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E416 Vol. 39, No. 5, September 2012 • Oncology Nursing Forum
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C hemotherapy-induced peripheral neurop- athy (CIPN) is an under-addressed prob- lem in oncology. Neurotoxic chemotherapy drugs are now used on the majority of patients who receive chemotherapy
for cancer treatment in the United States (American Cancer Society, 2012). Numbness, muscle weakness, and loss of balance affecting the lower extremities are common manifestations of CIPN and lead to falls and other injuries (Hile, Fitzgerald, & Studenski, 2010; Tofthagen, Overcash, & Kip, 2011; Wampler et al., 2007). Primary treatment for CIPN includes dose reduction or discontinuation of the offending chemotherapeutic agent. Treatment of painful neuropathic symptoms with medications also has been a focus in clinical prac- tice (Quasthoff & Hartung, 2002; Uceyler, Rogausch, Toyka, & Sommer, 2007). Medications often are useful for treating neuropathic pain; however, they have not demonstrated any benefit for improving strength, gait, or balance (Kaley & Deangelis, 2009; Smith, Cohen, Pett, & Beck, 2010; Smith, Torrance, Bennett, & Lee, 2007). Little attention has been given to the deleterious effects of CIPN on physical performance in either research or clinical practice. With CIPN becoming a growing prob- lem among patients undergoing cancer treatment and cancer survivors, new methods of treating CIPN and its negative influence on physical performance must be discovered (Visovsky, 2003; Visovsky, Collins, Abbott, Aschenbrenner, & Hart, 2007).
A conceptual model developed by author Constance Visovsky (see Figure 1) illustrates the relationships between CIPN; exercise, including strength and bal- ance training; and clinical outcomes. Neurotoxic chemotherapeutic agents induce sensory and motor
Strength and Balance Training for Adults With Peripheral Neuropathy and High Risk of Fall: Current Evidence and Implications for Future Research
Cindy Tofthagen, PhD, ARNP, AOCNP®, Constance Visovsky, PhD, RN, ACNP, and Donna L. Berry, PhD, RN, AOCN®, FAAN
Purpose/Objectives: To evaluate the evidence for strength- and balance-training programs in patients at high risk for falls, discuss how results of existing studies might guide clini- cal practice, and discuss directions for additional research.
Data Sources: A search of PubMed and CINAHL® data- bases was conducted in June 2011 using the terms strength, balance training, falls, elderly, and neuropathy. Only clinical trials conducted using specific strength- or balance-training exercises that included community-dwelling adults and ex- amined falls, fall risk, balance, and/or strength as outcome measures were included in this review.
Data Synthesis: One matched case-control study and two randomized, controlled studies evaluating strength and balance training in patients with diabetes-related periph- eral neuropathy were identified. Eleven studies evaluating strength and balance programs in community-dwelling adults at high risk for falls were identified.
Conclusions: The findings from the reviewed studies pro- vide substantial evidence to support the use of strength and balance training for older adults at risk for falls, and detail early evidence to support strength and balance training for individuals with peripheral neuropathy.
Implications for Nursing: The evidence demonstrates that strength and balance training is safe and effective at reducing falls and improving lower extremity strength and balance in adults aged 50 years and older at high risk for falls, including patients with diabetic peripheral neuropathy. Future studies should evaluate the effects of strength and balance training in patients with cancer, particularly indi- viduals with chemotherapy-induced peripheral neuropathy.
neuropathy by activating mitochondrial and vascular dysfunction (Bennett, 2010; Flatters & Bennett, 2006; Siau, Xiao, & Bennett, 2006; Xiao & Bennett, 2007). Those metabolic and vascular dysfunctions lead to
Oncology Nursing Forum • Vol. 39, No. 5, September 2012 E417
sensory loss and reduced muscle strength, functions that depend on cellular mitochondria to generate energy in the form of adenosine triphosphate (ATP). Therefore, mitochondrial dysfunction results in the loss of energy-generating capability and vascular impair- ment deprives muscle and nerve cells of oxygen-rich nutrients, further impairing neuronal function. A lim- ited number of human and animal studies have demon- strated that exercise stimulates endothelium-dependent vasodilation and vascular endothelial growth factor (VEGF) expression, increasing endoneurial blood flow and energy-generating capacity through mitochon- drial protein synthesis and glycolysis (Gustafsson, Puntschart, Kaijser, Jansson, & Sundberg, 1999; Ojala, Page, Moore, & Thompson, 2001). Exercises, including those designed to increase strength and balance, as well as aerobic exercise, may increase the supply of blood, oxygen, and glucose to mitochondria, allowing the mitochondria to produce energy in a more efficient manner. Increasing mitochondrial energy production and blood flow to peripheral nerves may result in fewer neuropathic symptoms, increased strength and balance, and better quality of life. Additional studies designed to test this conceptual model are needed.
Although studies in cancer populations are lacking, a growing body of evidence exists to support specific muscle- and balance-training exercises in community- dwelling older adults at risk for falls. Although new studies of patients with CIPN are crucial, existing data suggest multiple benefits of strength and balance training that can be used in clinical oncology practice. A Cochrane Review by Gillespie et al. (2009) analyzed the strength of evidence to support interventions for preventing falls in community-dwelling older adults. Falls were defined as an unintentional and sudden vertical decline to the floor or ground (Conroy et al., 2010). Fall risk measurement included measures of gait, balance, and performance status using measures such as the Timed Up and Go test, which calculates the time
it takes to arise from a chair, walk 10 feet, turn around, walk back, and sit down. Timed Up and Go is highly sensitive and specific for fall prediction (Shumway- Cook, Brauer, & Woollacott, 2000). The meta-analysis included 31 randomized clinical trials of strength- and balance-training programs conducted from 1994–2008. The authors concluded that strength, balance, flexibil- ity, and endurance training were effective in reducing falls and improving balance in community-dwelling older adults provided that a combination of at least two of the four elements (strength, balance, flexibility, and endurance training) were in place. Although some conflicting evidence exists that such programs reduce fall risk, discrepancies are most likely related to meth- odologic concerns (Gillespie et al., 2009).
