Support Care Cancer (2010) 18:351358

DOI 10.1007/s00520-009-0659-6

ORIGINAL ARTICLE

The effect of in-patient chest physiotherapy in lung

cancer patients
Sevgi Ozalevli & Duygu Ilgin & Hayriye Kul Karaali &
Serpil Bulac & Atilla Akkoclu

Received: 14 November 2008 / Accepted: 13 May 2009 / Published online: 28 May 2009
# Springer-Verlag 2009

Abstract
Goals of work The aim of our study was to investigate the
effect of the in-patient chest physiotherapy (ICP) in patients
with lung cancer.
Patients and methods Eighteen patients with stage IIIA,
IIIB, or IV lung cancer (3 females and 15 males) were
included. The demographic characteristics and the clinical
history of the patients were recorded. Pain (visual analog
scale), pulmonary function (pulmonary function test),
functional capacity (6-min walking test, Karnofsky performance status (KPS) scale), and health-related quality of life
(Nottingham Health Profile (NHP)) parameters were evaluated. The ICP program, including breathing control,
breathing exercises, relaxation training, upper and lower
extremity exercises, mobilization, and transcutaneous nerve
stimulation, was designed to meet each patients individual
needs.
Main results After the exercise program, there was a
significant decrease in the severity of the dyspnea, fatigue,
and pain symptoms (p < 0.05), improvement in the physical
mobility, pain, energy, emotional status and sleep subcategories of the NHP (p0.05), and increase in the 6-min
walking distance (75 15.95 m, p = 0.003). However,
pulmonary function test results and KPS scores did not
show statistically significant changes (p > 0.05).
S. Ozalevli (*) : D. Ilgin : H. Kul Karaali
School of Physical Therapy and Rehabilitation,
Dokuz Eylul University,
Inciralti,
Izmir 35340, Turkey
e-mail: sevgi.ozalevli@deu.edu.tr
S. Bulac : A. Akkoclu
Department of Chest Diseases, Dokuz Eylul University,
Inciralti,
Izmir 35340, Turkey

Conclusions ICP programs may be beneficial to lung

cancer patients by reducing respiratory symptoms, pain,
and improving health-related quality of life and exercise
capacity. For this reason, the results of this study suggest
that ICP programs, which are prepared by taking the
individual requirements of lung cancer patients, should be
placed in the treatment of the lung cancer.
Keywords Lung cancer . Chest physiotherapy .
Respiratory symptoms

Introduction
Lung cancer is the type of cancer, which is most
commonly seen in the chest diseases and chest surgery
clinics, and treatment choices, including radiotherapy,
chemotherapy, and lung surgery, are used for this disease
[27]. Most of the lung cancer patients complain from
dyspnea, fatigue, pain, cough, loss of appetite, and weight
loss. In addition to these symptoms, factors such as
fatigue, exhaustion, and treatment side effects have
negative effects on the patients exercise capacity and
quality of life [1, 4, 9, 10, 36, 38].
In the previous literature, it has been shown that the inpatient pulmonary rehabilitation (PR) programs reduce the
risk of cardiopulmonary complications and health-related
costs; shorten the length of hospital stay; increase exercise
capacity, pulmonary function test results, and partial arterial
oxygen pressure values; and improve psychological symptoms such as anxiety and depression and quality of life
[5, 7, 11, 12, 19, 21, 24, 29, 34, 35, 37, 40]. However, these
programs has been applied especially during pre- and
postoperative periods, although it has been known that
stage 34 patients with lung cancer have respiratory

352

symptoms resulting from medical applications; and different comorbids in addition to lung cancer symptoms, their
exercise capacity, and quality of life are poor; and they have
frequent hospital admissions and longer hospital stay [3, 8,
30, 39]. The effects of in-patient chest physiotherapy (ICP)
programs in stage 3 and 4 patients with lung cancer who do
not have surgical indications and receive intense chemotherapy and radiotherapy has not been investigated. Thus,
the aim of this study was to investigate the effect of ICP in
patients with lung cancer.

Patients and methods

Support Care Cancer (2010) 18:351358

criteria were evaluated twice (on the first day of hospitalization and on the day of discharge) with the same gain
parameters.
The main characteristics of the patients including the
demographic and clinical data (age, height, body weight,
body mass index, sex, smoking history, respiratory symptoms (dyspnea, cough, secretion, and fatigue), type/stage of
cancer, presence/localization of metastasis, and the applied
medical treatments) were recorded. Pain (visual analog
scale (VAS)), pulmonary function (pulmonary function
test), functional capacity (6-min walking test (6MWT),
Karnofsky performance status (KPS) scale), and healthrelated quality of life (Nottingham Health Profile (NHP))
parameters were evaluated.

