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The effect of two exercise programs on the rehabilitation of individuals with colorectal cancer in an inpatient setting in Germany

©2004 Doktorarbeit / Dissertation 134 Seiten


Research in the field of exercise therapy for cancer patients primarily focused on individuals with breast cancer who receive exercise interventions under outpatient conditions. This research study investigated individuals with colorectal cancer under inpatient conditions and aimed to broaden the application of exercise intervention treatments beyond that of breast cancer. The research included two study groups; standard exercise group (SEG, n=44) receiving indoor gymnastic exercise (IGE) and modified exercise group (MEG, n=39) receiving IGE plus additional outdoor walking activity. Participation in the specific exercise therapy program was independent of other therapies received in the inpatient rehabilitation program (IRP). The patients completed QOL questionnaires (QLQ-C30 & QLQ-CR38), psychological distress scale (HADS) and underwent treadmill stress-testing (TST) at the beginning (T1) and upon completion (T2) of the IRP. The QOL and the HADS questionnaires were administrated after a six month follow up (T3) proceeding the IRP completion.
Results indicate significant QOL and HADS improvements in pre to post-testing for both study groups. The TST results indicate superior improvements in the MEG in comparison to the SEG. Some of the T1 to T2 QOL and HADS improvement maintained at T3.
We conclude that 3 weeks IRP was adequate to reveal improvements in QOL, psychological measures and functional capacity. Future research should emphasize patient motivation for participation in physical activity after completing IRP.
This background chapter encompasses the different fields of knowledge which are relevant to the present study, starting with colorectal cancer (epidemiology, etiology, pathology and the International Classification of Functioning, Disability and Health), continuing with the subjects Quality of life, Movement and Sports in the Rehabilitation. The chapter ends with a review of previous physical activity and cancer studies.
Descriptive epidemiological knowledge of colorectal cancer is essential for understanding the etiology of the disease and is used in the process of developing screening methods. Large bowel carcinoma is one of the most common cancers in the western world (15% of all cancer cases) and despite advanced diagnostic and therapeutic methods, the prognosis is relatively poor (Faivre et al. 2002). The WHO classification supplies the mortality data of colon cancer separately from rectum cancer. […]


Table of Contents


List of Tables

List of Figures

1 Background
1.1 Epidemiology
1.1.1 Cancer Epidemiology - Germany
1.1.2 Colorectal cancer - Geographical distribution
1.2 The ICF
1.2.1 Functioning Activity and Participation
1.2.2 Application of the ICF
1.3 Etiology and Pathology
1.3.1 The Structure of Colon
1.3.2 The Colorectal Carcinoma Clinical symptoms for colorectal cancer Risk Factors Predisposing conditions: Inflammatory bowel diseases Colon Cancer Diagnosis Colon cancer staging Treatment of colorectal cancer Pre and post treatment symptom Rehabilitation
1.4 Quality of life
1.4.1 Quality of life in the oncological field
1.5 Movement and Sports in the Rehabilitation
1.5.1 Definitions
1.5.2 Aims
1.5.3 Movement and sport throughout the rehabilitation process
1.5.4 Framework to studying movement and sport through the cancer rehabilitation process
1.6 Physical activity and cancer – literature review
1.6.1 Descriptive studies
1.6.2 Intervention studies at the treatment time period
1.6.3 Intervention studies at the post treatment time period
1.6.4 Summary of the research in the field
1.6.5 Comparison of the current study with previous research Study sample Design The choice of the intervention program Outcome measures

2 Research Questions

3 Patients and Method
3.1 Design
3.2 Study Population
3.2.2 Patients demographics and cancer history
3.2.3 Participation in additional therapies within the rehabilitation clinic
3.3 The intervention program
3.4 Measuring instruments
3.4.1 Demographics and cancer history
3.4.2 Aerobic capacity
3.4.3 Pattern of exercise behavior before and after the disease
3.4.4 Quality of life variables The EORTC core questionnaire: QLQ-30 Colorectal cancer module: QLQ-CR38
3.4.5 The Hospital Anxiety Depression Scale (HADS)

4 Results
4.1 Statistics
4.2 Response rate
4.3 QLQ-C30
4.3.1 QLQ-C30 – Interval T1 to T2
4.3.2 QLQ-C30 – Interval T1 to T3
4.4 QLQ-CR38
4.4.1 QLQ-CR38 – Interval T1 to T2
4.4.2 QLQ-CR38 – Interval T1 to T3
4.5 Hospital Anxiety and Depression Scale (HADS)
4.5.1 HADS score – T1 to T2
4.5.2 HADS score - baseline to T3
4.6 Treadmill stress-test
4.7 Pattern of exercise behavior
4.8 Results summary

5 Discussion
5.1 Discussion of the method
5.1.1 The measuring instruments
5.1.2 The intervention program
5.1.3 The design
5.2 Discussion of the results
5.2.1 Adherence-motivation
5.2.2 Quality Of Life and psychological measures QLQ-C30 QLQ-CR38 HADS QOL and anxiety and HADS outcomes
5.2.3 Functional capacity
5.2.4 Patterns of exercise behavior
5.3 General discussion and future directions
5.3.1 The sample
5.3.2 The design
5.3.3 The intervention

6 Summary and conclusion

7 References

8 Appendix


This doctoral dissertation was written with the great support of my Doktorvater Professor Klaus Schüle of the Sports University of Cologne. Professor Schüle has supported and conducted research in the subject of cancer and sport in Germany since 1980 and showed a great willingness to be my dissertation adviser, in the hope that similar positive initiatives could be developed in my home country of Israel as well.

Through this dissertation I got to know the cancer inpatient rehabilitation system in Germany, which offers exercise therapy as a key feature of the rehabilitation.

I learned that successful movement therapy can motivate patients to change their attitude towards their cancer disease. Exercise therapy offers the patient a possibility to take charge of their lives and to be active in their own healing process. The resulting sense of control is a factor of great importance when fighting a life-threatening disease such as cancer.

The advantage of this kind of therapy, in comparison to other interventions (e.g. psychotherapy), is that the patients are shown an efficient method for improving their well-being, a method that they can practice during leisure time in a sports group or on their own after hospital discharge. Nevertheless, as this paper demonstrates, not all patients change their physical activity patterns in the long term, and thus, the positive influence of the three-week comprehensive rehabilitation cannot always be maintained.

For the cancer patients and survivors who do decide to continue being physically active after the rehabilitation stay, a truly impressive opportunity is the 600 exercise therapy groups for cancer patients and survivors which are active in Germany. This is a blessed initiative that should be applied in other countries as well as a part of long-term support for cancer patients and survivors.

I want to warmly thank all the patients who have been involved in my research, for answering the questionnaires, and for being so cooperative and thankful. It was a great pleasure for me to instruct the sports group in this study.

I also want to express here again my great appreciation to Professor Schüle, who accompanied me the four years of my stay in Germany, gave a great effort in helping me get to know its fascinating rehabilitation system, and patiently accepted the often-changed research plans. For all that, I am grateful to him.

Many thanks to the “Porta Westfalica” rehabilitation clinic in Bad Oeynhausen, who gave me the possibility to conduct my research in their facility.

I am grateful to the Konrad Adenauer Foundation for supporting me financially during my postgraduate studies in Germany.

Due to the great support from my Doktorvater and the generous financial support from the Konrad Adenauer Foundation I submit this paper.