Numerous studies published since Gillespie et al. (2009) may provide additional information about the ef- ficacy of these interventions. The purpose of this article is to evaluate the evidence for strength- and balance- training programs in patients at high risk for falls, dis- cuss how results of existing studies might guide clinical practice, and discuss directions for additional research.
Methods A search of PubMed and CINAHL® databases was
conducted in June 2011 using the terms strength, bal- ance training, falls, elderly, and neuropathy. Clinical trials included in this review were conducted using specific strength- or balance-training exercises that focused on community-dwelling adults and examined falls, fall risk, balance, and/or strength as outcome measures (see Table 1). Studies of patients with peripheral neu- ropathy, or those at high risk for peripheral neuropathy, also were included. Studies were excluded if the sample was focused on patients with noncancer comorbidities such as osteopenia, dementia, osteoporosis, stroke, or multiple sclerosis. Case studies, and studies compar- ing strength and balance training to another type of
Administration of neurotoxic chemotherapy
Prevalence of atypical mitochondria in unmyelinated and myelinated neurons
Reduced nerve blood flow; reduced number of vasa nervorum
Intervention
Strength- and balance-training exercises
Blood supply to peripheral nerves O2 delivery to mitochondria
Glucose delivery to mitochondria
Neuropathy symptoms
Gait and balance
Muscle strength
Figure 1. Mechanistic Model of Possible Effects of Exercise on Peripheral Neuropathy
E418 Vol. 39, No. 5, September 2012 • Oncology Nursing Forum
intervention, also were excluded. Because Gillespie et al. (2009) included research through October 2008, only studies published from October 2008 to June 2011 were reviewed. One matched case-control study and two randomized, controlled studies evaluating strength and balance training in patients with diabetes-related peripheral neuropathy were identified. Eleven studies evaluating strength and balance programs in community- dwelling adults at high risk of fall were identified.
Symptoms of neuropathy are similar, regardless of the underlying cause; therefore, in the absence of stud- ies evaluating strength and balance training for CIPN, data from patients with diabetic neuropathy provide the best support for recommending strength and bal- ance training to patients with neuropathy. Compared to healthy controls, patients with neuropathy secondary to diabetes have reduced proprioception, lower extrem- ity sensation, and reduced ankle strength predisposing them to falls. Following participation in a strength- and balance-training intervention, significantly fewer falls occurred (Morrison, Colberg, Mariano, Parson, & Vinik, 2010).
Effects of Strength and Balance Training in Peripheral Neuropathy
Two randomized, controlled trials provided pre- liminary evidence to support the efficacy of strength and balance training for neuropathy. Allet et al. (2010) reported significantly improved balance and strength, increased walking speed, and decreased fear of fall- ing in participants in a 60-minute, twice a week for 12 weeks, strength, balance, and functional training program. The results were sustained for a period of six months. In addition, the training program was feasible and safe for patients with peripheral neuropathy.
Kruse, Lemaster, and Madsen (2010) assessed the effects of weight-bearing exercise on lower extremity strength, balance, and falls. Although few differences in balance, muscle strength, fall, or fear of falling were identified, the intervention was determined to be safe and well tolerated in patients with diabetes with peripheral neuropathy. This conclusion is of great importance because, as Kruse et al. (2010) explained, exercise has not been encouraged in patients with dia- betic neuropathy because of concerns of increased foot ulceration and fall.
Improved Gait and Postural Control
Steady gait requires strength and coordination of the larger muscles of the lower extremities, which are diminished in patients with neuropathy. Progressive resistance training is considered to be the most effec- tive intervention for building muscle strength in older adults (Ferri et al., 2003; Paterson, Jones, & Rice, 2007; Symons, Vandervoort, Rice, Overend, & Marsh, 2005).
Strengthening of muscles around the knee joint is related to stride length and cadence changes and can influence reduction in falls in older adults. Strength training is an intervention that also can improve gait pattern (Persch, Ugrinowitsch, Pereira, & Rodacki, 2009). Other interventions that improve standing balance or increase foot strength and ankle range of motion (ROM) also show promise in reducing falls and improving physical performance (Miller, Magel, & Hayes, 2010). Interventions specifically targeted toward improving muscle strength, balance, or ROM have been efficacious in improving gait parameters and reducing falls (Hartmann, Murer, de Bie, & de Bruin, 2009; Miller et al., 2010). Significant improvements in knee extension, ankle dorsiflexion, sitting to standing, the six-minute walk test, and balance with eyes closed have been demonstrated even among frail older adults who displayed increased physical endurance and static balance after participating in standard balance training and computer-assisted balance training (Hagedorn & Holm, 2010). Interventions to improve balance and stability also may be important in assisting older adults to adapt to changes in terrain or gait speed and regain balance after forward falls (Arampatzis, Peper, & Bier- baum, 2011).
Reducing Falls
Falls and fall-related injuries are a major concern in patients with CIPN (Tofthagen et al., 2011). Several studies have demonstrated reductions in falls or fall risk in older adults participating in strength- and balance-training programs. Patients at greatest fall risk, who are the most likely to benefit from a falls prevention program, also may have the greatest dif- ficulty participating (Conroy et al., 2010). Researchers in Australia identified the need for a strength- and balance-training program that imbeds strength- and balance-training exercises into daily activities (Clemson et al., 2010). They evaluated a home-based program called Lifestyle Approach to Reducing Falls Through Exercise (LiFE). The group of older adults receiving the LiFE intervention experienced fewer falls, improve- ments in dynamic balance, and fall-related self-efficacy (Clemson et al., 2010). Interventions that include muscle power–building exercises and walking in addition to strength and balance training also have resulted in improved balance, walking ability, and fall incidence (Iwamoto et al., 2009).
