Jana Müller

In recent years, remote exercise services (“telerehabilitation”) have been increasingly explored and implemented, including in supportive cancer care, on the promise of greater convenience, access independent of geographic location, reduced infection risk, and cost savings. Ethical commentary on telehealth in general is substantial, but sustained discussion of questions specific to telerehabilitation remains comparatively sparse. As contributors to PREFERBALE-II, a European Union–funded project evaluating live-remote exercise for people recovering from cancer treatment, we sought practical guidance on how to deliver such services responsibly, and found little to work with. This prompted this viewpoint, which sets out our own position as researchers and clinicians engaged in this work. We draw on a purposive sample of professional guidance documents, which were assembled through our professional networks and a supplementary web search, and on a narrative reading of qualitative studies chosen to represent accounts of benefits as well as burdens. We read these documents through an analytical lens of responsible innovation. We make 3 arguments. First, the ethical content of current telerehabilitation guidance is largely confined to the products and processes of innovation, covering safety, privacy, consent, and compliance, while the question of purpose, that is, whether, for whom, and why remote rehabilitation should be offered at all, is left largely unasked. Anticipation appears only implicitly, and reflexivity, inclusion, and responsiveness barely at all. Responsibility is repeatedly delegated to individual professionals without commensurate structural support. Second, the situated experience of users and professionals forms part of the ethics of telerehabilitation and is not merely data to be assessed. Reported benefits and burdens depend on social context, including age, digital literacy, connectivity, caregiver availability, language, and sensory or cognitive impairment, so an equity claim made for the modality in general may not hold for the individual patient. Third, the ethics of telerehabilitation consequently has to be institutionalized across 3 overlapping domains: the interpersonal and experiential quality of remote care, the legal and institutional conditions of delivery, and the positioning of telerehabilitation within health systems. We address these arguments primarily to rehabilitation professionals and the associations and standard-setting bodies that issue guidance for them, and secondarily to digital health and ethical, legal, and social implications researchers, policymakers, and health-system decision-makers who commission or implement such services. We offer an agenda for a broader ethics conversation across professional societies, curricula, and affected publics, together with observations from a consortium put forward as hypotheses for study.

Good supervision plays a pivotal role in fostering a range of skills crucial for academic and professional growth. This study presents a subgroup analysis of previously published data (see Müller et al., 2023 ) and aims to investigate doctoral candidates in sport psychology with respect to their perception and satisfaction regarding supervision, as well as facets of their supervisory situation. A total of 70 doctoral candidates in sport psychology in Germany ( M _age = 30.81 years; SD _age = 3.60 years) provided information on their satisfaction with supervision and their perception of other facets of their supervisory situation (i. e., infrastructure, scientific work and thinking, relationship and health). Our results – which, due to incomplete data, do not consistently include all 70 participants – show that microecological (e. g., regular meetings, existence of a supervision agreement) and macroecological (i. e., time spent on doctoral research) aspects are positively related to doctoral candidates’ supervision satisfaction and their perception of other facets of the supervisory situation. Despite generally positive supervision, some expressed dissatisfaction, prompting recommendations for future improvements.

Purpose: As survival of patients with metastatic breast cancer (MBC) improves, their work situation is gaining importance. The aim of the current study was to identify factors associated with work status and quality of working life (QWL) in patients with MBC. Additionally, we investigated the effects of an exercise intervention on work status. Methods: Within the multinational PREFERABLE‐EFFECT exercise trial, 287 patients with MBC of working age (18–65 years) reported on their working situation over 9 months as a secondary endpoint. Among a subgroup of participants, QWL was assessed by the Quality of Working Life Questionnaire for Cancer Survivors (QWLQ‐CS) ( N = 59). Results: At baseline, 157 (54.7%) participants were employed, of whom one‐third reported having recently reduced their amount of work because of fatigue (41.7%), cognitive problems (33.3%), or inability to meet work demands (33.3%). Participants wished for more flexible working hours (29.2%) and less productivity pressure (37.5%). Participants were less likely to work if they experienced higher levels of pain ( p = 0.014). Among working participants, an academic education and higher levels of psychological distress were associated with a higher number of working hours (all p < 0.05). Fatigue, an academic education, and performing mentally strenuous tasks at work were negatively associated with QWL (all p < 0.05). The exercise intervention did not affect the number of hours worked during the study. Conclusions: Symptom management might be important for patients' ability to work. To help patients stay employed and improve QWL, employers should consider offering more flexible work arrangements and adapting to their employees' changing needs and abilities. Trial Registration: The PREFERABLE‐EFFECT trial was registered with ClinicalTrials.gov on October 9, 2019 (NCT04120298).

