Can a Post-AHCT, High-Intensity Exercise Program Improve Quality of Life in Patients With Myeloma?

Patients with myeloma who undergo autologous hematopoietic cell transplantation (AHCT) may experience a decline in health-related quality of life (HRQoL). Although exercise has been shown to improve physical fitness and cancer-related fatigue for other conditions, researchers found that a prescribed high-intensity exercise program provided no substantial benefits over usual care, according to a study published in PLoS One.

In the single-blind, multicenter, prospective, randomized, controlled EXIST (EXercise Intervention after Stem cell Transplantation) study, Saskia Persoon, PhD, from the Department of Rehabilitation at the Academic Medical Center at the University of Amsterdam in the Netherlands, and co-authors compared physical fitness – and HRQoL– outcomes between patients assigned to usual care and those assigned to an 18-week high-intensity resistance exercise and interval training program.

The investigators recruited 469 patients who were receiving AHCT for myeloma or lymphoma between March 2011 and February 2014. Patients were eligible for the study if they were six to 14 weeks post-AHCT, had blood counts that had sufficiently recovered (defined as hemoglobin >10.5 g/dL and platelets >80×109/L), and were able to undergo exercise testing.

A total of 109 patients (median age = 55 years; range = 19-67 years) agreed to participate (representing only 23% of screened patients, which the authors noted as a limitation). Fifty-four patients were randomized to the exercise program and 55 were randomized to usual care (control group).

Patients engaged in the exercise intervention program twice a week during the first 12 weeks of follow-up then once a week from 13 to 18 weeks under the supervision of local physiotherapists. To improve compliance and motivate participants to pursue an active lifestyle outside of the study program, the intervention group also attended five short counseling sessions during weeks one, four, 10, 12, and 18.

The control cohort was not specifically motivated to exercise, but they were also not restricted in physical activities or the use of health-care services.

Between baseline and follow-up physical tests, patients completed diaries that documented medication use and physiotherapy session attendance. Physiotherapists also reported on session attendance and adverse events (AEs) in a training log.

At last follow-up (July 2014), 12 patients were lost to follow-up (4 in the intervention group and 8 in the control group). An additional two patients in each group were excluded from the final analysis, including one patient in the control group who experienced disease progression.

Eight serious AEs were reported (4 in each cohort), none of which was considered related to study participation; however, one patient in the intervention cohort strained a calf muscle during a training session.

The intervention cohort attended an average of 25.8 of the 30 prescribed exercise sessions, with most patients (n=36; 75%) attending ≥80 percent of sessions. Reasons for missed sessions included illness or injury (34%), holiday (27%), and session taking place after final follow-up (19%).

Both groups experienced cardiorespiratory and muscular fitness improvements, as well as decreased fatigue (primary outcomes), with no significant between-group differences (TABLE). Median improvements in physical fitness (both cardiorespiratory and muscular) ranged from 16 percent to 25 percent in the intervention group and 12 percent to 19 percent in the control group; general and physical fatigue declined a median of 25 percent to 32 percent in the intervention group and 12 percent to 25 percent in the control group (p values not provided).

Ultimately, the authors noted “no significant favorable effects of a supervised high-intensity exercise program on physical fitness, fatigue, body composition, HRQoL, distress, or physical activity, compared [with] usual care.”

In a post-hoc analysis to assess potential favorable effects of attending 10 or more sessions of physiotherapy, the authors found that patients who participated in any exercise group (regardless of their assigned treatment group) had a larger increase in level of self-reported physical activity (β=35.0; 95% CI 0.9-69.1), but a smaller reduction in anxiety (β=1.3; 95% CI 0.2-2.3) and depression (β=1.5; 95% CI 0.5-2.5) at follow-up (p values not provided).

“We hypothesize that the lack of significant between-group differences in our study may be related to suboptimal timing of intervention delivery, contamination in the control group, and/or suboptimal compliance to the prescribed exercise intervention,” the researchers noted. “Therefore, further studies are needed to clarify the optimal timing of intervention delivery.”

The study is limited by its “relatively high number of missing values,” as well as potential contamination in the control group.

The authors report no conflicts.


Reference

Persoon S, ChinAPaw MJM, Buffart LM, et al. Randomized controlled trial on the effects of a supervised high intensity exercise program in patients with a hematologic malignancy treated with autologous stem cell transplantation: results from the EXIST study. PLoS One. 2017;12:e0181313.

TABLE. Effects on Primary Outcomes in Intervention and Control Cohorts*
  Exercise Intervention Group

(n=50)

Usual-Care Control Group

(n=47)

ß
Baseline Follow-Up Baseline Follow-Up
Cardiorespiratory fitness
VO2peak 21.7 mL/kg/min

(SD=4.8)

26.0 mL/kg/min

(SD=6.3)

21.2 mL/kg/min

(SD= 5.4)

24.2 mL/kg/min

(SD= 6.6)

1.2

(95% CI 0.5-2.9)

Wpeak 2.0 Watt/kg

(SD= 0.5)

2.4 Watt/kg

(SD=0.7)

2.0 Watt/kg

(SD=0.6)

2.4 Watt/kg

(SD=0.8)

0.1

(95% CI 0.1-0.2)

Muscular fitness
Chair stand test 15.5

(SD=4.6)

18.7

(SD=6.0)

14.5

(SD=4.6)

17.1

(SD=4.3)

0.7

(95% CI -0.5-1.9)

Grip strength test 35.5 kg

(SD=10.7)

40.9 kg

(SD=12.0)

36.9 kg

(SD=10.1)

41.3 kg

(SD=11.7)

1.3

(95% CI -0.5-3.1)

Fatigue†
Physical fatigue 13.2

(SD=4.2)

9.8

(SD=4.4)

14.4

(SD=4.8)

11.1

(SD=5.0)

-0.8

(95% CI -2.2-0.7)

General fatigue 12.7

(SD=3.8)

10.0

(SD=4.5)

13.5

(SD=4.3)

11.8

(SD=4.8)

-1.4

(95% CI -2.9-0.1)

Mental fatigue 10.0

(SD=4.3)

9.7

(SD=4.5)

10.3

(SD=4.8)

9.7

(SD=4.2)

0.1

12.2(95% CI -1.4-1.6)

*Physical fitness assessments were available for 48 patients in the exercise intervention group and 45 in the usual care control group.

†Measured using the Multidimensional Fatigue Inventory.

VO2peak = highest 15-second interval values for oxygen uptake; Wpeak = highest achieved workload

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