PSYCHO-ONCOLOGY

Psycho-Oncology 9: 127–136 (2000)

PHYSICAL EXERCISE AND QUALITY OF LIFE

IN CANCER PATIENTS FOLLOWING HIGH
DOSE CHEMOTHERAPY AND AUTOLOGOUS
BONE MARROW TRANSPLANTATION
KERRY S. COURNEYAa,*, MELANIE R. KEATSa and A. ROBERT TURNERb,1
a
Faculty of Physical Education, Van Vliet Center, Uni6ersity of Alberta, Edmonton, AB, Canada
b
Department of Medicine, Uni6ersity of Alberta, Cross Cancer Institute, 11560 Uni6ersity A6enue, Edmonton,
AB, Canada

SUMMARY
Preliminary evidence indicates that physical exercise may be an effective strategy for the rehabilitation of cancer
patients following high dose chemotherapy (HDC) and bone marrow transplantation (BMT), but the focus of this
research has been on physical fitness and medical outcomes. In the present study, we employed a prospective
design to examine the relationship between physical exercise and various quality of life (QOL) indices in 25 BMT
patients. Participants completed weekly self-administered questionnaires upon being admitted to hospital, and
monitored the frequency and duration of their exercise during hospitalization. Statistical analyses indicated that
exercise during hospitalization was significantly correlated with almost all QOL indices, including physical
well-being, psychological well-being, depression, anxiety and days hospitalized. Moreover, only some of the
correlations were attenuated after controlling for relevant demographic and medical variables. It was concluded
that physical exercise may be related to QOL in BMT patients, but that experimental research is needed before any
definitive conclusions can be drawn. Copyright © 2000 John Wiley & Sons, Ltd.

High dose chemotherapy (HDC) is an intensive
cancer therapy that has been commonly used over
the past two decades to treat patients with re-
lapsed Hodgkin’s and non-Hodgkin’s lymphoma,
acute and chronic leukemia, multiple myeloma,
some breast cancers, ovarian cancer, and testicu-
lar cancer. The life threatening myelosuppression
produced by HDC requires that bone marrow
function be protected with the use of bone mar-
row transplantation (BMT). Autologous BMT
(i.e. patients are reinfused with their own stem
cells) is the most common type and can take
various forms, depending upon the source of he-
matopoietic stem cells (i.e. bone marrow or pe-
ripheral blood), the conditioning therapy that
precedes the transplant, and the use of hemato-
poietic growth factors that can shorten the cyto-
penic period following the transplant.
* Correspondence to: Faculty of Physical Education, Univer-
sity of Alberta, E-401 Van Vliet Center, Edmonton, AB,
Canada T6G 2H9. Tel: +1 780 492 1031; fax: + 1 780 492
2364; e-mail: kerry.courneya@ualberta.ca
1
Tel: + 1 780 432 8514; fax: +1 780 432 8888; e-mail:
roberttu@cancerboard.ab.ca
Not surprisingly, BMT has numerous acute and
chronic side effects that impinge on quality of life
(QOL), including cytopenias, asthenia, reduced
functional capacity, fatigue, difficulty sleeping,
and psychological distress (see Neitzert et al.,
1998). The potential role of exercise in the rehabil-
itation of cancer patients following BMT has
received empirical attention, but the primary fo-
cus has been on physical fitness and medical
outcomes. Specifically, exercise in BMT patients
has been shown to have beneficial effects on
creatine excretion (Cunningham et al., 1986),
hemoglobin concentration (Dimeo et al., 1997b),
functional capacity (Dimeo et al., 1996, 1997a,b),
duration of neutropenia and thrombocytopenia
(Dimeo et al., 1997a), severity of diarrhea and
pain (Dimeo et al., 1997a), and duration of hospi-
talization (Dimeo et al., 1997a).
The effects of exercise on psychosocial and
QOL issues in BMT patients, however, has not
been examined. Research on cancer patients re-
ceiving conventional levels of cancer therapies has
shown that exercise has beneficial effects on a
variety of psychosocial and QOL outcomes that

Copyright © 2000 John Wiley & Sons, Ltd. Recei6ed 30 June 1999
Accepted 10 No6ember 1999
128 K.S. COURNEYA ET AL.
are compromised in BMT patients, including fa-
tigue, anxiety, depression, perceived physical com-
petence, general QOL and satisfaction with life
(SWL) (Courneya and Friedenreich, 1999). More-
over, Dimeo et al. (1997b), in their study of
exercise and fitness in BMT patients stated ‘The
authors repeatedly observed that patients gained
self-confidence and improved their often de-
pressed mood. . . although this clinical observa-
tion was not objectively assessed with
questionnaires. . . ’ (p. 1721).
