Literature evaluation table grand canyon university

Literature Evaluation Table

 

Author, Journal (Peer-Reviewed), and Permalink or Working Link to Access Article

Article Title and Year Published

Research Questions (Qualitative) or Hypothesis (Quantitative), and Purposes or Aim of Study

Design (Type of Quantitative, or Type of Qualitative)

Setting or Sample

Methods: Intervention or Instruments

Analysis

Key Findings

Recommendation

1.

Abbatecola, A., Paolisso, G., & Sinclair, A.  Current Pharmaceutical Design,

( Source: NCBI)

Treating Diabetes Mellitus in Older and Oldest Old Patients. ( 2015)

Qualitative literature review.

The purpose of the journal article was to explore the challenge encountered by geriatric patients in anti-diabetic treatment options. 



The design is qualitative literature review. 

The paper investigates barriers to treatment of diabetes two among elder group. 

Secondary research method was utilized. 

The paper shows that risk of hypoglycaemia during treatment can be a barrier to treatment and management of diabetes 2 among elder patients with geriatric condition.  



There are a lot of underlying challenges in treatment and management of diabetes 2 among elder patients with geriatric conditions. 

Several underlying factors should be considered as part of treatment and medication. 

2.

Awoyemi, A., Trøseid, M., Solheim, S., Arnesen, H., & Seljeflot, I.

Atherosclerosis,

( Source: https://www.atherosclerosis-journal.com/article/S0021-9150(18)30461-1/abstract) 

Metabolic endotoxemia as related to metabolic syndrome in an elderly male population at high cardiovascular risk. ( 2018)

The study was quantitative. Study investigates syndrome that is strongly associated with inflammation, IL-6 and CRP and ways it leads to metabolic disturbance  among type 2 diabetes  patients



Design type is quantitative

The paper looks at the physiological factors that affect treatment geriatric patients  under diabetes treatment. 

Different animal models were used to determine reaction to various insulin type and treatment. 

Patient physiological aspects determines the body response to treatment of type 2 diabetes. 

The right treatment will result to better cell function  and insulin secretion. 

Patients should be screened for the right treatment as one medication may not work for all patient since there are other underlying conditions. 

3

Guo, M., & Xu, Y. 

Diabetes, 67 

( Source: NCBI)

Inhibitors and Stroke Risk in Patients with Type 2 Diabetes—A Systematic Review and Meta-analysis. (2018)

Qualitative study was done. Article investigates the effects of sodium-glucose contrasnporter 2 (SGLT2) inhibitors in respect to the risk of stroke. 

Meta-analysis was done

Patients with type 2 diabetes mellitus

Randomized trials were done measuring the R.R values. 

The analysis indicated that the RR value were not affected by age, gender, duration of diabetes, BMI, HbA1C levels. However there was a lower incidence of stroke observed on Black patients that Asian and white patients. 

Treatment also depends on social and cultural aspects of patient lifestyle

Change of lifestyle should be incorporated as part of diabetes 2 treatment. 

4

Komkova, A., Brandt, C. J., Hansen Pedersen, D., Emneus, M., & Sortsø, C.

(source NCBI and PubMed)

Electronic Health Lifestyle Coaching Among Diabetes Patients in a Real-Life Municipality Setting: Observational Study. (2018)

Qualitative Observational Study.  This study seeks to find the effects related to eHealth intervention among diabetes patients in a real-life municipal setting. 

Observational study

103 patients living with diabetes in a municipal setting. 

Regression method was done among these sample, where weight change was observed. Regression method was also used to assess the impact of intervention.  

The impact of eHealth was analysed and regression was used to test impact of eHealth intervention on weight.

eHealth intervention reduces weight risk among people with diabetes.

eHealth intervention should be encouraged as part of Evidence Based Practice. 

5

Mañas, L. R., Rodríguez, M. C., & Sinclair, A. J. Oxford Textbook of Geriatric Medicine

Management of diabetes in older adults. (2017).

study evaluates 

the currently available hypoglycaemic drugs  and indications  to diabetology community in treatment of adults aged 75 and above

Systematic literature review

Adult of 75 years and above

None

Comprehensive geriatric assessment to identify glycaemic targets

Hypoglycaemic therapy works well with same set of drugs when dosage is altered based on existing pharmacologic interactions

Patient history with hypoglycaemic drugs should be assessed

6

Migdal, A. L., & Abrahamson, M. J

Principles of Diabetes Mellitus

( Source PubMed)

.

Treating Type 2 Diabetes Mellitus (2016)

Literature review qualitative study. Article looks at the changes in lifestyle and impact in delaying the effects of diabetes. 

Literature review

Sample study was for adults over 50 years

None

Lifestyle change include exercises and diet was observed to whether it impacted in the development of diabetes 2 among the elder group.

Changes of lifestyle have an impact in the development of diabetes 2 and this could be delayed with proper behavior change

Diabetes Self-management education should be encouraged. 

7

Nyambuya, T. M., Dludla, P. V., & Nkambule, B. B. 

Systematic Reviews

(Source NCBI)

T cell activation and cardiovascular risk in type 2 diabetes mellitus: a protocol for a systematic review and meta-analysis. (2018)

Systematic review and meta-analysis. Study provide an assessment of the T cell activation and the cardiovascular risk in the adults with T2DM

Systematic literature review  and meta-analysis

The study incorporate medical subjects from PubMed and MEDLINE databases. 

Assessment of quality of strength across all studies. 

Study was able to reveal levels of statistical heterogeneity, depicting a random effect meta-analysis which is performed using the R statistics software. 

T Cells could be a major component in the development of T2DM among other complication. 

Self-management education is important. In reducing the effects of T Cells. 

8

Onofrei, L., & Smith, A. G. 

Advocacy in Neurology (https://oxfordmedicine.com/view/10.1093/med/9780198796039.001.0001/med-9780198796039-chapter-30)

Advocacy for patients with neuropathic pain. Advocacy in Neurology (2019)

Qualitative literature review. Paper looks at how pain impacts T2DM individuals, health providers and general health system with emphasis on advocacy. 

Literature review qualitative study

Non

Advocacy mechanisms for intervention on the impacts of  T2DM

non

The impact of advocacy was observed and other forms of intervention.

Advocacy should include training on Self-management.

9

Rodriguez-Saldana, J.

The Diabetes Textbook ( Source: Research gate)

Clinical Practice Guidelines, Evidence-Based Medicine, and Diabetes. ( 2019)

Quantitative study. 

Looks at the impact of unjustified variations of medical practice in relation to clinical outcomes, the cost of healthcare and patients with T2DM.

Quantitative design

Patients and medical practitioners dealing with patients with T2DM

Medical and clinical practice for treatment of T2DM

Recognition of the impact of clinical intervention is formidable to the treatment and management of T2DM

Various levels of clinical interventions will be required including administration of the condition and training for nurses to ensure the right intervention per individual patient

Clinical intervention is also as important as change of lifestyle and should be incorporated as part of T2DM interventions. 

10

Wu, F., Tai, H., & Sun, J. Asian Nursing Research

Self-management experience of middle-aged and older adults with type 2 diabetes: A qualitative study (2019).

Paper investigates the self-management experiences of middle aged and older adults with diabetes using a focus group.

Qualitative study

Older Adults with DM2

Focus group of 23 participants on self-management discussions

Study provides  insights to the experiences of middle aged and older adults self-management of diabetes

Listening to the voice of patients and observing challenges, delimma in self-management, recognize challenges in diabetes

Adherence education

References

Abbatecola, A., Paolisso, G., & Sinclair, A. (2015). Treating Diabetes Mellitus in Older and Oldest Old Patients. Current Pharmaceutical Design, 21(13), 1665-1671. Doi:10.2174/1381612821666150130120747

Awoyemi, A., Trøseid, M., Solheim, S., Arnesen, H., & Seljeflot, I. (2018). Metabolic endotoxemia as related to metabolic syndrome in an elderly male population at high cardiovascular risk. Atherosclerosis, 275, e55-e56. doi:10.1016/j.atherosclerosis.2018.06.149

Guo, M., & Xu, Y. (2018). SGLT2 Inhibitors and Stroke Risk in Patients with Type 2 Diabetes—A Systematic Review and Meta-analysis. Diabetes, 67(Supplement 1), 165-OR. Doi: 10.2337/db18-165-or

Komkova, A., Brandt, C. J., Hansen Pedersen, D., Emneus, M., & Sortsø, C. (2018). Electronic Health Lifestyle Coaching Among Diabetes Patients in a Real-Life Municipality Setting: Observational Study (Preprint). doi:10.2196/preprints.12140

Migdal, A. L., & Abrahamson, M. J. (2016). Treating Type 2 Diabetes Mellitus. Principles of Diabetes Mellitus, 1-24. Doi: 10.1007/978-3-319-20797-1_44-1

Nyambuya, T. M., Dludla, P. V., & Nkambule, B. B. (2018). T cell activation and cardiovascular risk in type 2 diabetes mellitus: a protocol for a systematic review and meta-analysis. Systematic Reviews, 7(1). Doi: 10.1186/s13643-018-0835-1

Onofrei, L., & Smith, A. G. (2019). Advocacy for patients with neuropathic pain. Advocacy in Neurology, 347-360. doi:10.1093/med/9780198796039.003.0030

Rodriguez-Saldana, J. (2019). Clinical Practice Guidelines, Evidence-Based Medicine, and Diabetes. The Diabetes Textbook, 333-355. Doi: 10.1007/978-3-030-11815-0_21

 

Capstone Change Project GCU

Background

Even with the many efforts to promote healthy living and awareness of the dangers of diabetes, the disease I still a major health issue in the United States as it continues to prevail.   In most cases, diabetes is accompanied by other conditions that lead to a lot of burdens for the patient. This includes financial burden, disability, and reduced quality of life. Older patients with geriatric conditions suffer the most and undergo a lot of trauma especially given that they will need to be under a lot of care (Awoyemi, Trøseid, Solheim, Arnesen, & Seljeflot, 2018).  Patient education and health promotion may not promote the occurrence of various diseases related to geriatric patients. However, with better support, promotion of adherence to doctor’s appointment and self-management interventions for diabetic patients including better screening can aid in the prevention of worsening of their conditions some of which might to would development and inevitable amputations. Of the many aspects of diabetes treatment, the issue of self-management and adherence has been found to be efficient in the healing of many conditions and reducing the worsening of the current patient situation (GUO & XU, 2018).  Implementation of a self-management program in both the clinical and home care setting can allow for patient assessment, more detail screening and promote early intervention to reduce or prevent more complications of a geriatric patient with diabetes.  

