Exercise for the management of cancer-related fatigue in adults

© 2015 The Cochrane Collaboration. Background: Cancer-related fatigue is recognised as an important symptom associated with cancer and its treatment. A number of studies have investigated the effects of physical activity in reducing cancer-related fatigue. This is an updated version of the original Cochrane review published in The Cochrane Library (2008, Issue 1). The original review identified some benefits of physical activity on fatigue in cancer both during and after adjuvant treatment. We identified a number of limitations in the evidence, providing clear justification for an updated review. Objectives: To evaluate the effect of exercise on cancer-related fatigue both during and after cancer treatment. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), CINAHL (1982 to March 2011), British Nursing Index (January 1984 to March 2011), AMED (1985 to March 2011), SIGLE (1980 to March 2011) and Dissertation Abstracts International (1861 to March 2011) using key words. We also searched reference lists offall studies identified for inclusion and relevant reviews. In addition, we handsearched relevant journals and contacted experts in the field of cancer-related fatigue. Selection criteria: We sought and included randomised controlled trials (RCTs) that investigated the effect of exercise on cancer-related fatigue in adults. Data collection and analysis: Two review authors independently assessed the risk of bias of studies and extracted data based upon predefined criteria. Where data were available we performed meta-analyses for fatigue using a random-effects model. Main results: For this update we identified a total of 56 studies (4068 participants) for inclusion (28 from the original search and 28 from the updated search), with the majority carried out in participants with breast cancer (28 studies). A meta-analysis of all fatigue data, incorporating 38 comparisons, provided data for 1461 participants who received an exercise intervention and 1187 control participants. At the end of the intervention period exercise was seen to be statistically more effective than the control intervention (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.37 to -0.17). Benefits of exercise on fatigue were observed for interventions delivered during or post-adjuvant cancer therapy. In relation to diagnosis, we identified benefits of exercise on fatigue for breast and prostate cancer but not for those with haematological malignancies. Finally, aerobic exercise significantly reduced fatigue but resistance training and alternative forms of exercise failed to reach significance. Authors' conclusions: The findings of the updated review have enabled a more precise conclusion to be made in that aerobic exercise can be regarded as beneficial for individuals with cancer-related fatigue during and post-cancer therapy, specifically those with solid tumours. Further research is required to determine the optimal type, intensity and timing of an exercise intervention

Problems, solutions, and strategies reported by users of TENS for chronic musculoskeletal pain: A qualitative exploration using patient interviews

BACKGROUND: Transcutaneous Electrical Nerve Stimulation (TENS) could offer a non-drug form of pain relief, but there is no consensus regarding its effectiveness for chronic musculoskeletal pain or chronic low back pain. A recent review of previous trial methodology identified significant problems with low treatment fidelity. There is little information available to inform the development of a pragmatic implementation design for a TENS evaluation.OBJECTIVES: To explore the experiences of secondary care Pain Clinic patients with expertise in using TENS to manage chronic musculoskeletal pain. These key informants were selected as they had the potential to generate knowledge which could inform research design and clinical practice.DESIGN: A qualitative method using individual semi- Structured interviews with open questions was selected for its capacity to generate rich data.METHODS: Semi-structured interviews were conducted with nine patients (6 women). Thematic analysis was used as the primary data analysis method, and this was enhanced by a case level analysis of the context and processes of TENS use of each individual.FINDINGS: Data analysis indicated that patients learned to address a range of problems in order to optimise TENS use. Patients may need to personalise the positioning of electrodes, and the TENS settings, and to re-adjust these over time. Patients learned to use TENS in a strategic manner, and the outcomes of each strategy varied.CONCLUSIONS: The findings indicated that a pragmatic TENS evaluation may need to incorporate a learning phase to allow patients to optimise this complex pattern of TENS usage, and evaluation may need to be sensitive to the outcomes of strategic use. These findings also have implications for clinical practice

Combining a psychological intervention with physiotherapy: A systematic review to determine the effect on physical function and quality of life for adults with chronic pain

© 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group. Background: Chronic pain affects approximately 28 million people in the UK. It does not always respond to conventional curative treatments and can have a devastating impact on an individual’s ability to function and perform life roles in the way they would like. Psychological approaches to pain management have been advocated for over 40 years, but it is unclear whether the addition of such approaches to physiotherapy increases treatment effectiveness. Objectives: To systematically review the literature to determine whether the addition of psychological approaches to physiotherapy is more effective in improving physical functioning and quality of life than physiotherapy alone. Methods: An electronic database search focused on randomised controlled trials comparing a physiotherapy intervention for chronic pain with a matched intervention with an additional psychological therapy component. All eligible studies were independently reviewed by two researchers and the strength of evidence and results evaluated. A meta-analysis was conducted on post-test mean data for physical functioning. Results: Eight studies were identified for inclusion. Meta-analysis of the data showed combined treatments to be superior in modifying functional outcomes (standardised mean difference −1.12 95% confidence intervals −1.94 to −0.31). This was echoed in the narrative review of the quality of life evidence. Study quality was variable and thus the findings should be interpreted with caution. Conclusions: There is evidence that combining physiotherapy and psychological approaches improves physical function in chronic pain in comparison with physiotherapy alone. Further examination of this field is required to inform changes in practice and to develop treatment methods

