Feasibility was determined by analyzing the recruitment rate, which was measured as the percentage of eligible patients who were recruited who consented. Adherence was measured as the percentage of those participating in the intervention that adhered to the intervention. Weekly adherence was calculated by taking the number of times the prescribed intervention was completed divided by the number of interventions prescribed for the week. Retention was measured as the percentage of those enrolled that completed the program from the first phone visit after surgery to the final data collection at week 6. Adverse events were to be recorded in the Daily Diary and monitored by the nurse and principal investigator. Likewise, any unmanaged symptoms or clinical problems requiring physician referral were recorded by the nurse in the nurse intervener log and monitored by the principal investigator. Our goal to show feasibility was to be able to recruit 50% of eligible participants and show adherence and retention to the intervention at a rate of 70% with minimal adverse effects. These goals were based on the NSCLC exercise study results from the work conducted by Jones et al46,47 and the home-based exercise study results from the study of Mock et al.48
Acceptability assessment for this study was similar to those used in other exercise studies.49,50 The research team developed a questionnaire for the participants with a Flesch-Kincaid reading grade level of 6. Participants rated their degree of satisfaction with the exercise intervention for 15 items on a 6-point Likert scale from strongly disagree to strongly agree. An average positive acceptability score of 4 (1–6; 6 = agrees strongly) was set as the minimum level to achieve to indicate the intervention was acceptable.
The BFI is a 9-item measure of CRF severity and its impact on daily functioning. On an 11-point scale (0–10, 10 = most severe), 3 items measure fatigue severity (now, usual, and worst fatigue), and 6 items measure the impact of fatigue on daily functioning in the past 24 hours. Substantial evidence supports the psychometrics of the BFI in the cancer population, with Cronbach’s α ranging from .82 to .97.51,52
Perceived Self-efficacy for Fatigue Self-management Instrument contains 6 items measuring on an 11-point scale (0–10, 10 = very certain) confidence in performing fatigue self-management behaviors. Content and construct validity through mediation analyses and structural modeling demonstrated sound psychometrics in persons with cancer diagnoses, with a reported Cronbach’s α of .92 for persons with cancer including lung cancer.53
Perceived Self-efficacy for Walking Duration Instrument measures a person’s confidence to complete incremental 5-minute periods of light-intensity pace walking (5–30 minutes) on an 11-point scale (0%–100%, 100% = highly confident). Internal consistency reliability reported for a sedentary, older sample with comorbid conditions including cancer for pre-exercise and postexercise was a Cronbach’s α greater than .95.54
Activities-Specific Balance Confidence Scale is a 16-item scale measuring confidence for balance during specific everyday physical activities. On an 11-point scale (0%–100%, 100% = most confident), higher scores indicate greater balance confidence during physical activities such as walking in and outside the home. The scale has demonstrated sound psychometrics tested in diverse populations of older adults living at home or in retirement communities with test-retest reliability over a 2-week period, high internal consistency with Cronbach’s α ranging from .82 to .90, convergent and discriminant validity, and the ability to discriminate between fallers and nonfallers and low-versus high-mobility groups.55–57
The Daily Diary is a weekly diary that provides the participant with a structured format using a tabular design for which they can enter their weekly exercise prescription (provided by the nurse during the weekly home or phone visit) as well as their daily exercise performance. The Daily Diary provides the participant a means to capture CRF self-management behaviors such as the daily number of minutes walked and number and type of balance exercises performed. The participant also records the number of steps taken each day in the Daily Diary as indicated by the Sportsline Step and Distance Pedometer. Except for riding a bike and swimming, pedometer readings have been found to be valid and reliable measures of functional performance.58,59 Participants wore the pedometer every day for 6 weeks of the study except during Nintendo Wii exercise so that nonintervention performance levels could be assessed.
All analyses were conducted with IBM SPSS Statistics version 19.0. Descriptive statistics were calculated to estimate the frequencies, means, and SDs of the study variables. Next, the pattern of change in CRF severity; PSE for fatigue self-management, walking, and balance; CRF self-management walking and balance exercise behaviors; and the number of pedometer steps per day per week were longitudinally displayed. Results were depicted at baseline presurgery and postsurgery prior to the start of the intervention and at the end of each week of the 6-week intervention.
