Evidence-Based Practice for Fatigue Management in Adults With … · 2018-12-06 · (2001) posited...

ONCOLOGY NURSING FORUM – VOL 31, NO 5, 2004963

Key Points . . .

➤ Exercise has been shown to be the most effective nonpharma-cologic intervention for cancer-related fatigue (CRF).

➤ Home-based aerobic exercise programs, including walking,are feasible and effective for CRF in diverse patients with can-cer undergoing treatment.

➤ Oncology nurses have a responsibility to apply the knowledgeof exercise for CRF to practice through education, limited ex-ercise prescription, and referral.

Purpose/Objectives: To review and summarize the current state of theevidence for exercise as an intervention for cancer-related fatigue and tofacilitate application to clinical practice.

Data Sources: Articles, abstracts, and practice guidelines publishedthrough October 2003.

Data Synthesis: The strength of the evidence of effectiveness of ex-ercise in managing cancer-related fatigue is growing.

Conclusions: All patients with cancer should be encouraged to main-tain an optimum level of physical activity during and following cancertreatment. Patients with breast cancer and other selected patients shouldreceive recommendations for moderate exercise programs. Referrals tophysical therapy and/or rehabilitation may benefit certain patients, includ-ing those with comorbidities or deconditioning. Published multidisci-plinary evidence-based guidelines for exercise programs involving pa-tients with cancer are needed.

Implications for Nursing: Nurses may participate in implementing ex-ercise interventions with patients with cancer in various roles dependingon skill and knowledge—from encouraging physical activity to referringpatients to physical therapy and/or rehabilitation programs to prescrib-ing and monitoring exercise in certain patient populations.

Goal for CE Enrollees:To enhance nurses’ knowledge about current evidence re-

lated to exercise as an intervention for cancer-related fatigue.

Objectives for CE Enrollees:On completion of this CE, the participant will be able to

1. Describe the theoretical basis for the use of exercise in themanagement of fatigue in people with cancer.

2. Outline the evidence currently available related to the useof exercise in the management of cancer-related fatigue.

3. Discuss the clinical and research implications of exercisein the management of fatigue in people with cancer.

CONTINUING EDUCATION

Evidence-Based Practice for Fatigue Managementin Adults With Cancer: Exercise as an Intervention

Carrie Tompkins Stricker, MSN, APRN-BC, AOCN®, Diane Drake, PhD, RN,Kyle-Anne Hoyer, MSN, RN, and Victoria Mock, DNSc, AOCN®, FAAN

Carrie Tompkins Stricker, MSN,APRN-BC, AOCN®, is an oncologynurse practitioner at the Universityof Pennsylvania Medical Center anda doctoral student in the School of

Nursing at the University of Pennsylvania, both in Philadelphia; DianeDrake, PhD, RN, is a postdoctoral fellow at the University of Califor-nia, San Francisco; Kyle-Anne Hoyer, MSN, RN, was a clinical nursespecialist at the Billings Clinic in Missouri at the time this article waswritten; and Victoria Mock, DNSc, AOCN®, FAAN, is director of theCenter for Nursing Research in the School of Nursing at JohnsHopkins University and director of Nursing Research at the KimmelCancer Center at the Johns Hopkins Hospital, both in Baltimore, MD.(Submitted June 2003. Accepted for publication January 6, 2004.)

Digital Object Identifier: 10.1188/04.ONF.963-976

Cancer-related fatigue (CRF) is the most common anddistressing side effect of cancer treatment. This fatiguehas a profound effect on patients’ ability to perform

activities of daily living. As the evidence for exercise in theprevention and management of CRF has grown since the1990s, oncology nurses and healthcare professionals are chal-lenged to integrate exercise interventions for patients withcancer. Effective management of CRF through strategies suchas exercise can affect the multidimensional experience of fa-tigue and improve patients’ functional status and quality oflife (QOL). This article is a review and summary of the cur-rent state of the evidence on exercise as an intervention forCRF. This clinically relevant synthesis facilitates applicationto nursing practice and identifies directions for future researchneeded to address gaps in current knowledge.

DefinitionsCRF is a multidimensional phenomenon influenced by physi-

cal, psychological, and other diverse factors. CRF is defined bythe National Comprehensive Cancer Network (NCCN) as “apersistent, subjective sense of tiredness related to cancer orcancer treatment that interferes with usual functioning” (Mock

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et al., 2003, p. 310). Although knowledge about CRF is evolv-ing, the NCCN definition is used for the purposes of this re-view. Patients with cancer consistently have reported fatigueas the most common and distressing symptom experiencedduring cancer and its treatment (Curt et al., 2000; Greene,Nail, Fieler, Dudgeon, & Jones, 1994; Irvine, Vincent,Graydon, Bubela, & Thompson, 1994; Jacobsen et al., 1999;Piper, Lindsey, & Dodd, 1987). The prevalence of fatigue isreported as high as 61%–100% in studies of patients with can-cer, and in one study, patients reported that fatigue was threetimes more distressing than pain (Piper et al.). More than 75%of patients with metastatic disease have reported CRF, andeven cancer survivors report fatigue as a disruptive symptommonths or years after treatment ends (Broeckel, Jacobsen,Horton, Balducci, & Lyman, 1998).

Exercise is planned, structured, and repetitive bodily move-ment performed with the intent of improving or maintainingone or more components of physical fitness (Brooks & Fahey,2000). NCCN recently revised its guidelines for fatigue man-agement developed by a multidisciplinary national panel ofexperts (Mock et al., 2003) and recognized exercise as thenonpharmacologic intervention with the strongest evidence ofeffectiveness in managing CRF.

A growing demand to integrate contemporary evidence intoclinical practice is facing oncology nurses (Stricker & Sul-livan, 2003). This process is known as evidence-based prac-tice (EBP). EBP is characterized by the critical review andpurposeful integration of various types of evidence, includingresearch, theory, clinical expertise, and patient preferencesregarding patient care and decision making (Rutledge &Grant, 2002).

Systematic Review of the EvidenceIdentification of Evidence

A literature search was conducted in January 2002, and re-peated in October 2003, of the CINAHL® and MEDLINE®

databases and Database of Abstracts of Reviews Effects usingthe terms “fatigue,” “cancer,” and “exercise.” Forty-two ar-ticles were identified in English, of which 21 were selected forreview. In addition, 13 research studies were identified andobtained based on a book chapter by Mock (2003), most ofwhich were represented in the literature search. Proceedingsof the annual meetings of the American Society of ClinicalOncology, American College of Sports Medicine (ACSM),and Oncology Nursing Society, as well as the Seventh Na-tional Conference on Cancer Nursing Research, also weresearched at these times to identify published abstracts on thistopic; the authors added three abstracts from these meetingsto this review (Headley, 2003; John, 2003; Poniatowski,Mock, & Cohen, 2001).

Selection of Study ReportsAll identified research reports and case studies, regardless

of date, as well as review articles and reports of practiceguidelines from 1995 to October 2003 were included in thissystematic review, provided that exercise was identified as anintervention and fatigue as an outcome variable. Non-experimental research studies that included physical activityor exercise as the primary independent variable and fatigue asa primary outcome variable also were included. The PrioritySymptom Management (PRISM) system for leveling evi-

dence (Ropka & Spencer-Cisek, 2001) was selected to rate thelevels of evidence for each of the articles (see Table 1). Thissystem is based on three broad PRISM levels (I, II, and III)that are subdivided into eight specific levels of evidence (1–8). Throughout this article, sources of evidence are rated ac-cording to the Arabic numbered levels of evidence from thismodel. Study designs are based on the definitions and descrip-tions by Cook and Campbell (1979).

Critical Appraisal of the EvidenceTheoretical Background on Exercise as anIntervention

The use of theory is a critical component of EBP (Rutledge& Grant, 2002). Conceptual models and theories have beendeveloped to advance the understanding of CRF and providetheoretical evidence to support the role of exercise in manag-ing CRF. A common conceptual theme of CRF is the multi-dimensionality of the phenomenon. Ream and Richardson(1999) reviewed five theories used in the development andtesting of fatigue interventions. The Winningham Psychobio-logic Entropy Model and a physiologic model by Dimeo con-tributed to understanding the role of exercise in managingCRF.

