Exercise intensity prescription in cancer survivors

Thanks to the numerous positive effects of exercise (1-5) and its steadily growing importance in exercise oncology, exercise is recommended to all cancer survivors (CS) (3, 6-9). The existing oncology exercise guidelines are based on the assumption that intensity specifications can be transferred from healthy individuals to CS. However, it was shown that cardio-metabolic parameters used for intensity prescription may be altered in CS due to cancer treatment (10, 11). So-called second-generation trials are demanded which compare the effects of different training prescriptions aiming at elaborating the optimal exercise prescription for CS (12). Consequently, before conducting the demanded studies, a fundamental question must first be clarified: “Is my selected dosage actually what it claims to be when I prescribe a certain intensity for a cancer survivor?”. This was the leading question of this dissertation; Without its final clarification no progress can be made towards individualized training prescription. A precise intensity prescription is a prerequisite for eliciting the greatest possible training effects without provoking training overload. The TOP study was the first to systematically investigate whether currently used methods of intensity prescription are reliable for its use in CS. The main questions were (I) whether maximal oxygen uptake (VO2max) as the major parameter used for intensity prescription, is actually attained by CS during a cardiopulmonary exercise test (CPET), (II) whether three different established methods for intensity prescription for endurance exercise are equally suitable for targeting a specific intensity zone, and (III) whether commonly used methods of intensity testing and prescription in resistance exercise are also valid in CS. The TOP study was designed to answer these research questions; The results were discussed in three manuscripts which constitute the main body of this dissertation. I. Manuscript 1 (chapter 5) targets the question whether CS attain their true VO2max in a CPET. We analyzed data from 75 CS who underwent a supramaximal verification test to confirm the attainment of VO2max. We found that VO2max was not underestimated in the CPET on the group level, yet one third of CS did not attain their true VO2max. We concluded that the verification test appears feasible and beneficial for distinguishing between patients who attained their true VO2max and those who did not. II. In manuscript 2 (chapter 6) we evaluated whether threshold concepts might be useful submaximal alternatives to %VO2max in terms of meeting the vigorous intensity zone. We compared physiological and psychological responses of three training sessions defined by Abstract III three different prescription methods: blood lactate (bLa) thresholds, ventilatory thresholds, and %VO2max as reference. The data showed that all intensity prescription methods met the targeted intensity zone on average, however the session prescribed via bLa thresholds provoked the most homogeneous bLa responses. Furthermore, not all CS were able to complete the training sessions, we therefore concluded that slightly lower percentages should be chosen to improve durability of the training sessions. III. Manuscript 3 (chapter 7) focused on whether different maximum strength tests yield comparable results and are therefore applicable interchangeably. Maximal strength values derived from two indirect strength testing methods (h1-RM after Brzycki (13) and Epley (14)) were compared to one direct method of 1-RM determination, all performed at six different resistance machines. The results vary between the different methods with the occurrence of both, over- and underestimation of patients’ strength performance. This should be considered when training intensities are to be described based on maximal strength values, and when comparing maximal strength data between studies using different testing procedures. Moreover, we aimed to investigate the prediction accuracy for targeting specific intensity zones in resistance exercise in CS, i.e., whether the achieved number of repetitions (NOR) corresponding to specific values of %1-RM/h1-RM were accurately predicted. We found in part extreme deviations between the targeted NOR and the NOR actually performed. We conclude that the prediction accuracy of all test procedures seems to be very poor for all tested strength training machines for the chosen intensities. The use of %1-RM/h1-RM for intensity prescription is therefore questionable for this population. Our results demonstrate that currently used methods of exercise testing and prescription seem to have only limited applicability in CS. The overall conclusion for endurance exercise is that threshold concepts seem to be suitable alternatives to %VO2max for intensity prescription, yet bLa thresholds should be favored if a defined metabolic strain is intended as this method evokes the most homogeneous bLa response between individuals. Furthermore, a verification test seems necessary to ensure VO2max attainment, if percentages of VO2max are used for intensity prescription, or if the effect of a training intervention is evaluated based on changes of VO2max. Regarding resistance exercise, commonly used methods for testing are not safe (1-RM) or imprecise (h1-RM) which is also true when %1-RM/h1-RM is used for intensity prescription. Abstract IV Directly approaching specified intensities might be an alternative method for intensity prescription in resistance training. A phenomenon that connects all three manuscripts is that the individual data show in part extreme interindividual variations which tell different stories than the group means. Therefore, special attention should be paid to interindividual variability when prescribing exercise for CS. The choice of methods should fit the goals and possibilities of the patients. Subsequently, maximum accuracy is warranted in the context of studies, whereas in practice, more inaccuracies can be accepted, and the methods should be chosen accordingly. Independent of the setting, our results demonstrate that it is important not to blindly trust on calculated exercise intensity specifications but to consider them as orientation. For this, it is important to closely monitor the patients for signs of over- or underload, to ensure maximum safety and adequate training stimulus at the same time. There will and can never be one method that fits all. People are individuals and training should be prescribed accordingly. The results presented in this dissertation contribute important insights about the accuracy of different exercise testing as well as prescription methods, and further advance the field of personalized exercise oncology. However, they only represent a first step in the still largely unresearched field of exercise prescription in CS and point to a need for further research

