Preliminary Effectiveness of a Telehealth-Delivered Exercise Program in Older Adults Living With and Beyond Cancer: Retrospective Study.

Introduction

Adults aged 65 years and older currently account for 67% of cancer survivors (eg, individuals living with and beyond a cancer diagnosis) in the United States [ 1 ]. By 2040 it is projected that 73% of cancer survivors in the United States will be aged 65 years and older [ 2 ]. Cancer treatment compounds the normal effects of aging resulting in an accelerated aging effect [ 3 ]. A hallmark characteristic of accelerated aging is poor physical functioning [ 3 ]. Older adults with cancer experience worse physical function than their younger counterparts [ 4 ] and older adults without cancer [ 5 6 ]. Physical function plays a critical role in the health of older adults with cancer and poor function is associated with decreased cancer survival [ 7 ], increased all-cause mortality [ 8 ], and increased symptom severity [ 9 ].

Regular participation in exercise is one strategy to help mitigate declines in physical function among cancer survivors of all ages. Among older adults with cancer, individualized, in-person supervised exercise programming, including combined aerobic and resistance training, for at least 12-weeks significantly improves physical function [ 10 11 ], quality of life [ 12 ], muscular strength [ 10 11 ], aerobic endurance [ 10 11 ], and symptoms of anxiety and depression [ 11 ]. Despite the numerous benefits of exercise for older adults with cancer, participation in exercise in this population is low with only 12% of older cancer survivors meeting both the aerobic and strength training guidelines [ 13 ]. Reasons for low engagement among this population include: lack of available exercise programming in convenient locations [ 14 ], transportation concerns [ 14 15 ], lack of time [ 14 16 ], physical symptoms (eg, fatigue) [ 14 16 17 ], and comorbidities [ 14 17 ]. Strategies to reduce barriers to participating in exercise among older adults with cancer are needed to improve exercise engagement and physical function in this population.

Delivering exercise programs using telehealth is a useful strategy in attenuating these barriers. Telehealth delivery of exercise detaches the exercise program from a physical location, resulting in exercise engagement in a more convenient location, such as the home, eliminating the need for travel, and reducing overall time commitment [ 18 ]. Telehealth delivered exercise can also lower the cost of participation as participants do not need to pay for transportation or parking [ 18 ]. After transitioning two trials from in-person to telehealth exercise, due to the impact of the COVID-19 pandemic on in-person research, Winters-Stone et al [ 19 ] observed better adherence and retention for telehealth exercise compared to in-person exercise among adult cancer survivors of all ages. In addition to addressing these barriers, supervised, telehealth-delivered exercise programs among adult cancer survivors of all ages have demonstrated improvements in physical symptoms and comorbidities such as: physical function [ 20 21 ], aerobic endurance [ 20 22 ], muscular endurance [ 20 22 ], and fatigue [ 22 ]. Specific to older adults living with cancer, telehealth delivery of exercise programming is considered acceptable [ 23 ], feasible [ 24 ], and safe [ 25 ]. Moreover, older cancer survivors view telehealth delivery of exercise positively and report limited technology related barriers to telehealth exercise participation [ 26 ]. Barriers and facilitators to participating in telehealth exercise reported by older cancer survivors are similar to those reported by their younger counterparts [ 26 ]. To our knowledge, only two studies to date have evaluated effectiveness of supervised telehealth exercise programming (ie, delivered via telehealth in real time) exclusively in older adults with cancer [ 24 27 ]. Both trials delivered group resistance training programs and observed significant improvements in markers of physical function after participating in the program [ 24 27 ]. However, little is known regarding the effectiveness of one-on-one telehealth supervised exercise in older adults with cancer. Given the dearth of research, we sought to address the issue in this investigation.

The purpose of this investigation was to explore the preliminary effectiveness of a one-on-one, supervised telehealth clinical exercise oncology program among older adults with cancer on physical function, muscular endurance, balance, and flexibility. We hypothesized that participation in telehealth exercise would result in a statistically significant improvement in physical function, muscular endurance, aerobic endurance, balance, and flexibility among older adults with cancer.