PURPOSE: To evaluate the cost utility of a 9-month supervised exercise program for patients with metastatic breast cancer (mBC), compared with control (usual care, supplemented with general activity advice and an activity tracker). Evidence on the cost-effectiveness of exercise for patients with mBC is essential for implementation in clinical practice and is currently lacking. METHODS: A cost-utility analysis was performed alongside the multinational PREFERABLE-EFFECT randomized controlled trial, conducted in 8 centers across Europe and Australia. Patients with mBC (N = 357) were randomly assigned to either a 9-month, twice-weekly, supervised exercise group (EG) or control group (CG). Costs of the exercise program were calculated through a bottom-up approach. Other health care resource use, productivity losses, and quality of life were collected using country-adapted, self-reported questionnaires. Analyses were conducted from a societal perspective with a time horizon of 9 months. Costs were collected and reported in 2021 Euros (€1 = $1.18 US dollars). RESULTS: Compared with the CG, EG resulted in a quality-adjusted life-year (QALY) gain of 0.013 (95% CI, –0.02 to 0.05) over a 9-month period. The mean costs of the exercise program were €1,696 per patient with one-on-one supervision (scenario 1) and €609 with one-on-four supervision (scenario 2). These costs were offset by savings in health care and productivity costs, resulting in mean total cost differences of –€163 (scenario 1) and –€1,249 (scenario 2) in favor of EG. The probability of supervised exercise being cost-effective was 65% in scenario 1 and 91% in scenario 2 at a willingness-to-pay threshold of €20,000 per QALY. CONCLUSION: Exercise for patients with mBC increases quality of life, decreases costs, and is likely to be cost-effective. Group-based supervision is expected to have even higher cost-savings. Our positive findings can inform reimbursement of supervised exercise interventions for patients with mBC.

The understanding and treatment of sexual health problems, impaired body image, and other non‐life threatening but burdensome symptoms of women with metastatic breast cancer (mBC) is still insufficient. We studied the factors associated with such symptoms and investigated whether these problems could be alleviated by a structured exercise intervention. In the multinational PREFERABLE‐EFFECT study, 355 women with mBC were randomly assigned to usual care (n = 178) or a 9‐month supervised exercise program (n = 177). Breast cancer‐specific functions and symptoms (EORTC QLQ‐BR42) were assessed at baseline, 3, 6 (primary timepoint), and 9 months. Linear regression models and linear mixed models for repeated measures were calculated. At baseline, participants were 55.4 ± 11.2 years old, 52.4% were undergoing endocrine therapy, and 25.4% chemotherapy. Baseline sexual functioning was low, with 94.3% reporting no or little sexual activity. Age and depressive symptoms were negatively associated with sexual functioning. Among sexually active women, 46.2% felt no or little sexual enjoyment and 37.3% suffered from vaginal dryness. Body image was reported as low by 23.7%. Exercise significantly improved sexual functioning (6‐months between‐group difference (BGD) = 5.6, 95% CI [1.9, 9.4], effect size (ES) = 0.28) and vaginal symptoms (BGD = −7.1 [−11.7, −2.5], ES = 0.25), compared to usual care. Effects on body image were marginal (BGD = 4.0 [−0.2, 8.3], ES = 0.14). Among participants undergoing chemotherapy (n = 90), exercise reduced chemotherapy side‐effects (BGD = −8.2 [−15.4, −1.0], ES = 0.48). In conclusion, women with mBC often experience sexual and vaginal problems and other treatment‐related side‐effects. A 9‐month supervised exercise program vs. control was effective in improving sexual functioning and vaginal symptoms among women with mBC.

