Limited Evidence for the Benefits of Exercise in Older Adults with Hematological Malignancies: A Systematic Review and Meta-Analysis
Abstract
:Simple Summary
Abstract
1. Introduction
2. Materials and Methods
2.1. Information Sources and Search Strategy
2.2. Eligibility Criteria
2.3. Data Collection Process
2.4. Outcomes
2.5. Risk of Bias Assessment
2.6. Certainty of Evidence
2.7. Data Synthesis and Analysis
3. Results
3.1. Study Characteristics
3.2. Exercise Interventions
3.3. Effects of Exercise Interventions on Primary Outcomes
3.4. Effects of Exercise Interventions on Secondary Outcomes
3.5. Feasibility, Adverse Events, Adherence and Exclusion Criteria
3.6. Risk of Bias in Individual Studies and across Studies
3.7. Quality of Evidence (GRADE)
3.8. Ongoing Studies Registered in Clinical Trials
4. Discussion
Strengths and Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
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Author, Year, Country | Diagnose | Study Design |
Sample Size, n IG/CG Female (%) |
Age Mean, (Range) Median, (Range) | Exclusion Criteria | Timing of Intervention | Intervention Group | Control Group | |
---|---|---|---|---|---|---|---|---|---|
Type: T Intensity: I Length: L Duration: D | Extensiveness | Type: T Intensity: I Length: L Duration: D | |||||||
Accogli 2022 Italy [36] | Lymph, Leuk, MM | RCT | 46 (23/23) (47.8) | Mean 59.9 Median IG: 66.7 (51.3–72.1) CG: 60.4 (49.9–67.5) | Poor prognosis (<12 months) and clinical conditions hindering participation (e.g., dementia, psychiatric pathology, blindness) | Before, during and after chemotherapy | Partly supervised Supervised, hospital-based: T: Therapeutic education I: Individual intensity L: 2 × 60 min (group) and face-to-face (individual) 6 × 20 min 1x/week or every 2 weeks Unsupervised, homebased: T: Individual physical exercise D: 8 weeks | Less | T: Educational therapeutic group sessions L: 2x in total |
Alibhai 2014 Canada [37] | AML | RCT Feasibility | 38 (21/17) (55.3) | Mean 56.1 IG: 53.9 CG: 58.8 | Another active malignancy, life expectancy < 3 months, severe or unstable cardiorespiratory or musculoskeletal disease, awaiting HSCT and regular participation in a moderate-vigorous PA program | After HSCT or chemotherapy | Partly supervised Supervised, hospital-based: T: Workout and education (group) L: 1.5 h/week Unsupervised, home-based: T: Aerobic, resistance and flexibility components I: Moderate intensity L: 30 min, 3–5x/week D: 12 weeks | Moderate | T: UC, Usual level of PA |
Alibhai 2015 Canada [38] | AML | RCT | 81 (57/24) (45.7) | Mean 57 (23–80) IG: 58 CG: 52 Median 59 >60: IG, n = 32 CG, n = 7 | Another active malignancy, life expectancy < 1-month, significant medical comorbidity that would preclude exercise, uncontrolled pain, hemo-dynamic instability | During chemotherapy | Supervised, hospital-based: T: Individualized aerobic (treadmill, hall walking, stationary cycling), resistance (body weight, bands, free weights) and flexibility training I: RPE of 3–6, equivalent to 50–75% of HRR L: 30–60 min, 4–5x/week | Moderate | T: UC, Suggestions to walk regularly and weekly document on tracking sheets |
Baumann 2010 Germany [39] | AML, ALL, CML, MM, NHL/CLL, MDS/MPS, Solid tumor, Immuno-deficiency | RCT Pilot | 64 32/32 (45.4) | Mean IG: 44.9 CG: 44.1 | Severe orthopaedic illness of legs, severe heart failure (NYHA III-IV), metastatic bone disease, thrombocytopenia (≤30 × 109/L) and/or acute somatic complaint (e.g., infection, fever, acute bleeding) | During ASCT, allo-HSCT or chemotherapy | Supervised, hospital-based: T: Aerobic (ergometer) and ADL training (walking, stepping, stretching) I: Aerobic: 80% of achieved watt load in WHO-test, ADL-training: Borg scale: “slighty strenuous”-“strenuous” L: Aerobic 10–20 min + ADL 20 min/2x daily, ADL 5x/week D: Mean: 26.6 days | Moderate | T: UC, Standard mobilization program |
Baumann 2011 Germany [40] | AML ALL, CML, CLL, MPS, MDS, CMML, MM, PID | RCT | 47 (24/23) (51.5) | Mean IG: 41.4 CG: 42.8 | Severe cardiac disease (NYHA III-IV) or orthopaedic illness of the legs, bone metastases, thrombocytopenia (≤10 × 109/L) or acute bleeding, respectively, and/or acute health or somatic complaints (e.g., infection, fever) | During allo-HSCT | Supervised, hospital-based: T: Aerobic (ergometer) and ADL training (walking, stepping, stretching) I: Aerobic: 80% of achieved watt load in WHO-test, ADL-training: Borg scale: “slighty strenuous”-”strenuous L: Aerobic: 10–20 min + ADL 20 min, 1–2x/day D: Mean: 56.1 days | Moderate | T: UC, Standard PT |
Bayram 2024 Turkey [41] | ALL, AML, Biphenotypic Leuk, MDS, NHL, Burkitt Lymph, CNS Lymph, Myelofibrosis, Thalassemia major, MM | RCT | 30 (15/15) (26.7) | Mean IG: 45.67 CG: 52.07 | Orthopaedic, neurological, or cognitive disease affecting functional capacity, psychiatric disorders, pneumonia, acute infections, sepsis, and pulmonary diseases | During HSCT | Supervised, hospital-based: T: Aerobic (arm ergometer), resistance (free weights) and inspiratory muscle (inspiratory pressure device) exercises I: Aerobic: 50–80% of HR. Resistance: 4–6 on modified Borg scale, 3 sets of 10 reps. Inspiratory: 30% of max inspiratory pressure L: Aerobic: 10–30 min, 1x/day, 5 days/week. Resistance: 10–15 min, 5 days/week. Inspiratory: 15 min, 2x/day, 5 days/week D: During inpatient period. Mean: 25.2 days | Extensive | T: Aerobic and resistance exercises I: As IG L: As IG D: During inpatient period. Mean: 21.33 days |
