Physical activity (PA) is defined as any skeletal muscle movement that requires energy (World Health Organisation, 2019). Whilst patients are undergoing treatment for haematological malignancies (HM), PA may reduce dramatically. Due to treatment side effects such as nausea/vomiting, cancer-related fatigue (CRF) and mucositis, a majority of patients will spend a large percentage of their day in an inactive state. In addition, due to neutropenia/risk of infection, patients may be in protective isolation, further restricting PA (Annibali et al., 2017).
Whilst HM can affect people of all ages, they mainly occur within the elderly population, with a mean age of 70.6 years (Li et al., 2016). Consequently, at diagnosis, individuals may present with numerous co-morbidities. For example, 40% of individuals with Chronic Lymphocytic Leukaemia (CLL) have osteoarthritis, high cholesterol and hypertension (Strati et al., 2017). Additionally, Multiple Myeloma (MM) patients, with a median age of 69, often have a history of cardiovascular disease and renal impairment (Hari et al., 2017). Such co-morbidities affect a person’s ability to carry out everyday tasks (Sarfati and Koczwara, 2016). Therefore, these co-morbidities, combined with HM treatment, may have a detrimental effect on a person’s PA whilst in hospital.
Systematic anti-cancer therapy is often the first line of treatment (Haematological Malignancy Research Network, 2014). However, side effects include weight loss due to changes in appetite, nausea and vomiting, CRF, affecting 70% of patients, and neutropenia, resulting in the need for protective isolation due to the risk of infection (Cancer Research UK, 2017; Macmillan Cancer Support, 2018). Combined, these contribute to a loss of muscle mass, functional decline and a possible reduction in the intensity of future treatments (Duregon et al., 2019; Klepin et al., 2016).
The frailty cycle is a deconditioning syndrome in which the reduction of muscle mass leads to reduced strength, a consequent decline in PA, and increased fatigue, all of which lead to decreased functional ability, further exacerbating muscle loss (Hacker et al., 2017). This vicious cycle can be found in the HM population (Koll and Rosko, 2018). It has been argued that PA, before, during and after treatment, can improve physical functioning/fitness, and impact on CRF (Campbell et al., 2019; Cha et al., 2018; Hacker et al., 2017).
Whilst PA guidelines for the older adult population are clear – 75 to 150 minutes of PA per week (Department of Health and Social Care, 2019) – recommendations for the haemato-oncology population remain vague (Knips et al., 2019). Campbell et al. (2019) advises that exercise is safe for the cancer survivor population and that previous medical advice to rest and avoid exercise is no longer applicable (Knips et al., 2019).
Deconditioning is the process of physiological change, primarily muscular, following prolonged inactivity (Ploutz-Snyder et al., 2018). Deconditioning has been linked to increased risk of falls, functional decline and immobility (Arora, 2017). Furthermore, the loss of skeletal muscle due to inactivity during treatment, has been linked to increased levels of CRF (LaVoy, Fagundes and Dantzer, 2016). During HM treatment, physical functioning declines rapidly, and recovery to baseline, once treatment is complete, can be slow (Bewarder et al., 2019).
Cha et al. (2018) investigated an inpatient rehabilitation programme on recovery from deconditioning in individuals undergoing treatment for HM which found statistically significant functional improvement after rehabilitation. This was particularly evident in MM patients. Within the MM group, the body mass index (BMI) was higher, an average of 23.7. An average BMI of 23.7 is at the upper end of what is classed as a healthy BMI (18.5-24.9) (National Health Service, 2019). Individuals with a higher BMI experience less toxicity than those with a lower or normal BMI, a protective effect known as the “Obesity Paradox” (Morrison et al., 2019; Shachar and Williams, 2017). Therefore, it could be argued that, due to the higher BMI of the MM sample, they may have experienced reduced toxicity and, as a result, were then able to partake in a more intensive exercise session, resulting in reduced deconditioning. Therefore, if PA enables patients to maintain/increase their BMI whist undergoing treatment, arguably this could counteract side effects and prevent deconditioning. However, a limitation of the Cha et al. (2018) study is the participants’ mean age of 53.9 years. As previously mentioned, the average age of individuals with an HM is 70.6 years. Therefore, these findings may not be transferable to the general HM population. By not including older HM patients within such studies, it could be argued that clinicians can only estimate the benefits/risk of PA.