Maryl Winningham, a pioneer of exercise prescription dur-ing cancer treatment, developed a model that built on the priorwork of exercise physiologists with other chronic diseasepopulations. The Winningham Psychobiologic Entropy Modelprovided a framework for research investigating the impact ofaerobic interval training on fatigue and other outcomes inpatients with cancer during treatment (Winningham, 1996). Amajor hypothesis of the model is that reductions in physicalactivity lead to reduced energy capacity and subsequently tofatigue and decreased functional status. This self-perpetuatingcycle may result in disability and occur regardless of whetherthe decrease in physical activity is the result of treatment-re-lated symptoms, fatigue as a primary symptom, or a multitudeof other factors (Nail & Winningham, 1993). The model em-phasizes the importance of maintaining a balance betweenactivity and rest. Winningham (2001) concluded that indi-vidualized activity and exercise programs ameliorate fatiguethrough preservation of energy efficiency.

Dimeo, Rumberger, and Keul (1998) provided a more de-tailed physiologic explanation for the relationship betweenactivity and CRF. Using complex propositions to describeetiologic mechanisms and consequences of fatigue, Dimeo(2001) posited that fatigue is caused partially by declines inneuromuscular efficiency resulting from metabolic and cellu-lar mechanisms altered by cancer and its treatment. Subse-quent physical inactivity further exacerbates fatigue by induc-ing muscular catabolism, leading to a cycle of further declinein performance, reduction in activity, and easy fatigability.Exercise alters the cycle of fatigue by improving neuromus-cular efficiency.

Because patients with cancer have reported high levels offatigue during the first 72 hours following the initial dose ofchemotherapy, inactivity and deconditioning clearly are notthe sole primary causes of CRF. CRF probably is caused bya combination of changes in physiology initiated by disease,treatment, and inactivity and is influenced further by psycho-logical factors, alterations in nutritional status, and sleep pat-terns (Mock et al., 2003). Winningham’s and Dimeo’s models


provide relevant frameworks to explain the roles of exercisein reducing CRF.

Research-Based EvidenceDescriptive and correlational studies: To better describe

the patterns and correlates of CRF, researchers have con-ducted descriptive studies of patients with cancer and cancersurvivors. In populations of women receiving adjuvant che-motherapy for breast cancer, Berger (1995, 1998), Berger andFarr (1999), and Berger and Higginbotham (2000) identifiedan inverse relationship between activity level and fatigue andpositive relationships among fatigue and sleep disturbance,daytime naps, and symptom distress. One study (Berger,1998) used wrist actigraphs to measure activity and rest cyclesin women with breast cancer. These descriptive studies pro-vided support for the hypothesis that fatigue is related to re-duced activity levels and exercise may be an effective inter-vention for CRF by increasing individuals’ activity levels. Inaddition, exercise has been shown previously to positivelyaffect intermediary variables, such as sleep, that are identifiedas influencing the experience of CRF (Poniatowski et al.,2001).

Two additional descriptive studies provide further support forexercise as an intervention for CRF. In a landmark retrospec-tive study of 71 breast cancer survivors, Young-McCaughanand Sexton (1991) reported significantly higher perceivedQOL among women who had exercised during treatmentcompared to those who had not. The QOL tool employed inthis study included an item about tiring easily. Schwartz(1998) studied 219 cancer survivors who had high levels of

prediagnosis physical activity and maintained their activity tovarying degrees during treatment. Although overall exerciseintensity, duration, and frequency were decreased in individu-als compared to their baseline, the participants reported usingmoderate exercise to reduce CRF during treatment.

Experimental and quasi-experimental studies: Twentyexperimental research articles evaluated in this article providestrong support for exercise as an intervention for CRF (seeTable 2). All of these studies reported positive effects of ex-ercise, either through reduction in levels of fatigue in partici-pants who exercised as compared to those who did not or bydocumenting a decrease—or in hospice patients, a stabiliza-tion—in fatigue experienced by exercising participants frombaseline to end of participation in a structured exercise pro-gram. Nine randomized clinical trials and 11 quasi-experi-mental studies were evaluated, all of which used a pretest/post-test design. Three of the quasi-experimental studies in-cluded a concurrent control group; Schwartz, Thompson, andMasood (2002) used historical controls. The remainder evalu-ated the efficacy of the exercise intervention by measuringfatigue outcomes in one treatment group before and after par-ticipation in a structured exercise program.

To date, the vast majority of research investigating the ef-ficacy of exercise as an intervention for CRF has been con-ducted with patients undergoing active cancer treatments suchas chemotherapy, radiation therapy, and stem cell transplant.Women with breast cancer represent the largest group of par-ticipants in these studies, although investigators are broaden-ing their focus to include mixed cancer populations and indi-viduals with advanced disease. All exercise interventions were

Evidence Source

Qualitative systematic review (also called “integrative review”) or quantitative systematic review (also called “meta-analysis”) ofmultiple, well-designed, randomized, controlled trials of adequate quality

At least one properly designed, randomized, controlled trial of appropriate size (record if multisite and over 100 subjects, but notrequired)

Well-designed trial without randomization (e.g., single group pre/post, cohort, time series, meta-analysis of cohort studies)

Well-conducted, qualitative, systematic review of nonexperimental design studies

Well-conducted case-control study

Poorly controlled study (e.g., randomized controlled trial with major flaws) or uncontrolled studies (e.g., correlational descriptivestudy, case series)

Conflicting evidence with the weight of evidence supporting the recommendation or meta-analysis showing a trend that did notreach statistical significance

National Institutes of Health Consensus Reports

Published practice guidelines, for example, from professional organizations (e.g., Oncology Nursing Society, American Societyof Clinical Oncology), healthcare organizations (e.g., American Cancer Society), or federal agencies (e.g., National Cancer Insti-tute, Centers for Disease Control and Prevention)

Qualitative designs

Case studies; opinions from expert authorities, agencies, or committees

Table 1. Priority Symptom Management (PRISM) Levels of Evidence

PRISMLevel

I

II

III

Level ofEvidencea

1

2

3

4

5

6

7

8

a Levels of evidence range from the strongest evidence at the top to the weakest level of evidence at the bottom.Note. From “Rating the Quality of Evidence for Clinical Practice Guidelines” by D.C. Hadorn, D. Baker, J.S. Hodges, & N. Hicks, 1996, Journal of Clinical Epidemiol-ogy, 49, 750. Copyright 1996 by Elsevier Inc. Adapted with permission in “PRISM: Priority Symptom Management Project Phase I: Assessment” by M.E. Ropka &P. Spencer-Cisek, 2001, Oncology Nursing Forum, 28, 1589. Copyright 2001 by the Oncology Nursing Society. Reprinted with permission.


Tabl

e 2.

Exe

rcis

e as

an

Inte

rven

tion

for C

ance

r-Re

late

d Fa

tigue

: Exp

erim

enta

l and

Qua

si-E

xper

imen

tal S

tudi

es

Auth

or a

nd Y

ear

Mac

Vica

r &W

inni

ngha

m, 1

986

Moc

k et

al.,

199

4

Dim

eo e

t al.,

199

7

Moc

k, D

ow, e

t al.,

1997

Dim

eo e

t al.,

199

8

Dim

eo e

t al.,

199

9

Schw

artz

, 199

9,20

00a

Poro

ck e

t al.,

200

0

Schw

artz

, 200

0b

Moc

k et

al.,

200

1

Sam

plea

(N)

10 14 32 46

5; 2

wer

e po

st tr

eat-

men

t by

9 an

d 18

mon

ths

59 27 9 71 48

Diag

nosi

s an

d Tr

eatm

ent

Brea

st c

ance

r (CA

) tre

ated

with

chem

othe

rapy

(CT)

Brea

st C

A w

ith C

T

Mix

ed s

olid

tum

or a

nd n

on-

Hodg

kin

lym

phom

a w

ith p

erip

h-er

al b

lood

ste

m c

ell t

rans

plan

ta-

tion

(PBS

CT),

imm

edia

tely

afte

rdi

scha

rge

Brea

st C

A w

ith r

adia

tion

ther

-ap

y (R

T)

Patie

nts

had

seve

re b

asel

ine

fatig

ue a

nd w

ere

trea

ted

with

CT, R

T, o

r PBS

CT.