Subjects
Based on the files of the 65 patients who were admitted to
the Chest Diseases Department of Dokuz Eylul University
between January and June 2006 for the planning and
application of the treatment after being diagnosed with lung
cancer were initially considered for the eligibility. Eighteen
of the 65 patients (mean age 66.17 7.33, three females and
15 males) were retained according to the inclusion criteria.
The inclusion criteria were (1) being pathologically
diagnosed as having lung cancer and being informed about
the diagnosis (n = 65); (2) having an advanced clinical
stage (i.e., clinical stage IIIA [unresectable], IIIB, or IV,
n = 36); (3) not developing chronic obstructive pulmonary
disease exacerbation, pneumonia, and lung infection at least
in the last 2 weeks (n = 24); (4) not receiving oxygen
therapy (n = 20); (5) not having a neurological disease
(n = 20); (6) not having an orthopedic condition that may
impede ambulation (n = 20); (7) not having uncontrolled
hypertension and cardiac diseases (n = 20); (8) not suffering
from severe mental or cognitive impairment (n = 20); (9)
not being previously enrolled in a physiotherapy or exercise
program (n = 18); and (10) accepting to participate in the
study (n = 18). The exclusion criteria were to be a patient
who did not meet the inclusion criteria (n = 47), did not
attend regularly the ICP program, wanted to leave from the
study, died during the hospitalization period, had learning
disability, or had major psychopathology related to lung
cancer during the program.
The study protocol was approved by Dokuz Eylul
University Clinical and Laboratory Researches Ethics
Committee, and the methods to be applied were explained
to the participators whose written consents were obtained.
Study design and outcomes
The design of this study was a prospective case series in
clinical trial design. The patients who met the inclusion

Pain The presence, localization, severity of pain and the

use of analgesic were recorded. Pain severity was assessed
using VAS, which uses a 10-cm-long bar (0 = no pain,
10 = very severe pain). The patients were instructed to put a
mark on a point on the bar, which corresponds to the
severity of the pain they feel. The scoring was performed
by measuring the space between the starting point of the bar
and the mark by using a tape measure [31].
Functional capacity
Six-minute walking test 6MWT was used to evaluate
functional capacity. During the test, which was performed
according to the American Thoracic Society criteria, heart
rate, blood pressure, respiration frequency, peripheral
oxygen saturation, dyspnea intensity and leg fatigue, the
distance walked in 6 min, and the complaints that caused
the cancelation of the test were recorded [2]. The test was
performed twice in order to eliminate learning effect. One
hour of rest was allowed between the two tests. Dyspnea
and leg fatigue intensity were evaluated by a modified Borg
scale (010) [6], and peripheral oxygen saturation was
recorded using a Palco 400 pulse oximeter.
Karnofsky performance status instrument The KPS instrument was used to assess functional capacity. KPS numerically describes in an easily administered, single global
score the patients ability to carry on his normal activity
and work, or his need for a certain amount of custodial care,
or his dependence on constant medical care. The description of each ten-point increment on the 0100 point scale
(100: normal, no complaints) [22].
Health-related quality of life The NHP was used to assess
health-related quality of life. NHP includes a total of 38
questions covering the categories of energy, sleep, physical
mobility, pain, emotional, and social isolation. In this

Support Care Cancer (2010) 18:351358

questionnaire, which can be filled out by the patients, the

patients are instructed to respond to the questions with
yes or no. The weighted score of each response is
different, and the total weighted score of each category is
calculated. A score of 100 indicates that the quality of life
related to that category is poor, while 0 reflects a high
health-related quality of life [18, 23].