Problem Statement

Geriatric patients with diabetes 2 most often will suffer other impediments which comprise but are not restricted to peripheral nerve damage, kidney diseases, foot ulcers, circulatory system disorder, hyperglycemia which is one of the leading causes of delayed foot healing. I most cases these patients will undergo a lot of pain and discomfort, they will not be active, unable to move and experience a diminished quality of life.  The treatment of these geriatric conditions can be expensive, time-consuming, and when all the remedies are not successful, patients will have to make difficult choices that include inevitable amputation.

Purpose of Change Proposal

The purpose of this change proposal is to establish mechanisms for early intervention for these patients through the promotion of self-management education for patients coming to the clinic and ensure that they understand and practice the importance of adherence to treatment schedules which can bring about hope to many geriatric patients.  If this is done well, more lives for people living with diabetes will be prolonged; there will be a reduction of would development leading to amputations and increased quality of life for these patients.  

PICOT

For geriatric patients with Type 2 diabetes at DaVita Medical Groups Fountain Oaks (P), does lifestyle modification coupled with medication compliance (I) compared to only medication compliance (C) lead to decreased hgb A1C and increased self-reported diabetes control (O) over a three-month timeframe (T)? 

Literature Search Strategy Employed

The strategy employed for searching literature entailed going through various medical journal platforms like NCBI, CINALH PLUS and PubMed where keywords like prevention and promotion, Diabetes Self-Management, Geriatric wounds, hyperbaric oxygen, diabetes treatment adherence were used to research studies from 2014-2019.  This project was able to find some recent studies pertaining to geriatric diabetes management. However 8 articles were reviewed to provide the effects of diabetes Type 2 on geriatric patients, the impact of non-adherence to treatment, the importance, and strategies for self-management education (Abbatecola, Paolisso, & Sinclair, 2015). Also, 2 articles were reviewed to examine the impact of self-management and adherence tools in the promotion of wound healing among geriatric patients and avoiding amputation. Other articles also offered information on geriatric complications and mechanisms to promote healing. 

Evaluation of the Literature

From the literature, Abbatecola, Paolisso, & Sinclair, (2015) defined ‘geriatric patients' as people with diabetes with several conditions in which ischemia, neuropathy, and infection will lead to injury, cause skin problems and potential surgeries or amputations.  Onofrei & Smith, (2019) looks at the importance of self-management education for both the health care providers and the patients in addition to adherence to treatment which is required for assessment of the healing as a way of reducing various geriatric conditions.  Also Nyambuya, Dludla, & Nkambule, (2018) argued that diabetes prevention is better than cure since, with the increase of patients not adhering to treatment, this leads to renal failure, wound infections and development calling for nurses and medical doctors to find better ways to prevent worsening of the condition and avoid chances of surgery. Migdal & Abrahamson, (2016) calls for the implementation of a diabetes self-management program in the clinics, which must also focus on wound care and general self-management of patients with diabetes. 

Applicable Change or Nursing Theory Utilized

This project will apply the Diffusion of innovation theory which multiplies the number of people that are subject to or are going to be affected by any intervention by reinforcing their influence in public health.  It may always not be enough to come up with innovative programs; this is because in any case, programs need to be extensively publicized and broadcasted.  The diffusion and innovation theory thus will take a deep look at how new products, concepts, and social practices are incorporated in organizations, society, or a community (Migdal & Abrahamson, 2016).  According to this theory, thus, when a community, organization, or society work together, then it becomes possible for the intended intervention to succeed.  

In this project thus, the intended population is geriatric patients with diabetes 22 who are at risk of not adhering to doctor appointments and self-care ( this includes lifestyle change, taking medications the right way and personal exercise) that may lead to the worsening of their geriatric conditions.  The proposed solution thus focuses on self-management and adherence to appointments to encourage screening and identify whether they are at high risk of developing serious conditions like foot ulcers to intervene through self-management education, attendance to clinics, following prescriptions and personal hygiene and care for other related conditions (Rodriguez-Saldana, 2019).  At this, the diffusion of innovations theory will work with the proposed solution as a way of promoting all levels of care and healing with the patient and the individual, clinical, community, and organizational level.  On the patient level, diffusion will provide education and change of lifestyle. At the clinical level, this will require adjustment of regulations and starting new patient programs like the implementation of new screening and assessment tools (Migdal & Abrahamson, 2016). At the community level, this will entail publicity, best practice exchange forums, and advancement of policies.

Proposed Implementation Plan

After the proposed solution is approved, it will go straight to implementation which will begin by hiring an assistant nurse and a specialist and self-management therapy who will assist in the development of self-management and patient adherence to appointment toolkit.  The nurse will have to be knowledgeable and experienced inpatient training, including staff regarding diabetes self-management and adherence issues.  In the implementation plan, this nurse is also going to work in collaboration with other fellow nurses and the medical doctors to incorporate sufficient material required for training and therapy and to also understand the patients being seen at the clinic.  Together, there will be a team formed where resources will be pulled together and networks to invite specialist’s speakers for patient self-management, care workshops, and training.  There will also be a budgeting committee that will ensure all the necessary supplies like tuning forks, demonstration medicines, and training materials and publics are availed (Komkova, Brandt, Hansen Pedersen, Emneus, & Sortsø, 2018).  Also, the team will work with the IT team in coming up with an electronic version of the diabetes self-management video and adherence to the appointment and medication tool, which will be distributed to all patients.  There will also be a pre and post-test to determine the knowledge of patients and staff regarding self-management and adherence issues as identified in the clinic. 

Identification of Potential Barriers to Plan Implementation and a discussion of this could be overcome

Among the barriers anticipated during the implementation of the project includes; stigma from the geriatric patients with diabetes 2  of which might prevent them from participating in the project, there could also be social and cultural issues which may see patients not attending the seminars.  Also, other patients could be in worse conditions that would prevent them from reaching the clinic during the training and demonstration.  Lack of funding to support the training process could also be a barrier (Komkova, Brandt, Hansen Pedersen, Emneus, & Sortsø, 2018). To overcome these barriers, all the training process will be explained to each patient in person so they can understand the health benefit of the training. Their medical records will not be used during the training, and there will also be electronic materials developed for patients that might not attend all the sessions. There will also be a local fundraiser from diabetes institutions to support the training needs. 

Conclusion

This project insists on self-management and adherence to treatment and doctor’s appointments; this is because when geriatric patients with diabetes Type 2 do not know how to manage their conditions, they are bound to worsen their conditions resulting in pain, reduced quality of life, including disability.  The goal of this project is to provide geriatric patients with diabetes 2 early intervention mechanisms that support the need to manage and combat the disease through self-care and to form partnerships with healthcare professionals.  

References

Abbatecola, A., Paolisso, G., & Sinclair, A. (2015). Treating Diabetes Mellitus in Older and Oldest Old Patients. Current Pharmaceutical Design, 21(13), 1665-1671. Doi: 10.2174/1381612821666150130120747

Awoyemi, A., Trøseid, M., Solheim, S., Arnesen, H., & Seljeflot, I. (2018). Metabolic endotoxemia as related to metabolic syndrome in an elderly male population at high cardiovascular risk. Atherosclerosis, 275, e55-e56. doi:10.1016/j.atherosclerosis.2018.06.149

GUO, M., & Xu, Y. (2018). SGLT2 Inhibitors and Stroke Risk in Patients with Type 2 Diabetes—A Systematic Review and Meta-analysis. Diabetes, 67(Supplement 1), 165-OR. Doi: 10.2337/db18-165-or

Komkova, A., Brandt, C. J., Hansen Pedersen, D., Emneus, M., & Sortsø, C. (2018). Electronic Health Lifestyle Coaching Among Diabetes Patients in a Real-Life Municipality Setting: Observational Study (Preprint). doi:10.2196/preprints.12140

Migdal, A. L., & Abrahamson, M. J. (2016). Treating Type 2 Diabetes Mellitus. Principles of Diabetes Mellitus, 1-24. Doi: 10.1007/978-3-319-20797-1_44-1