Background: Physical activity has been shown to be beneficial for people diagnosed with cancer. MOVE-ONKO aims at implementing a new multiprofessional care pathway in 3 large regions in Germany at the interface of oncological treatment and exercise therapy for cancer patients. The related study aims to evaluate the implementation processes and patient outcomes. Methods: The project comprises 3 phases: 1) preparation, 2) implementation in Comprehensive Cancer Centres (CCCs), 3) implementation in remote cancer centres. In phase 1, individual prerequisites for the implementation are assessed in the participating CCCs. The care pathway which is supported by digital/app-based exercise oncology health record is developed and adapted to the CCCs. Phases 2 and 3 focus on the implementation and evaluation of the care pathway. To study the effectiveness, primarily changes in patients' health-related quality of life are examined in a prospective design. Secondary outcomes include physical activity behaviour, motivation for physical activity and patient activation. A sample of 2240 cancer patients ≥ 18 years (n = 280 patients at seven CCCs in phase 2 and n = 1.960 patients at the seven CCCs and 49 remote oncological centres in phase 3) are recruited for assessment at inclusion and at 4, 12 and 24 weeks. The newly implemented care structures and processes will be assessed from the perspective of key informants, healthcare providers and patients. The perspectives of key informants on the implementation from the CCCs will be recorded in a prospective design based on a questionnaire and supplemented by in-depth semi-structured interviews across the three phases. The implementation processes are documented by assessing existing structures in CCCs. In phase 2 (n = 105) and phase 3 (n = 350), healthcare providers will be surveyed with questionnaires. Based on purposeful sampling (n = 18) will be interviewed. Additionally, qualitative patient interviews will be conducted about their experiences in the care pathway. Discussion: A successful implementation of the care pathway as part of the study will contribute to the growing evidence on the implementation of a nationwide structured approach to exercise therapy for patients with cancer. Trial registration: ClinicalTrials.gov (ClinicalTrials Identifier NCT06185777) at December 29, 2023.

Physical exercise both during and after curative cancer treatment has been shown to reduce side effects. Evidence in the metastatic cancer setting is scarce, and interventions that improve health-related quality of life (HRQOL) are much needed for patients with metastatic breast cancer (MBC). The multinational randomized controlled PREFERABLE-EFFECT trial assessed the effects of exercise on fatigue and HRQOL in patients with MBC. In total, 357 patients with MBC and a life expectancy of ≥6 months but without unstable bone metastases were recruited at eight study centers across five European countries and Australia. Participants were randomly assigned (1:1) to usual care (control group, n = 179) or a 9-month supervised exercise program (exercise group, n = 178). Intervention effects on physical fatigue (European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-FA12 scale) and HRQOL (EORTC QLQ-C30 summary score) were determined by comparing the change from baseline to 3, 6 (primary timepoint) and 9 months between groups using mixed models for repeated measures, adjusted for baseline values of the outcome, line of treatment (first or second versus third or higher) and study center. Exercise resulted in significant positive effects on both primary outcomes. Physical fatigue was significantly lower (−5.3 (95% confidence interval (CI), −10.0 to −0.6), Bonferroni–Holm-adjusted P = 0.027; Cohen's effect size, 0.22) and HRQOL significantly higher (4.8 (95% CI, 2.2–7.4), Bonferroni–Holm-adjusted P = 0.0003; effect size, 0.33) in the exercise group than in the control group at 6 months. Two serious adverse events occurred (that is, fractures), but both were not related to bone metastases. These results demonstrate that supervised exercise has positive effects on physical fatigue and HRQOL in patients with MBC and should be recommended as part of supportive care.ClinicalTrials.gov Identifier: NCT04120298.

Objective: Traditional posturography measurements characterize postural instability in patients with chemotherapy‐induced peripheral neuropathy (CIPN), while underlying postural control mechanisms remain unclear. Taking a model‐based approach can yield insights into these mechanisms. This study’s aim was to characterize the modifications in postural control of CIPN patients associated with exercise in relation to the postural behavior of healthy control participants (hCON) via an exploratory approach.Methods: Thirty‐one CIPN patients were randomly assigned to two interventions (balance plus moderate endurance training vs. moderate endurance training only) and exercised twice per week over 12 weeks. Baseline data were compared to 36 matched hCONs. We recorded spontaneous sway and postural reactions to platform tilts using Optotrak and a Kistler force platform pre‐ and post‐intervention. Data interpretation relied on a model‐based parameter identification procedure.Results: Spontaneous sway amplitudes were larger and postural reactions smaller, with a relative phase advance, in our pre‐intervention patients than the hCONs. Post‐intervention, spontaneous sway, and postural reactions were reduced and the sensory‐motor ratio larger in both groups, while the postural reaction timing differed between groups.Interpretation: The abnormally small postural reactions in CIPN patients before the intervention can be interpreted as the consequence of abnormally strong velocity control—a strategy modification that may serve as a prediction mechanism to compensate for the lack of timely and accurate proprioceptive signals. While both groups reduced postural sway and showed an adapted sensory‐motor ratio post‐intervention, the interventions seemed to trigger different velocity control strategies. This study emphasizes the need for taking a more differentiated perspective on intervention effects.Trial registration: German Clinical Trials Register (DRKS) number: DRKS00005419, prospectively registered on November 19, 2013.

