Translating Evidence from Dutch Exercise Oncology Trials in Patients with Breast Cancer into Clinical Practice Using the RE-AIM Framework

Purpose. We aimed to evaluate the potential for implementing exercise interventions for patients with breast cancer in the Netherlands, based on findings of the Dutch randomized controlled trials in this population. Methods. We evaluated the implementation of four Dutch exercise trials retrospectively, using the five dimensions of the RE-AIM framework: Reach (exercise participation rate), Effectiveness for physical fitness, fatigue, quality of life, and physical function, Adoption (e.g., satisfaction of physical therapists guiding the exercise intervention), Implementation (cost-effectiveness and exercise adherence correlates thereof), and Maintenance (maintenance of exercise levels by individual patients and sustainability of exercise delivery at organization level). Thereby, we reflect on these results using (international) literature to gain better insight in overall barriers, facilitators, and opportunities for further implementation of exercise interventions. Results. Participation rates of 44-52% not only indicated acceptable Reach in the context of a trial but also indicated room for improvement. Effectiveness of exercise during and after treatment was demonstrated in most trials showing benefits for aerobic fitness, physical fatigue, quality of life and physical function, and high patient satisfaction. Adoption of the exercise interventions by physical therapists was adequate (satisfaction score: 7.5 out of 10). Evaluation of Implementation indicated adequate adherence to supervised exercise, inconsistent findings on potential correlates of adherence, and promising results on cost-effectiveness. Currently, reimbursement for exercise programs is lacking. Maintenance of intervention effects at the patient level was limited and inconsistent. Maintenance of intervention availability at the organizational level was facilitated by an extensive network of specially trained physical therapists, but better communication and collaboration between different healthcare professionals are desired. Conclusions. Improved implementation could particularly be achieved by increasing reach and improved focus on exercise maintenance on both the patient and organizational level

Design of the ExCersion-VCI study: The effect of aerobic exercise on cerebral perfusion in patients with vascular cognitive impairment

There is evidence for a beneficial effect of aerobic exercise on cognition, but underlying mechanisms are unclear. In this study, we test the hypothesis that aerobic exercise increases cerebral blood flow (CBF) in patients with vascular cognitive impairment (VCI). This study is a multicenter single-blind randomized controlled trial among 80 patients with VCI. Most important inclusion criteria are a diagnosis of VCI with Mini-Mental State Examination ≥22 and Clinical Dementia Rating ≤0.5. Participants are randomized into an aerobic exercise group or a control group. The aerobic exercise program aims to improve cardiorespiratory fitness and takes 14 weeks, with a frequency of three times a week. Participants are provided with a bicycle ergometer at home. The control group receives two information meetings. Primary outcome measure is change in CBF. We expect this study to provide insight into the potential mechanism by which aerobic exercise improves hemodynamic status

Structured clinical reasoning for exercise prescription in patients with comorbidity

Purpose: Exercise therapy is an effective intervention in a variety of chronic diseases. The prescription of exercise therapy is usually directed toward an index disease. The presence of comorbidity may require adaptations to the exercise program as intended for the index disease. This paper aims to structure the clinical reasoning process of health professionals when prescribing exercise therapy for the individual patient with an index disease and comorbidity. Methods: We adapted the previously published strategy for developing guidelines and protocols on comorbidity-adapted exercise to a version that can be used for individual exercise prescription. Results: Essential steps and considerations involved in prescribing an exercise program to an individual patient with comorbidity are described. A case description is used as an example of how the proposed strategy leads to clinical decisions. Conclusions: The proposed strategy may have a role in educational and professional development. The advanced clinical expertise needed for safe and effective exercise therapy in patients with a complex health status is emphasized.Implications for Rehabilitation The presence of comorbidity may require adaptations to exercise therapy. We describe the essential steps and considerations involved in prescribing an exercise program to an individual patient with an index disease and comorbidity. The proposed strategy can be used to structure the clinical reasoning process of health professionals

Structured clinical reasoning for exercise prescription in patients with comorbidity