Bird 2010 UK [42] | Leuk, Lymph, MM, other | RCT | 58 (29/29) (34.5) | Median 55 IG: 57 CG:52 | NR | After ASCT or allo-HSCT | Supervised, hospital-based: T: Circuit training exercise, relaxation, and information (group) I: NR L: 1x/week D: 10 weeks | Less | T: UC, Self-managed program: information leaflets and home-based exercise program |
Bryant 2018 USA [43] | AML, ALL | RCT Pilot | 18 (9/9) (29.4) | Mean IG: 52 (34–67) CG: 49 (28–69) Median IG: 58 (34–67) CG: 48 (28–69) | Cardiovasc. disease, acute or chronic respiratory disease, acute or chronic bone, muscle, or joint abnormalities, altered mental state, dementia or any other psychological condition, another active malignancy, active bleeding, acute thrombosis, ischemia, hemodynamic instability, or uncontrolled pain | During chemotherapy | Supervised, hospital-based: T: Aerobic (walking or stationary bike) and resistance training (resistance band) I: Aerobic: 50–70% of HRR. Resistance: Increased from lighter to heavier resistance, 10 RM L: 20–40 min, 2x/day, 4x/week D: 4 weeks | Moderate | T: UC |
Chang 2008 Taiwan [44] | AML | RCT | 24 (12/12) (45.5) | Mean IG: 49.4 CG: 53.3 | NR | During chemotherapy | Supervised, hospital-based: T: Walking exercise program I: A speed to reach target HR (resting heart rate plus 30) L: 12 min, 5x/week D: 3 weeks | Less | T: Nurse-led control L/D: 1x/day, 5 days/week, 3 weeks |
Chen 2021 China [45] | AML, ALL | RCT Pilot | 30 (15/15) (58.6) | Mean IG: 40.2 CG: 37.6 | Medical conditions in arms, legs, or abdomen, paralysis, or disability and intended to receive HSCT in the next 3 months | During chemotherapy | Partly supervised, hospital-based T: Individualized self-help relaxation exercises I: NR L: 30 min, 2x daily D: 4 weeks | Less | T: UC |
Chow 2020 USA [46] | Leuk, Lymph, other | RCT Pilot | 41 (24/17) (48.8) | Median 45.1 (20.2–54.8) IG: 44.0 (20.9–54.0) CG: 46.0 (20.2–54.8) | Pre-existing ischemic heart disease or ongoing symptomatic cardiomyopathy, active cGvHD, pregnant | After ASCT, allo-HSCT | Unsupervised, home-based: T: Individualized, multiple mHealth app-based lifestyle counselling and goal-setting intervention, step count goals based on the past week’s daily average steps I: NR L: 16 weeks | Less | T: Fitbit tracker and Healthwatch360 app, no goal setting or peer support |
Chuang 2017 Taiwan [47] | NHL | RCT | 100 (50/50) (45.0) | Mean IG: 55.9 CG: 64.5 | Major medical disease, MM, or bone metastasis with medical contra-indications for exercise and already practicing qigong or other exercise regular | During chemotherapy | Unsupervised, home-based: T: Chan-Chuang qigong program with weekly telephone calls I: NR L: 25 min, 2–3x/day D: 21 consecutive days | Less | T: UC, Nursing on side effects of chemotherapy and care |
Cohen 2004 USA [48] | Lymph, HL, NHL | RCT | 39 (20/19) (30.8) | Mean 51 | Major psychotic illness, <18 years | During and after chemotherapy | Supervised, hospital-based: T: Group-based Tibetan yoga program I: NR L: 7x/week D: 7 weeks | Less | T: UC |
Coleman 2003 USA [49] | MM | RCT Pilot Feasibility | 24 (14/10) (41.7) | Mean 55 (42–74) | NR | During chemotherapy and ASCT | Unsupervised, home-based: T: Aerobic (walking, running, or cycling) and strength training (exercise bands), exercise log I: Borg Scale 12–15 L: Approx. 50 min, individual frequency D: 26 weeks | Moderate | T: UC, Encouragement to remain active and walk |
Coleman 2012 USA [50] | MM | RCT | 187 (95/92) (41.7) | Mean IG: 56.0 (25–76) CG: 56.4 (35–76) | Unable to understand intent of the study, major psychiatric illness, or presence of microcytic or macrocytic anaemia, uncontrolled hypertension, RBC transfusions within two weeks of study enrolment, or recombinant epoetin alfa within eight weeks of study enrolment | During unspecified intensive treatment (PBSCT) | Unsupervised, home-based: T: Individualized combination of stretching, aerobic exercise (walk, jog on treadmills) and strength resistance training (exercise bands), exercise log I: Aerobic:65–80% max HR, Borg Scale 11–13. Strength: 60–80% of 1 RM L: Individual length and frequency D: 15 weeks | Moderate | T: UC, Recommendation to walk L: 20 min, 3x/week |
Courneya 2009 Canada [51] | Lymph, NHL indolent, NHL aggressive, HL | RCT | 122 (60/62) (41) | Mean 53.2 (18–80) >60: n = 49 | Uncontrolled hypertension, cardiac illness, resides >80 km from facility, not approved by oncologist | Before, during and after chemotherapy | Supervised, hospital-based: T: Aerobic (ergometer) I: Initial 60% of VO2peak, progressing 75% L: 15–45 min, 3x/week D: 12 weeks | Moderate | T: UC, Supervised exercise L: 12 sessions, 1 month, after postintervention assessments |
Defor 2007 USA [52] | AA, ALL, AML, MDS, CML, NHL/HL, other malignancies | RCT | 100 (51/49) (39.0) | Median 47 (18–68) IG: 46 (18–68) CG: 49 (22–64) | Unavailable treadmills at hospital admission (n = 21 excluded) | During and after allo-HSCT From transplant admission to day 100 posttransplant | Partly supervised Supervised, hospital-based: T: Individualized treadmill I: Comfortable speed L: 15 min, 2x/day Unsupervised, homebased: T: Walking I: Comfortable speed L: 30 min, 1x/day | Moderate | T: UC, Not asked to perform any formal exercise |