Methods

Study Design and Sample

This was a retrospective analysis of electronic health record data collected between March 2020 and December 2021 from the Huntsman Cancer Institute (HCI) at the University of Utah’s clinical exercise oncology program, the Personal Optimism With Exercise Recovery (POWER) program. This study was approved by the University of Utah Institutional Review Board (IRB_00072431). To be included in this analysis participants must have met the following inclusion criteria: (1) ≥65 years of age, (2) diagnosis of invasive cancer, and (3) completion of an initial POWER program assessment via telehealth. Demographic and clinical data including age, sex, race, ethnicity, cancer site, cancer stage, and cancer treatment history, were pulled from the medical record. Initial and follow-up assessment data were abstracted from the POWER program clinical database by a trained researcher (ERD) with support from certified exercise physiologists within our hospital-based exercise oncology program using a study specific spreadsheet developed in partnership with this study’s team. Data were cleaned to ensure all measures were within a physiologically reasonable range and units were consistent within measures (eg, all plank assessments were reported in seconds). Cancer treatment history from manual data abstraction was verified with the electronic health record.

Exercise Program

The POWER program is a hospital-based exercise oncology program embedded into clinical practice at the HCI. Details of this clinical program have been previously published [ 28 ]; therefore, only pertinent details will be discussed here. While the program has traditionally been offered both in-person and via telehealth, the POWER program shifted to exclusive telehealth delivery due to the COVID-19 pandemic in March 2020 and continued to operate primarily via telehealth through December 2021. Anyone seeking care at the HCI is eligible to participate in the POWER program and patients can enroll in the program through self-referral or physician referral.

POWER provides personalized exercise prescriptions, including both aerobic and resistance training, to program participants based on an initial assessment conducted by a physiatrist and certified exercise physiologist with expertise in cancer via telehealth. The typical length of the program was 12-weeks, but varied based on participant preference. After about 12-weeks, participants were encouraged to complete a telehealth follow-up assessment to evaluate their progress (ie, reassess all baseline measures) and revise the exercise prescription to promote continued progress. Ultimately, the POWER program aims to help survivors become comfortable and capable of safely engaging in exercise independently.

The exercise prescription was individualized to each participant’s needs and was informed by the initial telehealth assessment which included a review of medical and cancer treatment history, physical examination, review of current exercise behavior, and assessment of physical function, muscular endurance, and flexibility. Following the initial assessment each participant met with a certified exercise physiologist twice weekly, via telehealth, for the duration of their program, for a supervised, 60-minute resistance training session. Body weight training and resistance bands were the primary mode of resistance training delivery; however, the resistance training program may have also included resistance machines or free weights per participant access and preference. No equipment was provided to participants by the exercise program. Prescribed aerobic exercise was completed unsupervised by each participant. The goal of each participant’s program was to work toward meeting the physical activity guidelines for cancer survivors [ 29 ].

Participants accessed the telehealth exercise visits directly through their online patient portal using any electronic device that was capable of video calls (eg, smartphone, tablet, laptop, etc). Telehealth visits were conducted directly through electronic health records (Epic Systems Corporation) which allow certified exercise physiologists easy access to the participants address, contact information, and emergency contacts. Participants’ location for each telehealth exercise session and contact information, in case the telehealth session was disconnected, was verified by the certified exercise physiologist at the start of each session. While survivors had an out-of-pocket cost of approximately US $8 per telehealth exercise training visit, the baseline and follow-up assessments were covered by medical insurance reimbursement.

Measures

Overview

The following measures were included in the telehealth initial and follow-up assessments in the POWER program. When developing the telehealth assessment procedures, decisions about which measures to include were based on the feasibility of carrying out measures in a telehealth format and alignment with the in-person POWER program assessment [ 28 ]. When administering the telehealth assessments, the video camera angle was adjusted for each assessment so that the certified exercise physiologist could observe the full range of motion and ensure proper form was being used.

30-Second Chair Stand Test

Lower extremity function was evaluated with the 30-second chair stand test. Participants stood from a seated position, with arms crossed across their chest, and were instructed to stand up and sit down as many times as they could in 30-seconds [ 30 ]. The number of repetitions (ie, return to seated) completed in 30-seconds were recorded. Repetitions were counted using consistent methods across assessments and assessors to optimize the reliability of this assessment. The 30-second chair stand test has been shown to be a good predictor of lower extremity function in older adults [ 31 ] and safe to conduct using telehealth in adults with cancer [ 32 ]. Moreover, the 30-second chair stand test has good test-retest reliability in older adults with cancer (intraclass correlation [ICC]=0.89) [ 33 34 ]. A minimal clinically important difference (MCID) of 2.0 has been established for the 30-second chair stand test [ 35 ].