German Sports University Cologne

Cologne, July 2004

Liat Levy

List of Tables

Table 1: The relative 5 years survival in male and females – Germany

Table 2: Time trends of the colorectal cancer mortality rates in Germany

Table 3: Concepts and terminology of the ICF related to component

Table 4: ICF application for colorectal cancer

Table 5: Stage Grouping - TNM

Table 6: Five year Survival Rate (TNM Stages)

Table 7: Five year Survival Rate (Duke’s Classification)

Table 8: Follow up recommendations for patients with colon cancer stage I

Table 9: QOL four domains

Table 10: Summary of evaluated outcome measures in the literature since 1986

Table 11: The measured factors in the different check points

Table 12: Patient characteristics

Table 13: Group comparison of exercise and psychotherapy participation

Table 14: Treadmill stress-tests protocols

Table 15: Changes in QLQ-C30 subscales for T1/T2 time interval

Table 16: Changes in QLQ-C30 subscales for T1/T3 time interval

Table 17: Changes in QLQ-CR38 subscales for T1/T2 time interval

Table 18: Changes in QLQ-CR38 subscales for T1/T3 time interval

Table 19: Changes in anxiety and depression measures T1/T2 time interval

Table 20: Changes in anxiety and depression measures T1/T3 time interval

Table 21: Treadmill stress-test results

Table 22: Patterns of exercise behavior – before to the disease

Table 23: Changes over time in patterns of exercise behavior -before and after the disease

Table 24: Patterns of exercise behavior – before and after the disease

List of Figures

Figure 1: Basic elements of the movement therapy in the rehabilitation

Figure 2: Outline of the different forms of movement therapy through the cancer rehabilitation process

Figure 3: Movement and sports therapy in the cancer rehabilitation process

Figure 4: Proposed model of exercise and QOL during cancer treatment

Figure 5: Fatigue - Group comparison (QLQ 30, T1/T2)

Figure 6: Role functioning - Group comparison (QLQ 30, T1/T2)

Figure 7: Functional scales Over time changes (QLQ CR-38 T1/T3)

Figure 8: Symptom scales Over time changes (QLQ CR-38 T1/T3)

Figure 9: Anxiety - Group comparison (HADS T1/T2)

Figure 10: Depression - Group comparison (HADS T1/T2)

Figure 11: Depression and Anxiety Over time effect (HADS T1/T2)

Figure 12: Anxiety - Group comparison (HADS T1/T3)

Figure 13: Depression - Group comparison (HADS T1/T3)

Figure 14: Depression and Anxiety Over time effect (HADS T1/T3)

Figure 15: Walking capacity (Treadmill stress-test T1/T2)

1 Background

This background chapter encompasses the different fields of knowledge which are relevant to the present study, starting with colorectal cancer (epidemiology, etiology, pathology and the International Classification of Functioning, Disability and Health), continuing with the subjects Quality of life, Movement and Sports in the Rehabilitation. The chapter ends with a review of previous physical activity and cancer studies.

1.1 Epidemiology

Descriptive epidemiological knowledge of colorectal cancer is essential for understanding the etiology of the disease and is used in the process of developing screening methods. Large bowel carcinoma is one of the most common cancers in the western world (15% of all cancer cases) and despite advanced diagnostic and therapeutic methods, the prognosis is relatively poor (Faivre et al. 2002). The WHO classification supplies the mortality data of colon cancer separately from rectum cancer. However, the information on death certificates is often imprecise and does not enable correct classification. That is the reason for the presentation of malignant neoplasm of the colon and rectum in the literature as a single entity (Becker & Wahrendorf 1998, 162). Considering colon and rectum to be a single unit does not allow recording the epidemiological characteristic differences between colon and rectal cancer. One of those differences is the magnitude of geographical variation of the incidence rate between high and low risk areas. For rectal cancer there are four to fivefold variations in incidence rates between high and low risk areas, whereas these variations for colon cancer is 10 to 15-fold (excluding Africa). Furthermore, there are often variations of high risk areas for colon and rectal cancer. In North America and Australia, colon cancer is more frequent than rectal cancer, while in Europe the colon cancer incidence rate is rather similar to rectal cancer rates. The I nternational C lassification of D iseases (ICD) allows the colon cancer descriptive epidemiology to study the subsites of the colon. Incidence rates of right colon cancer are similar for both genders, whereas left colon cancer is more frequent in males and shows a higher incidence rate than that of right colon cancer in males, this is true especially for populations with a high risk of colon cancer. By women in North America right colon cancer is more frequent than left colon cancer, while in Europe women show a slight predominance of left colon cancer (Faivre et al. 2002).

1.1.1 Cancer Epidemiology - Germany

Statistics of cancer mortality in Germany relies on the death certificate, and therefore is reliable. In the German Federal Republic there is no official documentation for the number of new cases. The federal state Saarland is the only state which has long term documentation for all cancer diseases. Therefore, the number of new cases of all cancer diseases can only be estimated. The estimated number of new cases is published annually by the Robert Koch institute, this publication is based on the national German cancer register. Nowadays all the federal states in Germany are in the process of preparing for future official documentation of new cases for all cancer diseases (Schriftenreihe des Bundesministeriums für Gesundheit 2001, 122).

Statistical Data – Germany: The German statistical federal department report indicates for the year 2000 that 25% of all the death cases were caused by cancer. The total number of death cases for that year were 838,796 (388,981 males and 499,815 females) and the total number of death cases caused by cancer were 211,000 (109,700 males and 101,300 females) (Statistisches Bundesamt 2001). The colorectal cancer statistics in Germany show in the west higher mortality for colon cancer and in the east higher mortality for rectal cancer. Here, too, the data might be biased because of false classification. These two types of cancer together represent the second leading cause of cancer death in Germany. The colorectal cancer mortality rate is almost identical in both parts of Germany: approximately 12% in males and 14% in females. The incidence rate for colorectal cancer is significantly higher than the mortality rate. In 1995 the number of colorectal cancer death cases was 13,465 males and 17,094 females (Becker & Wahrendorf 1998, 188), while the estimated annual incidence is 22,800 new cases of colorectal cancer in male, and 27,700 new cases of colorectal cancer in female (Becker & Wahrendorf 1998, 162). The great difference between the incidence and death rates is explained through the high survival rate of colorectal cancer. Fifty to sixty percent of newly diagnosed colon cancer and 70% to 80% of rectum carcinoma patients are cured (Markman 2003, 215). The relative 5 years survival in male and females in Germany is shown in Table 1. For the general survival rate for the different colorectal stages see Tables 6 and 7 in section (Becker & Wahrendorf 1998, 162).

Abbildung in dieser Leseprobe nicht enthalten

Table 1: The relative 5 years survival in male and females – Germany

(Becker & Wahrendorf 1998, 162)

Time trends in Germany: The decades following the Second World War were characterized by a significant increase in the mortality rate from colorectal cancer. This tendency lasted through the mid 1970’s; thereafter no increase was shown in Western Germany. The recorded tendency since reaching the stable level in the end of the 1980’s was a slight reduction of male mortality and even greater decline of female mortality. On the other hand, Eastern Germany showed until 1990 a consistently lower mortality rate than in Western Germany (for both genders). In 1990 following German reunification the colorectal mortality rates in Eastern Germany have shown a steady rise, this increase was greater for males than for females and reached the levels of West German mortality rates (see Table 2) (Becker & Wahrendorf 1998, 162).

Abbildung in dieser Leseprobe nicht enthalten

Table 2: Time trends of the colorectal cancer mortality rates in Germany

(Becker & Wahrendorf 1998, 162)

1.1.2 Colorectal cancer - Geographical distribution

The incidence rate of colorectal carcinoma varies greatly throughout the world. The latest world data (1988-1992) provided by cancer registers show very high incidence rates in North America, Australia and New Zealand. The incidence rate in Europe and Japan are slightly lower. A great variation in incidence rates is found within continents and countries, for example in Europe: the incidence rate for males in Triest, Italy is 49.4 per 100,000 compared to 16.4 in Kielce, Poland. Female incidence rates vary in Europe from 31.4 per 100,000 Saarland, Germany to 10.3 per 10,000 in Kielce, Poland. One of the highest incidence rate is found in the Czech Republic and that is despite general low incidence rate which is recorded in Eastern Europe. This tendency of contrasted incidence rates is also observed in Northern Europe. In Southern Europe, a high incidence rate is reported in Northern Italy and low rates in Greece (Faivre et al. 2002).

1.2 The ICF

The ICD is used in the medical field for categorizing diseases and introduces the etiology pathology and symptomatology of diseases. This classification is insufficient for the field of rehabilitation, since it does not include information to the rehabilitation potential and handicapped. The missing required information to the disease consequences is brought up in the I nternational C lassification of F unctioning, Disability and Health (ICF) (Schüle & Jochheim 2000, 50). The ICF is a result of an alternation process based on the I nternational C lassification of I mpairments, D isabilities, and H andicaps (ICIDH) which was published at 1980. The ICIDH was not recognized as an official classification; nevertheless it had a great influence on development in research and education (Dahl 2002). This classification was criticized for supplying only a biomedical view on disability through classifying people with disabilities in the same way as diseases, and thus maintaining the stigmatization of people with disabilities (Pfeiffer 2000). The ICF framework, on the other hand, introduces a bio-psycho-social view to disability, which includes contextual factors: environmental factors and personal factors. This bio-psycho-social view of disability demonstrates the modern understanding of “disability” and “functioning”; disability not only is a consequence of a health condition, but is also determined by a physical environment, the services available in the society, attitudes and legislation, which are environmental factors in this respect” (Pfeiffer 2000) . The new WHO classification was officially approved by the World Health Assembly in May 2001 as one of the WHO family of classifications (Dahl 2002).

