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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.
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.
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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. 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.
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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.
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A cross-over study design would have been impossible given the imperative surgery schedule. Only a few studies evaluating the impact of exercise training in postoperative lung cancer patients have included a control group, confirming the challenges associated with this methodological design 42 , Patients showed good adherence and were able to achieve the objectives of participation. In addition, our study found that a four-week HBETP produces physiological effects such as improved cycling exercise endurance, 6MWT distance and muscle strength.
Such improvements may be clinically relevant because exercise intolerance and muscle weakness are predictors of cardiopulmonary complications of thoracic surgical procedures. The authors also thank Serge Simard for statistical assistance and Debbie Deslauriers for her helpful linguistic revision.
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The authors also thank the anonymous reviewers for their excellent suggestions. This work was supported by the Canadian Lung Association. All authors were substantially involved in design, acquisition, analysis and interpretation of the study. All authors contributed to the intellectual content of the manuscript and were consulted for final approval of the submitted version.
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Accordingly, the authors did not omit to include any other author who would fulfill these authorship requirements. National Center for Biotechnology Information , U. Journal List Can Respir J v. Author information Copyright and License information Disclaimer. Telephone ext , fax , e-mail ac. This article has been cited by other articles in PMC. Exercise, Exercise tolerance, Home-based pulmonary rehabilitation, Lung cancer, Muscle strength, Quality of life, Training.
Assessments Anthropometric and pulmonary measurements: Exercise capacity was assessed using the following exercise tests: Incremental cycling exercise test: Constant workrate cycle exercise: Feasibility outcomes 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.
Open in a separate window. Participant characteristics The baseline characteristics for the 13 patients who completed the four-week HBETP are presented in Table 1. TABLE 2 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. CA Cancer J Clin. CA Cancer J Clin ; Pulmonary rehabilitation improves functional status in oncology patients. Arch Phys Med Rehabil. Safety and feasibility of aerobic training on cardiopulmonary function and quality of life in postsurgical nonsmall cell lung cancer patients: Quality of life before and after major lung resection for lung cancer: A prospective follow-up analysis.
Exercise capacity as a predictor of postoperative complications in lung resection candidates. Exercise capacity and extent of resection as predictors of surgical risk in lung cancer.
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Pulmonary rehabilitation in lung cancer: J Cardiopulm Rehabil Prev. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Effects of aerobic exercise on the physical performance and incidence of treatment-related complications after high-dose chemotherapy. Review of exercise intervention studies in cancer patients.
Pre-operative pulmonary rehabilitation and surgery for lung cancer. Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Eur J Cardiothorac Surg. Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: A structured exercise program for patients with advanced non-small cell lung cancer. Characterization of pulmonary rehabilitation programs in Canada in Feasibility and efficacy of home exercise training before lung volume reduction.
Effects of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: Standardization of spirometry — update. Official statement of American Thoracic Society.