Weight and height were measured to determine body mass index. Standard pulmonary function tests including spirometry, lung volumes and carbon monoxide diffusion capacity, were performed for all subjects according to previously described guidelines 21 and compared with predicted reference values 22 , Peak exercise capacity and oxygen consumption were determined during incremental cycle ergometry with lead electrocardiogram monitoring Cardiosoft, Corina, USA as originally described by Jones et al 3 and following the ATS guidelines After 3 min of rest, participants began unloaded cycling for 1 min.
Each subsequent minute, workload was increased by 10 W to 20 W until a symptom limitation was achieved. Dyspnea and leg fatigue were evaluated every 2 min using a modified Borg scale for perceived exertion The constant workrate cycle exercise test was monitored similarly to the maximal exercise test. Heart rate, dyspnea Borg score and oxygen saturation were monitored.
The endurance time was defined as the duration of the test excluding the 1 min warm-up period. According to the ATS guidelines 25 , the 6MWT was conducted in an enclosed corridor on a flat, 30 m long course between two cones. Patients were instructed to cover the longest distance possible in 6 min with or without pause. During the test, only standardized encouragement was given to the patient The test was performed twice and the greater distance was recorded.
Quadriceps strength of the dominant leg was assessed by measuring maximum voluntary contraction. Maximum voluntary contraction of the dominant biceps, triceps, deltoid and hamstring were measured using a hand-held dynamometer Microfet, Hoggan Inc, USA using the method described and validated by Andrews et al Muscle strength assessment was performed during the rest period between cycling tests.
Université de Ngozi
Reported values for maximum voluntary contraction of all muscles are the mean of the two strongest contractions and strength is reported in kilograms. QoL was assessed using three standard questionnaires described and validated for patients with lung cancer. The item Short-Form Health Survey SF was selected as a generic questionnaire to assess QoL for its ease of administration and because it has comparative normative values A French-Canadian version of the SF is currently available and was previously validated This questionnaire was developed and validated for cancer patients.
It includes 30 items divided into functional, symptom and health-related subscales. Questionaires were systematically completed at the beginning of the evaluation day. Following the initial assessment, participants began a four-week exercise-training program. This was a self-monitored and minimally supervised home-exercise program. It included aerobic and strength exercises three to five times per week for four weeks. Aerobic training was performed on a loaned portable ergocycle on which resistance could be manually adjusted. Free weights 1 kg to 2 kg and gravity-resisted exercises were used to train the muscle groups of the upper limbs biceps curl, wall push-up, lateral shoulder raise , lower limbs wall squat, hips raise and abdominal wall sit up.
Ten repetitions of each movement were initially performed.
The number of repetitions was progressively increased, as tolerated, until two sets of 15 repetitions were achieved. Home training periods, training intensity and adverse events were noted in a diary. Individual teaching with practice and feedback were performed by a kinesiologist before the program to ensure complete understanding from participants. Furthermore, weekly telephone follow-ups were conducted to ensure patient adherence, to adjust the exercise prescription and to follow potential adverse events. This strategy was previously used successfully in clinical trials involving patients with COPD 19 and patients with emphysema in preparation for lung volume reduction surgery To assess the feasibility of the HBETP, recruitment rate, completion rate, adherence, adverse events, subjective perception of obstacles, and benefits and acceptability were collected and analyzed.
Recruitment rate was defined as the ratio of the recruited patients to those who were eligible. Completion rate was defined as the proportion of participants who completed all of the intervention from the moment of the initial assessment. Adherence was calculated from the ratio of the number of completed exercise sessions over the number of prescribed sessions Therefore, a similar adherence rate was anticipated in the present population.
In addition, adverse events were systematically tracked during the weekly telephone call. Finally, a motivational survey developed by the authors was used to describe the subjective perception of obstacles and benefits, and the acceptability of the program. The survey also provided an overview of which situations may increase or decrease the motivation of the patient to perform physical activities and asked questions about perception of physical fitness.
Questions such as the following were asked: A high score generally indicates a positive association, except for the obstacles scales in which a higher score indicates more perceived obstacles. Isotime was defined as the highest equivalent duration reached pre- and post-HBETP for the cycle endurance test. The data were analyzed using SAS version 9. A flow chart of the study is presented in Figure 1.
From May to November , 72 patients were initially identified as potentially eligible. Among those who consented, 16 completed the baseline evaluation. Finally, no adverse events were reported by patients during telephone follow-up. Some patients had one or more of the following comorbidities: No significant difference for physiological or psychological characteristics were observed between patients who completed the program and those who did not. Physiological response at peak incremental exercise and at the end of constant workrate exercise before and after the four-week home-based exercise training program.
Strength of the deltoid, triceps and hamstring muscles increased significantly with training by 1. In contrast, changes in hand grip, biceps and quadriceps strength with training were not statistically significant. The most commonly perceived benefits reported by the patients were: The most important obstacle was the lack of time to perform the program and the difficulties in integrating it into an already busy schedule of several medical appointments.
Nevertheless, patients believed that the intervention was relevant for individuals with lung cancer, that they were willing to encourage a friend with cancer to engage in such a program and that they were globally very satisfied with their participation mean 5. With the exception of an improvement in the depression scale of the HADS, there were no significant changes for any measure of QoL after the intervention.