Nyambuya, T. M., Dludla, P. V., & Nkambule, B. B. (2018). T cell activation and cardiovascular risk in type 2 diabetes mellitus: a protocol for a systematic review and meta-analysis. Systematic Reviews, 7(1). Doi: 10.1186/s13643-018-0835-1

Onofrei, L., & Smith, A. G. (2019). Advocacy for patients with neuropathic pain. Advocacy in Neurology, 347-360. doi:10.1093/med/9780198796039.003.0030

Rodriguez-Saldana, J. (2019). Clinical Practice Guidelines, Evidence-Based Medicine, and Diabetes. The Diabetes Textbook, 333-355. Doi: 10.1007/978-3-030-11815-0_21


Appendix 1

Appendix 2

Diabetes Self-Management Evaluation Form



Assignment 8.2: Final Literature Review Paper

Final Literature Review

Introduction and Search History

Introduction

The purpose of this project is to evaluate the effectiveness of a nurse-driven exercise program compared to staying inactive to reduce cancer-related fatigue (CRF) among cancer patients. Cancer-related fatigue remains a significant healthcare problem among cancer patients undergoing treatments such as chemotherapy. The effects of CRF limit cancer patients undergoing treatment to engage in their normal daily activities because they lack energy (Zhang, Li, Zhang, Yu, & Cong, 2018). Specifically, the proposed study endeavors to determine the effectiveness of a nurse-driven exercise program aimed at reducing CRF as compared to when cancer survivors stay inactive. The goal is to assist patients in improving their fatigue levels during their hospital stay and after discharge. Therefore, finding and reviewing the current literature on reducing CRF is important for healthcare providers. This paper will include a search strategy to locate current evidence related to the PICOT question as well as appraise the evidence synthesis the articles reviewed and offer recommendations for practice change. 

Search history

The researcher will perform a comprehensive literature search to locate background evidence and gaps that need to be filled in the literature. The researcher will utilize various databases to search for evidence-based research that addresses the PICOT question. The databases incorporate Google Scholar, Medline through PubMed CINAHL Plus with Full Text, EBSCOhost, and the Cochrane Library. EBSCOhost databases enable users to search several databases simultaneously using keywords (Gusenbauer & Haddaway, 2020). Keywords used for searching the databases include cancer-related fatigue, physical activity, chemotherapy, exercise, cancer survivors, and nurse-driven exercise program. The authors will delimit the search by clicking on "Find all my search terms" and "Also search with a full test of the articles." Full-Text articles will be specified and ensuring that only peer-review articles are included. In the search, the researcher will also specify articles that were published between 2015 and 2020.  All the studies that will be reviewed are those published within the last five years.

Synthesis of Evidence

Cancer and Cancer-Related Fatigue

From a biological point of view, cancer itself and its related treatments can cause elevated levels of pro-inflammatory cytokines like interleukin 6 and tumor necrosis factors, which have all been linked to CRF. According to Ulrich et al. (2018), cancer is a significant burden on society globally, and the most common cause of death. However, cancer treatment modalities, such as surgery or chemotherapy, are associated with significant adverse events. Lee, Kim, & Jeon, (2018) found that despite enhancement in the prognosis of colorectal cancer, colorectal cancer survivors often suffer from adverse events of cancer treatment, incorporating decreased health-related fitness level. According to Berntsen et al. (2017), cancer-related fatigue (CRF) is a common adverse event experienced by most cancer patients. CRF is a multidimensional term that includes physical, social, emotional, psychological and biological elements that individuals treated for cancer often experience (Berntsen et al., 2017). CRF can be distinguished from other types of fatigue in that it is not alleviated through resting. Matsugaki et al. (2018) argue that the symptoms of cancer patients experience are affected by a range of factors related to the disease itself and the treatments utilized and CRF is one of the symptoms. According to Baguley et al. (2020), cancer-related fatigue is a prevalent, persistent symptom of cancer treatment, thus influencing health-related quality of life, resulting in a significant challenge to the community. 

According to Zhang et al. (2018), increased levels of fatigue are positively associated with a high risk of sleep disturbance and depression. Besides, CRF has been constantly ranked as the most elusive, common, and severe symptoms that patients with cancer undergoing chemotherapy experience. A study conducted by Berntsen et al. (2017) found that physical therapy is beneficial in decreasing CRF. Other studies also show similar results. For instance, Mijwel et al. (2018) found that physical exercise is an effective intervention to improve physical function and decrease fatigue in patients undergoing chemotherapy. Schuler et al. (2017) also conducted a study to examine the effects of a structured, individual sports program on fatigue in patients with advanced cancer. They found that the severe general fatigue experienced by tumour patients can be reduced when patients perform appropriate physical exercise. In their study, Schuler et al. (2017) noted that physical exercise could alleviate CRF. Similarly, Pyszora et al. (2017) noted that a nurse-led exercise program significantly reduced fatigue scores in terms of severity of fatigue and its impact on daily functioning. 

Immobility and Effects on CRF  

Immobility is related to a wide range of adverse outcomes that negatively affect individuals with cancer. Immobility among cancer patients is a deconditioning associated with prolonged bed rest (Matsugaki et al., 2018). Studies show that persistent bed rest leads to muscle strength decline of about 10 percent every week. Therefore, continued mobility for an extended period of five weeks may further cause the proximal lower extremity muscles to lose as much as 24 percent of their force and muscle shortening as well as leading to joint contractures. In the past years, physicians often advised cancer patients to rest and refrain from any physical activity for comfort reasons. However, studies indicated that while these patients avoid strenuous activity resulted in less discomfort, the recommended inactivity induced muscle wasting, leading to weakness, tachycardia, as well as fatigue. Research also indicates that muscle wasting among cancer patients is associated with a potential decrease in the responsiveness to cancer treatments and may further lead to a rise in morbidity and mortality. According to Minnella et al. (018), preserving muscle tone and minimizing muscle wasting via regular exercise can significantly lead to positive outcomes in persons experiencing CRF. 

Effects of Exercise on CRF

Lack of physical exercise among cancer patients undergoing treatment has been cited as one of the most consistently identified risk factor for all cancer mortalities. Studies indicate that routine physical activity can positively affect an individual’s psychological well-being through decreasing stress, anxiety, and depression. There is a significant pool of evidence that exercise is beneficial in reducing CRF. However, recommendations for an individualized exercise program in cancer patients undergoing treatment need to take account of the stage of cancer, the patient’s stage, the pain condition, and psychosocial status of the patient. Therefore, treatment should be started at a lower intensity and gradually increased as the person’s aerobic capacity enhances. 

Studies also indicate that rare adverse events from exercise occur, incorporating back, wrist, lower leg, and rotator cuff injury. A study by Zhang et al. (2018), which investigated the feasibility of a nurse-led home-based exercise and cognitive behavioral therapy for ovarian cancer adults with cancer-related fatigue on outcomes of fatigue, found that Nurse-delivered home-based E & CBT have measurable benefits in assisting women with ovarian cancer to reduce cancer-related fatigue, depressive symptoms, and enhancing their quality of sleep. The study by Matsugaki et al. (2018) to verify the immediate effect of exercise therapy on CRF in cancer patients suggested that exercise therapy targeting a rating of 4 on the CR-10 can immediately decrease CRF in cancer patients. Similarly, Mijwel et al. (2017) also conducted a study to examine the effects of concurrent resistance and high-intensity training or concurrent moderate-intensity aerobic and high-intensity interval training to normal care on pain sensitivity and physiological outcomes in patients with breast cancer during chemotherapy. The authors concluded that Sixteen weeks of RT-HIIT significantly enhanced muscle strength and decreased pain sensitivity. This study proved that physical exercise is an effective intervention to improve physical functioning and reducing fatigue in cancer patients undergoing chemotherapy. 

Further, Lee et al. (2019) also conducted a study to assess the feasibility and efficacy of a 6-week home-based exercise program on the level of physical activity and physical fitness in stage II to III colorectal cancer survivors. They concluded that the 6-week home-based mixed aerobic and resistance exercise program was feasible and effective in enhancing physical activity level and physical fitness in stage II to III colorectal cancer survivors. However, this study did not indicate the feasibility of the exercise program to reduce CRF. Moreover, Pyszora et al. (2017) conducted a study to assess the effect of a physiotherapy program on CRF and other symptoms in individuals diagnosed with advanced cancer and concluded that physiotherapy program had positive effects on CRF and other symptoms in patients with advanced cancer who received palliative care. The results of this study suggested that physiotherapy is a safe and effective technique for managing CRF. 

Berntsen et al. (2017) also conducted a study to examine whether exercise intensity affects fatigue and health-related quality of life in individuals undergoing adjuvant cancer treatment. Though this is an ongoing study, the authors believe that it will contribute to the comprehension of the value of exercise and exercise intensity in decreasing fatigue and enhancing health-related quality of life and, potentially, clinical outcomes. Another ongoing study by Ulrich et al. (2018) that that used a Precision-Exercise-Prescription (PEP) intervention to examine the effect of a personalized exercise program on physical function, as measured by the 6 min walk test in patients with NSCLC and patients with secondary lung cancer who are undergoing surgical treatment. This study will also provide insight on how cancer patients undergoing surgery can use PEP to maintain, regain, and enhance their physical function during the continuum from surgery to cancer survivorship. Compared to other studies reviewed, this study does not show how exercise and CRF are correlated. 