In two larger single-blind randomised control trials (RCT), both focusing on individuals undergoing stem cell transplant (SCT) for HM, Hacker et al. (2017) investigated strength training, whilst Persoon et al. (2017) looked at a high intensity exercise programme. Hacker et al. (2017) explored PA, CRF, functional ability, muscle strength and quality of life in a programme beginning immediately after the SCT (67 participants), whilst Persoon et al. (2017) began their PA programme 6-14 weeks after SCT (109 participants). Hacker et al. (2017) found that the Interventional Group experienced improvements in PA, fatigue, walk time and arm strength. However, not all results were statistically significant. Persoon et al. (2017) found that physical fitness and fatigue improved in both groups, but the results were also statistically non-significant. A possible reason for this may be the timing of the intervention, as Liang et al. (2018) found that deconditioning and CRF primarily occurs in the period immediately following HM treatment. Therefore, it could be said that the timing of a PA intervention is key when aiming to prevent deconditioning and fatigue.
Cancer-related fatigue, defined as ‘a subjective unrelenting sense of physical, emotional and mental exhaustion’ as a result of treatment or the cancer itself, can hinder/restrict activities associated with daily living (National Comprehensive Cancer Network, 2018. Page FT1). Exercise and CRF in breast cancer has been widely researched, and PA has been found to reduce CRF by counteracting low-grade inflammatory cytokines such as interleukin 6 (Meneses-Echavez et al., 2016), which is also found in HM patients undergoing treatment (Burger, 2013). Solid tumours and HM have very different trajectories (Chan and Chan, 2015). However, these findings could be transferable as it was found that interleukin 6 correlates to fatigue in the HM population (Khosravi et al., 2018). However, in a larger study by Alibhai et al. (2019), inflammatory cytokines could only be held accountable for a small percentage of CRF in HM. Despite this, this study highlighted that interventions such as exercise may still be valuable in reducing cytokine-induced CRF. However, HM treatment tends to be more intensive and longer in duration (Minton, Foster and Maher, 2015), therefore the level of cytokines, and subsequent CRF, may be more significant and harder to resolve.
It is proposed that the creation of exercise-prompt posters, an example of which can be seen in Appendix 1, would help to promote in-patient exercise opportunities that would contribute to the patient’s overall health and, possibly, promote long-term behavioural changes. Bellettiere et al. (2018) investigated the use of sign prompts, encouraging individuals to use the stairs/climb an escalator, rather than passively using an escalator. Within this study, poster prompts increased stair use by 115% when compared to escalator use, highlighting the effectiveness of point-of-choice prompts. These posters would be placed at “points-of-choice” such as at a windowsill prompting patients to march on the spot, in front of the bed where they could do arm/leg raises whilst in bed, or near to a chair where they could do standing up/sitting down exercises.
During hospital admission, patients can become very reliant on nurses in relation to daily living activities (Sung and Herbst, 2017). Encouraging patients to engage in PA could promote independence and contribute to a safe discharge (Clarke, Stack and Martin, 2017). Consequently, by empowering patients to take ownership of their own body maintenance through poster prompts, it could be argued that this could promote independence on the part of the patient and make their transition from inpatient to outpatient easier.
However, as seen in home exercise programmes where responsibility falls to the individual, non-adherence can be as high as 50% (Argent, Daly and Caulfield, 2018). Therefore, when combined with treatment side effects, inpatient adherence may be similar, or worse. In an RCT investigating exercise telephone counselling in HM, exercise adherence was 93%, highlighting the importance of clinician involvement/encouragement (Vallerand et al., 2018). The success of any intervention depends on adherence, and the clinician’s recognition that non-adherence does occur (Argent, Daly and Caulfield, 2018). Health care professionals (HCP) are in a prime position to encourage and promote inpatient PA. However, a lack of HCP knowledge, a fear of patient falls, and the “rest and recuperate” ideology, can prevent the promotion of PA (Blackburn et al., 2016; Knips et al., 2019). Through effective education, HCP’s could be made aware that resting actually exacerbates fatigue (Knips et al., 2019) and that exercise can, in fact, reduce falls (Hill et al., 2015). In this way, HCP can have a key role in encouraging PA.