Participant characteristics (n = 7) are displayed in Table 2. The mean age was 64.6 years (range, 53–73 years); most were women, employed, and with no children living at home. The participants had a diverse educational background from completing high school to completing a college education. Likewise, participants reported annual household incomes ranging from $15 000 to $19 999 to more than $100 000 per year. Prior to surgery, participants were found to be assessed in 1 of 2 categories of the KPS Scale: 70%, meaning able to care for self but unable to carry on normal activity and do active work, and 90%, meaning having minor signs and symptoms of disease. All participants reported tobacco usage, with 5 participants using tobacco up to diagnosis and all reporting no tobacco usage after learning they required surgery for suspected NSCLC through 1 month after surgery. The mean number of comorbid conditions per participant was 5.9, ranging from 2 to 12 comorbid conditions per participant. The most common comorbid conditions requiring active treatment included osteoarthritis (n = 5), hypertension (n = 4), hyperlipidemia (n = 4), and chronic obstructive pulmonary disease (n = 2). The BMI (in kg/m2) for participants before surgery and after surgery at the first home visit indicated that 1 participant had a normal BMI (18.5–24.9 kg/m2), 5 participants were overweight (25–29.9 kg/m2), and 1 participant was obese (>30 kg/m2). One month after the first home visit postsurgery, one participant moved from the obese BMI category to the overweight BMI category, and 2 participants moved from the overweight BMI category to the normal BMI category, leaving a total of 3 participants in the normal BMI category and 4 participants in the overweight BMI category. Participants all underwent lobectomy and were found to have either adenocarcinoma (71.4%) or squamous carcinoma (28.6%) NSCLC, whereas stage of diagnosis varied from stage IA through stage IIIA. The mean hospital stay was 7.8 days, with a range of 5 to 12 days. Overall, 5 patients experienced commonly reported complications prior to discharge from the hospital consisting of atrial arrhythmia (28.6%), atelectasis (14.3%), hemorrhage requiring surgical correction (14.3%), and hypotension (14.3%).
The mean time between the symptom screening and the first home visit to initiate the exercise intervention for all participants was 32.3 hours (range, 5–54 hours). Five participants started chemotherapy on average of 42.4 days after surgery. For those who underwent chemotherapy, the chemotherapy treatment was initiated at a mean time of 5.2 weeks after the start of the intervention. As seen in Table 2, all chemotherapy protocols used 2 drugs, one of which was a platinum compound. In combination with chemotherapy, 1 participant received radiation treatments 5 days a week for stage IIIA NSCLC.
Study Aim 1: Feasibility to Recruit and Retain Participants
The study flow is presented in Figures 1 and 2. Figure 1 depicts the initiation of the study on November 16, 2010, under a study protocol with stringent eligibility criteria through May 30, 2011. Figure 2 depicts the revised, modified study protocol, and eligibility criteria starting May 31, 2011, through September 15, 2011, incorporating lessons learned during the first part of the study. In brief, 5 participants were approached, and 1 participant consented, completing the entire intervention using the stringent study protocol and eligibility criteria. Following the revised study protocol and eligibility criteria, 8 patients consented, with 2 deemed ineligible from the study and the remaining 6 patients completing the entire intervention. Feasibility to recruit based on the revised study protocol and eligibility criteria resulted in 8 of 10 participants (80%) who were approached and consented, exceeding our goal of 50%. All 7 patients enrolled in the study completed the 6-week exercise intervention for 100% retention, exceeding our goal of 70%.
Study Aim 2: Participant’s Level of Adherence to the Intervention
The mean adherence rate for the entire exercise intervention was 96.6% (SD, 3.4%) (range, 90–100%), which included both walking and balance exercise adherence levels (exceeding our goal of 70%). Participants did not report any exercise-related problems or symptoms during or after their exercise sessions. However, all 7 participants reported unmanaged symptoms at some point in the study during the nurse home or phone visits that resulted in the nurse advising the participant to contact his/her physician. In each case, these symptoms were deemed not related to the exercise intervention.
