Prehabilitation to Improve outcomes afteR Autologous sTem cEll transplantation (PIRATE) – A randomised controlled trial

Name of intervention: Prehabilitation - nutrition education and advice and exercise Who will deliver the intervention: The intervention will be delivered by a physiotherapist and dietitian with experience treating people with cancer. Mode of delivery: exercise - face to face, nutrition face to face and telephone Dose: Participants randomised to the prehabilitation group will be offered a comprehensive physiotherapy assessment and twice weekly, 60-minute exercise classes for up to 8 weeks pre-transplant. All participants enrolled in the study will aim to complete 8 weeks of prehabilitation however it is possible they will receive a shorter period of prehabilitation dependent of timing of their stem cell transplant as some patients may not be notified if they are proceeding to transplant until 6 weeks prior. The exercise intervention will be in a circuit format and consist of aerobic and resistance exercise, completed at a moderate intensity (4-6 BORG rating of perceived exertion (RPE) and/or 60-80% Heart rate (HR) maximum for aerobic exercises, 60-80% 1-repetition maximum (for pin-loaded machines or 10-12 repetition maximum (RM) for resistance exercise) in accordance with published guidelines. Exercise will be tailored to each patient following an assessment by the physiotherapist. Participants will complete a 5 minute warm up, aim to complete 25 minutes aerobic exercise, 20 minutes of resistance exercise, 5 minutes of flexibility or balance training (as indicated) and 5 minute cool down. Exercise intensity during aerobic exercise will be monitored by the physiotherapist using the modified BORG scale and using a portable heart rate monitor. During weeks one and two, participants will aim to work at a BORG RPE of 3 (moderate), and by week 8 participants will aim to work at a 5-6 (hard) on the scale. For resistance exercise, weights will be progressed once a participant is achieving 2 to 3 sets of 10-12 repetitions. Resistance exercise may include upper and lower body resistance exercise such as squats, step ups, free weights, wall push-ups, free weights, resistance exercise bands, pin-loaded machines (lat pull down, leg press, chest press). Estimated 1 RM testing will be reassessed at week 4 to ensure sufficient strength training stimulus. Aerobic exercise may include treadmill, stationary cycle, and arm ergometer. Various upper and lower body stretches and balance exercise will also be incorporated into the program as required. Participants in the prehabilitation group will be encouraged to complete an additional 30-minute aerobic exercise training session at home to comply with exercise guidelines for people with cancer. Readily available written instructions with guidelines for exercise after cancer readily available from the American College of Sports Medicine will also be given. Patients will be instructed to remain as active as possible and avoid prolonged periods of sitting and lying in the period following stem cell transplant. Patients will also receive a comprehensive, 60 minute face to face nutrition assessment with a dietitian. The nutrition assessment will comprise review of patients energy intake, food group adequacy and malnutrition screening. The dietitian will provide written information handouts readily available from the Peter Macallum Cancer Centre and fortnightly phone calls including education about weight management, protein intake and dietary balance over the 8 weeks (up to 4 sessions). Location/timing: all exercise and nutrition interventions are completed at home 1:1 with the therapist prior to autologous stem cell transplantation Procedures and Personalisation: Exercise will be tailored to each patient following an assessment by the physiotherapist in accordance with guidelines from the American College of Sports Medicine 2019. Patients will be offered tailored dietary education and advice based on their assessment results with the dietitian.