Exercise
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Intervention
Attrition, compliance, adherence, and progression following
M
hematopoietic stem cell transplantation
Tara Peters, BS, Ruby Erdmann, RD, LDN, and Eileen Danaher Hacker, PhD, APN, AOCN®, FAAN
BACKGROUND: Exercise is widely touted as an
effective intervention to optimize health and
well-being after high-dose chemotherapy and
hematopoietic stem cell transplantation.
OBJECTIVES: This article reports attrition,
compliance, adherence, and progression from the
strength training arm of the single-blind random-
ized, controlled trial Strength Training to Enhance
Early Recovery (STEER).
METHODS: 37 patients were randomized to the
intervention and participated in a structured strength
training program introduced during hospitalization
and continued for six weeks after release. Research
staff and patients maintained exercise logs to docu-
ment compliance, adherence, and progression.
FINDINGS: No patients left the study because of
burden. Patients were compliant with completion
of exercise sessions, and their adherence was high;
they also progressed on their exercise prescription.
Because STEER balances intervention effectiveness
with patient burden, the findings support the likeli-
hood of successful translation into clinical practice.
KEYWORDS
attrition; compliance; adherence; progres-
sion; hematopoietic stem cell transplantation
DIGITAL OBJECT IDENTIFIER
10.1188/18.CJON.97-103
CJON.ONS.ORG
MORE THAN 20,000 HEMATOPOIETIC STEM CELL TRANSPLANTATIONS (HSCTs) were
performed in the United States in 2015, a rate that continues to increase (D’Souza
& Zhu, 2016). This figure includes recipients of autologous and allogeneic
HSCTs. The preparatory regimens used in conjunction with HSCT frequently
result in a wide range of acute and chronic side effects, such as infection, throm-
bocytopenia, and fatigue (Copelan, 2006). Recipients of allogeneic HSCT are
at risk for additional complications, including graft-versus-host disease.
The adverse effects of the high-dose chemotherapy may be severe and
highly distressing, negatively affecting the recipient’s quality of life (Cohen
et al., 2012). Although many side effects are temporary and resolve within
three to six months, others are long-term and develop months or years after
HSCT (Morrison et al., 2016). For example, moderate to severe persistent
fatigue has been documented during the early recovery period and years
after HSCT (Gielissen et al., 2007; Hacker, Fink, et al., 2017; Jim et al., 2016).
Interventions to address these distressing symptoms are needed to improve
the long-term outcomes of HSCT recipients.
Strong interest exists in the development of effective exercise interventions
for patients receiving intensive cancer therapy, including those undergoing
HSCT. Fewer than 20 randomized, controlled trials (RCTs) testing exer-
cise interventions have been conducted in this population (Hacker, Collins,
et al., 2017; Jacobsen et al., 2014; Persoon et al., 2013). Although the general
evidence supports the use of exercise in this population, implementation
varies across studies, such as timing of exercise initiation and the exercise
modality, intensity, and duration. Because of the challenges associated with
conducting exercise studies and then translating these findings into clinical
practice, multiple additional pragmatic factors need to be fully assessed prior
to implementing exercise interventions in the general population of patients
undergoing HSCT. These study factors include the following:
ɐɐ Patient attrition (number of patients leaving the study prior to completion)
ɐɐ Exercise compliance (ability to complete the prescribed number of exer-
cise sessions)
ɐɐ Exercise adherence (ability to complete the specific exercises as detailed in
the exercise prescription)
ɐɐ Exercise progression (ability to advance the exercise prescription)
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EXERCISE INTERVENTION
In addition, information related to how actively HSCT recipients
participated in the exercise activities when categorized according
to age, gender, and type of transplantation may prove helpful when
translating evidence into practice.
A single-blind RCT conducted by Hacker, Collins, et al. (2017)
(Strength Training to Enhance Early Recovery [STEER]) found
that strength training positively affected fatigue, physical activity,
muscle strength, and functional ability in those assigned to
strength training compared to usual care plus attention control
with health education. The purpose of this article is to provide
more detailed information regarding patient attrition and exer-
cise compliance, adherence, and progression from the strength
training arm of the STEER study to help facilitate translation into
practice and to report exercise compliance, adherence, and pro-
gression based on age, gender, and type of transplantation.
