The impact of task-oriented training on frailty among post-cancer victims – a pilot study

INTRODUCTION

Cancer survivors experience particular health issues as a result of their diagnosis and the effects of treatment on physical function. Frailty is widespread among cancer survivors, it leads to poor physical functioning, hospitalisation, and death. Frailty is caused by a reduction in functional mobility and strength, which impacts quality of life [1]. Functional status refers to an individual’s ability to carry out essential activities required for maintaining adequate health and meeting basic needs. While a decline in functional status is a natural aspect of aging, characterised by a gradual decrease over the lifespan, individuals with cancer often experience accelerated deterioration following diagnosis and treatment compared to those without cancer [2]. This decline not only affects quality of life but also contributes to increased comorbidities, greater reliance on caregivers, higher rates of institutionalisation, and elevated mortality [3, 4].
According to the Global Cancer Observatory, around 19.3 million new cases of cancer were diagnosed globally in 2020, with advancements in treatment boosting the 5-year survival rate to 69.8% [5, 6]. Among elderly cancer survivors, frailty prevalence varies widely between 30 and 60%, underscoring its significant impact [7]. Recent research indicates that 68.6% of cancer survivors suffer from moderate to severe functional limitations due to pain, and 48.3% due to emotional distress, with approximately 10% experiencing severe limitations from concurrent symptoms [8]. Physical frailty in older adults is marked by reduced strength, endurance, and physiological function, heightening vulnerability to dependency, and mortality [9]. Post-hospital discharge, mobility disabilities increase the risk of mortality, affecting 39% of older patients [10].
Functional decline often manifests as reduced mobility, significantly impairing essential daily activities crucial for maintaining independence and quality of life [11]. This decline increases the risk of falls and fractures, posing immediate physical dangers. Prolonged recovery periods after interventions add to the burden on patients and caregivers, while dependency on others for basic tasks diminishes autonomy and dignity. Reduced mobility also compromises the ability to undergo subsequent cancer treatments effectively, potentially limiting therapeutic options and complicating disease management [12]. Adequate muscle strength contributes to functional independence by allowing individuals to perform tasks without excessive fatigue or reliance on assistance. For cancer survivors, maintaining or improving muscle strength through targeted exercises can enhance their ability to engage in daily activities.
Functional decline in cancer survivors is multifactorial, influenced by various factors including shared risks, social dynamics, comorbidities, tumour-related issues, and treatment toxicities. Older adults experience functional decline alongside aging, exacerbated by poor lifestyle choices and acute stressors such as cancer and its treatments [13]. Chemotherapy accelerates aging processes through DNA damage and immune system compromise, contributing to functional decline [14]. Chronic inflammation associated with cancer and treatments further complicates health outcomes, potentially increasing weakness and mortality rates [15]
Preventative measures and management strategies for functional decline closely align with those for frailty, as frailty often precedes indicators of functional decline. Early detection and interventions such as physical activity and dietary adjustments are crucial. Addressing cognitive decline, reducing fall risks, and managing polypharmacy are also essential components of effective management strategies [16]. Interventions like resistance and aerobic exercises, nutritional support, and multicomponent approaches combining physical exercise, dietary counselling, and psychosocial support have shown promise in mitigating frailty and improving overall well-being [17, 18].
However, there appears to be a gap in interventions specifically tailored for frail cancer survivors, with a focus on functional mobility and strength. Addressing these components can better cater to the unique needs of frail cancer survivors and can promote their overall well-being. Task-oriented training (TOT) is a rehabilitation approach that focuses on improving specific functional tasks through repetitive and goal-directed activities. This approach has shown promise in various populations, including those with neurological conditions and older adults. However, its effectiveness in improving functional mobility and strength among cancer survivors remains underexplored. Thus, the purpose of the study is to explore TOT to improve functional mobility and strength, which have a positive impact on frailty among cancer survivors.