Eckert 2022 USA [53] | BMT patients | RCT Feasibility | 72 (33/39) (55.6) | NR | Engaged in yoga in past year, history of recurrent falls (>two falls in 2 months), residency outside USA, participation in a previous study with the research team, ECOG 3 questionnaire score > 3, pregnant | After ASCT | Unsupervised, home-based: T: Online Hatha yoga program I: NR L: Min. 60 min/week D: 12 weeks | Less | T: Online cancer health education podcasts L: 60 min/week D: 12 weeks |
Furzer 2016 Australia [54] | NHL, HL, MM | RCT | 37 (18/19) (NR) | Mean 48.9 (22–68) IG: 48.2 (22–64) CG: 49.6 (25–68) | Hematologist did not approve exercise due to identified risks | After chemotherapy or radiation or HSCT | Partly supervised, in local gyms and clinics: T: Aerobic (individual) and resistance training (machines and dumbbells) I: Cardio: 50–85% of HRmax, RPE of 10–16. Resistance: Initial 3 sets of 10–15 rep at 50% of 1 RM to 2–3 sets of 6–8 rep at 80% of 1 RM L: Max. 30 min, 3x/week D: 12 weeks | Moderate | T: Diary and general healthy lifestyle advice |
Gallardo-Rodriquez 2023 Mexico [55] | ALL | RCT Pilot 3-arm | 33 (11/11/11) (66.7) | Mean 23.7 (18–45) CEG: 20.5 (18–36) REG: 22.5 (18–36) CG: 28.0 (18–45) | Neutropenia, infections, bleeding at admission, were nonmotile or unable to carry out exercise; with a CNS disease preventing movement, alterations of heart function, with bone marrow or CNS relapse, with a referral from another hospital | During chemotherapy treatment | Supervised, hospital- and home-based: T: Cross-training or resistance (weights) exercises I: RPE of 3–6 (50–75% of HRR), 3–5 sets of 8–15 reps L: 30–50 min, 3–5x/week D: During inpatient period | Moderate | T: Mobilization I: Low L: 30 min, daily |
Hacker 2017 USA [56] | ALL, AML, CLL, CML, HL, NHL, MM, MDS | RCT | 67 (33/34) (38.8) | Mean 53.3 IG: 51.9 CG: 54.6 | Significant comorbidity, like impending pathological fracture, making exercise potentially unsafe | During and after ASCT or allo-HSCT | Partly supervised Supervised, hospital-based: T: Progressive resistance training (elastic resistance bands and body weights) I: Moderate intensity, Borg scale 13 L: 2–3x/week, D: During inpatient period Unsupervised, home-based: T: Progressive resistance training (elastic resistance bands and body weights) I: Moderate intensity, Borg scale 13 L: 2–3x/week D: 6 weeks after discharge | Moderate | T: UC, Attention control with health education |
Hacker 2022 USA [57] | MM | RCT Pilot | 32 (17/15) (34.4) | Mean 62.78 IG: 62.21 CG: 63.44 | NR | After ASCT and after discharge | Partly supervised Supervised, hospital-based: T: Weekly goal setting, daily step tracking, and individualized coaching I: NR L: Daily Unsupervised, home-based: T: Free-living PA, step trackers I: NR L: Daily D: 6 weeks | Moderate | T: UC, Recommendations regarding rest, PA, and exercise |
Hathiramani 2020 UK [58] | Lymph | RCT | 46 (23/23) (63) | Mean 61 IG: 61.5 CG: 60.4 | Active disease, unstable angina or unexplained electrocardiogram, poor PS (ECOG 3 or more), pregnancy, difficulty breathing at rest, persistent cough, fever or illness, or any cognitive impairment limiting the ability to give informed consent or complete questionnaires | During and after chemotherapy | Unsupervised, home-based: T: Individual elements of aerobic (walking), resistance training (resistance bands, body weight), core stability and stretches I: Aerobic: Moderate intensity Resistance: ACSM guidelines with 3 sets for 8–12 rep L: 50 min, 3x/week D: 12 weeks | Moderate | T: Bed or chair-based program, mindfulness-based. CD audio guidance to relaxation techniques: mindfulness meditation, breathing exercises, guided visualization and progressive muscle relaxation. I: No advice to exercise outside of normal habits, nor asked to avoid activity L: 50 min, 3x/week |
Huberty 2019 USA [59] | MPN: Polycythaemia Vera, Essential, Thrombocythemia, Myelofibrosis | RCT Pilot | 62 (34/28) (93.7) | Mean 56.9 IG: 58.3 CG: 55.0 | Reported performing tai chi, qi gong, or yoga for ≥60 min/week, reported engaging in ≥150 min/week of PA, utilized the study’s online yoga site: Udaya.com, (accessed on 21 August 2024) syncope in the last two months, recurrent falls: ≥2 in past two months, score of ≥15 on the PHQ-9, score of >3 on the ECOG-3, pregnant, residency outside USA | During or after chemotherapy | Unsupervised, home-based: T: Online homebased Hatha/Vinyasa yoga I: NR L: 5–30 min, 60 min/week D: 12 weeks | Less | T: UC, Maintain usual activity |
Hung 2014 Australia [60] | Lymph, ML | RCT Pilot | 37 (18/19) (46) | Mean IG: 57.5 CG: 59.9 | Undergoing allo-HSCT, deemed unsuitable for study participation by physicians | After ASCT | Unsupervised, home-based: T: Individual telephone-delivered nutrition and exercise counselling, unsupervised aerobic (walking or cycling) and resistance (sit-to-stand or free weight) I: Recommendations based on ACSM guidelines for cancer survivors L: Various length, 3–7x/week D: 12 weeks | Moderate | T: UC |