PBSC

T

Brea

st C

A w

ith C

T

Adva

nced

CA

with

mix

ed d

iag-

nose

s; p

atie

nts

rece

ived

hos

-pi

ce, R

T =

1, o

r CT

= 2

Brea

st C

A w

ith C

T

Brea

st C

A w

ith C

T (3

6%)

or R

T (6

4%)

Desi

gn

Qua

si-e

xper

imen

tal,

thre

egr

oup

Rand

omize

d cl

inic

al tr

ial

Pret

est/

post

-tes

t w

ith u

n-tre

ated

con

trol g

roup

Rand

omize

d cl

inic

al tr

ial

One-

grou

p, p

rete

st/p

ost-t

est

Pret

est/

post

-tes

t w

ith u

n-tre

ated

con

trol g

roup

One

grou

p pr

etes

t/pos

t-tes

t

One

grou

p, p

rete

st/p

ost-t

est;

case

stu

dies

als

o re

porte

d

One

grou

p, p

rete

st/p

ost-t

est

Ran

dom

ized

clin

ical

tri

al,

mul

ti-in

stitu

tiona

l

Exer

cise

Inte

rven

tion

Cycl

e er

gom

etry

(ins

titut

ion

base

d [I]

, in-

terv

al tr

aini

ng [

IT])

for

20–3

0 m

inut

es,

thre

e tim

es p

er w

eek,

for 1

0 w

eeks

; 60%

–85

% m

axim

um h

eart

rate

(HR

max

)

Wal

king

pro

gram

(co

ntin

uous

[C]

, hom

eba

sed

[H])

for

30

min

utes

, fou

r to

fiv

etim

es w

eekl

y, a

nd s

uppo

rt g

roup

for

90m

inut

es e

very

two

wee

ks (D

urat

ion

of b

oth

was

four

to s

ix m

onth

s.)

Trea

dmill

aero

bic

wal

king

(I, I

T) d

aily

for 1

5–30

min

utes

for s

ix w

eeks

; 80

% H

R m

ax

Wal

king

pro

gram

(H

, C)

for

30 m

inut

es,

four

to fi

ve ti

mes

wee

kly,

for s

ix w

eeks

; in-

tens

ity w

as s

elf-d

eter

min

ed.

Trea

dmill

aer

obic

wal

king

(I, I

T) fo

r 15–

35m

inut

es, f

ive

times

wee

kly,

for s

ix w

eeks

;80

% H

R m

ax

Supi

ne b

icyc

le e

rgom

etry

, aer

obic

(I,

IT);

30 m

inut

es d

aily

dur

ing

hosp

italiz

atio

n

Aero

bic

exer

cise

of c

hoic

e (H

, C) f

or 1

5–30

min

utes

, thr

ee to

four

tim

es w

eekl

y, fo

rei

ght w

eeks

Duke

Ene

rgizi

ng E

xerc

ise

Prog

ram

(H, I

T)fo

r tw

o to

four

wee

ks; r

ange

of a

ctiv

ities

(wal

king

, tre

adm

ill, c

hair

or b

ed e

xerc

ises

)

Aero

bic

exer

cise

of c

hoic

e (H

, C) f

or 1

5–30

min

utes

, fou

r tim

es w

eekl

y, fo

r eig

ht w

eeks

Wal

king

pro

gram

(H, C

) sta

rting

for 1

0–30

min

utes

, fiv

e to

six

tim

es w

eekl

y, fo

r si

xw

eeks

(w

ith R

T) o

r fo

ur to

five

mon

ths

(with

CT)

Resu

lts

Fatig

ue d

ecre

ased

in e

xerc

isin

gpa

tient

s an

d no

npat

ient

s.

Fatig

ue d

ecre

ased

dur

ing

and

afte

r CT

in e

xerc

iser

s.

No

repo

rts

of fa

tigue

in e

xer-

cise

gro

up;

four

con

trol

s(2

5%) r

epor

ted

fatig

ue.

Fatig

ue w

as lo

wer

in e

xerc

iser

sve

rsus

con

trols

and

dec

reas

edfro

m p

re- t

o po

st-te

st in

exe

r-ci

sers

.

Thre

e pe

ople

repo

rted

no m

ore

fatig

ue w

ith d

aily

act

iviti

es; t

wo

resu

med

wor

k.

No s

igni

fican

t cha

nge

in fa

tigue

over

tim

e in

exe

rcis

ers;

fatig

uein

crea

sed

in c

ontro

ls.

Decr

ease

d fa

tigue

in e

xerc

iser

s;fa

tigue

med

iates

incr

ease

d qu

al-ity

of l

ife in

exe

rcise

rs. P

eak,

av-

erag

e, a

nd w

orst

fatig

ue le

vels

decr

ease

d ov

er ti

me

in e

xerc

is-

ers.

Fatig

ue s

tabi

lized

.

Fatig

ue w

as lo

wer

in e

xerc

ise

adhe

rers

ver

sus

nona

dher

ers.

Fatig

ue d

ecre

ased

in e

xerc

iser

s(“

high

wal

kers

”) a

nd in

crea

sed

in “

low

-wal

kers

.”

Leve

l of E

vide

nce

3 2 3 2 6(C

ase

serie

s)

3 3 6 3 2

(Con

tinu

ed o

n ne

xt p

age)

a N is

the

actu

al n

umbe

r of s

ubje

cts

com

plet

ing

the

stud

y fo

r who

m d

ata

are

repo

rted,

unl

ess

othe

rwis

e in

dica

ted.


Tabl

e 2.

Exe

rcis

e as

an

Inte

rven

tion

for C

ance

r-Re

late

d Fa

tigue

: Exp

erim

enta

l and

Qua

si-E

xper

imen

tal S

tudi

es (c

ontin

ued)

Schw

artz

et a

l.,20

01

Burn

ham

& W

ilcox

,20

02

Schw

artz

et a

l.,20

02

Adam

sen

et a

l.,20

03

Cole

man

et a

l., 2

003

Cour

neya

, Frie

den-

reic

h, e

t al.,

200

3

Cour

neya

, Mac

key,

et a

l., 2

003

Moc

k et

al.,

in p

ress

Olde

rvol

l et a

l., 2

003

Sega

l et a

l., 2

003

61 18 12 23

24 (1

4 in

ana

lysi

s)

96 52 111 9

155

(135

in a

naly

sis)

Brea

st C

A w

ith C

T

Brea

st a

nd c

olon

CA

surv

ivor

s(n

= 1

5, 3

) who

wer

e 9.

0–10

.3m

onth

s po

st-t

reat

men

t with

CT, R

T, o

r sur

gery

Mal

igna

nt m

elan

oma

Mix

ed C

A di

agno

ses

with

CT

Mul

tiple

mye

lom

a w

ith C

T

Mix

ed C

A di

agno

ses;

— X =

16.2

8 m

onth

s si

nce

diag

nosi

s;44

% a

ctiv

ely

on C

T or

RT

Brea

st C

A su

rviv

ors;

— X =

14m

onth

s po

st-tr

eatm

ent

Brea

st C

A w

ith C

T an

d RT

Hodg

kin

dise

ase

surv

ivor

s

Pros

tate

CA

with

and

roge

nde

priv

atio

n th

erap

y

One

grou

p, p

rete

st/p

ost-t

est

Ran

dom

ized

clin

ical

tri

al;

mat

ched

for

bas

elin

e fu

nc-

tiona

l cap

acity

One

grou

p pr

e/po

st-tr

eatm

ent

com

pare

d to

his

toric

al c

on-

trols

Two-

grou

p br

eakd

own

(ret

ro-

spec

tivel

y)1.

