Compared with lower respiratory tract cancer (i.e., lung and bronchus), head and neck cancer (HNC) has better relative survival. This survival rate comes from advanced cancer treatments. Yet these treatments often lead to unbearable symptoms. The two most distressing symptoms are fatigue and pain and are frequently related to negative activities of daily living (ADL). Fatigue and musculoskeletal pain often improve in response to physical activity (PA). However, 51% of HNC survivors rarely engage in any type of PA because of the barriers of poor fitness, PA health beliefs and physical symptoms. A personalized behavioral telehealth Physical Activity intervention with fitness graded Motion Exergames (PAfitME) was designed to overcome these barriers. The aims of the study included: (1) to assess the feasibility, acceptability, and safety of the PAfitME intervention, (2) to describe exergame PA behavior (adherence rate) during the 6-week PAfitME intervention, and (3) to analyze changes in fatigue, pain, and ADL in HNC patients after cancer treatment.
Conceptual Framework:
PAfitME is built on the social cognitive theory (observed behavior is influenced by the interaction of personal factors, behavioral responses, and environmental setup) and the exercise principal of adaptation (cardiorespiratory and skeletal muscle functional adaptation and remodeling happen in response to frequent PA stimuli).
Gamification Approach to Overcome Behavioral Barriers
Three major components in the PAfitME: (1) Assess and Match Fitness: The first component was to assess the fitness grading parameter of a participant and match his/her parameter to Exergame Grading Scheme rating of exergames. (2) Assess and Match in Health Beliefs and Symptoms: The second component was to select exergames in which the participant reports at least 70% in PA self-efficacy and 70% in PA enjoyment when asked in the next 7 days on a 0-100% scale. Pain and fatigue scores was monitored each week. The exergames prescription would be changed if the fatigue/pain score worsened over 2 points on a single 0-10 scale in the previous week. (3) Deliver, progress, manage risks. The Personalized Exergame Prescription Guideline is the basis to deliver and progress PAfitME, including mode, intensity, frequency, and duration of exergame PA. PAfitME health risks for HNC patients was monitored in each week and included: fall, body weight loss, and cancer recurrence.
The Pre-Efficacy Study in the NIH ORBIT Model
A pre/post-test design was used to test the 6-week PAfitME intervention. Eligibility (73%) and enrollment (47%) rates were similar to those of other HNC studies, but attendance (98%) and attrition (20%) were better. A total of 10 participants were enrolled into the study. During the study, 2 participants dropped out due to cancer recurrence or withdrawal of consent. The remaining 8 were, on average, 58.2±13.3 years old; 7 (87.5%) were male; 7 (87.5%) were White. Sex and racial distributions were similar to those in national data. Three (37.5%) had oral cancer and 5 (62.5%) had laryngeal cancer. Four participants (50%) had stages III and IV cancer. Three (38%) had a feeding tube and two (25%) had a tracheostomy. Participants reported being satisfied with the intervention (3.2 on a 1-4 scale). The interventionist reported a high level of participant engagement (9.1 on a 0-10 scale). The participant burden was about 43 minutes per home visit which is better than a typical one-hour group session with additional time spent for patient transportation. Body weight did not significantly decrease from baseline at weeks 3 and 6, meaning very minimal negative nutrition balance. No falls related to the intervention occurred during the 6-week study period. Those with feeding tube/tracheostomy did not have issues to engage exergame PA. All this supports the safety of the intervention in this population. The adherence rate (exergame minutes÷ prescribed minutes x100%) during the 6-week intervention was >100% (i.e. participants did more than what was prescribed). In symptoms, changes in Brief Fatigue Inventory (mean difference= −2.0, Cohen’s d=1.3) and Brief Pain Inventory (mean difference= −1.2, Cohen’s d=1.1) were in the right direction with large effect sizes. The Lawton Instrumental ADL score also had a large effect sizes (mean difference= 1.8, Cohen’s d=1.0).
Conclusion
PAfitME is feasible and acceptable in HNC patients. These HNC patients showed improvement in fatigue, pain, and ADL after the 6-week intervention. A larger randomized trial to test the efficacy of this innovative intervention is necessary. If efficacy is supported, providers can offer this intervention to reduce fatigue and to improve physical function among HNC patients.