Another study by Minnella et al. (2018) also investigated whether pre-habilitation exercise was effective in improving functional status in patients undergoing esophagogastric cancer resection. In this study, the primary outcome was also measured by a change in functional capacity, measured with an absolute change in 6-minute walk distance. The authors concluded that prehabilitation enhances perioperative functional capacity in esophagogastric surgery. Besides, the authors also found that keeping patients from physical and nutritional status decline could have a considerable effect on the cancer care continuum.

Critique of Evidence

All the studies reviewed to address the issue of CRF, which is particularly prevalent among patients undergoing cancer treatment. For instance, Matsugaki et al. (2018) noted that the symptoms experienced by cancer patients are affected by several factors, and CRF is the most common symptom. The strength of this study is that the authors were able to find that exercise therapy targeting a rating of 4 on the CR-10 can be performed without aggravating CRF. However, this study lacked a control group, which made it impossible to demonstrate the exact effects of exercise therapy. Besides, the study did not clarify how exercise therapy caused an immediate decrease in CRF. 

On the other hand, the study by Zhang et al. (2018) also addressed the issue of CRF and noted that high levels of fatigue had been observed in ovarian cancer patients. The strength of this study was the well-balanced socio-demographic and medical variables at baseline in both control and experimental groups. This study also had limited availability of research time since only outcome changes in two-time points during the intervention period were examined. Even though the study by Ulrich is still an ongoing one, it is the first randomized controlled trial to investigate a personalized exercise program for both patients with primary and secondary lung cancer. The strength of this study is that the exercise intervention was designed to be aligned with and easily translatable into clinical workflow and spanned the whole continuum of care from the pre-surgery to post-surgery duration incorporating lung cancer survivorship. However, one limitation of this study is that the cost of the intervention delivered for weekly phone calls may be too high, thus may hinder the implementation of the intervention. 

Further, the study by Minnella et al. (2018) also noted preserving functional capacity through pre-habilitation exercise is an essential element in the care of cancer patients. The strength of this study lies on the fact that it showed that by attenuating functional impairment, pre-habilitation in cancer treatment pathways is of significant value. However, this study had several limitations. For instance, the study used a small sample size of 68 from 222 patients which preclude secondary outcomes. Besides, the variability of neoadjuvant treatment in terms of duration and regimen could limit the consistency, generalizability, and applicability of the study findings. 

Additionally, the study by Mijwel et al. (22018) showed that physical exercise is an effective intervention to reduce CRF. The strength of this study is that OptiTrain intervention used is a sufficiently powered, supervised, in-clinic, randomized intervention trialling two types of progressive exercise regimens with validated measures. Again, the attendance rates were within the range commonly reported in exercise trials. The limitation of this study was that the first assessment was performed after one cycle of chemotherapy that could affect the applicability of the study. Moreover, a selection bias may have been introduced by the relatively large number of UC-patients, thus reducing participation directly after randomization. Again, the study by Schuler et al. (2017) had some strengths and limitations. The strength of this study was that it added evidence for the advantages physical exercise can offer in improving fatigue as well as a source for the careful reconsideration of daily clinical routine and possible prescription of physical therapy. However, the limitation of the study was that since blinding in this type of trial is not possible, several possible confounders occur

Gaps in Evidence

There are gaps in the reviewed studies. Out of the ten reviewed studies, no single study demonstrated how the exercise program reduced CRF. For instance, while Matsugaki et al. (2018) verified the immediate effect of exercise therapy on CRF, but did not describe how CRF changes immediately after an exercise intervention. Therefore, there is a need for the current study to investigate how exercise leads to changes in CRF during the intervention period. Besides, from the reviewed literature, it is clear that further investigation is required to determine the optimal modality of the exercise intervention in reducing CRF and its effect on overall oncologic patient outcomes. Moreover, the reviewed studies have not investigated and identified the factors involved in immediate decreases in CRF.

Implication for Practice

As an oncology nurse who works in the surgical unit, I am intimately concerned with the havoc that CRF can inflict on the lives of cancer patients undergoing treatment. While virtually all cancer patients are encouraged to exercise after undergoing chemotherapy, some individuals are highly resistant to this type of plan of care. Therefore, the reviewed research will provide recommendations that are made clear by the research evidence. The evidence reviewed also offer alternatives methods of managing CRF that might be helpful in my clinical practice. For instance, the study by Zhang et al. (2019) used both cognitive behavioral therapies in conjunction with a nurse-led home-based exercise program to reduce CRF. This study shows that when exercise is augmented with other techniques, the outcomes are greater improvement in the management of CRF. Besides, the ongoing studies by Ulrich et al. (2018) and Berntsen et al. (2017) hold great potential for aiding practitioners in their efforts to improve the care for cancer patients and reduce CRF. Therefore, as an oncology nurse, one should stay abreast of these studies to promote a nurse-led exercise program to reduce CRF. The intervention will promote quality of life while ensuring that the CRF is significantly reduced.

Conclusion

There is enough evidence that physical exercise intervention is effective in reducing CRF. The studies reviewed can be used by oncology nurses as a reference for evidence-based clinical nursing practices and home-based interventions to reduce CRF. Besides, the literature indicates that treatment of fatigue in advanced cancer patients should incorporate an appropriate selection of physiotherapy techniques suited for the patient depending on the health status and cancer stage. The literature thus provides a pool of evidence-based intervention that oncology nurse could use to reduce CRF while improving the quality of life of their patients.

References

Baguley, B. J., Skinner, T. L., Jenkins, D. G., & Wright, O. R. (2020). Mediterranean-style dietary pattern improves cancer-related fatigue and quality of life in men with prostate cancer treated with androgen deprivation therapy: A pilot randomized control trial. Clinical Nutrition.

Berntsen, S., Aaronson, N. K., Buffart, L., Börjeson, S., Demmelmaier, I., Hellbom, M., ... & Raastad, T. (2017). Design of a randomized controlled trial of physical training and cancer (Phys-Can)–the impact of exercise intensity on cancer related fatigue, quality of life and disease outcome. BMC cancer17(1), 218.

Gusenbauer, M., & Haddaway, N. R. (2020). Which academic search systems are suitable for systematic reviews or metaanalyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research synthesis methods11(2), 181-217.

Ingham-Broomfield, J. R. (2016). A nurses' guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing (Online)33(3), 38.

Lee, M. K., Kim, N. K., & Jeon, J. Y. (2018). Effect of the 6-week home-based exercise program on physical activity level and physical fitness in colorectal cancer survivors: A randomized controlled pilot study. PloS one13(4), e0196220.

Matsugaki, R., Akebi, T., Shitama, H., Wada, F., & Saeki, S. (2018). Immediate effects of exercise intervention on cancer-related fatigue. Journal of physical therapy science30(2), 262-265.

Mijwel, S., Backman, M., Bolam, K. A., Olofsson, E., Norrbom, J., Bergh, J., ... & Rundqvist, H. (2018). Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial. Breast cancer research and treatment169(1), 93-103.

Minnella, E. M., Awasthi, R., Loiselle, S. E., Agnihotram, R. V., Ferri, L. E., & Carli, F. (2018). Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: a randomized clinical trial. JAMA surgery153(12), 1081-1089.

Pyszora, A., Budzyński, J., Wójcik, A., Prokop, A., & Krajnik, M. (2017). Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial. Supportive Care in Cancer25(9), 2899-2908.

Schuler, M. K., Hentschel, L., Kisel, W., Kramer, M., Lenz, F., Hornemann, B., ... & Kroschinsky, F. (2017). Impact of different exercise programs on severe fatigue in patients undergoing anticancer treatment—a randomized controlled trial. Journal of pain and symptom management53(1), 57-66.

Ulrich, C. M., Himbert, C., Boucher, K., Wetter, D. W., Hess, R., Kim, J., & Marcus, R. (2018). Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial. BMJ open8(12).

Zhang, Q., Li, F., Zhang, H., Yu, X., & Cong, Y. (2018). Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial. International journal of nursing studies78, 52.

Nurs 6050 Week 6 assignment


Partial Literature Review

The purpose of this project is to evaluate the effectiveness of a nurse-driven exercise program compared to staying inactive to reduce cancer-related fatigue (CRF) among cancer patients. Cancer-related fatigue remains a significant healthcare problem among cancer patients undergoing treatments such as chemotherapy. The effects of CRF limit cancer patients undergoing treatment to engage in their normal daily activities because they lack energy (Zhang, Li, Zhang, Yu, & Cong, 2018). Specifically, the proposed study endeavors to determine the effectiveness of a nurse-driven exercise program aimed at reducing CRF as compared to when cancer survivors stay inactive. The goal is to assist patients in improving their fatigue levels during their hospital stay and after discharge. Therefore, finding and reviewing the current literature on reducing CRF is important for healthcare providers. This paper will include a search strategy to locate current evidence related to the PICOT question as well as appraise the evidence synthesis the articles reviewed and offer recommendations for practice change. 

Search history

The researcher will perform a comprehensive literature search to locate background evidence and gaps that need to be filled in the literature. The researcher will utilize various databases to search for evidence-based research that addresses the PICOT question. The databases incorporate Google Scholar, Medline through PubMed CINAHL Plus with Full Text, EBSCOhost, and the Cochrane Library. EBSCOhost databases enable users to search several databases simultaneously using keywords (Gusenbauer & Haddaway, 2020). Keywords used for searching the databases include cancer-related fatigue, physical activity, chemotherapy, exercise, cancer survivors, and nurse-driven exercise program. The authors will delimit the search by clicking on "Find all my search terms" and "Also search with a full test of the articles." Full-Text articles will be specified and ensuring that only peer-review articles are included. In the search, the researcher will also specify articles that were published between 2015 and 2020.  All the studies that will be reviewed are those published within the last five years.