Research into practice : collaboration for leadership in applied health research and care (CLAHRC) for Nottinghamshire, Derbyshire, Lincolnshire (NDL)

To address the problem of translation from research-based evidence to routine healthcare practice, the Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire, and Lincolnshire (CLAHRC-NDL) was funded by the National Institute for Health Research as one of nine CLAHRCs across England. This paper outlines the underlying theory and its application that CLAHRC-NDL has adopted, as a case example that might be generalised to practice outside the CLAHRC, in comparison to alternative models of implementation

Quality of care: testing some measures in homes for elderly people

In this national study of 17 residential homes, 309 residents were interviewed, 264 members of staff completed an anonymous survey, and 228 relatives responded to a postal questionnaire. The data were collected between January andSeptember 1995. The aim of the study was to suggest promising measures of quality of care, looking particularly at depression as a possible indicator. It also served as a follow-up study of the Caring in Homes Initiative, although its timing ruled out evaluation of the impact of this development programme, because changes occurred in the homes before this study began. No strict definition of quality was adopted a priori, but a pragmatic approach was taken, addressing the perspectives of residents, health and social care professionals, home staff, managers, and relatives

Evaluation of the impact on audiences of Inside Out of Mind, research-based theatre for dementia carers

Background Inside Out of Mind is an ethno-drama about dementia carers in hospital, intended to raise awareness of this role, and about dementia care in general. Following a successful premiere in 2013, it was taken on a live tour funded by the Big Lottery through Arts Council England to six cities. This paper explores the impact on audiences consisting largely of professional carers. Methods Mixed methods were applied; semi-structured self-completion questionnaires for post-show feedback, and one month later telephone interviews to a stratified sample of respondents. Framework analysis was used to explore the data, paying particular attention to critical comments. Results Of the 5,426 people who attended, 19% completed post-show questionnaires. Sixty-four were subsequently interviewed in depth. Both lay and professional audience members expressed heightened awareness of the needs of people with dementia. They expressed greater appreciation of the care process and the challenges faced by the people employed to care for people with dementia in hospitals and other long-term settings. Conclusions As research-based theatre this production of Inside Out of Mind afforded an effective medium for knowledge transfer. It engaged audiences with the key issues - including dignity, identity and loss - and enabled them to relate these to their own lives, while encouraging appropriate practical responses

Additional interventions to enhance the effectiveness of individual placement and support: a rapid evidence assessment

Topic: Additional interventions used to enhance the effectiveness of individual placement and support (IPS). Aim: To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method: A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions. Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is difficult to establish. Some evidence suggests that work-related social skills and cognitive training are effective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence

The arts as a medium for care and self-care in dementia: arguments and evidence

The growing prevalence of dementia, combined with an absence of effective pharmacological treatments, highlights the potential of psychosocial interventions to alleviate the effects of dementia and enhance quality of life. With reference to a manifesto from the researcher network Interdem, this paper shows how arts activities correspond to its definition of psycho-social care. It presents key dimensions that help to define different arts activities in this context, and illustrates the arts with reference to three major approaches that can be viewed online; visual art, music and dance. It goes on to discuss the features of each of these arts activities, and to present relevant evidence from systematic reviews on the arts in dementia in general. Developing the analysis into a template for differentiating arts interventions in dementia, the paper goes on to discuss implications for future research and for the uptake of the arts by people with dementia as a means to self-care

Improving community support for older people’s needs through commissioning third sector services: a qualitative study