The purpose of the present study was to extend
the research of Dimeo et al. by examining the
potential role of exercise in influencing psycho-
social and QOL issues in BMT patients. The
specific objectives were to determine (a) the
amount of exercise performed by BMT patients
when a structured intervention is not delivered,
(b) the relative presence and importance of vari-
ous QOL dimensions in BMT patients, and (c) the
relationship between exercise during hospitaliza-
tion and QOL in BMT patients. Consistent with
previous research on exercise and QOL in cancer
patients receiving conventional levels of cancer
therapies (Courneya and Friedenreich, 1999), we
hypothesized that (a) the amount of exercise per-
formed by BMT patients during hospitalization
would be minimal and represent a significant de-
cline from pre-BMT levels, (b) functional well-be-
ing would be the least possessed but most
important dimension underlying overall QOL for
BMT patients, and (c) exercise during hospitaliza-
tion would be associated with various QOL in-
dices in BMT patients, including physical
well-being, functional well-being, anxiety, depres-
sion, and additional disease-specific concerns
(Courneya and Friedenreich, 1997a,b, 1999;
Courneya et al., 1999).
METHODS
Participants
Participants in the study were 25 cancer pa-
tients who received HDC followed by autologous
BMT at the Cross Cancer Institute (CCI) in Ed-
monton, AB, Canada, between 1 February 1998
and 12 April 1999. All participants received physi-
cian approval and were able to complete question-
naires in English. Over the 14 month recruitment
period, 48 patients were eligible for the study and
Copyright © 2000 John Wiley & Sons, Ltd.
39 (81.3%) were initially recruited. The reasons
for non-recruitment were (a) failure to complete
the baseline questionnaire (n= 4), (b) too sick
(n = 1), (c) not interested (n= 1), (d) unwilling to
commit time (n = 1), and (d) refused with no
reason (n= 2). Of the 39 participants who com-
pleted the baseline questionnaire, 25 (64.1%) com-
pleted at least one follow-up QOL assessment. Of
the 14 participants who did not complete a QOL
questionnaire, four withdrew from the study (one
felt too rough, two did not want to complete a
second questionnaire and one was discharged
early because of insufficient stem cell numbers);
the other 10 were discharged before completing
the first QOL assessment (which was scheduled
for 1 week after completion of the baseline
questionnaire).
Design and procedures
The following is a brief description of the BMT
protocol for patients at the CCI with multiple
myeloma, breast cancer, non-Hodgkin’s lym-
phoma and Hodgkin’s lymphoma. Prior to admis-
sion, peripheral blood stem cells are collected
using a large central venous access device and are
cryopreserved. All patients are free of active infec-
tions with hepatitis B, hepatitis C and HIV.
Shortly after admission, a HDC-specific to the
neoplasm under treatment is started, during which
time the patient receives large doses of antinausea
medicines, sedatives, diuretics, and intravenous
fluids. Transplantation of the previously cryopre-
served stem cells is performed at least 24 h follow-
ing the last administration of chemotherapy.
Again, large doses of antinausea medication are
administered, as well as analgesics. Patients are
then monitored closely as inpatients while they
develop pancytopenia from the chemotherapy. At
this time, they are at risk for the development of
oral mucositis, pharyngitis and other gastrointes-
tinal complications. Intravenous nutrition is
sometimes required. Patients may develop signs
and symptoms of sepsis coincident with a low
white blood cell count and require intravenous
antibiotic treatment. All patients in this study
received Neupogen (G-CSF) to shorten the
leukopenic period. Some patients required trans-
fusions of platelets and red cells.
Patients with multiple myeloma received high
dose melphalan as a conditioning agent. Patients
with Hodgkin’s lymphoma received a combina-
tion of cyclophosphamide, etoposide, cisplatin
Psycho-Oncology 9: 127–136 (2000)
 EXERCISE, BMT, AND QOL 129

and lomustine. Patients with non-Hodgkin’s discharge. The baseline questionnaire included as-
lymphoma received a combination of lomustine, sessments of demographic characteristics, past ex-
etoposide, cytosine arabinoside and melphalan. ercise (prediagnosis and postdiagnosis), and social
Patients with breast cancer received cyclophos- cognitive determinants of exercise (see Courneya
phamide, vinblastine and mitoxantrone. The et al., submitted for the results of the social
HDC regimens for Hodgkin’s lymphoma, non- cognitive determinants data). The QOL question-
Hodgkin’s lymphoma, and breast cancer were naire included various indices of physical, func-
given over 5–6 days. All patients were treated in tional, social, psychological and emotional
a single room with positive pressured HEPA fil- well-being. The Week 1 QOL questionnaire was
tered air, avoidance of uncooked food and fresh completed by all 25 participants, and the Week 2
flowers, and strict hand washing protocols. QOL questionnaire was completed by 14 partici-
The current exercise protocol in the transplant pants. For statistical analyses, we used the final
unit at the CCI is for physicians and nurses to QOL assessment before discharge as our end-
encourage patients to exercise as soon and as point1. Consequently, for 14 participants, that
much as possible following their transplants. No was the Week 2 QOL assessment, whereas for 11
structured exercise program exists, however, and participants, it was the Week 1 assessment. On
no effort beyond encouragement is made to moti- average, the final QOL assessment was completed
vate patients to exercise. To this end, the trans- within 3.92 (S.D.=3.55; Range= 0–15) days of
plant unit houses two older model cycle discharge. Table 1 summarizes the timing of the
ergometers, that are made available to patients, major medical and study-related events from hos-
and can be placed in their room if desired. Pa- pital admittance (day 0) to discharge.
