Pharmacophore an International Research Journal
THE ROLE OF PHYSIOTHERAPY IN THE MANAGEMENT OF LYMPHOMA PATIENTS: SYSTEMATIC REVIEW
Saif Habib Mahmoud Jerbi1*, Sami Najeeb Shubat Alanazi2, Waad Alazri Shubat Alanazi2, Alanazi Yasser Hamoud Mutlaq3, Freh Sayah Mezal Alotaibi4, Maha Afat Hnde Alenezi5
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ABSTRACT
Patients diagnosed with lymphoma can experience many significant long-term effects, including fatigue and decreased QoL. This systematic review aims to investigate the published literature that discusses the role of physical therapy and exercise in the care of lymphoma patients. PubMed, Web of Science, Science Direct, EBSCO, and Cochrane library were searched. Study articles were screened by title and abstract using Rayyan QCRI then a full-text assessment was implemented. Fourteen studies were included, with a total of 2071 lymphoma patients. All the included studies demonstrated that exercise significantly improves the QoL of lymphoma survivors. The included studies reported that these programs improve the patient's mental health, improve average fatigue and overall quality of sleep, decrease limitations brought on by side effects such as peripheral neuropathy, and enhance patients' balance and mobility. We found that physical therapy and exercise dramatically improve the QoL of lymphoma survivors.
Keywords: Lymphoma, Exercise, Physiotherapy, Rehabilitation, Systematic review
Introduction
The global public health concern of cancer is significant. Lymphoma is one of the most prevalent cancer kinds [1]. Lymphomas are hematological malignancies that develop in the lymph nodes and immune system tissues of the body. They come in a variety of subtypes with different biological and clinical characteristics. Non-lymphoma Hodgkin's (NHL) and Hodgkin's lymphoma (HL) are the two primary subtypes (NHL). In recent decades, the development of monoclonal antibody therapy targeted against cell surface molecules expressed on the majority of NHL cells has played a significant role in the rapid improvement in lymphoma survival rates [2].
The number of cancer survivors has increased as a result of advancements in cancer detection and therapy. Patients with lymphoma are typically treated with chemotherapy, sometimes in conjunction with radiation therapy, which can have a number of serious long-term and late effects, such as fatigue, disturbed sleep, neuropathy, physical loss, chronic pain, depression, anxiety, and a decreased quality of life (QoL) [3, 4].
To help enhance QOL and physical function, physical therapy intervention has been promoted as a part of the multidisciplinary approach. It is difficult for rehabilitation professionals because the PT intervention mostly depends on the treatment regimen, accompanying problems, and influence on patients' function. A recent systematic review found that patients' fatigue, psychiatric symptoms, and QOL improved as a result of aerobic endurance training, sensorimotor training, and strength training [5].
Numerous studies have demonstrated the benefits of physical activity in reducing the symptoms of several chronic conditions, including type II diabetes and obesity [6], as well as in some malignancies, including breast, ovarian, colon, and lung cancer [7-9]. However, because they have significant anemia and thrombocytopenia, lymphoma patients have always been prohibited from exercising. The impact of exercise on cancer patients has been the subject of numerous system reviews and meta-analyses.
Rebecca et al. [10] analyzed 102 study articles in 2010, 90% were randomized controlled trials (RCTs), and 6% were lymphomas. Nearly 40% of the interventions have a duration of more than 3 months. During and after cancer treatment, they discovered slightly to moderately favorable impacts of physical activity on the improvement of life quality, physical activity levels, anxiety, and self-esteem.
Many previous studies suggested that exercise programs positively affect the QoL of lymphoma patients, including the patients' fatigue and psychomotor activities. This systematic review aims to study the published literature investigating the effect of physiotherapy and exercise in managing patients with lymphoma.
Materials and Methods
Preferred Reporting Items for Systematic Reviews and Meta-Analyses, (PRISMA) guidelines were used as the points of reference for the current review.
