The importance of cancer patients' functional recollections to explore the acceptability of an isometric‐resistance exercise intervention: A qualitative study

Abstract Background and Aims Although it has been widely recognized the potential of physical activity to help cancer patients' preparation for and recovery from surgery, there is little consideration of patient reflections and recovery experiences to help shape adherence to exercise programs. The aim was to explore the acceptability of our newly proposed isometric exercise program in a large general hospital trust in England providing specialist cancer care by using patient recollections of illness and therapy prior to undertaking a randomized controlled trial. Methods Four Focus groups (FGs) were conducted with cancer survivors with an explicit focus on patient identity, functional capacity, physical strength, exercise advice, types of activities as well as the timing of our exercise program and its suitability. Thematic framework analysis was used with NVivo 11. Results FG data was collected in January 2016. A total of 13 patients were participated, 10 were male and 3 were female with participants' ages ranging from 39 to 77. Data saturation was achieved when no new information had been generated reaching “information redundancy.” Participants reflected upon their post‐surgery recovery experiences on the appropriateness and suitability of the proposed intervention, what they thought about its delivery and format, and with hindsight what the psychological enablers and barriers would be to participation. Conclusion Based upon the subjective recollections and recovery experiences of cancer survivors, isometric‐resistance exercise interventions tailored to individuals with abdominal cancer has the potential to be acceptable for perioperative patients to help increase their physical activity and can also help with emotional and psychological recovery.


| INTRODUCTION
Annually, nearly 50 000 United Kingdom patients undergo abdominal cancer surgery with the commonest types of cancer including colorectal, liver, pancreatic, kidney, renal, stomach, ovarian, and cervical cancer. 1 This group of patients often experience complications that necessitate readmission to hospital requiring high dependency or intensive care, suffer post-operatively, and longer-term, many patients experience weight loss and muscle atrophy. 2 In the United Kingdom, there is no consistent information or advice provided to such patients prior to and following abdominal surgery, in order to mitigate a period of decreased health, combined with fatigue, functional problems, raised anxiety, and limitations in social life, culminating in an overall reduction in quality of life over a prolonged period of time. 3,4 Currently interventions drawing on patient reflections and recovery experiences from abdominal cancer surgery remain limited indicating a need to consult cancer survivors when introducing new exercise interventions drawing from their subjective recollections as patients to help shape adherence of future health care interventions. The aim of the study was to explore the acceptability of our newly proposed isometric exercise program by using patient recollections of illness and therapy prior to undertaking a randomized controlled trial.
There is a voluminous body of literature on the potential of exercise to help cancer surgery patients' preparation for and recovery from surgery, by minimizing the effects of muscle loss through exercise training. [5][6][7][8] The effect of strength training, as highlighted by Bergenthal et al, alongside physical activity has the potential to increase mobility and function to aid cancer recovery. 9 Yet, this literature has been limited in terms of scope and focus with findings on rehabilitation programs being reported on a range cancer types, rather than associated specifically to abdominal cancer.
In recent years, the findings on cancer treatment and exercise have been more nuanced with consideration on cancer type. Hijazi et al, 10 systematic review on prehabilitation for patients undergoing major abdominal cancer surgery, found that it was unclear what the optimal composition of what programs should consist of, how they should be delivered and what outcome measures should be used to evaluate such programs. Beck et al 11 examined patients' ability to prepare themselves for major abdominal surgery through a prehabilitation program and found that in order to understand patient compliance, prehabilitation regimes needed to take into consideration patient perspectives to enhance patient-centredness and adherence. De Almeida et al 12 found in an early mobilization program following abdominal surgery that performance of exercise activity amongst patients was rather heterogeneous with many partially completing the exercises in the first postoperative days. Colorectal cancer surgery and recovery programs have also been reported in the literature providing a further adjunct to studies on abdominal cancer surgery and physical activity. 13,14 What remains unanswered are the factors that go beyond physical performance, therefore consideration should be given to tailoring exercise interventions that take into account individual physical activity levels, attitudes toward exercise willingness and preferences through a deeper understanding in relation to adherence. 15 Our participants underwent focus group (FG) exploration of their perioperative recollections of self-efficacy to undertake an isometricresistance program in order to prospectively inform our RCT evaluating physical function improvement after cancer surgery (forthcoming). were undergoing further emergency procedures; and lastly, patients who were undergoing operations which were scheduled in less than 2 weeks' time and therefore receiving urgent care.

