Kwiatkowski, F., Mouret-Reynier, M.A., Duclos, M., Leger-Enreille, A., Bridon, F., Hahn, T., . . . Bignon, Y.J. (2013). Long term improved quality of life by a 2-week group physical and educational intervention shortly after breast cancer chemotherapy completion. Results of the 'Programme of Accompanying women after breast Cancer treatment completion in Thermal resorts' (PACThe) randomised clinical trial of 251 patients. European Journal of Cancer, 49(7), 1530–1538.
Determine the effectiveness of an intensive intervention (i.e., two weeks at a SPA centre involving exercise, physiotherapy, and dietary education) on overall quality of life, weight, nutrition, and physical activity in women who recently had completed treatment for non-metastatic breast cancer
The intervention included a two-week stay at a SPA centre with a daily routine of physical training (i.e., two hours daily under the supervision of a physiotherapist, which included walking, strength training, and aquaexercise), dietary education with cooking lessons and provision of healthy meals, and aesthetic care, massage, etc. Dietary consultations every six months for three years also were incorporated into standard follow-up care.
PHASE OF CARE: Transition phase after active treatment
Prospective, randomized, repeated measures (baseline, 6, 12, 18, and 24 months after intervention) two-group clinical trial
Statistically significant differences were seen between groups on the SF-36 measure at six months, but these differences did not persist in any dimension at year one except for a difference in vitality at one year between groups. Although data were collected on weight/body mass index, diet, and sleep, results for these variables are not reported (except to note no significant differences in sleep between the groups). The plots/trends in quality of life over time (at 6, 12, 18, and 24 months) look very similar for both groups, except for a significant upward trend at six months for the intervention group. The correlation was stronger between HADS depression and SF-36 quality of life. In the SPA group, an overall decrease was seen in anxiety compared to baseline scores (p = 0.0005). No significant difference was seen in the anxiety scores between the SPA and control groups at six months. Depression decreased in both groups but to a greater degree in the SPA group. A significant difference was seen between the SPA group and control group in terms of depression scores. What the “control” or comparison group was or what care was given to them is not clear.
As reported, patients with non-metastatic breast cancer did not appear to derive significant benefit (improved quality of life as measured by the SF-36) from a two-week SPA intervention in terms of improving quality of life and reducing anxiety and depression.
This unrealistic intervention (two-week SPA stay) does not seem sustainable. Furthermore, if this “intensive” intervention did not demonstrate significant impact on quality of life or anxiety, except for depression, then the “cost” of such an intensive intervention is not worth the benefit. When exactly the intervention occurred is not reported relative to timing of completion of breast cancer treatment except to say “within nine months,” but this is an important variable/covariate because time since treatment completion (and intervention) might impact study results. Importantly, unclear is how subjects were screened or that only a “distressed” group was enrolled. The report that global SF-36 scores at study inclusion were 56 and 54 respectively (treatment and control groups) indicates that this is not a very “stressed” group, as evidenced by SF-36. The higher the scores on the SF-36, the better the quality of life. These scores at study inclusion are right at the midpoint range of 0%–100%; thus, a possible floor effect is at play. Overall, this is not a very well developed or reported study.
No real meaningful nursing implications are drawn from this study. The intervention seems unrealistic and unsustainable and did not impact outcome measures as predicted, except for depression.
Kwekkeboom, K. L., Cherwin, C. H., Lee, J. W., & Wanta, B. (2010). Mind-body treatments for the pain-fatigue-sleep disturbance symptom cluster in persons with cancer. Journal of Pain and Symptom Management, 39, 126–138.
To identify and synthesize the evidence for mind-body interventions for which the evidence suggests benefit for at least two of the three cluster symptoms of pain, fatigue, and sleep disturbance.
Databases searched were CINAHL, MEDLINE, and PsycINFO through March 2009.
Search keywords were guided imagery, hypnosis, relaxation, biofeedback, cognitive behavioral therapy, coping skills training, meditation, virtual reality, music AND cancer AND fatigue, sleep disturbance, sleep difficulty, insomnia, and pain.