Study Design
The review was systematic.
Study Duration
The month of April through to May 2022.
Study Condition
This review investigates the effect of physiotherapy and exercise in the management of patients with lymphoma.
Search Strategy
PubMed, Science Direct, Cochrane Library, Web of Science, and EBSCO were thoroughly searched in order to identify the pertinent literature. Only English-based works were considered in the search which followed the specific requirements for each database. "Lymphoma," "Hodgkin lymphoma," "Non-Hodgkin lymphoma," "Hematological cancers," "Physical therapy," "Physiotherapy," "Exercise programs," and "Rehabilitation" were some of the Mesh terms that were keyed into the PubMed database to look for the right studies. Boolean operators like "OR" and "AND" were employed to filter the results. The search returned freely available studies, full-text English publications, and human trials.
Selection Criteria
Inclusion Criteria
The papers chosen were selected based on the following criteria; male or female patients with lymphoma who underwent exercise programs to improve their life quality.
Exclusion Criteria
Any publications that were not focused on the current research were omitted.
Data Extraction
Duplicate results were fished from the search strategy using the Rayyan (QCRI) [11]. By restricting the combined search results based on the inclusion/exclusion criteria, the researchers were able to determine the bearing of the titles and abstracts. The reviewers looked over the papers that met the inclusion criteria while discussing ways to resolve conflicts. The qualifying studies were added using a made-up data extraction form. The study titles, authors, study year, study designs, participant count, mean age, cancer type, length of exercise programs, program type, and primary outcomes were all retrieved by the authors.
Strategy for Data Synthesis
Summary tables created from the data gathered from the eligible studies were given a qualitative overview of the included research components and results. Once the data for the systematic review were extracted, the most effective method for utilizing the data from the included study articles was selected. Studies that did not show the influence of exercise regimens on lymphoma patients were ignored.
Results and Discussion
Search Results
Ninety-two duplicates were removed from the total of 780 study articles retrieved by the systematic search. After the title and abstract screening, only 200 articles passed and they were enquired about for retrieval, with only 9 articles not being recovered. The full-text assessment was performed on the 191 studies whereby; 89 were dismissed for wrong study conclusions, 70 for unavailable data on the effect of physiotherapy on lymphoma patients, and 18 for the incorrect population type. This systematic review only included 14 appropriate studies. Figure 1 represents a summary of the selection procedure.
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Figure 1. PRISMA flowchart summarizes the study selection process |
Characteristics of the Included Studies
A total of 14 studies were included in this review, with 2071 patients with lymphoma who underwent various exercise programs. Eleven studies were RCTs [12-22], two were retrospective cohort studies [23, 24], and one was an observational study [25]. Physiotherapy and different exercise programs were applied to lymphoma patients. All the included studies demonstrated that exercise significantly improves the QoL of lymphoma survivors. Two studies reported that Self-directed exercise (SDE) improves the patients' mental health and their sense of emotional self-efficacy [14, 25]. Other studies found that physiotherapy decreases limitations brought on by side effects such as peripheral neuropathy, and enhances patients' balance, degree of physical performance, and mobility [15, 20, 21]. Chan-Chuang qigong exercise was found to improve average fatigue and overall quality of sleep [16, 17]. Vigorous exercise was linked to a dose-dependent reduction in the risk of CV events [23].
Table 1. A summary of characteristics of the included study articles.