To conclude, haematological malignancies occur mainly in the elderly population. Physical activity in the HM population has been deemed safe and can prevent deconditioning and improve CRF. However, treatment has a high symptom burden which can contribute to deconditioning and CRF. It has been found that PA before, during and after HM treatment can have a positive effect on deconditioning and reduce CRF. Point-of-choice prompts have been found to increase PA. Therefore, through the development of PA posters, it is hoped that this will encourage, empower and motivate patients to undertake PA during their inpatient stay. However, recognition that adherence may be poor, highlights the importance of HCP involvement in PA promotion. Therefore, it is hoped that inpatient PA promotion can prevent deconditioning and reduce CRF, thereby improving patient outcomes.
References
Alibhai, S.M.H., Breunis, H., Matelski, J., Timilshina, N., Kundra, A., Lee, C.H., and Li, M. (2019) ‘Age-Related Cytokine Effects on Cancer-Related Fatigue and Quality of Life in Acute Myeloid Leukaemia’, Journal of Geriatric Oncology, 18, pp.1-8.
Annibali, O., Pensieri, C., Tomarchio, V., Biagioli, V., Pennacchini, M., Tendas, A., Tambone, V., and Tirindelli, M.C. (2017) ‘Protective Isolation for Patients with Haematological Malignancies: A Pilot Study Investigating Patients’ Distress and Use of Time’, International Journal of Hematology-Oncology and Stem Cell Research, 11(4), pp.313-318.
Argent, R., Daly, A., and Caulfield, B. (2018) ‘Patient Involvement with Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?’, JMIR mHealth uHealth, 6(3), pp.1-23.
Arora, A. (2017) Time to Move: Get Up, Get Dressed, Get Moving. Available at: https://www.england.nhs.uk/blog/amit-arora/. Accessed 20/12/2019.
Bellettiere, J. Nguyen, B., Liles, S., Berardi, V., Adams, M.A., Dempsey, P., Benporat, Y., Kerr, J., LaCroix, A.Z., and Hovell, M. (2018) ‘Prompts to Increase Physical Activity at Points-of-Choice between Stairs and Escalators: What about Escalator Climbers?’, Translational Behavioural Medicine, 9, pp.656-662.
Bewarder, M., Klostermann, A., Ahlgrimm, M., Bittenbring, J.T., Pfreundschuh, M. Wagenpfeil, S., and Kaddu-Mulindwa, D. (2019) ‘Safety and Feasibility of Electrical Muscle Stimulation in Patients Undergoing’, Supportive Care in Cancer, 27(3), pp.1013-1020.
Blackburn, R., Presson, K., Laufman, R., Tomczak, N., and Brassil, K.J. (2016) ‘Establishing an Inpatient Gym for Recipients of Stem Cell Transplantation: A Multidisciplinary Collaborative’, Clinical Journal of Oncology Nursing, 20(1), pp.66-71.
Burger, R. (2013) ‘Impact of Interleukin-6 in Haematological Malignancies, Transfusion Medicine and Hemotherapy’, Transfusion Medicine and Hemotherapy, 40(5), pp.336-343.
Campbell, K.L., Winters-Stone, K.M., Wiskemann, J., May, A.M., Schwartz, A.L., Courneya, K.S., Zucker, D.S., Matthews, C.E., Ligibel, J.L., Gerber, L.H., Morris, G.S., Patel, A.V., Hue, T.F., Perna, F.M., and Schmitz, K.H. (2019) ‘Exercise Guidelines for Cancer Survivors: Consensus Statement from International Multidisciplinary’, Medicine and Science in Sports and Exercise, 51(11), pp.2375-2390.
Cancer Research UK (2017) Fatigue and Cancer Drugs. Available at: https://www.cancerresearchuk.org/about-cancer/cancer-in-general/treatmen.... Accessed 06/12/2019.
Cha, S., Kim, I., Lee, S., and Seo, K.S. (2018) ‘Effect of an Inpatient Rehabilitation Program for Recovery of Deconditioning in Hematologic Cancer Patients After Chemotherapy’, Annals of Rehabilitation Medicine, 42(6), pp.838-845.
Chan, R.J., and Chan, A. (2015) ‘Survivorship Care Provision for Patients with Hematologic Malignancies' the Quest for Quality Evidence’, Cancer Nursing, 38(5), pp.414-415.