Literature Review

Cancer and Cancer-Related Fatigue

From a biological point of view, cancer itself and its related treatments can cause elevated levels of pro-inflammatory cytokines like interleukin 6 and tumor necrosis factors, which have all been linked to CRF. According to Ulrich et al. (2018), cancer is a significant burden on society globally, and the most common cause of death. However, cancer treatment modalities, such as surgery or chemotherapy, are associated with significant adverse events. Lee, Kim, & Jeon, (2018) found that despite enhancement in the prognosis of colorectal cancer, colorectal cancer survivors often suffer from adverse events of cancer treatment, incorporating decreased health-related fitness level. According to Berntsen et al. (2017), cancer-related fatigue (CRF) is a common adverse event experienced by most cancer patients. CRF is a multidimensional term that includes physical, social, emotional, psychological and biological elements that individuals treated for cancer often experience (Berntsen et al., 2017). CRF can be distinguished from other types of fatigue in that it is not alleviated through resting. Matsugaki et al. (2018) argue that the symptoms of cancer patients experience are affected by a range of factors related to the disease itself and the treatments utilized and CRF is one of the symptoms. According to Baguley et al. (2020), cancer-related fatigue is a prevalent, persistent symptom of cancer treatment, thus influencing health-related quality of life, resulting in a significant challenge to the community. 

According to Zhang et al. (2018), increased levels of fatigue are positively associated with a high risk of sleep disturbance and depression. Besides, CRF has been constantly ranked as the most elusive, common, and severe symptoms that patients with cancer undergoing chemotherapy experience. A study conducted by Berntsen et al. (2017) found that physical therapy is beneficial in decreasing CRF. Other studies also show similar results. For instance, Mijwel et al. (2018) found that physical exercise is an effective intervention to improve physical function and decrease fatigue in patients undergoing chemotherapy. Schuler et al. (2017) also conducted a study to examine the effects of a structured, individual sports program on fatigue in patients with advanced cancer. They found that the severe general fatigue experienced by tumour patients can be reduced when patients perform appropriate physical exercise. In their study, Schuler et al. (2017) noted that physical exercise could alleviate CRF. Similarly, Pyszora et al. (2017) noted that a nurse-led exercise program significantly reduced fatigue scores in terms of severity of fatigue and its impact on daily functioning. 

Immobility and Effects on CRF  

Immobility is related to a wide range of adverse outcomes that negatively affect individuals with cancer. Immobility among cancer patients is a deconditioning associated with prolonged bed rest (Matsugaki et al., 2018). Studies show that persistent bed rest leads to muscle strength decline of about 10 percent every week. Therefore, continued mobility for an extended period of five weeks may further cause the proximal lower extremity muscles to lose as much as 24 percent of their force and muscle shortening as well as leading to joint contractures. In the past years, physicians often advised cancer patients to rest and refrain from any physical activity for comfort reasons. However, studies indicated that while these patients avoid strenuous activity resulted in less discomfort, the recommended inactivity induced muscle wasting, leading to weakness, tachycardia, as well as fatigue. Research also indicates that muscle wasting among cancer patients is associated with a potential decrease in the responsiveness to cancer treatments and may further lead to a rise in morbidity and mortality. According to Minnella et al. (018), preserving muscle tone and minimizing muscle wasting via regular exercise can significantly lead to positive outcomes in persons experiencing CRF. 

Effects of Exercise on CRF

Lack of physical exercise among cancer patients undergoing treatment has been cited as one of the most consistently identified risk factor for all cancer mortalities. Studies indicate that routine physical activity can positively affect an individual’s psychological well-being through decreasing stress, anxiety, and depression. There is a significant pool of evidence that exercise is beneficial in reducing CRF. However, recommendations for an individualized exercise program in cancer patients undergoing treatment need to take account of the stage of cancer, the patient’s stage, the pain condition, and psychosocial status of the patient. Therefore, treatment should be started at a lower intensity and gradually increased as the person’s aerobic capacity enhances. 

Studies also indicate that rare adverse events from exercise occur, incorporating back, wrist, lower leg, and rotator cuff injury. A study by Zhang et al. (2018), which investigated the feasibility of a nurse-led home-based exercise and cognitive behavioral therapy for ovarian cancer adults with cancer-related fatigue on outcomes of fatigue, found that Nurse-delivered home-based E & CBT have measurable benefits in assisting women with ovarian cancer to reduce cancer-related fatigue, depressive symptoms, and enhancing their quality of sleep. The study by Matsugaki et al. (2018) to verify the immediate effect of exercise therapy on CRF in cancer patients suggested that exercise therapy targeting a rating of 4 on the CR-10 can immediately decrease CRF in cancer patients. Similarly, Mijwel et al. (2017) also conducted a study to examine the effects of concurrent resistance and high-intensity training or concurrent moderate-intensity aerobic and high-intensity interval training to normal care on pain sensitivity and physiological outcomes in patients with breast cancer during chemotherapy. The authors concluded that Sixteen weeks of RT-HIIT significantly enhanced muscle strength and decreased pain sensitivity. This study proved that physical exercise is an effective intervention to improve physical functioning and reducing fatigue in cancer patients undergoing chemotherapy. 

Further, Lee et al. (2019) also conducted a study to assess the feasibility and efficacy of a 6-week home-based exercise program on the level of physical activity and physical fitness in stage II to III colorectal cancer survivors. They concluded that the 6-week home-based mixed aerobic and resistance exercise program was feasible and effective in enhancing physical activity level and physical fitness in stage II to III colorectal cancer survivors. However, this study did not indicate the feasibility of the exercise program to reduce CRF. Moreover, Pyszora et al. (2017) conducted a study to assess the effect of a physiotherapy program on CRF and other symptoms in individuals diagnosed with advanced cancer and concluded that physiotherapy program had positive effects on CRF and other symptoms in patients with advanced cancer who received palliative care. The results of this study suggested that physiotherapy is a safe and effective technique for managing CRF. 

Berntsen et al. (2017) also conducted a study to examine whether exercise intensity affects fatigue and health-related quality of life in individuals undergoing adjuvant cancer treatment. Though this is an ongoing study, the authors believe that it will contribute to the comprehension of the value of exercise and exercise intensity in decreasing fatigue and enhancing health-related quality of life and, potentially, clinical outcomes. Another ongoing study by Ulrich et al. (2018) that that used a Precision-Exercise-Prescription (PEP) intervention to examine the effect of a personalized exercise program on physical function, as measured by the 6 min walk test in patients with NSCLC and patients with secondary lung cancer who are undergoing surgical treatment. This study will also provide insight on how cancer patients undergoing surgery can use PEP to maintain, regain, and enhance their physical function during the continuum from surgery to cancer survivorship. Compared to other studies reviewed, this study does not show how exercise and CRF are correlated. 

Another study by Minnella et al. (2018) also investigated whether pre-habilitation exercise was effective in improving functional status in patients undergoing esophagogastric cancer resection. In this study, the primary outcome was also measured by a change in functional capacity, measured with an absolute change in 6-minute walk distance. The authors concluded that prehabilitation enhances perioperative functional capacity in esophagogastric surgery. Besides, the authors also found that keeping patients from physical and nutritional status decline could have a considerable effect on the cancer care continuum.

Critique of Evidence

All the studies reviewed to address the issue of CRF, which is particularly prevalent among patients undergoing cancer treatment. For instance, Matsugaki et al. (2018) noted that the symptoms experienced by cancer patients are affected by several factors, and CRF is the most common symptom. The strength of this study is that the authors were able to find that exercise therapy targeting a rating of 4 on the CR-10 can be performed without aggravating CRF. However, this study lacked a control group, which made it impossible to demonstrate the exact effects of exercise therapy. Besides, the study did not clarify how exercise therapy caused an immediate decrease in CRF. 

On the other hand, the study by Zhang et al. (2018) also addressed the issue of CRF and noted that high levels of fatigue had been observed in ovarian cancer patients. The strength of this study was the well-balanced socio-demographic and medical variables at baseline in both control and experimental groups. This study also had limited availability of research time since only outcome changes in two-time points during the intervention period were examined. Even though the study by Ulrich is still an ongoing one, it is the first randomized controlled trial to investigate a personalized exercise program for both patients with primary and secondary lung cancer. The strength of this study is that the exercise intervention was designed to be aligned with and easily translatable into clinical workflow and spanned the whole continuum of care from the pre-surgery to post-surgery duration incorporating lung cancer survivorship. However, one limitation of this study is that the cost of the intervention delivered for weekly phone calls may be too high, thus may hinder the implementation of the intervention. 

Further, the study by Minnella et al. (2018) also noted preserving functional capacity through pre-habilitation exercise is an essential element in the care of cancer patients. The strength of this study lies on the fact that it showed that by attenuating functional impairment, pre-habilitation in cancer treatment pathways is of significant value. However, this study had several limitations. For instance, the study used a small sample size of 68 from 222 patients which preclude secondary outcomes. Besides, the variability of neoadjuvant treatment in terms of duration and regimen could limit the consistency, generalizability, and applicability of the study findings. 