Purpose: Exercise therapy is an effective intervention in a variety of chronic diseases. The prescription of exercise therapy is usually directed toward an index disease. The presence of comorbidity may require adaptations to the exercise program as intended for the index disease. This paper aims to structure the clinical reasoning process of health professionals when prescribing exercise therapy for the individual patient with an index disease and comorbidity.Methods: We adapted the previously published strategy for developing guidelines and protocols on comorbidity-adapted exercise to a version that can be used for individual exercise prescription.Results: Essential steps and considerations involved in prescribing an exercise program to an individual patient with comorbidity are described. A case description is used as an example of how the proposed strategy leads to clinical decisions.Conclusions: The proposed strategy may have a role in educational and professional development. The advanced clinical expertise needed for safe and effective exercise therapy in patients with a complex health status is emphasized.Implications for RehabilitationThe presence of comorbidity may require adaptations to exercise therapy.We describe the essential steps and considerations involved in prescribing an exercise program to an individual patient with an index disease and comorbidity.The proposed strategy can be used to structure the clinical reasoning process of health professionals

In-Hospital Mobilization, Physical Fitness, and Physical Functioning After Lung Cancer Surgery

BACKGROUND: Apart from clinical experience and theoretical considerations, there is a lack of evidence that the level of adherence to in-hospital mobilization protocols is related to functional recovery in patients after resection for lung cancer. The objectives of the study were to determine (1) the relationship between adherence to the in-hospital mobilization protocol and physical fitness at hospital discharge and (2) the value of physical fitness measures at discharge in predicting physical functioning 6 weeks and 3 months postoperatively. METHODS: This observational study included 62 patients who underwent surgical resection for lung cancer. Adherence to the in-hospital mobilization protocol was abstracted from patients' records. Physical fitness measures before the operation and at hospital discharge included handgrip strength, 30-second sit-to-stand test, and 6-minute walk test (6MWT). Self-reported physical functioning was assessed preoperatively and 6 weeks and 3 months postoperatively, using the Medical Outcome Study 36-Item Short Form (SF-36) Physical Function subscale (RAND Corp, Santa Monica, CA). Linear regression analyses were used to estimate the relationships of interest, adjusting for potential confounders. RESULTS: Level of adherence to the mobilization protocol was significantly and independently related to handgrip strength, sit-to-stand test, and 6MWT at discharge. Handgrip strength and 6MWT at discharge significantly predicted SF-36 Physical Function at 6 weeks and 3 months postoperatively. The sit-to-stand test only predicted SF-36 Physical Function at 6 weeks. CONCLUSIONS: Suboptimal postoperative mobilization after surgical resection for lung cancer negatively affects physical fitness at discharge. Our results underline the importance of adherence to early postoperative mobilization protocols. Measuring physical fitness at discharge may be useful to inform clinicians on elective referral of patients for postdischarge rehabilitation

In-Hospital Mobilization, Physical Fitness, and Physical Functioning After Lung Cancer Surgery

Background: Apart from clinical experience and theoretical considerations, there is a lack of evidence that the level of adherence to in-hospital mobilization protocols is related to functional recovery in patients after resection for lung cancer. The objectives of the study were to determine (1)the relationship between adherence to the in-hospital mobilization protocol and physical fitness at hospital discharge and (2)the value of physical fitness measures at discharge in predicting physical functioning 6 weeks and 3 months postoperatively. Methods: This observational study included 62 patients who underwent surgical resection for lung cancer. Adherence to the in-hospital mobilization protocol was abstracted from patients’ records. Physical fitness measures before the operation and at hospital discharge included handgrip strength, 30-second sit-to-stand test, and 6-minute walk test (6MWT). Self-reported physical functioning was assessed preoperatively and 6 weeks and 3 months postoperatively, using the Medical Outcome Study 36-Item Short Form (SF-36)Physical Function subscale (RAND Corp, Santa Monica, CA). Linear regression analyses were used to estimate the relationships of interest, adjusting for potential confounders. Results: Level of adherence to the mobilization protocol was significantly and independently related to handgrip strength, sit-to-stand test, and 6MWT at discharge. Handgrip strength and 6MWT at discharge significantly predicted SF-36 Physical Function at 6 weeks and 3 months postoperatively. The sit-to-stand test only predicted SF-36 Physical Function at 6 weeks. Conclusions: Suboptimal postoperative mobilization after surgical resection for lung cancer negatively affects physical fitness at discharge. Our results underline the importance of adherence to early postoperative mobilization protocols. Measuring physical fitness at discharge may be useful to inform clinicians on elective referral of patients for postdischarge rehabilitation