tients can also walk around the transplant unit for
exercise if they so chose. For the purposes of this
study, an additional cycle ergometer was pur- Measures
chased that provided a more comfortable seating
position, with back support and computerized Background Information consisted of demo-
information. This purchase was made, in part, to graphic and medical characteristics. The demo-
provide an accurate objective assessment of exer- graphic characteristics were self-reported and
cise duration, rather than relying on subjective consisted of age, sex, marital status, education,
assessments. All participants who chose to cycle income, employment, and height and weight.
for exercise in this study used the computerized Body mass index (BMI) was calculated as weight
in kg divided by height in m2. Medical informa-
ergometer.
tion was obtained from a review of the medical
Upon being admitted to the hospital, potential
charts, and consisted of the type of cancer, the
participants received a single page ‘Notice of Re-
dates of medical events (i.e. admittance,
search Study’ in their information package which
chemotherapy start, chemotherapy end, trans-
provided general information about the study. If
plant and discharge), and the absence (coded as
physician approval was granted, patients were
‘0’) or presence (coded as ‘1’) of major adverse
approached by a research assistant and invited to
participate in the study. Those who agreed to
Table 1. Timing of medical events and questionnaire assess-
participate completed an informed consent at that ments (n =25)
time, received a baseline questionnaire, and were
shown how to operate the cycle ergometer’s com- Mean S.D. Range
puter system, and what to record on their exercise
log. Admitted to hospital 0.00 0.00 0–0
The design of the study was prospective and HDC begins 0.83 0.76 0–3
observational. That is, patients were followed Baseline questionnaire 3.83 4.60 0–17
over the length of their hospital stay but no HDC ends 3.88 2.15 0–7
Stem cell transplant 5.96 2.49 2–10
intervention was attempted (beyond the encour-
Week 1 questionnaire 11.79 4.93 7–24
agement mentioned earlier). Participants were Week 2 questionnaire (n =14) 17.7 95.35 14–31
asked to record the mode (cycling or walking), Hospital discharge 19.83 5.07 14–32
frequency, and duration of any exercise they
chose to do. The QOL assessments were made on All statistics are calculated as the number of days following
a weekly basis after the baseline assessment until hospital admittance.

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 127–136 (2000)
130 K.S. COURNEYA ET AL.
medical events during hospitalization, including
anemia, fever, nausea, mucositis, neutropenia and
thrombocytopenia. The absence or presence of the
hematologic conditions was based on blood
counts. Days hospitalized was calculated as the
date of hospital discharge, minus the date of the
stem cell transplant.
Past Exercise was assessed by the leisure score
index (LSI) of the Godin Leisure-Time Exercise
Questionnaire (GLTEQ; Godin and Shepard,
1985; Godin et al., 1986). The LSI contains three
questions that assessed the frequency of mild,
moderate and strenuous exercise performed for at
least 15 min duration, during free time in a typical
week. An independent evaluation of this measure
found it to be easily administered, brief, reliable,
and in possession of concurrent validity, based on
various criteria, including objective activity moni-
tors and fitness indices (Jacobs et al., 1993). The
LSI demonstrated a 1 month test – retest reliability
of 0.62, and concurrent validity coefficients of
0.32 with an objective activity indicator (CAL-
TRAC accelerometer), of 0.56 with VO2max (as
measured by expired gases), and − 0.43 with %
body fat (as measured by hydrostatic weighing).
These levels of reliability and validity compared
favorably with nine other self-report measures of
exercise that were examined (Jacobs et al., 1993).
The GLTEQ has previously been used success-
fully with adult cancer patients and survivors
(Courneya and Friedenreich, 1997a,b; Courneya
et al., 1999). In the present study, participants
were asked to recall their exercise levels prediag-
nosis (i.e. the months prior to their cancer diagno-
sis) and postdiagnosis (i.e. the months between
their diagnosis and the HDC/BMT procedure).
Exercise During Hospitalization was assessed by
the exercise log that solicited information on the
type (cycling or walking), frequency, and duration
of exercise. Total duration of exercise during hos-
pitalization was calculated for cycling/walking
combined, and cycling alone, because of the ob-
jective estimate of duration provided by the com-
puterized cycle ergometer. To control for the
length of time in the hospital, the two exercise
measures were calculated on a per day basis. That
is, total duration for cycling/walking combined
and cycling alone was divided by the number of
days available to exercise (i.e. the date of dis-
charge minus the date of baseline questionnaire
completion).
QOL was assessed by the Functional Assess-
ment of Cancer Therapy-BMT (FACT-BMT)
Copyright © 2000 John Wiley & Sons, Ltd.
Scale developed specifically for the BMT popula-
tion (Cella et al., 1993). The FACT-BMT Scale
includes physical, functional, emotional, and so-
cial well-being subscales that are generic and per-
tain to all cancer patients. It also contains a
subscale labeled ‘additional concerns’ that is
specific to BMT patients. Each item is rated on a
five point scale, with verbal anchors of not at all
(0), a little bit (1), somewhat (2), quite a bit (3),
and very much (4), and, thus, each subscale can
range from 0 to 4. The FACT-BMT Scale has
been tested in a large sample of cancer patients
and been found to be reliable, valid, responsive,
brief and easy to administer (Cella et al., 1993).