30-Second Maximum Push-Up Test

Muscular endurance was assessed using the 30-second push-up test. The starting position for push-ups was with the hands on the floor approximately shoulder width apart and arms straight. Participants were instructed to lower themselves down toward the floor until their chest was one fist width above the floor and then return to the starting position; this is one repetition. Participants were asked to complete as many push-ups as possible in 30-seconds. If the participant was unable to perform a standard push-up (on toes), they were able to modify by starting on their knees or performing wall push-ups depending on ability [ 36 ]. Any modifications made at baseline were replicated at follow-up.

2-Minute Standing March

Aerobic endurance was assessed using the 2-minute standing march test. Participants stepped in place with a step height no lower than the midpoint between the patella and iliac crest. The number of steps (right and left equals one) completed in 2-minutes were recorded. If necessary, participants could use one hand on a counter-top or a chair to assist with balance. The 2-minute standing march has been shown to be a good alternative to the 6-minute walk test [ 37 38 ] with strong test-retest reliability (ICC=0.99) when assessed among older adults via telehealth [ 39 ].

Single Leg Stance

Balance was assessed using a single leg stance. Participants were instructed to lift one foot off of the ground and balance on one leg without holding onto anything for support for as long as possible with their eyes open. The single leg stance was performed once on each leg. Time balancing without assistance (from hands or the other foot) was recorded for each leg. No maximum time cap was imposed for the single leg stance. The single leg stance test has demonstrated good reliability (ICC=0.86) among older adults [ 40 ].

Plank

Participants were asked to hold a forearm plank on either their toes or knees, self-selected based on their ability, for as long as they were able to assess torso muscular endurance. Each participant was instructed to keep their elbows directly under their shoulders with forearms extended forward and a neutral spine and neck. The variation (ie, knees or toes) participants selected and total time participants were able to hold the plank were recorded. The plank assessment was not performed in cases where contraindications, such as cardiovascular concerns or upper extremity injuries, were present. Telehealth plank assessment has demonstrated good reliability (ICC=0.97) among adults [ 41 ].

Chair Sit and Reach

Hamstring flexibility was assessed using the chair sit and reach test. Participants sat on a chair near the front edge of the seat with one leg extended (ie, heel on the floor and foot dorsiflexed at approximately 90 degrees) and the other leg bent with the sole of the foot flat on the floor. Then they were asked to place one hand on top of the other with palms facing down. Participants were then instructed to slowly bend forward at the hips, keeping their back flat, as they reached down the extended leg as far as they could. A score was assigned based on how far participants were able to reach: a 2 for the toes, 1.5 for the ankle, 1.0 for the shin, 0 for anything above the shin. The chair sit and reach test has demonstrated good reliability (ICC=0.95) and validity among older adults [ 35 42 ].

Shoulder Range of Motion

Range of motion in the shoulder joint was assessed by measuring shoulder flexion, shoulder extension, and shoulder abduction. Range of motion for each movement was observed and visually estimated to the nearest 10 degrees during the telehealth initial assessment. Visual estimation of shoulder range of motion has demonstrated acceptable reliability (ICC=0.57‐0.70) among adults [ 43 ].

Clock Test

The clock test is a modified back scratch test used to assess shoulder internal rotation. Participants were instructed to reach behind their back with their palm facing out with the goal of reaching their hand as far up their back as possible. The test was conducted on both the right and left sides. The test is scored by visually estimating the position of the arm in correspondence to a position on the face of a clock during the telehealth initial assessment. Scores range from six to eleven on the right and six to one on the left with eleven and one indicating the highest levels of shoulder flexibility, respectively.

Statistical Analysis

Descriptive statistics were reported as means and SDs or medians and IQRs for continuous variables and frequencies and percentages for categorical variables. Differences in age, BMI, and continuous initial assessment variables between older adults with cancer who did and did not complete a follow-up assessment were determined using independent samples t tests. Differences in categorical demographic, clinical, and initial assessment variables were assessed using chi-square tests. Among the older adults with cancer that completed a follow-up assessment, mean change variables were computed as the difference between the follow-up and baseline values. Missing assessment data were excluded case-wise to maximize the sample size for each variable. Change scores were compared to values considered to be the MCID. The 30-second chair stand test was the only assessment with a published MCID value [ 35 ]. Paired samples t tests were conducted to determine if there were significant differences in assessment outcomes following the exercise intervention. Cohen d effect sizes are reported as an indicator of effect size. A Cohen d of 0.2 was considered a small effect, 0.5 was considered medium, and 0.8 was considered large. For categorical outcomes mean change scores and 95% CIs were calculated to determine change across the intervention. All data were analyzed in SPSS (version 29.0; IBM Corp).