MATERIAL AND METHODS

This pilot study was conducted on 35 cancer survivors. The study was conducted at the Oncology Outpatient Department of a private hospital. All subjects were provided with an information sheet and a consent form. This study was proposed to the Institutional Ethics Committee (IEC) before the commencement of patient recruitment and was approved with the IEC number 024/11/2023/IEC/SMCH. The purpose, treatment methods, potential benefits, and risks in the study were explained prior to participation, according to the Declaration of Helsinki.

Inclusion and exclusion criteria

Subjects between 60–75 years of age, both male and female, diagnosed with cancer, with only a primary tumour with no metastasis, who had undergone chemotherapy and were cancer-free, and had a clinical frailty scale score of 6 or more were included. Subject with psychiatric conditions, cognitive impairment, neurological conditions, unstable cardiopulmonary problems, having undergone recent surgery, or with audiovisual impairment were excluded.

Study procedure

A total of 75 cancer survivors were screened using the clinical frailty scale, and 35 were recruited based on the inclusion and exclusion criteria. Demographic details such as age and gender were collected from the subjects. Prior to the intervention, all subjects underwent pre-test assessments including the time up and go (TUG) test and the 5 times sit to stand test (5XSTS) to establish baseline measurements. Subjects received TOT combined with strengthening exercises, with sessions conducted 3 times per week. After 6 weeks of intervention, post-intervention outcome measures were reassessed using the same tools to evaluate changes in functional mobility and strength. Figure 1 illustrates the study flow, detailing the participant selection process and intervention timeline.

Intervention

Subjects participate in a structured regimen designed to improve functional mobility and strength. Participants attended sessions 3 days per week, with each session lasting for 30 minutes. These sessions integrated moderate-intensity functional tasks with specific strengthening exercises. The functional tasks replicated everyday movements and challenges, promoting practical fitness gains. The strengthening exercises concentrated on major muscle groups of the upper and lower limbs to enhance overall physical resilience. The program duration was 6 weeks, with adjustments in exercise intensity and progression tailored to individual capabilities and improvement over time. The interventions are described in Table 1.

Outcome measures

The time up and go test is utilised to assess functional mobility in the elderly. Participants are instructed to walk a distance of 3 metres, turn around, return to their chair, and sit down. A normative value of 15 seconds is established for the cancer population, with reported sensitivity and specificity at 87%. This test demonstrates favourable screening properties, effectively identifying vulnerable or pre-frail older cancer individuals who could benefit from a comprehensive geriatric assessment [19].
The 5 times sit to stand test (5XSTS) is employed to evaluate lower extremity strength in the elderly. It measures the time it takes for a patient to transition from a seated to a standing position and back, repeated 5 times. Research has indicated that the self-performed 5XSTS is a valid and reliable measure for assessing lower body function and serves as an unbiased screening tool for frailty among cancer survivors [20].

Statistical analysis

The data collected from the study were analysed using Sigma Plot software, Version 14. Within-group comparisons of TUG test and 5XSTS were conducted using the paired Student t-test. This statistical method was employed to assess differences between baseline measurements and those obtained after the intervention period, showing the effectiveness of the intervention on functional capacity and strength among the subjects.

ŚRESULTS

The comprehensive analysis of a dataset comprising 35 subjects demonstrated a notable contrast between the baseline measurements and those recorded after 6 weeks of intervention. The clinical characteristics of 35 patients aged 60–75 years (mean age 69.67) were studied. The majority were female (57%) and had a BMI of < 18.9 (68%). Breast cancer was the most common type (43%), and all patients underwent chemotherapy. Significant comorbidities included hypertension (71%) and diabetes (60%), and all the subjects had scores > 6 on the clinical frailty scale (Table 2).
After 6 weeks of intervention and statistical analysis, the TUG and 5XSTS tests showed a significant improvement (p ≤ 0.001) in post-test mean values, indicating that the task-oriented approach is more effective on improving functional mobility and strength among cancer survivors (Fig. 2, Table 3).