A survey examining the use of mechanical insufflation-exsufflation on adult intensive care units across the UK

Introduction: Despite potential benefits, it is not known how widely physiotherapists use mechanical insufflation-exsufflation devices on UK adult intensive care units. This survey aimed to describe mechanical insufflation-exsufflation use in UK adult intensive care units. Methods: Cross-sectional electronic survey of physiotherapists working in a permanent post on adult intensive care units. Results: One hundred and sixty-six complete surveys were available for analysis, reflecting a diverse geographical spread. Nearly all (98%; 163/166) clinicians had access to mechanical insufflation-exsufflation. The estimated frequency of use varied, with the majority reporting weekly or monthly use (52/163, 32%; 50/163, 31%, respectively). Nearly all clinicians (99%) used mechanical insufflation-exsufflation with extubated patients. In contrast, around half of respondents (86/163, 53%) used mechanical insufflation-exsufflation with intubated patients, with a range of perceived barriers reported. Conclusions: Mechanical insufflation-exsufflation devices are widely available on UK adult intensive care units, with use more common in extubated patients. Barriers to mechanical insufflation-exsufflation use in the intubated population warrant further investigatio

A personal experience of performing a systematic literature review

This paper describes the personal experience of two novice reviewers in developing and conducting a systematic literature review (SLR) in the field of medical ultrasound. The review was performed as part of a PhD study by the first author, which required the researcher to critically review all relevant studies in their specific research area. The review was conducted using a formal, scientific process and highlighted 20 relevant papers. Among the lessons learnt, undertaking an SLR was a time-consuming process. The search produced 1,987 papers, and screening the search yield was facilitated by using a pre-defined protocol. Extraction of data from each study was standardised and generated a 1-page summary of the key findings and methodology to facilitate comparisons of the included studies. The Critical Appraisal Skills Programme (CASP) tool was used for quality assessment. In the critical appraisal process, it is essential that reviewers have good baseline knowledge in the research subject, a solid understanding of the fundamentals of a robust research study including potential bias in research. With the great amount of information that a critical appraisal produces, good information management was key throughout the review to ensure the process was explicit and replicable and so that reviewers could justify their decisions. The methods and processes detailed in this report, as well as its lessons, are relevant to an SLR for any research subject

A randomised trial comparing the clinical effectiveness of different emergency department healthcare professionals in soft tissue injury management

Objectives: To evaluate the clinical effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared to the routine care provided by doctors in a UK emergency department (ED). Design: Randomised, pragmatic trial of equivalence. Setting: One adult ED in England. Participants: 372 patients were randomised; 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (older than 16 years) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. Patients were excluded if they had any of the following: injury greater than 72 hours old; systemic disease; dislocated joints; recent surgery; unable to give informed consent (eg, dementia), open wounds; major deformities; opiate analgesia required; concurrent chest/rib injury; neurovascular deficits and associated fracture. Interventions: Patients were randomised to treatment by ESPs, ENPs or routine care provided by doctors (of all grades). Main outcome measures: Upper-limb and lower-limb functional scores, quality of life, physical well-being, preference-based health measures and the number of days off work. Results: The clinical outcomes of soft tissue injury treated by ESPs and ENPs in the ED were equivalent to routine care provided by doctors. Conclusions: As all groups were clinically equivalent it is other factors such as cost, workforce sustainability, service provision and skill mix that become important. This result validates the role of the ENP, which is becoming established as an integral part of minor injuries care, and demonstrates that the ESP should be considered as part of the clinical skill mix without detriment to outcomes. ISRCTN-ISRCTN trials register number: 70891354

