key: cord-1029018-f6jv52qd authors: Bland, Kelcey A; Bigaran, Ashley; Campbell, Kristin L; Trevaskis, Mark; Zopf, Eva M title: Exercising in Isolation? The Role of Telehealth in Exercise Oncology During the COVID-19 Pandemic and Beyond date: 2020-07-31 journal: Phys Ther DOI: 10.1093/ptj/pzaa141 sha: 6e102dc793d304e43f42da4f6c309630f402540d doc_id: 1029018 cord_uid: f6jv52qd nan The COVID-19 pandemic, affecting over 200 countries and territories worldwide, has abruptly altered how we carry out our daily lives. This includes adapting to physical distancing restrictions, and varying degrees of isolating at home or quarantining. The sudden and lasting health impacts of this new normal are unknown. Recently reviewed psychological effects of quarantine included post-traumatic stress symptoms, confusion, and anger 1 . The physical impact may include a loss in daily physical activity needed to maintain an adequate health status, and to prevent and manage chronic disease 2 . For people with cancer the health impacts of our new normal may be intensified and continue for longer, even as physical distancing restrictions ease. Adults with cancer are commonly immunocomporimsed while receving treatment and may be twice as likely to test positive for COVID-19 and have higher morbidity and mortality after contracting COVID-19 3 . Medical advice, particularly for people receiving immunocompromising cancer treatments, may therefore include spending more time isolating, or adopting stricter physical distancing practices, to minimise the risk of COVID-19 infection. It is well established that physical activity levels decrease following a cancer diagnosis 4 . And during the COVID-19 pandemic, this vulnerable population may be moving even less. The benefits of exercise for cancer are well-studied and recently updated exercise oncology guidelines recommend weekly moderate-to-high intensity aerobic and resistance exercise training 5 . Evidence from randomized controlled trials suggests exercise can attenuate declines in physical fitness and function during and after anti-cancer therapies 5, 6 . Exercise can also improve symptoms, like fatigue, manage anxiety and depression, and improve quality of life 5, 6 . In observational studies, higher levels of physical activity after diagnosis also predict improved survival in select cancer types, including breast, prostate, and colon cancer 6 . As long as no vaccine exists, physical distancing is the best available option to stop the spread of COVID-19. However, physical distancing creates an added challenge to providing evidence-based exercise support to people with cancer at a time when exercise support is more 3 . This may open a window of opportunity to deliver more comprehensive prehabilitation exercise in preparation for planned treatments to improve patient outcomes 8 . Altogether, there is a need to devise strategies to promote or maintain engagement in exercise among people with cancer when typical opportunities to participate in exercise are limited due to physical distancing during the COVID-19 pandemic. Identifying strategies to deliver "best-practice" exercise in lieu of restrictions to face-toface clinical or community-based programs during the COVID-19 pandemic is an unforseen challenge. Evidence suggests home-based exercise interventions may be "less effective" than supervised interventions, as intervention effects tend to be smaller 9 . This may be a consequence of intervention heterogeneity, as the type and level of intervention support varies across studies 10, 11 . The level of support from physical therapists or other qualified exercise professionals, access to exercise equipment, and adherence may be key factors influencing home-based exercise intervention effectiveness 12 . Incorporating telehealth in home-based intervention design is one potential way to increase the level of interventional support. Telehealth, telemedicine, or telerehabilitation are broadly used terms that are used to describe distance-based interventions delivered using information and communication technologies to assess, educate, monitor and/or deliver exercise or other healthcare interventions 13 . This can include telephone calls, text messaging, mobile health or smart phone applications, web-based platforms, and videoconferencing. These interventions are increasingly being studied, however, their quality and effectiveness is still unclear in the exercise oncology setting, including relative to non-telehealth home-based exercise or rehabiliation interventions 11, 14, 15 . Recent trials evaluating home-based exercise interventions that have incorporated technology to increase the level of interventional support have reported good adherence and favourable effects [16] [17] [18] [19] [20] . One randomised trial in 81 women with breast cancer delivered a novel internet-based platform that participants accessed on their own to perform tailored home-based exercise 18 . Optional telephone calls, instant messages, and videoconferencing was also included to allow research staff to receive participant comments and monitor exercise 18 . Improvements in physical fitness and patient-reported outcomes, and high exercise adherence (94%) and participant satisfaction, was reported 18 . An important aspect of this trial was that research staff individualized and modified the exercise throughout the intervention, based on frequent participant feedback 18 . Another randomised trial in 68 women with breast cancer undergoing chemotherapy adopted the same interventional approach using a tailored internet-based platform plus communication with research staff and reported physical fitness improvements and adherence (73%) 19 comparable to published adherence rates of supervised and "face-to-face" interventions in this population 21 . To-date, many exercise interventions incorporating telehealth and technology prescribe unsupervised exercise and focus on self-management or strategies to promote behaviour change to increase levels of physical activity. In a recent review summarising interventional support for home-based exercise interventions in oncology, technology emerged as a prominent strategy across 122 studies (53% of all included studies) 10 . Technology was often used for physical activity self-monitoring, such as through the use of physical activity (n = 66 studies) or heart rate monitors (n = 29 studies). Other studies (n = 33) utilized videos in the form of DVDs, online websites, or smartphone applications to provide visual guidance and exercise instructions, but not necessarily real-time guidance from qualified rehabilitation or exercise professionals. Homebased exercise, however, does not necessarily have to mean "unsupervised" exercise. Thus, a key research question includes evaluating telehealth interventions that mimic the delivery of traditional supervised exercise interventions to improve key physical fitness, patient-reported and health outcomes in people living with and beyond cancer. Of particular interest is the potential of videoconferencing telehealth platforms that allow exercise professionals to demonstrate and provide exercise guidance virtually in real-time, while participants complete the intervention from home. An obvious advantage of telehealth is that guidance from a qualified exercise professional can be provided to patients at home, limiting the need for travel or non-essential exposure. Certain videoconference platforms can be used to provide one-on-one individually tailored exercise sessions, but also have the potential to be used to deliver interventions in a virtual "group-based" setting that mimics supervised group exercise training. Although, whether a virtual group environment offers the same psychosocial support as in-person settings is unknown. Beyond the COVID-19 pandemic, telehealth can reach those living in regional or remote communities, where exercise oncology resources may be limited, or those who prefer exercising from home. Home-based interventions also overcome commonly reported exercise barriers, such travel, access to facilities, and cost 22 . Prominent disadvantages and key considerations, however, include a potential lack of exercise equipment, inadequate space for exercising at home, limited access to technology or low technology-literacy, inability to assess patients in-person, and potential limitations around safety, namely in-person monitoring of exercise response (i.e., heart rate, blood pressure) and hands-on assistance with exercise or movement technique. Further, the cost and training needed to use and navigate specific telehealth platforms may also be a potential The psychological impact of quarantine and how to reduce it: rapid review of the evidence A tale of two pandemics: how will COVID-19 and global trends in physical inactivity and sedentary behavior affect one another? A practical approach to the management of cancer patients during the novel coronavirus disease 2019 (COVID-19) pandemic: an international collaborative group Is a cancer diagnosis a trigger for health behaviour change? 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