Additionally, the study by Mijwel et al. (22018) showed that physical exercise is an effective intervention to reduce CRF. The strength of this study is that OptiTrain intervention used is a sufficiently powered, supervised, in-clinic, randomized intervention trialling two types of progressive exercise regimens with validated measures. Again, the attendance rates were within the range commonly reported in exercise trials. The limitation of this study was that the first assessment was performed after one cycle of chemotherapy that could affect the applicability of the study. Moreover, a selection bias may have been introduced by the relatively large number of UC-patients, thus reducing participation directly after randomization. Again, the study by Schuler et al. (2017) had some strengths and limitations. The strength of this study was that it added evidence for the advantages physical exercise can offer in improving fatigue as well as a source for the careful reconsideration of daily clinical routine and possible prescription of physical therapy. However, the limitation of the study was that since blinding in this type of trial is not possible, several possible confounders occur

Gaps in Evidence

There are gaps in the reviewed studies. Out of the ten reviewed studies, no single study demonstrated how the exercise program reduced CRF. For instance, while Matsugaki et al. (2018) verified the immediate effect of exercise therapy on CRF, but did not describe how CRF changes immediately after an exercise intervention. Therefore, there is a need for the current study to investigate how exercise leads to changes in CRF during the intervention period. Besides, from the reviewed literature, it is clear that further investigation is required to determine the optimal modality of the exercise intervention in reducing CRF and its effect on overall oncologic patient outcomes. Moreover, the reviewed studies have not investigated and identified the factors involved in immediate decreases in CRF.

Implication for Practice 

As an oncology nurse who works in the surgical unit, I am intimately concerned with the havoc that CRF can inflict on the lives of cancer patients undergoing treatment. While virtually all cancer patients are encouraged to exercise after undergoing chemotherapy, some individuals are highly resistant to this type of plan of care. Therefore, the reviewed research will provide recommendations that are made clear by the research evidence. The evidence reviewed also offer alternatives methods of managing CRF that might be helpful in my clinical practice. For instance, the study by Zhang et al. (2019) used both cognitive behavioral therapies in conjunction with a nurse-led home-based exercise program to reduce CRF. This study shows that when exercise is augmented with other techniques, the outcomes are greater improvement in the management of CRF. Besides, the ongoing studies by Ulrich et al. (2018) and Berntsen et al. (2017) hold great potential for aiding practitioners in their efforts to improve the care for cancer patients and reduce CRF. Therefore, as an oncology nurse, nurse, one should stay abreast of these studies to promote a nurse-led exercise program to reduce CRF. The intervention will promote quality of life while ensuring that the CRF is significantly reduced.

Conclusion

Based on the literature, physical exercise intervention is effective in reducing CRF. These studies can be used by oncology nurses as a reference for evidence-based clinical nursing practices and home-based interventions to reduce CRF. Besides, the literature indicates that treatment of fatigue in advanced cancer patients should incorporate an appropriate selection of physiotherapy techniques suited for the patient depending on the health status and cancer stage. The literature thus provides a pool of evidence-based intervention that oncology nurse could use to reduce CRF while improving the quality of life of their patients.

References

Baguley, B. J., Skinner, T. L., Jenkins, D. G., & Wright, O. R. (2020). Mediterranean-style dietary pattern improves cancer-related fatigue and quality of life in men with prostate cancer treated with androgen deprivation therapy: A pilot randomized control trial. Clinical Nutrition.

Berntsen, S., Aaronson, N. K., Buffart, L., Börjeson, S., Demmelmaier, I., Hellbom, M., ... & Raastad, T. (2017). Design of a randomized controlled trial of physical training and cancer (Phys-Can)–the impact of exercise intensity on cancer related fatigue, quality of life and disease outcome. BMC cancer17(1), 218.

Gusenbauer, M., & Haddaway, N. R. (2020). Which academic search systems are suitable for systematic reviews or metaanalyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research synthesis methods11(2), 181-217.

Ingham-Broomfield, J. R. (2016). A nurses' guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing (Online)33(3), 38.

Lee, M. K., Kim, N. K., & Jeon, J. Y. (2018). Effect of the 6-week home-based exercise program on physical activity level and physical fitness in colorectal cancer survivors: A randomized controlled pilot study. PloS one13(4), e0196220.

Matsugaki, R., Akebi, T., Shitama, H., Wada, F., & Saeki, S. (2018). Immediate effects of exercise intervention on cancer-related fatigue. Journal of physical therapy science30(2), 262-265.

Mijwel, S., Backman, M., Bolam, K. A., Olofsson, E., Norrbom, J., Bergh, J., ... & Rundqvist, H. (2018). Highly favorable physiological responses to concurrent resistance and high-intensity interval training during chemotherapy: the OptiTrain breast cancer trial. Breast cancer research and treatment169(1), 93-103.

Minnella, E. M., Awasthi, R., Loiselle, S. E., Agnihotram, R. V., Ferri, L. E., & Carli, F. (2018). Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: a randomized clinical trial. JAMA surgery153(12), 1081-1089.

Minnella, E. M., Awasthi, R., Loiselle, S. E., Agnihotram, R. V., Ferri, L. E., & Carli, F. (2018). Effect of exercise and nutrition prehabilitation on functional capacity in esophagogastric cancer surgery: a randomized clinical trial. JAMA surgery153(12), 1081-1089.

Pyszora, A., Budzyński, J., Wójcik, A., Prokop, A., & Krajnik, M. (2017). Physiotherapy programme reduces fatigue in patients with advanced cancer receiving palliative care: randomized controlled trial. Supportive Care in Cancer25(9), 2899-2908.

Schuler, M. K., Hentschel, L., Kisel, W., Kramer, M., Lenz, F., Hornemann, B., ... & Kroschinsky, F. (2017). Impact of different exercise programs on severe fatigue in patients undergoing anticancer treatment—a randomized controlled trial. Journal of pain and symptom management53(1), 57-66.

Ulrich, C. M., Himbert, C., Boucher, K., Wetter, D. W., Hess, R., Kim, J., & Marcus, R. (2018). Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial. BMJ open8(12).

Zhang, Q., Li, F., Zhang, H., Yu, X., & Cong, Y. (2018). Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial. International journal of nursing studies78, 52.

NURS 601 Assignment 6

Introduction and Search History

The purpose of this project is to evaluate the effectiveness of a nurse-driven exercise program compared to staying inactive to reduce cancer-related fatigue (CRF) among cancer patients. Cancer-related fatigue remains a significant healthcare problem among cancer patients undergoing treatments such as chemotherapy. The effects of CRF limit cancer patients undergoing treatment to engage in their normal daily activities because they lack energy (Zhang, Li, Zhang, Yu, & Cong, 2018). Specifically, the proposed study endeavors to determine the effectiveness of a nurse-driven exercise program aimed at reducing CRF as compared to when cancer survivors stay inactive. The goal is to assist patients in improving their fatigue levels during their hospital stay and after discharge. Therefore, finding and reviewing the current literature on reducing CRF is important for healthcare providers. This paper will include a search strategy to locate current evidence related to the PICOT question as well as appraise the evidence synthesis the articles reviewed and offer recommendations for practice change. 

Search history

The researcher will perform a comprehensive literature search to locate background evidence and gaps that need to be filled in the literature. The researcher will utilize various databases to search for evidence-based research that addresses the PICOT question. The databases incorporate Google Scholar, Medline through PubMed CINAHL Plus with Full Text, EBSCOhost, and the Cochrane Library. EBSCOhost databases enable users to search several databases simultaneously using keywords (Gusenbauer & Haddaway, 2020). Keywords used for searching the databases include cancer-related fatigue, physical activity, chemotherapy, exercise, cancer survivors, and nurse-driven exercise program. The authors will delimit the search by clicking on "Find all my search terms" and "Also search with a full test of the articles." Full-Text articles will be specified and ensuring that only peer-review articles are included. In the search, the researcher will also specify articles that were published between 2015 and 2020.  All the studies that will be reviewed are those published within the last five years.

Integration of Evidence 

Evidence relating to the PICOT question will be integrated to determine the extent of the problem. Ten evidence-based studies relating to the PICOT question will be reviewed systematically to build on the knowledge gap. The articles included in the review are those published within the last five years.

Cancer and Cancer-Related Fatigue

This section will describe the prevalence and incidence of cancer and cancer-related fatigue. The definition of CRF and its cause will also be discussed in this section. The researcher will also dig deep into the features and consequences of CRF and justify why the issue needs to be dealt with in the oncology department.

Immobility and Effects on CRF  

This section will address the part of the PICO question that concerns the effect of inactivity on cancer-related fatigue. The issues related to inactivity are important when viewed from the perspective of oncology patients who have additional comorbidities. Some studied suggest that physicians recommend that oncology patients need to rest after chemotherapy and avoid physical activity for comfort reasons. This section will also demonstrate how the inactivity can lead to other comorbidities and CRF.

Effects of Exercise on CRF

This section will review the benefits of exercise and how it impacts CRF. The discussion will incorporate the effects of exercise on a person’s psychological well-being by considering the effects of exercise on stress, anxiety, and depression. Psychological well-being is vital for the prevention and management of cancer-related fatigue. In this section, evidence will be drawn to support the evidence-based conclusion that the use of exercise is an efficient intervention to decrease cancer-related fatigue.