Jacobsen 2014 USA [61] | ALL, CML, CLL, MDS, MM, Lymph | RCT 4-arm | 711 (180/178/178/175) (43) | Median IG E: 58 (20–76) IG SM: 58 (20–75) IG E/SM: 57 (18–75) CG: 55 (19–76) >65, n = 154 (21.6%) | Orthopaedic, neurological, or other problems that prevented safe ambulation or protocol adherence, participation in another clinical trial with QoL or functional status as a primary endpoint, planned anticancer therapies other than tyrosine kinase inhibitor or rituximab within 100 days after HSCT, planned donor lymphocyte infusion within 100 days after HSCT, planned tandem transplantation | Before, during and after allo-HSCT or ASCT | Unsupervised, home-based: T: Self-directed exercise program, a DVD reinforcing the program, tracking of participation in exercise and/or stress management. Exercise component: Calculation of target HR and pedometer. The stress management component also included provision of a relaxation CD I: 50–75% of estimated HRR L: 20–30 min, 3–5x/week D: 180 dayS | Moderate | T: DVD with general instruction about HSCT L: 45 min |
Jarden 2009 Denmark [62] | CML, AML, ALL, AA, MDS, WM, PNH, MF | RCT | 42 (21/21) (38.1) | Mean 39.2 (18–60) IG: 40.9 (18–60) CG: 37.4 (18–55) Median 40.5 IG: 45.0 CG: 38.0 | Prior HSCT, recent cardiovascular, or pulmonary disease, abnormal EKG, psychiatric disorder, and motor, musculoskeletal or neurological dysfunction requiring walking aids and bony metastasis. Prior to testing: Signs of infection, anaemia, neutropenia, or thrombocytopenia, disqualified or testing postponed | During allo-HSCT | Supervised, hospital-based: T: Multimodal program of aerobic (ergometer), resistance (machines and weights) and active exercises, progressive relaxation, and psychoeducation I: Aerobic: Low to moderate, 50–75% HR max. RPE: 10–13. Dynamic and stretching 1–2 sets, 10–12 reps. Static: 1 set, hold for 15–30 s. Resistance: Low to moderate, 1–2 sets of 10–12 reps. Progressive relaxation: low L: 60–70 min, 3–5x/week D: 4–6 weeks | Moderate | T: UC, Conventional treatment and care, standard care for PA, PT is individualized, not providing a stationary cycle unless requested L: PT < 1½ hour/week, after allogeneic HSCT (day +1) |
Jarden 2016 Denmark [63] Jarden 2021 Denmark [85] | Acute Leuk, AML de novo, AML following MDS, APL, ALL | RCT | 70 (34/36) (41.4) | Mean 53.1 (19.8–73.7) IG: 51.1 (19.8–70.0) CG: 55.0 (20.3–73.7) | Severe or unstable psychological, cardio-respiratory, neurological, or musculoskeletal disease, secondary active malignancy, abnormal EKG | During chemotherapy | Supervised, hospital-based: T: Multimodal intervention of aerobic (ergometer), strength (weights) and relaxation exercise, nutrition support, pedometer, and health counselling I: Aerobic: 75–80% of HRmax. Dynamic resistance: Moderate to hard, 2 sets, 12 reps L: 60 min, 3x/week D: 12 weeks | Extensive | T: UC |
Kim 2005 South Korea [64] | AML, ALL, SAA | RCT | 35 (18/17) (51.4) | Mean IG: 32.9 CG: 34.3 (20–48) | Medicated for anxiety or depression | After allo-HSCT | Supervised, hospital-based: T: Individual physical exercises combined with relaxation breathing I: NR L: 30 min/daily D: 6 weeks | Less | T: UC, Routine care |
Knols 2011 Switzerland [65] | AML, CLL, ALL, HL, NHL, MM, Osteo-myelofibrosis, Leuk, Amyloidosis, Testicular C. | RCT | 131 64/67 (41.2) | Mean 46.7 IG: 46.6 (18–75) CG: 46.6 (20–67) | GvHD except for grade I not requiring treatment, painful joints, unstable osteolysis, chronic pain, lesions of the central or peripheral nervous system, uncontrolled cardiovascular disease, thyroid disease, or diabetes | After allo-HSCT or ASCT | Supervised, physiotherapy practice or fitness centre: T: Individual, physical exercises with both endurance aerobic (ergometer or walking tread mill) and resistance strength (machines and dumbbells) exercises I: Individual HR (from 50–60%, increasing to 70–80% of estimated HR max) L: 30 min, 2x/week D: 12 weeks | Moderate | T: UC |
Kobayashi 2020 Japan [66] | AML, DLBCL, ALL | RCT Crossover | 33 (13/20) (18.2) | Mean Wii PT/Therapist PT: 44.9 Therapist PT/Wii PT: 44.6 | Grade 2 or worse CTC for Adverse Events version 4.0 | During chemotherapy | Supervised, hospital-based: T: Individual aerobic and resistance exercises using the Wii Fit balance board I: NR L: 30 min, 5x/week D: 1 week (and then crossover) | Less | T: Individual aerobic and resistance exercises. I: Aerobic: 40–60%. Resistance: Borg 11–13 L: 30 min, 5x/week D: 1 week and then crossover |
Koutoukidis 2020 UK [67] | MM, Myeloma IgG, Myeloma IgA, Myeloma Light chain, non-sec/oligo-sec. | RCT | 131 (89/42) (45) | Median IG: 64 (35–86) CG: 63 (40–80) | Spinal instability. Recent spinal or other surgery for pathological fractures within 4 weeks. Abnormal EKG with unexplained clinical indication after cardiological work-up. At risk of pathological fracture based on Mirel’s score. Currently enrolled in research exercise study. Unstable angina. Musculoskeletal mobility limitations. Cognitive impairment hindering completion of questionnaire | After auto-HSCT, radiotherapy or chemotherapy | Partly supervised Supervised, hospital-based: T: Individual aerobic (treadmill walking, ergometer, cross-trainer or stepping) and resistance (weightlifting, body weight or resistance bands) training, exercise diaries, goal setting with physiotherapist I: Aerobic: 50–75% of predicted HR max-Resistance: 10 RM L: 1x/week D: 6 months Unsupervised, home-based: T: Individual aerobic training and resistance training, exercise diaries, goal setting with PT I: Aerobic: 50–75% of predicted HR max. Resistance: 10 RM L: Max 30 min, 2–3x/week D: 6 months | Moderate | T: UC |