Study Aim 3: Participant’s Level of Acceptability to the Intervention
Participants agreed strongly to a high level of satisfaction with the exercise intervention, giving it a mean score of 5.8 of 6 (SD, 0.18) (range, 5.6–6, with 6 meaning agreed strongly), exceeding our goal of 4 of 6. All participants strongly agreed that exercising at home was convenient, the nurse interaction from the telephone calls were helpful, that they would recommend the program for someone like themselves after having surgery for lung cancer, and overall, that the program helped to build their confidence to manage fatigue. Moreover, the majority agreed strongly that the CRF resource book was useful, exercising at home was convenient, the Wii walking and balance program was enjoyable and easy to use, having a wristwatch and perceived exertion scale to monitor heart rate was helpful, the Daily Diary to record progress was easy to use, and overall, the participants found that they improved each time they used the Wii to exercise. Two participants recommended that toward the end of the 6-week program (when strength had improved while walking for longer periods) other walking activities be introduced to prevent boredom from exercise. Likewise, participants commented that in-home walking activities are important to have available when undergoing chemotherapy and on hot, humid, and cold days that flare allergies and asthma. Also, when asked if they would like to extend participation to phase 2 of the study, all 7 participants elected to continue to participate for the additional 10 weeks.
Study Aim 4: Examination of Change in Study End Points
As shown in Table 3, the mean CRF severity scores before surgery for NSCLC began at 3.3 (SD, 1.7) and increased to a mean CRF severity score of 4.8 (SD, 2.9) after surgery prior to the start of the exercise intervention. However, mean CRF severity scores showed a pattern of decline from postsurgery baseline through the end of week 4 (mean, 2.4 [SD, 1.9]) of the exercise intervention. A subtle increase in the mean CRF severity score at the end of weeks 5 (mean, 2.5 [SD, 1.7]) and 6 (mean, 2.8 [SD, 2.8]) occurred when chemotherapy began on average 4.8 weeks after the start of the exercise intervention for 4 of 7 participants. All participants stated that the exercise intervention helped them manage their fatigue, with 1 participant stating “It gave me a lot of strength so I could keep going.” Another participant stated, “I really believe that it helped me very much. I don’t believe I would have gotten the same result without it.” A third participant stated “I would recommend the program to everyone.”
PERCEIVED SELF-EFFICACY FOR FATIGUE SELF-MANAGEMENT
As shown in Table 3, at both presurgery and postsurgery baseline, the mean PSEFSM score was 7, indicating an acceptable level of ability to manage fatigue. However, at postsurgery baseline, the SD increased from 1.5 to 2.2, showing an increased range in scores over presurgery baseline. The mean PSEFSM score declined after week 1 of the intervention and continued to decline to a mean score of 5.4 (SD, 2.3) after week 2. This decline in PSEFSM corresponded to increasing mean CRF scores of 4.0 to 4.3 from week 1 to week 2. However, after week 3, the mean CRF score decreased from 4.3 to 3.7, whereas PSEFSM had its most significant increase in mean PSEFSM from 5.4 to 7.7. As CRF continued to improve in week 4 to a low of 2.4, PSEFSM reached its highest level with a mean of 8.8. As some participants began chemotherapy over weeks 5 and 6, PSEFSM decreased from 8.8 to 8.3 as CRF increased from a mean of 2.5 to 2.8. Note that all PSEFSM levels exceeded presurgical levels from weeks 3 through 6.
PERCEIVED SELF-EFFICACY FOR WALKING DURATION
As shown in Table 4, the mean PSE for walking 30 minutes at presurgery baseline was 96.4% (SD, 6.1%) and dropped more than 50% to a postsurgery mean of 47.4% (SD, 22.6%) prior to the start of the intervention. With each week of the intervention, the mean score for walking 30 minutes continued to build until it nearly achieved presurgery levels at week 6 with a mean of 93.3% (SD, 10.9%), with all participants reporting acceptable confidence levels (≥70%) to walk 30 minutes at a light intensity without stopping, with 5 of 7 reporting a greater than 90% confidence level.
PERCEIVED SELF-EFFICACY FOR BALANCE
As depicted in Table 4, similar to the participant’s PSE for walking 30 minutes, the participant’s mean level of balance confidence decreased from a presurgery mean of 86.0% (SD, 18.6%) to a postsurgery mean of 72.8% (SD, 20.5%) prior to the start of the intervention. The participant’s mean PSE for balance score returned to near presurgery levels, with a mean of 84% (SD, 18.2%) by week 3 and remaining stable to week 6 with a mean of 83.7% (SD, 24.8%).