Methods
Design
The methods and study procedures for the main study have
been reported (Hacker, Collins, et al., 2017). As a review, the
single-blind RCT examined the efficacy of the STEER interven-
tion compared to usual care plus attention control with health
education following HSCT on fatigue, physical activity, muscle
strength, functional ability, and quality of life. The sample was
stratified by type of transplantation (allogeneic, autologous)
and age (aged younger than 60 years, aged 60 years or older).
Random allocation to treatment and allocation concealment
were achieved using sequentially numbered sealed envelopes
(Doig & Simpson, 2005). All patients were recruited from the
University of Illinois Hospital and Health Systems in Chicago.
Strength training instruction and active range of motion began
during HSCT hospitalization, with moderate-intensity training
for six weeks following hospital discharge. This article details
the attrition, compliance, adherence, and progression findings
from those randomized to the moderate-intensity strength train-
ing arm following HSCT hospitalization to facilitate translation
into practice. The University of Illinois at Chicago’s institutional
review board approved the study.
Sample
Eligibility criteria for the STEER study included being aged 18
years or older, being cognitively able to provide informed con-
sent, and receiving HSCT for treatment of a malignancy. Potential
HSCT recipients undergo an extensive medical workup prior to
HSCT, which is the standard of care. The results of this workup
were reviewed by the treating physicians who provided approval
for patients to take part in the study if randomized to the strength
training arm. Patients were ineligible if they had a condition that
would make exercise unsafe, such as an impending pathologic
fracture or other musculoskeletal condition that resulted in a
nonambulatory status. Following discharge from the hospital,
98   CLINICAL JOURNAL OF ONCOLOGY NURSING  VOLUME 22, NUMBER 1
“Fewer than 20
randomized,
controlled trials
testing exercise
interventions have
been conducted in
this population.”
patients needed to be ambulatory (with or without the use of
an assistive device) to continue participation in the moderate-
intensity strength training phase of the study.
The study was open to enrollment from May 2013 to July
2015. Overall, 118 patients were eligible to participate, and 84
(71%) agreed. Reasons for refusal included feeling overwhelmed
and being uninterested in research participation. Five of the 84
patients did not proceed to HSCT and were withdrawn from the
study prior to completing any research activities. Seventy-nine
patients completed baseline testing, and four were later withdrawn
because they did not proceed to HSCT. Seventy-five patients
were randomized to the STEER intervention (n = 37) or to usual
care plus attention control with health education (n = 38). Seven
patients died during the study, and one was lost to follow-up.
These deaths were unrelated to the research. A total of 67
patients completed all research activities (STEER, n = 33; usual
care plus attention control with health education, n = 34). This
article focuses solely on those randomized to the STEER arm of
the study.
Strength Training Intervention
The STEER intervention is a comprehensive exercise program that
employs progressive resistance exercise to strengthen the upper
and lower body and abdominal muscles. Strength training instruc-
tion and active range of motion began during hospitalization for
HSCT (two times per week). Following hospital discharge, patients
completed the moderate-intensity strength training portion of the
program using elastic resistance bands. Moderate intensity was
defined as a self-reported rating of moderately hard using the Borg
Rating of Perceived Exertion scale (Borg, 1998). This phase of the
program lasted six weeks, for a total of 18 exercise sessions (three
times per week for six weeks).
Eleven preselected exercises with concentric and eccentric
muscle contractions were included in the STEER intervention.
CJON.ONS.ORG
Eight exercises used elastic resistance bands (chest fly, bicep TABLE 1.
curl, tricep extension, shoulder shrug, shoulder upright row, SAMPLE CHARACTERISTICS BY GROUP
shoulder lateral raise, knee flexion, and knee extension) and
three exercises used body weight as resistance (wall push-up, HOSPITAL POST-HOSPITAL
EXERCISE GROUP EXERCISE GROUP
squat, and bed sit-up). The exercise prescription was tailored to (N = 37) (N = 33)
the individual’s capabilities. Because safety was a primary con-
cern, patients were prescribed as many exercises as they could CHARACTERISTIC n n
safely perform, beginning with the easiest and progressing to the
Age (years)
most complex. For example, a patient with low exercise tolerance
would be initially prescribed fewer exercises and/or fewer repe- Younger than 60 23 22
titions or sets, with additional exercises, repetitions, and/or sets
60 or older 14 11
added in later weeks as his or her exercise tolerance improved.