No clear indication is noted from the literature as to whether home- or institution-based falls preven- tion programs are better. Home-based programs have demonstrated similar efficacy in improving physical function, but institution-based programs may offer greater benefits in terms of reducing falls. Data suggest that although institution-based programs may be more
Oncology Nursing Forum • Vol. 39, No. 5, September 2012 E419
Ta b le 1 . L it er at u re R ev ie w
R ef er en ce
D es ig n
an d P u rp o se
Sa m p le
In te rv en ti o n
M ea su re m en t
R es u lt s an d C o m m en ts
A lle
t et
a l.,
20
10
R an
d om
iz ed
, c on
- tr
ol le
d t
ri al
(R C
T)
to e
va lu
at e
a 12
- w
ee k
st re
ng th
a nd
ba
la nc
e tr
ai ni
ng
p ro
gr am
fo cu
si ng
on
g ai
t, b
al an
ce ,
an d
fe ar
o f f
al lin
g
71 p
at ie
nt s
w ith
d
ia be
tic n
eu -
ro p
at hy
(c on
tr ol
, n=
36 ;
in te
rv en
- tio
n, n
= 35
)
60 -m
in ut
e gr
ou p
e xe
rc is
e se
ss io
ns w
ith a
p hy
si ca
l t he
ra p
is t
tw ic
e a
w ee
k fo
r 12
w ee
ks . E
xe rc
is e
co ns
is te
d o
f a fi
ve -
m in
ut e
w ar
m -u
p a
nd 4
0 m
in ut
es o
f c ir
cu it
tr ai
ni ng
(h ee
l/ to
e st
an ce
, t an
d em
s ta
nc e,
a nd
d iff
er en
t ty
p es
o f w
al ki
ng
al te
rn at
in g
w ith
fu nc
tio na
l e xe
rc is
es s
uc h
as s
lo p
e w
al k-
in g,
s ta
ir c
lim bi
ng , a
nd h
op p
in g)
p er
fo rm
ed t
w ic
e fo
r on
e m
in ut
e. S
es si
on s
co nc
lu d
ed w
ith in
te ra
ct iv
e ga
m es
fo r
10 m
in ut
es , f
ee d
ba ck
s es
si on
s, a
nd r
ec om
m en
d at
io ns
fo r
ho m
e ex
er ci
se s.
T he
c on
tr ol
g ro
up m
ai nt
ai ne
d u
su al
p hy
si -
ca l a
ct iv
iti es
, w hi
ch w
er e
un m
on ito
re d
.
Pe rf
or m
an ce
-o ri
en te
d m
ob ili
ty
as se
ss m
en t
(P O
M A
), ou
td oo
r ga
it as
se ss
m en
t us
in g
a gy
ro -
sc op
e d
ev ic
e, d
yn am
ic b
al -
an ce
t es
t, a
nd s
ta tic
b al
an ce
te
st u
si ng
a b
io d
ex d
ev ic
e
W al
ki ng
s p
ee d
, s tr
en gt
h, a
nd b
al -
an ce
w er
e si
gn ifi
ca nt
ly b
et te
r in
th
e in
te rv
en tio
n gr
ou p
. R es
ul ts
w
er e
su st
ai ne
d a
t si
x m
on th
s. Th
e st
ud y
d em
on st
ra te
d s
us ta
in ed
re
su lts
t hr
ee m
on th
s af
te r
th e
in -
te rv
en tio
n en
d ed
. H ow
ev er
, f al
ls
w er
e no
t an
o ut
co m
e m
ea su
re .
A ra
m p
at zi
s et
a l.,
2 01
1 R
TC t
o d
et er
m in
e m
ec ha
ni sm
s
re sp
on si
bl e
fo r
d
yn am
ic s
ta bi
lit y
55 h
ea lth
y ol
d er
ad
ul ts
a ge
d
65 –7
5 ye
ar s
A th
re e-
gr ou
p st
ud y
co ns
is tin
g of
tw o
in te
rv en
tio n
gr ou
ps (1
an
d 2)
a nd
a c
on tr
ol g
ro up
(3 ).
G ro
up 1
(s ta
bi lit
y) p
er fo
rm ed
w
ar m
-u p
an d
dy na
m ic
s ta
bi lit
y ex
er ci
se s
us in
g la
rg e
an d
sm
al l,
fa st
a nd
s lo
w , a
nd s
in gl
e an
d m
ul tip
le s
te ps
in a
nt er
io r-
po st
er io
r an
d m
ed io
la te
ra l d
ire ct
io ns
w ith
a rm
a nd
le g
m ov
e- m
en ts
to m
ai nt
ai n
ba la
nc e
pe rf
or m
ed o
n a
va rie
ty o
f s ur
fa ce
s.
G ro
up 2
(s ta
bi lit
y an
d m
us cl
e st
re ng
th ) p
er fo
rm ed
th e
sa m
e ex
er ci
se s
fo r
dy na
m ic
s ta
bi lit
y as
g ro
up 1
p lu
s m
us cl
e st
re ng
th
of lo
w er
e xt
re m
iti es
fo r
kn ee
fl ex
io n
an d
ex te
ns io
n, h
ip fl
ex -
io n,
a nd
a nk
le e
xt en
si on
in s
et s
of 1
0– 15
r ep
et iti
on s
at 5
0% –
70 %
o ne
r ep
et iti
on m
ax im
um (R
M ).
Th e
in te
rv en
tio n
gr ou
p
ex er
ci se
d fo
r 1.
5 ho
ur s
tw ic
e a
w ee
k fo
r 14
w ee
ks .
Fo rw
ar d
fa ll
si m
ul at
io n
fo r
ba la
nc e
an d
d yn
am om
et er
fo r
m us
cl e
st re
ng th
B ot
h co
nt ro
l g ro
up s
sh ow
ed im
- p
ro ve
m en
ts in
a bi
lit y
to r
eg ai
n ba
la nc
e. 38
p ar
tic ip
an ts
c om
p le
te d
t he
st
ud y.
In te
rv en
tio ns
w er
e on
ly
br ie
fly d
es cr
ib ed
.
B el
in g
&
R ol
le r,
20 09
R TC
t o
ev al
ua te
a
sm al
l g ro
up b
al -
an ce
p ro
gr am
23 a
d ul
ts o
ld er
th
an a
ge 6
4 Th
e gr
ou p
p ar
tic ip
at ed
in a
3 0-
m in
ut e
ba la
nc e
p ro
gr am
th
re e
tim es
p er
w ee
k fo
r 12
w ee
ks .