CANCER-RELATED FATIGUE SELF-MANAGEMENT BEHAVIOR VIA WALKING AND BALANCE EXERCISE
As shown in Table 5, the mean minimum prescription for walking increased, with all participants walking 5 min/d, 5 days a week for the first week, and incrementally increasing to 25 (SD, 4.0) min/d (range, 20–30 min/d). Participants exceeded the minimum walking prescription with a mean walking time of 5.3 (SD, 0.48) min/d (range, 5–6.3 min/d) during the first week of exercise and increased walking time to 26.1 (SD, 4.6 min/d; range 20–31.2 min/d) during the last week of the exercise intervention. Participants’ mean minimum number of prescribed balance exercises per day was set at 3 initially and remained relatively constant through the 6-week intervention. Participants exceeded the minimum number of prescribed balance exercises per day, averaging 4 balance exercises per day throughout the study.
The mean level of steps taken per day increased from week 1 (mean, 4650 [SD, 3105] steps) through week 6 (mean, 6393 [SD, 3752] steps) (Table 6).
The results of this feasibility study demonstrate that a home-based, light-intensity walking and balance exercise intervention for patients immediately following discharge from the hospital after surgery for NSCLC is feasible, safe, well tolerated, and highly acceptable. Likewise, the results indicated that the intervention positively impacted end points such as CRF severity; PSE for fatigue self-management, walking, and balance; CRF self-management behaviors (walking and balance exercise); and functional performance (number of steps taken per day). Relative to functional performance, there was some speculation that the number of steps taken each day by study participants may decrease with increased intervention walking durations. That was not the case in this feasibility study as participants increased their daily walking activity at the same time they were increasing their intervention walking duration. This is consistent with the expectation that increased functional capacity through exercise would increase functional performance.60 Likewise, there was speculation that the initiation of adjuvant chemotherapy and/or radiation therapy would trigger the cessation from the exercise intervention. However, this was not the case as participants continued the exercise intervention. Likewise, the question of whether participants would continue to want to exercise after phase 1 was answered as all 7 participants elected to participate in phase 2 of the study, which extended the intervention an additional 10 weeks. Also, because CRF is one of the most frequently reported and distressing symptoms for persons with NSCLC, the findings that PSEFSM and CRF severity improved to levels better than presurgical levels with the incorporation of a safe, well-tolerated and highly acceptable PSEFSM-enhancing intervention are promising. Moreover, being able to provide an intervention to a highly vulnerable population (postsurgical NSCLC participants) within days of discharge from the hospital could provide a means for rehabilitation that does not currently exist.
To date, postsurgical exercise interventions for the cancer population have been initiated much later in the recovery period; consisted of moderate to vigorous intensity; were longer in duration (>10 weeks); were structured, inpatient or facility based; and have not incorporated transitional plans from hospital to home to address fatigue.21,24–26 The literature indicates that adoption of exercise even in healthy populations is difficult and requires PSE to engage in exercise.33 Consequently, this exercise intervention was designed mindful of the challenges that both healthy persons and those recovering from NSCLC surgery would face in an effort to enhance PSE for CRF self-management to augment their rehabilitation. Thus, the exercise intervention in this study was designed to span 6 weeks starting promptly after hospital discharge extending to a critical juncture where patients may transition to initiation of adjuvant therapy (eg, chemotherapy, radiation therapy) and/or can increase to more demanding physical activity levels (eg, greater lifting, pushing, pulling). In addition, the exercise intervention was initiated promptly after discharge from the hospital, knowing that CRF can be induced by many factors including becoming less active, which knowingly occurs when a person is hospitalized after undergoing surgery for NSCLC. Our pressing rehabilitation concern was driven by the follow-up results of the renowned Dallas Bedrest and Training Study conducted in 1966.61 In the follow-up study conducted by McGuire et al,62 the short-term effects of 3 weeks of bed rest in 5 healthy young men at age 20 years in 1966 were found to be more profound than 30 years of aging, highlighting the deleterious effects that inactivity can have on a patient. In this current study, with participants having a mean hospital stay of 7.8 days, the immediacy of the intervention for NSCLC patients is deemed critical. Also, to promote the initiation of exercise for participants after surgery, we used a light-intensity, less-than-3.0 metabolic equivalents, rather than a moderate- to vigorous-intensity walking and balance exercise, which corresponds to usual activities of daily living.38 The American College of Sports Medicine,23,63 the American Heart Association,64 and the American Cancer Society22 recommend that persons who are sedentary, deconditioned, recovering from surgery, and with multiple comorbid conditions first focus on developing a habit of regular exercise including walking in order to complete usual activities of daily living. Likewise, balance exercises were combined with walking because balance exercises when combined with walking have been found to have a positive effect on balance as well as walking confidence and speed.