The FACT-BMT Measurement System also in-
cludes a 13-item Fatigue Scale (FS) developed
specifically for the cancer population, that in-
cludes items concerning the consequences of fa-
tigue, as well as symptom expression (Yellen et
al., 1997). The FS is brief, easy to administer and
has been shown to possess excellent internal con-
sistency, test–retest reliability, and convergent
and discriminant validity, based on comparisons
with both subjective (e.g. Piper FS, Profile of
Mood States and performance status ratings) and
objective (e.g. hemoglobin level) criteria (Yellen et
al., 1997). Internal consistencies for the FACT
Measurement System in the present study were as
follows:
Week 1 (n= 25)
1. physical well-being (a=0.90)
2. functional well-being (a= 0.86)
3. emotional well-being (a= 0.84)
4. social/family well-being (a= 0.83)
5. additional concerns (a= 0.71)
6. fatigue and energy concerns (a= 0.96)
Week 2 (n= 14)
1. physical well-being (a= 0.90)
2. functional well-being (a=0.80)
3. emotional well-being (a=0.75)
4. social/family well-being (a= 0.64)
5. additional concerns (a= 0.61)
6. fatigue and energy concerns (a= 0.95)
Psychological Well-Being (PWB) was assessed
by the Affect Balance Scale (ABS) developed by
Bradburn (1969) which assesses the frequency of
positive and negative affect during the past week.
The ABS is a ten-item scale with individual items
rated on a three point scale with verbal anchors
‘never’ (0), ‘sometimes’ (1), and ‘often’ (2). Five
items each represent positive and negative affect.
Psycho-Oncology 9: 127–136 (2000)
 EXERCISE, BMT, AND QOL
An overall score is determined by summing the
positive and negative items separately and then
subtracting the negative from the positive. Scores
for the ABS can range from − 10 to +10. Inter-
nal consistencies for positive affect scale in the
present study were a = 0.86 (Week 1) and a = 0.83
(Week 2), and for the negative affect scale, were
a = 0.66 (Week 1) and a = 0.75 (Week 2).
SWL was assessed by the SWL Scale (SWLS)
developed by Diener et al. (1985). The SWLS
allows individuals to assess their QOL, based on
their own unique set of criteria without reference
to a specific domain. This approach is consistent
with accepted conceptual definitions of QOL that
emphasize overall SWL. The SWLS contains five
items that are rated on seven point scales and
averaged for an overall score. The SWLS has
been shown to be a highly reliable, valid, and
responsive measure of overall QOL (Pavot and
Diener, 1993). Internal consistencies in the pres-
ent study were a = 0.83 (Week 1) and a =0.79
(Week 2).
Depression was assessed by the Center for Epi-
demiological Studies Depression (CES-D) Scale
which is a well-validated, 20-item scale that mea-
sures the frequency of depressive symptoms over
the past week (Radloff, 1977). Items are scored
from 0 (B 1 day) to 3 (5 – 7 days), and summed to
provide an overall score (i.e. 0 – 60). A cutoff score
of 16 or greater has been used to denote individu-
als who may need diagnostic follow-up for clinical
depression (Myers and Weismann, 1980). Internal
consistencies for the CES-D in the present study
were a= 0.93 (Week 1) and a = 0.79 (Week 2).
Anxiety was assessed by the State-Trait Anxiety
Inventory (STAI) developed by Spielberger et al.
(1970). Each scale has 20 items that are rated
from 1 (not at all) to 4 (very much so) on a scale
with an overall range of 20 – 80. The version used
in the present study asked participants how they
felt ‘during the past week’. The STAI has been
widely used in research on clinical and medical
populations and has good psychometric proper-
ties. Internal consistencies for the STAI in the
present study were a = 0.96 (Week 1) and a = 0.77
(Week 2).
RESULTS
Demographic information indicated that the age
of participants ranged from 24 to 70 years, with a
Copyright © 2000 John Wiley & Sons, Ltd.
131
mean of 47.16 (S.D.= 12.09), 52% were male,
80% were married/common law, 36% had com-
pleted university, 52% were full-time employed,
and 56% had a family income in excess of $40 000
per year. Medical information indicated that the
BMI of participants ranged from 17.64 to 37.58
with a mean of 26.88 (S.D.= 5.08); 36% were
being treated for breast cancer, 23% for non-
Hodgkin’s lymphoma, 23% for multiple myeloma,
9% for Hodgkin’s disease, and 9% for other can-
cers. In terms of medical complications, 28% ex-
perienced anemia, 60% experienced fever, 80%
experienced mucositis, 64% experienced neutrope-
nia, and 36% experienced thrombocytopenia dur-
ing hospitalization.