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Study |
Country |
Study designs |
Participants (n) |
Male (n) |
Mean age |
Duration of program (weeks) |
Type of intervention |
Key findings |
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Hathiramani et al., 2021 [12] |
United Kingdom |
RCT |
46 |
17 |
61 ± 16.7 |
12 |
Relaxation and exercise programs |
Exercise or relaxation can considerably enhance QoL for lymphoma survivors. |
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Courneya et al., 2015 [13] |
Canada |
RCT |
122 |
69 |
53.2 |
12 |
The Healthy Exercise for Lymphoma Patients (HELP) Trial |
Increased progression-free survival in lymphoma patients may be related to supervised aerobic activity among lymphoma patients. |
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Vallerand et al., 2018 [14] |
Canada |
RCT |
51 |
20 |
52.6 ± 13.7 |
12 |
SDE and basing telephone counselling exercise |
Various mental health QoL scores showed clinically significant improvements. The program had a high level of approval from participants, demonstrating its broad acceptance among this group of cancer survivors. |
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Streckmann et al., 2014 [15] |
Germany |
RCT |
56 |
42 |
19-73 |
NA |
Physiotherapy as a common form of standardized clinical management |
Cancer patients can benefit from exercise, especially sensorimotor training, which is a practical and promising approach. It enhances patients' quality of life, decreases limitations brought on by side effects as peripheral neuropathy, and enhances patients' balance, degree of physical performance, and mobility. |
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Yeh and Chung et al., 2016 [16] |
Taiwan |
RCT |
102 |
57 |
59.79 ± 16.54 |
3 |
Chan-Chuang qigong exercise lasting 20-min twice per day |
The 21-day Chan-Chuang qigong exercise program dramatically improved average fatigue, worst fatigue, and overall sleep quality. |
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Chuang et al., 2017 [17] |
Taiwan |
RCT |
96 |
55 |
55.85 ± 16.78 |
3 |
Chan-Chuang qigong exercise lasting 20-min twice per day |
The 21-day Chan-Chuang qigong program can substantially reduce tiredness intensity and interference and enhance white blood cell counts, hemoglobin levels, sleep quality, and QoL. |
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Furzer et al., 2016 [18] |
Australia |
Prospective RCT |
37 |
NA |
48.9 ±13.1 |
12 |
Customized exercise plan with advanced cardiovascular and resistance training |
Following therapy, patients with hematological cancer benefited from this program in terms of extra outcomes and significant statistical and clinical improvements in cancer-related fatigue. |
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Van Dongen et al., 2019 [19] |
Netherlands |
Prospective RCT |
109 |
69 |
52 ±11 |
18 |
The supervised high-intensity combined resistance and interval exercise program |
This program had significant long-term positive effects on physical fitness and tiredness compared to standard care, but it was not a cost-effective intervention for society. |
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Courneya et al., 2009 [20] |
Canada |
RCT |
122 |
72 |
53.2 |
12 |
Supervised aerobic exercise training |
Without impairing medical treatments or responses, aerobic exercise training significantly improved crucial patient-rated outcomes and objective physical functioning in lymphoma patients. |
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Fischetti et al., 2019 [25] |
Italy |
Observational study |
36 |
12 |
54.4 ± 19.1 |
8 |
combined aerobic, resistance and postural exercises on both the psychological and physical fitness |
Exercise may lessen the perception of cancer-related fatigue, confirming its importance as a major preventive measure. It may also increase one's sense of emotional self-efficacy in controlling negative affect and expressing positive emotions. |
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Jones et al., 2014 [23] |
USA |
Retrospective cohort study |
1187 |
632 |
41.9 |
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Vigorous intensity exercise |
In survivors of HL, vigorous exercise was linked to a dose-dependent reduction in the risk of CV events, regardless of CV risk profile or treatment. |
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Cox et al., 2021 [24] |
Italy |
Prospective cohort study |
30 |
21 |
65.5 (median) |
16 |
Exercise training |
Exercise training is possible and safe during chemotherapy, even for patients over the age of 65. Additionally, it might enhance the delivery of care. |
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Gaser et al., 2022 [21] |
Germany |
RCT |
41 |
27 |
10.4 ± 4.0 |
3.5 |
Tailored exercise program |
Exercise programs were successful in maintaining daily living activities and motor function during intensive therapy. In contrast, regular strength training interventions throughout therapy tend to be more advantageous in muscle explosive and endurance strength. |
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Zimmer et al., 2014 [22] |
Germany |
RCT |
36 |
27 |
62.23 ± 13.09 |
NA |
exercising for 30 minutes at a moderate level on a bicycle ergometer |
Exercise has the potential to alter cytokine levels, which could alter the epigenetic patterns of tumour-competitive lymphocytes. |
This systematic review investigated the available published literature regarding the effect of physiotherapy and exercise in patients diagnosed with lymphoma with reference to the improvements in psychological status, QoL, physical performance, fatigue, and sleep quality. The review yielded 14 with variable methodological quality and sample sizes. These studies showed significant diversity in the inclusion criteria for diagnosis.