Strengths and Limitations
This single-arm feasibility study was intentionally planned with a sample size of 5 to 10 participants. To the best of our knowledge, this was the first home-based exercise intervention conducted immediately following discharge from the hospital after surgery for NSCLC, which includes patients transitioning to adjunct treatment with chemotherapy alone or combined with radiation therapy. However, this study does have limitations, including the small sample size and the nonrandomized controlled design. Consequently, observed changes in study end points may be explained by the natural course of postoperative recovery. Also, no biochemical verification was used to confirm self-report of smoking status. The study was bounded by time with baseline assessment occurring before and after surgery prior to the intervention with the addition of a symptom assessment screen to ensure all participants were safe to initiate the intervention with key symptoms (pain, nausea, vomiting, and dyspnea) at a similar level of symptom severity. In addition, collecting data on key variables on a daily and weekly basis tightened the ability to observe changes that occurred over time. The study provided variation in participant ages, income, and education levels and included both men and women. Participants had a range of performance status scores prior to surgery and an array of comorbid conditions from a minimum of 2 to a high of 12. All participants were white, with the exception of 1 minority candidate who was successfully recruited but subsequently deemed ineligible because of exacerbation of an existing comorbid condition at baseline assessment. The sample included participants with each stage of NSCLC from IA through IIIA with varied histology. Although the study provided for the inclusion of varied types of surgical procedures, all patients underwent a lobectomy. Postsurgical treatment trajectories varied, with some participants requiring no further treatment, some requiring chemotherapy, and one other requiring both chemotherapy and radiation. In addition, the study was conducted in 2 participating sites within a single organization as the tertiary care center.
To date, postsurgical NSCLC patients with multiple comorbid conditions have been left with no standard rehabilitation options. The findings from this home-based exercise intervention feasibility study indicate that it is not only feasible and safe for these very sick patients to exercise immediately upon discharge from the hospital, but it is also acceptable to the patients, and they will adhere to the exercise for up to 6 weeks even through the initiation of adjuvant chemotherapy and/or radiation therapy. Likewise, when given the option, all participants opted to extend the intervention for an additional 10 weeks, indicating their enthusiasm for the intervention. As such, postsurgical NSCLC patients can be equipped with a light-intensity, self-paced walking and balance program that may have a long-lasting impact on the reduction of CRF and the prevention of further development of CRF. Having an intervention that is readily available in the home and can be implemented within days of returning home from the hospital provides patients with empowerment that they can do something to directly impact the quality of their health. The intervention’s utilization of a nurse to assess the participant’s readiness to start exercise and assist the participant in addressing his/her symptoms (should they preclude the participant from initiating exercise) is critical to the success of the intervention. Participants within this feasibility study reported a feeling of being alone and sad after returning home, and the nurse was able to fill this void and provide a continuum of care to help initiate the intervention and to provide support (eg, advise participant to call physician) if any symptoms or clinical problems were unmanaged. The nurse’s weekly calls providing self-efficacy–enhancing support to the participant also proved valuable for participants not knowing what to expect relative to their symptoms and their exercise progress. Because NSCLC participants are among the most vulnerable and may be further compromised by comorbidities, should this intervention prove efficacious, it could also be generalizable across similar vulnerable populations that currently have few or no rehabilitation options. Moreover, a home-based program with a light-intensity exercise program during the initial weeks upon discharge from the hospital is practical because the intensity of the program falls within their current prescribed physical activity level. Likewise, participants within this feasibility study continued the home-based program through the initiation of their adjuvant chemotherapy and/or radiation therapy without any issues as the intensity of the program continued to fall within their prescribed physical activity level. Additionally, patients report that traveling outside the home is often physically challenging and wrought with difficulty in finding someone to assist in helping them to make appointments. Last, further research should focus on a 2-arm study comparing the effects of this exercise intervention to a usual care group with a larger sample size. This feasibility study was valuable in progressing toward this goal by allowing our team to assess the key processes, procedures, resources, and research information (eg, that performance status was more critical than stage of cancer when assessing for readiness to start the exercise intervention) relative to the specific aims.