1.2.1 Functioning Activity and Participation

Functioning is the overall term of the ICF framework which includes: body functioning, body structure, activity and participation, the definitions of these components are shown in Table 3.

Abbildung in dieser Leseprobe nicht enthalten

Table 3: Concepts and terminology of the ICF related to component (Dahl 2002 )

Using the term functioning and not the term disability demonstrates the positive approach of the classification (Dahl 2002). The Body Functions in the ICF are classified by codes, for example: b2801 Pain in body part (Cieza et al. 2002).

1.2.2 Application of the ICF

An example application of ICF in planning a successful rehabilitation intervention for rectal cancer is demonstrated in Table 4

Abbildung in dieser Leseprobe nicht enthalten

Table 4: ICF application for colorectal cancer

Understanding the association between selected target problems and impaired body functions and structure while considering the influence of context factors is the basis for a successful rehabilitation process. Not all impairments in body function and structure and context factors are similarly modifiable through the rehabilitation intervention and also are not of equal importance for the patient, therefore it is necessary by target problem selection to identify the most important factors which have the an improvement potential (Stucki et al. 2002).

1.3 Etiology and Pathology

This etiology and pathology part illuminates the medical side of the colorectal cancer disease. This part begins with description of the structure of the colon as a background for the following review of the colorectal cancer: the disease, clinical symptoms, risk factors, diagnosis, staging, management, rehabilitation and aftercare.

1.3.1 The Structure of Colon

The colon, or in the medical term the large intestine, is a 1.5 meter long organ which is located at the lower right side of the abdomen. The colon is a component of the digestive system. The girth of the large intestine is wider than the girth of the small intestine, and from here we get the definition of it. The main function of the colon is salt and water absorption from the remaining food which was digested in the small intestine (Miskovitz & Betancourt 1997, 4).

The order of the different parts of the colon; from proximal to distal are: cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum. The lower part of the rectum includes the sphincter muscles which control the defecation of the body wastes. Digested matter emptied into the colon travels through the colon and then to the rectum. The colon tubes are supported by the mesentery, a membrain-like fold of tissue attached to the back of the abdominal wall and which contains blood vessels, nerves, and a lymphatic system (Miskovitz & Betancourt 1997, 5).

1.3.2 The Colorectal Carcinoma

The colorectal tumor is characterized by a fleshy polypoid form. The mechanism by which colorectal cancer metastases includes local growth within and through the bowel wall to the exterior surface, dissemination into the paracolic regional lymphatic system, and hematogenous metastasis through the blood stream in distant organs. Secondary sites which might be involved are bone and lung (Tobias & Williams 1991, 118). Clinical symptoms for colorectal cancer

Clinical symptoms usually occur only as soon as the tumor becomes larger than one centimeter (Miskovitz & Betancourt 1997, 15). The frequency of the clinical presentation varies with the site of the malignancy in the colon. For example, rectal cancer is characterized by changes in bowel habits and rectal bleeding, obstructive symptoms in this case are uncommon. Whereas a tumor in the ascending colon is characterized by strong abdominal pains but usually no overt rectal bleeding or diarrhea (Tobias & Williams 1991, 118)

Abdominal pain: Caused by the tumor invading adjacent organs. The pain symptoms differ depending on which tissue is invaded. For example: a tumor that penetrates the bladder will cause urinary symptoms. Abdominal pain can also appear due to colonic obstruction. The colonic lumen is narrower in the transverse colon or sigmoid colon and thus, in this part of the colon, obstruction is more likely to occur. Extreme obstruction might also be the reason for nausea and vomiting.

Change in bowel habit: Colorectal tumor might cause diarrhea, constipation, gas pain, bleeding, or narrowing of the stool.

Rectal bleeding: The fecal stream traumatizes the tumor which grows into the passageway and causes bleeding. In tumors which are located near the anus the

bleeding might be overt. In other colorectal cancers the tumor bleeding appears as hidden blood in the stool.

Weight loss and obstructive symptoms: Some colorectal tumors cause loss of appetite, lose of weight, and weakness (Miskovitz & Betancourt 1997, 17). Risk Factors

The cancer disease is a genetic mutation produced by exposure to environmental carcinogens, and is associated with lifestyle factors as well. Lung cancer and leukemia are examples of carcinomas which are strongly associated with environmental carcinogens (smoking, radiation). Colorectal cancer, on the other hand, is not as strongly associated with environmental carcinogens and lifestyle factors as the cancers above, for this type of cancer, heredity plays a very important role (Miskovitz & Betancourt 1997, 11).

Heredity: Colorectal cancer risk is 3 fold greater by individuals who have a first degree relative with this type of cancer (Miskovitz & Betancourt 1997, 12).

Age: The process of aging enhances the probability for developing colorectal cancer. Acceleration in the new cases of colorectal cancer takes place by the age of 40 and is doubling every decade until the age of 80, the peak prevalence in men and women is after the age of 60. Age is a major determinant for colorectal cancer incidence, and thus, 70% of the colorectal patients show age as the only risk factor (Miskovitz & Betancourt 1997, 12).

Diet: The following nutrition factors have shown to effect the development of colorectal cancer: frequent consumption of fruits and vegetables have a definite protective effect (Block et al. 1992). A high total fat consumption is considered a risk factor. In their study, Willett et al. (1990) have singled out animal fat consumption as the most important factor. Frequent consumption of meat has also been identified as a risk factor. “Red meats” (beef, pork, and veal) are associated with greater risk while the “white meats” (fish and poultry) are associated with lower risk. The methods of meat preparation can also have carcinogenic implications. Heating the meat to very high temperatures during the preparation is associated with higher risk for colorectal cancer (Gerhardsson De Verdier et al. 1991). Willett et al. (1990) investigated the role of dietary fibers. This study was unable to demonstrate a protective effect of high fiber diet, and they assumed that the association between a high fiber diet and reduced colorectal cancer is due to the presence of protective vitamins in this fiber rich food.

Occupational Exposures: Work related colorectal risks have been implicated as possible. For example, Gubéran et al. (1992) observed an increased colorectal cancer incidence among professional drivers. This association is assumed to due to exposure to gasoline and diesel, or to the prolonged sitting.

Physical activity/inactivity: An increased colorectal cancer risk was noted in a few studies for sedentary occupation.The risk was found to increase with the amount of time in which the individual spends in sitting posture (Longnecker et al. 1995, Gerhardsson De Verdier et al. 1990). Slattery 2000 indicated that individuals with sedentary lifestyle have 60% to 2 fold increased risk of developing colon cancer. Moreover 13% of colon cancer cases can be attributed to being physically inactive. Physical activity has been one of the most consistently identified factors associated with reduced risk of colon cancer, but not rectal cancer (Potter et al. 1993, Gerhardsson de Verdier et al. 1990). Steindorf et al. (2000) in their research investigating colorectal cancer patients indicated that higher level of occupational or leisure time physical activity may provide a protective effect against colorectal cancer independent from nutrient intake. The investigators included only colon and upper rectal cancer cases (the upper part of the rectum is biologically similar to the rest of the colon). This study was in agreement with that of Levi et al. (1999) which shows a similar preventive effect of physical activity in the age groups of 15-19, 30-39, and 50-59. The hypothesized mechanism for the protective effect of physical activity on colon cancer is that it increases the velocity with which food residues pass through the colon, it has effect on body mass index and body fat composition, and it induces changes in serum cholesterol and bile acid metabolism (Lowenfels 1994).

Body Mass Index (BMI): A positive association between body fatness measured by BMI and colorectal cancer is suggested from cohort studies (International Agency for Research on Cancer WHO 2002, 86). This observed association is stronger for men than for women. Murphy et al. (2000) in their cohort study indicated that the association between colorectal cancer relative risk and BMI is one and a half as high by man as by women.