Ethical Considerations

The protocol and waiver of informed consent was approved by the University of Utah Institutional Review Board (IRB_00072431) in accordance with the Declaration of Helsinki. All data presented were deidentified using study identification numbers prior to analysis. Compensation was not included for this study.

Results

Participants

A total of 68 older adults with cancer completed an initial assessment via telehealth and participated in the POWER program between March 2020 and December 2021. Older adults with cancer who participated in POWER via telehealth were 71.8 (SD 5.3) years of age on average (range 65‐92 y) and had a median BMI of 26.7 kg/m 2 (IQR 7.3; Table 1 ). Most older adults with cancer were female (n=45, 66.2%) and were not actively receiving treatment during their participation in POWER (n=40, 58.8%). The most common cancer types among older adults were breast (n=18, 26.5%), prostate (n=13, 19.1%), and multiple myeloma (n=8, 11.8%).

Of the 68 older adults who completed an initial assessment and participated in POWER, 29.4% (n=20) completed a telehealth follow-up assessment. The median time elapsed between initial and follow-up assessments was 16.5 weeks (IQR 5.75). The majority of older adults with cancer who completed a follow-up were on active treatment (n=12, 60%). Statistically significant differences were not observed among the following clinical and demographic variables among older adults with cancer who did and did not complete a follow-up assessment: age, BMI, sex, race, ethnicity, cancer stage, history of hormone therapy, immunotherapy, surgery, and radiation, number of treatment types, or cancer type. A statistically significant difference was observed for the proportion of older adults with cancer who reported being on active treatment ( P =.04) and having received chemotherapy ( P =.04) between those who did and did not complete a follow-up assessment.

Change in Measured Outcomes

Values for each measured outcome from the initial telehealth assessment are reported in Table 2 . There were no significant differences in initial assessment outcomes between the follow-up and no follow-up grou ps ( P > .05).

Change in measured outcomes are reported in Table 3 . Statistically significant changes were observed for the 30-second chair stand test (mean change +2.00 repetitions, 95% CI 0.12 to 3.88, Cohen d =0.51) and 30-second maximum push-up test (mean change +2.85 repetitions, 95% CI 1.60 to 4.11, Cohen d =1.06). Nine (47.3%) older adults with cancer had a change in 30-second chair stand scores that exceeded the MCID of 2.0 repetitions [ 35 ], and 14 (73.7%) older adults maintained their 30-second chair stand scores across the intervention. Although not statistically significant, positive changes were observed for the 2-minute standing march (mean change +12.79 repetitions, 95% CI −0.64 to 26.22, Cohen d =0.46), single leg stance on the left (mean change +4.80 s, 95% CI −0.67 to 10.27, Cohen d =0.44) and right (mean change +1.0 s, 95% CI −8.04 to 10.05, Cohen d =0.06), and shoulder abduction on the left (mean change +2.25 degrees, 95% CI −3.75 to 8.25, Cohen d =0.18) and right (mean change +0.25 degrees, 95% CI −4.34 to 4.84, Cohen d =0.03). The results from univariate analysis of covariance paralleled results from paired samples t tests.

Discussion

Principal Findings

This study aimed to evaluate the preliminary effectiveness of a hospital-based telehealth exercise oncology program on physical function, muscular endurance, balance, and flexibility among older adults with cancer. Our findings demonstrate that supervised, one-on-one telehealth exercise may positively influence physical function among older adults with cancer. Additionally, nearly half (n=9) of individuals who completed a follow-up assessment exceeded an MCID change in the 30-second chair-stand test, a marker of lower extremity function.

Comparison to Prior Work

The majority of research surrounding telehealth supervised exercise programs for older adults without [ 44 45 ] and with cancer [ 24 27 ] has focused on group exercise. Less is known about one-on-one telehealth exercise. Among older adults without cancer, participating in at least 12-weeks of supervised group telehealth exercise training prevents declines in physical function [ 44 45 ]. Among older adults with cancer, a feasibility study by Sattar et al [ 24 ] evaluated an 8-week group telehealth strength and balance training program and observed significant improvements in five time chair stand test scores. Additionally, Gell et al [ 27 ] carried out a pilot trial examining a 16-week group telehealth aerobic and resistance training program and observed significant improvements in 30-second chair stand test scores. Collectively, group telehealth exercise programming among older adults with and without cancer is effective at improving physical function.

