effects of Tai Chi and walking on fatigue and body mass index in women living with breast cancer: A pilot study
ABSTRACT
Purpose: The purpose of this study was to examine the effect of Tai Chi and walking on cancer related fatigue (CRF) and body mass index (BMI) in women living with breast cancer. Subjects: Eleven women between the ages of 40 to 59 were randomized to the Tai Chi or walking intervention. Methods: A specific program was designed and modified for this population by a Tai Chi instructor and was administered for 1 hour 3 times throughout the study. The walking program also had similar group meetings, which included postural assessment, stretching, and education. All participants were given videos to reinforce the 3 group sessions and received weekly phone calls to answer questions regarding the program. Primary outcome measures included the 6-minute walk test and the body mass index. Survey instruments included the Functional Assessment of Cancer Therapy-Breast (FACT-B) and the Brief Fatigue Inventory (BFI). All measures were taken at baseline and at 6 weeks. Subjects kept a diary of when they performed the program and how they felt throughout the 6-week intervention. Results: Due to the small number of subjects, no statistical significance was found. Trends in the functional measures showed decreased blood pressure and decreased fatigue for both groups. The walking group had an increase in body mass index (BMI) of +0.33, while the Tai Chi group had a decrease in BMI of -0.03. Analysis of the diaries revealed the following frequency of responses (1) walking and Tai Chi group intervention motivated the participants to participate in a regular exercise program and (2) both interventions fostered decreased fatigue and new awareness/learning. Discussion: Patients with CRF might benefit from Tai Chi and walking interventions. The impact on fatigue and BMI may be a primary outcome for further study. Additional functional outcome measures should be explored. This pilot study supports the need for further research in the effect of alternative forms of exercise to manage fatigue in this population.
INTRODUCTION
Fatigue has been recognized as a universal side-effect of cancer and cancer treatment.1-4 Ninety-six percent of cancer patients experience fatigue after receiving chemotherapy and radiotherapy.1 Cancer related fatigue (CRF) impacts one’s quality of life and ability to carry out activities of daily living. Exercise is one of the few interventions that have been used to decrease CRF.2,5-7 Most exercise and quality of life studies use traditional forms of exercises. However, as noted in a study by Lester and colleagues, alternative therapies are becoming more common. The 3 most frequently used alternative therapies were prayer (76%), exercise (38%), and spiritual healing (29%) in the surveyed subjects.11 One of the limiting factors for the effectiveness of an exercise program is poor overall adherence. This pilot study examined an alternative form of exercise to address this issue.
In addition to helping ameliorate CRF, exercise has been shown to improve quality of life in women with breast cancer.8-10 Breast cancer patients who exercise have reported decreased levels of anxiety and depression.11-15 Participants of exercise programs score higher in areas of physical function and overall satisfaction with life.9,10,16 Exercise can affect body mass index (BMI), which may affect the overall prognosis of women with cancer. Body mass index tends to increase in women with breast cancer following treatment.17 Women who have an average of 2.5 increase in their BMI (highest quartile of BMI) are more likely to have a poor prognosis.18,19 A gap in the literature exists addressing the effects of exercise on BMI in women with breast cancer. Furthermore, there is a lack of evidence-based research in the effect of nontraditional exercise in women living with breast cancer.
WALKING AND TAI CHI-AEROBIC EXERCISE MODALITIES FOR MANAGEMENT OF FATIGUE
Mock and colleagues evaluated the effects of exercise on fatigue, physical functioning, and emotional distress in patients undergoing radiation therapy for breast cancer.20 Forty-six women between the ages of 35 to 65 who were undergoing radiation therapy for stage I or II breast cancer participated in a 6-week exercise program. The exercise group participated in an individualized, self-paced, home-based walking exercise program, Rhythmic Walking: Exercise for People Living with Cancer, throughout treatment. In this study, the exercise group scored significantly higher than the control group on physical functioning. Subjects experienced less fatigue when participating in a walking exercise program. Another study by this same group focused on a rehabilitation program for women receiving chemotherapy for breast cancer. The 2 groups consisted of a walking program and support group. The walking group improved in physical functioning and had lower fatigue level.21 Finally, a study by Mac Vicar and colleagues used hiking as the modality for a 10-week exercise program for 45 women with breast cancer. Results showed significant reduction in nausea and lowered fatigue levels through cycling. Limitations of this study include its applicability to everyday life secondary to laboratory conditions.16
An alternative form of exercise, Tai Chi, was used in this study to determine its effectiveness in fatigue management as compared to a traditional walking program. Tai Chi is a form of exercise that recognizes the mind/body connection.22 The movements are graceful and controlled throughout the range of motion and there is no impact on the joints.23 The movements summon all postural responses and challenge kinesthetic and proprioceptive senses.24 Tai Chi has been known to have an aerobic training effect,25 lower blood pressure,26 and facilitate nutrient uptake and waste removal.27 Tai Chi is often described as a ‘moving meditation,’ where the individual must concentrate on each part of the body during movement while coordinated with slow breathing. With this type of focused movement a person’s mind is emptied of distracting thoughts and a sense of being in the here and now, along with a feeling of peacefulness ensues.
