1. "Local initiatives developing exercise programmes for cancer patients" Louise Ballagher Senior Physiotherapist Oncology and Haematology RD&E Foundation Trust July 21 st 2011

2. Aims  To establish exercise programmes for patients receiving treatment for cancer Jones & Courneya 2002 Jones & Courneya 2002  To review the use of a Physiotherapy Technical Instructor in the prescribing and monitoring of exercise programmes for Haematology patients in isolation

3. Common Symptoms of cancer treatment  Fatigue / decreased energy levels 70% 70%  Decreased muscle strength  Decreased functional status  Nausea  Pain  Body image problems  Sleep disturbances  Depression and anxiety 20-50% 20-50%

4. Positive effects of exercise  Reduces stress on the heart and blood vessels  Increases ability of heart and lungs to deliver oxygen efficiently to the working tissues  Increases muscular strength and endurance  Improves immune system  Improves mood, body image and sleep patterns  Improves quality of life both physically and emotionally

5. Benefits of exercise for cancer patients

6. “Evidence is accumulating that exercise is beneficial for cancer sufferers” CancerLevel of Evidence Strength of evidence ColonHighStrong RectalMediumNo effect BreastHighModerate LungLowModerate ProstateMediumEquivocal OverallMediumModerate OthersLowEquivocal

7. Research - Fatigue  Speck et al (2010) Meta analysis – Concluded that physical activity significantly reduced fatigue post Rx. Meta analysis – Concluded that physical activity significantly reduced fatigue post Rx. 14 studies- 93% positive, 50% statistically significant 14 studies- 93% positive, 50% statistically significant  Dimeo et al (2008) 32 pts; 3 week programme of endurance training  25%  in fatigue; 28%  in exercise capacity 32 pts; 3 week programme of endurance training  25%  in fatigue; 28%  in exercise capacity

8. Research Quality of Life  Courneya et al (2005) studies concluded that exercise had significant positive effects on the QOL of cancer patients studies concluded that exercise had significant positive effects on the QOL of cancer patientsNausea  Lee et al (2008) Moderate aerobic exercise is related to less intense nausea Moderate aerobic exercise is related to less intense nausea

9. Research Neutropenia / thrombocytopenia  Dimeo et al (1997) RCT on bone marrow transplant patients undergoing high-dose chemotherapy RCT on bone marrow transplant patients undergoing high-dose chemotherapy Duration of neutropenia and thrombocytopenia was reduced in the exercise group Duration of neutropenia and thrombocytopenia was reduced in the exercise group Recurrence / survival  Meyerhardt et al (2006) Cancer specific death was 60% lower in women who exercised 6 or more hours a week (walking at average pace) Cancer specific death was 60% lower in women who exercised 6 or more hours a week (walking at average pace)

10. If there is one message from the evidence it is: If there is one message from the evidence it is: NOT always Rest is NOT always best “STAY ACTIVE”

11. What has been happening at the RD&E !

12. Problems facing haematology patients  Intensive and lengthy chemotherapy regimes, often HSCT.  Frequent hospital admissions often in isolation  Side effects of Rx  De-conditioning Reduced QOL Low morale / low motivation

13. RD&E Haematology Unit Past Past Present Present

14. The Wii! “ There is growing evidence of the benefits of the Wii, and physiotherapists are looking into outcomes with their patients. There is definitely evidence that they are of benefit” Professional Adviser Chartered Society of Physiotherapy 2008

15. The introduction of the Wii  ELF donation  Wii sport and Wii fit  Study Jan 09- July 09  Patient Satisfaction Survey Initial assessment Initial assessment Goal setting Goal setting Exercise diary Exercise diary Follow up questionnaire Follow up questionnaire Guidelines Guidelines

16. The Results Wii Study 2009

17. Initial Assessment Type of exercise % of patients No exercise 40 % Bed exercises 15% Seated exercises 31% Static bike 15% Resistance exercise 0%

21. Results  85% study reported average of 30 mins accumulated exercise  Positive feedback !  Difficulties!  Access to equipment  Staffing Availability of staff Increased referrals

22. What happened next! Proposal for funding of Physiotherapy Technical instructor post Proposal for funding of Physiotherapy Technical instructor post 6 month pilot agreed 6 month pilot agreed 8 Hrs/week 8 Hrs/week

23. Evaluation of Pilot  Patients identified by MDT  New diagnosis, new physio referral  Questionnaire completed.

24. “Was it useful having a Technical Instructor monitor your exercise programme?”

25. Results

26. How would you rate the improvement ?

27. ‘Are there any other comments you would like to make?’  “Feel good factor and gets you motivated to push yourself”  “Without technical instructor I wouldn’t have been able to do it !  “Great motivation by a smiley instructor ! ”  “Exercises to suit personal needs”  “An excellent programme”  “This should be regarded as an essential service

28. What is going well ? Many Thanks to ELF Permanent Technical Instructor Post Permanent Technical Instructor Post Increased to 12 hrs/week Increased to 12 hrs/week  “ The Way Forward ” Group  Advice and information Leaflets Out-patients/ Daycare unit  Cancer Rehabilitation Programmes Campbell 2007

29. Cancer Rehabilitation Programmes  Pilot agreed !  Two 8 week programmes  The programme format : Pre assessment / screening Exercise programme – warm-up, aerobics, relaxation/cool down Educational component  One meeting to take place at Fitness First Leisure Centre

30. The Future  More Promotion of Information  Fly fishing / Dragon Boat racing!  More Research  More Hannahs !

31. Any Questions?

32. References  Campbell, A. (2007) Exercise after cancer diagnosis. Available at: www.canrehab.co.uk www.canrehab.co.uk  Courneya, K. (2005) Exercise can improve breast cancer survival. CA: A Cancer Journal for Clinicians 55:5: 265-266  Dimeo, F., Bertz, H., Finke, S., Mertlesmann, R., Keul, J. (1996) An Aerobic Exercise Programme for patients with haematological malignancies after bone marrow Transplant. Bone Marrow Transplant, 18:1157-60  Dimeo, F., Bertz, H., Finke, S., Mertlesmann, R., Keul, J. (1996) An Aerobic Exercise Programme for patients with haematological malignancies after bone marrow Transplant. Bone Marrow Transplant, 18:1157-60

33.  Jones, L and Courneya, K. (2002) Exercise discussions during cancer treatment consultations. Cancer Practice 10(2):66-74  Lee, J., Dodd, S., Dibbles, D., Abrams, D. (2008) Nausea at the end of adjuvant cancer treatment in relation to exercise during treatment in patients with breast cancer. Oncology Nursing Forum 35(5): 830-835

34.  Meyerhardt, J., Giovannucci, E., Holmes, M. (2006) Physical activity and survival after colorectal cancer diagnosis. Journal of Clinical Oncology 24(22): 3527-3534  Winningham, M. (1992) The Role of Exercise in Cancer Therapy. In: Watson, R., Eisinger, M. (eds) Exercise and Disease. Boca Raton: CRC Press