Fo r
st re
ng th
, m an
ua l m
us cl
e te
st in
g; fo
r ga
it, c
ad en
ce s
tr id
e le
ng th
, s te
p le
ng th
, v el
oc ity
, b as
e w
id th
, d ou
bl e
su pp
or t,
sw in
g,
an d
st an
ce u
si ng
G A
IT R
ite ;
an d,
fo r b
al an
ce , d
yn am
ic p
os -
tu ro
gr ap
hy w
ith S
m ar
t E qu
ite st
, M
ot or
C on
tr ol
T es
t, A
da pt
at io
n Te
st , a
nd B
er g
B al
an ce
S ca
le .
M ea
su re
s of
s tr
en gt
h, b
al an
ce , a
nd
fa lls
w er
e si
gn ifi
ca nt
ly b
et te
r in
th
e in
te rv
en tio
n gr
ou p
. Th
e st
ud y
ha d
no o
bj ec
tiv e
m ea
- su
re s
of s
tr en
gt h,
h ad
a s
m al
l sa
m pl
e si
ze , a
nd la
ck ed
in te
r- ra
te r
re lia
bi lit
y fo
r m
an ua
l m us
cl e
te st
- in
g (M
M T)
.
C le
m so
n et
al
., 20
10
R C
T to
e va
lu at
e a
p ro
gr am
t ha
t em
- be
d s
st re
ng th
a nd
ba
la nc
e ex
er ci
se s
in to
d ai
ly a
ct iv
iti es
A d
ul ts
y ou
ng er
th
an a
ge 7
0 w
ith
tw o
or m
or e
fa lls
or
a fa
ll- re
la te
d
in ju
ry in
t he
p as
t ye
ar (c
on tr
ol , n
=
16 ;
in te
rv en
tio n,
n
= 1
8)
Th e
in te
rv en
tio n
gr ou
p r
ec ei
ve d
e d
uc at
io n
on c
or e
ba l-
an ce
a nd
s tr
en gt
h tr
ai ni
ng p
ri nc
ip le
s ta
ug ht
in fi
ve h
om e
vi si
ts fo
llo w
ed b
y tw
o bo
os te
r vi
si ts
a nd
t w
o p
ho ne
c al
ls .
Fo r
ba la
nc e,
n ar
ro w
b as
e; h
al f
ta nd
em ;
ta nd
em a
nd u
ni p
ed al
st
an d
t im
es ;
tim ed
t an
d em
w
al k;
a nd
d yn
am om
et er
fo r
hi p
, k ne
e, a
nd a
nk le
s tr
en gt
h.
Fa lls
w er
e se
lf- re
p or
te d
.
A r
ed uc
ed r
is k
of r
ec ur
re nt
fa lls
a nd
im
pr ov
em en
t i n
dy na
m ic
b al
an ce
an
d kn
ee s
tr en
gt h
w er
e id
en tif
ie d.
Lo
w b
ur de
n on
p ar
tic ip
an ts
a nd
hi
gh a
ttr iti
on in
th e
in te
rv en
tio n
gr ou
p w
er e
no te
d. O
ut co
m e
m ea
- su
re m
en ts
w er
e ta
ke n
at b
as el
in e
an d
m on
th s
3 an
d 6.
T he
r es
ul ts
w
er e
no t s
us ta
in ed
a t m
on th
6 .
(C on
tin ue
d on
t he
n ex
t p
ag e)
E420 Vol. 39, No. 5, September 2012 • Oncology Nursing Forum
Ta b le 1 . L it er at u re R ev ie w
R ef er en ce
D es ig n
an d P u rp o se
Sa m p le
In te rv en ti o n
M ea su re m en t
R es u lt s an d C o m m en ts
C om
an s
et
al .,
20 10
R
TC t
o co
m p
ar e
ho m
e- ba
se d
a nd
ce
nt er
-b as
ed
d el
iv er
y of
a fa
lls
p re
ve nt
io n
p ro
- gr
am
10 7
ad ul
ts o
ld er
th
an a
ge 6
0 w
ho
ha d
a n
in cr
ea se
d
ri sk
o f f
al ls
B ot
h gr
ou p
s re
ce iv
ed w
ee kl
y su
p er
vi se
d b
al an
ce t
ra in
in g
fo r
ei gh
t w
ee ks
a nd
w er
e as
ke d
t o
p er
fo rm
t hr
ee b
al an
ce
ex er
ci se
s tw
ic e
a d
ay fo
r 10
m in
ut es
o n
ot he
r d
ay s.
Fa lls
in fo
rm at
io n
w as
c ol
le ct
ed
m on
th ly
b y
te le
p ho
ne .
Fa ll
in ci
d en
ce w
as lo
w er
in t
he
ce nt
er -b
as ed
g ro
up t
ha n
in t
he
ho m
e- ba
se d
g ro
up .
Th e
ce nt
er -b
as ed
in te
rv en
tio n
al so
co
nt ai
ne d
a h
om e
ex er
ci se
c om
- p
on en
t.
C on
ro y
et
al .,
20 10
R
C T
to d
et er
m in
e th
e ef
fic ac
y of
a
fa lls
p re
ve nt
io n
p ro
gr am
fo r
co m
- m
un ity
-d w
el lin
g ol
d er
a d
ul ts
a t
hi gh
r is
k fo
r fa
lls
A d
ul ts
o ld
er t
ha n
ag e
70 w
ith a
p
re vi
ou s
fa ll
or
tw o
fa ll
ri sk
fa
ct or
s (c
on tr
ol ,
n =
1 81
; in
te r-
ve nt
io n,
n =
1 83
)
12 m
on th
s of
s tr
en gt
h an
d b
al an
ce t
ra in
in g
w er
e ta
ilo re
d
to t
he n
ee d
s an
d a
bi lit
ie s
of t
he in
d iv
id ua
l, al
on g
w ith
o c-
cu p
at io
na l t
he ra
p y,
h om
e sa
fe ty
a ss
es sm
en t,
a nd
m ed
ic al
ca
re .