Critique of Evidence

A critique of the evidence presented will be done in this section. The researcher will employ a critical appraisal guide for nurses and nursing students that rates empirical evidence according to an eight-level hierarchy (Ingham-Broomfield, 2016). Each article will be appraised based on the eight-level hierarchy. The researcher will determine whether the search terms were used appropriately to search for the articles integrated into the review. From the critique, one can determine whether the evidence used ill make the study reliable.

Gaps in Evidence

From the integrated evidence and critique, the researchers will identify the literature gap that needs to be filled by the study. The gaps in the evidence presented will be used to guide the study to find the effective intervention to reduce CRF.

Implication for Practice 

The applicability of the evidence presented in a clinical setting will be evaluated. The implications for patients to reduce fatigue will also be assessed to determine the most effective intervention. The recommendations for practice will also be addressed in this section.

Conclusion

This section will summarize the evidence-based studies reviewed and their implications for practice. The researcher will summarize the major themes, critique, and the knowledge gaps identified in the literature that need to be filled by the current study.

References

Gusenbauer, M., & Haddaway, N. R. (2020). Which academic search systems are suitable for systematic reviews or metaanalyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research synthesis methods11(2), 181-217.

Ingham-Broomfield, J. R. (2016). A nurses' guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing (Online)33(3), 38.

Zhang, Q., Li, F., Zhang, H., Yu, X., & Cong, Y. (2018). Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial. International Journal of Nursing Studies78, 52-60.

NURS 6052 wk 3 assignment Matrix Worksheet Template

Matrix A

Zhang, Q., Li, F., Zhang, H., Yu, X., & Cong, Y. (2018). Effects of nurse-led home-based exercise & cognitive behavioral therapy on reducing cancer-related fatigue in patients with ovarian cancer during and after chemotherapy: A randomized controlled trial. International Journal of Nursing Studies78, 52-60.

Variable and key concepts

  • The Objective of this study was to investigate the feasibility of a nurse-led home-based exercise and cognitive behavioral therapy (E & CBT) for ovarian cancer adults with cancer-related fatigue on outcomes of fatigue, plus other secondary outcomes  such as sleep disturbance and depression; either during or after completion of primary cancer treatment.
  • The setting for this study was Gynaecologic oncology department of the First Hospital of Jilin University in China.
  • However, the hypothesis was not stated. The implied hypothesis was that a nurse-delivered home-based exercise and cognitive behavioral therapy can be beneficial for the management of cancer-related fatigue, depressive symptoms, and improved quality of sleep. 
  • Besides, the researchers aimed at answering the question about the feasibility of a nurse-led home-based E & CBT for adults with ovarian cancer and to study the effects on both primary (CRF) and secondary outcomes (sleep disturbance and depression). However, this research question was not clearly stated.
  • The independent variables include T1 (before second chemotherapy treatment),
  • T2 (immediately after a 12-week intervention but before the sixth chemotherapy treatment) and T3 (3 months after the end of the sixth chemotherapy treatment). Sub-independent variables included subjective sleep quality, sleep latency, sleep duration, sleep efficiency, and sleep dysfunction, use of sleeping medications and daytime dysfunction. The dependent variable was CRF.

Sampling

  • The participants included 72 eligible women who recently had surgery and completed their first cycle of adjuvant chemotherapy. 
  • The participants were randomly selected and assigned to two groups. That is, the experimental group received exercise and cognitive behavioral therapy. 
  • The samples size of 72 was enough to provide sufficient evidence concerning the effectiveness of the intervention to reduce CRF. 
  • Moreover, there were 2 drop-outs and 1 loss to follow-up in the experimental group during the study. The reason for dropping out or loss of follow up was not given.

Design and Method

  • The researcher used randomized, single-blind control trial research design.
  • The research was quantitative as it used randomized controlled trial (RCT) research design. RCTs seek to measure and compare the outcomes after the participants receive the interventions. Since the outcomes were measured, this study was quantitative.

Instruments/Data Collection

  • The data collected included baseline data, such as demographic, disease, and chemotherapy treatment, as well as the differences between experimental and comparison groups.
  • The zung self-Rating depression scale (SDS) was used to evaluate depressive symptoms.
  • The Pittsburgh sleep quality index (PSQI) questionnaire was used to evaluate quality of sleep.
  • The instruments were valid because the Cronbach’s α was 0.81–0.85. 

Results

  • The results showed that for baseline comparisons, no significant differences were found between the two groups. After the interventions, the experimental group had lower behavioral fatigue subscale scores, sensory fatigue subscale scores, and cognitive fatigue subscale scores at T2 and T3 compared with the comparison group. However, no significant change in affective subscales was found between the two groups at three time-point comparisons. The comparison group showed almost no change in total fatigue score over time.
  • Further, after the interventions, the experimental group participants demonstrated significantly lower symptoms of depression compared with the comparison group. The comparison group indicated almost no change in depression score over time.
  • These results were expected and it makes sense because as the participants engage in the intervention, it is expected that the levels of fatigue will reduce over time and remain the same when no intervention is applied.

Strengths & Limitations

Strengths:

  • The major strengths of this trial were the well-balanced socio-demographic and medical variables at baseline in both groups.
  • Statistical significance was represented as p-values (two-sided) less than 0.05.
  • The comparison group showed almost no change in total fatigue score over time. The repeated measures ANOVA, indicated that the differences of behavioral fatigue score  and cognitive fatigue score were statistically significant for the group by time interaction.

Limitations:

  • Only outcome changes in two time points during the nearly 6-month intervention were investigated.
  • Excluding the elderly patients who did not have the ability to exercise independently impaired the ability to generalize the results to the entire ovarian cancer population. 
  • Further, the questionnaires were self-reported, and self-reported data is considered less accurate than objective data.

Critique

  • Overall, this trial can be used to deliver exercise program coordinated with CBT to assist women with ovarian cancer to attain a clinically meaningful decrease in cancer-related fatigue, depressive symptoms, and improved quality of sleep. Based on the study findings, this study can be used for a literature review.
  • The researchers did an excellent job in explicitly explaining the research to make it easy to comprehend. The research findings also make sense and can be used as evidence to advance clinical practice.

Matrix B

Ulrich, C. M., Himbert, C., Boucher, K., Wetter, D. W., Hess, R., Kim, J., & Marcus, R. (2018). Precision-Exercise-Prescription in patients with lung cancer undergoing surgery: rationale and design of the PEP study trial. BMJ open8(12).

Variable and key concepts

This Precision-Exercise-Prescription (PEP) study is a randomized phase III clinical trial that aimed at investigating the effect of a personalized exercise program on physical function, as measured by the 6 min walk (6 MW) test, in patients with NSCLC (Stage I, II, III) and patients with secondary lung cancer who are undergoing surgical treatment at the Huntsman Cancer Institute (HCI).

The independent variables include quality of life (QoL), fatigue, pain, sleep and self-efficacy), clinical outcomes (length of stay, complications, readmission and pulmonary function) and treatment-related cost.

The depended variables included individually prescribed exercise modes (mobility, flexibility, callisthenic, aerobic and resistance) and dosages (low, moderate, high) tailored to the patient’s AM-PAC mobility stage. The researchers hypothesized that patients with lung cancer undergoing surgical resection will improve their physical function by participating in a PEP tailored to their mobility level, motivation, and other behavioral and environment factors as they progress (or regress) through the multiple phases of the pre-surgery and post-surgery periods. 

The research question was not clearly stated. However, the researchers aimed at answering the question about the clinical effectiveness and feasibility a personalized exercise intervention in patients with lung cancer undergoing surgery.

Sampling

This study used a sample size of 200 patients with NSCLC stage I, II or IIIa, or secondary lung cancer over 18 years old, who undergo surgical lung resection at HCI. The researchers used enough sample size to enable the findings to be generalized. 

However, of the 200 participants, 25 percent are expected to drop out without any reason.

Design and Method

The researchers employed single-center, prospective, two-armed, phase III randomized controlled trial at HCI in Salt Lake City, Utah. Because the researchers used RCT, the study is quantitative considering RTC are intended to measure outcomes.

Instruments/Data Collection

The researchers collected data concerning gender, age, baseline smoking status, primary or secondary lung cancer, neo-adjuvant treatment, tumor stage, baseline level of outcome, pain, and sleep. The data was sufficient to determine the clinical effectiveness and feasibility of a personalized exercise intervention in patients with lung cancer undergoing surgery.

The researchers used the Activity Measure for Post-Acute-Care outpatient basic mobility (AM-PAC) measurement tool which is a well-validated and highly standardized instrument. 

Results

This is an ongoing trial and the primary results from the PEP study will test the clinical effectiveness and feasibility of a personalized exercise intervention in patients with lung cancer undergoing surgery. 

This trial makes sense because it fills the gap in knowledge precisely, by testing an exercise intervention that can be readily integrated into the clinic and by obtaining data on functional efficacy and PROs.

Strengths & Limitations

Strengths:

  • This is the first randomized controlled trial to examine a personalized exercise program for both, patients with primary and secondary lung cancer. 
  • The intervention is designed to be aligned with and easily translatable into the clinical workflow and spans the entire continuum of care from the pre-surgery to post-surgery period including lung cancer survivorship.
  • The results will yield important healthcare cost information using the value-driven outcomes tool.

Limitations:

The biggest limitation of this study is that the cost of the behavioral intervention delivered by a physical therapist for weekly phone calls during the outpatient period may still be too high for future implementation in healthcare settings.