Studies were included in the review if they
Studies were excluded if they
A total of 47 studies were identified. In four of those, all testing virtual reality, only the symptom of fatigue was measured, so these were eliminated.
The final sample included 43 studies. Study sample sizes and total patients involved across studies were not reported.
Relaxation
Six studies examined relaxation interventions in hospitalized patients, outpatients with chronic pain, and women with early-stage breast cancer.
Imagery and Hypnosis
Six studies examined imagery and hypnosis.
Cognitive Behavioral Therapy (CBT)/Coping Skills Training (CST)
Twenty-one studies tested CBT/CST.
Meditation
Four studies were included.
Music
Findings of this review were equivocal.
Although the findings did not clearly demonstrate the effects of these interventions across studies, the authors concluded that these interventions hold promise. Although such interventions carry minimal risk to patients, some interventions would require substantial time and resource commitment to provide.
Kwekkeboom, K.L., Wanta, B., & Bumpus, M. (2008). Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. Journal of Pain and Symptom Management, 36, 604–615.
To assess, among hospitalized patients with cancer-related pain, responses to progressive muscle relaxation (PMR) and analgesic imagery, including the impact of these interventions on pain-related distress and perceived control over pain
To examine the influence of ability, outcome expectancy, previous experience, and concurrent symptoms on the effectiveness of the interventions
Scripts relating to \"control conditions,\" PMR, and guided imagery interventions were recorded on a CD. The recorded voice was male, and the recording did not include music. The day 1 control recording consisted of identification of health team members, explanation of patient rights, and a description of various hospital services. The second control recording described exercise and other activities to maintain strength while hospitalized and presented issues for consideration in discharge planning. The PMR recording guided listeners in tensing and relaxing muscles in a series of 12 major muscle groups from head to feet. The analgesic, or guided imagery, recording asked listeners to scan their bodies to identify areas of pain and to imagine replacing pain with comforting sensations. Then the recording asked listeners to imagine putting their hand in an anesthetic fluid, feeling it go numb, and then transfer the numbness to painful areas of the body. All recordings were of similar length. Trials were done when current pain was rated 2–8 on a 10-point scale. Trials were delayed if patients had received an oral analgesic within one hour or an IV analgesic within 30 minutes. Patients with the option of patient-controlled analgesia were asked to refrain from increasing doses during the 15-minute trial and were maintained on basal continuous infusion. A control trial was the first trial done each day. If pain persisted at the end of the control trial, the research nurse continued with whichever experimental trial was assigned for that day. Two intervention trials were done each day, at least one hour apart. Patients completed pre- and post-trial ratings of pain intensity and related distress. For each outcome measured, scores were averaged across two control, two PMR, and two analgesic imagery trials. In cases where only one trial was completed, this score was used in analysis. Patients were randomly assigned to two different groups. In one group, PMR preceded imagery interventions; in the other, the sequence was reversed. All patients received the same control trials.
The study used a crossover design with control.
In only 50% of patients did PMR and guided imagery appear to have a more positive short-term effect on pain intensity, pain-related distress, and perceived control of pain than did simple distraction. Variables examined did not appear to influence the effects of PMR, but expectations and number of concurrent symptoms appeared to influence the effects of guided imagery.
PMR and analgesic imagery, facilitated by a recording on CD, might be helpful to some patients to reduce short-term pain intensity, decrease pain-related distress, and increase sense of control over pain. However, much more evidence is needed before investigators can draw firm conclusions. These interventions could be implemented easily in a hospital setting and do not appear to harm patients. They appear to be more effective for individuals with greater ability to imagine, greater expectations of effectiveness, and fewer additional symptoms. This fact might lead clinicians to identify that group of patients most likely to benefit from such interventions.
Kwekkeboom, K. L., Abbott-Anderson, K., & Wanta, B. (2010). Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Oncology Nursing Forum, 37, E151–E159.
To evaluate the feasibility of a patient-controlled, cognitive-behavioral intervention for pain, fatigue, and sleep disturbance during treatment for advanced cancer and to assess the initial efficacy of the intervention.