Return demonstrations were required for all patients to ensure Gender
proper form, assess tolerance, and reduce the risk of injury. Using
downtime during regularly scheduled clinic visits, patients gen- Male 22 20
erally exercised once a week under the supervision of a member Female 15 13
of the research team and completed the remaining two sessions
unsupervised at home. The STEER intervention took about 20 Race
minutes to complete. Changes to the exercise prescription, pri-
Black or African American 15 14
marily advancements, were made during the supervised sessions.
Progression of the exercise prescription was structured to first White or Caucasian 17 14
increase the number of repetitions, followed by an increase in
Latino, Hispanic, or Mexican
the number of sets (from one to two sets) and an increase in the American
4 4
resistance level of elastic bands. Patients and research staff main-
tained detailed exercise logs documenting the completion of each Other 1 1
individual exercise, including information about the number of
Marital status
repetitions and sets on preprinted exercise logs. Queries related
to exercise tolerance were made during weekly clinic visits. If Never married 6 6
a weekly visit was not scheduled with the healthcare provider,
Married 21 18
patients were contacted by telephone to review the exercise pre-
scription, tolerance, and progress. Divorced 7 6
All equipment needed for study participation was provided to
the participating patients. Each patient received elastic resistance Separated 2 2
bands with handles for upper-body exercises, elastic resistance Widowed 1 1
bands with extremity straps for lower-extremity exercises, a
door anchor for exercises that required external fixation (chest Education level
fly), individualized preprinted exercise instructions, preprinted
Some high school 2 2
exercise logs for tracking, a folder to store the instructions and
logs, and a small gym bag to carry all equipment for a total supply Graduated from high school 10 9
weight of less than three pounds. Patients were instructed to
Some college 16 15
bring all supplies to the weekly supervised sessions.
Graduated from college 6 5
Results
Demographic and Clinical Characteristics Graduate school 3 2
Thirty-seven patients undergoing HSCT were randomized into
Type of HSCT
the STEER intervention group. Demographic and clinical charac-
teristics are reported in Table 1. Those randomized to STEER were Autologous 21 20
—
primarily middle-aged (X = 53.1 years, SD = 13.5), and slightly more
Allogeneic 16 13
than half were male (n = 22) and married (n = 21). The sample was
racially diverse. Most patients had completed some high school, Continued on the next page
graduated from high school, or attended some college, and they

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EXERCISE INTERVENTION

TABLE 1. (CONTINUED) Adherence

SAMPLE CHARACTERISTICS BY GROUP The adherence results for the moderate-intensity strength train-
ing portion of the study are reported in Table 3. The strength
HOSPITAL POST-HOSPITAL training prescription was tailored to the individual’s capabilities
EXERCISE GROUP EXERCISE GROUP
(N = 37) (N = 33)
and contained information related to the number of exercises
to be performed, the number of sets and repetitions for each
CHARACTERISTIC n n exercise, and the color of the elastic resistance bands to be used
Annual family income ($) for exercises employing bands. Adherence rates are reported
as the number of exercises performed in each session divided
Less than 40,000 23 21 by the total number of exercises prescribed for each session. A
41,000–60,000 4 3 maximum of 11 exercises could be prescribed, depending on the
patient’s physical condition. Patients were highly adherent to the
61,000 or more 10 9 exercise prescription, with an adherence rate of 89%. Although
Diagnosis little difference was noted between recipients of autologous and
allogeneic HSCT, men and those aged 60 years or older were
Acute lymphoblastic leukemia 2 2 more likely to adhere to the exercise prescription. Most patients
Acute myelogenous leukemia 9 7 completed 9–11 exercises during each session.

Chronic lymphocytic leukemia 1 1 Progressions After Initial Prescription

Chronic myelogenous leukemia 2 2 The ability of a patient to progress on the exercise prescription
generally indicates improving health fitness. Progression may
Hodgkin lymphoma 2 2 occur by adding more exercises to the exercise prescription, adding
Non-Hodgkin lymphoma 6 5 repetitions to the individual exercise(s), adding sets to the individ-
ual exercise(s), and/or increasing resistance used, as demonstrated
Multiple myeloma 12 12 by using a band with increased resistance. The mean number of
Myelodysplastic syndrome 3 2 progressions for patients assigned to the strength training arm was
2.6 (SD = 1.6).
