Advs Exp. Medicine, Biology - Neuroscience and Respiration DOI 10.1007/5584_2015_134 # Springer International Publishing Switzerland 2015
Pulmonary Rehabilitation in Advanced Lung Cancer Patients During Chemotherapy D. Jastrze˛bski, M. Maksymiak, S. Kostorz, B. Bezubka, I. Osmanska, T. Młynczak, A. Rutkowska, Z. Baczek, D. Ziora, and J. Kozielski Abstract
The aim of this study was to investigate the utility of pulmonary rehabilitation for improving of exercises efficiency, dyspnea, and quality of life of patients with lung cancer during chemotherapy. After the enrollment selection, the study included 20 patients with newly diagnosed advanced lung cancer and performance status 0–2. There were 12 patients randomly allocated to the pulmonary rehabilitation group and another 8 constituted the control group that did not undergo physical rehabilitation. Both groups of patients had continual cycles of chemotherapy. Data were analyzed before and after 8 weeks of physical rehabilitation, and before and after 8 weeks of observation without rehabilitation in controls. The inpatient rehabilitation program was based on exercise training with ski poles and respiratory muscle training. We found an increase in mobility (6 Minute Walk Test: 527.3 vs. 563.4 m; p > 0.05) and forced expired volume in 1 s (66.9 13.2 vs. 78.4 17.7 %predicted; p ¼ 0.016), less dyspnea (p ¼ 0.05), and a tendency for improvement in the general quality of life questionnaire after completion of pulmonary rehabilitation as compared with the control group. This report suggests that pulmonary rehabilitation in advanced lung cancer patients during chemotherapy is a beneficial intervention to reduce dyspnea and enhance the quality of life and mobility. Keywords
Dyspnea • Exercises efficiency • Lung cancer • Lung function • Nordic walking • Pulmonary rehabilitation • Quality of life D. Jastrze˛bski (*), S. Kostorz, B. Bezubka, I. Osmanska, T. Młynczak, D. Ziora, and J. Kozielski Department of Lung Diseases and Tuberculosis, Medical University of Silesia, 1 Koziolka St., 41-803 Zabrze, Poland e-mail: [email protected] M. Maksymiak Department of Rehabilitation, School of Health Sciences, Medical University of Silesia, Katowice, Poland
A. Rutkowska Institute of Physiotherapy, Opole University of Technology and Physiotherapy, Opole, Poland Z. Baczek Upper Silesian Rehabilitation Center, Ustron´, Poland
D. Jastrze˛bski et al.
1
Introduction
Over the last decade, many studies supported the efficacy of pulmonary rehabilitation in patients with lung diseases, especially in chronic obstructive pulmonary disease (COPD), asthma, mucoviscidosis, and interstitial lung fibrosis. Pulmonary rehabilitation has become a recognized method of treatment (Nici et al. 2006) and is recommended by the Polish Society of Lung Diseases (Pierzchała et al. 2010), as well as international expert groups (Rabe et al. 2007). Therefore, it is proposed that pulmonary rehabilitation program should be introduced in cancer patients, based on the strategies established for patients with COPD, postulating that physical effort will improve physical activity and exercise tolerance, and will significantly decrease the level of dyspnea; thereby enhancing the healthrelated quality of life. The hitherto consensus has been that oncological patients should not be subjected to rehabilitation training. Broadly defined physiotherapy has been considered an absolute contraindication for them. In 2010, the American College of Sport Medicine published the first recommendations on the usefulness of rehabilitation in cancer (Schmitz at al. 2010). The recommendations did not concern rehabilitation in lung cancer. The current state of knowledge is insufficient to answer the question of the relevance and influence of physical therapy in lung cancer patients. A review of the literature shows positive effects of physiotherapy in lung cancer after surgery (Jones et al. 2010, 2008; Spruit et al. 2006) and there seem to be a single only article that describes the results of rehabilitation in inoperable lung cancer during chemotherapy (Temel et al. 2009). The currently used anticancer treatment, although extending the patient’s life expectancy, is highly toxic. This situation has a bearing on the physiological and psychological state of patients. These effects lead to increased pain, loss of physical fitness and efficiency, increase fatigue, cause immune dysfunction, and reduce quality of life (McTieman 2004). Therefore, implementation of
programs based on physical activity for reducing the above mentioned symptoms seems an attractive notion, particularly in view of overall beneficial effects of physical training reported in a number of meta-analyses. It has also been shown that physical training may reduce the risk of tumor recurrence, as well as it may extend life expectancy. Therefore, the aim of this study was to investigate the utility of pulmonary rehabilitation on exercises efficiency, dyspnea, and quality of life in patients with lung cancer during chemotherapy.