The main finding of the present study was that a short, moderate intensity, HBETP was feasible, safe and well tolerated in this context. In addition, participation in such a program produced physiological effects, including improved cycling endurance, walk distance and muscle strength.
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Although the recruitment rate was low, the completion rate and adherence to the program were acceptable. In other studies, completion rates for exercise intervention programs varied widely. There are several possible explanations for the high completion rate in our study. First, most of our patients were young and had early stage lung cancer and, furthermore, as suggested by Temel and al 16 , an HBETP may be more feasible in this population. In addition to to this close follow-up, a potential selection bias associated with referral patterns by the nurses, pulmonologists and surgeons may have influenced the results by selecting people who were initially more motivated to perform physical activities.
On the other hand, none of the participating patients were regularly physically active before the intervention. Another important finding was that the HBETP had beneficial effects on exercise capacity and muscle strength. The absence of improved peak exercise capacity in such a short training program is not unexpected because this parameter does not change markedly with exercise training We found a statistically and clinically significant improvement in the endurance time to constant workrate cycling exercise and in the 6MWT distance. The s increase in the endurance time to constant workrate exercise exceeded the s that is generally considered to represent a clinically significant outcome for this variable Similarly, the gain in the 6MWT distance was superior to the minimal important difference for this variable The possibility to improve muscle strength before the surgery is of clinical interest.
Bolliger et al 37 recently reported the frequent occurrence of muscle weakness in lung cancer patients and confirmed that after lobectomy, much of the limitation in exercise capacity may be explained by peripheral muscle function. While exercise led to a substantial improvement of physiological parameters, no statistically significant or clinically meaningful changes in QoL were observed, apart from a reduction in depression score, which was statically and clinically reduced postrehabilitation.
This improvement may be clinically relevant because in cancer patients, depression is associated with increased mortality, poorer adherence to treatment and increased length of hospitalization after thoracic surgery for malignancy 38 , Also, for the SF, compared with normative data 40 , physical functioning, general health and social functioning were all significantly lower in our patients. However, following the program, social functioning was no longer different from normative data but role limitations due to physical problems, role limitations due to emotional problems and mental health became different, suggesting that the preoperative period itself may have had an impact on QoL.
On a positive note, it is possible that without exercise training, patients may have experienced a worse decline of their QoL; however, in the absence of a control group, it is difficult to draw a definitive conclusion. Nevertheless, these findings are consistent with the conflicting results in the literature and with the other studies that did not find any change in QoL following exercise training in patients with lung cancer 41 — Other studies specially designed to address this relevant question need to be conducted.
In addition, it could be hypothesized that the absence of any educational or group-based sessions in the present study may have impacted the capacity of the intervention to improve QoL. Other studies specifically designed to address this relevant question need to be conducted. The main reasons for this relatively low recruitment rate included a high level of anxiety, lack of interest and lack of time.
Nonparticipation in this type of intervention could be explained by a variety of barriers such as psychological distress anxiety, depression or physical symptoms pain, fatigue. Some methodological aspects of our study warrant consideration. First, due to the short period of time between the final diagnosis of lung cancer and surgery, we decided a priori to include patients immediately when they began their investigation for lung cancer.
Despite this recruitment strategy, only one patient did not ultimately have lung cancer. Thus, we are confident that the data from our study can be generalized to a large proportion of patients with lung cancer awaiting LRS.
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The tight schedule of the patients during the preoperative period led to another challenging limitation: In a perfect setting, the evaluation would be performed during two different visits. However, in the present study, this design was not possible because of the short period of time allowed. However, to minimize bias, all tests were administered in the same order in pre- and post-HBETP and a 2 h rest period between incremental and constant cycle exercise tests and 20 min between the two 6MWT was allowed.
Additionally, the small number of patients who agreed to participate reduced the statistical power of the study. One message to gain from this is that rehabilitative interventions are challenging to implement in clinical practice. From this perspective, it could be hypothesized that due to implementation difficulties of rehabilitation on a large scale, this modality should be primarily considered for compromised patients who are seldom candidates for surgery because of their marginal cardiovascular capacity and because of the postoperative cardiopulmonary complications related to it.
Indeed, based on physiological results achieved in our study and the available literature, it is reasonable to believe that it is possible to sufficiently improve the aerobic capacity of some of these patients to place them above the threshold where the risk of complications are acceptable to consider surgery. In addition, a recent study by Bozcuk and Martin 44 found that delaying treatment until 48 days after diagnosis did not appear to have any effect on survival. Thus, it may be beneficial to use an extended preoperative period to improve cardiovascular fitness of some patients with the aim of reducing postoperative complications.
However, the present study was not designed nor did it have the statistical power to determine whether exercise training could lower postoperative surgical complications. Also, from a clinical perspective, it may have been interesting to perform a formal economic analysis of HBETP. However, based on the COPD literature 19 , we had no reason to believe that there were major differences in related costs between home-based and in-patient intervention.
The absence of a control group was another potential limitation with regard to interpretation of the results. We elected not to include a control group given that one of our main goals was to demonstrate the feasibility of the intervention. At this stage, we did not want to compromise and slow the progression of the study by trying to include a control group. Are you an author? Help us improve our Author Pages by updating your bibliography and submitting a new or current image and biography. Learn more at Author Central. Popularity Popularity Featured Price: Low to High Price: High to Low Avg.
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