HSCT—hematopoietic stem cell transplantation

reported annual family income levels of less than $40,000. Most
received autologous transplantations.
Attrition
Four patients died during the study because of disease- and/or
treatment-related complications, which represented an 11%
attrition rate. None of the deaths, which occurred during HSCT
hospitalization, were attributable to STEER study–related activ-
ities. This resulted in a post-hospital STEER intervention group
of 33 patients.
Compliance
The compliance results for the moderate-intensity strength
training portion of the study (number of sessions completed of
18 scheduled sessions) are reported in Table 2. Overall, patients
—
were highly complaint, with a compliance rate of 83% (X = 15 ses-
sions, SD = 4). One patient did not complete any exercise sessions;
when this patient was removed from the analysis, the compliance
—
rate rose to 86% (X = 15.4 sessions, SD = 3). Independent sam-
ples t tests were used to compare compliance rates based on age,
gender, and type of transplantation. No significant differences
were observed in compliance rates based on these variables.
Discussion
Growing evidence supports the health benefits of exercise in
the population of patients undergoing HSCT (Persoon et al.,
2013; van Haren et al., 2013). However, wide variation exists in
the HSCT population examined, timing of the exercise interven-
tion, and exercise mode, duration, and intensity. Understanding
patient attrition, along with exercise compliance, adherence,
and progression, is important for interpreting outcomes. A sin-
gle-blind RCT supports the use of strength training for reducing
fatigue and improving functional ability (Hacker, Collins, et al.,
2017). Results from this study provide additional information
for clinicians to translate these findings into clinical practice. In
this study, no patients assigned to the STEER intervention left
the study because it was too burdensome. In addition, patients
demonstrated high compliance and adherence. Patients assigned
to the STEER intervention were able to demonstrate progression
on the exercise prescription, further indicating improvement in
health status. Findings from the current study, along with out-
comes from the main study, suggest that the STEER intervention
is effective for reducing fatigue and improving functional abil-
ity. The STEER intervention effectively balances intervention
effectiveness with patient burden, as evidenced by the very low
attrition and high compliance and adherence rates, as well as by

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 IMPLICATIONS FOR PRACTICE
ɔɔ Realize that recipients of hematopoietic stem cell transplantation
(HSCT) may be able to tolerate a moderate-intensity strength train-
ing intervention during the acute recovery period following HSCT.
the ability of patients to progress on the exercise intervention ɔɔ Address pragmatic concerns (e.g., attrition, compliance, adher-
during the study. ence, progression) in exercise studies with positive outcomes for
Putting evidence into practice is a key component of oncology interpretation of study findings and eventual translation into clinical
nursing care. As clinicians pool results from RCTs that examine practice.
the effects of exercise on health outcomes following HSCT, ɔɔ Use a patient-centered approach when developing exercise inter-
answers to multiple pragmatic questions can serve as a template ventions to balance intervention effectiveness with patient burden.
for translating results into clinical practice. Issues to address
include attrition, compliance, adherence, and progression so that
RCT findings can be interpreted in light of practical issues fre- people receiving intensive cancer therapy. Compared to other
quently faced in the clinical setting. For example, understanding cancer populations, patients undergoing HSCT are understudied
why patients drop out of exercise studies following HSCT is in exercise intervention studies because of methodologic chal-
important for assessing acceptability of the exercise interven- lenges, such as initiating an exercise routine despite severe
tion. HSCT exercise studies that are highly effective but have fatigue during the acute recovery period. The STEER interven-
high dropout rates related to the exercise intervention may be tion required more than three years of pilot testing to ensure
more difficult to implement in a clinical setting, particularly if the feasibility, acceptability, and safety, laying the foundation for this
patient burden is too high. single-blind RCT (Hacker, Collins, et al., 2017; Hacker, Larson,
Thoughtful consideration of the specific needs of the patient Kujath, et al., 2011; Hacker, Larson, & Peace, 2011). Importantly,
population must be given when developing an exercise inter- STEER was designed to be a pragmatic, inexpensive, nurse-driven
vention; this becomes even more important when working with intervention that could be seamlessly integrated into clinical prac-
tice. To facilitate this, the STEER intervention was implemented
TABLE 2. in two phases. The inpatient phase of the study was designed
COMPLIANCE WITH MODERATE-INTENSITY to instruct patients on the exercises, initiate muscle memory
STRENGTH TRAINING AFTER HSCT HOSPITAL by having patients perform active range of motion to simulate
DISCHARGE the exercises, and establish rapport so patients would become
familiar with the exercise team. The second phase, moderate-
EXERCISE SESSIONS COMPLETED intensity strength training, began following hospital discharge
— when patients were considered to be medically stable. Because of
COMPLIANCE N X SD %
the two-phase process, the moderate-intensity strength training
Compliance was likely perceived as a continuation of their exercise program
33 15 4 83
overall
and not as a new activity. This is important because the transi-
Compliance of tion from hospital to home can be a particularly stressful time for
32 15.4 3 86
active patients patients and their families. Initiating new activities during this
Type of HSCT time frame may be difficult. As a result, the inpatient phase was
instrumental for the success of the moderate-intensity training
Autologous 20 15.1 4.9 84 following hospital discharge.