DISCUSSION

This study found that improving functional mobility and strength can have a positive impact on frailty and increase overall well-being for cancer survivors. Task-oriented training appears to provide a complete strategy to address the complex issues associated with frailty in this population. Individuals with improved functional mobility can participate more actively in their everyday lives, creating a sense of autonomy and minimising reliance on others in the activity of daily living.
Handforth et al. found in a comprehensive analysis that over half of older cancer patients exhibit frailty or pre-frailty, placing them at significantly higher risk of death, postoperative complications, and chemotherapy intolerance. As a result, an effective intervention should be provided to promote functional mobility and strength, both of which affect frailty [21]. Functional mobility and strength decline with age, and patients who have undergone chemotherapy are more prone to rapid ageing due to alterations in the ageing mechanism. Giné-Garriga et al. found that functional balance and lower body strength-based training improved physical performance. So, this strategy has been implemented in the cancer survivor community to treat frailty [22].
The effects of exercise on functional capacity are more likely to be effective when incorporating it into multiple physical fitness components, such as strength, endurance, or balance, rather than focusing on a singular form of exercise. Cadore et al. observed improvements in functional outcomes and a reduction in falls among frail nonagenarians after a 12-week multidomain exercise intervention. Our findings align with a recent study examining the impact of multidomain interventions in the frail elderly to improve functional mobility [23].
In another study by Serra-Rexach et al. elderly individuals of advanced age who engaged in resistance and endurance training demonstrated enhanced lower body strength. However, this intervention did not yield improvements in their gait ability [24]. In our study strengthening exercise along with task training shows improvement in strength as well as mobility. It is difficult to quantify fragility in research because there is no gold standard method. Frailty is defined and assessed differently among researchers. Welford et al. found that the clinical frailty scale can assist in predicting outcomes in hospitalized oncology patients of any age. In ordinary procedures, an ideal tool for assessing frailty would be one that is rapid, easy to access and interpret, requires little training, and can be used by any type of healthcare provider [25].
The focus on frailty prevention and intervention is consistent with the ideals of proactive and patient-centred treatment. Routine frailty assessments in healthcare protocols enable early identification of at-risk individuals, paving the path for prompt and focused interventions [26]. This approach not only decreases the load on healthcare systems by minimising preventable complications, but it also promotes a culture of proactive health management, emphasising the importance of total well-being throughout life.
Task-oriented training stands out for its patient-centred approach, emphasising functional activities that have a direct impact on daily life. This method takes a holistic approach to rehabilitation, considering the interplay between physical strength, mobility, and overall frailty. Instead of treating symptoms in isolation, TOT promotes comprehensive improvements in daily functioning. Moreover, TOT significantly boosts patient engagement and motivation, which are pivotal for sustained rehabilitation progress. By involving individuals in exercises directly relevant to their daily lives, this method ensures high levels of commitment and enthusiasm throughout the rehabilitation journey.
Future investigations could delve into the optimal duration and frequency of task-oriented interventions, explore the impact on diverse cancer types, and assess the long-term sustainability of improvements on frailty. The screening instrument employed in this study was the clinical frailty scale; therefore, future research can focus on other new frailty screening techniques that are more exact and cover all dimensions of frailty.

CONCLUSIONS

In conclusion, the findings of this study show TOT to be effective in mitigating frailty by enhancing strength and functional mobility among cancer survivors. Task-oriented training stands out for its patient-centred approach, emphasising functional activities that have a direct impact on daily life. Instead of treating symptoms in isolation, TOT promotes comprehensive improvements in daily functioning. Moreover, TOT significantly boosts patient engagement and motivation, which are pivotal for sustained rehabilitation. By involving individuals in exercises directly relevant to their daily lives, this method ensures high levels of commitment and enthusiasm throughout the rehabilitation journey.

DISCLOSURES

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

REFERENCES