Findings from this study contribute to the literature by addressing an important gap in our understanding regarding the effectiveness of one-on-one telehealth exercise among older cancer survivors. Among cancer survivors of all ages (range 14‐83 y), effectiveness of one-on-one supervised telehealth exercise has been evaluated [ 22 ]. Following 12-weeks of one-on-one training with a cancer exercise trainer once per week, cancer survivors significantly improved cardiovascular endurance, muscular endurance, and flexibility [ 22 ]. Findings from our study support previous research suggesting one-on-one telehealth exercise programs may positively influence physical function among older adults with cancer. Without exercise intervention, we would expect to see little to no change in physical function parameters over short durations in older adults living with cancer. Over 13-weeks Mikklesen et al [ 11 ] found a mean change of +0.4 repetitions in the 30-second chair stand test and −1.0 points in self-reported physical function among older cancer survivors receiving standard of care and no exercise intervention. Over longer durations (eg, ≥1 y) functional declines are greater and can persist for years following diagnosis [ 6 ]. Preventing declines in physical function is important in this population because physical function has been shown to have a protective effect against all-cause mortality in older adults with cancer [ 8 ].

In addition to examining the effect of one-on-one, supervised telehealth exercise on physical function in older adults with cancer, we also characterized older adults with cancer who chose to participate in a telehealth exercise program. This information adds to our body of knowledge by demonstrating that older adults with cancer can engage in one-on-one telehealth delivered exercise programs. Additionally, we observed that a significantly greater proportion of older adults with cancer who were on active treatment or had received chemotherapy completed a follow-up assessment. This finding suggests that older cancer survivors on active cancer treatment are willing to engage in telehealth exercise which is important as recent recommendations from the American Society of Clinical Oncology encourage cancer survivors on active treatment to participate in aerobic and resistance exercise [ 46 ]. Understanding who we are reaching with telehealth exercise programs, who may be missing, and who completes a telehealth follow-up assessment can inform the development of interventions to improve the engagement and reach of telehealth delivered exercise programming among cancer survivors of all ages.

Strengths and Limitations

To our knowledge, this is one of the first studies that has evaluated effectiveness of one-on-one telehealth exercise programming exclusively among older adults with cancer and characterized the older adults who used this programming. We consider this a strength of our work. Additionally, the use of an established hospital-based exercise oncology program with over 15 years of experience offering telehealth exercise ensured high-quality exercise programming in this study. However, our study is not without limitations. First, the low follow-up assessment completion rate resulted in a small sample size and an underpowered analysis to demonstrate statistically significant changes in all outcomes measured. Therefore, the findings from this study are preliminary and additional research with a larger sample is needed. Second, the retrospective design of this study may have resulted in selection bias of participants who were more motivated to exercise and follow-up. Highly motivated individuals may be more likely to complete a follow-up assessment in the program potentially confounding the effects of the telehealth exercise program. Third, baseline and follow-up assessments were scheduled based on the participants’ availability which resulted in different staff conducting baseline and follow-up assessments for some participants. However, a small team of certified exercise physiologists administered all virtual assessments, adhering to standardized program procedures to minimize interrater variability. Fourth, the lack of a nonexercise control group limits the conclusions that can be made regarding the ability of telehealth exercise to prevent declines in physical function. Future work should consider a prospective study design and inclusion of potential confounding variables as covariates to determine the effectiveness of one-on-one telehealth exercise on markers of physical function.

Conclusions

In summary, older adults living with and beyond cancer are able to participate in an exercise oncology program delivered via telehealth. Our findings provide preliminary evidence that telehealth may be a beneficial tool to facilitate exercise program delivery among older adults following a cancer diagnosis. However, telehealth exercise should not be considered a one-size-fits-all all approach as in-person, telehealth, or a combination of the two may be a better fit for some older adults with cancer, based on their needs and preferences. Further research is needed to understand the magnitude of the effects of one-on-one, supervised telehealth exercise on physical function among older adults with cancer.

Acknowledgments

Research reported in this publication was supported by the University of Utah Graduate Research Fellowship and Alice Oakes Bronson Research Fellowship.

Authors’ Contributions: ERD and AMC were responsible for study conceptualization, data acquisition, quality control of data, data analysis, and paper preparation. ERD was responsible for statistical analysis. SO, PAH, RWZ, DW, and KL participated in data collection. ERD, AMC, LP, MN, YB, and SO were responsible for study design and paper editing. All authors reviewed this paper and approved the final version.

Data Availability: The datasets analyzed during this study are available from the corresponding author on reasonable request.

