the higher numbers are the more positive results.
So where are we now
There is now great interest in the role of exercise for haematology patients during and after Rx and as a preventative strategy for those undergoing SCT Evidence shows that exercise is safe, feasible and beneficial
I am now participating in the Exeter “ The way Forward “ group where I provide advice and information of the benefits of exercise to pts that have completed their cancer Rx
We now feel confident that our message regarding the importance of exercise during Rx is reaching all our pts that become in-pts, providing them with information and Hannah’s exercise programmes. However we are aware that we are still missing a large number of pts that are seen only in Daycase and yet go on for HSCT.. So we now are displaying posters and have information about how pts can be referred tp physio for advice about exercise ,maintaining fitness or getting pts fitter prior to transplantation.
Cancer care is taking its time to catch up with cardiovascular medicine in understanding the benefits of exercise.
For 20 years there have been cardiac and pulmonary rehabilitation programmes for patients with heart and lung disorders
Dr Anna Campbell in Scotland has undertaken research into the effects of exercise classes for breast cancer pts during Rx and found that not only the pt themseves have improvements in side effects and general well being but was also able to demonstrate cost savings with reduced hospital admissions and less frequent visits to GPs. She now runs seminars and training programmes for Health care Professionals across the UK, focused on developing exercise based rehabilitation programmes for all cancer pts.
Having attended one of her seminars last year, together with Exeter’s FORCE cancer Charity we have just had a proposal accepted to run a pilot study of 2 Cancer rehabilitation programmes to start later this year- one for pts still undergoing Rx and the other for those who have completed Rx.. Very exciting times
And Well what can we say about the Wiis and Hannah’s role. They have been a huge success on Yarty. The exercise is fun and interactive and Hannah is so motivationing for pts, producing fantastic results as shown in the study.
So what else does the future hold?
More Research
More Hannahs!
Thank you very Much
So where are we now
There is now great interest in the role of exercise for haematology patients during and after Rx and as a preventative strategy for those undergoing SCT Evidence shows that exercise is safe, feasible and beneficial
I am now participating in the Exeter “ The way Forward “ group where I provide advice and information of the benefits of exercise to pts that have completed their cancer Rx
We now feel confident that our message regarding the importance of exercise during Rx is reaching all our pts that become in-pts, providing them with information and Hannah’s exercise programmes. However we are aware that we are still missing a large number of pts that are seen only in Daycase and yet go on for HSCT.. So we now are displaying posters and have information about how pts can be referred tp physio for advice about exercise ,maintaining fitness or getting pts fitter prior to transplantation.
Cancer care is taking its time to catch up with cardiovascular medicine in understanding the benefits of exercise.
For 20 years there have been cardiac and pulmonary rehabilitation programmes for patients with heart and lung disorders
Dr Anna Campbell in Scotland has undertaken research into the effects of exercise classes for breast cancer pts during Rx and found that not only the pt themseves have improvements in side effects and general well being but was also able to demonstrate cost savings with reduced hospital admissions and less frequent visits to GPs. She now runs seminars and training programmes for Health care Professionals across the UK, focused on developing exercise based rehabilitation programmes for all cancer pts.
Having attended one of her seminars last year, together with Exeter’s FORCE cancer Charity we have just had a proposal accepted to run a pilot study of 2 Cancer rehabilitation programmes to start later this year- one for pts still undergoing Rx and the other for those who have completed Rx.. Very exciting times
And Well what can we say about the Wiis and Hannah’s role. They have been a huge success on Yarty. The exercise is fun and interactive and Hannah is so motivationing for pts, producing fantastic results as shown in the study.
So what else does the future hold?
More Research
More Hannahs!
Thank you very Much
Pink Champagne encourages women who have been diagnosed with breast cancer to lead full and active lives through the sport of dragon boat racing. How flyfishing can help women with breast cancerNot many people with breast cancer would think of picking up a fishing rod and heading off to their nearest lake and river. But that’s just what a group of women have started doing as a way of helping women who’ve had the disease. The scheme is called ‘Casting For Recovery’ and the idea is that fly fishing can help women with breast cancer – the physical action of casting is similar to the physiotherapy exercises prescribed post-surgery. And there are psychological benefits too – fishing is well known as a relaxing pursuit. Louise Adamson met up with Sue Hunter, a member of the National Ladies’ Fly Fishing Team who's also the person responsible for introducing ‘Casting For Recovery’ to this country.