Risk of cancer as a function of Polyps Histology: Polyps can be histologically classified to four groups: adenomatous, hamartomatous, hyperplastic, or inflammatory. Adenomatous polyps are premalignant, whereas the last three have no malignant potential. The adenomatous polyp can be subclassified into: tubular, villous, and tubolvillous types (Miskovitz & Betancourt 1997, 7). Tubular adenoumas have a 5% risk of being cancer, tubolvillous adenoumas have a 20% risk, and villous adenoumas have a 40% risk. Adenomas which are greater than 2 cm are considered large, and have a greater malignancy risk than small adenomas (Markman 2003, 222). Predisposing conditions: Inflammatory bowel diseases

In addition to the general risk factors, the medical history of the patient plays a very important role in estimating patient's colorectal cancer relative risk. Patients with inflammatory bowel diseases like chronic ulcerative colitis, familial adenomatous polyposis, and Crohn’s disease are predisposed to colorectal cancer and therefore have a greater relative risk than the general population (Miskovitz & Betancourt 1997, 11).

Chronic Ulcerative Colitis (CUC): Occurs in the ages between 15 and 35. CUC begins at the rectum and progresses through the colon. The symptoms are bloody diarrhea, pain which can be accompanied by loss of appetite and weight (Miskovitz & Betancourt 1997, 13). Patients with CUC have a higher risk for developing cancer of the large bowel than the general population. The incidence of colorectal cancer among CUC patient rises with the duration of the disease, its severity and the extent of colonic involvement. The risk of cancer in the first decade after the onset of the disease is relatively low, and rises in 20% in each decade following. Annual surveillance coloscopy is recommended at an early age (Markman 2003, 221).

Crohn’s Disease: Patients with Crohn’s disease show to have a higher risk for developing cancer of the large bowel than the general population. The higher risk is likely to be depending on the age of the patient by the disease onset, and thus the patients with symptomatic Crohn’s disease, who develop disease in early life, may have 3 to 20 fold higher colorectal cancer risk than the general population (Markman 2003, 222).

Familial Adenomatous Polyposis (FAP): Inherited conditions of inflammatory bowel disease and polyps which are estimated to occur one in 7,000-10,000 live births. FAP patients have a 100% lifetime risk of developing colorectal cancer. The median age of colorectal cancer onset among PAF patients is 40, which is almost 2 decades earlier than in the general population. Offspring of predisposed individuals have a 50% chance of developing FAP. Descendants of affected patients should begin undergoing annually or biannually coloscopy at the age of 15. The surveillance should continue until the age of 30 (Markman 2003, 220). The treatment of choice for FAP patients is total proctocolectomy, which is a resection of the colon and rectum, particularly since the present techniques allow removal of the large bowel mucosa and maintain continence (Fonkalsrud, 1987). Colon Cancer Diagnosis

The American Cancer Society Guideline for screening and surveillance for colorectal polyps and cancer recommendations are: by asymptomatic individuals with average risk for both gender beginning of colorectal cancer screening at the age of 50 utilizing one of the five following screening options: (1) annual Fecal Occult Blood Test (FOTB); (2) flexible sigmoidscopy every five years; (3) annual FOBT and flexible sigmoidscopy every five years; (4) Double Contrast Barium Enema every five years (5) coloscopy every 10 years (Byers et al. 1997).

Fecal Occult Blood Test (FOTB): The FOBT is a test which checks the presence of hidden blood in the stool (Miskovitz & Betancourt 1997, 21). The test employs a guaiac-impregnated card. Guaiac is a natural substance, which turns blue in presence of an oxidating agent. The card should be blue to be considered positive. The FOBT is recommended as a screening for non-high-risk asymptomatic patients (Byers et al. 1997). The test is also being used as a screening test for symptomatic patients. The sensitivity, specificity and clinical implication of this test has not been proven, and, thus any positive FOBT will only indicate the need of colonic imaging for colorectal cancer. Unfortunately, there is a difficulty to distinguish between the amount of bleeding in a disease free individual and the in patients with colorectal cancer. This fact impairs the effectiveness of the FOBT (Markman 2003, 226).

Flexible Sigmoidoscopy and Colonscopy: The flexible sigmoidoscope allows viewing and sampling of the suspicious polys and masses in the distal 60 to 70 cm of the colon and rectum. The colonscope has similar qualities but it can reach also the cecum and terminal illeum (small intestine). Both videoscopes allow the excision of the polyps (polypectomy). The polypectomy can be partial or complete (Markman 2003, 227). Winawer & Zauber (1993) in their study stated that colorectal mortality is significantly reduced in patients which undergo the screening procedure of coloscopy and remain polyp free.

Barium Enema X ray or Double Contrast Barium Enema (DCBE): In this X- ray screening test the colon is first cleaned with enemas. Following the procedure an inert substance, which contains barium is inserted into the colon through the anus. An X-ray camera follows the colon and rectum as they fill with barium. The accuracy of this test can be improved through inserting air into the colon, causing the colon to expand. This method is called Double Contrast Barium Enema (Miskovitz & Betancourt 1997, 24). The DCBE is not as sensitive for small polys as coloscopy. In case of colon obstruction, enable to survey the remainder of the colon which can not be reached with the coloscope (Markman 2003, 228).

Transrectal Ultrasound: An endosonographic probe, which is considered an essential staging tool for rectal carcinoma. The pretherapy staging is especially important for determining the necessity of pre-operative chemo-radiotherapy or local excision approaches (Markman 2003, 228).

CT scan: An imaging modality for diagnosis and screening of colorectal patients. It is especially efficient in the case of obstruction in order to pinpoint the area and the reason of the obstruction (Markman 2003, 228). A CT scan offers an excellent possibility to view the abdominal wall, lymph nodes, and other solid organs while searching for metastasis. The radiation dose of this imaging modality is much higher than X-ray routine (Miskovitz & Betancourt 1997, 29). Colon cancer staging

TNM and Duke's classification for colorectal cancer are the most widely used classifications for large bowel tumors.

The TNM classification: A staging system categorizing cancer through the three criterions: depth of the invasion into the intestine wall including extension to adjacent organs (T), number of regional lymph node involved (N), and the presence or absence of distant Metastases (M) (American Joint Committee on Cancer 2002, 127).

Primary Tumor (T): TX - Primary tumor cannot be assessed

Tis - Cancer i n s itu (is)

T1- Tumor invades submucosa

T2 - Tumor invades muscularis propria

T3 - Tumor invades through muscularis propria and subserosa or into perirectal


Regional Lymph Nodes (N):

NX - Regional lymph nodes cannot be assessed

N0 - No lymph nodes involved

N1 - One to three regional lymph nodes involved

N2 - Four or more regional lymph nodes involved

Distant Metastasis (M):

MX - Distant Metastasis cannot be assessed

M0 - No distant metastasis

M1 - Distant metastasis (American Joint Committee on Cancer 2002, 129)

Duke’s Classification:

A - Cancer in situ (tumor within the polyp and has not broken through surrounding

tissues), or high-grade dysplasia: limited growth into the mucosa or submucosa

that lines the colon.

B1 – Penetration into the muscularis propria, a deeper layer of the colon wall.

B2 – Penetration through the muscularis propria and serosa, which is the outer lining

of the colon wall.

C1 and B1 - In addition of lymph node metastasis.

C2 – B2 In addition of lymph node metastasis.

D – Existence of distal metastasis (Bresalier & Kim, 1993 in Markman 2003, 235).

The stage grouping of the TNM classification and the equivalent stage in the Duke´s classification are shown in Table 5

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Table 5: Stage Grouping - TNM

( American Joint Committee on Cancer 2002 , 132)

Tables 6-7 demonstrate the five year survival rates of colorectal cancer according to the TNM and the Duke´s classification.

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Table 6: Five year Survival Rate (TNM Stages)

(Markman 2003, 236)

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Table 7: Five year Survival Rate(Duke’s Classification)

(Miskovitz & Betancourt 1997, 40) Treatment of colorectal cancer

The treatment of colon and rectal cancer, like in other types of cancer, differs according to the tumor's staging. The indication for treatment at stages A, B and C (according to Duke's tumor classification) is surgical intervention, adjuvant chemotherapy is applied for stage C and some cases of stage B. Patients with rectal cancer stage B and C receive additional radiation therapy. By non-operable tumors in stage D radiotherapy and chemotherapy is applied as pain relieving or as preoperative treatment (Miskovitz & Betancourt 1997, 66, 98).

Colon Cancer Surgery: Colectomy (or Hemicolectomy) defines the surgical process of removing a part of or the whole colon and is considered to be the only curative intervention for colon cancer. The basic surgical principle of colectomy is the resection of the primary tumor including a margin of healthy tissue and resection of surrounding lymphatics. The extent of colonic resection varies with the tumor location, blood supply and distribution of regional lymph nodes (Markman 2003, 242).