In summary, the review of the literature points to positive benefits of aerobic exercise for the patient living with breast cancer. The type, frequency, intensity, and duration of exercise are reportedly different in each of the aforementioned studies, however significant improvements are noted. In an effort to offer a variety of exercise interventions to help modulate CRF, this study compared the effectiveness of Tai Chi versus a traditional walking program.
METHODS
Sample
All subjects in this study were women between the ages of 40 to 59 with a diagnosis of Stage II to IV breast cancer. They all experienced CRF. Their oncologist screened the subjects for specific inclusion and exclusion criteria. Subjects were included in the study if she (1) had undergone adjuvant therapy (chemotherapy or radiation therapy) for breast cancer in the past year, and (2) was suffering from self-reported fatigue. A subject was excluded if she had (1) a hemoglobin count of less than 10g/dl, (2) any musculoskeletal or neurological conditions that may interfere with her ability to participate in an exercise program, (3) a stem cell transplant, (4) a thyroid condition, (5) an inability to speak, read, and write English, and (6) been exercising regularly (3 times per week) in the last year. Physicians or practitioners at various outpatient cancer centers in the Southern New Jersey area referred qualified subjects. They were properly screened, and signed an IRB approved informed consent. Groups were assigned to walking or Tai Chi by the use of a table of random numbers.
Measurement Tools
Each subject completed baseline surveys including the Functional Assessment of Cancer Therapy-Breast (FACT-B), and Brief Fatigue Inventory (BFI). The physical measurements included the BMI, (recorded as height and weight); percent body fat (measured with skin fold calipers), and a 6-minute walk test. The BMI was calculated using the equation kg/m^sup 2^ at baseline and following 6 weeks after the study. Skin fold measurements were collected pre- and poststudy using a skin fold caliber at 3 sites-the triceps, suprailium, and abdominal folds.28 Body density was calculated following the procedure by Jackson and Pollack.29 Equations produced by Heyward and Stolarczyk were used to calculate percent body fat from body density with ethnic and gender consideration.32
Patients were asked to rate their perceived exertion (RPE) on the Borg Scale.30 The Borg Scale has a high correlation with heart rate (HR), increases linearly with exercise intensity and is simple and understandable. Patients were asked to record their HR before, mid-way through the session, and after each bout of exercise to quantify the Borg Scale. They were instructed how to monitor radial pulse and rate their RPE during the initial session. Several trials were performed to ensure accuracy of HR monitoring by the subjects.
Procedure
At the first informational meeting, the women completed the FACT-B and the BFI. They participated in the 6-minute walk test and had height, weight, and skin fold measurements collected. Subjects randomly assigned to the walking program received instructions in warm-up and proper fit of footwear. They were given a booklet and Every Step Counts: A Walking Exercise Program for Persons Living with Cancer30 video and written instructional packet.
The Tai Chi participants reviewed the various forms with an instructor. Currently there are 5 major styles of Tai Chi. While each style is built upon the same foundation of relaxation and slow, gentle movements, there are significant differences in the size of movements and the emphasis-whether it is for health, martial art, or meditative practice. The style used in the study is derived from the Yang family form. It consists of a series of 38 movements that are characterized by their large circular movements. Minor arm position changes were made to accommodate the subjects’ limited arm range of motion due to the nature of the breast and axillary surgical procedures. This in no way compromised the Tai Chi form. At the conclusion of the meeting, subjects received the T’ ai Chi Fundamentals Video.29 A question/answer period was allotted for both groups.
Over the next 6 weeks, subjects followed their designed home exercise program a minimum of 3 times per week. Both groups kept a diary of their progress and adherence to the home exercise program. Weekly phone calls were made to participants in both groups to maintain personal contact and answer specific questions.
RESULTS
Fatigue Measures: Brief Fatigue Inventory and FACT-B
The BFI asks a series of questions in which the subject rates her level of fatigue. The subjects rated their fatigue levels at various time intervals: currently, during the past 24 hours, at its worst, and how much fatigue interfered with various aspects of their life. The general trend revealed that the majority of women experienced less fatigue at the conclusion of the study (6/8 or 75%). There was no evidence to support trends that either walking or Tai Chi was more effective in helping to improve fatigue levels. Although the BFI has several aspects of fatigue measurement, the focus of this discussion will examine the relationship of fatigue on the subject’s function. The BFI examines how fatigue interferes with general activity, mood, walking ability, normal work (including work outside and within the home), relations with other people, and enjoyment of life. The majority of women (6/8 or 75%) rated their fatigue as interfering less at the conclusion of this study in all areas, with the only exception of interference with general activity. As a general note, the women in this study were employed, so it is somewhat difficult to ascertain the type of fatigue, due to CRF or work and daily life fatigue. This pilot study revealed a trend that both Tai Chi and walking helps to reduce fatigue levels in women living with breast cancer.