2 2.1
Methods Subjects
The study was approved by the Ethics Committee of the Silesian Medical University (permission KNW/0022/KB1/184a/I/11/12 from 22.05.2012). There were initially 28 patients recruited for this study. All were diagnosed with stage III or IV lung cancer, or with an earlier stage of the disease but judged unsuitable for surgery or radiation. The diagnosis was set within the 6 weeks prior to the enrollment and was confirmed by cytology or histology. Of the 28 patients, five did not give final agreement to participate in the study, two were excluded from further proceedings due to rapid disease progression, and one patient died in seventh week of the rehabilitation program. Finally, 12 patients (10 men and 2 women; mean age 59 7 years) were chosen to the rehabilitation group. In this group, ten patients were diagnosed with nonsmall-cell lung carcinoma (NSCLC) and two with small-cell lung cancer (SCLC). These patients were continually undergoing chemotherapy that was interspersed with the rehabilitation cycles (see below). The control group consisted of further eight patients with NSCLC stage III or IV. The group closely corresponded to the rehabilitation program group in terms of gender and age. The patients of the control group were assesses before and after 8 weeks of chemotherapy alone.
Pulmonary Rehabilitation in Advanced Lung Cancer Patients During Chemotherapy
2.2
Methodological Highlights
Exercise capacity, pulmonary function, dyspnea, and a patient-reported survey of overall health and quality of life were investigated in the rehabilitation group, before and after completion of 8 weeks of rehabilitation. Physical rehabilitation was performed in 2-week cycles interspersed with consecutive rounds of chemotherapy with the cytostatic Platidiam-Vepesid. In the control group, which was not subjected to physical rehabilitation, the functional indices outlined above were compared before and after 8 weeks of chemotherapy alone (four consecutive rounds of the cytostatic). Six-minute walk test (6MWT) was performed to assess exercise capacity. The test was conducted according to the 2002 ATS guidelines (Crapo et al. 2002). The test was performed twice in each patient. For the analysis, the best record was taken into account. The same rules were followed while performing the test in both rehabilitation and control groups. The basic estimated parameter was the distance covered during the test, expressed the absolute value of meters (m). Pulmonary function was examined spirometrically using forced vital capacity (FVC) and forced expired volume in 1 s (FEV1) as performance indices (Jaeger-Masterlab; Erich–Jaeger GmbH, Wurtzburg, Germany). The results were normalized to the reference values proposed by the European Coal and Steel Community (Quanjer et al. 1993), and presented as a percentage of the predicted value (%pred.). Dyspnea was assessed with the following scales. (1) Modified dyspnea scale of the Medical Research Council (MRC); (2) basic dyspnea index (BDI) describing dyspnea in five steps integrated into the following three categories: (a) Functional Impairment (FI), (b) Magnitude of Task (MT), and (c) Magnitude of Effort (ME); and (3) oxygen cost diagram (OCD). The methodological aspects of dyspnea rating and quantification using the methods above outlined have been described elsewhere (Jastrze˛bski et al. 2005).
A patient-reported survey of health and quality of life was conducted using a Short Form Health Survey (SF-36). The SF-36 questionnaire consists of 36 questions describing the state of health. It allows assessing of the physical quality of life – Physical Cumulative Score (PCM), which consist of 4 domains: Physical Functioning (PF), limits of, and difficulties in, physical functioning – Role Physical (RP), pain perception – Bodily Pain (BP), General Health (GH), and the mental quality of life consisting – Role Emotional (RE) and Mental Health (MH). The score ranges from 0 to 100; the higher the score the better the outcome is. The patients filled out the questionnaires individually. The methodological rules and the SF-36 data analysis have been described elsewhere (Jastrze˛bski et al. 2005).