Rectal Cancer Surgery: Any tumor staged higher than Duke’s stage A requires a wide extension. Rectal cancer in the lower part of the rectum will oblige entire rectum and anus resection and a permanent colostomy. Recent surgical advances enable sphincter muscle and nerves tissue preservation by an increasing number of rectal cancer patients (Tobias & Williams 1991, 118). This operative process has a high potential for complications which is due to removal of the sacral nerves. These nerves are located in the rectum and are responsible for urinary and sexual function. There is no possibility to restore these nerves after surgery and thus it may lead to lasting changes in lifestyle such as urinary retention (through damaging the micturition reflex that enables the release of urine) and sexual functioning problems (Miskovitz & Betancourt 1997, 87).

Colostomy (stoma): An opening provides a new path for waste material from the colon to the outside of the body. In some cases a temporal setting of colostomy is made, in order to enable the healing of the lower rectum (Miskovitz & Betancourt 1997, 87). Life with stoma requires learning the correct maintenance techniques from the onset. Help and support with colostomy is offered to the patient in most large hospitals. Modern coloscopy bags are extremely reliable, and do not allow leaking of matter or releasing an offensive gas (Tobias & Williams 1991, 119).

Radiotherapy: An effective X-ray therapy used for rectal cancer as post or preoperative therapy. Radiation has not proven successful for colon carcinoma and therefore is rarely used for colon patients. Furthermore, the combination of colonic chemotherapy and radiotherapy is potentially toxic. Preoperative radiation serves the purpose of shrinking the tumor and is used only in special cases. Postoperative radiation is used in order to eliminate lingering cancer cells, and prevent spread of cancer cells into surgically inaccessible tissues. The treatment begins four to six weeks after surgery and it is applied daily. Treatment’s duration is five to seven weeks. The radiation can be external through X-ray beams, or internal by implantation of radioactive isotopes (Miskovitz & Betancourt 1997, 101).

Radiotherapy side effects: The possible side effects of the radiotherapy are: gastrointestinal symptoms; e.g. nausea, vomiting, bladder inflammation and diarrhea, loss of pubic hair, skin irritation, and fatigue. Most side effects of the radiotherapy treatment are temporary; however, pelvic hair loss might be either permanent or temporary (Miskovitz & Betancourt 1997, 101).

Chemotherapy: Chemotherapy is mostly used in cases of metastastic colon cancer, with one or more positive lymph nodes or in case of aggressive cancer. The course of chemotherapy for colon cancer is six month or one year. The chemotherapy can be applied as: (1) Neoadjuvant chemotherapy – pre-surgery chemotherapy. This therapy is used in some cases of rectum carcinoma in order to shrink the tumor before the surgery. (2) Adjuvant chemotherapy – post-surgery chemotherapy, this therapy is applied in order to inhibit metastasic spread and avoid recurrence of the disease (Miskovitz & Betancourt 1997, 106).

Cytotoxic drugs: The cytotoxic drugs used for chemotherapy have a variety of mechanisms, such as interference with DNA syntheses to inhibit cell growth, antibiotic, steroids, or strengthen the immune system. The most prevalent drug used for colon carcinoma is Fluorouracil (5-FU). This drug incorporates itself with the cell’s normal DNA and thus, prevents the malignant cell from dividing. The use of cytotoxic drugs can be in combination from a variety of drugs with a different duration of treatment. 5-FU and Levamisole are most often used combination of drugs for colon cancer chemotherapy. Levamisole is an immunity-stimulating agent. 5-FU and leucovorin are combination of drugs used for rectal cancer. The duration of this treatment is generally 6 months. Leucovorin is folic acid or vitamin B-1, it irritates the enzymes and makes the 5-FU more toxic to the cells (Miskovitz & Betancourt 1997, 108).

Chemotherapy side effects of: The incidence, severity and frequency of chemotherapy side effect was studied by Dikken & Sitzia (1998) examining colorectal patients receiving chemotherapy. Fatigue and diarrhea were the most common and severe side effect, which were reported by mean of 97% and 75% of the patients, respectively. The mean incidence of nausea was 54%, and the mean incidence of vomiting was 1%, the mean incidence of hair loss was 66%. The most frequent and troublesome side effect reported was mouth ulcers. Additional side effects included soreness of the mouth, lips, tongue, and gums. Pre and post treatment symptom

Whynes and Neilson (1997) developed a specific symptom checklist for colorectal cancer patients in order to study the symptoms before and after the surgery. The symptoms included in the checklist were selected based on advice from colorectal surgeons. The selected symptoms were divided into three subscales:

Psychological distress subscale: Crying spells, depressed mood, desperate feelings, difficulties in concentrating, feeling anxious, feeling lonely, irritability, nervousness, tension, and worrying.

Physical distress subscale: Constipation, decreased sexual interest, diarrhea, difficulties in sleeping, feeling of nausea, heartburn/belching, lack of appetite, lack of energy, shortage of breath, stomach pains, tiredness, and vomiting.

Disease specific symptoms: Bleeding from back passage, bowel incontinence, excessive wind from back passage, incomplete bowel evacuation, loss of weight, pain in back passage, problems with passing water, urgency in bowel movement. The presence of anxiety, worry, and nervousness was reported prior to treatment by more than 80% of the patients. The most commonly reported post operative symptoms were tiredness, lack of energy, and fatigue. Fatigue is one of the most common impairments of cancer patients undergoing chemotherapy and radiotherapy (70%) (Smets et al. 1993). The term is usually defined as a feeling of weariness, tiredness, or lack of energy (Dimeo, 2001). Fatigue is a normal physiological regulation mechanism which appears after vigorous or continuous activity in order to protect the human body from exaggerated efforts that may cause injury.

Pathological fatigue is reported to occur during normal activities among cancer patients. The symptom persists for long periods of time and do not improve in spite of rest. This side effect forces the patient to reduce their daily activity (Holmes et al. 1997). Thirty percent of cancer patients report this functional limitation also years after completion of the therapy and thus fatigue is also a long term impairment of physical functioning (Berglund et al. 1991). The impairment can be so limiting that it could keep the cancer patient from going back to work and thus has a devastating effect on mental, economic and social aspects for the cancer patient (Dimeo 2001). Rehabilitation

This section opens with definitions for rehabilitation which is followed by describing the unique rehabilitation system in Germany. The psycho-oncology and the medical follow up are reviewed here as well. The subject movement and sport in the rehabilitation is reviewed in a separate chapter (1.5).

Definitions: The three aspects of the oncological rehabilitation field are medical, occupational, and social. The term “rehabilitation” has a variety of definitions; the 4th German governmental report about the handicapped and development in the rehabilitation field defined rehabilitation while considering the three rehabilitation aspects: “helping to integrate the handicapped, or individuals who are at risk of becoming handicapped, back into the work circle and into society in general” (Bundesministerium für Arbeit und Sozialordnung 1998, 4 in Schüle & Jochheim 2000, 40). Another definition which matches the ICF (see 1.2) was formulated by Stucky et al. (2002): “multi and interdisciplinary management of a person’s functioning and health. Its goals are to minimize symptoms and disability. Rehabilitation options are to: (1) treat impaired body structures and functions – a treatment strategy, (2) overcome impaired body function, activity limitation and participation restrictions – a rehabilitative strategy, (3) prevent further symptoms and disability – a preventive strategy”. This definition covers the medical and social aspects of the rehabilitation but does not refer to the occupational aspect.

Rehabilitation in Germany: The medical rehabilitation in Germany is an integral part of the health system. Under this holistic approach it is not always possible to separate strictly the curative medicine in the acute care hospital from the rehabilitative medicine in the rehabilitation hospital. Nevertheless an artificial separation is necessary in some cases due to financial reasons (Schüle & Jochheim 2000, 43).

The inpatient rehabilitation institutes in Germany were initiated in the 1970s, the “Anschlussheilbehandlung”(AHB) which means: follow-up healing treatment, was also developed under this initiation. The patient continues directly from the treatment in the acute clinic into the AHB in the rehabilitation clinic. The time period between the patient’s hospital discharge and the begin of the AHB should not be longer than 14 days. The acute-care clinic is responsible for the diagnostic operative and conservative treatment and nursing. The rehabilitation clinic, on the other hand, puts the main emphasis on using one's ability to make one healthier under professional guidance (Schüle & Jochheim 2000, 45). The setting of the inpatient rehabilitation offers the cancer patient an interdisciplinary complex rehabilitation program. The purpose of this program is to eliminate or compensate the impairments which follow the cancer therapy, as well as giving assistance to accepting remaining impairments. The inpatient program for cancer patients takes the three oncological rehabilitation aspects into account, and therefore offers not only medical care, but also psychological help, social support, and takes care of occupational reintegration (Hermanek et al. 1996).