Clarke, C., Stack, C., and Martin, M. (2017) ‘Lack of meaningful activity on acute physical hospital wards: Older people’s experiences’, British Journal of Occupational Therapy, 81(1), pp.15-23.
Department of Health and Social Care (2019) UK Chief Medical Officers’ Physical Activity Guidelines. Available at: https://assets.publishing.service.gov.uk/government/uploads /system/uploads/attachment_data/file/832868/uk-chief-medical-officers-physical-activity-guidelines.pdf. Accessed 20/11/2019.
Duregon, F., Gobbo, S., Bullo, V., Roma, E., Vendramin, B., Bergamo, M., Bocalini, D.S. Di Blasio, A., Cugusi, L., Neunhaeuserer, D., Bergamin, M., and Ermolao, A. (2019) ‘Exercise Prescription and Tailored Physical Activity Intervention in Onco‐Hematology Inpatients, a Personalized Bedside Approach to Improve Clinical Best Practice’, Hematological Oncology, 37(3), pp.277-284.
Hacker, E.D., Collins, E., Park, C., Peters, T., Patel, P., and Rondelli, D. (2017) ‘Strength Training to Enhance Early Recovery after Hematopoietic Stem Cell Transplantation’, Biology of Blood and Bone Marrow Transplant, 23(4), pp.659-669.
Haematological Malignancy Research Network (2014) Patient’s age and treatment for haematological malignancy: a report from the Haematological Malignancy Research Network (HMRN). Available at: https://www.hmrn.org/Download.aspx? target=document&id=41. Accessed 02/01/2020.
Hari, P., Romanus, D., Luptakova, K., Blazer, M., Yong, C., Raju, A., Farrelly, E., Labotka, R., and Morrison, V.A. (2017) ‘The Impact of Age and Comorbidities on Practice Patterns and Outcomes in Patients with Relapsed/Refractory Multiple Myeloma in the Era of Novel Therapies’, Journal of Geriatric Oncology, 9(2), pp.138-144.
Hill, K.D., Hunter, S.W., Batchelor, F.A., Cavalheri, V., and Burton, E. (2015) ‘Individualized home-based exercise programs for older people to reduce falls and improve physical performance: A systematic review and meta-analysis’, Maturitas, 82(1), pp.72-84.
Khosravi, M., Masoumi, H.T., Gholami, K., Vaezi, M., Hadjibabaei, M., and Ghavamzadeh, A. (2018) ‘The Relationship between Fatigue and Cytokine Levels in Patients with Acute Myeloid Leukaemia’, International Journal of Haematologic Oncology Stem Cell Research, 12(4), pp.318-321.
Klepin, H.D., Tooze, J.A., Pardee, T.S., Ellis, L.R., Berenzon, D., Mihalko, S.L., Danhauer, S.C., Rao, A.R., Wildes, T.M., Williamson, J.D., Powell, B.L., and Kritchevsky, S.B. (2016) ‘Effect of Intensive Chemotherapy on Physical, Cognitive, and Emotional Health of Older Adults with Acute Myeloid Leukemia’, Journal of the American Geriatric Society, 64(10), pp.1988–1995.
Knips, L., Bergenthal, N., Streckmann, F., Monsef, I., Elter, T., and Skoetz, N. (2019) Aerobic physical exercise for adult patients with haematological malignancies. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30702150. Accessed 22/11/2019.
Koll, T., and Rosko, A.E. (2018) ‘Frailty in Haematologic Malignancy’, Current Haematologic Malignancy Reports, 13(3), pp.143-154.
LaVoy, E.C.P., Fagundes, C.P., and Dantzer, R. (2016) ‘Exercise, Inflammation and Fatigue in Cancer Survivors’, Exercise Immunology Review, 22, pp.82-93.
Li, J., Smith, A., Crouch, S., Oliver, S., and Roman, E. (2016) ‘Estimating the prevalence of Haematological Malignancies and Precursor Conditions Using Data from Haematological Malignancy Research Network (HMRN)’, Cancer Causes Control, 27(8), pp.1019-1026.
Liang, Y., Zhou, M., Wang, F., and Wu, Z. (2018) ‘Exercise for physical fitness, fatigue and quality of life of patients undergoing hematopoietic stem cell transplantation: a meta-analysis of randomized controlled trials’, Japanese Journal of Clinical Oncology, 48(12), pp.1046–1057.