In-patient chest physiotherapy program

The ICP program, including breathing control, breathing
exercises, relaxation exercises, upper and lower extremity
exercises, mobilization, and transcutaneous nerve stimulation (TENS), was designed to meet each patients individual
needs. On the first day of hospitalization, the patients were
included in the ICP program after their evaluations were
performed on the morning of that day.
The patients were informed of the benefits of all
breathing techniques and exercises and were taught how
to perform them. Breathing control training was given, and
pursed-lip breathing was taught to the patients. Breathing
exercises (chest and diaphragmatic breathing exercises)
were performed. Relaxation training and information about
relaxation positions were given to the patients. Along with
breathing control, exercises for upper and lower extremities
(bilateral shoulder flexion-inspiration, shoulder extensionexpiration, terminal knee extension exercise for the QF
muscle etc.), and mobilization were performed.
Each exercise was repeated ten times, two times per day
during the ICP program. The development of the program
was adjusted according to the tolerance and fatigue of the
patients, and they were allowed to rest for a while in case of
necessity. Each session lasted about 2030 min. Heart rate,
blood pressure, and peripheral oxygen saturation were
monitored continuously throughout the ICP program.
TENS, a non-invasive and non-pharmacological method,
was used for pain control. Conventional TENS was applied
to the region of pain using a dual channel portable device
(Biomedical Life Systems, 2000, Vista, CA, USA) twice a
day, with each session lasting 20 min. The conventional
TENS, which is recommended in the treatment of chronic
pain, is applied at a frequency of 60120 Hz and pulse
duration of 50100 s [16, 20]. Our treatment protocol
used stimulation given in continuous trains at high
frequency (80 Hz, using square-wave 100 s pulses). Two
surface electrodes (32 cm) were placed in or adjacent to
the painful area at a distance of 520 cm apart. The
intensity of TENS was adjusted to produce a tingling
sensation that was approximately two to three times the
sensory threshold. Since the use of TENS is contraindicated
in patients with pacemakers and arrhythmia, the patients

353

were evaluated for these problems. It was determined that

TENS was not contraindicated for any of our patients.
Statistical analysis
The statistical analysis was performed using Statistical Package
for the Social Sciences 11.0 software package. All data were
shown as numbers, percentages, and meanstandard deviation. The statistical analysis of the difference between the data
recorded during the admission (before the physiotherapy) and
discharge (after the physiotherapy) periods was interpreted
with Wilcoxon matched pairs test and chi-squared test. A
p value <0.05 was considered statistically significant.

Results
The demographic and clinical characteristics of the patients
were presented in Table 1. All the patients completed the
ICP program without any problems. During the ICP
sessions, no complications that might worsen the clinical
status and hemodynamic stability of the patients were
encountered. The mean hospitalization length and the
number of ICP sessions were 16.22 9.73 days and
24.61 15.71 CP sessions, respectively (Table 1).
Pulmonary function test results did not show any
significant changes during the follow-up of the patients
(p > 0.05). A decrease in the occurrence of the dyspnea and
fatigue symptoms, which had been reported at the time of
admission, were determined after the ICP program
(p = 0.01, Table 2).
The severity of pain in the lumbar-hip and thorax regions
showed a significant decrease at the time of discharge
(p = 0.002). The ratio of the patients using analgesics at
different dosages during hospitalization period was 55.6%
(n = 10). Since a standard medical treatment was applied,
no changes occurred in the dose and the frequency of use of
the analgesics. However, it was determined that the number
of patients complaining from pain showed a decrease
during the follow-up (p = 0.03, Table 3).
The increase in walking distance after ICP (the mean
increase in walking distance = 75 15.95 m, p = 0.003)
were found. The severities of the dyspnea and leg fatigue
were increased after the 6MWT performed both before and
after the ICP program. However, the severities of the
dyspnea and leg fatigue were lower at the baseline and end
of the 6MWT performed after the ICP program (p < 0.05).
KPS score did not change significantly after the ICP
program (p = 0.10, Table 4).
The significant improvements in the physical mobility,
pain, energy, emotional status, and sleep subcategories of
the NHP are summarized in Table 5 (p0.05).

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Support Care Cancer (2010) 18:351358

Table 1 Characteristics of the

patients

Values
Gender, % (n)
Female
Male
Age, mean (range), years
BMI, mean (range), kg/m2
Education level, % (n)
<8 years
8 years
Smoking history, % (n)
Cigarette consumption, packet.years
The type of lung cancer, % (n)
Small cell carcinoma
Non-small cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Lung epidermoid carcinoma
The stage of the lung cancer, % (n)
IIIB
IV
The presence of metastasis, %
Localization of metastasis, %
Bone
Brain
Liver
Liver + bone
Pleura
Bone + kidney
Pancreas
The types of the treatments, % (n)
Chemotherapy + radiotherapy
Chemotherapy
Radiotherapy
Comorbids, % (n)

Data were presented as mean

SD and/or percentage
ICP in-patient chest physiotherapy,
BMI body mass index, F/M
female/male

Chronic obstructive pulmonary disease, pneumonia, and tuberculosis

Hypertension and coronary artery disease
Diabetes mellitus
Lumbar disk herniation
Surgery, % (n)
Lobectomy (upper right and lower right),
Prostate surgery
Cholecystectomy
Brain surgery
Cervix-endometrium surgery
The length of hospital stay, days
The number of ICP sessions