Psycho-oncology: The psycho-oncology is an interdisciplinary field which deals with psychosocial aspects of the cancer disease. This field covers not only the different psycho-oncological disciplines but also a few other areas, for example: psychology, psychiatry, psychosomatic and sociology. The psycho-oncology is nowadays an integrated component of the patient oriented cancer therapy (Weis 2001).

The psychosocial treatment in the acute care hospital and in the rehabilitation hospital in Germany: The acute care hospital has a different task than the rehabilitation hospital and therefore different types of psychosocial support are applied in the different settings. The patients in the acute setting are treated more on an individual base, whereas the treatment in the rehabilitation setting takes place mostly in groups. The group therapy in the rehabilitation hospital is organized under guidance of a psychologist or a physician. The members of the group have the possibility to express themselves and share their feelings with other cancer patients. The subjects which are discussed in the group refer to the cancer experience (Weis et al. 1996).

Oncological follow up in Germany: The medical follow up is carried out by the patient’s physician in cooperation with the hospital medical team. The main aim of the follow up is early detection of cancer relapse. The detection of an early stage asymptomatic tumor enables the medical team to repeat a curative therapy. Another important aim of the follow up is the post operative surveillance in order to diagnose limitations followed by the cancer treatment. The colorectal cancer follow up includes anamnesis, full body check-up, abdominal sonography, chest x-ray, sigmoidscopy and coloscopy. The recommended timing for undergoing this medical examination differs depending on the tumor stage and the location in the lower intestine (Hermanek et al. 1996). Table 8 demonstrates an example for follow up recommendations for stage I

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Table 8: Follow up recommendations for patients with colon cancer stage I (Hermanek et al. 1996).

* 3 month postoperative, only if the preoperative check of the whole colon was not possible,

after the 5th year coloscopy every 3 years

** After endoscopic removal

1.4 Quality of life

The term Quality of Life (QOL) is used today in everyday speech and in the context of research linked to various scientific areas such as sociology, medicine, nursing, psychology, economics, geography, social history and philosophy. To date, there is no firm consensus about the meaning of the QOL term which results in multifaceted definitions. The available definitions of QOL can be classified into four types:

Global definitions: This type of definition is all-encompassing, incorporates normally terms of satisfaction/dissatisfaction and happyness/unhappyness and does not identify the possible components of QOL. For example, Dalkey & Rourke (1973) described QOL as “a person sense of well-being, his satisfaction or dissatisfaction with his life, or his happiness or unhappiness” (in Farquhar 1995).

Component definitions: These definitions divide the QOL into a series of component parts or dimensions, these components can be further subdivided. Patterson (1975), for example, described the components of QOL as health, function, comfort, emotional response and economics (in Farquhar 1995).

Focused definitions: These are the QOL definitions which incorporate only a small number of components of QOL, these focused definitions are found in the literature as “health related QOL” or “a micro-economic definition of QOL” (Farquhar 1995).

Combination definitions: These are global definitions of QOL which also specify the components. For example: Holmes and Dickerson’s (1987) definition for QOL “abstract and complex term representing individual responses to the physical, mental and social factor which contribute to “normal” daily living. It comprises many diverse areas all of which contribute to the whole including personal satisfaction, self esteem, performance ability, comparison with others, previous knowledge/experience, economics status, general health, and emotional status all as factors contributing to the overall quality of life”.

1.4.1 Quality of life in the oncological field

The QOL of cancer patients is defined in the literature applying a component definition. The two baseline components for analyzing QOL are subjectivity and multidimensionality. Subjectivity emphasizes the fact that QOL can only be assessed from patient’s perspective (Cella 1992). In this context QOL is defined as “referring to patient’s appraisal of and satisfaction with their current level of functioning compared with what they perceive to be possible or ideal” (Cella 1988). A value-based rating of QOL provide subjective evaluation of patient’s tolerance to dysfunction. This subjective information is essential for various treatment decisions (Cella 1992). There is a clear consensus that health related QOL is multidimensional yet there is less agreement as to the specific dimension which should be incorporated in the definition. Ferrel’s 1996 QOL conceptual model analyzes QOL in four well-being domains; physical, psychological, social, and spiritual (components subdivision: Table 9).

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Table 9: QOL four domains (Ferrel 1996)

Cella (1992) describes QOL in term of four underlying dimensions: psychological, functional, emotional, and social well-being. This definition does not include the spirituality as a component of QOL. Generally, in the oncology most of the commonly used instruments for measuring QOL do not include spiritual well being as a key component. Brady et al. (1999) in their study, investigated the relevance of including spirituality in QOL measurements. The findings indicate that spiritual well-being is associated with QOL in the same degree as physical well-being which is a QOL domain with unquestioned importance. Furthermore, spiritual well-being was found to be correlated with the ability to enjoy life in spite of suffering from symptoms, and thus this domain is especially relevant for clinical target. The QOL domains as suggested in Ferrel´s conceptual model (1996) and in Cella´s concept (1992) are detailed in the following section.

Physical field: Physical well-being is the control or relief of symptoms and the maintenance of function and independence” Ferrel (1996) . The physical domain of QOL is greatly influenced by the symptom of the cancer disease and it’s treatment. Moreover, the physical symptoms (e.g. fatigue, bowel management, nausea) demonstrate a great association to each other, and thus one untreated symptom might result in suffering from a group of symptoms. Patients have expressed their concern about having physical symptoms which are ignored by the healthcare professionals and their frustration of having to focus their life on this physical problem (Ferrel 1996). Ferrel (1996) indicated the functional aspect to be a part of the physical aspect while Cella (1992) refers to the functional aspect as a separate unit that encompasses: “one’s ability to perform the activities related to personal needs, ambitions, and social role”. The reason for separating the functional aspect is the need to consider the differences in patient’s responsibilities and needs, for example: a single parent with young child might have great difficulties carrying out the daily responsibilities, whereas a married parent with grown up descendants might be able to carry out the daily responsibilities despite periodic physical discomfort.

Psychological field: “ Psychological well-being is seeking a sense of control in the face of a life-threatening illness characterized by emotional distress, altered life priorities, and fears of the unknown, as well as positive life changes” Ferrel (1996) . The psychological aspect of well-being is a predominant aspect predicting the overall QOL. Ferrel (1996) indicated that the survey item measuring distress from the initial cancer diagnosis was rated as the most distressing item among all the psychological components. This first period of living with cancer diagnosis was indicated to be devastating; furthermore its negative influence was suggested to remain throughout the whole cancer experience and affected the long-term QOL. Nevertheless, patients indicated positive changes through the cancer experience: a higher appreciation for life, family, and relationships, and balancing the priorities in life (Ferrel et al. 1995a, Ferrel et al. 1995b, Ferrel & Dow 1996). Psychological well-being was not included as a key component by Cella (1992), emotional well-being was suggested in this review as an alternative key component

Social field: “ The social well-being domain provides a way to view not only the cancer or its symptoms but also the person surrounding the tumor; it is the means by which we recognize people with cancer, their roles, and relationship” Ferrel (1996) . The social aspect includes the activities related to roles and relationship at work or at home. The factor of family members’ perspective of cancer was suggested to have a great influence on social well-being (Ferrel 1996). Cella’s (1992) definition of the social well-being includes few further components: perceived social support, maintenance of leisure activities, and family functioning to intimacy, including sexuality.

Spiritual field: “ Spiritual well-being is the ability to maintain hope and derive meaning from the cancer experience that is characterized by uncertainty. Spiritual well-being involves issues of transcendence and is enhanced by one’s religion and other sources of spiritual support” (Ferrel 1996). To some cancer patients spirituality has a great importance for others less. Among the patients who highly regard spirituality, in some cases the challenges of the illness promote a spiritual growth, in other cases the disease results a spiritual crisis (Cella 1992).

1.5 Movement and Sports in the Rehabilitation

Movement and sports are fundamental elements of the inpatients rehabilitation. This field encompasses physiotherapy, exercise, fitness training, walking exercise, aquatic exercises, relaxation therapy and more.