To evaluate the generalizability of our results,
we compared the 14 individuals who completed
the baseline questionnaire, but not a QOL assess-
ment, with the 25 who completed at least one
QOL assessment. There were no differences be-
tween the two groups in age, sex distribution,
marital status, education, employment status,
family income, BMI, prediagnosis exercise, post-
diagnosis exercise, type of cancer, or the presence
of fever, nausea, neutropenia or thrombocytope-
nia. Differences were found, however, for hospital
discharge [t(37)=2.68, pB 0.05], presence of ane-
mia [x 2(39)= 3.21, pB0.05], and presence of
mucositis [x 2(39)= 6.43, p B0.05]. Specifically,
non-completers as compared with completers
were discharged earlier (14.459 6.44 versus
19.839 5.07 days) and were less likely to have
experienced anemia (0% versus 28%), or mucositis
(33% versus 80%), during hospitalization. It is not
surprising that non-completers were discharged
earlier (and experienced fewer medical complica-
tions), as the main reason for not completing at
least one QOL assessment was early discharge.
Descriptive statistics for physical exercise and
QOL for the 25 participants who completed the
study are presented in Table 2.
Changes in exercise from prediagnosis to
postdiagnosis to post-transplant
Changes in the weekly frequency of exercise
from prediagnosis to postdiagnosis were examined
using dependent t-tests. Results indicated signifi-
cant reductions in the weekly frequency of mild
[t(24)= 2.51, pB 0.001, one-tailed], moderate
[t(24)= 1.84, pB 0.04, one-tailed], and strenu-
ous [t(24)= 1.74, pB0.05, one-tailed] exercise.
Psycho-Oncology 9: 127–136 (2000)
132 K.S. COURNEYA ET AL.

Table 2. Descriptive statistics for physical exercise and QOL tive presence of the five well-being dimensions of
(n= 25) the FACT-BMT. Results indicated a significant
difference among the five well-being dimen-
Mean S.D. Range sions [Wilks’ Lambda= 0.17; F(4, 21)= 24.85,
pB 0.001] and follow-up dependent t-tests re-
Past exercise
vealed significant differences (pB 0.05, two-tailed)
Mild exercise 2.96 2.73 0.00–7.00
prediagnosis
in all pairwise comparisons, except physical and
Moderate exercise 1.04 1.43 0.00–5.00 functional. The rank order of the five well-being
prediagnosis dimensions was social, emotional, additional,
Strenuous exercise 0.48 1.12 0.00–4.00 physical, and functional well-being. Pearson corre-
prediagnosis lations were used to examine the relative impor-
Mild exercise 2.12 1.96 0.00–7.00 tance of each of the five well-being dimensions
postdiagnosis from the FACT-BMT, as well as PWB, for overall
Moderate exercise 0.60 1.19 0.00–4.00 SWL. The results showed that functional (r=
postdiagnosis
0.57), additional (r= 0.54), and social (r= 0.45)
Strenuous exercise 0.12 0.44 0.00–2.00
well-being correlated significantly with SWL.
postdiagnosis
Exercise during hospitalization
Cycling duration per 2.21 2.73 0.00–8.85 Relationships between exercise during
day hospitalization and QOL
Cycling/walking 7.71 8.59 0.00–32.31
duration per day The main hypotheses concerning the relation-
QOL ships between exercise during hospitalization and
Physical well-being 1.92 1.11 0.14–3.71 QOL were tested using Pearson correlations.
Functional well-being 1.87 0.77 0.43–3.57 Specifically, the duration of cycling per day and
Emotional well-being 3.20 0.61 1.50–4.00 cycling/walking combined per day were correlated
Social well-being 3.51 0.55 2.00–4.00 with the final QOL assessments (and days hospi-
Additional concerns 2.81 0.52 1.58–3.90 talized). The results indicated that there were sig-
PWB 1.73 4.46 −4.50–10.00 nificant correlations in the hypothesized direction
SWL 4.85 1.29 2.20–6.80 between at least one exercise measure and every
Fatigue 2.17 1.06 0.31–3.85
QOL indicator, except emotional and social well-
Depression 19.77 12.02 2.00–50.00
Anxiety 43.23 12.01 20.00–72.00
being (Table 3). Moreover, the significant correla-
Days hospitalized 13.87 4.13 7.00–22.00 tions were all in the medium to large range based
on Cohen’s (1988, 1992) guidelines for the behav-
ioral sciences of small (r= 0.10), medium (r=
Further changes in exercise following the BMT 0.30), and large (r=0.50).
could not be evaluated because the measures were In an attempt to determine if demographic or
not comparable (i.e. there were no minimum stan- medical variables might explain some of the rela-
dards for the intensity or duration of exercise tionships between physical exercise and QOL,
reported during hospitalization, and no specific correlations were computed between the
duration reported on the GLTEQ). The absolute demographic/medical variables and the physical
levels of exercise post-transplant, however, were exercise/QOL variables. For a demographic/medi-
very low, with 40% reporting no cycling at all, 24% cal variable to be a potential explanation for the
reporting no exercise at all (i.e. cycling or walk- relationship between physical exercise and QOL, it
ing), and the mean combined cycling/walking du- must correlate with both the exercise and QOL
ration for participants being less than 8 min per measure in a consistent direction. The results indi-
day. cated that there were no systematic relationships
between the demographic/medical characteristics
and physical exercise/QOL that might explain the
Relati6e presence and importance of QOL relationships between exercise and functional well-
dimensions being, social well-being, SWL, or depression.
