Exercise Guidelines for People with Cancer
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Effectiveness of guideline dissemination and implementation strategies on health care professionals’ behaviour and patient outcomes in the cancer care context: a systematic review protocol 
Health care professionals (HCPs) are able to make effective decisions regarding patient care through the use of systematically developed clinical practice guidelines (CPGs). These recommendations are especially important in a cancer health care context as patients are exposed to a multitude of interdisciplinary HCPs offering high-quality care throughout diagnosis, treatment, survivorship and palliative care. Although a large number of CPGs targeted towards cancer are widely disseminated, it is unknown whether implementation strategies targeting the use of these guidelines are effective in effecting HCP behaviour and patient outcomes in the cancer care context. The purpose of this systematic review will be to determine the effectiveness of different CPG dissemination and implementation interventions on HCPs’ behaviour and patient outcomes in the cancer health care context.
Exercise is a safe, cost-effective means to prevent and manage secondary health complications and enhance quality of life (QoL) among cancer survivors (CS). Published exercise recommendations for CS have been based on literature reviews and roundtable consensus and were not underpinned by a robust, standardized guideline development process using rigorous methodology (e.g., a systematic review of research evidence, extensive peer review). The objective of this study was to systematically develop evidence-informed exercise guidelines to improve aerobic and muscular fitness, and increase QOL, among CS. The Appraisal of Guidelines, Research and Evaluation II guideline development protocol was used as a methodological strategy. The evidence base for the guideline development process consisted of a systematic review and quality appraisal of research examining the effects of exercise on aerobic and muscular fitness and QoL among adults with cancer. A multidisciplinary working group reflected on the evidence and generated the guidelines. The guidelines underwent a four-stage review process in which they were reviewed by 12 internal content experts, three guideline methodology experts, five external content experts, and 69 potential end-users, with refinements made at each stage. The guidelines contain recommendations regarding the duration, frequency, and intensity of aerobic and resistance-training sessions. The guideline also includes considerations for safety, delivery methods, and long-term maintenance of exercise behaviour. More research is necessary to generate more exact exercise programs for specific cancer types. Oncologists, primary care providers, and other members of the healthcare team (e.g., rehabilitation therapists, kinesiologists, psychologists) are encouraged to adopt these rigorously developed guidelines.
The definition of exercise used in this guideline is a ny physical activity resulting in an increase in energy expenditure and involving planned or structured movement of the body performed in a systematic manner in terms of frequency, intensity, and duration, and designed to maintain or enhance health - related o utcomes [ 1 ] . There are different types of exercise and exercise programs that can affect quality of life (QoL) and fitness. Aerobic exer cise, or endurance training, impacts the cardiovascular system and depends primarily on oxygen use . Resistance exercise, or strength training, uses weights or elastic resistance bands to overload the muscle with the intention of improving strength and endurance. The intensity of the exercise dictates the amount of energy that is expended when the exercise is performed. Objective measures of intensity include heart rate, metabolic equivalents (METs), or amount of oxygen consumed during an activity (VO 2 ). Subjective measures include patient - reported outcomes such as rate of perceived exertion (RPE) on a scale of one to 10 . Low - intensity exercise refers to physical activity or effort Guideline 19 - 5 Section 1: Recommendations Summary – June 30, 2015 Page 2 performed at one to three times the intensity of baseline resting energy expenditure ( < 3 METs; e.g., walking) ; moderate intensity refers to physical activity three to six times the intensity of baseline , which requires a moderate amount of effort and noticeably accelerates the heart rate ( 3 - 6 METs; e.g., brisk walking / bike riding ) ; and vigorous intensity refers to physical activity six or more times over baseline , which requires a large amount of effort a nd causes rapid breathing and a substantial increase in heart rate ( >6 METs; e.g., running / jumping rope). People with cancer who follow the exercise recommendations provided in this document can expect improvements in QoL and aerobic and muscular fitness. The degree of improvement will vary with each person and will be influenced by his or her past and current medical health status . The potential benefits of exercise far exceed the potential associated risks; however, people with cancer should consult with an exercise specialist to understand the modes and amounts of exercise appropriate for them (as per any other adult populations) before starting an exercise program. Cancer - specific modifications to ex ercise can be found in Appendix 8 [ 1 ] . For those who are physically inactive, performing levels of exercise below the recommended levels may bring some benefits. For these adults, it is appropriate to start with small amounts of exercise and gradually increase duration, frequency, and/or intensity under the guidance of an exercise specialist with the goal of meeting the recommendations. RECOMMENDATIONS 1. People living with cancer can safely engage in moderate amounts of exercise (see Recommendation 3) while on active treatment or post completion of treatment . 2. Moderate amounts of exercise (see Recommendation 3) are recommended to improve the QoL, as well as the muscular and aerobic fitness of people living with cancer. 3. Clinicians should advise their patients to engage in exercise consistent with the recommendations outlined by the Canadian Socie ty of Exercise Physiology and the America n Colle ge of Sports Medicine . The recommended duration, frequency, and/or intensity are the following: 150 minutes of moderate - intensity aerobic exercise spread over three to five days and resistance training at least two days per week; Resistance sessions should involve major muscle groups two to three days per week ( eight to 10 muscle groups, eight to 10 rep etition s, two sets); and Each session should i nclude a warm up and cool down. 4. A p re - exercise assessment for all people living with cancer before starting an exercise intervention is recommended to evaluate for any effect s of disease, treatments and /or co morbidities. 5. It is recommended , where possible, that people living with cancer exercise in a group or supervised setting as it may provide a superior benefit/outcome in QoL and muscular and aerobic fitness. 6. It is recommended, where possible, that people living with cancer perform exercise at a moderat e intensity ( three to six times the baseline resting state) on an ongoing basis as a part of their lifestyle so that improvements in QoL and muscular and aerobic fitness can be maintained for the long term.