Background: Chemotherapy-induced peripheral neuropathy (CIPN) is a common, unpleasant and usually long-lasting side effect of neurotoxic chemotherapeutic agents. This study aimed to investigate the preventive potential of sensorimotor- (SMT) and resistance training (RT) on CIPN. Methods: Patients (N = 170) were randomised to SMT, RT or usual care (UC). Both exercise groups trained 3×/week for a total of 105 min/week during neurotoxic chemotherapy (mean length: 20 weeks). Before and 3 weeks after neurotoxic chemotherapy, CIPN signs/symptoms were assessed via Total Neuropathy Score (TNSr; primary endpoint) and EORTC QLQ-CIPN15 questionnaire. In addition, balance (centre of pressure), muscle strength (isokinetic), quality of life (QoL, EORTC QLQ-C30) and relative chemotherapy dose intensity (RDI) were investigated. The follow-up period covered 6 months after the end of chemotherapy. Results: Intention-to-treat analyses (N = 159) revealed no differences regarding CIPN signs/symptoms. Exploratory per-protocol analyses (minimum training attendance rate 67%; N = 89) indicated that subjectively perceived sensory symptoms in the feet increased less during chemotherapy in the adherent exercisers (pooled group: SMT+RT) than in the UC group (−8.3 points (−16.1 to −0.4); P = 0.039, ES = 1.27). Furthermore, adherent exercisers received a higher RDI (96.6 ± 4.8 vs. 92.2 ± 9.4; P = 0.045), showed a better course of muscular strength (+20.8 Nm (11.2–30.4); P < 0.001, ES = 0.57) and QoL (+12.9 points (3.9–21.8); P = 0.005, ES = 0.64). During follow-up, CIPN signs/symptoms persisted in all groups. Conclusions: This study demonstrates that SMT and/or RT alleviate subjectively perceived sensory CIPN symptoms in the feet and other clinically relevant cancer therapy-related outcomes, if an appropriate training stimulus is achieved. Clinical trial registration: NCT02871284.

Impaired postural control is often observed in response to neurotoxic chemotherapy. However, potential explanatory factors other than chemotherapy-induced peripheral neuropathy (CIPN) have not been adequately considered to date due to primarily cross-sectional study designs. Our objective was to comprehensively analyze postural control during and after neurotoxic chemotherapy, and to identify potential CIPN-independent predictors for its impairment. Postural control and CIPN symptoms (EORTC QLQ-CIPN20) were longitudinally assessed before, during and three weeks after neurotoxic chemotherapy, and in three and six months follow-up examinations (N = 54). The influence of peripheral nerve function as determined by nerve conduction studies (NCS: compound motor action potentials (CMAP) and sensory action potentials (SNAP)), physical activity, and muscle strength on the change in postural control during and after chemotherapy was analyzed by multiple linear regression adjusted for age and body mass index. Postural control, CIPN signs/symptoms, and CMAP/SNAP amplitudes significantly deteriorated during chemotherapy (p < .01). During follow-up, patients recovered from postural instabilities (p < .01), whereas CIPN signs/symptoms and pathologic NCS findings persisted compared to baseline (p < .001). The regression model showed that low CMAP and high SNAP amplitudes at baseline predicted impairment of postural control during but not after chemotherapy. Hence, pre-therapeutically disturbed somatosensory inputs may induce adaptive processes that have compensatory effects and allow recovery of postural control while CIPN signs/symptoms and pathologic peripheral nerve function persist. Baseline NCS findings in cancer patients who receive neurotoxic chemotherapy thus might assist in delineating individual CIPN risk profiles more precisely to which specific exercise intervention programs could be tailor-made.