Timothy R. Ackland

Purpose: Adolescents and young adults (AYAs) experience vast symptom burden resulting from cancer treatment-related toxicities (TRTs). Evidence supports integrated exercise to mitigate several TRTs in other cohorts; however, evidence in AYAs is lacking. Conventional reporting of TRTs adopts a maximum grade approach failing to recognise the trajectory over time, of persistent, or lower grade toxicities. Alternatively, longitudinal analysis of toxicities over time (ToxT) may provide clinically meaningful summaries of this data. We evaluated the longitudinal impact of an exercise intervention on TRTs in AYAs undergoing cancer treatment. Methods: A prospective, randomised trial allocated participants to a 10-week exercise intervention (EG) or control group (CG) undergoing usual care. Detailed information on TRTs was collected throughout the intervention. All TRTs were graded per the Common Terminology Criteria for Adverse Events (CTCAE v5.0). Results: Forty-three (43) participants (63% male, mean age 21.1 years) were enrolled. When categorised to reflect the maximal worst grade experienced (Grade 0, Grade 1–2 and ≥ Grade 3), the CG reported an increased incidence of severe fatigue (≥ Grade 3) compared with the EG (p = 0.05). No other differences between groups were evident (p > 0.05). ToxT analysis of the four most common toxicities (fatigue, pain, nausea and mood disturbances) demonstrated no difference in the mean grade of each over time (p > 0.05). Conclusion: A 10-week exercise intervention reduces the severity of fatigue in AYAs undergoing treatment. While the ToxT approach provided insight into the toxicity profile, adequately powered studies are needed to better understand these differences within a homogenous sample. Trial registration: (ACTRN12620000663954) 10^th June 2020.

Background The assessment of body composition (BC) in sport raises concern for athlete health, especially where an overfocus on being lighter or leaner increases the risk of Relative Energy Deficiency in Sport (REDs) and disordered eating. Methods We undertook a critical review of the effect of BC on performance (29 longitudinal, prospective or intervention studies) and explored current practice related to BC considerations via a follow-up to a 2013 internationally distributed survey. Results The review found that a higher level of body fat was negatively associated with endurance performance, while a gain in muscle mass resulted in performance benefits across sports. BC did not contribute to early talent identification, and no unique cut-off to signify a performance advantage for BC was identified. BC appears to be one of an array of variables impacting performance, and its influence should not be overstated. The survey (125 practitioners, 61 sports and 26 countries) showed subtle changes in BC considerations over time, such as an increased role for sport dietitian/nutrition practitioners as BC measurers (2013: 54%, 2022: 78%); less emphasis on reporting of body fat percentage (2013: 68%, 2022: 46%) and reduced frequency of BC assessment if ≥every fourth week (2013: 18%, 2022: 5%). Respondents remained concerned about a problematic focus on BC (2013: 69%, 2022: 78%). To address these findings, we provide detailed recommendations for BC considerations, including an overview of preferable BC methodology. Conclusions The ‘best practice’ guidelines stress the importance of a multidisciplinary athlete health and performance team, and the treatment of BC data as confidential medical information. The guidelines provide a health focus around BC, aiming to reduce the associated burden of disordered eating, problematic low energy availability and REDs.

Introduction: Exercise is recognised as integral in mitigating a myriad negative consequences of cancer treatment. However, its benefit within adolescent and young adult (AYA) cancer cohorts remains relatively under researched, and caution should be taken in extrapolating outcomes from adult and paediatric populations given AYA distinctly different physiological and psychosocial contexts. This study sought to evaluate the impact of an exercise intervention on mitigating the expected decline in fitness, strength, physical functioning, and quality of life (QOL) in AYA undergoing cancer treatment.Methods: This prospective, randomised controlled trial (FiGHTINGF!T) allocated 43 participants (63% male, mean age 21.1 years) to a 10-week, multimodal, bi-weekly exercise intervention (EG) or control group (CG) undergoing usual care. Pre- and post-intervention assessments included cardiopulmonary exercise tests, one-repetition maximum (1RM) strength, functional tests, and QOL patient-reported outcome measures. Data were analysed via linear mixed models and regression.Results: While no significant group differences (p > 0.05) were observed, neither group significantly declined (p > 0.05) in any outcome measure over the 10-week period. No significant (p˃0.05) strength or functional improvements were observed in the CG, though the EG demonstrated significant improvements in their 1RM leg press (p = 0.004) and chest press (p = 0.032), maximal push ups (p = 0.032), and global QOL (p = 0.011). The EG reported a significant increase in fatigue (p = 0.014), while the CG reported significant positive changes in anxiety measures (p = 0.005).Conclusion: The exercise intervention produced superior improvements in strength and global QOL, compared with the CG. Regardless of group allocation, enrolment in the exercise study appeared to mitigate the treatment-related decline expected in AYA undergoing cancer treatment.