| Sampling
Our FG method anticipated variation in the number of purposively sampled participants 18 who were selected as they possessed information rich knowledge of the requisite cancer operation experience. 19 In addition to knowledge and experience, they were available and willing to take part, as well as able to communicate their experience and opinions in an expressive and reflective manner. 20

| Procedures
A research nurse (MG) approached 25 potential participants face-toface and over the telephone selected via a hospital registry in December 2015. Patient anonymity was maintained as only the research nurse had access to patient contact details available on the registry. An invitation letter and an information sheet were sent by a research nurse and received by former patients before commencement of the FGs outlining the study purposes and aims. Five people approached were unwilling to take part, and five people indicated that they were unavailable. Two further participants who agreed initially did not attend a FG session indicating last minute changes to plans.
Due to patient recruitment taking place in the weeks leading up to winter closures few volunteers came forward to take part, so the recruitment criteria for the FGs was widened to include esophageal patients. Written informed consent was obtained from all participants.
Ethical approval was granted by the UK's Health Research Authority's National Research Ethics Service. A FG topic guide was piloted on the project's Patient and Public Involvement members (n = 4) who had undergone the requisite operative experience. Feedback on relevance, comprehension, clarity, and consistency were incorporated in order to refine the topic guide. 19,26 At the beginning of each FG, the researcher and research physiothera-   30 Transcripts were not returned to the participants for comment, correction, or feedback due to the difficulty in separating individual responses from collective focus group data. Analysis was derived from the data, and involved familiarization with the transcripts, identification of key themes, indexing data (highlighting quotes/comparing to participants), charting/mapping quotes according to the identified themes and interpretation with reference to the context, with both researchers mutually checking indexing for internal consistency, frequency, and extensiveness of statements/specificity of comments. 29,31 In order to ensure reliability and validity, we used the strategies developed by Guba and Lincoln associated with credibility in qualitative research to enhance: truth value (through peer debriefing to uncover bias and audio-recordings of FGs to crosscheck emerging themes); consistency and neutrality (documenting the research process using transparent and clear descriptions, and discussing emergent themes in the team); and applicability (providing rich descriptions of context to evaluate transferability to other settings through guest contributors at research team meetings). 32,33 Our analysis enabled an exploration of the respondents' discursive recollections of their capacities for perioperative exercise, their foci on the mind and/or the body and the discursive emergence of perioperative operative identities.  July 28, 2015). All participants who took part provided informed consent for their participation in the study.

| Participant characteristics
Thirteen different patients participated in four separate FGs: FG1 (n = 3); FG2 (n = 4); FG3 (n = 4); and FG4 (n = 2), respectively. Table 2 shows the characteristics and cancer diagnoses of those 13 participants who were finally included, many of whom were of retirement Participants agreed that an exercise intervention were needed to help with quotidian functional recovery being surprised that none existed. Of explicit importance was that any newly adopted program must take into account different operation-types, subsequent recovery times and baseline levels of physical activity (see final theme).

| Responses to the delivery and format of the intervention
Participants recollected their pre-operative experience and the exercises that professionals advised to do. They reflected on how they acted on this advice in order to prepare themselves before surgery to enhance their recovery. It is noticeable how some participants recollected consciously guiding (easing) bodily behavior. Others spoke of the body as a distinct entity in relation to weakening due to chemotherapy yet also in terms of perseverance:  Setting and building upon realistic goals was an important consideration for sustaining motivation levels. This again points to the mind ("mental thing") consciously aiding sensate improvement ("feel better in yourself").
That's right, and it's to build on that. And it goes back to it's a mental thing as well. You've got to set yourself some goals and targets. And they mustn't be stupid.
They've got to be sensible. And that's what you strive to achieve. And every time you do it, it's a success, and you feel better in yourself. (Focus Group Three) Others felt that designing any exercise intervention must take account of varying age/ability to ensure patient motivation. Thus, a more "performative" type of design may more likely "fit" different bodies rather like a shoe is designed to fit different types of feet and be "tried on" beforehand in order to judge/help gauge the "fit": It'd be good if you could actually have maybe three different sets of different types of exercises aimed at different age groups and see whoever fits into them.
(Focus Group Four) One participant reflexively spoke of frustration/spousal dependency as spurs to bodily action. There was a consensus that some patients were willing dependency and not proactive with physical recovery, a tacit reality which was "called out" as above by one patient to the other as "peers." One respondent spoke of lack self-motivation as a barrier to exercise: The effects of surgery/chemotherapy had an immense emotional impact on participants' post-operative identity referred to as "becoming back to who you were," an explicit recollection of an influential preoperative identity. It suggests how feeling able to overcome emotional barriers is a key to patients considering performing a new physical task in an exercise program.