Critique

Overall, this PEP study will be the first study to test the clinical effectiveness and feasibility of a personalized exercise intervention in patients with lung cancer undergoing surgery. This study provides valuable information concerning a personalized intervention to reduce CRF, thus, can be used in the literature review. After following through the pilot study, this study seems easy to understand and makes sense because the authors have heighted the procedures of how the study will be conducted and how the variables of concerned will be measured.



Matrix C

Berntsen, S., Aaronson, N. K., Buffart, L., Börjeson, S., Demmelmaier, I., Hellbom, M., ... & Raastad, T. (2017). Design of a randomized controlled trial of physical training and cancer (Phys-Can)–the impact of exercise intensity on cancer related fatigue, quality of life and disease outcome. BMC cancer17(1), 218.

Variable and key concepts

This study aimed at conducting a Phys-Can project that implemented an endurance exercise to determine the effects of low-to-moderate and high intensity physical exercise with or without BCTs on CRF and HRQoL in persons with cancer, both during treatment and in the long-term, post-treatment survivorship period. The primary (outcomes independent variables) in this study included fatigue and health related quality of life, which are measured by self-reports. Secondary outcomes (independent variables) include fitness, mood disturbance, and adherence to the cancer treatment, adverse effects, and return to activities of daily living after completed treatment, return to work as well as inflammatory markers, cytokines, and gene expression. The dependent variable was the Cancer-related fatigue (CRF). 

Sampling

The researchers used a sample size of 600 newly diagnosed persons with breast, colorectal or prostate cancer undergoing adjuvant therapy. The sample size was large enough to be generalized to the targeted population.\

the participants were  randomized in a 2 × 2 factorial design to following conditions individually tailored

low-to-moderate intensity exercise with or without behavior change techniques; or individually tailored high

Intensity exercise with or without behavior change techniques. The dropout rate was at 30 percent without any reason.

Design and Method

The researchers used a randomized controlled trial research design with a preceding descriptive observational study used for comparisons.  The RCT was stratified and within each stratum randomization was carried out following a permuted block design with 8 participants per block. The defined strata were the three hospitals (Linköping, Lund, and Uppsala) and three cancer sites yielding 9 strata.

Since this study employed RCT research design, it is quantitative because the RTC measured outcomes.

Instruments/Data Collection

A web-portal was designed to facilitate collection of outcome measures in the multiple study sites and to enable easily accessible electronic self-monitoring of exercise behavior. The data collected on mood was assessed by Hospital Anxiety and Depressions scale HADS. Data collected on functioning in daily life was assessed by the World Health Organization Disability Assessment Schedule WHODAS II. Data collected on readiness to change physical activity behavior  was measured by the Exercise Stage Assessment Instrument (ESAI), Exercise Barrier Self-Efficacy Scale (ESES); progressive goal attainment and perceived behavioral control are used to assess cognitive-behavioral moderators and mediators data. Cardiorespiratory fitness data collected was measured as maximal oxygen uptake during maximal walking/running until exhaustion on a treadmill using a modified Balk protocol. These instruments are valid as they are standardized tools. 

Results

The results suggest that  the Phys-can study will contribute to the understanding of the value of exercise and exercise intensity in preventing CRF and maintaining HRQOL during and after treatment and, potentially, clinical outcomes as well. The results also implied that BCT do not have to target the exercise behavior during supervised sessions; rather, the support should target behaviors pertaining to unsupervised or home-based exercise. These results are expected and make sense because they also offer insights into possible biological mechanisms through which exercise influence treatment outcomes.

Strengths & Limitations

Strengths:

  • All the physical fitness tests, physical activity monitoring, and conducting exercise of low-to moderate or high intensity, seem feasible to implement in exercise oncology interventions. 
  • Strength is that the exercise including resistance training with arm movements above the head and repetitive muscle contractions of the arm is feasible and may be safe for patients wearing a peripherally inserted central venous catheter because of the adjuvant chemotherapy.
  • A 5% significance level was adjusted using Bonferroni correction. Statistical significance was supported by the 80% power to detect a main factorial effect of 2 under the null hypothesis of no effect.

Limitations:

The greatest limitation was that the sample size was calculated to be 600 persons in total, which proved to be a challenge in a multicenter, complex intervention study as the current study.

There are also there are significant challenges associated with a change of lifestyle during and following cancer treatment.

Critique

Overall, this study showed that the value of BCTs in terms of adherence to, and maintenances in, exercise behavior in persons with cancer will be evaluated. Therefore, it is understandable that the implementation of the findings of this study into clinical practice need to be facilitated by the close collaboration between researchers and clinicians including the facts that the study is performed in non-clinical setting to establish a pathway between hospitals to society. This study is easy to understand and makes sense because the researcher took their time to explain the results in simple terms that make sense to anyone without clinical knowledge.



NUR 601 Evidence-Based Practice in Nursing

The effectiveness of Yoga Exercise Program in Improving Cancer Patients Fatigue

Introduction

Cancer and its treatment often lead to several physical and psychological problems that do not go away with time and can have negative side effects on the quality of life of cancer survivors. Often, cancer patient patients experience pain, depression, anxiety, and fatigue, which always continue even after the treatment is complete (Yang et al., 2019). In most cases, cancer patients frequently report fatigue as one of the most distressing side effects of chemotherapy with potentially significant long-term implications. According to Fabi et al. (2020), cancer-related fatigue (CRF) is the distressing, persistent, subjective sense of physical, emotional, and cognitive tiredness or exhaustion associated with cancer or cancer-related treatment not proportional to recent activity and interferes with normal functioning. Fabi et al. (2020) also state that CRF is different from other categories of fatigue due to its severity and persistence and the inability to eradicate it via resting or sleeping.  Moreover, evidence suggests that CRF begins in the skeletal muscles because of a progressive decline in physical activity. However, research also indicates that yoga interventions on self-reported fatigue can produce invigorating effects on physical and mental energy and consequently improve levels of fatigue (Tolia et al., 2018). This study, therefore, assesses whether yoga intervention improves cancer-related fatigue among cancer patients who report fatigue at diagnosis or during cancer treatment.

Problem Statement

Cancer-related fatigue has become a common problem among cancer patients, especially at diagnosis and during treatment. CRF is characterized by excessive and persistent exhaustion that interferes with an individual’s daily activity and function (Fabi et al., 2020).  In most cases, CRF starts before one is diagnosed with cancer, gets worse during treatment, and may persist for a long duration ranging from months to years after completing treatment (Yang et al., 2019). Unlike other types of fatigue that a normal person may experience from time to time, CRF is more severe, and some people experience muscle weakness and difficulty concentrating. Statistics indicate that approximately 40 percent of patients report fatigue at cancer diagnosis, and 80 to 90 percent during chemotherapy and radiotherapy (Fabi et al., 2020). 

In some cases, hormonal therapy, targeted therapy, as well as immunotherapy can contribute to CRF. Moreover, most patients with cancers find CRF as more distressing and disabling than other cancer-related or treatment-related symptoms like pain, depression, or nausea. Notably, research shows that exercise can improve CRF. As a result, scholars have questioned whether yoga intervention can help cancer patients combat CRF and live a satisfying life. Therefore, a PICO question that can be designed to investigate the effectiveness of yoga intervention in improving CRF among cancer patients would be: When caring for cancer patients with self-reported CRF, what is the effectiveness of yoga intervention as compared to usual care helps in combating CRF in 3 months? This PICO question can further be illustrated as follows:

PICOT Question: When caring for cancer patients with self-reported CRF, what is the effectiveness of yoga intervention as compared to usual care in combating CRF in 3 months?

Population/Patient (P): Cancer patients

Intervention (I): Yoga

Comparison (C): Usual care

Outcome (O): improving CRF by 60 percent.

Time (T): 3 months

Conclusion

Overall, CRF has severe consequences on the quality of life of cancer patients at diagnosis, during the course of treatment, and even after treatment. The effects of CRF include reduced ability to carry out daily activities, sleep disruption, depression, and anxiety. However, scholars believe that nurses caring for cancer patients can use yoga intervention to combat CRF. This topic is important in the field of nursing because it focuses on improve patients’ quality of life and achieve the desired treatment effect, which is the key objective of nursing. The PCOT question developed can therefore, assist nurses to find evidence-based practices to combat CRF and educate cancer patients about managing their fatigue.

References

Fabi, A., Bhargava, R., Fatigoni, S., Guglielmo, M., Horneber, M., Roila, F., ... & Ripamonti, C. I. (2020). Cancer-related fatigue: ESMO Clinical Practice Guidelines for diagnosis and treatment. Annals of Oncology31(6), 713-723.

Kessels, E., Husson, O., & Van der Feltz-Cornelis, C. M. (2018). The effect of exercise on cancer-related fatigue in cancer survivors: a systematic review and meta-analysis. Neuropsychiatric disease and treatment14, 479.

Tolia, M., Tsoukalas, N., Nikolaou, M., Mosa, E., Nazos, I., Poultsidi, A., ... & Kardamakis, D. (2018). Utilizing Yoga in oncologic patients treated with radiotherapy. Indian journal of palliative care24(3), 355.

Yang, S., Chu, S., Gao, Y., Ai, Q., Liu, Y., Li, X., & Chen, N. (2019). A Narrative Review of Cancer-Related Fatigue (CRF) and Its Possible Pathogenesis. Cells8(7), 738. https://doi.org/10.3390/cells8070738

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