McCourt 2023 UK [68] | MM | RCT Pilot | 50 (23/27) (38) | Mean 60.4 (37–72) IG: 59.3 (37–72) CG: 61.3 (40–72) | Declined or not suitable for auto-HSCT or too close to transplantation, restricted mobility, non-English language | Before, during and after ASCT | Partly supervised Supervised, hospital-based: T: Aerobic (treadmill walking or ergometer) and resistance (machines and resistance bands) exercise and behaviour change support I: Aerobic: 60–80% of HRR. Resistance: 10 RM and individually tailored to progress and/or adapt to bone disease. L: 1x/week Unsupervised, home-based: T: Aerobic (walking) and resistance (resistance bands) exercise and behaviour change support, virtual I: Aerobic: 60–80% of HRR. Resistance: 10 RM and individually tailored to progress and/or adapt to bone disease L: Aerobic exercise (Phase 1 and 3): 15–40 min, 3x/week. Resistance exercise (Phase 1 and 3): 3x/week. During phase 2 (transplant admission) | Extensive | T: UC |
Mello 2003 Brazil [69] | CML, AML, SAA, NHL, MDS | RCT | 18 (9/9) (55.6) | Mean IG: 27.9 (18–39) CG: 30.2 (18–44) | NR | During and after allo-HSCT | Supervised, hospital-based: T: Individualized exercise program with active exercise, muscle stretching and treadmill walking I: Progressing, no higher than 70% of HR max L: 40 min, 5x/week D: 6 weeks | Moderate | NR |
Oechsle 2014 Germany [70] | AML, NHL, MM, Germ cell | RCT Pilot | 58 (29/29) (29.2) | Mean IG: 51.7 CG: 52.9 | Symptomatic cardiovascular diseases, tumor infiltration of the skeletal system with risk of pathologic fractures or compression of spinal cord, epilepsy, rheumatologic diseases, BMI < 18, BMI > 30, insufficient cognitive function, inadequate knowledge of German language for questionnaire analysis | During chemotherapy | Supervised, hospital-based: T: Aerobic (ergometer) and strength (body weights and resistance bands) training I: Ergometer individually adjusted Strength training: Up to 20 min at 40–60% of estimated 1 RM, sets of 16–25 repetitions L: 30–40 min, 5x/week D: Median: 21 days | Moderate | T: UC, Standard PT |
Pahl 2018 Germany [71] | Leuk, AML, ALL, APL, NHL, HL, T-cell lymph, WM, MM, PMF | RCT Pilot | 17 (10/7) (30) | Median 55 (47–63) IG: 47 (19–62) CG: 56 (32–63) | Unstable bone metastasis, knee or hip endoprosthesis, epilepsy, pacemaker, severe cardiovascular disease and threshold blood-count values below safety criteria, stents, or former joint injuries | During chemotherapy | Supervised, hospital-based: T: Whole body vibration (Galileo Sport vibration platform), including three sets of two to four different exercises (body weight) I: Borg scale 14–16 L: 20 min, 3x/week D: Median: 27 days | Moderate | T: Aerobic exercise; ergometer I: Borg scale 14–16 L: 20 min. |
Pahl 2020 Germany [72] | AML, ALL, CLL, CMML, MDS, Lymph, MM, MF, Septic granulomatosis Immuno-deficiency, SAA | RCT | 44 (18/26) (31.8) | Median IG: 55 (50–63) CG: 56 (32–63) | Unstable bone metastasis, endoprosthesis of knee or hip, epilepsy, pacemaker, and severe cardiovascular disease | During allo-HSCT | Supervised, hospital-based: T: Whole body vibration (Galileo Sport vibration platform) I: NR L: 20 min, 5x/week D: 35–44 days | Moderate | T: Mobilization and stretching L: 5x/week |
Persoon 2017 Netherlands [73] | MM, (N)HL, Lymph | RCT | 109 (54/55) (36.7) | Median 55 (19–67) IG: 53.5 (20–67) CG: 56 (19–67) | NR | After ASCT | Supervised, at local physiotherapy practices: T: Aerobic interval (cycling) and resistance (machines) training, counselling sessions (5x) I: Resistance: High intensity. Week 1–12 2 × 10 rep at 65–80% of 1 RM, week 12–18 2 × 20 rep at 35–40% of 1 RM L: 60 min, 1–2x/week D: 18 weeks | Extensive | T: UC, Not encouraged to exercise, participate in sports, PT, or rehabilitation programs |
Potiaumpai 2021 USA [74] | AML, ALL, CML, MDS, MM, other Lymph | RCT | 35 (19/16) (45.7) | Mean 58.8 IG: 59.3 CG: 58.2 | Dementia, altered mental status, severe psychiatric conditions, pre-existing comorbid conditions that would contraindicate exercise testing, concurrent non-transplant-related chemotherapy, or radiation | Before and after allo-HSCT or ASCT | Supervised, hospital-based: T: Multidirectional drills and walking program I: Exertion level of moderate intensity during the multidirectional drills and a high intensity during the walking portion L: 5–30 min, 3x/weeks D: Varied | Moderate | T: UC |
Safran 2022 Turkey [75] | AML, B-cell ALL, T-cell ALL, MDS, NHL, MF | RCT | 43 (21/22) (51.6) | Mean IG: 38 (23–63) CG: 40.5 (24–58) | <18 years, ECOG > 3, comorbidities causing fatigue (e.g., multiple sclerosis, Parkinson’s disease, heart failure), rapid deterioration of general condition (sudden uncontrolled weight loss, confused consciousness, high CRP values), brain metastases or metastases to the femur, DVT within last 6 months, neuropathy, and rejecting NMES intervention or exercise therapy | During chemotherapy, after allo-HSCT | Supervised, hospital-based: T: Resistance exercise (body weights and resistance bands) combined with neuromuscular electrical stimulation I: Borg scale: Initial recommended RPE is 12–13 and is increased to about 15–16. The intensity was adjusted to a target score of 12–14 (moderate level) using the RPE scale. Intensity (~RPE 15–16) and resistance were gradually increased L: 60–90 min, 2–3x/week D: 4 weeks | Moderate | T: Resistance exercise L: 40–60 min, 2–3 days/week |