Allogeneic 13 14.9 2.3 82 Adopting a patient-centered approach to implementing an
exercise intervention is also important for successful outcomes
Age (years) and translation into clinical practice. This study capitalized on
Younger than common clinical situations to implement the study and interven-
22 15.1 4.2 84
60 tion. For example, this study did not require extra visits outside
of the patients’ regularly scheduled clinic visits. The supervised
60 or older 11 14.7 3.7 82
exercise sessions were conducted in the clinic during downtime
Gender to make effective use of the patients’ time. Many people prefer to
exercise with a partner; having patients exercise with a member
Male 20 15.9 2.9 88
of the research team in the clinic examination room created a
Female 13 13.5 5.1 75 friendly and respectful relationship. These simple strategies were
implemented to maximize benefit to patients while minimizing
HSCT—hematopoietic stem cell transplantation; STEER—Strength Training to Enhance
Early Recovery burden. Findings from this study suggest that this approach was
Note. Compliance was defined as the number of STEER sessions completed divided by highly successful, as evidenced by high compliance and adher-
the total number of STEER sessions. Participants were expected to complete 18 exercise
sessions following hospital discharge (three times per week for six weeks). ence to the moderate-intensity strength training program. This
is important because patients undergoing HSCT are arguably one

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EXERCISE INTERVENTION

of the most complex cancer populations, particularly during the among people with cancer include community-based exercise
acute recovery period following transplantation. programs for cancer survivors (Musanti & Murley, 2016) and the
Other activities and advancements in technology may prove power of exercise from a survivor’s perspective (Hope, 2016).
beneficial in exercise studies following HSCT in the future. For
example, motivational text or voice messages may be used as an Conclusion
extra tool to facilitate compliance and adherence (Wang et al., Recipients of HSCT are able to tolerate a moderate-intensity
2015). Incentives, such as goal-related certificates or small prizes, strength training intervention during the acute recovery period
have been used in other studies with good results and should be following transplantation, as demonstrated by the low attrition
considered for future studies (Brassil et al., 2014). Adding a wear- and high compliance and adherence rates, as well as the patients’
able step counter may also be beneficial to patients enrolled in ability to progress on their exercise prescription during the study.
studies. Some patients could find the addition of group exercise These findings suggest that the STEER intervention maintains a
sessions in the clinical setting to be helpful; however, the need for beneficial sustained exercise regimen without placing additional
constant individualized reevaluation of exercise prescription may stress on an already highly burdened population. Addressing the
make that unmanageable. pragmatic concerns of intervention effectiveness and uptake
From a clinical practice perspective, oncology nurses are among participants provides important information to translate
uniquely qualified to lead programs aimed at increasing physical successful interventions, such as STEER, into clinical practice.
activity across the cancer survivorship trajectory. In consultation
with other oncology practitioners, efforts geared toward assessing Tara Peters, BS, is a visiting research specialist in the College of Nursing in the
patients for functional limitations, designing individualized phys- Department of Biobehavioral Health Science at the University of Illinois at Chicago;
ical activity and exercise interventions, and providing patients Ruby Erdmann, RD, LDN, is the director of nutrition services at Near North Health
with appropriate resources to facilitate successful implementa- Service Corporation in Chicago; and Eileen Danaher Hacker, PhD, APN, AOCN®,
tion will help to move exercise science forward (Austin, Damani, FAAN, is a professor in the School of Nursing and chair of the Department of
& Bevers, 2016; Haas, Hermanns, & Kimmel, 2016; McNeely, Science of Nursing Care at Indiana University in Indianapolis and was, at the time
Dolgoy, Al Onazi, & Suderman, 2016; Musanti & Murley, 2016). of this research, an associate professor in the College of Nursing at the University
Examples of initiatives to promote physical activity and exercise of Illinois at Chicago. Hacker can be reached at edhacker@iu.edu, with copy to
CJONEditor@ons.org. (Submitted April 2017. Accepted for publication June 19,
TABLE 3. 2017.)
