Improving Sleep Quality for Cancer Patients: Benefits of a Home-Based Exercise Intervention

1. Improving Sleep Quality for Cancer Patients: Benefits of a Home-Based Exercise Intervention Mei-Fang Tang, RN, MS, Wan-Fang Hospital, Taipei, Taiwan

2. Journal : Supportive Care In Cancer(2009.9) Authors : 1.Mei-Fang Tang, RN, MS, Wan-Fang Hospital, Taipei, Taiwan 2.Tsan-Hon Liou, MD, PhD, Shuang-Ho Hosptial, Taipei, Taiwan 3.Chia-Chin Lin, RN, PhD, Professor, School of Nursing, Taipei Medical University; Taipei Medical University Hospital, Taipei, Taiwan

3. Introduction • Exercise as an intervention has been suggested as having the potential to improve sleep quality (Sherrill DL, et al;1998). • In large surveys, up to 80% of people spontaneously report exercise as a factor that promotes sleep quality (Shapiro CM, et al ;1988)

4. Introduction • Poor sleep quality is a common and distressing problem for cancer patients. • Patients with cancer often report that their sleep is disturbed during the stressful periods associated with diagnosis, treatment side effects, and physical discomfort(Espie CA, et al ;2008).

5. Introduction • Payne et al.(2008) allocated 20 women with breast cancer who were receiving hormonal treatment to usual care or a home-based walking exercise Intervention. Self-reported sleep quality improved in the exercise group.

6. Purpose 1) To determine the effect of a home-based walking exercise program on the sleep quality and quality of life of cancer patients. 2)To determine if enhanced sleep quality was associated with improvement in quality of life over time.

7. Hypothesized • A home-based walking exercise would have beneficial effects on sleep quality and quality of life.

8. Methods-- Study Design • A prospective, longitudinal, two-arm, randomized clinical trial designed • A home-based walking exercise for cancer patients on sleep quality and quality of life. • Participants were allocated either to usual care (n = 35) or the walking exercise intervention group (n = 36).

9. Methods--Setting and Participants- • Participants were recruited from the oncology outpatient clinics of two teaching hospitals in Taipei, Taiwan.

10. Participants -- criteria (1) Have been diagnosed with cancer (2) Over the age of 18 years (3) Have complained of sleep disturbance with a PSQI score > 5 (4) No neuromuscular deficits that would contraindicate a walking exercise intervention

11. Participants -- criteria (5) No uncontrolled hypertension, cardiac or psychiatric illness. (6) Blood pressure less than 140/90 mmHg (7) Have not regularly undertaken more than one session of moderate intensity exercise each week over the past six months.

12. Participants -- criteria (8) Were approved for participation by their oncologists. (9) Are able to communicate in Mandarin or Taiwanese.

13. Methods -- Exercise training booklet • The 8-week time period was based on previous exercise research among cancer patients. • Patients were instructed to walk at a pace that was faster than normal and based on ratings of perceived exertion (RPE; 11–13).

14. Methods -- Exercise training booklet • Three days a week, for 30 minutes a day in the evening before supper(4:00 p.m. to 6:00 p.m.). • A five-minute warm up and finish with a five-minute cool down, after completing the 30-minute walking program.

15. Procedure • Patients were informed consent a baseline assessment . • Randomly assigned to either the experimental or control group . • Data collect from each patient during the initial visit (baseline) and two follow-up visits(1 and 2months).

16. Randomly Assigned (N=72) Exercise Group n=37 Control Group n=35 Allocation n=35 Discontinued (n=0) Baseline Assessment n=36 Not interested (n=1) n=35 Lost to follow-up (n=0) n=36 Lost to follow-up (n=0) First Follow-up n=35 Lost to follow-up (n=0) n=24 Lack of motivation (n=5) Discomfort (n=4) Insufficient time (n=3) Second Follow-up Figure 1 Flow diagram of participants’ progress through the study phases.

17. Methods -- Measures • The Taiwanese version of the Pittsburgh Sleep Quality Index • The Medical Outcomes Study Short Form-36 • The Taiwanese Version Ratings of the Perceived Exertion Scale, (RPE) • A walking exercise log

18. The Taiwanese version of the Pittsburgh Sleep Quality Index • Global PSQI score ranging from of 0∼21 • Including 19 items, each weighted equally on a 0∼3 scale. • Higher scores indicate poorer sleep quality.

19. The Taiwanese version of the Pittsburgh Sleep Quality Index seven component scores: • subjective sleep Quality • sleep latency • sleep duration • habitual sleep efficiency • sleep disturbances • sleeping medication use • daytime dysfunction.

20. The Medical Outcomes Study Short Form-36 • Lower scores indicate poorer life quality. • Physical Component Summary (PCS) • Mental Component Summary (MCS)

21. The Medical Outcomes Study Short Form-36 Physical Component Summary (PCS) • Physical Functioning (PF) • Role-Physical (RP) • Bodily Pain (BP) • General Health (GH)

22. The Medical Outcomes Study Short Form-36 Mental Component Summary (MCS) • Vitality (VT) • Social Functioning (SF) • Role-Emotional (RE) • Mental Health (MH)

23. The Taiwanese Version Ratings of the Perceived Exertion Scale, (RPE) • Exertion ratings range from 6 (resting) to 20 (very, very hard).

24. walking exercise log Patients were asked to complete walking exercise logs daily. Rentering ratings of ： • perceived exertion • exercise performed • duration of exercise • any symptoms experienced

25. Analysis • Generalized Estimating Equation(GEE) method was used to analyze whether the exercise program effectively improved patients' sleep quality and quality of life4 and 8 weeks following afterward.

26. Results • Patients in the exercise group reported significant improvements in sleep quality (β=−3.54, p<0.01) • Among patients who exercised, enhanced sleep quality also corresponded with reduced bodily pain (β=0.98,p=0.04) • Improvements over time in the mental health dimension of quality of life (β=−3.87, p<0.01).

27. Results • Demographic and Disease-related Information(Table 1) • GEE Model of Quality of Sleep, the PCS Score, and the MCS Score (Table 2 ) • Univariate Analysis of Changes in Sleep Quality in Relation to Quality of Life in the Exercise Group by GEE Method (Table 3)

28. Results • Changes in Sleep Quality (PSQI Score) in the Exercise and Control Groups (Figure 2 ) • Changes of Physical Component Summary (PCS) Scores of Quality of Life in the Exercise and Control Groups (Figure 3 ) • Changes in Mental Component Summary (MCS) Scores of Quality of Life in the Exercise and Control Groups(Figure 4 )

29. Conclusions • A home-based walking exercise program can be easily incorporated into care for cancer patients who are suffering from sleep disturbances. • Home-based walking exercise program improves sleep quality and quality of life.

30. Conclusions • Improvements in quality of life may in part be mediated by sleep. • Enhanced sleep quality also contributed to reduce bodily pain and improvements in the mental health dimension of quality of life.

31. Thank you for Attention