1.5.1 Definitions

This part starts with an overview of movement therapy element (figure 1), which is followed by definitions of the terms in the field of sports and movement therapies.

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Figure 1: Basic elements of the movement therapy in the rehabilitation

(Modified from: Schüle 2001, 654)

Physiotherapy: “Physiotherapy is mainly functionally oriented and works against deficits of the locomotor system. Besides active methods of movement and breathing therapy passive methods of massage, thermo-and cold-therapy as well as water and electronic therapy are used. Special measures serve among other things for loosing and strengthening the locomotor system as well as the treatment of damages of muscles, tendons, and connective tissue. In principle, physiotherapy is prescribed by a doctor and is carried out by a physical therapist as directed” (Schüle & Jochheim 1993-1996, 11) .

Sports therapy: “Sports therapy is a movement therapeutical measure. Adequate measures of sports can repair damaged physical, psychological and social functions. This repair can consist of compensation, regeneration and prevention of secondary damage. Health oriented behavior is promoted. It is based on biological rules and specially includes elements of pedagogical, psychological and socio-therapeutical methods, with the goal of achieving a long lasting healthy lifestyle” (Schüle & Jochheim 1993-1996, 12) .

Adapted physical activity: “Adapted physical activity refers to movement, physical activity and sports in which special emphasis is placed on the interests and capabilities of individuals with limiting conditions, such as the disabled, health impaired or aged” (Doll-Tepper et al. 1990, V).

1.5.2 Aims

The adapted physical activity and sports must be carried out in the rehabilitation with the aim of “harmonizing” the entire person; this aim can be fulfilled when the following four field goals are settled:

- Physical field: Muscle strengthening, increasing of the aerobic capacity, joint mobility, improvement of motor skills
- Social field: Developing of communication skill through communication between the group members, and with the adapted physical activity teacher.
- Psychological and emotional field: Integration through emphasizing the abilities of the person and not the disabilities, acceptance of other people's look, create motivation and or ambition for physical or psychological effort.
- Cognitive field: Awareness to the training effect and education to independence (Schüle & Jochheim 1993-1996, 14).

1.5.3 Movement and sport throughout the rehabilitation process

The four principles which should be followed in a comprehensive rehabilitation are immediate, continuous, individual, and holistic, these principles should also be applied within the movement therapy through the rehabilitation chain.

Figure 2 demonstrates the rehabilitation chain and the development of movement and sport-therapy through the healing process. The process starts in the primary hospitalization with an individual learning of motor and sport skills by the physical therapist which continues in the rehabilitation clinic. The sport-therapist in the rehabilitation clinic develops these basics in a form of adapted training. After hospital discharge, the participation in out-patient sport group ensures that the learned skills will become permanent and that new skills will be learned (Schüle & Jochheim 1993-1996, 9) .

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Figure 2: Outline of the different forms of movement therapy throughout the cancer rehabilitation process (Schüle 1994)

The rehabilitation clinic is the connecting link between the acute clinic and the adapted physical activity at local sport clubs (see figure 3), therefore a long lasting motivation for participation in physical activity in leisure time should be initiated in the in-patient rehabilitation setting (Schüle 1990, 314).

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Figure 3: Movement and sports therapy in the cancer rehabilitation process (Schüle 1994)

1.5.4 Framework to studying movement and sport through the cancer rehabilitation process

Courneya & Friedenreich (2001) provided the PEACE framework (Physical Exercise Across the Cancer Experience) this framework entitles physical exercise across the cancer experience dividing the cancer experience into 6 time periods:

1. Pre-screening - Is the period of time prior to cancer screening, the potential cancer control outcome of the exercise is cancer prevention.

2. Screening - Considers the time from the screening test until receiving the results, physical activity can positively influence the detection process through increasing the sensitivity and specificity of the screening test or it might also indirectly influence the cancer detection through promoting screening behavior (Courneya & Friedenreich 2001). Another potential influence is reduction of the levels of anxiety and stress associated with cancer screening (Streggles et al. 1998).

3. Pre-treatment - Indicate the time period since obtaining the definitive cancer diagnosis until the beginning of the cancer treatment, time period between successive treatments (e.g. between first line chemotherapy and dose intensive chemotherapy). The cancer control outcome of physical exercise in this time period is improving the physical condition as a preparation for the treatment. This prospective “buffering” exercise behavior has also a positive psychological influence (Courneya & Friedenreich 2001).

4. Treatment - Incorporate the time with in the patient is actively treated for cancer. The potential cancer control outcome in this time period is reduction of treatment side effects, thus potential help in the coping process (Courneya & Friedenreich 2001).

5. Post-treatment – Is the recovery time period starting with dissipation of the acute symptoms of the medical treatment and lasts until the recovery from the major functional impairments. The potential of physical activity effect in this time period is rehabilitation i.e., improvement of the health status. The rehabilitation time period will follow the treatment for objects which are considered to be cured. Palliation would follow a non resolvable cancer stage or unsuccessful treatment. Physical activity for palliative purposes may help maintaining the functional independence, and increase QOL (Courneya & Friedenreich 2001).

6. Resumption - Refers to the time period beginning with the completion of short term recovery. In case of multiple screening or recurrence the patient may have to go through this process more than once. In this time physical activity is used for health promotion, having the aim of optimizing the health of a person (Courneya & Friedenreich 2001).

Exercise may influence QOL during cancer treatment in various ways. Figure 4 presents a simple organization model on how exercise might ultimately enhance QOL.

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Figure 4: Proposed model of exercise and QOL during cancer treatment

(modified from Courneya 2001)

1.6 Physical activity and cancer – literature review

This section reviews the literature on the role of exercise in the rehabilitation of cancer patients and survivors, and exercise behavior through the cancer experience. The PEACE frame work is applied here for organizing the literature review across the time periods of the cancer experience. However, not all the disease time periods are equally represented here, the primary emphasize of this literature review is on the treatment, post treatment and resumption periods. The prescreening time period is reviewed under the section risk factors ( There is no reference in this paper to palliation. Most studies discussed in this chapter have a prospective design applying an exercise intervention or a multiple intervention package including exercise (e.g., exercise combined with social support, psychological counseling etc.). The review opens with descriptive studies, and concludes with interventional studies.

1.6.1 Descriptive studies

1. Young-McCaughan & Sexton 1991, USA - Madigan

The study group: 71 breast cancer patients, the time since diagnosis ranged from seven month to seven years, average age 60.2

Design: Retrospective study, mail administrated.

Factors measured: Activity/exercise report, QOL (QOL index – Padilla et al.), Perceived Barrier to Exercise (PBE scale – Given and Given).

Results: Comparing the mailed questionnaire answers of women with breast cancer who exercised (n=42), with women with breast cancer which did not exercise (n=29) indicates that women who exercised had a significantly higher score for QOL than the women who did not exercise. The group of women who exercised perceived significantly fewer barriers to exercise than the non-exercisers group.

2. Courneya & Friedenreich, C.M. (1997)

The study group: 130 colorectal cancer survivors (65% males, 35% females), average age 62.1 (range: 26-81) the patients received and completed adjuvant therapy within the four year previous to participation in the study.

Design: Retrospective study, mail administrated.

Factors measured: Exercise behavior in three phases of the disease: pre-diagnosis, treatment, post-treatment (Leisure Score Index – LSI of the Godin Leisure Time Exercise Questionnaire), QOL (Functional Assessment of Cancer Therapy-Colorectal FACT-C) overall satisfaction with life (Satisfaction With Life Scales -SWLS).

Results: The functional dimension QOL was scored lowest and had strongest relationship with SWT. The exercise level decreased in the phase from pre-diagnosis to treatment and than increased from treatment to post-treatment treatment not reaching the baseline level. Low level of exercise was found to correlate with lower QOL.

3. Pinto et al. 2002, Rhode Island – USA

The patient sample: 69 women with early stage breast cancer.

Design: 12 month prospective longitudinal study.

Factors measured: This study examines the natural progression of exercise participation after cancer treatment. The evaluated factors: Disease variables, performance status (Karnofsky Performance Status Scale - KPS), moods (POMS), QOL (SF-36), cancer related symptoms (Memorial Symptom Assessment Scale – MSAS), social support (Duke-UNC functional Social Support Questionnaire).