Aim: This exploratory study of commissioning third sector services for older people aimed to explore whether service data was fed back to commissioners and whether this could improve intelligence about the population and hence inform future commissioning decisions. Background: Third sector services are provided through charities and non-profit community organisations, and services that assess and advise people for self-management or provide wellbeing support in the community have developed over recent years. Third sector services have an opportunity to reach vulnerable populations and to provide intelligence about them. Some third sector services are state funded (commissioned) in the United Kingdom (UK). While evidence is available about the commissioning of statutory health and social care, as well as private providers, there is limited evidence about how third sector health services are funded. Methods: Participants were recruited from commissioner organisations and third sector organisations, both with an interest in supporting the independence, self-management and wellbeing of older people. Organisations were recruited from five purposively selected sites within one region of England (East Midlands). Semi-structured interviews explored the relationships between commissioners and providers and the nature of funding arrangements, including co-production. Interviews also explored collection of data within the service and how data was fed back to commissioners. Focus groups were held with older people with the potential to benefit from wellbeing services.Results: Commissioning arrangements were varied, sometimes complex, and often involved co-production with the third sector. Commissioners valued third sector organisations for their engagement with the local community, value for money, outreach services and ability to provide information about the community. Assessing the needs and outcomes of individuals was integral to delivery of support and advice to older people. Diverse approaches were used to assess an individual’s needs and outcomes, although there were concerns that some assessment questionnaires may be too complex for this vulnerable group. Assessment and outcomes data were also used to monitor the service contract and there was potential for the data to be summarised to inform commissioning strategies, but commissioners did not report using assessment data in this way. While the policy context encouraged partnerships with third sector organisations and their involvement in decision-making, the relationship with third sector organisations was not valued within contract arrangements, and may have been made more difficult by the tendering process and the lack of analysis of service data.Conclusion: This exploratory study has demonstrated a diversity of commissioning arrangements for third sector services across one region of England. Most commissioners invited co-production; that is, the commissioners sought input from the third sector while specifying details of the service. Service data, including assessments of needs and outcomes, were reported to commissioners, however commissioners did not appear to use this to full advantage to inform future commissioning decisions. This may indicate a need to improve measurement of needs and outcomes in order to improve the credibility of commissioning process

Dyadic construction of dementia: meta-ethnography and behaviour-process synthesis

Objectives: Positive identity in people with dementia is maintained when there is good interaction with family caregivers. However, research on the experiences of dyadic interaction in dementia care is still limited. For this reason, we aimed to systematically review the dyadic experience of dementia caring. Method: Studies were identified through searching five databases: MedLine, EMBASE, PsycInfo, ASSIA, and CINAHL. Eligible studies employed qualitative or mixed method design, reported the experience of dyads of dementia with no comorbid organic or psychiatric disorders. No restrictions were made on language or year of publication, nor on sex or age of participants. The quality appraisal of studies was conducted by two researchers independently. We used meta-ethnography to synthesise data and developed a behavioural model to explain dyadic interaction. Results: A total of 17 studies were included in the review. The meta-ethnography generated two third-order constructs: Personal orientation and noises. When both people with dementia and their carers opt for dyadic oriented goals, their behavioural responses are likely to promote positive interaction. When only one partner opts for dyadic goals, the stress posed by the context may affect the interaction because of no perceived shared understanding of the situation. Conclusion: Our findings suggest that unequal power distribution within dementia dyads, can cause significant stress especially when coping strategies are impaired. Implications are found for family carers, people with dementia, and health professionals as the model we derived enhances the understanding of dyadic dynamics to care

Bringing arts interventions into care settings

Artistic and creative activities are increasingly recognised as tools to support people with dementia. They can share these activities on equal terms with everyone else and the arts can help them to overcome the barriers they often face through cultural participation and social engagement. Participation in artistic activities provides mental stimulation, exercises existing skills and offers new learning experiences

Carers for older people with co-morbid cognitive impairment in general hospital: characteristics and psychological well-being

OBJECTIVE: This analysis sought to describe the characteristics and well-being of carers of older people with mental health problems admitted to a general hospital. METHODS: General medical and trauma orthopaedic patients aged 70 years or older admitted to an acute general teaching hospital were screened for mental health problems. Those screened positive, together with a carer, were invited to undergo further assessment with a battery of health status measurements. Carers were interviewed to ascertain strain (caregiver strain index (CSI)), psychological distress (12-item General Health Questionnaire) and quality of life (EQ-5D). RESULTS: We recruited 250 patients to the study, of whom 180 were cognitively impaired and had carers willing to take part. After 6 months, 57 patients (32%) had died, and we followed up 100 carers. Carers' own health, in terms of mobility, usual activities, and anxiety, was poor in a third of cases. At the time of admission, high carer strain was common (42% with CSI ≥ 7), particularly among co-resident carers (55%). High levels of behavioural and psychiatric symptoms at baseline were associated with more carer strain and distress. At follow-up, carer strain and distress had reduced only slightly, with no difference in outcomes for carers of patients who moved from the community to a care home. CONCLUSION: Hospital staff should be alert to sources of carer strain and offer carers practical advice and emotional support. Interventions are required to prevent and manage behavioural and psychiatric symptoms at the time of acute physical illness or to alleviate their effects on carers