2.3
Pulmonary Rehabilitation Program
Rehabilitation consisted of 8 weeks’ physiotherapy program in the hospital environment. There were four 2-week rehabilitation cycles, each preceded by a round of chemotherapy. Therefore, each rehabilitation cycle was followed by a consecutive round of cytostatic treatment, followed, in turn, by consecutive 2 weeks of rehabilitation. Rehabilitation program ended after 8 weeks, before a consecutive round of chemotherapy. In two patients, the rehabilitation program was extended to 10 and 12 weeks. The control group of patients was observed without any physical rehabilitation. Depending on the results of the initial 6MWT, the patients in the rehabilitation group were divided into 2 groups: Group A – 6MWT >200 m (8 patients); • Rehabilitation was conducted with the use of Nordic Walking, exercise was conducted once a day for 45 min at least 5 days a week, with a heart rate (HR) target of 70 % of predicted maximal HR (220 – age) ((HR ¼ 70 % ( HRmax – HRsp) + HRsp)), oxygen saturation control during exercise (cut-off value 88 % SaO2), and dyspnea (MRC scale
Pulmonary Rehabilitation in Advanced Lung Cancer Patients During Chemotherapy D. Jastrze˛bski, M. Maksymiak, S. Kostorz, B. Bezubka, I. Osmanska, T. Młynczak, A. Rutkowska, Z. Baczek, D. Ziora, and J. Kozielski Abstract
The aim of this study was to investigate the utility of pulmonary rehabilitation for improving of exercises efficiency, dyspnea, and quality of life of patients with lung cancer during chemotherapy. After the enrollment selection, the study included 20 patients with newly diagnosed advanced lung cancer and performance status 0–2. There were 12 patients randomly allocated to the pulmonary rehabilitation group and another 8 constituted the control group that did not undergo physical rehabilitation. Both groups of patients had continual cycles of chemotherapy. Data were analyzed before and after 8 weeks of physical rehabilitation, and before and after 8 weeks of observation without rehabilitation in controls. The inpatient rehabilitation program was based on exercise training with ski poles and respiratory muscle training. We found an increase in mobility (6 Minute Walk Test: 527.3 vs. 563.4 m; p > 0.05) and forced expired volume in 1 s (66.9 13.2 vs. 78.4 17.7 %predicted; p ¼ 0.016), less dyspnea (p ¼ 0.05), and a tendency for improvement in the general quality of life questionnaire after completion of pulmonary rehabilitation as compared with the control group. This report suggests that pulmonary rehabilitation in advanced lung cancer patients during chemotherapy is a beneficial intervention to reduce dyspnea and enhance the quality of life and mobility. Keywords
Dyspnea • Exercises efficiency • Lung cancer • Lung function • Nordic walking • Pulmonary rehabilitation • Quality of life D. Jastrze˛bski (*), S. Kostorz, B. Bezubka, I. Osmanska, T. Młynczak, D. Ziora, and J. Kozielski Department of Lung Diseases and Tuberculosis, Medical University of Silesia, 1 Koziolka St., 41-803 Zabrze, Poland e-mail: [email protected] M. Maksymiak Department of Rehabilitation, School of Health Sciences, Medical University of Silesia, Katowice, Poland
A. Rutkowska Institute of Physiotherapy, Opole University of Technology and Physiotherapy, Opole, Poland Z. Baczek Upper Silesian Rehabilitation Center, Ustron´, Poland
D. Jastrze˛bski et al.
1
Introduction
Over the last decade, many studies supported the efficacy of pulmonary rehabilitation in patients with lung diseases, especially in chronic obstructive pulmonary disease (COPD), asthma, mucoviscidosis, and interstitial lung fibrosis. Pulmonary rehabilitation has become a recognized method of treatment (Nici et al. 2006) and is recommended by the Polish Society of Lung Diseases (Pierzchała et al. 2010), as well as international expert groups (Rabe et al. 2007). Therefore, it is proposed that pulmonary rehabilitation program should be introduced in cancer patients, based on the strategies established for patients with COPD, postulating that physical effort will improve physical activity and exercise tolerance, and will significantly decrease the level of dyspnea; thereby enhancing the healthrelated quality of life. The hitherto consensus has been that oncological patients should not be subjected to rehabilitation training. Broadly defined physiotherapy has been considered an absolute contraindication for them. In 2010, the American College of Sport Medicine published the first recommendations on the usefulness of rehabilitation in cancer (Schmitz at al. 2010). The recommendations did not concern rehabilitation in lung cancer. The current state of knowledge is insufficient to answer the question of the relevance and influence of physical therapy in lung cancer patients. A review of the literature shows positive effects of physiotherapy in lung cancer after surgery (Jones et al. 2010, 2008; Spruit et al. 2006) and there seem to be a single only article that describes the results of rehabilitation in inoperable lung cancer during chemotherapy (Temel et al. 2009). The currently used anticancer treatment, although extending the patient’s life expectancy, is highly toxic. This situation has a bearing on the physiological and psychological state of patients. These effects lead to increased pain, loss of physical fitness and efficiency, increase fatigue, cause immune dysfunction, and reduce quality of life (McTieman 2004). Therefore, implementation of
programs based on physical activity for reducing the above mentioned symptoms seems an attractive notion, particularly in view of overall beneficial effects of physical training reported in a number of meta-analyses. It has also been shown that physical training may reduce the risk of tumor recurrence, as well as it may extend life expectancy. Therefore, the aim of this study was to investigate the utility of pulmonary rehabilitation on exercises efficiency, dyspnea, and quality of life in patients with lung cancer during chemotherapy.