This feasibility study provided our team with significant insight into whether a home-based exercise intervention would be feasible for a very vulnerable postsurgical NSCLC population. First, understanding and adjusting the eligibility criteria were significant in meeting our recruiting goals, which can be leveraged when applied to a larger randomized controlled trial (RCT). Next, learning that the intervention was highly acceptable and safe and that participants adhered to the exercise intervention through surgical recovery and subsequent initiation of chemotherapy and/or radiation therapy provides important data to justify that this intervention may be feasible, safe, and acceptable when applied to a larger RCT population. Likewise, knowing that upon conclusion of this study all 7 participants volunteered to continue with phase 2 of the study and extend for another 10 weeks was a strong endorsement of the value the participants believed they received from the intervention and its subsequent impact on study end points including their fatigue. The participants’ commitment to participate for an additional 10 weeks provides further data justifying that this intervention study is worthy of extension to a larger RCT population. The success of this feasibility study can be attributed to its basis in theory.
The synthesized theoretical framework was useful to guide our team through the details necessary to address the complex patient needs inherent in persons with NSCLC after thoracotomy. In particular, this patient population is susceptible to breakdowns during the critical transition when discharged from the hospital to home. Following principles of the Transitional Care Model provided an approach that facilitated the implementation of an empowering exercise intervention to promote CRF self-management immediately after discharge to expedite the rehabilitation of an already debilitated population. The TSSM provided a unique framework indicating that a person’s perception of ability to implement behaviors to manage difficult symptoms such as CRF can have a positive impact on the difficult symptom and functional performance. As found in this study, a trend was demonstrated—the stronger the participants believed that they could manage their CRF and implement walking and balance exercises, the greater the improvement in CRF severity, and the greater the implementation of exercise and increase in steps per day (functional performance). Consequently, equipping people to believe that they can exercise under taxing circumstances such as the immediate postthoracotomy recovery period in the NSCLC population is a pivotal step leading to the self-management of symptoms such as CRF. In essence, this study shows preliminary evidence that when participants believed they could address their CRF severity, they implemented the CRF self-management behaviors (walking and balance exercise) and persevered (as shown over time) in implementing these behaviors to reduce CRF severity. As a result, this feasibility study met each of its aims, indicating that the intervention was feasible, safe, and acceptable and showed positive changes in study end points, providing data justifying its extension to a larger RCT study population for further evaluation.
The authors express appreciation for the expertise and support in this effort from the following residing in the Grand Rapids, Michigan, area: the Office of West Michigan Cardiothoracic Surgeons, the Pulmonary Rehabilitation Department and cardiothoracic discharge nurses at Spectrum Health, and the Lung Multispecialty Team at Lemmen-Holton Cancer Pavilion at Spectrum Health.
1. Brown J, Cooley ME, Chernecky C, Sarna L. A symptom cluster and sentinel symptom experienced by women with lung cancer. Oncol Nurs Forum. 2011; 38: E425–E435.
2. Sarna L, Cooley M, Brown J, Chernecky C, Elashoff D, Kotlerman J. Symptom severity 1 to 4 months after thoracotomy for lung cancer. Am J Crit Care. 2008; 17: 455–468.
3. Sanders S, Bantum E, Owen J, Thornton A, Stanton A. Supportive care needs in patients with lung cancer. Psychooncology. 2010; 19: 480–489.
4. Li J, Girgis A. Supportive care needs: are patients with lung cancer a neglected population? Psychooncology. 2006; 15: 509–516.
5. Maliski S, Sarna L, Evangelista L, Padilla G. The aftermath of lung cancer: balancing the good and bad. Cancer Nurs. 2003; 26: 237–244.
8. Gupta D, Lis C, Grutsch J. The relationship between cancer-related fatigue and patient satisfaction with quality of life in cancer. J Pain Symptom Manag. 2007; 34: 40–47.
9. Berger A, Abernethy A, Atkinson A, et al. Cancer-related fatigue. J Natl Compr Canc Netw. 2010; 8: 904–931.
10. Cooley M. Symptoms in adults with lung cancer: a systematic research review. J Pain Symptom Manag. 2000; 19: 137–153.
11. Cooley M, Short T, Moriarty H. Patterns of symptom distress in adults receiving treatment for lung cancer. J Palliat Care. 2002; 18: 150–159.