Exe

rcis

e on

ly2.

Exe

rcis

e/m

ethy

lphe

nida

te

One

grou

p, p

rete

st/p

ost-t

est

Rand

omize

d cl

inic

al tr

ial

Ran

dom

ized

clin

ical

tri

al o

fgr

oup

psyc

hoth

erap

y (G

P)al

one

vers

us G

P pl

us e

xerc

ise

Rand

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individually based except for Adamsen et al.’s (2003) trial ofgroup exercise as part of a multimodality intervention.

Women who exercise while undergoing adjuvant therapyfor early-stage breast cancer experience less fatigue than theircounterparts who do not exercise, based on PRISM level 2and 3 evidence. Seven studies employed home-based aerobicexercise interventions in this population. Aerobic exerciseenhances the oxygen-carrying capacity of the cardiovascularsystem through the prolonged rhythmical contraction and re-laxation of large muscle masses (Dimeo et al., 1998). Mostwomen in these studies were young, married, college-edu-cated Caucasians; employed while undergoing cancer treat-ment; and were a mean of 44–49 years of age (Mock et al.,1994, 2001, in press; Mock, Dow, et al., 1997; Schwartz,1999, 2000a, 2000b; Schwartz, Mori, Gao, Nail, & King,2001). All of the women with breast cancer were undergoingeither chemotherapy (Mock et al., 1994, 2001, in press;Schwartz, 1999, 2000a, 2000b; Schwartz et al., 2001) or radia-tion therapy (Mock et al., 2001, in press; Mock, Dow, et al.)as adjuvant treatment. In all of these studies, exercise had astatistically significant effect in decreasing fatigue and im-proving functional ability during treatment.

Exercise also decreases CRF during and immediately follow-ing peripheral blood stem cell transplantation (PBSCT), sup-ported by PRISM level 3 evidence (Dimeo et al., 1997; Dimeo,Stieglitz, Novelli-Fischer, Fletcher, & Keul, 1999). Patientsundergoing PBSCT are the second-largest group in whom ex-ercise has been studied. Aerobic interval training patterns wereused in Dimeo et al.’s (1997, 1998, 1999) work. Interval train-ing is characterized by alternating brief periods of moderate- tohigh-intensity exercise with brief periods of low-intensity (of-ten half-speed) exercise. In Dimeo et al.’s (1997, 1998, 1999)research, participants ranged in age from 32–42; had a diagno-sis of lymphoma or a solid tumor, including lung cancer andseminoma; and were comprised of nearly twice as many femaleas male participants. All three studies demonstrated either lessfatigue in exercisers versus controls or a decrease in fatiguefrom pre- to post-test in exercising participants. However, inDimeo et al.’s (1999) study of supine bicycle ergometry (simu-lated biking) during hospitalization for PBSCT, a close exami-nation of the actual mean fatigue scores on the Profile of MoodStates challenges the clinical significance of these findings.Although controls demonstrated statistically significant in-creases in fatigue during hospitalization whereas exercisers didnot, the mean fatigue scores increased in both groups from pre-to post-test to a clinically similar degree (2.1 versus 2.3 points).Exercise may have ameliorated fatigue associated with treat-ment only slightly.

One PRISM level 6 study supported the efficacy of exercisein managing preexisting severe fatigue in PBSCT survivors.Dimeo et al. (1998) evaluated three individuals undergoingand two after PBSCT (one 9 months and another 18 monthsafter PBSCT); all five had severe fatigue at study entry. Af-ter six weeks of aerobic treadmill walking, three reportedresolution of fatigue with daily activities. This study is limitedby its small sample size, lack of a control group, and lack ofa standardized measure of CRF; nonetheless, it provides be-ginning evidence for the ability of exercise to resolve fatigueand improve function in individuals with preexisting severefatigue related to cancer and its treatment.

Recently, the role of exercise in decreasing fatigue in othergroups of patients with cancer has been supported by growing

PRISM level 2 and 3 evidence in studies of individuals under-going treatment for a variety of solid tumors and hematologicmalignancies (Adamsen et al., 2003; Coleman et al., 2003;Courneya, Friedenreich, et al., 2003; Schwartz et al., 2002;Segal et al., 2003). Schwartz et al. (2002) reported the effectsof an exercise intervention combined with or without meth-ylphenidate on the prevention and amelioration of fatigue inpatients with melanoma receiving interferon therapy. All 12participants adhered to the exercise intervention for the studyduration of four months, and eight participants also took me-thylphenidate during this time period. Despite the fact that allparticipants had modest increases in fatigue over the course ofthe study, both the exercise and the exercise with meth-ylphenidate groups demonstrated reduced fatigue scores anda less chaotic pattern of fatigue compared to historical con-trols. Although the sample size is small, the clinical findingsare noteworthy, because fatigue is reported to be a dose- andtreatment-limiting side effect of interferon therapy.

Segal et al. (2003) conducted a randomized clinical trial inmen with prostate cancer receiving androgen deprivationtherapy. They published the first study to demonstrate the posi-tive effects of resistance exercise training on CRF. Segal et al.defined resistance exercise as requiring the body’s musculatureto move against some type of opposition, and they tested a re-petitive upper- and lower-body strength-training program inthese individuals. Exercisers demonstrated a significantlygreater reduction in fatigue from baseline to post-test. Theseresults were statistically and clinically significant, as demon-strated by a three-point difference in scores on the FunctionalAssessment of Cancer Therapy–Fatigue (FACT-F) between thetwo groups—a magnitude of improvement comparable to indi-viduals who receive treatment for cancer-related anemia.

Also in 2003, Coleman et al. reported the results of a ran-domized pilot study of exercise in 24 individuals with multiplemyeloma who were not at high risk for pathologic fracture. Tocombat the common occurrence of dexamethasone-inducedskeletal muscle wasting, a strength-resistance training pro-gram was combined with aerobic exercise for the individualsrandomized to the exercise intervention. Fatigue decreasedand sleep outcomes (total sleep, sleep efficiency) improved inthe exercise group as compared to controls. These findings,however, were not statistically significant, in part because ofthe small sample size and high attrition rate, with only 14participants included in the change-over-time analyses. Thisstudy represented the first known exercise trial to include in-dividuals with bone metastases, and no participants were in-jured during the course of the study.

In 2003, two additional studies were published that highlightthe expansion of exercise research to more diverse patient popu-lations. One large randomized clinical trial (Courneya,Friedenreich, et al., 2003) and one small quasi-experimentalstudy (Adamsen et al., 2003) reported positive effects of exer-cise on fatigue in individuals with a diversity of solid tumorsand hematologic malignancies. Participant diagnoses includedcolon cancer, lung cancer, testicular carcinoma, and Hodgkinand non-Hodgkin lymphoma, and all stages of disease were rep-resented.

Each of the 23 participants in Adamsen et al.’s (2003) studywas undergoing chemotherapy and participated in group-basedaerobic interval training and strength-resistance training for 1.5hours three times weekly. The exercise sessions were part of amultimodality intervention (including massage, relaxation, and


body-awareness training) offered for a total time of nine hourseach week for a duration of six weeks. A trend of improvementin fatigue was reported as measured by the European Organi-zation for Research and Treatment of Cancer QOL Question-naire C-30. In a larger clinical trial, Courneya, Friedenreich, etal. (2003) reported a statistically significant improvement in fa-tigue, as measured by the FACT-F, in individuals with mixedcancer diagnoses randomized to home-based aerobic exercise(95% of participants walked) in combination with group psy-chotherapy, as compared to group psychotherapy alone. Al-though participants were an average of 16.28 months from theirinitial cancer diagnosis, 44% were undergoing chemotherapy orradiation therapy during the trial.