M on
th ly
fa lls
d ia
ri es
A d
ef in
ite t
re nd
w as
n ot
ed t
ow ar
d
re d
uc tio
n in
fa lls
, b ut
it w
as n
ot
st at
is tic
al ly
s ig
ni fic
an t.
Th is
s tu
d y
ha d
a la
rg e
sa m
p le
s iz
e an
d t
ar ge
te d
p eo
p le
a t
hi gh
r is
k.
Th e
st ud
y ha
d a
h ig
h at
tr iti
on
ra te
, f ew
d et
ai ls
w er
e p
ro vi
d ed
ab
ou t
th e
st re
ng th
a nd
b al
an ce
as
p ec
ts o
f t he
in te
rv en
tio n,
a nd
co
nt ro
l g ro
up p
ar tic
ip an
ts m
ay
ha ve
p ar
tic ip
at ed
in a
s im
ila r
p ro
gr am
a va
ila bl
e in
t he
c om
m u-
ni ty
. N o
m ea
su re
s of
s tr
en gt
h or
ba
la nc
e w
er e
in cl
ud ed
.
H ag
ed or
n &
H ol
m ,
20 10
R TC
t o
co m
p ar
e st
an d
ar d
b al
an ce
tr
ai ni
ng (T
B ) w
ith
co m
p ut
er -a
ss is
te d
ba
la nc
e (C
B ) t
ra in
- in
g
35 fr
ai l o
ld er
ad
ul ts
a ge
d
69 –9
5 ye
ar s
B ot
h gr
ou p
s ex
er ci
se d
fo r
1. 5
ho ur
s tw
ic e
a w
ee k
fo r
12
w ee
ks . T
he T
B a
nd C
B g
ro up
s re
ce iv
ed h
ig h-
in te
ns ity
p
ro gr
es si
ve r
es is
ta nc
e m
us cl
e st
re ng
th t
ra in
in g
of 1
0– 15
R
M t
hr ee
t im
es w
ith p
ro gr
es si
ve s
te p
t ra
in in
g an
d c
yc lin
g.
B al
an ce
t ra
in in
g co
ns is
te d
o f v
is ua
l c ha
lle ng
es u
si ng
d if-
fe re
nt s
ur fa
ce s,
o ne
-l eg
ge d
b al
an ce
t ra
in in
g, a
nd li
ne a
nd
ob st
ac le
c ou
rs e
w al
ki ng
.
M us
cl e
fo rc
e te
st in
g us
in g
sp ri
ng g
au ge
, s it
to s
ta nd
t es
t,
ar m
fl ex
io n,
T im
ed U
p a
nd G
o (T
U G
) t es
t, s
ix -m
in ut
e w
al k
te st
, M C
TS IB
, U ni
p ed
al S
ta nc
e Ti
m e,
t an
d em
t es
t, B
er g
B al
- an
ce S
ca le
, D yn
am ic
G ai
t In
d ex
, a nd
F al
ls E
ffi ca
cy S
ca le
– In
te rn
at io
na l
B ot
h gr
ou p
s d
em on
st ra
te d
s ig
ni fi-
ca nt
im p
ro ve
m en
ts in
s tr
en gt
h an
d b
al an
ce .
27 p
ar tic
ip an
ts c
om p
le te
d t
he
st ud
y. T
he C
B g
ro up
a ls
o ha
d im
- p
ro ve
d e
nd ur
an ce
.
H ar
tm an
n et
a l.,
2 00
9 R
TC c
om p
ar in
g a
st an
d ar
d e
xe rc
is e
p ro
gr am
w ith
a
si m
ila r
p ro
gr am
th
at a
ls o
in cl
ud ed
gy
m na
st ic
e xe
r- ci
se s
of t
he fe
et
56 c
om m
un ity
- d
w el
lin g
ad ul
ts
ol d
er t
ha n
ag e
64
G ro
up 1
(t ra
in in
g) p
er fo
rm ed
2 5
m in
ut es
o f a
er ob
ic a
nd
re si
st an
ce e
xe rc
is es
t w
ic e
a w
ee k
fo r
12 w
ee ks
. E xe
rc is
es
co ns
is te
d o
f 1 0
m in
ut e
w ar
m -u
p , 1
5 m
in ut
es o
f a er
ob ic
ex
er ci
se (w
al ki
ng , d
an ci
ng , a
nd b
al an
ce ),
an d
p ro
gr es
si ve
re
si st
an ce
e xe
rc is
es (l
eg p
re ss
, l eg
e xt
en si
on /fl
ex io
n, h
ip
ab d
uc tio
n/ ad
d uc
tio n,
r ow
in g,
fi ve
-m in
ut e
tr ea
d m
ill , s
p in
- ni
ng , a
nd b
al an
ce ).
G ro
up 2
(f oo
t gy
m na
st ic
s) p
er fo
rm ed
th
e sa
m e
ex er
ci se
s as
g ro
up 1
p lu
s fo
ur a
d d
iti on
al m
in ut
es
of fo
ot g
ym na
st ic
s co
ns is
tin g
of 1
0 m
in ut
es o
f s tr
et ch
in g
an d
r el
ax at
io n
fo ot
e xe
rc is
es . G
ro up
3 (c
on tr
ol g
ro up
) p er
- fo
rm ed
n o
ex er
ci se
.
Fa lls
E ffi
ca cy
S ca
le –I
nt er
na tio
na l
fo r
an kl
e ra
ng e
of m
ot io
n (R
O M
); e
xp an
d ed
T U
G t
es t;
ga
it an
al ys
is ;
an d
m us
cl e
p ow
er m
ea su
re m
en t
B ot
h ex
er ci
se g
ro up
s ex
hi bi
te d
im
p ro
ve m
en t
in s
tr en
gt h,
p ow
er ,
an d
p er
fo rm
an ce
. T he
a d
d iti
on
of fo
ot g
ym na
st ic
s m
ad e
no s
ig -
ni fic
an t
d iff
er en
ce .