There were, however, systematic correlations that
A repeated measures analysis of variance could explain the relationships between exercise
(ANOVA) was conducted to determine the rela- and physical well-being, additional concerns,

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 127–136 (2000)
 EXERCISE, BMT, AND QOL 133

PWB, fatigue, anxiety, and days hospitalized. (pB 0.05; one-tailed) correlated with days hospi-
Specifically, the absence/presence of a fever corre- talized.
lated significantly with cycling duration per day
(r = −0.47), walking/cycling duration per day
(r= − 0.46), physical well-being (r= − 0.46), and
days hospitalized (r = 0.36). Partial correlations DISCUSSION
indicated that after controlling for fever, there
were no significant relationships between exercise
The results of the present study extend previous
during hospitalization and physical well-being but
research that has shown that physical exercise is
a significant (pB 0.05; one-tailed) relationship did
related to QOL during and following conven-
remain between cycling duration per day and days
tional levels of cancer therapies (Courneya and
hospitalized (r = −0.42).
Friedenreich, 1999). Moreover, the present results
In addition, the absence/presence of mucositis
also extend research on exercise and BMT pa-
correlated with cycling duration per day (r=
tients that has focused on physical fitness and
−0.55), walking/cycling duration per day (r=
medical outcomes (Cunningham et al., 1986;
−0.60), additional concerns (r = − 0.52), PWB
Dimeo et al., 1996, 1997a,b). The key result of the
(r= − 0.44), fatigue (r = 0.53), and anxiety (r=
present study was that exercise during hospitaliza-
0.43). After controlling for mucositis, however,
tion correlated significantly with QOL, even after
there were still significant (p B 0.05; one-tailed)
controlling for potentially relevant demographic
correlations between cycling duration per day and
and medical variables. More specifically, exercise
additional concerns (r = 0.36) and anxiety (r=
during hospitalization correlated with all QOL
−0.40). Finally, the absence/presence of neu-
indices, except emotional and social well-being.
tropenia correlated with cycling duration per day
The most consistent relationships were found for
(r = −0.56), cycling/walking duration per day
physical well-being, additional concerns, PWB,
(r = −0.55), and days hospitalized (r= 0.40).
depression, and anxiety. Demographic and medi-
Partial correlations indicated, however, that even
cal variables did not provide alternative explana-
after controlling for neutropenia, cycling duration
tions for the relationships between exercise and
per day (r= − 0.39) and cycling/walking duration
functional well-being, social well-being, additional
per day (r = −0.40) were still significantly
concerns, SWL, depression, or anxiety. Finally,
the results of the present study also support previ-
Table 3. Pearson correlations between exercise during hospi- ous research suggesting that exercise may actually
talization and QOL (n= 25) reduce the length of hospital stay (Dimeo et al.,
1997a).
Cycling duration Cycling/walking The fact that medical complications accounted
per day duration per day statistically for the correlations between exercise
and physical well-being, PWB, and fatigue does
Physical 0.38** 0.39**
not necessarily mean that the correlations between
well-being
Functional 0.18 0.30*
exercise and these QOL indices are spurious (i.e.
well-being that medical complications caused reductions in
Emotional 0.16 0.16 both QOL indices and exercise levels, but that
well-being exercise and QOL are not causally related to each
Social 0.25 0.15 other). It may also be that exercise caused changes
well-being in the medical complications that, in turn, caused
Additional 0.50*** 0.47*** changes in QOL (i.e. a mediational role for medi-
concerns cal complications). In this scenario, fewer medical
PWB 0.46** 0.37** complications becomes the explanation for why
SWL 0.16 0.32*
exercise might improve QOL in BMT patients.
Fatigue −0.27* −0.22
Depression −0.47*** −0.40**
Based on the observational design of the present
Anxiety −0.54*** −0.36** study, it is not possible to determine the causal
Days −0.55*** −0.40** order of these relationships. However, Dimeo et
hospitalized al. (1997a) did employ an experimental design and
found significantly fewer medical complications
*pB0.10; **pB0.05; ***pB0.01 (one-tailed). in the exercise group, including duration of

Copyright © 2000 John Wiley & Sons, Ltd. Psycho-Oncology 9: 127–136 (2000)
134 K.S. COURNEYA ET AL.
neutropenia and thrombocytopenia, and severity
of diarrhea and pain, which may very well be
related to improved QOL. Clearly, experimental
research is needed to determine the interplay be-
tween exercise, physical fitness, medical compli-
cations, and QOL in BMT patients.
The results of the present study also support
previous research that has shown that functional
QOL is the least possessed but most important
dimension underlying overall SWL following
cancer diagnosis (Courneya and Friedenreich,
1997a,b). Specifically, functional well-being was
significantly lower than all other QOL dimen-
sions, except physical well-being. Moreover,
functional well-being was the strongest correlate
of SWL followed by additional concerns, and
social well-being. In the present study, exercise
was related to functional well-being and addi-
tional concerns plus overall SWL. These find-
ings highlight the importance of functional
well-being in BMT patients and underscore the
potential inadequacy of QOL interventions that
do not directly address these concerns (Cour-
neya and Friedenreich, 1997a,b; Courneya et al.,
1999). Such findings also create a strong ratio-
nale for examining the potential role of physical
exercise in optimizing QOL in BMT patients.