Schumacher 2018 Germany [76] | MM, AML/MDS, NHL Teratoma, CML, CLL | RCT feasibility | 42 (19/23) (40.5) | Median IG: 56.0 (21–65) CG: 56.5 (21–65) | Lack of compliance. Intercurrent diseases, like pulmonary and cardiac insufficiency or uncontrolled infections | During and after allo-HSCT or ASCT | Supervised, hospital-based: T: Exergaming on Nintendo Wii for exercising ping pong, tennis, boxing, frisbee, or aerobics and balance I: NR L: 30 min, 5x/week D: During and 30 days post HSCT | Moderate | T: PT program, eccentric and concentric movements, from supine to standing, walking, stepping or treadmill walking, stretching, strength exercise i.e., elastic bands and body weight |
Shelton 2009 USA [77] | Lymph, Leuk | RCT | 53 (26/27) (37.7) | Mean IG: 43.7 (22–68) CG: 48.9 (29–70) | <18 years, psychiatric disorder, significant cardiovascular disease, paraplegic or hemiplegic, unable to speak or understand English | After allo-HSCT | Supervised, hospital-based: T: Aerobic (treadmill and ergometer) and resistance (weights and machines) exercises I: Aerobic: 60–75% of age-predicted HR max. Strength: 1–3 sets of 10 reps L: 20–30 min aerobic, resistance individual, 3x/week D: 4 weeks | Moderate | T: multidisciplinary, inpatient, educational session incl. focus on staying active, information to exercise safely |
Streckmann 2014 Germany [78] | HL, B-NHL, T-NHL, MM | RCT | 56 (28/28) (25) | Mean IG: 44 (20–67) CG: 48 (19–73) | Unstable osteolysis, severe acute infections, severe cardiac and pulmonary impairments, restrictions for PA | During chemotherapy | Supervised, hospital-based: T: Aerobic (treadmill and ergometer), sensorimotor and strength (resistance bands) training I: Initial 60–70% HR max. At the end of session 70–80%. Sensorimotor training: Progressively increasing task difficulty. Strength training: 1 min at max force L: 60 min, 2x/week D: 36 weeks | Extensive | T: UC, Standard clinical care, incl. PT |
Vallerand 2018 Canada [79] | Leuk., HL, NHL | RCT | 51 (26/25) (60.8) | Mean 52.6 <60: n = 33 >60: n = 18 | Chronic medical condition precluding from aerobic exercise, plan of being away from home > 2 weeks, baseline exercise levels of ≥240 min. weekly | During or after chemotherapy, radiation, HSCT | Unsupervised, home-based: T: Tele counselling with PA guidance with a goal of increasing aerobic exercise (walking, group fitness) levels by at least 60 min/week up to 300 min/week of moderate-vigorous aerobic exercise I: Aerobic exercise: Moderate-vigorous L: Tele-health calls: Mean: 17 min, 1x/week. Aerobic: 60–300 min/week. D: 12 weeks | Moderate | T: UC, PT guidelines, goal setting of increasing aerobic exercise levels I: Aerobic exercise: moderate-vigorous L: 60–300 min/week |
Waked 2019 Egypt [80] | ALL | RCT | 54 (27/27) (34) | Mean IG: 33.4 CG: 32.4 | Antecedent neurological, developmental, or genetic disorder. Relapsed or secondary ALL. Received testicular, mediastinal, or craniospinal irradiation. Growth hormone insufficiency, hormone therapy. Medications that interfere with lipid metabolism. Diseases affecting cholesterol metabolism such as diabetes mellitus, thyroid dysfunction, or nephrotic syndrome | After treatment | Supervised, hospital-based: T: Aerobic training (ergometer) I: 60% of predictive age HR max L: 30–40 min, 3x/week D: 12 weeks | Moderate | T: UC, Normal daily activities |
Wehrle 2019 Germany [81] | AML, ALL | RCT Pilot 3-arm | 29 (9/10/10) (41) | Median EG: 47.7 (21.9–63.4) RG: 47.4 (41.2–62.2) CG: 50.6 (35.0–58.1) | Karnofsky score < 60, uncontrolled hypertension, cardiac illness (NYHA III-IV), instable bone metastases, lack of informed consent after screening | During chemotherapy | Supervised, hospital-based: T: Either aerobic (ergometer or treadmill) or resistance (body weight) training I: Endurance: 60–70% of HRmax, RPE of 12–14 Resistance: RPE 12–14 L: 30–45 min, 3x/week D: 5 weeks (median) | Moderate | T: Mobilization and stretching program, I: low intensity |
Wiskemann 2011 Germany [82] Wiskemann 2014 Germany [86] | AML, ALL, CML, CLL, MDS, Sec. AML, MPS, MM, other Lymph, AA | RCT | 105 (52/53) (32.4) | Mean 48.8 (18–71) IG: 47.6 (18–70) CG: 50 (20–71) | NR | Before, during and after allo-HSCT | Partly supervised, hospital-based and home-based: T: Aerobic (ergometer/treadmill or walking) and resistance (resistance bands) exercises I: Tailored intensity. Endurance: Borg scale: 12–14. Resistance: Borg scale: 14–16 w/8–20 rep × 2–3 sets L: 20–40 min, 2–5x/week. Endurance: 3–5x/week. Resistance: 2x/week | Moderate | T/I: Recommend moderate PA, received step counters L: Same frequency of social contact as in IG. PT up to 3x/week |
Wood 2020 USA [83] | AML, MDS, ALL, CML, HL, MM, MF, AA, MCL, HLH | RCT Pilot | 34 (17/17) (43) | Median 52 (28–73) | Transplant ineligibility, uncertain transplant candidacy, comorbid illness that would preclude maximal effort during exercise testing or participation in regular exercise determined by the treating physician or study exercise physiologist | Before allo-HSCT | Unsupervised, home-based: T: Aerobic exercise (walking, jogging, running, cycling, cross trainer or stair climbing) I: 80% HR max. From week 2 Interval, 2 min 80%, 3 min low recovery L: 30 min, 3–4x/week D: Mean: 11 weeks | Moderate | T: Fitbit Surge, no further instructions and information |