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management

Objectives: To evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an emergency department (ED). Design: Randomised, pragmatic trial of equivalence. Setting: A single ED in England. Participants:372 patients were randomised, 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (16 years and older) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups. Interventions: Patients were randomised to treatment by an ESP, ENP or routine care provided by doctors (of all grades). Main outcome measures: Economic costminimisation evaluation from a funder perspective of the National Health Service, England incorporating analysis of the direct, indirect and tangible costs of care in primary and secondary settings. Results: From a funder perspective in primary and secondary care, ESPs and ENPs are at best equivalent and could not cost less than routine care. Uncertainty in cost arises from ESPs and ENPs incurring greater indirect costs, such as those associated with follow-up appointments and subsequent primary care visits. Comparison from a funder perspective in secondary care, that is, considering those costs incurred in secondary care alone, demonstrates that ENPs are equivalent in cost to routine care, while ESPs are either equivalent or possibly cheaper than routine care. Conclusions: These results question the notion that training the healthcare workforce to undertake extensions of their role is generally cost effective. While the randomised trial indicated that the three professional groups have equivalent clinical outcomes, this economic analysis suggests that substitution of routine care with a predominantly ESP or ENP workforce could prove more expensive. Further research is required to understand the underlying reasons for this. The trial has been registered with ISRCTN-ISRCTN 70891354

Development of a physical activity programme for people with recently diagnosed rheumatoid arthritis

Background People with rheumatoid arthritis (RA) are less physically active (PA) than the general population and lower PA levels are associated with work disability, reduced physical function and co-morbidities. This suggests an urgent need to identify programmes that effectively promote sustainable PA to improve physical function in RA.Objectives The purpose of this research was to seek patient's views in relation to a range of potential PA programmes.Methods Focus groups were carried out with adults with RA with participants purposefully sampled to reflect a range of age and gender. Prior to commencing the research a draft interview guide was reviewed by the study Patient Research Partner and a pilot interview conducted. The interview guide was designed to explore PA support needs and experiences since diagnosis as well as motivators and facilitators to support engagement in PA. Each focus group was subsequently provided with information regarding potential PA programmes and invited to comment upon their suitability for people with a recent diagnosis of RA. Focus groups were audio recorded, transcribed and anonymised. Ethics approval for the study was obtained. Written informed consent was obtained from all participants. Thematic analysis was used to identify the main themes across the groups. Emerging themes were verified through discussion and a coding framework based on these themes developed. Themes and sub-themes were subsequently reviewed and the interpretation and analysis discussed and agreed.Results Three focus groups were conducted with 19 patients in total (15 female, 4 male); mean age (SD) 60 (±10) years; mean time (SD) since diagnosis 44 (±34) months. There was strong support for a PA programme with four key themes garnered from the focus groups:Recruitment and adherence included programme endorsement from peers and PA endorsement from health professionals; the need for support to overcome barriers to PA, such as pain and fatigue; and prompts such as text messages to improve adherence.Programme scheduling included timing with most suggesting six to 12 months following diagnosis, once a stable drug regime was established; afternoon sessions were preferred; views on frequency of sessions and duration of the programme were disparate.Programme content included support for education on relaxation and coping strategies, medication, flare, fatigue and pain; supervised exercise sessions; home exercise training; and expert physiotherapy input. Goal setting received mixed opinions with emphasis on the need to be patient-led.Programme delivery suggested group sessions were preferred by most, but not all; individual sessions in addition to the group were positively received; telephone support polarised opinion; but an accessible location was an agreed priority.Conclusions Participants supported development of a PA programme delivered at an accessible location, by physiotherapists within six to 12 months of diagnosis. Mixed views relating to delivery suggests a flexible approach may need to be developed.Disclosure of Interest None declare

Foundational research could improve future transcutaneous electrical nerve stimulation evaluations

Background and objectives: There is a lack of good quality evidence regarding the effectiveness of transcutaneous electrical nerve stimulation (TENS) for chronic musculoskeletal pain, including chronic low back pain. High quality randomised controlled trials (RCTs) have been called for to establish effectiveness over and above placebo and some guidance has already been offered regarding the design of such trials. This article expands the discussion regarding the design of future TENS trials. There is qualitative evidence of the complexity of TENS as an intervention which should be considered in future TENS evaluations. This complexity includes multiple benefits reported by patients, depending on their chosen contexts of TENS use. The ideal content and delivery of support for patients to optimise TENS use also lacks consensus. There is no evidence that a TENS education package has been designed to support the complex set of behaviours and choices which experienced users suggest are required to optimise TENS benefits. Finally, clinical and research outcomes have not been contextualised and related to the specific strategies of use. Conclusions: We suggest that research is required to develop consensus about the content and delivery of training in TENS use for patients who live with pain, informed by the experience of patients, clinicians, and researchers. Once a consensus about the content of TENS training has been reached, there is then a need to develop a TENS training course (TTC) based on this content. An effective and acceptable TTC is needed to develop the knowledge and skills required to optimise TENS use, supporting patients to build confidence in using TENS in everyday life situations with the aim of reducing the impact of chronic pain on function and quality of life. Further research is required to extend the evidence base regarding appropriate, contextualised TENS patient-reported outcomes