ADHERENCE TO MODERATE-INTENSITY STRENGTH
TRAINING AFTER HSCT HOSPITAL DISCHARGE The authors gratefully acknowledge Kevin Grandfield, MFA, for his editorial
assistance.
MEAN ADHERENCE
CHARACTERISTIC N RATE (%)
The authors take full responsibility for this content. This study was funded by a Research Scholar
Overall 33 89 Grant (RSG, 13-054-01-PCSM; principal investigator: Hacker) from the American Cancer Society.
The article has been reviewed by independent peer reviewers to ensure that it is objective and
Type of HSCT
free from bias.
Autologous 20 92
REFERENCES
Allogeneic 13 92
Austin, A., Damani, S., & Bevers, T. (2016). Clinical approach for patient-centered physical
Age (years) activity assessment and interventions. Clinical Journal of Oncology Nursing, 20(Suppl. 2),
S3–S7. https://doi.org/10.1188/16.CJON.S2.3-7
Younger than 60 21 86
Borg, G. (1998). Borg’s perceived exertion and pain scales. Champaign, IL: Human Kinetics.
60 or older 11 96 Brassil, K.J., Szewczyk, N., Fellman, B., Neumann, J., Burgess, J., Urbauer, D., & LoBiondo-
Wood, G. (2014). Impact of an incentive-based mobility program, “Motivated and Moving,”
Gender
on physiologic and quality of life outcomes in a stem cell transplant population. Cancer
Male 20 95 Nursing, 37, 345–354. https://doi.org/10.1097/NCC.0b013e3182a40db2
Cohen, M.Z., Rozmus, C.L., Mendoza, T.R., Padhye, N.S., Neumann, J., Gning, I., . . . Cleeland,
Female 13 80
C.S. (2012). Symptoms and quality of life in diverse patients undergoing hematopoietic
HSCT—hematopoietic stem cell transplantation stem cell transplantation. Journal of Pain and Symptom Management, 44, 168–180. https://
Note. The adherence rate was defined as the number of exercises performed during a doi.org/10.1016/j.jpainsymman.2011.08.011
session divided by the total number of exercises prescribed. A maximum of 11 exercises
could be prescribed. Copelan, E.A. (2006). Hematopoietic stem-cell transplantation. New England Journal of
Medicine, 354, 1813–1826. https://doi.org/10.1056/NEJMra052638

102   CLINICAL JOURNAL OF ONCOLOGY NURSING  VOLUME 22, NUMBER 1 CJON.ONS.ORG

D’Souza, A., & Zhu, X. (2016). Current uses and outcomes of hematopoietic cell transplantation
(HCT): CIBMTR summary slides. Retrieved from https://www.cibmtr.org/ReferenceCenter/
SlidesReports/SummarySlides/pages/index.aspx
Doig, G.S., & Simpson, F. (2005). Randomization and allocation concealment: A practical guide
for researchers. Journal of Critical Care, 20, 187–191. https://doi.org/10.1016/j.jcrc.2005
.04.005
Gielissen, M.F., Schattenberg, A.V., Verhagen, C.A., Rinkes, M.J., Bremmers, M.E., & Bleijenberg,