The present study also supports the well-
documented decline in exercise levels in cancer
patients from prediagnosis to postdiagnosis
(Courneya and Friedenreich, 1997a,b; Courneya
et al., 1999). In the present study, there were
significant declines in the weekly frequency of
all three levels of exercise intensity (i.e. mild,
moderate and strenuous). This means that there
is likely a significant decline in the physical con-
ditioning of these patients even before they un-
dergo the BMT procedure, most likely because
of the fact that many of these patients have
received conventional treatments of chemother-
apy, radiation therapy, and/or surgery prior to
their BMT. Dimeo et al. (1997a) have already
documented the significant decline in fitness that
occurs after the BMT. Our data raises the ques-
tion of whether or not an aerobic conditioning
program prior to the BMT procedure may also
be indicated in these patients, with the possibil-
ity of it buffering the effects of the BMT and
hastening recovery. An experimental study in
this regard is warranted.
One strength of an observational design, as
opposed to an experimental design, is that it
provides information on the naturally-occurring
Copyright © 2000 John Wiley & Sons, Ltd.
levels of exercise in BMT patients. Clearly, the
amount of exercise being performed by BMT
patients is low. Fully 40% of study participants
did not cycle at all, and 24% did no exercise at
all, not even walking. Moreover, the mean dura-
tion of walking/cycling combined per day in the
present study was less than 8 min. In the Dimeo
et al. (1997a) intervention, participants in the
experimental condition performed 30 min of
mild intensity exercise per day following trans-
plantation. Given the low levels of naturally-
occurring exercise in BMT patients, it appears
that structured interventions beyond simple en-
couragement will be needed to promote exercise
in this population.
Despite the important findings of the present
study, there are limitations that need to be
taken into consideration when interpreting the
results and planning future research. First, the
study sample contains important selection biases
that limit the generalizability of the findings.
The protocol of the present study was to com-
plete the baseline assessment as soon as possible
on being admitted to the transplant unit, and
the QOL assessments on a weekly basis there-
after, until discharge. With variations in when
the baseline assessment was completed and in
the duration of hospitalization, the 1-week time
period for the QOL assessment resulted in the
loss of a significant number of participants. The
primary bias in the present study, therefore, is
that it included patients who experienced more
severe medical complications that resulted in
their longer hospital stay. Future research
should consider obtaining QOL assessments im-
mediately prior to discharge rather than after
some structured time period.
A second limitation is the small absolute sam-
ple size, although relatively speaking, it com-
pares favorably with other studies of exercise in
BMT patients. We recruited for 14 months and
were only able to initially enroll 39 participants
from a major cancer hospital. Clearly, BMT is
still a relatively rare procedure, and multicenter
studies will be needed to accrue sufficient
numbers of participants in a timely manner.
A third limitation is the self-report assessment
of exercise behavior, although the self-
reports we obtained for cycling duration were
based on an objective source. Future re-
search might use objective activity monitors (i.e.
pedometers) or supervised fitness programs to
Psycho-Oncology 9: 127–136 (2000)
 EXERCISE, BMT, AND QOL
verify levels of exercise behavior. A fourth limita-
tion is the design of the present study. Although
prospective observational designs are a significant
improvement over retrospective designs, they do
not provide definitive information on causation.
However, the results of the present study suggest
that experimental designs examining exercise and
QOL in BMT patients are clearly warranted.
In summary, the present study has extended
research on the potential role of exercise in the
rehabilitation of BMT patients. Preliminary sup-
port was found for the relationship between exer-
cise and QOL that complements previous research
documenting important physical fitness and medi-
cal outcomes. Further research is necessary, how-
ever, using larger samples, objective assessments
of exercise and fitness, and experimental designs.
Such research will contribute much needed scien-
tific evidence to current clinical exercise prescrip-
tions being developed for BMT patients (e.g.
James, 1987; Hicks, 1990; Sayre and Marcoux,
1992).
ACKNOWLEDGEMENTS
This study was funded by a Social Sciences Research
Grant from the University of Alberta, Edmonton, AB,
Canada.
NOTES
1. We also analyzed the Week 1 QOL assessment as the
final endpoint and found results virtually identical to
those using the final QOL assessment as the end
point.
REFERENCES
Bradburn, N.M. (1969) The Structure of Psychological
Well-Being. Aldine, Chicago, IL.
Cella, D.F., Tulsky, D.S., Gray, G., Sarafian, B., Linn,
E., Bonomi, A., Silberman, M., Yellen, S.B., Wini-
cour, P., Brannon, J., Eckberg, J., Lloyd, S., Purl, S.,
Blendowski, C., Goodman, M., Barnicle, M., Stew-
art, I., McHale, M., Bonomi, P., Kaplan, E., Taylor,
S., Thomas, C.R. and Harris, J. (1993) The func-
tional assessment of cancer therapy scale: develop-
ment and validation of the general measure. J. Clin.
Oncol. 11, 570–579.