Yeh 2016 Taiwan [84] | NHL | RCT | 108 (54/54) (44.1) | Mean 59.8 (23–90) | Major medical disease, as uncontrolled arrhythmia, hypertension, unstable angina, severe respiratory disease, acute infection, multiple myeloma, bone metastasis, psychiatric disorders. Medical contraindications for exercise, e.g., orthopaedic problems and neurologic or musculoskeletal disturbances, or already practicing qigong or other exercise training programs | During chemotherapy | Unsupervised, home-based: T: Chan-Chuang qigong exercise, guidance booklet and weekly phone call I: NR L: 20–60 min, 2–3x/day (max. 5 times). D: 3 weeks | Less | T: UC |
Outcomes | SMD (95% CI) | Participants Completed Outcome Measures, n Studies, (n) | Quality of Evidence GRADE | Comments |
---|---|---|---|---|
Physical function * 12MWT; 2MSC; 2MWT; 6MWT; Accelerometer; KPS; SWT; TUG | 0.29 (0.12–0.45) | 1219 (25) | ⨁◯◯◯ Very low | Downgraded, due to RoB (majority of trials), Inconsistency (moderate heterogeneity: 48.17%), and risk of Publication bias (Egger’s test p = 0.0516) |
Aerobic capacity Aerobic Power Index; Modified Balke; Modified endurance test; Power Max, Timed Stair Climb; VO2 Max; VO2 Max Relative; VO2 Peak; VO2 Peak modified | 0.53 (0.27–0.79) | 853 (17) | ⨁⨁◯◯ Low | Downgraded, due to Inconsistency (substantial heterogeneity: 69.21%) and risk of Publication bias (Egger’s test p = 0.0443) |
Muscle strength GRIP; Max test; Isometric Knee Extension test; STS | 0.47 (0.17–0.78) | 1091 (25) | ⨁⨁⨁◯ Moderate | Downgraded, due to Inconsistency (substantial/considerable heterogeneity: 82.59%) |
Body composition BMI; BodPod; DEXA; SECA bioimpedance, Tanita Bioelectrical impedance | 0.20 (0.03–0.37) | 654 (12) | ⨁⨁⨁⨁ High | No change |
Physical activity GLTEQ; IPAQ; PASE | 0.32 (−0.00–0.65) | 358 (5) | ⨁◯◯◯ Very low | Downgraded, due to RoB (majority of trials), Inconsistency (moderate heterogeneity: 56.97%), Imprecision (95% CI does not exclude 0), and risk of Publication bias (Egger’s test p = 0.0132) |
QoL Global * CMSAS; EORTC QLQ-C30; FACT; FACT-An; FACT-BMT; FACT-Leu; GLQOL; POMS; PROMIS | 0.34 (0.04–0.64) | 1447 (29) | ⨁⨁◯◯ Low | Downgraded, due to RoB (majority of trials) and Inconsistency (substantial/considerable heterogeneity: 87.39%) |
QoL Emotional CMSAS; EORTC QLQ-C30; FACT-General, FACT-Leu; Happiness Scale; NCCN Distress Thermometer; POMS; PROMIS; SF-12; SF-36 | 0.33 (0.05–0.60) | 1764 (28) | ⨁⨁◯◯ Low | Downgraded, due to Inconsistency (substantial/considerable heterogeneity: 86.93%) |
QoL Functional EORTC QLQ-C30; FACT; FACT-An; FACT-BMT; FACT-Leu; FACT-TOI | 0.33 (0.09–0.57) | 455 (10) | ⨁⨁◯◯ Low | Downgraded, due to RoB (majority of trials), and Inconsistency (moderate heterogeneity: 37.54%) |
QoL Physical CMSAS; EORTC QLQ-C30; FACT-An; FACT-BMT; FACT-Leu; FACT-TOI; PROMIS; SF-12; SF-36 | 0.32 (0.03–0.60) | 1731 (28) | ⨁⨁◯◯ Low | Downgraded, due to RoB (majority of trials) and Inconsistency (substantial/considerable heterogeneity: 87.72%) |
Anxiety HADS; POMS; PROMIS; STAI | 0.21 (0.13–0.55) | 917 (17) | ⨁◯◯◯ Very low | Downgraded, due to RoB (majority of trials), Inconsistency (Substantial/considerable heterogeneity: 84.23%) and Imprecision (95% CI does not exclude 0) |
Depression CES-D; HADS; POMS; PROMIS | 0.37 (0.09–0.64) | 919 (17) | ⨁◯◯◯ Very low | Downgraded, due to RoB (majority of trials), Inconsistency (substantial/considerable heterogeneity: 76.33%), and risk of Publication bias (Egger’s test p = 0.0184) |
Fatigue BFI; EORTC QLQ-C30; FACT-An; FACIT-F; FACT-F; MFI; MPN-SAF; 11-point rating scale; POMS; PROMIS; SCFS | 0.44 (0.16–0.71) | 1860 (31) | ⨁⨁◯◯ Low | Downgraded, due to RoB (majority of trials) and Inconsistency (substantial/considerable heterogeneity: 87.89%) |
Pain EORTC QLQ-C30; PROMIS; SF-36 | 0.43 (0.13–0.73) | 811 (14) | ⨁⨁◯◯ Low | Downgraded, due to RoB (majority of trials) and Inconsistency (substantial/considerable heterogeneity: 77.82%) |
Recruitment IG and CG | Retention IG and CG | Participation | Adverse Events | |||
---|---|---|---|---|---|---|
IG | IG | |||||
Author Year/Country | Sample Size Estimated, n | Eligibility Assessed, n | Included, n | Completed Post-Test, n | Adherence to Exercise (%) | AE Type, n |
Accogli [36] 2022, Italy | 40 | 193 | 46 | 42 | 90 | No AE |
Alibhai [37] 2014, Canada | 40 | 232 | 38 | 36 | 28 | NR |
Alibhai [38] 2015, Canada | 72 | 264 | 81 | 70 | 54 | AE: 4 grade II musculoskeletal events |
Baumann [39] 2010, Germany | 60 | NR | 64 | 49 | NR | NR |
Baumann [40] 2011, Germany | 45 | NR | 47 | 33 | NR | No AE |
Bayram [41] 2024, Turkey | 28 | 39 | 30 | 26 | 20 (IMT) | No AE |
Bird [42] 2010, UK | 132 | 158 | 58 | 46 | NR | No AE |
Bryant [43] 2018, USA | 30 | 82 | 18 | 17 | 80 | No AE |
Chang [44] 2008, Taiwan | NR | 28 | 24 | 22 | NR | No AE |
Chen [45] 2021, China | 30 | 46 | 30 | 29 | 98 | NR |
Chow [46] 2020, USA | 41 | 420 | 41 | 37 | 75 | NR |
Chuang [47] 2017, Taiwan | 100 | 105 | 100 | 96 | 96 | No AE |
Cohen [48] 2004, USA | 38 | NR | 39 | 30 | 32 | NR |
Coleman [49] 2003, USA | NR | NR | 24 | 13 | NR | No AE |
Coleman [50] 2012, USA | 200 | NR | 187 | 166 | NR | NR |
Courneya [51] 2009, Canada | 120 | 1306 | 122 | 117 | 92 | No SAE. AE: 3 back, hip, and knee pain |
Defor [52] 2007, USA | NR | 122 | 100 | 85 | 24 | NR |
Eckert [53] 2022, USA | NR | 326 | 72 | 43 | NR | No AE |
Furzer [54] 2016, Australia | NR | 89 | 44 | 37 | 91 | No SAE. AE: 2 minor exercise modifications due to pre-existing knee and back injuries |
Gallardo-Rodriquez [55] 2023, Mexico | 114 | 50 | 33 | 18 | NR | No (significant) AE |
Hacker [56] 2017, USA | NR | 118 | 67 | 67 | 83 | NR |
Hacker [57] 2022, USA | NR | 45 | 32 | 30 | NR | NR |
Hathiramani [58] 2020, UK | 46 | 62 | 46 | 38 | NR | No AE |