N o
ba la
nc e-
sp ec
ifi c
ex er
ci se
s w
er e
in cl
ud ed
, b ut
4 5
p ar
tic ip
an ts
co
m p
le te
d t
he s
tu d
y. C
on tr
ol
gr ou
p d
at a
(n =
1 4)
c am
e fr
om a
p
re vi
ou s
st ud
y.
(C on
tin ue
d on
t he
n ex
t p
ag e)
(C o
n ti
n u
ed )
Oncology Nursing Forum • Vol. 39, No. 5, September 2012 E421
Ta b le 1 . L it er at u re R ev ie w
R ef er en ce
D es ig n
an d P u rp o se
Sa m p le
In te rv en ti o n
M ea su re m en t
R es u lt s an d C o m m en ts
Iw am
ot o
et
al .,
20 09
R
TC t
o ev
al u-
at e
an e
xe rc
is e
p ro
gr am
(i nc
lu d
- in
g st
re ng
th a
nd
ba la
nc e
tr ai
ni ng
) fo
r p
re ve
nt io
n of
fa
lls a
m on
g ol
d er
ad
ul ts
68 p
ar tic
ip an
ts
ol d
er t
ha n
ag e
50 30
m in
ut es
, t hr
ee t
im es
p er
w ee
k, fo
r fiv
e m
on th
s w
ith
st re
ng th
, b al
an ce
, p ow
er t
ra in
in g,
a nd
w al
ki ng
Fo r
ba la
nc e,
in d
ic es
o f f
le x-
ib ili
ty , t
an d
em s
ta nd
in g
tim e,
ta
nd em
g ai
t st
ep n
um be
r, an
d
un ip
ed al
s ta
nd in
g tim
e. F
or
m us
cl e
p ow
er , T
U G
, c ha
ir r
is -
in g
tim e,
a nd
1 0
m et
er w
al k
tim e.
Th e
in te
rv en
tio n
gr ou
p h
ad b
et te
r ba
la nc
e, m
us cl
e p
ow er
, a nd
fa lls
th
an t
he c
on tr
ol g
ro up
a t
th e
en d
of
t he
in te
rv en
tio n.
Th e
in te
rv en
tio n
w as
le d
b y
ge ne
ra l p
ra ct
iti on
er s
ra th
er t
ha n
p hy
si ca
l t he
ra p
is ts
. I nt
er ve
nt io
n gr
ou p
p ar
tic ip
an ts
c om
p le
te d
10
0% o
f t he
p ro
gr am
; ho
w ev
er ,
th e
st ud
y ha
d a
s m
al l s
am p
le s
iz e
w ith
n o
lo ng
itu d
in al
d at
a.
K ru
se e
t al
., 20
10
R TC
t o
ev al
ua te
th
e ef
fic ac
y of
a
ho m
e- ba
se d
e x-
er ci
se p
ro gr
am in
p
at ie
nt s
w ith
d ia
- be
tic n
eu ro
p at
hy
D ia
be tic
s ol
d er
th
an a
ge 4
9 w
ith
ne ur
op at
hy (c
on -
tr ol
, n =
38 ;
in te
r- ve
nt io
n, n
= 41
)
Th e
m on
th s
1– 3
in te
rv en
tio n
gr ou
p h
ad e
ig ht
p hy
si ca
l th
er ap
y se
ss io
ns fo
llo w
ed b
y th
re e
on e-
ho ur
s es
si on
s at
ho
m e
w ith
t he
t he
ra p
is t
re ga
rd in
g th
e d
ev el
op m
en t
of a
n in
d iv
id ua
liz ed
w al
ki ng
p ro
gr am
. T he
m on
th s
4– 12
in te
r- ve
nt io
n gr
ou p
r ec
ei ve
d w
ee kl
y p
ho ne
c al
ls e
nc ou
ra gi
ng
ex er
ci se
.
B er
g B
al an
ce T
es t,
U ni
p ed
al
St an
ce T
im e,
T U
G , F
al ls
E ffi
- ca
cy S
ca le
, F oo
t Fu
nc tio
n D
is -
ab ili
ty S
ca le
, a nd
s el
f- re
p or
te d
fa
lls d
at a
N o
si gn
ifi ca
nt d
iff er
en ce
s w
er e
no te
d be
tw ee
n gr
ou ps
in fa
lls o
r st
re ng
th ;
on e
m ea
su re
o f b
al an
ce
w as
b et
te r
in th
e in
te rv
en tio
n gr
ou p.
Th is
w as
a h
om e-
ba se
d p
ro gr
am
w ith
lo w
r at
es o
f c om
p lia
nc e,
si
ng le
b lin
d ed
, a nd
n o
su p
er vi
- si
on o
f e xe
rc is
e af
te r
th e
fir st
tw
o m
on th
s. T
he s
tr en
gt h
of t
he
in te
rv en
tio n
m ay
n ot
h av
e be
en
en ou
gh t
o d
et ec
t si
gn ifi
ca nt
gr
ou p
d iff
er en
ce s.
O ut
co m
e m
ea su
re s
w er
e ev
al ua
te d
a t
ba se
lin e
an d
m on
th s
3, 6
, a nd
12
, a lth
ou gh
t he
m on
th 3
d at
a w
er e
no t
p ro
vi d
ed o
r in
cl ud
ed in
th
e an
al ys
es .
M ill
er e
t al
., 20
10
A q
ua si
ex p
er im
en -
ta l s
tu d
y ev
al ua
t- in
g a
fo ur
-w ee
k st
an d
in g
ex er
ci se
an
d b
al an
ce t
ra in
- in
g in
te rv
en tio
n
A d
ul ts
a ge
d
71 –8
5 re
ce iv
in g
ho m
e he
al th
c ar
e
A t
he ra
p is
t le
d t
he s
ta nd
in g
ex er
ci se
a nd
b al
an ce
t ra
in in
g p
ro gr
am t
w ic
e a
d ay
, f iv
e d
ay s
a w
ee k,
fo r
fo ur
w ee
ks .