Macmillan Cancer Support (2018) Possible Side Effects of Chemotherapy. Available at: https://www.macmillan.org.uk/information-and-support/treating/chemothera.... Accessed 06/12/2019.
Meneses-Echavez, J.F., Correa-Bautista, J.E., Gonzalez-Jimenez, E., Schmidt Rio-Valle, J., Elkins, M.R., Lobelo, F., and Ramirez-Velez, R. (2016) ‘The Effect of Exercise Training on Mediators of Inflammation in Breast Cancer Survivors: A Systematic Review with Meta-Analysis’, Cancer Epidemiology, Biomarkers and Prevention, 25(7), pp.1009-1017.
Minton, O., Foster, J., and Maher, J. (2015) ‘The Roles of Behavioural Modification and Exercise in the Management of Cancer-Related Fatigue to Reduce its Impact During and After Cancer Treatment’, Acta Oncologica, 54(4), pp.581-586.
Morrison, V.A., McCall, L., Muss, H.B., Jatoi, A., Cohen, H.J., Cirrincione, C.T., Ligibel, J.A., Lafky, J.M., and Hurria, A. (2019) ‘The Impact of Actual Body Weight-Based Chemotherapy Dosing and Body Size on Adverse Events and Outcome in Older Patients with Breast Cancer: Results from Cancer and Leukemia Group B (CALGB) Trial 49907 (Alliance A151436)’, Journal of Geriatric Oncology, 9(3), pp.228-234.
National Comprehensive Cancer Network (2018) Cancer Related Fatigue. Available at: https://oncolife.com.ua/doc/nccn/fatigue.pdf. Accessed 13/12/2019.
National Health Service (2019) What is the Body Mass Index? Available at: https://www.nhs.uk/common-health-questions/lifestyle/what-is-the-body-ma.... Accessed 20/12/2019.
Persoon, S., ChinAPaw, M.J.M., Buffart, L.M., Liu, R.D.K., Wijermans, P., Koene, H.R., Minnema, M.C., Lugtenburg, P.J., Marijt, E.W.A., Brug, J., Nollet, F., and Kersten, M.J. (2017) ‘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’, PLoS ONE, 12(7), pp.1-14.
Ploutz-Snyder, L.L., Downs, M., Goetchius, E., Crowell, B., English, K.L., Ploutz-Snyder, R., Ryder, J.W., Dillon, E.L., Sheffield-Moore, M., and Scott, J.M. (2018) ‘Exercise Training Mitigates Multisystem Deconditioning during Bed Rest’, Medicine and Science in Sports and Exercise, 50(9), pp.1920-1928.
Sarfati, D., and Koczwara, B. (2016) ‘The Impact of Comorbidity on Cancer and Its Treatment’, A Cancer Journal for Clinicians, 66(4), pp.337-350.
Shachar, S.S., and Williams, G.R. (2017) ‘The Obesity Paradox in Cancer – Moving Beyond BMI’, Cancer Epidemiology, Biomarkers and Prevention, 26(1), pp.13-16.
Strati, P., Parikh, S.A., Chaffee, K.G., Kay, N.E., Call, T.G., Achenbach, S.J., Cerhan, J.R., Slager, S.L., and Shanafelt, T.D. (2017) ‘Relationship between Co-Morbidities at Diagnosis, Survival and Ultimate Cause of Death in Patients with Chronic Lymphocytic Leukaemia (CLL): A Prospective Cohort Study’, British Journal of Haematology, 178(3), pp.394–402.
Sung, C. and Herbst, J.L. (2017) ‘The ethics of caring for hospital-dependent patients’, BMC Medical Ethics, 18(1), pp 75-75.
Vallerand, J.R., Rhodes, R.E., Walker, G.J., and Courneya, K.S. (2018) ‘Feasibility and preliminary efficacy of an exercise telephone counselling intervention for hematologic cancer survivors: a phase II randomized controlled trial’, Journal of Cancer Survivorship, 12(3), pp.357-370.
World Health Organisation (2019) Physical Activity. Available at: https://www.who.int/dietphysicalactivity/pa/en/. Accessed 20/11/2019.