Patients provided baseline measures, such as measures relating to demographics and a symptom inventory, received education, and underwent training to use an mp3 player loaded with 12 cognitive-behavioral strategies (relaxation exercises, guided imagery, nature sounds). Patients used the strategies as needed for symptom management for two weeks and kept a log of symptom ratings with each use. Following the two-week intervention, patients completed a second symptom inventory and an evaluation of the intervention. Clinic staff identified patients who met the eligibility criteria based on diagnosis and treatment and then were briefly introduced to the study and asked if a research nurse could visit to provide additional information. The research nurse met with interested patients, assessed symptoms, and completed eligibility screening. Study purpose and procedures were explained, and written informed consent was obtained.
The study used a one-group, pre- and postintervention design.
The patient-controlled, cognitive-behavioral intervention is feasible and may reduce the day-to-day severity of co-occurring pain, fatigue, and sleep disturbance.
The findings support nurse education and the recommendation of the specified patient-controlled, cognitive-behavioral interventions for the management of pain, fatigue, and sleep disturbance. In regard to patient care and symptom management at all stages of cancer, nurses are the front-line educators of patients. This intervention supports the principle of autonomy for patients able to participate actively in care. Further study—a randomized, controlled trial to test the efficacy of the intervention for co-occurring pain, fatigue, and sleep disturbance—was under way at the time this study was published.
Kwekkeboom, K. L., Abbott-Anderson, K., Cherwin, C., Roiland, R., Serlin, R. C., & Ward, S. E. (2012). Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. Journal of Pain and Symptom Management, 44, 810–822.
To test the effects of a psychoeducational intervention on pain, fatigue, and sleep disturbance.
Patients were randomly assigned to the intervention group or the wait-list control group. The intervention consisted of a single one-on-one training session with a research nurse, which was followed by recorded guidance that provided imagery, relaxation exercises, and nature sounds. Most exercises lasted 20 minutes and were delivered via an mp3 player. The study lasted two weeks.
Patients were undergoing the active antitumor treatment phase of care.
The study used a randomized, controlled trial, pre- and postintervention design.
The intervention demonstrated a small statistically significant effect on the symptoms of pain and fatigue and the overall symptom cluster of pain, fatigue, and sleep disturbance.
The intervention was a relaxation or imagery therapy rather than a true CBT. The intervention was associated with short-term statistically significant benefits, but the actual size of the effect was small. Findings suggested that approaches using relaxation and imagery may result in some small benefit for patients, but the effect was weak.
Kwekkeboom, K.L., Abbott-Anderson, K., Cherwin, C., Roiland, R., Serlin, R.C., & Ward, S.E. (2012). Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. Journal of Pain and Symptom Management, 44, 810–822.
To assess the efficacy of a cognitive-behavioral (CB) intervention for the pain, fatigue, and sleep disturbance symptom cluster
Patients were randomized to the CB group or a waitlist control group. The intervention was a single one-on-one training session with a research nurse providing information about causes of pain, fatigue, and sleep disturbance; rational about how CB strategies could affect symptoms; overview of 12 strategies; and recommendations for patients to practice. CB strategies were relaxation and imagery approaches. Patients were provided scripted recordings to use on an MP3 player and written instructions. Patients were followed for two weeks and completed study assessments at baseline and at two weeks. The control group had usual care. Patients in the intervention group were to keep a log recording each use of CB strategies, and all patients in both groups were taught to complete a daily symptom diary. Follow-up phone calls were made to both groups on the second study day, the seventh study day, and at the end of the two-week study period. Post-intervention measures of symptom severity were mailed to participants to complete and provide to clinic staff.
CB strategies were used an average of 13.65 times (SD = 6.98) during the two weeks. Patients in the control group were significantly more depressed at baseline (p = .003). Total cluster scores post-intervention were lower in the intervention group (eta2 0.052, p = .032). Examination of individual symptoms showed differences between groups in pain (P = .006) and fatigue, but not in sleep.
Use of various patient self-controlled relaxation and imagery recordings appeared to have a beneficial effect in reducing pain and fatigue compared to controls. No clear effect was seen on sleep disruption.
Findings suggest that patient use of relaxation and imagery instructions and recordings may improve management of pain and fatigue during cancer treatment.