The effectiveness and safety of exercise in palliative careonly have begun to be evaluated, with one PRISM level 6study to support its use in this setting (Porock, Kristjanson,Tinnelly, Duke, & Blight, 2000). In their study of a home-based exercise program for patients with advanced cancerenrolled in hospice programs, Porock et al. contributed to theevidence base for the utility and feasibility of exercise in pa-tients with preexisting fatigue. Nine participants with mixedsolid tumor diagnoses and moderate to high baseline levels offatigue were evaluated. Three participants received chemo-therapy or radiation therapy during the 14- to 28-day exerciseprogram. The exercise interventions were prescribed individu-ally by an exercise physiotherapist familiar with the DukeEnergizing Exercise Program, in which patients are instructedto perform periods of exercise, such as dancing, stretches, andchair or bed exercises, several times daily at an intensity andduration equaling half of what they could comfortably per-form. The small sample size precluded meaningful statisticalanalyses; nonetheless, fatigue scores essentially remainedstable across the study period. The authors concluded thattheir findings were clinically significant because participantsbecame more active, without increased fatigue, despite ad-vanced disease. Case studies of three participants suggestedthat individuals with the most severe fatigue benefited themost from exercise. Although promising, further researchwith larger sample sizes and comparison groups is needed.

In 2002 and 2003, researchers reported on studies of exer-cise and fatigue in cancer survivors who have completed treat-ment. Within the six-month period from December 2002 toMay 2003, three articles (two PRISM level 2 randomizedclinical trials and one PRISM level 6 pilot study) were pub-lished that support the efficacy of exercise to reduce fatigueand improve QOL in cancer survivors. Oldervoll, Kaasa,Knobel, and Loge (2003) reported a positive effect of aerobicexercise on chronic fatigue in a pilot study of nine Hodgkindisease survivors. Two randomized clinical trials by Cour-neya, Mackey, et al. (2003) and Burnham and Wilcox (2002)evaluated fatigue as a secondary outcome in predominantlybreast cancer survivors, with Burnham and Wilcox includingthree colon cancer survivors. These cancer survivors were amean of 9 and 14 months, respectively, after cancer treatment(Burnham & Wilcox; Courneya, Mackey, et al.). Both ran-domized clinical trials reported the positive benefits of exer-cise in reducing fatigue in cancer survivors.

Researchers continue to broaden the knowledge base relatedto exercise and CRF by testing novel exercise interventions inpreviously unstudied populations of patients with cancer. Pre-liminary findings have been presented from two studies testingseated exercise programs on fatigue and QOL in patients with

lung cancer receiving chemotherapy (John, 2003) and in pa-tients with metastatic breast cancer (Headley, 2003). Interestalso is growing among nononcology healthcare professionalgroups. Since the 2002 meeting of ACSM, sessions have beendedicated annually to exercise in patients with cancer.

Additional EvidenceNursing scientists, exercise physiologists, clinicians, and

educators have contributed to the understanding of CRF. Thesignificance of the problem of fatigue for patients with cancerhas become an important focus of review articles and clinicalpractice guidelines. These strengthen the base of evidencesupporting exercise as an intervention for CRF.

Qualitative review articles: Two comprehensive system-atic qualitative reviews support the research-based conclu-sions that exercise is an effective intervention for CRF.Friedenreich and Courneya (1996) summarized nine researchstudies conducted through 1994 on the topic of exercise andrehabilitation of patients with cancer and identified the needsand proposed directions for further research. Based on exist-ing research at the time of publication, these authors recom-mended exercise as an innovative, inexpensive, and timelyintervention for rehabilitation. Ream and Richardson’s (1999)review of interventions for fatigue also supported the positiveimpact of exercise on CRF. In addition, a recent review of thestate of the knowledge of CRF was published in a leadingmedical journal and included an evaluation of the evidence tosupport interventions (Ahlberg, Ekman, Gaston-Johansson, &Mock, 2003). Exercise was determined to have the highestlevel of evidence of efficacy.

Clinical Practice GuidelinesThe 2003 NCCN Revised Guidelines for the Management

of Fatigue summarized the standards of care for fatigue man-agement that were developed by a multidisciplinary nationalpanel of experts and also supported the efficacy and utility ofexercise for management of CRF (Mock et al., 2003). Guide-lines for evaluating and treating CRF are presented in an al-gorithm categorizing interventions for fatigue into copingstrategies and cause-specific, nonpharmacologic, and pharma-cologic interventions. After reviewing research and nonresearchevidence addressing interventions for CRF, the panel recom-mended exercise as the most effective nonpharmacologic inter-vention. Exercise training at moderate levels was reported toimprove adaptive cardiorespiratory responses, increase car-diac output, lower heart rate, decrease fatigue, and improvemood state and sleep quality.

Strength of the EvidenceDetermination of the strength of the evidence in support of a

specific intervention relates to the number of studies testing theintervention, the scientific rigor of study designs and execution,and the size and consistency of reported effects (Briss et al.,2000). When using these well-accepted criteria, the strengthof the evidence of effectiveness of exercise in managing CRFmust be characterized as strong.

At least 20 studies have been conducted focusing on theeffects of exercise on CRF. Most included control or com-parison groups and prospective measurement of exposure tothe intervention and of study outcomes. The strongest evi-dence, in the form of four randomized clinical trials and four


quasi-experimental studies, exists for home-based exerciseprograms performed by middle-aged women undergoing ad-juvant chemotherapy or radiation therapy treatments fornonmetastatic breast cancer (Mock et al., 1994, 2001; Mock,Dow, et al., 1997; Mock, McCorkle, Ropka, & Pickett, 2002;Schwartz, 1999, 2000a, 2000b; Schwartz et al., 2001). Solitarytrials evaluating exercise in individuals with multiple my-eloma, melanoma, and prostate cancer offer promise that ex-ercise may be equally beneficial in other cancer populations(Coleman et al., 2003; Schwartz et al., 2002; Segal et al.,2003), as do recent PRISM level 2 and 3 trials in individualswith mixed solid tumor and hematologic malignancies(Adamsen et al., 2003; Courneya, Friedenreich, et al., 2003).In addition, growing PRISM level 2 and 3 evidence supportsthe efficacy of exercise in reducing fatigue in cancer survivors(Courneya, Friedenreich, et al.; Oldervoll et al., 2003; Segalet al.). Consistent but less robust (PRISM level 3 and 6) evi-dence supports the efficacy of aerobic laboratory-based inter-val training in individuals receiving PBSCT (Dimeo et al.,1997, 1998, 1999).

Although scientific rigor was adequate overall, each of the 20exercise intervention studies had some design limitations. Forexample, most of the studies used valid and reliable fatigueinstruments previously tested in cancer populations, and manyadded laboratory measures of functional capacity or exercisetolerance to correlate objective physical functioning outcomeswith patient-reported fatigue levels. However, four of the re-viewed studies did not evaluate fatigue as a primary outcome,and two others did not use a standardized fatigue measure. Sev-eral studies were pilot projects with small sample sizes. Othershad no comparison group. In still others, participants were notassigned randomly to treatment or control conditions. In two ofthe home-based programs, participants randomized to usualcare exercised during the study in a diffusion-of-treatment ef-fect that complicated the analysis of intervention effects. Addi-tional elements not controlled in the studies included the report-ing of anemia levels, intensity of chemotherapy or other cancertreatment across study groups, and timing of the measures inrelation to chemotherapy doses.

Although several forms of exercise were tested in the stud-ies, all but two (Porock et al., 2000; Segal et al., 2003) wereconsidered aerobic and all were performed at a level of inten-sity found effective in other chronic disease populations. Tworesearch teams (Adamsen et al., 2003; Coleman et al., 2003)added strength resistance training to aerobic exercise interven-tions. Differing operational definitions of exercise and adher-ence make clearly defining the necessary dose (intensity, fre-quency, and duration) of exercise to achieve the desiredreduction in CRF difficult. Nonetheless, at least 15 minutes ofexercise three to five times weekly, either for the duration ofhospitalization or for a minimum of six weeks in outpatients,seems necessary to achieve a reduction or stabilization in fa-tigue levels in patients with cancer undergoing active treatment.Adherence to the exercise intervention was 60%–100%, a sur-prisingly high rate when compared to the 50% rate for healthyindividuals beginning an exercise program (Dishman, 1998).

