Haem-Fit: an exercise and wellness program

Casey HutchinsonClinical Nurse Educator

Oncology/HaematologyCalvary Mater Newcastle

Difference between activity and exercise‘Physical activity’ is defined as any bodily movement produced by skeletal muscles that results in energy expenditure.

‘Exercise’ is a subset of physical activity that is planned, structured, and repetitive. The objective is to improve or maintain physical fitness.

Impact of exercise for patients

• Quicker recovery• Decrease length of hospital stay• Reduce muscle wastage• Maintain independence• Return to normal activities• Increased quality of life• Lower risk of falls• Lower risk of re-admission• Improved treatment completion

Giovannucci EL. Physical activity as a standard cancer treatment. J Natl Cancer Inst. 2012;104(11):797–9

Gap between evidence and practice

Within the Haematology inpatient ward education and promotion of exercise is not widely included as a component of usual care and referrals to supportive services are made on a ‘reactive’ rather than ‘proactive’ basis.

Investigators Lisa Lincz (Senior Research Officer)Ben Britton (Senior Clinical & Health Psychologist)Kerrie Clover (Research Manager, Clinical Psychologist Conjoint Associate Professor)Casey Hutchinson (Clinical Nurse Educator)Louisa Brown (Bone Marrow Transplant coordinator)Jackie Wykes (Lymphoma Care Coordinator)Megan Jackson (Dietician)Judy Holland (Physiotherapist)Alix Hall (Research Associate)Phil Rowlings (Director Haematology)

FundingApplied for funding HCRA Implementation Science Flagship Program 2017

HNE Priority Research Area that the project addressed: • Evidence-based exercise program for people

undergoing cancer treatment • Evaluating the utility of a hospital follow-up for cancer

patients post-discharge or post-treatment • Embedding PROMs or distress screening into patient

care

Wellness and Exercise ProgramPhase 1: Wellness and Exercise Survey (WES)Survey of haematology in-patients during a 3 month pre-implementation phase (Aug – Oct 2017; HNEHREC 17/06/21/5.07)

Phase 2: Implementation of Haem-FitHaem-Fit: Exercise and Wellness Program for Haematology Cancer Patients (Feb- May 2018; HNEHREC 17/12/13/5.15)

Eligibility Inclusion criteriaAll haematology cancer patient admissions with ≥7 days anticipated length of stay

Exclusion criteriaPeople with artificial electrical implants such as a defibrillator or pacemaker will be excluded from inBody570 testing

Phase 1: WESOn admission patients complete:

a) Inbody570 testingb) Questionnaires (QLQ-C30 & HADS)

At discharge patients complete:a) Inbody570 testingb) Questionnaires (QLQ-C30 & HADS) c) Survey to self-report mobility status and provide feedback about the

exercise program

*All participants received current standard of care without addition of a structured exercise program.

Phase 2: Haem-FitOn admission patients complete:

a) Inbody570 testingb) Questionnaires (QLQ-C30 & HADS) c) Consultation with physiotherapistd) Consultation with Dietician

During admission patients: a) Complete daily exercise goals, record activity in exercise diary

At discharge patients complete:a) Inbody570 testingb) Questionnaires (QLQ-C30 & HADS) c) Survey to self-report mobility status and provide feedback about the

exercise program

Follow up phone call 7-10 days post

OutcomesImplementation OutcomesPrimary: • Rate of patient adherence (patient diaries)Secondary:• Rate of patient accrual (#eligible vs #consented)• Patient satisfaction with the program (patient questionnaire and follow up

phone call)• Rate of patient continuation of program at 1 week post discharge (self report

by follow up phone call)Patient outcomes (evaluation of the program)Primary: • Difference in lean muscle mass between admission and discharge (inBody

570)Secondary:• admission vs discharge levels of mobility and QoL (HADS, QLQ-C30, self

reported mobility scales)

ExercisesTricep dips

Easy: 2 x 5 reps daily

Lying down use hand weights or water bottles. Lift arms above head (as shown) and slowly bend elbows so the hands come down next to your head. Then slowly raise again to above head. Recommended level if you have a PICC or port-a-cath

Moderate: 2 x 10 reps daily

Sitting down, position your hands shoulder width apart on the arm of a stable chair. Straighten your arms, pushing your bottom up off the chair. Slowly bend your elbows to lower your bottom back towards the chair.

Difficult: 1 x 20 reps daily

Place your arms shoulder width apart on a stable seat (as shown). Shift your bottom forward off the seat with arms straight. Bending elbows to lower your body towards the ground until elbows are about 90 degrees then push up again until the arms are straight. Keep your back close to the seat throughout.

Punching in front

Easy: 1 x 10 reps each arm.

Sit comfortably with legs shoulder width apart. Holding arms like you are going to punch someone. Reaching out one arm at a time and then back in repeat action with the other arm. Repeat action. No weight

Moderate: 2 x 10 reps each arm.

Stand or sit comfortably with legs shoulder width apart. Hold a light weight – 600ml bottle of water. Holding arms like you are going to punch someone. Reaching out one arm at a time and then back in repeat action with the other arm. Repeat action.