12. Cooley M, Short T, Moriarty H. Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer. Psychooncology. 2003; 12: 694–708.
13. Given C, Given B, Azzouz F, Kozachik S, Stommel M. Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients. J Pain Symptom Manag. 2001; 21: 456–466.
14. Handy J, Asaph J, Skokan L, et al. What happens to patients undergoing lung cancer surgery? Chest. 2002; 122 (1): 21–30.
15. Gift A, Stommel M, Jablonski A, Given C. A cluster of symptoms over time in patients with lung cancer. Nurs Res. 2003; 52: 393–400.
16. Ferguson M, Parma C, Celauro A, Vigneswaran W. Quality of life and mood in older patients after major lung resection. Ann Thorac Surg. 2009; 87: 1007–1013.
17. Win T, Sharples L, Wells F, Ritchie A, Munday H, Laroche C. Effect of lung cancer surgery on quality of life. Thorax. 2005; 60: 234–238.
18. Brunelli A, Socci L, Refai M, Salati M, Xiume F, Sabbatini A. Quality of life before and after major lung resection for lung cancer: a prospective follow-up analysis. Ann Thorac Surg. 2007; 84: 410–416.
19. John L. Self-care strategies used by patients with lung cancer to promote quality of life. Oncol Nurs Forum. 2010; 37: 339–348.
20. Granger C, Denehy L. Exercise interventions following surgery for non–small cell lung cancer: the need for randomised controlled trials. Lung Cancer. 2010; 70: 228–229.
21. Jones L, Eves N, Kraus W, et al. The lung cancer exercise training study: a randomized trial of aerobic training, resistance training, or both in postsurgical lung cancer patients: rationale and design. BMC Cancer. 2010; 10: 155.
22. Doyle C, Kushi L, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society Guide for Informed Choices. CA-Cancer J Clin. 2010; 56: 323–353.
23. Thompson W, ed American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
24. Cesario A, Ferri L, Galetta D, et al. Post-operative respiratory rehabilitation after lung resection for non–small cell lung cancer. Lung Cancer. 2007; 57: 175–180.
25. Jones L, Eves N, Peterson B. Safety and feasibility of aerobic training on cardiopulmonary function and quality of life in postsurgical non–small cell lung cancer patients: a pilot study. Cancer. 2008; 113: 3430–3439.
26. Spruit M, Janssen P, Willemsen S, Hochstenbag M, Wouters E. Exercise capacity before and after an 8-week multidisciplinary inpatient rehabilitation program in lung cancer patients: a pilot study. Lung Cancer. 2006; 52: 257–260.
27. Naylor M, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders a randomized clinical trial. JAMA. 1999; 281: 613–620.
28. Naylor M, Brooten D, Campbell R, Maislin G, McCauley K, Schwarz J. Transitional care of older adults hospitalized with heart failure: a randomized controlled trial. JAGS. 2004; 52: 675–684.
30. Schwartz A. Fatigue mediates the effects of exercise on quality of life. Qual Health Res. 1999; 8: 529–538.
31. Courneya K, Friedenreich C, Arthur K, Bobick T. Physical exercise and quality of life in postsurgical colorectal cancer patients. Psychol Health Med. 1999; 4: 181–187.
32. Kangas M, Bovbjerg D, Montgomery G. Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychol Bull. 2008; 134: 700–741.
33. Bandura A. Self-efficacy: The Exercise of Control. New York, NY: W. H. Freeman and Company; 1997.
35. Hoffman AJ. Enhancing self-efficacy for optimized patient outcomes through the Theory of Symptom Self-management. Cancer Nurs.
2012. Publish ahead of print, doi: 10.1097/NCC.0b013e31824a730a.
36. Hoffman A, von Eye A, Gift A, Given B, Given C, Rothert M. Testing a theoretical model of perceived self-efficacy for cancer-related fatigue self-management and optimal physical functional status. Nurs Res. 2009; 58: 32–41.
37. National Comprehensive Cancer Network. National Comprehensive Cancer Network Guidelines Cancer Related Fatigue Version 1. 2011. http://www.nccn.org/index.asp
. Accessed January 25, 2011.
38. Ainsworth B, Haskell W, Whitt M, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000; 32: S498–S504.
39. Steadman J, Donaldson N, Kalra L. A randomized controlled trial of an enhanced balance training program to improve mobility and reduce falls in elderly patients. JAGS. 2003; 51: 847–852.