Although the generalizability of findings is improving asstudy samples grow in diversity, key limitations remain. Ini-tial studies focused primarily on patients with breast canceraged 40–50 years, but more recent studies have broadened thefocus to include patients with other solid tumors or hemato-logic malignancies. Few allowed adults older than 65, and

only Porock et al. (2000) included patients with notablecomorbidities.

Effect sizes were moderate to large across studies, andstudy results were very consistent. All of the studies demon-strated significantly lower levels of fatigue in groups of par-ticipants who exercised regularly during the study, except fortwo small pilot studies that demonstrated trends toward im-provement in fatigue (Adamsen et al., 2003; Coleman et al.,2003). In summary, the strength of the evidence supportingexercise as an intervention to manage CRF is a result of thelarge number of studies conducted, the moderate-to-goodoverall quality of the designs and study methods, the largeeffect size of the intervention, and the absolute consistency ofresults across all studies in this review.

Implications for Clinical Practice,Research, and Nursing Education

Adequate evidence exists to support the efficacy of exerciseas an intervention for CRF in patients with cancer and cancersurvivors. Oncology nurses have a responsibility to apply thisevidence to clinical practice, research, and education. Specificchallenges include safely and effectively integrating the avail-able evidence into care of individual patients, identifying andpursuing research that will answer remaining questions relatedto exercise and CRF, and using current knowledge, includingtheories, to educate nurses about CRF.

Oncology clinicians must consider a number of issues relatedto exercise prescription. These include, but are not limited to,the type and dosage (intensity, frequency, and progression) ofexercise, baseline screening of individuals, a monitoring planto ensure the safety and efficacy of the program, adherence tothe exercise regimen, and use of available guidelines. Clini-cians must self-assess their own ability to safely develop anexercise prescription and must collaborate with other disci-plines where appropriate. Evidence-based guidelines areneeded to assist clinicians in teaching, prescribing, and moni-toring exercise for specific groups of patients such as those inactive cancer treatment, in disease-free follow-up, and thosereceiving palliative care. The guidelines should provide spe-cific information, based on research, for tailoring exercise pro-grams for children and older adults, patients with comorbidi-ties, and individuals who have been sedentary prior to thecancer diagnosis. In the absence of such guidelines, contem-porary evidence helps to guide practice.

In the available studies, various types of exercise weretested and can be considered for application to clinical prac-tice. These can be categorized into five exercise subgroupsbased on intensity: (a) comfort- or symptom-limited, low-in-tensity exercise, (b) aerobic interval-training programs, (c)low- to moderate-intensity aerobic exercise programs (some-times classified as symptom limited), (d) high-intensity con-tinuous exercise, and (e) resistance exercise. Aerobic intervaltraining and low- to moderate-intensity aerobic exercise pro-grams are best supported by the current available evidence forapplication to diverse oncology populations.

Based on current PRISM level 6 evidence, low-intensityexercise individualized to patient comfort is the only type ofexercise that can be considered safely for patients in palliativecare settings whose activity often is limited by a number ofdistressing symptoms, including pain and fatigue. Porock etal.’s (2000) study used the Duke Energizing Exercise Program,


in which an individual determines the preference for type ofexercise and regulates the intensity and duration based oncomfort. A significant limitation to the broad clinical applica-tion of such exercise programs is the level of professionaltraining necessary for implementation. Experienced physicaltherapists, exercise physiologists, or rehabilitation consulta-tion should guide individualized, comfort-based exercise pro-grams to stabilize fatigue levels.

Aerobic interval-training programs may be considered foruse in individuals with breast cancer as well as individualsundergoing PBSCT, with appropriate monitoring by physicaltherapists or exercise physiologists. This recommendation issupported by PRISM level 3 and 6 evidence. MacVicar andWinningham (1986) first tested the Winningham Aerobic In-terval Training Program in women receiving adjuvanttherapy for breast cancer. This program consisted of a pro-gressive cycle ergometry protocol performed three timesweekly. Aerobic interval training on treadmills and supinecycle ergometers subsequently has been evaluated more ex-tensively in individuals undergoing and following PBSCT fora variety of both solid tumor and hematologic malignancies.Individuals in these studies performed aerobic interval train-ing for 15–30 minutes daily, five to seven days per week, ata moderate intensity corresponding to 80% of the maximalheart rate or 50% of the heart rate reserve (Dimeo et al.,1997, 1998, 1999). Even during hematologic nadir, a pro-gram of bed- or chair-based bicycle ergometer pedaling wasfound to be safe and effective in reducing fatigue in hospital-ized patients undergoing PBSCT (Dimeo et al., 1999). Exer-cise was withheld only for platelet counts less than 20,000/mm3, fever, uncontrolled infection, or multiple complica-tions.

Home-based, moderate-intensity aerobic exercise programsfor individuals during and following radiation and chemo-therapy are supported by the most robust available evidence(PRISM level 2 and 3). Individuals with a wide variety ofsolid tumors and hematologic malignancies have participatedin this research, although women with breast cancer comprisethe majority of participants. Home-based exercise programsare convenient for implementation in clinical practice becausethey are low risk, require minimal baseline evaluation andongoing monitoring, and can be performed by patients in theirown homes or community environments.

Prescription of dose and intensity for home-based exerciseprograms may be guided by available research. Studies byMock’s research team (Mock et al., 1994, 2001, in press;Mock, Dow, et al., 1997) encouraged participants to walk ata moderate intensity for 15–45 minutes, four to five timesweekly, with an additional five-minute warm-up and cool-down, and to increase the duration of exercise by approxi-mately two to three minutes every one to two weeks. Individu-als deconditioned at baseline were advised to start as low asfive minutes of brisk walking twice daily. Similarly, partici-pants in studies by Schwartz’s research team (Schwartz, 1999,2000a, 2000b; Schwartz et al., 2001, 2002) were instructed toexercise for 15–30 minutes, three to four times weekly, to amaximal intensity that did not provoke symptoms. Partici-pants chose the type of exercise, and most participated inwalking. In one study, participants who exercised more than60 minutes per session were more likely to report increasedlevels of fatigue, suggesting a maximum effective dose(Schwartz et al., 2001).

In some studies, patients were given written instructionsregarding safety and monitoring issues related to exerciseperformance at home (Mock et al., 1994, in press; Mock,Dow, et al., 1997; Schwartz, 1999, 2000a, 2000b; Schwartz etal., 2001, 2002). A patient education booklet (Mock,Cameron, Tompkins, Lin, & Stewart, 1997) that was devel-oped by a multidisciplinary team of healthcare providers, in-cluding an exercise physiologist, is available from the JohnsHopkins University Press and was used in the Mock studies.This booklet provides basic exercise and safety guidelines andstrategies for adherence to and progression of the exerciseplan and includes instructions on moderating the level of in-tensity of exercise. A similar walking program is described indetail by Winningham (1991) and includes precautions,screening, and monitoring.

Continuous high-intensity aerobic exercise has been evalu-ated only in breast cancer survivors who were, on average,more than one year after cancer treatment (Courneya,Mackey, et al., 2003). Exercise bicycling was performed con-tinuously under supervision at 70%–75% maximal oxygenconsumption for 15- to 35-minute sessions. Based on limitedevidence (one PRISM level 2 trial), high-intensity exerciseshould be considered only in otherwise healthy individualswho have recovered from cancer therapy.