Kwekkeboom, K.L., Abbott-Anderson, K., Cherwin, C., Roiland, R., Serlin, R.C., & Ward, S.E. (2012). Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. Journal of Pain and Symptom Management, 44, 810–22.
To assess the efficacy of a cognitive-behavioral (CB) therapy intervention for the symptom cluster of pain, fatigue, and sleep disturbance
Patients were randomized to the CB group or a waitlist control group. The intervention was a single, one-on-one training session with a research nurse providing information about causes of pain, fatigue, and sleep disturbance. Patients learned how CB strategies could affect symptoms and received an overview of 12 strategies and recommendations to practice. CB strategies included relaxation and imagery approaches. Patients were provided scripted recordings to use on an MP3 player and written instructions. Participants were followed for two weeks, and study assessments were completed at baseline and at two weeks. The control group received usual care. Intervention patients kept a log recording each use of CB strategies, and all patients in both groups were taught to complete a daily symptom diary. Follow-up phone calls were made to both groups on study days 2 and 7 and at the end of the two-week study period. Postintervention measures of symptom severity were mailed to participants to complete and provide to clinic staff members.
Randomized, controlled trial
CB strategies were used an average of 13.65 times (SD = 6.98) during the two weeks. Patients in the control group were significantly more depressed at baseline (p = 0.003). Total cluster scores postintervention were lower in the intervention group (eta2 = 0.052, p = 0.032). An examination of individual symptoms showed differences between the groups in pain and fatigue but not in sleep.
The use of various patient-controlled relaxation and imagery recordings appeared to have a beneficial effect in reducing pain and fatigue compared to a control group. There was no clear effect on sleep disruption.
The findings of this study suggest that patient use of relaxation and imagery instructions and recordings may improve the management of pain and fatigue during cancer treatment.
Kwekkeboom, K.L. (2003). Music versus distraction for procedural pain and anxiety in patients with cancer. Oncology Nursing Forum, 30, 433–440.
This intervention was music versus simple distraction and control (treatment as usual).
The study reported on a sample of 58 patients with cancer having painful, cancer-related medical procedures.
A randomized controlled trial design was used.
There were no significant differences in post-procedure anxiety (no p values reported), pain, or perceived control across conditions.
Kwan, M.L., Cohn, J.C., Armer, J.M., Stewart, B.R., & Cormier, J.N. (2011). Exercise in patients with lymphedema: A systematic review of the contemporary literature. Journal of Cancer Survivorship: Research and Practice, 5(4), 320–336.
To examine the evidence and produce recommendations for exercise and lymphedema management in female breast cancer survivors
A total of 659 references were retrieved. Two authors used the Oncology Nursing Society Putting Evidence Into Practice (PEP) categories of evidence to evaluate the references.
Patients were undergoing multiple phases of care.
Resistance exercises were determined to be \"Likely to be effective.\" Aerobic and resistance exercise were rated as \"Benefits balanced with harms,\" though no clear harms were obvious in the review of the studies. Other exercise approaches studied were deemed \"Effectiveness not established.\"
Benefits of exercise have been reported, and this review suggests that current evidence supports the use of resistance exercising.
Findings support the use of resistance exercise in women with breast cancer for the management of arm lymphedema.
Kvillemo, P., & Branstrom, R. (2011). Experiences of a mindfulness-based stress-reduction intervention among patients with cancer. Cancer Nursing, 34, 24–31.
To examine the perceived effects and experiences of mindfulness-based stress-reduction (MBSR) training as described by patients with cancer
Eight group sessions of a modified MBSR program using relaxation, meditation, and yoga exercises. The instructors were two clinical psychologists. At the end of the intervention, quantitative psychological measures were assessed and participants were invited to participate in a semistructured telephone interview regarding their experiences. This study reports on the data from the qualitative analysis of interviews.
A qualitative study design was used.
Thematic analysis of audiotaped interview transcripts
Meditation and yoga exercises were experienced as most positive. The group itself offered a positive effect through shared experience, nonjudgmental approach, and acceptance.
The thematic analysis was insufficient to offer support for the researchers’ conclusions.
This intervention requires significant training, time, and effort for implementation.