Background: High-quality evidence supports the integration of exercise to mitigate treatment-related side effects in a wide range of paediatric and adult cancer cohorts. However, the implementation of exercise in adolescent and young adult (AYA) cancer patients is yet to be explored in depth. FiGHTINGF!T is a randomised controlled cross over trial designed to determine if a supervised, structured, and progressive exercise programme can reduce the decline in physical fitness (V0_2peak) associated with cancer treatment in AYAs from diagnosis. Methods/design: A total of 40 AYAs recently diagnosed and due to commence systemic treatment (± 2 weeks) for a primary haematological malignancy or solid tumour will be recruited and randomised to either an immediate exercise intervention or usual care (delayed exercise) for 10 weeks. This randomised controlled crossover trial will see both groups engage in a supervised exercise intervention from either diagnosis (baseline assessment) for 10 weeks (0–10 weeks) or following an interim assessment to 20 weeks (10–20 weeks). The bi-weekly tailored exercise programme will combine aerobic and resistance exercises and be supervised by an Accredited Exercise Physiologist. Participants will complete a range of assessments at 0, 10, and 20 weeks including cardiopulmonary exercise tests, 1 repetition maximum strength measures, physical functioning, and self-reported quality of life measurements. Patient-reported treatment-related toxicities will be recorded on a weekly basis. Discussion: The FiGHTINGF!T trial will provide insight into the potential benefits of a supervised exercise programme in AYAs undergoing cancer treatment. This trial will contribute to the evidence supporting the necessary integration of exercise during cancer treatment, specifically in the under-reported AYA cohort. Trial registration: This trial was registered retrospectively with the Australia New Zealand Clinical Trial registry (ACTRN12620000663954). Registered on 10 June 2020

Limited reference values exist for visceral adipose tissue (VAT) mass measured by DXA. The objectives of this study were to provide reference values for DXA-derived VAT mass and compare the association with anthropometry measures. The study cohort comprised 677 men and 738 women aged 18–65 years from Western Australia. Whole-body scans using a GE Lunar iDXA and anthropometry measures were collected. Reference percentile data were stratified by sex and age. Correlation analysis compared DXA-derived and anthropometry variables. Specificity, sensitivity, and Youden’s Index were used to evaluate the ability of anthropometric thresholds to predict individuals with high VAT. In men, waist circumference (WC), waist-hip ratio, and waist-height ratio (WHtR) had ‘high’ correlations with VAT mass. In women, only WHtR was ‘highly’ correlated with VAT mass. Overweight thresholds for WC, along with a body mass index of 25.0 kg/m² in women, had the highest combination of sensitivity and specificity when using anthropometry measures to identify individuals with high VAT mass. We provide the first reference data sets for DXA-derived VAT mass among Western Australians. Excessive VAT mass may be identified in men using the overweight WC threshold and in women using both the overweight BMI and WC thresholds.

Rehabilitation contributes to post-operative success following reverse total shoulder arthroplasty; however, randomised trials comparing the effectiveness of rehabilitation following reverse total shoulder arthroplasty are lacking. This study sought to determine if early, active mobilisation targeting the deltoid and the external rotator muscles, would exhibit greater improvements in post-operative outcomes compared to a delayed and deltoid-focused mobilisation programme. Patients scheduled for reverse total shoulder arthroplasty were randomly assigned to either an early active or delayed active rehabilitation group. Patient-reported outcomes for pain and function were assessed pre-surgery and at 3, 6 and 12 months post-surgery. Objective measures (Constant Score, range of motion, isometric strength) were assessed at 3, 6 and 12 months post-surgery. Sixty-one patients (63 shoulders) underwent reverse total shoulder arthroplasty. There were no significant interaction effects or between-group differences for any patient-reported outcomes or objective measures at 3, 6 or 12 months post-surgery. However, significantly better (p = 0.019) active arm flexion was observed in the early active group at three months post-surgery. Significantly more patients in the early active group reported improvement in patient-reported function that reached minimal clinically important difference from three to six months post-surgery (p = 0.016). Early, active rehabilitation after reverse total shoulder arthroplasty is safe and effective, and may have early clinical benefits over a conservative, delayed mobilisation programme. Therapy, level 1b. Trial registered 15 June 2016 at www.anzctr.org.au (ACTRN12616000779471).