Conflicts of Interest: None declared.

Abbreviations:

Huntsman Cancer Institute

intraclass correlation

minimal clinically important difference

Personal Optimism With Exercise Recovery

References

1. Miller KD Nogueira L Devasia T et al Cancer treatment and survivorship statistics, 2022 CA Cancer J Clin Sep 2022 72 5 409 436 doi 10.3322/caac.21731 Medline 35736631

2. Bluethmann SM Mariotto AB Rowland JH Anticipating the “silver tsunami”: prevalence trajectories and comorbidity burden among older cancer survivors in the United States Cancer Epidemiol Biomarkers Prev 07 2016 25 7 1029 1036 doi 10.1158/1055-9965.EPI-16-0133 Medline 27371756 PMC4933329

3. Hurria A Jones L Muss HB Cancer treatment as an accelerated aging process: assessment, biomarkers, and interventions Am Soc Clin Oncol Educ Book 2016 35 e516 22 doi 10.1200/EDBK_156160 Medline 27249761

4. Derks MGM de Glas NA Bastiaannet E et al Physical functioning in older patients with breast cancer: a prospective cohort study in the TEAM trial Oncol Aug 2016 21 8 946 953 doi 10.1634/theoncologist.2016-0033 Medline 27368882 PMC4978563

5. Leach CR Bellizzi KM Hurria A Reeve BB Is it my cancer or am I just getting older?: impact of cancer on age-related health conditions of older cancer survivors Cancer Jun 15 2016 122 12 1946 1953 doi 10.1002/cncr.29914 Medline 27159822

6. Feliciano EMC Vasan S Luo J et al Long-term trajectories of physical function decline in women with and without cancer JAMA Oncol Mar 1 2023 9 3 395 403 doi 10.1001/jamaoncol.2022.6881 Medline 36656572 PMC9857739

7. Sehl M Lu X Silliman R Ganz PA Decline in physical functioning in first 2 years after breast cancer diagnosis predicts 10-year survival in older women J Cancer Surviv Mar 2013 7 1 20 31 doi 10.1007/s11764-012-0239-5 Medline 23232922 PMC3568656

8. Ezzatvar Y Ramírez-Vélez R de Asteasu MLS et al Physical function and all-cause mortality in older adults diagnosed with cancer: a systematic review and meta-analysis J Gerontol A Biol Sci Med Sci 07 13 2021 76 8 1447 1453 doi 10.1093/gerona/glaa305 Medline 33421059

9. Kenzik KM Morey MC Cohen HJ Sloane R Demark-Wahnefried W Symptoms, weight loss, and physical function in a lifestyle intervention study of older cancer survivors J Geriatr Oncol Nov 2015 6 6 424 432 doi 10.1016/j.jgo.2015.08.004 Medline 26362355 PMC4662250

10. Olsen AP Vinther A Ragle AM et al Physical exercise program to older frail patients receiving chemotherapy for colorectal cancer - feasibility and experiences from the GERICO study J Geriatr Oncol 01 2023 14 1 101382 doi 10.1016/j.jgo.2022.09.011 Medline 36328878

11. Mikkelsen MK Lund CM Vinther A et al Effects of a 12-week multimodal exercise intervention among older patients with advanced cancer: results from a randomized controlled trial Oncol Feb 3 2022 27 1 67 78 doi 10.1002/onco.13970 Medline 34498352 PMC8842365

12. Paulo TRS Rossi FE Viezel J et al The impact of an exercise program on quality of life in older breast cancer survivors undergoing aromatase inhibitor therapy: a randomized controlled trial Health Qual Life Outcomes 01 18 2019 17 1 17 doi 10.1186/s12955-019-1090-4 Medline 30658629 PMC6339353

13. Zhang J Su M Cheng J Zhou S Liu L Yao NA A nationally representative study of aerobic activity and strength training in older cancer survivors and their psychological distress and sleep difficulties Support Care Cancer Nov 2022 30 11 9597 9605 doi 10.1007/s00520-022-07370-2 Medline 36171399

14. Perry CK Ali W Solanki E Winters-Stone K Attitudes and beliefs of older female breast cancer survivors and providers about exercise in cancer care Oncol Nurs Forum 01 1 2020 47 1 56 69 doi 10.1188/20.ONF.56-69 Medline 31845920