16.7 (n = 3)
83.3 (n = 15)
66.17 7.33 (5383)
24.04 2.95 (18.4228.38)
38.9 (n = 7)
61.1 (n = 11)
83.3 (n = 15) (+)
71.13 37.62
38.9 (n = 7)
33.3 (n = 6)
16.7 (n = 3)
5.6 (n = 1)
5.6 (n = 1)
16.7 (n = 3)
83.3 (n = 15)
100
44.4
22.2
11.1
11.1
5.6
5.6
5.6
61.1 (n = 11)
22.2 (n = 4)
16.7 (n = 3)
61.1 (n = 11)
27.8 (n = 5)
22.2 (n = 4)
5.6 (n = 1)
11.1 (n = 2)
11.1 (n = 2)
5.6 (n = 1)
5.6 (n = 1)
5.6 (n = 1)
16.22 9.73
24.61 15.71

Support Care Cancer (2010) 18:351358

355

Table 2 Effects of in-patient chest physiotherapy on pulmonary

function test results

FEV1, L
Percent predicted
FVC, L
Percent predicted
FEV1/FVC, %
Dyspnea, %
Cough, %
Secretion, %
Fatigue, %

Before ICP

After ICP

p value

1.99 0.96
72.10 24.43
2.62 1.13
80.80 21.70
74.40 7.75
72.2
61.1
72.2
94.4

1.94 0.92
74.00 21.06
2.64 1.08
82.90 19.13
75.10 6.77
38.9
44.4
22.2
50.0

0.31
0.26
0.33
0.14
0.31
0.01
0.08
0.16
0.01

Data were presented as mean SD and/or percentage

ICP in-patient chest physiotherapy, FEV1 forced expiratory volume in
1 s, FVC forced vital capacity

Discussion
The current literature indicates that the PR, which may be
applied as in-patient, has positive effects on dyspnea,
exercise capacity, and quality of life [17, 28]. It has been
shown that short-term in-patient PR programs bring out
positive results similar to long-term programs, and shorten
the length of hospitalization and maximize cost-efficiency
when applied during the exacerbation period in different
lung diseases [13, 14]. However, the effectiveness of PR
programs in stage 3 and 4 patients with advanced lung
cancer who do not have surgical indications has not been
investigated. Our study results showed that the ICP
program for patients with lung cancer reduced symptoms,
including dyspnea, fatigue, and pain, and improved
exercise capacity and quality of life.
Dyspnea, fatigue, pain, secretion, and cough are the
main symptoms restricting the daily life activities of lung
cancer patients. These symptoms have negative effects on
the exercise capacity and quality of life related to the stage,
cell type, and severity of the cancer and treatment

modalities such as chemotherapy and/or radiotherapy

applications [3, 8, 26, 30, 38, 39]. Thus, the main aim is
symptom management in the treatment of advanced stage
cancer patients. Chest physiotherapy applications, which
are included in the PR programs, have an important place
among the treatment approaches aiming at symptom
management [15, 25, 36]. In the previous studies investigating the efficiency of PR applications in lung cancer
patients, PR programs cover chest physiotherapy applications such as breathing exercises, breathing control training,
peripheral muscle training (isotonic exercises performed
with free weights and aimed at lower extremity and trunk
muscles and functional electric stimulation applied to
abdominal muscles), relaxation training, cough training,
intensive spirometer use, and energy conservation techniques
[5, 11, 12, 19, 34, 37]. In accordance with the abovementioned studies, the ICP program was designed to the
individual needs of the lung cancer patients in this study. The
most significant improvements were noted in the symptoms
including dyspnea, fatigue, and pain at the end of the
program. This symptomatic improvements demonstrated in
the present study were consistent with the effects of inpatient PR applications in different lung diseases [7, 28].
However, in our review of the literature, we did not come
across any studies on ICP applications aimed at the abovementioned symptoms in stage 3 and 4 cancer patients.
On the other hand, Benzo et al. emphasized that PR
programs might have a significant role in the treatment of lung
cancer patients by improving disease-related outcomes [3].
Thus, we considered that the increase in exercise capacity and
life quality of our patients after ICP might be associated with
the decrease in the dyspnea, fatigue, and pain symptoms. In
the previous studies, it has been shown that there is an
improvement in the exercise capacity of lung cancer patients
following a 4 to 12-week long in-patient PR program,
including aerobic training (145 m (43%), 122 m (33%), and
96 m (32%)) [12, 34, 37]. The development determined after
the ICP in 6MWT was 75 m (31%) on average, while a tenpoint increase was determined in the quality of life in our