Copyright © 2000 John Wiley & Sons, Ltd.
135
Cohen, J. (1988) Statistical Power Analysis for the
Beha6ioral Sciences (2nd edn.). Lawrence Erlbaum,
Hillsdale, NJ.
Cohen, J. (1992) A power primer. Psychol. Bull. 112,
155 – 159.
Courneya, K.S. and Friedenreich, C.M. (1997a) Rela-
tionship between exercise pattern across the cancer
experience and current quality of life in colorectal
cancer survivors. J. Altern. Complement. Med. 3,
215 – 226.
Courneya, K.S. and Friedenreich, C.M. (1997b) Rela-
tionship between exercise during cancer treatment
and current quality of life in survivors of breast
cancer. J. Psychosoc. Oncol. 15, 35 – 57.
Courneya, K.S. and Friedenreich, C.M. (1999) Physical
exercise and quality of life following cancer diagno-
sis: a literature review. Ann. Beha6. Med. 21, 171 –
179.
Courneya, K.S., Friedenreich, C.M., Arthur, K. and
Bobick, T.M. (1999) Physical exercise and quality of
life in postsurgical colorectal cancer patients. Psy-
chol. Health Med. 4, 181 – 187.
Cunningham B.A., Morris, G., Cheney, C.L., Buergel,
N., Aker, S.N. and Lenssen, P. (1986) Effects of
resistive exercise on skeletal muscle in marrow trans-
plant recipients receiving total parenteral nutrition. J.
Parenter. Enter. Nutr. 10, 558 – 563.
Diener, E., Emmons, R. A., Larsen, R. J. and Griffin,
S. (1985) The satisfaction with life scale. J. Personal.
Assess.,6 49, 71 – 75.
Dimeo, F., Bertz, H., Finke, J., Fetscher, S., Mertels-
mann, R. and Keul, J. (1996) An aerobic exercise
program for patients with haematological malignan-
cies after bone marrow transplantation. Bone Mar-
row Transplant. 18, 1157 – 1160.
Dimeo, F., Fetscher, S., Lange, W., Mertelsmann, R.
and Keul, J. (1997) Effects of aerobic exercise on the
physical performance and incidence of treatment-
related complications after high dose chemotherapy.
Blood 90, 3390 – 3394.
Dimeo, F., Tilmann, M.H.M., Bertz, H., Kanz, L.,
Mertelsmann, R. and Keul, J. (1997) Aerobic exercise
in the rehabilitation of cancer patients after high dose
chemotherapy and autologous peripheral stem cell
transplantation. Cancer 79, 1717 – 1722.
Godin, G. and Shepard, R.J. (1985) A simple method
to assess exercise behavior in the community. Can. J.
Appl. Sport Sci. 10, 141 – 146.
Godin, G., Jobin., J. and Bouillon, J. (1986) Assess-
ment of leisure-time exercise behavior by self-report.
A concurrent validity study. Can. J. Public Health 77,
359 – 361.
Hicks, J.E. (1990). Exercise for cancer patients, in
Therapeutic Exercise (5th edn; J.V. Basmajian, and
S.L. Wolf Eds). Williams & Wilkins, Baltimore, MD,
pp. 351 – 369.
Jacobs, D.R., Ainsworth, B.E., Hartman, T.J. and
Leon, A.S. (1993) A simultaneous evaluation of ten
Psycho-Oncology 9: 127–136 (2000)
136 K.S. COURNEYA ET AL.
commonly used physical activity questionnaires.
Med. Sci. Sports Exerc. 25, 81–91.
James, M.C. (1987) Physical therapy for patients after
bone marrow transplantation. Phys. Ther. 67, 946 –
952.
Myers, J.K. and Weismann, M.M. (1980) Use of a
self-report symptom scale to detect depression in a
community sample. Am. J. Psychiatry 137, 1081 –
1084.
Neitzert, C.S., Ritvo, P., Dancey, J., Weiser, K., Mur-
ray, C. and Avery, J. (1998) The psychosocial impact
of bone marrow transplantation: a review of the
literature. Bone Marrow Transplant. 22, 409–422.
Pavot, W. and Diener, E. (1993) Review of the satisfac-
tion with life scale. Psychol. Assess. 5, 164–172.
Copyright © 2000 John Wiley & Sons, Ltd.
Radloff, L.S. (1977) The CES-D scale: a self-report
depression scale for research in the general popula-
tion. Appl. Psychol. Meas. 1, 385 – 401.
Sayre, R.S. and Marcoux, B.C. (1992) Exercise and
autologous bone marrow transplants. Clin. Manag.
12, 78 – 82.
Spielberger, C.D., Gorusch, R.L. and Lushene, R.F.
(1970) Manual for the State –Trait Anxiety In6entory.
Consulting Psychologists Press, Palo Alto, CA.
Yellen, B.S., Cella, D.F., Webster, J., Blendowski, C.
and Kaplan, E. (1997) Measuring fatigue and other
anemia-related symptoms with the functional assess-
ment of cancer therapy (FACT) measurement sys-
tem. J. Pain Symptom Manag. 13, 63 – 74.
Psycho-Oncology 9: 127–136 (2000)