Fo ur
s ta
nd in
g ex
er ci
se s
in cl
ud ed
1 0
re p
et iti
on s
of p
ar tia
l sq
ua ts
, h ee
l r ai
se s,
h ip
a bd
uc tio
n an
d fl
ex io
n, a
nd s
ix
ba la
nc e
ex er
ci se
s of
lo ng
er t
ha n
10 fe
et c
on si
st in
g of
s id
e- st
ep p
in g,
t an
d em
w al
ki ng
, r et
ro w
al ki
ng , b
ra id
in g,
c ro
ss -
ov er
s, o
ne -l
eg s
ta nc
e, a
nd s
ta nd
in g
ex te
rn al
p er
tu rb
at io
n.
Fa lls
E ffi
ca cy
S ca
le , o
ne -l
eg
st an
ce t
es t,
a nd
P O
M A
B al
an ce
, b al
an ce
c on
fid en
ce , a
nd
ga it
im p
ro ve
d s
ig ni
fic an
tly fr
om
p re
te st
t o
p os
t- te
st .
Th e
ho m
e ex
er ci
se p
ro gr
am , l
ed b
y th
er ap
is t-
tr ai
ne d
ca re
gi ve
rs , h
ad
10 0%
c om
pl ia
nc e.
A s
ta nd
ar di
ze d
pr
ot oc
ol w
ith o
bj ec
tiv e
an d
su b-
je ct
iv e
m ea
su re
s w
as in
cl ud
ed ;
ho w
ev er
, n o
co nt
ro l g
ro up
w as
us
ed , t
he s
am pl
e si
ze w
as s
m al
l, an
d th
e st
ud y
w as
n on
-b lin
de d.
(C on
tin ue
d on
t he
n ex
t p
ag e)
(C o
n ti
n u
ed )
E422 Vol. 39, No. 5, September 2012 • Oncology Nursing Forum
effective, participation and adherence may in- crease when a home-based program is offered (Comans, Brauer, & Haines, 2010).
Discussion The findings from the reviewed studies
provide substantial evidence to support the use of strength and balance training for older adults at risk for falls and beginning evidence to support strength and balance training for individuals with peripheral neuropathy. The studies reviewed on strength- and balance- training programs for diabetics with periph- eral neuropathy indicate that patients with neuropathy can safely participate in and may receive benefit from strength- and balance- training (Allet et al., 2010; Kruse et al., 2010; Morrison et al., 2010). Several studies have described risk for postural instability, falls, and fall-related injury in patients with CIPN and recommended physical therapy as a treat- ment option, but no studies were identified that evaluate strength and balance training for treatment of CIPN (Hile et al., 2010; Toftha- gen, 2010; Tofthagen et al., 2011; Wampler et al., 2007). Although more studies are needed to evaluate efficacy, data from the reviewed studies support strength and balance training as a safe intervention for patients with CIPN. Strength and balance training should be rec- ommended when patients are experiencing loss of balance associated with CIPN, as CIPN is a source of significant disability with few evidence-based treatment strategies available (Visovsky et al., 2007).
Implications for Practice Numerous studies, primarily in the physical
therapy and geriatric literature, support the use of strength- and balance-training exercises among community-dwelling adults with pos- tural instability or at high risk for falls (Allet et al., 2010; Arampatzis et al., 2011; Beling & Roller, 2009; Clemson et al., 2010; Comans et al., 2010; Conroy et al., 2010; Hagedorn & Holm, 2010; Iwamoto et al., 2009; Kruse et al., 2010; Miller et al., 2010; Morrison et al., 2010; Persch et al., 2009). These studies have direct application to oncology practice and research because many patients, particularly during chemotherapy or radiation therapy, or in advanced stages of disease, experience generalized weakness, muscle weakness, un-
Ta b le 1 . L it er at u re R ev ie w
R ef er en ce
D es ig n
an d P u rp o se
Sa m p le
In te rv en ti o n
M ea su re m en t
R es u lt s an d C o m m en ts
M or
ri so
n et
al
., 20
10
Si ng
le -a
rm in
te r-
ve nt
io na
l c as
e- co
nt ro
l s tu
d y
to
as se
ss fa
ll ri
sk a
nd ef
fic ac
y of
s tr
en gt
h an
d b
al an
ce t
ra in
- in
g in
d ia
be tic
s
16 p
ar tic
ip an
ts
w ith
n eu
ro p
at hy
(g
ro up
1 ) a
nd 2
1 ag
e- m
at ch
ed c
on -
tr ol
s (g
ro up
2 )
St re
ng th
a nd
b al
an ce
p ro
gr am
t hr
ee t
im es
a w
ee k
fo r
si x
w ee
ks Ph
ys io
lo gi
c Pr
of ile
A ss
es sm
en t
an d
S im
p le
R ea
ct io
n Ti
m e
G ro
up 1
d em
on st
ra te
d d
ec re
as ed
fa
ll ri
sk .
Th e
in te
rv en
tio n
w as
n ot
fu lly
d e-
sc rib
ed , t
he s
tu dy
h ad
a s
m al
l s am
- pl
e siz
e, a
nd n
o lo
ng -t
er m
fo llo
w -
up w
as in
iti at
ed . A
ll pa
rti ci
pa nt
s ha
d ne
ur op
at hy
a nd
th e
st ud
y ha
d
no ra
nd om
a ss
ig nm
en t o
r b lin
di ng
.
Pe rs
ch e
t al
., 20
09 A
c ro
ss -o
ve r
d es
ig n
to d
et er
- m
in e
th e
ef fe
ct s
of a
lo w
er li
m b
st re
ng th
t ra
in in
g p
ro gr
am o
n ga
it ki
ne m
at ic
s as
- so
ci at
ed w
ith fa
ll ri
sk in
o ld
er a
d ul
t w
om en
27 c
om m
un ity
- d
w el
lin g
w om
en
ag ed
6 0
an d
ol
d er
Th e
ex er
ci se
g ro
up r
ec ei
ve d
1 2
w ee
ks o
f l ow
er li
m b
st re
ng th
t ra
in in
g (t
w o
se ts
o f 1
0– 12
r ep
et iti
on s
of b
ila te
ra l
kn ee
fl ex
io n/
ex te
ns io
n, b
ila te
ra l h
ip a
d d
uc tio
n/ ab
d uc
tio n,
un
ila te
ra l h
ip e
xt en
si on
/fl ex
io n,
b ila
te ra
l l eg
p re
ss , a
nd
bi la
te ra
l p la
nt ar
fl ex
io n)
p er
fo rm
ed t
hr ee
t im
es p
er w
ee k.