| DISCUSSION
The key messages from the results indicate that operation-type, postsurgery recovery experiences, and the impact on mobility all influence acceptability of an isometric-resistance exercise intervention in abdominal cancer surgery patients. How participants recollected their perioperative selves was notable in terms of the different roles and emphases discursively ascribed by participants reminiscent of a Cartesian-like duality of the "mind" and the "body." There were some data suggesting that ingrained tactile sensations are recollected from these pre-operative memories of physical functionality, a form of bodily-know-how, or stored habituated behavior, which some schools of educational theory suggest may be helpful for optimum task performance. 34 Variable and patchy exercise advice to enhance patient recovery was also a notable finding. The participants were dismayed that exercise advice was inconsistent perhaps reflecting an existing lack of robust evidence on the effects of physical activity on post-operative cancer recovery. Having access to recommended advice and information on post-surgery exercises has been noted by Gupta et al 35 as an important consideration for patients' recovery. He found that patients in his study were receptive to being given age-specific brochures, relevant references to web pages, and information on local exercise programs and walking activities that contributed to their sense of empowerment and helped to reenter normal like. Our participants clearly wanted a reliable regimen based on recommendation to encourage in their functional recovery. 35 We also found that participants reflected on the efficacy of undertaking perioperative prehabilitation exercise at home. We found that participants who had been advised to undertake home-based exercises reported being able to perform them following surgery as instructed even though when fatigued. This mirrors Chen et al's 36 findings who report upon a user-friendly home-based prehabilitation program who found higher levels of adherence and longer functional maintenance rates with home-based programs. A home-based setting was commented by our participants as beneficial for facilitating the ease of exercising once back in a familiar stable environment.
Despite the availability of online formats, the participants stated a preference for a face-to-face intervention with weekly practitioner contact. Rabin et al 37 reported that cancer survivors preferred inperson interventions especially those which required behavior change such as exercise/walking or yoga classes, as they offered an opportunity for developing better social connections with trainers. Professional oversight is reportedly imperative to ensure sufficient progression through any training process, 38 rather than traditional interventions for cancer survivors that have had a "one-size-fits-all" design. 39 Our participants felt that professional oversight was key for adherence and that a "one-size-fits-all" program was inappropriate, preferring an intervention tailored to different levels, abilities and ages, with progress measured in relation to individual goals/baselines in a self-selected manner.
The enablers/barriers identified in the findings focused on psychological considerations that either helped or hindered exercise participation. Participants reported wanting to return to feeling "normal," recollecting their pre-operative selves/identities, and if the prospect of taking part in an exercise regime would enable them to return to their pre-operative sense of "normality," then they felt it would be worth participating. These were reflecting feelings of weakness/vulnerability in the context of believing they had grown post-operatively to be somehow different from their earlier "selves." Cancer-diagnosed athletes engaging in an exercise intervention are known to start feeling "normal" even after cancer therapy, as the exercise environment fosters both the self-realization of a functioning body with reserve resources and a positive self-identity. 40 For the athletes in Adamsen et al's study, exercise provided a platform for participants to reclaim a sense of self-identity and bodily control through exercise participation. Similarly, our participants reported expectations that an exercise program would help to restore their sense of personal and physical identity perhaps akin to their pre-operative selves.
The barriers to exercise participation related to limited mobility and a concomitant impact on post-operative/post-chemotherapy motivation, all of which reportedly caused low morale/frustration not uncommon in perioperative cancer patients. 38 Given the known rate of anxiety/depression within our demographic, supporting interventions focusing on physique/mental well-being to help negate this morbidity is advised. 38 It has also been noted in other studies by Sjösten

| Limitations
The patients invited to take part in the FGs varied in terms of age, sex, and self-reported physical fitness, with some in their late seventies and others in their forties with variable experiences of exercise. This may limit the transferability of the findings to all patients. From the FGs, participants had differing views on what they conceived as physical exercise, with some indicating walking, while others perceived cardio-vascular exercises as the main forms of activity. The FG discussions encouraged participants to recall their functional mobility post-surgery and to reflect upon whether they would be able to perform regular exercises, yet any negative experiences may have created a recall bias in gauging whether a program would be acceptable.

| Clinical implications
The

| CONCLUSION
Our study showed that based upon the subjective recollections and recovery experiences of cancer survivors, an isometric exercise intervention tailored to individuals with abdominal cancer has the potential to be acceptable for perioperative patients to help increase their physical activity, as well as helping with emotional and psychological recovery. A structured isometric-resistance exercise intervention was welcomed, one which was professionally guided/tailored in hospital to individual functional capacity to help improve safe quotidian home recovery. The enablers/barriers to program engagement included psychological factors influencing exercise adherence and self-efficacy to safely perform exercises given the psychological distress associated with surgical cancer treatment. Health and Social Care. The NIHR RfPB programme did not have any involvement in the study design, data collection, analysis, interpretation of the data, writing of the report, or the decision to submit the report for publication.