15. Mikkelsen MK Michelsen H Nielsen DL Vinther A Lund CM Jarden M “Doing What Only I Can Do”: experiences from participating in a multimodal exercise-based intervention in older patients with advanced cancer-a qualitative explorative study Cancer Nurs 2022 45 2 E514 E523 doi 10.1097/NCC.0000000000000987 Medline 34294645 PMC8849132

16. Cheung DST Takemura N Chau PH Ng AYM Xu X Lin CC Exercise levels and preferences on exercise counselling and programming among older cancer survivors: a mixed-methods study J Geriatr Oncol Nov 2021 12 8 1173 1180 doi 10.1016/j.jgo.2021.05.002 Medline 33985930

17. Mikkelsen MK Nielsen DL Vinther A Lund CM Jarden M Attitudes towards physical activity and exercise in older patients with advanced cancer during oncological treatment - a qualitative interview study Eur J Oncol Nurs Aug 2019 41 16 23 doi 10.1016/j.ejon.2019.04.005 Medline 31358249

18. Dennett A Harding KE Reimert J Morris R Parente P Taylor NF Telerehabilitation’s safety, feasibility, and exercise uptake in cancer survivors: process evaluation JMIR Cancer Dec 21 2021 7 4 e33130 doi 10.2196/33130 Medline 34854817 PMC8768007

19. Winters-Stone KM Boisvert C Li F et al Delivering exercise medicine to cancer survivors: has COVID-19 shifted the landscape for how and who can be reached with supervised group exercise? Support Care Cancer Mar 2022 30 3 1903 1906 doi 10.1007/s00520-021-06669-w Medline 34741653 PMC8571667

20. Crosby BJ Newton RU Galvão DA et al Feasibility of supervised telehealth exercise for patients with advanced melanoma receiving checkpoint inhibitor therapy Cancer Med 07 2023 12 13 14694 14706 doi 10.1002/cam4.6091 Medline 37184115 PMC10358269

21. Myers SA Weller S Schwartz S et al Feasibility of a supervised virtual exercise program for women on hormone therapy for breast cancer Transl J ACSM 2022 7 4 e000213 doi 10.1249/TJX.0000000000000213

22. Wonders KY Gnau K Schmitz KH Measuring the feasibility and effectiveness of an individualized exercise program delivered virtually to cancer survivors Curr Sports Med Rep 05 1 2021 20 5 271 276 doi 10.1249/JSR.0000000000000846 Medline 33908915

23. Lafaro KJ Raz DJ Kim JY et al Pilot study of a telehealth perioperative physical activity intervention for older adults with cancer and their caregivers Support Care Cancer Aug 2020 28 8 3867 3876 doi 10.1007/s00520-019-05230-0 Medline 31845007 PMC8805142

24. Sattar S Haase K Penz K et al Feasibility of a remotely delivered strength and balance training program for older adults with cancer Curr Oncol Nov 2 2021 28 6 4408 4419 doi 10.3390/curroncol28060374 Medline 34898562 PMC8628693

25. Sattar S Papadopoulos E Smith GVH et al State of research, feasibility, safety, acceptability, and outcomes examined on remotely delivered exercises using technology for older adult with cancer: a scoping review J Cancer Surviv Dec 2024 18 6 1861 1888 doi 10.1007/s11764-023-01427-9 Medline 37418170

26. Dunston ER Malouf A Podlog LW et al Experiences participating in a telehealth exercise program among older adults with cancer: a qualitative study J Cancer Surviv Mar 16 2024 doi 10.1007/s11764-024-01564-9 Medline 38492170

27. Gell NM Dittus K Caefer J Martin A Bae M Patel KV Remotely delivered exercise to older rural cancer survivors: a randomized controlled pilot trial J Cancer Surviv Apr 2024 18 2 596 605 doi 10.1007/s11764-022-01292-y Medline 36374436 PMC9662104

28. Coletta AM Rose NB Johnson AF et al The impact of a hospital-based exercise oncology program on cancer treatment-related side effects among rural cancer survivors Support Care Cancer Aug 2021 29 8 4663 4672 doi 10.1007/s00520-021-06010-5 Medline 33502590 PMC7838462

29. Campbell KL Winters-Stone KM Wiskemann J et al Exercise guidelines for cancer survivors: consensus statement from international multidisciplinary roundtable Med Sci Sports Exerc Nov 2019 51 11 2375 2390 doi 10.1249/MSS.0000000000002116 Medline 31626055 PMC8576825

30. Jones CJ Rikli RE Beam WC A 30-s chair-stand test as a measure of lower body strength in community-residing older adults Res Q Exerc Sport Jun 1999 70 2 113 119 doi 10.1080/02701367.1999.10608028 Medline 10380242