Our study reported that physiotherapy/ physical activity significantly improves the QoL of lymphoma survivors. Exercise's impact on health-related QoL in adult cancer survivors following treatment was examined by Mishra et al. [26] in 2012. The results of 40 randomized controlled or controlled trials involving 3694 cancer patients suggest that exercise may improve health-related QoL, although further research is necessary due to high variability. Additionally, the authors advise concentrating on a single cancer type in order to examine its biggest effects on QoL. In 2014, Bergenthal et al. [27] carried out a review that comprised 9 RCTs and 818 patients with hematological malignancies. They discovered no discernible difference in mortality between the exercise intervention and control groups.
While physical functions, weariness, and depression can all be improved via exercise, adverse events, physical performance, and anxiety cannot. In 2018, 4519 cancer survivors from 34 randomized exercise trials were aggregated by Buffart et al. [28]. They discovered that the best ways to improve QoL and muscle strength were to target particular subgroups with high levels of fatigue and poor levels of self-reported physical functioning. The lymphoma survivors, however, were the subject of few investigations. According to some studies, CRF cannot be eased by rest because of its putative connections to biochemical/inflammatory alterations or because it is defined by its subjective property [29].
Additionally, there are conflicting studies on the link between physical activity and improved life quality and cancer risk reduction. In a 12-week multi-center randomized controlled trial conducted by Elizabeth et al., it was discovered that physical and psychosocial interventions had no impact on psychosocial function or health-related quality of life (HrQoL) in children with cancer, with the exception of parental reported pain and procedural anxiety [30].
We also found that these exercise programs positively affect mental health [14, 25], and decrease side effects such as peripheral neuropathy, and enhance patients' balance, degree of physical performance, and mobility [15, 20, 21].
Two studies [16, 17] used a mind-body practice called qigong employs both exercise and meditation to synchronize the body, mind, and spirit [31]. Qigong is an essential component of traditional Chinese medicine and is practiced regularly to avoid illness, enhance health, and increase vitality. Any age or physical condition can learn the qigong exercises, which include breathing, meditation, intention, and rhythmic movements [32]. These studies reported that Chan-Chuang qigong exercises dramatically improved average fatigue, worst fatigue, and overall sleep quality. Additionally, they enhance white blood cell counts and hemoglobin levels [16, 17].
According to a number of earlier research, qigong has therapeutic advantages for cancer patients, including the reduction of symptom severity and psychological anguish [33]. In addition to reducing fatigue, leucopenia, and depression, qigong also enhances mood, inflammation, and quality of life [21]. However, a comprehensive study by Lee et al. [31] found no evidence to support the usefulness of qigong in the treatment of cancer.
Conclusion
This systematic review reported that physical therapy and exercise dramatically improve the QoL of lymphoma survivors. We also found that these exercise programs positively affect mental health, average fatigue, overall quality of sleep, and decrease side effects such as peripheral neuropathy, and enhance patients' balance, degree of physical performance, and mobility.
Acknowledgments: Many thanks to Dr. Saif Habib Mahmoud Jerbi; Registrar of Physical Medicine and Rehabilitation, North Medical Tower Hospital, Arar, Saudi Arabia, for his continuous help, support and encouragement to complete this work.
Conflict of interest: None
Financial support: None
Ethics statement: None
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