Finally, strength-resistance training exercise has receivedlimited evaluation in patients with prostate cancer undergoingandrogen deprivation therapy (Segal et al., 2003), as well asin combination with aerobic exercise in patients with multiplemyeloma receiving aggressive chemotherapy and PBSCT(Coleman et al., 2003). Supervised resistance training wasevaluated in patients with prostate cancer. Stretch bands wereused at home by patients with multiple myeloma, and theirexercise prescriptions were adapted continuously based ontheir individual clinical status. Based on these two PRISMlevel 2 trials, nurses may consider referring individuals at riskfor skeletal muscle wasting to physical therapists or otherqualified professionals for resistance training, either alone orin combination with aerobic exercise.

The ACSM has published recommendations for baselinetesting and exercise prescription in a number of populationssuch as patients with cardiac and diabetic diseases. However,no guidelines for patients with cancer currently exist, includ-ing which, if any, baseline testing should occur prior to initia-tion of exercise. Consideration of health status, current and an-ticipated illness, disability and impairments, and previousexercise level and necessary precautions are needed prior toexercise prescription. Winningham (1991) suggested addi-tional screening related to cancer and treatment-specific fac-tors such as cancer diagnosis, type and timing of cancertherapy and related side effects, and psychological status.

Once the exercise program has begun, regular evaluation ofmotivation and adherence, as well as assessment of risks andbenefits, can optimize exercise prescription and modification.All of the research studies reported here used some form ofregular monitoring, ranging from weekly telephone calls orreview of participant daily diaries to facility-based supervi-sion. At a minimum, patients should be educated about symp-toms to report to care providers and should be queried as toadverse reactions related to exercise participation.

Adherence to exercise programs is a crucial component aboutwhich little is known, particularly in patients with cancer, andis an area in great need of further research. Identification of


motivators and barriers is essential in facilitating the acceptanceand regular implementation of exercise. Methods of providingsafety for high-risk patients who exercise also are needed. Re-searchers must target more diverse populations with a varietyof ages, socioeconomic levels, and cultural backgrounds so thatresearch findings may be generalized to less commonly studiedpatients with cancer. Exercise interventions must be studied inpatients with other types of cancer receiving a variety of can-cer therapies. More rigorous experimental designs with largersample sizes would facilitate development of the science. In-struments should include a combination of objective physi-ologic measures of exercise and CRF as well as patient reportedoutcomes to enhance reliability and validity. Use of a consistentset of high-quality measures would permit comparison of out-comes across studies.

With respect to nursing education, theories explaining CRFcan be applied in the classroom, particularly for understand-ing CRF assessment and management. Frequent literaturesearches of published studies and review articles are requiredto keep pace with the expanding knowledge on the topic ofexercise in patients with cancer. Since the 1990s, six majorreview articles have included summaries of fatigue and exer-cise and provided a strong foundation for advanced cancernursing education. Winningham et al.’s (1994) comprehensivesummary of fatigue in cancer was an important early descrip-tion of the problem of CRF. Helpful tables list extensive ques-

tions and recommendations for clinical practice and researchthat can be useful in guiding classroom discussion or topics tobe developed in lectures for advanced practice nurses. Reamand Richardson’s (1999) review of interventions to decreaseCRF highlighted useful conceptual models, in addition to ex-tensively discussing nursing theories relevant to clinical prac-tice and nursing research. Their article provides an opportu-nity to educate advanced practice nurses in the importance oftheoretical applications. The review by Ahlberg et al. (2003)included a discussion of assessment and measurement of CRFas well as information on pathophysiologic mechanisms.

A structural framework used for analysis and critique of thereview articles was adapted from Meleis’ (1997) critical evalu-ation of nursing theories. The adapted framework was used toorganize the review of each article and is summarized in Table3. The usefulness and relevance of the articles for advancedcancer nursing education have been evaluated based on theconcepts discussed, the extent of supporting evidence, and thereview method and logical explanation of CRF and exercise.

ConclusionsDespite the noted limitations in the research to date, the

cumulative evidence is strong in support of exercise as an in-tervention to manage CRF in selected patients. The followingconclusions can be made based on the available evidence. All

Table 3. Summary of Fatigue and Exercise Review Articles for Advanced Cancer Nursing Education

Author and Background

Winningham et al., 1994; pio-neer nurse researcher in field;panel of nursing experts

Friedenreich & Courneya,1996; Canadian kinesiologistand epidemiologist

Ream & Richardson, 1999;British nurse researchers; uni-versity based

Dimeo, 2001; physician inGermany at sports medicineinstitute

Mock et al., 2001; nurse re-searcher; leader in CRF re-search

Ahlberg et al., 2003; Swedishnurse researcher with interna-tional team

Conceptsand Level of Evidence

Thorough review of causes,indicators, and effects of fa-tigue; cites references and in-terventions with relevant the-oretical background

Cancer rehabilitation treat-ment and exercise are definedand developed; cancer-re-lated fatigue (CRF) is not de-fined.

Assumes a limited under-standing of CRF; relevant ref-erences are cited and re-viewed.

Well-defined etiologic mecha-nisms and consequences offatigue and muscular ener-getic systems

Patterns of CRF and mecha-nisms are discussed and de-veloped.

Understanding of CRF isgrounded in evidence-basedreview of contributing factorsas well as patient perspective.

Review Methodand Logical Explanation

Superior rationale and organi-zation; wide scope and goaloriented; interesting visuals

Extensive review with goodtable of references for qualityof life and exercise; interestingdiscussion of “exercise isgood for you”

Review of nursing (only)practice, theory, and researchliterature

References cited with devel-opment of complex proposi-tions; no tables

Cited and discussed relevantreferences; had helpful tablesof references and standards.

Review of multidisciplinaryresearch literature and guide-lines; logical flow of clinicaland research implications

Usefulness and Relevance

Relevant to nursing education,practice, research, and otherprofessions (e.g., sports medi-cine, physical therapy, and ex-ercise physiology)

Useful information for re-search and education andhelpful for nononcology pro-fessionals

No empirical evidence to sub-stantiate practice recommen-dations of holistic approachfor fatigue management; in-teresting discussion for re-search and education

Congruent with nursing sci-ence, but not instructive topractice; applicable to re-search and education

Useful summary guidelinesfor oncology practice andeducation standards

Thorough evidence-based re-view of fatigue assessmentand management facilitatesapplication to practice.

Comments

Important summary of fatigueand exercise, with guidelinesfor practice and strategies forresearch

Informative review of exercisein the cancer literature

Informative tables. Authoropinion is given without em-pirical evidence (e.g., “singleintervention can only providepartial relief”).

Interesting lecture presenta-tion; brief review of the litera-ture

Instructive to nurses and dis-ciplines other than nursingscience

Highlights areas in need offurther CRF research; usefulreview of fatigue measure-ment tools

Note. Based on information from Meleis, 1997.


patients should be encouraged to maintain an optimum levelof activity or exercise to manage CRF during and followingcancer treatment. Patients who become weak or decondi-tioned—or those with comorbidities—can benefit from refer-rals to physical therapy, physical medicine, or rehabilitationprograms to maximize functional status and decrease CRF andother symptoms. Patients with breast cancer and other selectedpatients should receive recommendations for a moderate ex-ercise program during and following chemotherapy and radia-tion therapy. Patients undergoing and recovering from PBSCTcan benefit from supervised progressive exercise. High-inten-sity exercise can be considered for otherwise healthy individu-als who have recovered from cancer therapy. Patients withprogressive disease can maximize their activity level throughsupervised programs adapted for individual safety. Exercisefor individuals at risk for skeletal muscle weakness shouldinclude strength training. Overall, exercise interventionsshould be tailored to an individual’s specific disease and treat-ment characteristics and health status.

The exercise programs tested in the studies reviewed inthis article were taught and monitored by oncology nurses orexercise physiologists trained to conduct exercise programs.ACSM offers certification for clinical health and fitness pro-fessionals. Although ACSM does not certify for exerciseprescription in patients with cancer, collaboration amongACSM-certified specialists and oncology healthcare clini-cians, researchers, and educators can benefit individual pa-tients and advance the science of exercise prescription forpatients with cancer. Published multidisciplinary evidence-based guidelines for exercise programs and the multidisci-plinary development of a related professional curriculum inexercise prescription for patients would facilitate applicationto clinical practice.