Huberty [59] 2019, USA | NR | 260 | 62 | 48 | 15 | No AE |
Hung [60] 2014, Australia | NR | 55 | 37 | 33 | NR | No AE |
Jacobsen [61] 2014, USA | 700 | NR | 711 | 560 | NR | No AE |
Jarden [62] 2009, Denmark | 40 | 82 | 42 | 34 | NR | No AE |
Jarden [63] 2016, Denmark Jarden [85] 2021, Denmark | 70 | 170 | 70 | 62 | 71 | No SAE. AE: 8: sport-related (n = 5), cardioresp (n = 5), dizziness (n = 3), gastrointestinal (n = 3), pain/discomfort (n = 2) and bruising (n = 1) |
Kim [64] 2005, S. Korea | 42 | NR | 42 | 35 | NR | NR |
Knols [65] 2011, Switzerland | 128 | 310 | 131 | 114 | 85 | No AE |
Kobayashi [66] 2020, Japan | 32 | 33 | 33 | 22 | 67 | No AE |
Koutoukidis [67] 2020, UK | 140 | 313 | 131 | 99 | 75 | No AE |
McCourt [68] 2023, UK | NR | 123 | 50 | 33 | NR | No SAE. AE: 1 mild episode of dizziness |
Mello [69] 2003, Brazil | NR | 32 | 18 | 18 | NR | NR |
Oechsle [70] 2014, Germany | 48 | NR | 58 | 48 | NR | No AE |
Pahl [71] 2018, Germany | NR | 121 | 20 | 11 | 62 | No AE |
Pahl [72] 2020, Germany | NR | 112 | 71 | 44 | 59 | No SAE. AE: 2 sessions stopped prematurely due to knee pain and discomfort |
Persoon [73] 2017, The Netherlands | 120 | 469 | 109 | 97 | 86 | AE: 1 strained calf muscle |
Potiaumpai [74] 2021, USA | NR | 57 | 36 | 32 | 79 | NR |
Safran [75] 2022, Turkey | 32 | 77 | 43 | 31 | NR | No AE |
Schumacher [76] 2018, Germany | NR | 49 | 42 | 31 | NR | No AE |
Shelton [77] 2009, USA | 164 | 250 | 61 | 53 | 75 | NR |
Streckmann [78] 2014, Germany | 184 | 186 | 61 | 51 | 65 | No AE |
Vallerand [79] 2018, Canada | 50 | 407 | 51 | 51 | 93 | No AE |
Waked [80] 2019, Egypt | 54 | 60 | 54 | 50 | NR | NR |
Wehrle [81] 2019, Germany | 36 | 39 | 29 | 22 | 68 | No AE |
Wiskemann [82] 2011, Germany Wiskemann [86] 2014, Germany | NR | 141 | 105 | 80 | 87 | NR |
Wood [83] 2020, USA | 60 | 113 | 34 | 16 | NR | NR |
Yeh [84] 2016, Taiwan | 64 | 118 | 108 | 102 | 100 | No AE |
Total | NR (n = 16) | 7262 NR (n = 8) | 3552 | 2924 (82.3%) | Mean: 70% (15–100) NR (n = 21) | No AE (n = 26) AE (n = 7) SAE (n = 1) NR (n = 15) |
Trial Identifier Design | Investigator Country | Title | Diagnosis | Sample Size, n | Age | Intervention Type and Duration | Treatment Trajectory | Primary Outcome | Study Status |
---|---|---|---|---|---|---|---|---|---|
NCT05642884 RCT | Smith Giri USA | Prehabilitation Feasibility Among Older Adults Undergoing Transplantation | MM | 30 | >60 years | Home-based prehabilitation multimodal exercise program delivered using a telehealth format 8 weeks | Before ASCT | Feasibility | Recruiting 2023-07-10 Estimated completion 2025-12-31 |
NCT04898790 RCT | Thuy Koll USA | Improving Cognitive Function in Older Adults Undergoing Stem Cell Transplant (PROACTIVE) | Leukemia Lymphoma MM MDS MPN | 88 | >60 years | Partially supervised PA in the Community Health Activities Model Program for Seniors 12 weeks | Undergoing HSCT | Change in executive function and working memory | Recruiting 2021-11-18 Estimated completion 2025-04 |
NCT04670029 RCT | Magali Bavaloine France | Impact of an APA Program on EFS in Patients with Diffuse Large-cell B Lymphoma Treated in 1st Line (PHARAOM) | Diffuse Large B Cell Lymphoma | 186 | >65 years | Partially supervised adapted physical activity with aerobic and anaerobic sessions on site and at home | During treatment | To detect an absolute difference of 15% in event-free survival between groups | Recruiting 2021-09-08 Estimated completion 2029-02 |
NCT04057443 RCT | Maite Antonio Spain | Nutritional and Physical Exercise Intervention in Older Patients with Malignant Hemopathies | MDS LPS MM | 80 | >70 years | Nutritional support according to nutritional body composition parameters (Nutritional assessment and sarcopenia evaluation). Diet counselling, oral supplemented nutrition, enteral or parenteral nutrition. Exercise program with a mixed structure, designed individually with group sessions. 24 weeks, 3 days a week | During treatment | Adherence to oncological treatment from baseline to post treatment or 6 months. Difference between dose administered and prescribed. | Unknown status Start 2019-04-11 Estimated completion 2023-06-01 |
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Jarden, M.; Tscherning Lindholm, S.; Kaldan, G.; Grønset, C.; Faebo Larsen, R.; Larsen, A.T.S.; Schaufuss Engedal, M.; Kramer Mikkelsen, M.; Nielsen, D.; Vinther, A.; et al. Limited Evidence for the Benefits of Exercise in Older Adults with Hematological Malignancies: A Systematic Review and Meta-Analysis. Cancers 2024, 16, 2962. https://doi.org/10.3390/cancers16172962
Jarden M, Tscherning Lindholm S, Kaldan G, Grønset C, Faebo Larsen R, Larsen ATS, Schaufuss Engedal M, Kramer Mikkelsen M, Nielsen D, Vinther A, et al. Limited Evidence for the Benefits of Exercise in Older Adults with Hematological Malignancies: A Systematic Review and Meta-Analysis. Cancers. 2024; 16(17):2962. https://doi.org/10.3390/cancers16172962
Chicago/Turabian StyleJarden, Mary, Sofie Tscherning Lindholm, Gudrun Kaldan, Charlotte Grønset, Rikke Faebo Larsen, Anders Thyge Steen Larsen, Mette Schaufuss Engedal, Marta Kramer Mikkelsen, Dorte Nielsen, Anders Vinther, and et al. 2024. "Limited Evidence for the Benefits of Exercise in Older Adults with Hematological Malignancies: A Systematic Review and Meta-Analysis" Cancers 16, no. 17: 2962. https://doi.org/10.3390/cancers16172962