Table 3 Effects of in-patient

chest physiotherapy on pain

Data were presented as mean

SD and/or percentage
ICP in-patient chest physiotherapy, VAS/010 visual analog
scale

The ratio of patients with pain, % (n)

The severity of pain, (VAS/010)
The ratio of analgesic use, % (n)
The localization of pain, % (n)
Lumbar-hip
Thorax
Upper extremity
Lower extremity
Headneck

Before ICP

After ICP

p value

77.8 (n = 14)
4.44 3.24
55.6 (n = 10)

50 (n = 9)
1.50 2.04

0.03
0.002

27.8 (n = 5)
22.2 (n = 4)
11.1 (n = 2)
11.1 (n = 2)
5.6 (n = 1)

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Support Care Cancer (2010) 18:351358

Table 4 Effects of in-patient

chest physiotherapy on functional capacity

Data were presented as mean

SD
ICP in-patient chest physiotherapy, 6MWT 6-min walking test
a

The difference between the

means before and after the ICP
b

The difference between the

means before and after the
6MWT

Walking distance, m
Dyspnea severity
Before 6MWT
After 6MWT
pb
Leg fatigue
Before 6MWT
After 6MWT
pb
Karnofsky performance score, 0100

study. The improvement that we determined in the quality of

life and exercise capacity was same with the other studies,
although no changes were obtained in the KPS score. We
hypothesized that this difference might have resulted from the
fact that surgery was not performed on our patients, they were
younger, and were diagnosed more recently than the other
studies. Furthermore, we think that TENS application might
have contributed to this improvement by decreasing pain
severity. Because pain is defined as a factor that restricts the
exercise capacity and the daily life activities of the individuals
increases the severity of other lung cancer symptoms such as
depression and anxiety and decreases the quality of life as
much as the other cancer symptoms do [38, 39]. However, the
efficiency of TENS, which is used in the treatment of pain,
has not been investigated in stage 3 and 4 lung cancer
patients, although its pre- and postoperative positive effects on
patients with different cancer types are known [33]. We also
think that the decrease in pain severity recorded in our study
might be associated with the relaxation and breathing control
trainings, which were applied supplementary to TENS, used
in our ICP program [32], because it is known that relaxation
exercises are effective in decreasing respiratory workload by
reducing subjective symptoms such as dyspnea and pain and
psychological symptoms such as anxiety and depression.

Table 5 Effects of the in-patient

chest physiotherapy on healthrelated quality of life

Data were presented as mean

SD
ICP in-patient chest physiotherapy

Before ICP

After ICP

pa value

246.39 162.75

321.39 178.70

0.003

2.11 1.49
4.06 1.89
0.0001

1.33 1.04
2.06 1.31
0.01

0.02
0.001

1.50 1.06
4.61 3.43
0.002
66.11 18.20

0.50 1.04
1.56 0.53
0.03
68.89 16.41

0.02
0.002
0.10

Our study is the first investigating the effects of ICP

program in stage 34 patients with lung cancer. The most
important limitations of our study were the small number of
patients and the lack of a control group. We also investigated
the short-term effects of ICP program on functional parameters in patient with lung cancer. In addition, we did not assess
the effects of ICP program on anxiety and depression, which
are defined to be closely associated with subjective symptoms. For this reason, further studies, including larger sample
size, control group, detailed clinical history, long-term effects,
the effects on the number of hospital admissions and length of
hospital stay, psychological outcomes, medication use, and
cost analysis, are needed to confirm these results.

Conclusion
The results of this study conclude that ICP programs may
be beneficial to lung cancer patients by reducing respiratory
symptoms, pain, and improving health-related quality of
life and exercise capacity. Thus, we recommend that ICP
programs, which are tailored to the individual needs of lung
cancer patients, should be placed in the treatment of the
lung cancer.

Nottingham Health Profile

Before ICP

After ICP

Physical mobility
Pain
Energy
Emotional
Sleep
Social isolation

35.27
33.47
57.21
49.84
51.86
13.35

22.74
15.77
36.13
32.85
27.85
9.13

27.78
35.23
43.60
35.76
38.68
23.06

p value
23.33
19.76
32.36
30.00
30.36
19.49

0.03
0.02
0.05
0.01
0.01
0.50

Support Care Cancer (2010) 18:351358

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