31. Rikli RE Jones CJ Development and validation of criterion-referenced clinically relevant fitness standards for maintaining physical independence in later years Gerontologist Apr 2013 53 2 255 267 doi 10.1093/geront/gns071 Medline 22613940

32. Bowman A Denehy L Benjemaa A et al Feasibility and safety of the 30‐second sit‐to‐stand test delivered via telehealth: an observational study PM R 01 2023 15 1 31 40 doi 10.1002/pmrj.12783 Medline 35138036

33. Blackwood J Rybicki K Physical function measurement in older long-term cancer survivors J Frailty Sarcopenia Falls Sep 2021 6 3 139 146 doi 10.22540/JFSF-06-139 Medline 34557613 PMC8419850

34. Eden MM Tompkins J Verheijde JL Reliability and a correlational analysis of the 6MWT, ten-meter walk test, thirty second sit to stand, and the linear analog scale of function in patients with head and neck cancer Physiother Theory Pract Mar 2018 34 3 202 211 doi 10.1080/09593985.2017.1390803 Medline 29068767

35. Wright AA Cook CE Baxter GD Dockerty JD Abbott JH A comparison of 3 methodological approaches to defining major clinically important improvement of 4 performance measures in patients with hip osteoarthritis J Orthop Sports Phys Ther 05 2011 41 5 319 327 doi 10.2519/jospt.2011.3515 Medline 21335930

36. Whitehurst MA Johnson BL Parker CM Brown LE Ford AM The benefits of a functional exercise circuit for older adults J Strength Cond Res Aug 2005 19 3 647 651 doi 10.1519/R-14964.1 Medline 16095420

37. Węgrzynowska-Teodorczyk K Mozdzanowska D Josiak K et al Could the two-minute step test be an alternative to the six-minute walk test for patients with systolic heart failure? Eur J Prev Cardiol Aug 2016 23 12 1307 1313 doi 10.1177/2047487315625235 Medline 26743588

38. Bohannon RW Crouch RH Two-minute step test of exercise capacity: systematic review of procedures, performance, and clinimetric properties J Geriatr Phys Ther 2019 42 2 105 112 doi 10.1519/JPT.0000000000000164 Medline 29210933

39. Ogawa EF Harris R Dufour AB Morey MC Bean J Reliability of virtual physical performance assessments in veterans during the COVID-19 pandemic Arch Rehabil Res Clin Transl Sep 2021 3 3 100146 doi 10.1016/j.arrct.2021.100146 Medline 34589696 PMC8463460

40. Goldberg A Casby A Wasielewski M Minimum detectable change for single-leg-stance-time in older adults Gait Posture Apr 2011 33 4 737 739 doi 10.1016/j.gaitpost.2011.02.020 Medline 21444208

41. Güngör F Ovacık U Harputlu ÖE et al Tele-assessment of core performance and functional capacity: reliability, validity, and feasibility in healthy individuals J Telemed Telecare 07 2024 30 6 1017 1025 doi 10.1177/1357633X221117335 Medline 35916001

42. Jones CJ Rikli RE Max J Noffal G The reliability and validity of a chair sit-and-reach test as a measure of hamstring flexibility in older adults Res Q Exerc Sport Dec 1998 69 4 338 343 doi 10.1080/02701367.1998.10607708 Medline 9864752

43. Hayes K Walton JR Szomor ZR Murrell GA Reliability of five methods for assessing shoulder range of motion Aust J Physiother 2001 47 4 289 294 doi 10.1016/s0004-9514(14)60274-9 Medline 11722295

44. Buckinx F Aubertin-Leheudre M Daoust R et al Impacts of remote physical exercises on functional status and mobility among community-dwelling pre-disabled seniors during the COVID-19 lockdown J Nutr Health Aging 2023 27 5 354 361 doi 10.1007/s12603-023-1914-1 Medline 37248759 PMC10155135

45. Carrapatoso SM Abdalla PP Cadete CM Carvalho JM Santos MPM Bohn L Does real-time online physical exercise improve physical fitness in seniors? Act Adapt Aging Oct 2 2022 46 4 286 302 doi 10.1080/01924788.2022.2100686

46. Ligibel JA Bohlke K May AM et al Exercise, diet, and weight management during cancer treatment: ASCO guideline J Clin Oncol Aug 1 2022 40 22 2491 2507 doi 10.1200/JCO.22.00687 Medline 35576506