Results: The results indicated that women did not increase their exercise participation over time and that overall mean of exercise participation was below recommended levels (the recommendation was approximately 150 min/week of moderate intensity exercise or 120 min/week of vigorous intensity exercise). Nevertheless, the data showed that although a majority of the women sampled was not exercising at levels that can yield health benefits, they expressed the intention to increase activity levels. This suggests that cancer patients in an early stage are motivated to participate in physical activity, and might respond positively to a recommendation from the health care representative to get physically active. However, a large subgroup (35-52%) did not express any motivation to become physically active.

1.6.2 Intervention studies at the treatment time period

The following literature review demonstrates interventional studies which investigated the effect of exercise on cancer patients undergoing adjuvant cancer treatment (chemotherapy / radiation therapy). For each research the factors detailed are patient sample, study groups, intervention, evaluation and results.

1. MacVicar, M.G., Winningham, M.L. 1986, USA - Ohio

The patient sample: Breast cancer patients who were on post surgical chemotherapy protocol, average age was not mentioned.

Study groups: Exercising patients (PE, n=6), non exercising patients – patients controls (PC, n=4) age-matched exercising control group - healthy exercise controls (HE, n=16).

The intervention: PE, HE – progressive, interval training program on bicycle ergometer (exercise heart rate range of 60% to 85%), PC – no additional treatment.

The intervention frequency and duration: Exercise meetings 3 times a week X 10 weeks, exercise duration was not mentioned.

Evaluation: Pre and post-test procedures evaluating functional capacity (VO2 max) heart rate, and profile of mood state (POMS).

Results: The PE and HE groups demonstrated a pre-to post-test improvement in functional capacity of 20.7% and 17.4% respectively, furthermore the exercise groups showed a decrease in total mood disturbance (POMS). The PC demonstrated a pre-to post-test decrease of 1.8% in functional capacity, and an increase of total mood disturbance score.

2. Winningham and MacVicar 1988, USA - Ohio

The patient sample: Breast cancer patients on chemotherapy, average age 47.

Study groups: Exercise group (EG, n=16), placebo group (PG, n=14), control group (CG, N=12).

The intervention: EG: individual aerobic training on bicycle ergometer following the Winningham Aerobic Interval-Training protocol (WAIT) at workload that induces a heart rate of 60% to 85% of the heart rate reserve calculated from the highest heart rate achieved at pretest. PG: mild stretching and flexibility exercises. CG: no additional treatment.

The intervention frequency and duration: 20 to 30 minutes exercise, 3 times a week x 10 weeks.

Evaluation: Pre and post-test procedures evaluating nausea using an item on a Symptom Checklist 90-Revised (SCL-90-R) somatization subscale.

Results: In post-test the EG subjects demonstrate a marked improvement in nausea compared with PG or CG the differences between the groups were statistically significant.

3. MacVicar et al. 1989, USA - Ohio

The patient sample: Breast cancer patients stage II receiving chemotherapy treatment for, average age 45.

Study groups: Exercise group (EX, n=18), placebo group (PL, n=11) control group (CO, n=16).

The intervention: EX – individualized aerobic interval cycling training program following the WAIT protocol at workload that induces a heart rate of 60% to 85% of the heart rate reserve calculated from the highest heart rate achieved at pretest. PL – no aerobic stretching and flexibility exercises. CO – no additional treatment.

The intervention frequency and duration: 20 to 30 minutes exercise, 3 times a week x 10 weeks.

Evaluation: Pre and post-test procedures evaluating functional capacity (VO2 max) and heart rate.

Results: The EX achieved mean improvement of 40% on the functional capacity from pre-test to post-test. No significant improvement from pre-to post-test was observed by the PL and CO. For heart rate there was a significant difference in post-test between the EX and CO groups, but not between EX and PL.

4. Winningham et al. 1989, USA - Ohio

The patient sample: Breast cancer patients on chemotherapy, average age 46.

Study groups: exercise group (EG, n=12 ), control group (CG, N=12).

The intervention: EG individualized aerobic interval cycling training program following the WAIT protocol at workload that induces a heart rate of 60% to 85% of the heart rate reserve calculated from the highest heart rate achieved at pretest.. CG: no exercise treatment.

The intervention frequency and duration: 20 to 30 minutes exercise, 3 times a week x 10 weeks.

Evaluation: Pre and post-test procedures evaluating body weight and body composition.

Results: Both groups gained weight, the CG gained a mean of 1.99 kg that in comparison to 0.82 kg (NS), nevertheless comparison of pre and post results indicate that exercise had a moderating effect on gain in body fat.

5. Berglund et al. 1994, Sweden - Stockholm

The patient sample: 80% breast cancer patients, 7-8% ovarian cancer patients and the rest represented a variety of cancer diagnosis, inclusion within two months post operative treatment, with radio- or chemotherapy, average age: 52-53.

Study groups: Study group (SG, n=98), information group (IG, n=36) control group (CG, n=65), training workload was not mentioned.

The intervention: SG received 11 sessions of exercise and information. The exercise includes mobility, muscle strength, general fitness and relaxation. The information includes treatment effects, diet, crises, and alternative treatments. IG received a single information session, CG received no additional treatment.

The intervention frequency and duration: Eleven sessions were held in 7 weeks: first four week – two meetings per week, one for exercise, one for information, the last three weeks were devoted to coping skills. Every session lasted two hours.

Evaluation: Pre and post-test procedures with three, six and twelve month follow up evaluating: physical strength, physical training, tiredness, body image problems, pain (self developed scale), depression and anxiety (shortened HADS).

Results: The SG differed significantly from the IG and CG with respect to: physical strength (at the three follow up measurements), physical training (at 3 month, and 12 month follow up). No significant differences were shown in respect to: tiredness, body image problems, pain, depression and anxiety.

6. Mock et al. 1994, USA - Boston

The patient sample: Breast cancer patients stage I or II which received breast conserving surgery and were scheduled to receive chemotherapy, average age 44.

Study groups: Exercise group (EG, n=9), control group (CG, n=5)

The intervention: EG – self directed progressive walking program (following the protocol of Winningham et al.: Rhythmic walking –exercise for people living with cancer, the protocol was not detailed) and support group, CG – usual treatment.

The intervention frequency and duration: 30 minutes exercise (minimum), 3 - 5 times a week x 4-6 month (incorporated with the chemotherapy treatment), support group meeting once every two weeks x 4-6 month.

Evaluation: Pretest mid test and post-test procedures (before beginning chemotherapy, during the course of chemotherapy, and one month following chemotherapy completion) evaluating walking capacity (the 12 minutes – Cooper), performance status (KPC - Mor et al.), psychological adjustment (Psychological Adjustment to Illness Scale –PAIS and the Brief Symptom Inventory – BSI), self concept (Tennessee Self Concept Scale -TSCS), body image (Body Image Visual Analogue Scale - BIVAS), Symptom Assessment Scale (SAS – Satherland et al.).

Results: Measures of physical performance, psychosocial adjustment, and symptoms intensity, revealed improved adaptation to the disease in subjects who completed the walking and support group program.

7. Dimeo et al. 1996, Germany – Freiburg

The patient sample: Hematological cancer patients, 30 days status post bone marrow transplantation (BMT), average age 36.

Study groups: Training group (pre-test: n=20, post-test n=14), no control group.

The intervention: Walking on a treadmill according to an interval-training pattern. The workload induced a heart rate of 80+5% of the calculated maximal heart rate (220 minus age in years).

The intervention frequency and duration: 5 days a week x 6 weeks. The exercise duration increased gradually; 1st week: 5 workloads x 3 min per day, 2nd week: 4 workloads x 5 min per day, 3rd week: 3 workloads x 8 min per day, 4th week: 3 workloads x 10 min per day, 5th week: 2 workloads x 15 min per day. The training program was initiated during hospitalization and concluded while participants were out-patients

Evaluation: Pre and post-test procedures evaluating maximum physical performance, maximum walking distance on a treadmill stress-test, heart rate in the different workloads, and body weight.

Results: A significant improvement in maximal physical performance, and maximal walking distance, and a significant lowering of the heart rate within equivalent workloads was observed at the end of the post-test. At the end of the program all participants reached a peak performance which was more than sufficient for carrying out all activities of daily living.



ISBN (eBook)
ISBN (Paperback)
4 MB
Institution / Hochschule
Deutsche Sporthochschule Köln – Sportwissenschaften
2005 (Februar)



Titel: The effect of two exercise programs on the rehabilitation of individuals with colorectal cancer in an inpatient setting in Germany