40. Anacker S, DeFabio R. Influence of sensory inputs on standing balance in community dwelling elders with a recent history of falling. Phys Ther. 1992; 72: 575–581.
41. Jonas S, Phillips E, eds. American College of Sports Medicine’s Exercise Is Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
42. Katz J, Chang L, Sangha O, Fossel A, Bates D. Can co-morbidity be measured by questionnaire rather than medical record review? Med Care. 1996; 34: 73–84.
45. Ganz P, Haskell C, Figlin R, LaSoto N, Siau J. Estimating the quality of life in a clinical trial with metastatic lung cancer unsing the Karnofsky Performance Status and the Functional Living Index–Cancer. Cancer. 1988; 61: 849–856.
46. Jones L, Peddle C, Eves N. Effects of presurgical exercise training on cardiorespiratory fitness among patients undergoing thoracic surgery for malignant lung lesions. Cancer Nurs. 2007; 110: 590–598.
47. Jones L, Eves N, Peterson B. Safety and feasibility of aerobic training on cardiopulmonary function and quality of life in post-surgical non–small cell lung cancer patients: a pilot study. Cancer. 2008; 113: 3430–3439.
48. Mock V, Grangakis C, Davidson N, et al. Exercise manages fatigue during breast cancer treatment: a randomized controlled trial. Psychooncology. 2005; 14: 464–477.
49. Rabin C, Pinto B, Dunsiger S, Nash J, Trask P. Exercise and relaxation intervention for breast cancer survivors: feasibility, acceptability and effects. Psychooncology. 2009; 18: 258–266.
50. Irwin M, Cadmus L, Alvarez-Reeves M, et al. Recruiting and retaining breast cancer survivors into a randomized controlled exercise trial: the Yale Exercise and Survivorship Study. Cancer. 2008; 112: 2593–2606.
51. Mendoza T, Wang S, Cleeland C, et al. The rapid assessment of fatigue severity in cancer patients: use of the brief fatigue inventory. Cancer. 1999; 85: 1186–1196.
53. Hoffman A, von Eye A, Gift A, Given B, Given C, Rothert M. The development and testing of an instrument for perceived self-efficacy for fatigue self-management. Cancer Nurs. 2011; 34: 167–175.
54. Rudolph D, McAuley E. Self-efficacy and perceptions of effort: a reciprocal relationship. J Sport Exerc Psychol. 1996; 18: 216–233.
55. Lajoie Y, Gallagher S. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg Balance Scale, and the Activities-Specific Balance Confidence (ABC) Scale for comparing fallers and non-fallers. Arch Gerontol Geriat. 2004; 38: 11–26.
56. Myers A, Fletcher P, Myers A, Sherk W. Discriminative and evaluative properties of the Activities-Specific Balance Confidence (ABC) Scale. J Gerontol. 1998; 53A: M287–M294.
57. Powell L, Myers A. The Activities-Specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995; 50A: M28–34.
58. Stel V, Smit J, Pluijm S, Visser M, Deeg D, Lips P. Comparison of the LSAS physical activity questionnaire with a 7-day diary and pedometer. J Clin Epidemiol. 2004; 57: 252–258.
59. Croteau K, Richeson N, Farmer B, Jones D. Effect of a pedometer-based intervention on daily step counts of community-dwelling older adults. Res Q Exercise Sport. 2007; 78: 401–406.
60. Leidy N. Functional status and the forward progress of merry-go-rounds: toward a coherent analytical framework. Nurs Res. 1994; 43: 196–202.
61. Saltin B, Blomqvist G, Mitchell J. Response to exercise after bed rest and after training: a longitudinal study of adaptive changes in oxygen transport and body composition. Circulation. 1968; 37/38 (suppl VII): 1–78.
62. McGuire D, Levine B, Williamson J, et al. A 30-year follow-up of the Dallas Bedrest and training study: effect of age on cardiovascular response to exercise. Circulation. 2001; 104: 1350–1357.
63. Schmitz K, Courneya K, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010; 42: 1409–1426.
64. Nelson M, Rejeski W, Blair S, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007; 39: 1435–1445.
Keywords:© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cancer-related fatigue; Exercise; Lung cancer; Theory of symptom self-management; Transitional care model; Virtual reality