Introduction: Pelvic floor muscle (PFM) training for postprostatectomy incontinence is considered a first line approach to rehabilitation, but PFM training for erectile dysfunction (ED) after surgery is less well known. With more than 1.4 million new cases diagnosed globally per year, there is a need for non-invasive options to assist sexual dysfunction recovery. Aim: Commencing preoperatively and using both fast and slow twitch fibre training performed in standing postures, new protocols were developed to address clinical presentations with aims to reduce ED and impact on quality of life (QoL). Comparisons with “usual care” PFM training, prerehabilitation and postrehabilitation were then assessed. Methods: A randomised controlled trial of 97 men undergoing radical prostatectomy (RP) were allocated to either a control group (n = 47) performing “usual care” of 3 sets/d PFMT or an intervention group (n = 50), performing 6 sets/d in standing, commencing 5 weeks before RP. Outcome measures: Participants were assessed preoperatively and at 2, 6, and 12 weeks after RP using the Expanded Prostate Cancer Index Composite for Clinical Practice, International Index of Erectile Function-5, and real time ultrasound measurements of PFM function. Results: At all time points, there was a significant difference (P< 0.05) between groups; however, the only time point where this difference was clinically relevant was at 2 weeks after RP, with the intervention group reporting less distress in the Expanded Prostate Cancer Index Composite for Clinical Practice QoL outcome. Secondary measures of EPIC-EF and real time ultrasound PFM function tests demonstrated improvement over all time points in both groups with lower bothersome scores in the intervention group. Conclusions: Early PFM training reduces early QoL impact for postprostatectomy ED, with faster return to continence enabling earlier commencement of penile rehabilitation. While our 12-week protocol and sample size was not powerful enough to demonstrate conclusive benefits of early PFM training for ED, PFM intervention after RP over longer times has been supported by others. Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. J Sex Med 2020;8:414–421.

Introduction Patients frequently have discomfort or difficulty with kneeling following anterior cruciate ligament reconstruction (ACLR). This study aimed to report the prevalence of, and reasons for, kneeling difficulty after ACLR with a hamstring autograft; and to investigate the association between the degree of kneeling difficulty, presence of concurrent meniscal surgery, and clinical outcomes, including patient-reported outcome measures (PROMs) and functional tests. Materials and methods A total of 104 patients undergoing ACLR with ipsilateral hamstring autograft were enrolled. Participants completed a kneeling difficulty questionnaire and other PROMs including the International Knee Documentation Committee (IKDC) questionnaire, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Cincinnati Knee Rating System (CKRS), the Lysholm Knee Scoring Scale (LKS), the Tegner Activity Scale (TAS), the 36-Item Short Form Health Survey (SF-36), and the Knee Outcome Survey (KOS). Patients were also assessed objectively via peak isokinetic knee extensor and flexor strength, range of movement (ROM), and functional hop tests. Results The prevalence of kneeling difficulty on the operated knee was 77% and 54% at 1 and 2 years after ACLR, respectively. Strong associations were observed between kneeling difficulty and PROMs, ranging from CKRS at 1 year of r = 0.403 (95% CI 0.228–0.553, p < 0.001) to KOS at 2 years of r = 0.724 (95% CI 0.618, 0.804, p < 0.001). No associations were observed with age, body mass index, or knee ROM measures. Weak-to-moderate associations were demonstrated with functional hop tests. The degree of kneeling difficulty did not differ with concurrent meniscal surgery. Conclusions Kneeling difficulty occurs in as much as 77% of patients following ACLR with hamstring grafts at 1 year, and 54% at 2 years. This has a moderate-to-very strong association with patient-reported assessment of knee pain, symptoms, sport and recreation, and knee-related quality of life. There appears to be no association with patient age, BMI, time from injury to surgery, knee ROM, or concurrent meniscal surgery. Level of evidence IV