The FACT-B (version 3) is a self-rating questionnaire that includes questions from 6 categories. The following categories were analyzed: physical well-being, emotional well-being, and social/family well-being. These categories were chosen because the intervention was thought to have had the most impact on these areas. The physical well-being section focuses on the side effects of treatment and illness for each participant. Results in the walking group showed improvement in 50% of the subjects, while the Tai Chi group had 3 out of 7 (75%) improved. The emotional well-being section focuses on the participants’ attitude towards their illness. In the walking group, 2 out of the 4 subjects (50%) showed improvement, while 1 of the 4 showed improvement (25%) in the Tai Chi group. The social/family well-being section focuses on aspects of support and communication within the family and friend network. In both groups, 2 out of the 4 subjects (50%) showed improvement in this subsection. Overall, in the walking and Tai Chi groups, 2 out of the 4 subjects in each group showed improvement (50%), while the remaining 2 subjects showed a decline in their total FACT-B scores (50%).
Physiological Measures: Six-minute Walk Test
Tables 1 and 2 depict the original data of the 8 subjects’ blood pressure and heart rate. Six out of the 8 subjects’ resting systolic BP decreased (75%), and 7 out of the 8 subjects’ postwalking systolic BP decreased after their 6-week intervention program (88%). In the walking group, 3 out of the 4 subjects’ resting and postwalking BP decreased after their programs (75%). In the Tai Chi group, 3 out of the 4 subjects’ resting BP decreased (75%), and (100%) of the subjects’ poslwalking BP decreased after their program.
Five out of the 8 subjects’ resting HR and post-walking HR increased after their 6-week programs (63%). In the walking group, 2 out of the 4 subjects’ resting HR increased, while the other 2 decreased; and 3 out of the 4 subjects’ postwalking HR increased, while the other one decreased, after their programs. In the Tai Chi group, 3 out of the 4 subjects’ resting HR increased while the other one remained the same; and 2 of the 4 subjects’ postwalking HR increased, while the other 2 decreased after the program.
Six out of the 8 subjects’ walking distance increased after their 6-week programs (75%). The average increase in walking distance for subjects who improved was 183 feet. In the walking group, all of the 4 subjects’ walking distance increased. Their average change in walking distance was 163.3 feet. In the Tai Chi group, 2 out of the 4 subjects’ walking distance increased, while the other 2 decreased. The average change in walking distance was 222.5 feel for the 2 subjects who improved, and 42.5 feet for the 2 subjecls who declined. Although increased distance ambulated at baseline and at the end of the study is a measure of progress, other factors may affect the outcome. This includes weather, energy levels, and end of the workday concerns.
BMI/Body Fat Findings
Table 3 depicts the summary of findings. The walking group as a whole had an increase in body mass index (BMI) of +0.33 as calculated from pre- to poststudy. However, the Tai Chi group had a decrease in BMI of -0.03. On the contrary the walking group’s overall percent body fat decreased by - 6.39, while the Tai Chi group increased in percent body fat by +0.25.
Self-Report: Journal Results
The weekly journal inquired about the nature of fatigue before and after exercise, how competent the women felt performing the exercise and finding time to do the activity. Data was compared at week 1 and 6. Although the complete diary data includes only 7 of the 11 women, these results confirm the findings of the BFI above. Five of the 7 (71%) felt more invigorated after the exercise, while 2 remained unchanged from week 1 (29%). Improved competence was noted primarily in the Tai Chi group, as this was a novel skill and required the use of the video and instruction to maximize performance. Overall, finding time was not noted as a problem (71%). The women attempted to maintain a record of the heart rate and rate of perceived exertion through the use of a BORG scale, however this was inconsistently reported.
CONCLUSION/DISCUSSION
Traditional exercise interventions are available for the treatment of fatigue for the person living with breast cancer. Alternative forms of exercise such as Tai Chi may prove to be beneficial in the management of cancer related fatigue as an adjunct to traditional exercise programs for women living with breast cancer. Tai Chi is a form of exercise that allows the individual to assume an active role in obtaining maximal health and focusing on the prevention of disease rather than the passive acceptance of illness as a consequence of life, aging, fate, or genetics.22
Due to a small sample size, no significant differences were found between the walking and Tai Chi groups. However, our study did find trends in fatigue reduction and improved quality of life that should encourage further comprehensive and carefully designed studies. The most significant change within the percent body fat measurement was a -6.39 decrease within the walking group. This may be attributed to the convenience of the activity and the participants’ consistency with the program. Although most of the women in the group (3/4) did not participate in regular exercise programs prior to the study, their levels of activity may have varied. Thus, for some of the women the onset of a walking program may have brought on a decrease in body fat secondary to the new heightened activity level with which the body was unfamiliar prior to the study.
People with chronic diseases often explore alternative movement therapies to deal with various aspects of fatigue and pain. Tai Chi, when adapted for the patient with breast cancer, may complement traditional physical therapy interventions. It also has been shown that group intervention provides a socialization context for support and may offer a potential cost effective way to manage this population. The impact on fatigue and quality of life is a primary outcome for further study. Additional functional outcome measures should be explored. This pilot study supports the need for further research in the effect of Tai Chi for this population.
by Galantino, Mary Lou, Capito, Laurie, Kane, Rhonda J, Ottey, Nicole, Et al