Author Contact: Carrie Tompkins Stricker, MSN, APRN-BC,AOCN®, can be reached at [email protected], withcopy to editor at [email protected].

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Dimeo, F.C., Tilmann, M.H., Bertz, H., Kanz, L., Mertelsman, R., & Keul,J. (1997). Aerobic exercise in the rehabilitation of cancer patients after highdose chemotherapy and autologous peripheral stem cell transplantation.Cancer, 79, 1717–1722.

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Mock, V., Atkinson, A., Barsevick, A., Blackwell, S., Cella, D., Cianfrocca,M.E., et al. (2003). Clinical practice guidelines in oncology: Cancer-relatedfatigue [Version 1.2003]. Journal of the National Comprehensive CancerNetwork, 1, 308–331.

Mock, V., Burke, M.B., Sheehan, P., Creaton, E.M., Winningham, M.L.,McKenney-Tedder, S., et al. (1994). A nursing rehabilitation program forwomen with breast cancer receiving adjuvant chemotherapy. OncologyNursing Forum, 21, 899–908.

Mock, V., Cameron, L., Tompkins, C., Lin, E., & Stewart, K. (1997). Everystep counts: A walking exercise program for persons living with cancer[Booklet]. Baltimore: Johns Hopkins University.

Mock, V., Dow, K.H., Meares, C.J., Grimm, P.M., Dienemann, J.A., Hais-field-Wolfe, M.E., et al. (1997). Effects of exercise on fatigue, physicalfunctioning, and emotional distress during radiation therapy for breast can-cer. Oncology Nursing Forum, 24, 991–1000.

Mock, V., Frangakis, C., Davidson, N., Ropka, M.E., Pickett, M., Ponia-towski, B., et al. (in press). Exercise manages fatigue during breast cancertreatment: A randomized controlled trial. Psycho-Oncology.

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➤ CancerSymptoms: Fatiguewww.cancersymptoms.org/symptoms/fatigue

➤ Mayo Clinic: Fatigue: Cancer-Related Causes and How to Copewww.mayoclinic.com/invoke.cfm?id=CA00032

➤ MedlinePlus: Fatiguewww.nlm.nih.gov/medlineplus/ency/article/003088.htm

For more information . . .

Links can be found at www.ons.org.

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The continuing education examinationand test form for the preceding articleappear on the following pages.


ONF Continuing Education Examination

Evidence-Based Practice for Fatigue Management in Adults With Cancer:Exercise as an Intervention

Credit Hours: 1.7Passing Score: 80%Test ID#: 04-31/5-13Test Processing Fee: $15

The Oncology Nursing Society is accredited as a providerof continuing education in nursing by the• American Nurses Credentialing Center’s Commission on

Accreditation• California Board of Nursing, Provider #2850.

CE Test Questions

01. Cancer-related fatigue isa. Known to interfere with usual functioning.b. Primarily a psychological experience.c. The third most-commonly cited symptom of cancer.d. A persistent, objective sense of tiredness.

02. The Winningham Psychobiologic Entropy Model isbased on the premise thata. Maintaining a balance of activity and rest is important.b. Too much activity can exacerbate preexisting fatigue.c. Energy capacity must be increased through structured

rest periods.d. Fatigue primarily occurs as a result of treatment-re-

lated symptoms.03. Dimeo’s physiologic model suggests that exercise alters

the cycle of fatigue bya. Stimulating appetite and food tolerance.b. Alleviating mental stress and anxiety.c. Improving neuromuscular efficiency.d. Increasing muscular catabolism.

04. Studies of patients receiving adjuvant therapy for breastcancer have shown a positive relationship between fa-tigue anda. Symptom tolerance.b. Activity level.c. Quality of life.d. Sleep difficulties.

05. Aerobic exercise has consistently been shown to havewhat effect on women with breast cancer undergoingadjuvant therapy?a. Improved functional abilityb. Decreased risk of bone metastasesc. Lowered energy levelsd. Enhanced muscle strength

06. Which intervention can decrease fatigue in men withprostate cancer on androgen deprivation therapy?a. Methylphenidateb. Resistance exercisec. Dexamethasoned. Aerobic exercise

07. An exercise intervention for patients receiving palliativecare was found toa. Prevent the development of severe fatigue.b. Allow more activity without increased fatigue.c. Be most effective in those with lower levels of fa-

tigue.d. Increase fatigue but also improve quality of life.

08. A patient is interested in trying exercise to reduce thefatigue he is experiencing with his cancer and treatment.Which of the following responses is correct?a. “Exercise only decreases fatigue in women with breast

cancer.”b. “Less than half of people with cancer stick with exer-

cise to decrease fatigue.”c. “You should exercise at least 15 minutes three to five

times each week.”d. “Exercise does not get rid of fatigue; it will only pre-

vent it.”09. High-intensity aerobic exercise should be recommended

only for which of the following?a. A person fully recovered from cancer therapyb. A person receiving adjuvant therapy for colon cancerc. A person receiving biotherapy for melanomad. A person undergoing radiation therapy for lung cancer

10. Current evidence most strongly supports what type of ex-ercise intervention for cancer-related fatigue?a. Resistanceb. Aerobic exercisec. High-intensity continuousd. Weight training

11. One advantage of a home-based, moderate-intensity aero-bic exercise program is that ita. Carries only a moderate risk for the participant.b. Includes the support of an exercise therapist.c. Is based on extensive baseline evaluation.d. Requires minimal ongoing monitoring.

12. To avoid increasing their level of fatigue, what is themaximal amount of time per session most people under-going treatment for cancer should exercise?a. 15 minutesb. 60 minutesc. 90 minutesd. 120 minutes

13. For which of the following patients would aerobic inter-val training most likely be recommended?a. Man with metastatic colon cancer receiving chemo-

therapyb. Woman with head and neck cancer receiving radiation

therapyc. Man with lymphoma receiving biologic therapyd. Woman with leukemia undergoing peripheral stem

cell transplantation


14. To maximize an exercise plan, what should be a part ofthe program?a. Method by which to monitor adherence to the programb. Referral to an exercise physiologist for all patientsc. Encouragement to continue exercise even when feel-

ing poorlyd. Standardized approach to exercise for all people with

cancer

15. Future research into the effects of exercise on cancer-re-lated fatigue shoulda. Exclude people at high risk for complications.b. Focus primarily on objective physiologic measures.c. Help to identify motivators and barriers to exercise.d. Include more in-depth case study analysis.

Oncology Nursing Forum Answer/Enrollment Form

Evidence-Based Practice for Fatigue Management in Adults With Cancer:Exercise as an Intervention (Test ID #04-31/5-13)

To receive continuing education (CE) credit for this issue, simply1. Read the article.2. Oncology Nursing Society (ONS) members may take the

test and get results immediately on the ONS Web site. Sim-ply log on to www.ons.org and click on Oncology Nursing Fo-rum under the Publications heading. Use your ONS member-ship number to access the site, select the issue you wish to use,scroll down to find the CE test, and follow the instructions.After successfully completing the test, pay with a credit card.

3. To enroll via the mail, record your answers on the form be-low and complete the program evaluation (you may makecopies of the form). Mail the completed answer/enrollment

form along with a check or money order for $15 per test pay-able to the Oncology Nursing Society. Payment must be in-cluded for your examination to be processed.

4. The deadline for submitting the answer/enrollment form istwo years from the date of this issue.

5. Contact hours will be awarded to RNs who successfully com-plete the program. Successful completion is defined as an80% correct score on the examination and a completed evalu-ation program. Verification of your CE credit will be sent toyou. Certificates will be mailed within six weeks followingreceipt of your answer/enrollment form. For more informa-tion, call 866-257-4667, ext. 6296.

Instructions: Markyour answers clearly byplacing an “x” in thebox next to the correctanswer. This is a stan-dard form; use only thenumber of spaces re-quired for the test youare taking.

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