Title: Development of a perioperative isometric-resistance exercise intervention programme (Basic Exercise Training To Enhance Recovery - BETTER) for patients undergoing elective abdominal and thoracic surgery for cancer
Funder: Department of Health and Social Care

Abstract: Background to the research: Abdominal and thoracic cancer is a debilitating illness, affecting many people in the UK (1). Many of these patients will undergo surgery, after which there is a high risk of post-operative complications and decline in physical functional (2, 3). Especially, upper GI patients are susceptible to muscle wasting (sarcopenia) and weight loss (cachexia). One promising treatment option, to combat the muscle wasting, is exercise training. It is thought that, due to its multifactorial effects, exercise training (especially resistance exercise) could act on several muscle metabolism signalling pathways to combat sarcopenia (4). One form of resistance exercise &ndash; isometric-resistance exercise &ndash; has long been established as effective in stimulating muscle anabolic processes and increasing muscle strength (5) and has been used in cancer patients (6). Also, it requires very little equipment and space, and it can be performed whilst patients are bed-bound in hospital or at home. Currently, there are no isometric-resistance exercise intervention programmes that can be applied to this patient group. Recovery of physical function in cancer patients has been assessed in a myriad of different ways. A physical performance test battery (PPTB) seems to be the most appropriate (7) but even this type of measure has been adapted and modified in many studies (8). Therefore, there seems to be no standardised way to assess physical function and thus there is a need for careful consideration of this befor assessing the effects of any exercise programme in patients. Aim: We aim to develop a safe, simple, suitable, effective isometric-resistance exercise intervention programme for patients who have undergone treatment for abdominal and thoracic cancer, which involves surgery. Research question: Can a safe, simple, suitable, effective isometric-resistance exercise intervention programme (BETTER) be developed, that patients undergoing elective abdominal and thoracic surgery for cancer can perform in hospital and at home, to improve recovery of their physical function? Plan of investigation: The proposed study will have TWO main phases, comprising EIGHT parts in total: Phase 1 (FOUR parts). A qualitative phase in which patients, clinicians, physiotherapists, exercise specialists and nurses will (i) identify the physical function challenges of the patient group; (ii) systematically search for previous and existing exercise programmes; (iii) develop a patient-specific isometric-resistance exercise programme (Basic Exercise Training To Enhance Recovery &ndash; BETTER); (iv) identify the most appropriate outcome measure(s) of physical function, for use with this patient group. Phase 2 (FOUR parts). The isometric-resistance exercise intervention (BETTER) programme will then be assessed for its suitability and effectiveness in a small group (n=50) of patients, who will be randomised into two groups; intervention (usual treatment + isometric-resistance exercise programme) or control (usual treatment). The intervention will be evaluated in four ways: (i) completion of the programme and adverse incidents; (ii) effects on physical function (iii) overall evaluation, by patients, of suitability and effectiveness (iv) cost-effectiveness. Results will be analysed by the research team, with expert input from the co-applicant statistician, using qualitative and quantitative methods. The potential benefit to patients, of the BETTER intervention programme, would be in enhanced recovery of physical function, especially in recovery of muscle strength and combating of muscle-wasting. This could aid earlier return to independent living, perhaps with reduced length of hospital stay. The potential benefits to the NHS are (i) in the development of new practices, in relation to patient recovery from surgery for cancer; (ii) provision of a new non-pharmacological tool, for clinicians and other medical practitioners, which may help patients to recover from their illness sooner and (iii) potential cost-savings from enhanced recovery.

Lay abstract: Every year in the UK, about 12,000 patients are diagnosed with oesophageal and stomach cancer (known as upper GI cancer) and about 25% undergo surgery involving the torso (abdominal) or chest (thoracic). Patients who have had this type of surgery often experience complications, mostly related to breathing problems caused by a decrease in lung function, and often need to go back into hospital and be admitted into intensive care for several days. Their intensive care stay is often lengthy and many do not survive. Longer-term, many patients suffer weight loss and muscle wastage. Recently, there has been a growing interest in how exercise can help cancer surgery patients recovery &ndash; before, during and after surgery. There have been very few previous studies of resistance exercise (or strength training) involving isometric-resistance (or static) exercise programmes in such patients. The advantage of this type of exercise is that it is known to be effective in increasing muscle strength and could therefore combat the particular muscle-wasting problems experienced by this patient group. Also, it requires very little equipment and space, and it can be performed whilst patients are bed-bound in hospital or at home. The purpose of this study is to develop an isometric-resistance exercise programme and then to try it out in a small-scale study. The idea for the programme is based on evidence which suggests that an isometric-resistance exercise programme may increase physical function in patients undergoing treatment for upper GI cancer. We are therefore proposing a developmental study to identify (i) the most appropriate format for the exercise programme (ii) the most appropriate measure(s) we can use to review the effects of the exercise programme on physical function and (iii) then scrutinise the effects of the exercise programme on physical function in a small-scale pilot study in patients.

Research activity codes: 5.7 PHYSICAL;6.7 PHYSICAL
Health categories: CANCER AND NEOPLASMS