G. (2007). Experience of severe fatigue in long-term survivors of stem cell transplantation.
Bone Marrow Transplantation, 39, 595–603. https://doi.org/10.1038/sj.bmt.1705624
Haas, B.K., Hermanns, M., & Kimmel, G. (2016). Incorporating exercise into the cancer treat-
ment paradigm. Clinical Journal of Oncology Nursing, 20(Suppl. 2), S17–S24. https://doi
.org/10.1188/16.CJON.S2.17-24
Hacker, E.D., Collins, E., Park, C., Peters, T., Patel, P., & Rondelli, D. (2017). Strength training
to enhance early recovery after hematopoietic stem cell transplantation. Biology of
Blood and Marrow Transplantation, 23, 659–669. https://doi.org/10.1016/j
.bbmt.2016.12.637
Hacker, E.D., Fink, A.M., Peters, T., Park, C., Fantuzzi, G., & Rondelli, D. (2017). Persistent fatigue
in hematopoietic stem cell transplantation survivors. Cancer Nursing, 40, 174–183. https://
doi.org/10.1097/NCC.0000000000000405
Hacker, E.D., Larson, J., Kujath, A., Peace, D., Rondelli, D., & Gaston, L. (2011). Strength training
following hematopoietic stem cell transplantation. Cancer Nursing, 34, 238–249. https://
doi.org/10.1097/NCC.0b013e3181fb3686
Hacker, E.D., Larson, J.L., & Peace, D. (2011). Exercise in patients receiving hematopoietic stem
cell transplantation: Lessons learned and results from a feasibility study. Oncology Nursing
Forum, 38, 216–223. https://doi.org/10.1188/11.ONF.216-223
Hope, A. (2016). A survivor’s perspective on the power of exercise following a cancer diagnosis.
Clinical Journal of Oncology Nursing, 20(Suppl.), S31–S32. https://doi.org/10.1188/16
.CJON.S2.31-32
CJON.ONS.ORG
Jacobsen, P.B., Le-Rademacher, J., Jim, H., Syrjala, K., Wingard, J.R., Logan, B., . . . Lee, S.J. (2014).
Exercise and stress management training prior to hematopoietic cell transplantation: Blood
and Marrow Transplant Clinical Trials Network (BMTCTN) 0902. Biology of Blood and Marrow
Transplantation, 20, 1530–1536. https://doi.org/10.1016/j.bbmt.2014.05.027
Jim, H.S., Sutton, S.K., Jacobsen, P.B., Martin, P.J., Flowers, M.E., & Lee, S.J. (2016). Risk factors
for depression and fatigue among survivors of hematopoietic cell transplantation. Cancer,
122, 1290–1297. https://doi.org/10.1002/cncr.29877
McNeely, M.L., Dolgoy, N., Al Onazi, M., & Suderman, K. (2016). The interdisciplinary rehabil-
itation care team and the role of physical therapy in survivor exercise. Clinical Journal of
Oncology Nursing, 20(Suppl. 2), S8–S16. https://doi.org/10.1188/16.CJON.S2.8-16
Morrison, E.J., Ehlers, S.L., Bronars, C.A., Patten, C.A., Brockman, T.A., Cerhan, J.R., . . . Gastin-
eau, D.A. (2016). Employment status as an indicator of recovery and function one year after
hematopoietic stem cell transplantation. Biology of Blood and Marrow Transplantation, 22,
1690–1695. https://doi.org/10.1016/j.bbmt.2016.05.013
Musanti, R., & Murley, B. (2016). Community-based exercise programs for cancer survivors. Clinical
Journal of Oncology Nursing, 20(Suppl. 2), S25–S30. https://doi.org/10.1188/16.CJON.S2.25-30
Persoon, S., Kersten, M.J., van der Weiden, K., Buffart, L.M., Nollet, F., Brug, J., & Chinapaw, M.J.
(2013). Effects of exercise in patients treated with stem cell transplantation for a hemato-
logic malignancy: A systematic review and meta-analysis. Cancer Treatment Reviews, 39,
682–690. https://doi.org/10.1016/j.ctrv.2013.01.001
van Haren, I.E., Timmerman, H., Potting, C.M., Blijlevens, N.M., Staal, J.B., & Nijhuis-van der
Sanden, M.W. (2013). Physical exercise for patients undergoing hematopoietic stem cell
transplantation: Systematic review and meta-analyses of randomized controlled trials.
Physical Therapy, 93, 514–528. https://doi.org/10.2522/ptj.20120181
Wang, J.B., Cadmus-Bertram, L.A., Natarajan, L., White, M.M., Madanat, H., Nichols, J.F., . . .
Pierce, J.P. (2015). Wearable sensor/device (Fitbit One) and SMS text-messaging prompts
to increase physical activity in overweight and obese adults: A randomized controlled trial.
Telemedicine and e-Health, 21, 782–792. https://doi.org/10.1089/tmj.2014.0176
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