Difficult: 3 x 10 reps each arm.

Stand comfortably with legs shoulder width apart. Make the weight heavier. At home, fill the bottle with sand or rice.

Patient demographicsWES (N=16) Haem-Fit (N=11) p-value

M:F 10:6 6:5 0.6794

Age (years) 58.13 ± 13.26 49.91 ± 16.84 0.1685

Smokers 0 0

Haematological condition AML 5 (31%) 4 (36%) 0.7818

NHL 4 (25%) 2 (18%) 0.6754

MM 2 (12%) 2 (18%) 0.6830

T-ALL 1 (<10%) 1 (<10%) 0.7818

B-ALL 1 (<10%) 0 0.3981

CMML 1 (<10%) 0 0.3981

AMML 1 (<10%) 0 0.3981

CLL 1 (<10%) 0 0.3981

HD 0 1 (<10%) 0.2191

MDS/AML 0 1 (<10%) 0.2191

Length of hospital stay 21.3 ± 12.3 22.9 ± 6.3 0.6621

Prior admission within last 28 days 10 (63%) 1 (<10%) 0.0055

Results

WES (N=16) Haem-Fit (N=11)

Mean ± stdev Mean ± stdev p-value

Weight (kg) 79.14 ± 21.45 84.98 ± 26.29 0.5313

BMI 27.54 ± 5.42 29.24 ± 11.20 0.6480

Skeletal muscle mass (kg)

28.32 ± 6.4032.32 ± 9.06 0.1900

Segmental muscle mass:

trunk 23.14 ± 5.08 25.29 ± 6.66 0.3492

right arm 2.87 ± 0.84 3.24 ± 1.13 0.3292

Left arm 2.83 ± 0.82 3.17 ± 1.09 0.3766

Right leg 8.16 ± 2.27 9.02 ± 2.34 0.3480

Left leg 8.04 ± 2.15 9.00 ± 2.28 0.2776

% body fat 32.20 ± 10.24 28.68 ± 12.27 0.4259

QLQ30 summary score

66.35 ± 13.53 66.46 ± 17.24 0.9849

Anxiety score (HADS)

5.44 ± 3.20 6.81 ± 2.40 0.2370

Depression score (HADS)

4.50 ± 3.08 5.91 ± 4.09 0.3159

WES (N=16) Haem-Fit (N=10)

Mean ± stdev Mean ± stdev p-value

Weight (kg) -2.07 ± 3.78* -3.25 ± 2.19** 0.3814

BMI -2.14 ± 3.78* -3.25 ± 2.19** 0.4091

Skeletal muscle

mass (kg)

-3.88 ± 6.21* -4.62 ± 3.12** 0.6920

Segmental muscle

mass:

trunk -3.39 ± 6.77* -3.96 ± 4.15* 0.8126

right arm -4.19 ± 10.75 -5.60 ± 5.09** 0.6569

Left arm -4.66 ± 13.10 -5.11 ± 6.71* 0.9104

Right leg -2.66 ± 6.52 -2.72 ± 4.44 0.9804

Left leg -1.23 ± 8.07 -2.02 ± 2.94 0.7244

% body fat 2.19 ± 10.44 1.43 ± 6.10 0.8374

QLQ30 summary

score

-3.81 ± 19.30 -11.11 ± 25.35 0.4133

Anxiety score

(HADS)

38.65 ± 215.30 -18.8 ± 43.00 0.3152

Depression score

(HADS)

5.82 ± 60.69 61.41 ± 297.72 0.5736

Patient status at discharge compared to admission (% change)Patient status at time of admission

* p<0.05, **p<0.01

-10

-5

0

5% change in skeletal muscle mass

-15

-10

-5

0

5

10

15% change in skeletal muscle mass

Patient feedback• It was good motivation to get up and complete set activities. Helpful for both physical and mental health• My last visit to hospital I got quite a bit of fluid. I feel because of exercise program, this was not a major problem this visit.• The program gives you something to focus on each day as a positive, and after doing program you feel like you have accomplished something for yourself.• Something to focus on and maintain strength.• I think it is a great idea and gives patients that little push to do something extra.

• Muscles weren't as weak compared to first admission. • Felt in much better condition when he was d/c

Have you been able to integrate the exercise program into your daily routine at home?

• Patient been walking and other activities. Plan to reinstate program

on next admission. • Normally active person. Returned to normal activities. Incorporated resistance exercise with weights. Likes to swim, go to gym. • Not the same program but has been keeping active. Normally active in day-day work. Doesn't participate in dedicated/gym based exercise.• Walking and stretching, lunges, push-ups, yoga. Not specifically the program.• Continued with normal activities when got home.• Resumed normal activities - work physically active. Normal behaviours - doesn't do dedicated exercise.

Would you recommend this program to other patients?

100% answered YES

• Routine (provides). Something patient could do for self. Motivation. Good for physical and mental health.• Importance for focus on being well.• Found helpful - wasn't damaging.• Good for young pts.• Definitely. Gives motivation and obviously beneficial.

Exercise promotioninitiatives