Th
e co
nt ro
l g ro
up r
ec ei
ve d
u p
p er
li m
b st
re ng
th t
ra in
in g
(b ic
ep c
ur ls
, s itt
in g
tr ic
ep s,
p us
h d
ow n,
a nd
s ho
ul d
er p
re ss
) an
d w
as o
ffe re
d t
he lo
w er
li m
b p
ro gr
am a
ft er
t he
e xp
er i-
m en
ta l p
er io
d .
M ax
im um
s tr
en gt
h ga
in s
(o ne
R
M t
es t)
, p ea
k to
rq ue
(s tr
ai n
te st
), jo
in t
R O
M (m
ax im
um
jo in
t am
p lit
ud e)
, a nd
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Oncology Nursing Forum • Vol. 39, No. 5, September 2012 E423
steadiness, or problems maintaining balance. Cancer- related fatigue from disease and treatment effects often induces patients to rest, leading to muscle weakness and atrophy that then can contribute to fall and injury risk. As the incidence of cancer increases exponentially with age, comorbid conditions and age-related physiologic changes contribute to muscle weakness, loss of balance, and increase the likelihood of falls and fall-related inju- ries. A growing amount of data in noncancer populations demonstrate that neuropathy, which is caused by many of the treatments used in patients with cancer and also can occur as a result of the cancer itself, is a risk factor for falls and fall-related injuries (Allet et al., 2010; Kruse et al., 2010; Morrison et al., 2010). A holistic and multidisci- plinary approach to cancer treatment includes attention to treating the cancer and the symptoms that arise from the cancer and/or its treatment, as well as addressing issues that negatively affect quality of life.
Strength- and balance-training exercises can easily be provided by a physical therapist and a great deal of data exist that support physical therapist-led exercise interventions, including specific exercises to strengthen the lower extremities and improve balance (Allet et al., 2010; Arampatzis et al., 2011; Beling & Roller, 2009; Clemson et al., 2010; Comans et al., 2010; Conroy et al., 2010; Hagedorn & Holm, 2010; Iwamoto et al., 2009; Kruse et al., 2010; Miller et al., 2010; Morrison et al., 2010; Persch et al., 2009). Participation in exercise pro- grams focused on improving lower-extremity strength and balance has been repeatedly demonstrated as safe, even among people with a very high risk of falls (Clem- son et al., 2010; Comans et al., 2010; Conroy et al., 2010).
Directions for Future Research A great need exists for additional research explor-
ing the benefits and limitations of strength and bal- ance training in patients with cancer. The studies in this review indicate that, although patients may be more likely to adhere to a home-based strength- and balance-training program, institution-based programs may offer better results, probably because of the in- herent challenges of monitoring adherence in a home setting (Comans et al., 2010). Interventions that focus on strength and balance have not been adequately tested on patients with cancer, and have not examined falls or related injury as the primary outcome. As the population ages and cancer survival rates increase, interventions aimed at improving strength and balance and, ultimately, physical functioning become important in assisting older adults in maintaining independence.
The best time to offer strength and balance training should be explored. Patients receiving chemotherapy and radiation therapy, who have multiple appointments for cancer therapy, blood draws, injections, and physi-
cian and nursing visits, may benefit; however, making a commitment to attend or participate may prove chal- lenging because of multiple demands on their time. Symptoms such as fatigue, weakness, and insomnia also can interfere with patients’ ability to participate.
The amount of exercise (dose) needed to achieve the desired improvements in strength and balance and re- duction in falls has not been determined and may vary from one population to the next. In the reviewed studies, the time that participants engaged in exercise ranged from 10 minutes to 1 hour at a time, from once a week to twice a day, and from 4 weeks to 12 months. Therefore, although strength- and balance-training exercises can be recommended, the frequency and duration with which they should be prescribed are, to date, indeterminate.
Exercise in general is known to decrease fatigue among patients with cancer, but how strength and balance training might affect cancer-related symptoms such as fatigue, sleep disturbance, or depression is unknown. Exercise programs that include strength and balance training may increase physical performance, increase independence, and have positive effects on role function or other elements of health-related quality of life. Future studies involving patients with cancer should include those as secondary outcomes. In ad- dition to improving strength and balance, researchers should examine whether strength and balance training can decrease pain or numbness associated with CIPN.
Conclusions The evidence demonstrates that strength and bal-
ance training is safe and effective at reducing falls and improving lower-extremity strength and balance in adults aged 50 and older who are at high risk for falls, including patients with diabetic peripheral neuropathy. Future studies should evaluate the effects of strength and balance training in patients with cancer, particu- larly individuals with CIPN. Important goals for future studies include identifying the most effective dose and method of delivery and evaluating the effects on cancer-related symptoms and quality of life.
Cindy Tofthagen, PhD, ARNP, AOCNP®, is an assistant professor in the College of Nursing at the University of South Florida in Tampa and a postdoctoral fellow at the Phyllis F. Cantor Center for Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute and the University of Massachusetts Boston; Constance Visovsky, PhD, RN, ACNP, is an associate professor and associate dean of Student Affairs and Community Engage- ment in the College of Nursing at the University of South Florida; and Donna L. Berry, PhD, RN, AOCN®, FAAN, is the director of the Phyllis F. Cantor Center for Research in Nursing and Patient Care Services at the Dana-Farber Cancer Institute and an associate pro- fessor at Harvard Medical School in Boston. No financial relation- ships to disclose. Tofthagen can be reached at ctofthag@health .usf.edu, with copy to editor at [email protected]. (Submitted July 2011. Accepted for publication December 15, 2011.)
Digital Object Identifier: 10.1188/12.ONF.E416-E424
E424 Vol. 39, No. 5, September 2012 • Oncology Nursing Forum
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