2 2.1
Methods Subjects
The study was approved by the Ethics Committee of the Silesian Medical University (permission KNW/0022/KB1/184a/I/11/12 from 22.05.2012). There were initially 28 patients recruited for this study. All were diagnosed with stage III or IV lung cancer, or with an earlier stage of the disease but judged unsuitable for surgery or radiation. The diagnosis was set within the 6 weeks prior to the enrollment and was confirmed by cytology or histology. Of the 28 patients, five did not give final agreement to participate in the study, two were excluded from further proceedings due to rapid disease progression, and one patient died in seventh week of the rehabilitation program. Finally, 12 patients (10 men and 2 women; mean age 59 7 years) were chosen to the rehabilitation group. In this group, ten patients were diagnosed with nonsmall-cell lung carcinoma (NSCLC) and two with small-cell lung cancer (SCLC). These patients were continually undergoing chemotherapy that was interspersed with the rehabilitation cycles (see below). The control group consisted of further eight patients with NSCLC stage III or IV. The group closely corresponded to the rehabilitation program group in terms of gender and age. The patients of the control group were assesses before and after 8 weeks of chemotherapy alone.
Pulmonary Rehabilitation in Advanced Lung Cancer Patients During Chemotherapy
2.2
Methodological Highlights
Exercise capacity, pulmonary function, dyspnea, and a patient-reported survey of overall health and quality of life were investigated in the rehabilitation group, before and after completion of 8 weeks of rehabilitation. Physical rehabilitation was performed in 2-week cycles interspersed with consecutive rounds of chemotherapy with the cytostatic Platidiam-Vepesid. In the control group, which was not subjected to physical rehabilitation, the functional indices outlined above were compared before and after 8 weeks of chemotherapy alone (four consecutive rounds of the cytostatic). Six-minute walk test (6MWT) was performed to assess exercise capacity. The test was conducted according to the 2002 ATS guidelines (Crapo et al. 2002). The test was performed twice in each patient. For the analysis, the best record was taken into account. The same rules were followed while performing the test in both rehabilitation and control groups. The basic estimated parameter was the distance covered during the test, expressed the absolute value of meters (m). Pulmonary function was examined spirometrically using forced vital capacity (FVC) and forced expired volume in 1 s (FEV1) as performance indices (Jaeger-Masterlab; Erich–Jaeger GmbH, Wurtzburg, Germany). The results were normalized to the reference values proposed by the European Coal and Steel Community (Quanjer et al. 1993), and presented as a percentage of the predicted value (%pred.). Dyspnea was assessed with the following scales. (1) Modified dyspnea scale of the Medical Research Council (MRC); (2) basic dyspnea index (BDI) describing dyspnea in five steps integrated into the following three categories: (a) Functional Impairment (FI), (b) Magnitude of Task (MT), and (c) Magnitude of Effort (ME); and (3) oxygen cost diagram (OCD). The methodological aspects of dyspnea rating and quantification using the methods above outlined have been described elsewhere (Jastrze˛bski et al. 2005).
A patient-reported survey of health and quality of life was conducted using a Short Form Health Survey (SF-36). The SF-36 questionnaire consists of 36 questions describing the state of health. It allows assessing of the physical quality of life – Physical Cumulative Score (PCM), which consist of 4 domains: Physical Functioning (PF), limits of, and difficulties in, physical functioning – Role Physical (RP), pain perception – Bodily Pain (BP), General Health (GH), and the mental quality of life consisting – Role Emotional (RE) and Mental Health (MH). The score ranges from 0 to 100; the higher the score the better the outcome is. The patients filled out the questionnaires individually. The methodological rules and the SF-36 data analysis have been described elsewhere (Jastrze˛bski et al. 2005).
2.3
Pulmonary Rehabilitation Program
Rehabilitation consisted of 8 weeks’ physiotherapy program in the hospital environment. There were four 2-week rehabilitation cycles, each preceded by a round of chemotherapy. Therefore, each rehabilitation cycle was followed by a consecutive round of cytostatic treatment, followed, in turn, by consecutive 2 weeks of rehabilitation. Rehabilitation program ended after 8 weeks, before a consecutive round of chemotherapy. In two patients, the rehabilitation program was extended to 10 and 12 weeks. The control group of patients was observed without any physical rehabilitation. Depending on the results of the initial 6MWT, the patients in the rehabilitation group were divided into 2 groups: Group A – 6MWT >200 m (8 patients); • Rehabilitation was conducted with the use of Nordic Walking, exercise was conducted once a day for 45 min at least 5 days a week, with a heart rate (HR) target of 70 % of predicted maximal HR (220 – age) ((HR ¼ 70 % ( HRmax – HRsp) + HRsp)), oxygen saturation control during exercise (cut-off value 88 % SaO2), and dyspnea (MRC scale