Cost-Effectiveness of the Transmural Trauma Care Model (TTCM) for the Rehabilitation of Trauma Patients

Objectives To assess the societal cost-effectiveness of the Transmural Trauma Care Model (TTCM), a multidisciplinary transmural rehabilitation model for trauma patients, compared with regular care.Methods The economic evaluation was performed alongside a before-and-after study, with a convenience control group measured only afterward, and a 9-month follow-up. Control group patients received regular care and were measured before implementation of the TTCM. Intervention group patients received the TTCM and were measured after its implementation. The primary outcome was generic health-related quality of life (HR-QOL). Secondary outcomes included disease-specific HR-QOL, pain, functional status, and perceived recovery.Results Eighty-three trauma patients were included in the intervention group and fifty-seven in the control group. Total societal costs were lower in the intervention group than in the control group, but not statistically significantly so (EUR-267; 95 percent confidence interval [CI], EUR-4,175-3011). At 9 months, there was no statistically significant between-group differences in generic HR-QOL (0.05;95 percent CI, -0.02-0.12) and perceived recovery (0.09;95 percent CI, -0.09-0.28). However, mean between-group differences were statistically significantly in favor of the intervention group for disease-specific HR-QOL (-8.2;95 percent CI, -15.0 - 1.4), pain (-0.84;95CI, -1.42 - 0.26), and functional status (-20.1;95 percent CI, -29.6 - 10.7). Cost-effectiveness acceptability curves indicated that if decision makers are not willing to pay anything per unit of effect gained, the TTCM has a 0.54-0.58 probability of being cost-effective compared with regular care. For all outcomes, this probability increased with increasing values of willingness-to-pay.Conclusions The TTCM may be cost-effective compared with regular care, depending on the decision-makers willingness to pay and the probability of cost-effectiveness that they perceive as acceptable

Development of a physical capacity framework to support clinical reasoning of physiotherapists treating hospitalised patients

Applying an appropriate physiotherapy intervention to a hospitalised patient can be challenging because the clinical status can change rapidly, affecting the patient’s physical capacity. Determining the appropriate type and dose of the physiotherapy intervention requires dynamic assessment of physical capacity and adequate clinical reasoning by the physiotherapist. To develop a framework for determining physical capacity to support physiotherapists in their clinical reasoning process when treating hospitalised patients. A framework was developed using a multi-method approach. First, the scientific literature was searched for existing frameworks for clinical reasoning in physiotherapy. These methods were inventoried and relevant elements were extracted. Second, a first draft of the framework was developed by a group of experts. Third, the framework was tested in practice, leading to a final version. A total of 17 frameworks were identified from the literature. No framework was found for generic use in the hospital for the purpose of determining patient’s physical capacity. Relevant elements from the identified frameworks were: the use of ICF terminology, the use of a patient management model, and frequent monitoring of clinical parameters. Field testing of the first draft of the framework led to improvement of the framework for use in clinical practice. A framework was developed to support physiotherapists in their clinical reasoning process when treating hospitalised patients. The framework can provide guidance for determining the patient’s physical capacity to allow for an adequate training stimulus.</p

From accelerometer output to physical activity intensities in breast cancer patients.

We aimed to investigate accelerometer output corresponding to physical activity intensity cut-points based on percentage of peak oxygen consumption (%VO2peak) and Metabolic Equivalent of Task (MET) value in women treated for breast cancer