Acupressure, Cancer-related Problem/Condition, Exercise
Conditions
Keywords
Cancer related fatigue, Exercise, biomarkers, Auricular Point Acupressure
Brief summary
A 12 weeks technology enhanced home exercise (TEHE) program using mobile technologies that provide immediate feedback and send reminder messages to improve exercise motivation is developed. Investigators combine this TEHE program with techniques including auricular point pressure (APA) and brief mindfulness body scan (MBI). This study will examine the feasibility of the TEHE program and combined programs, and ascertain the effect of TEHE program alone, the combined programs on fatigue and biological markers among cancer survivors. Main Research Variable(s): The independent variables are the 12-week program of TEHE alone, APA alone, combined APA and TEHE (TEHEplus) and combined MBI and TEHE (TEHE-MBI). Outcome variables are fatigue, physical activity, contributing factors of fatigue and biomarkers. Design: Repeated measures randomized controlled trial. Setting: Participants will be recruited through the Comprehensive Cancer Center, Johns Hopkins University. Sample: Participants diagnosed with non-metastatic solid tumor cancer; who had completed all primary cancer treatment (surgery, chemotherapy, and radiation therapy )within at least 3 months OR non-metastatic prostate cancer completed all primary cancer treatment and have hormone therapy for at least 6 month, OR participants diagnosed with solid tumor cancer; who are receiving immunotherapy for at least 3 months before enrollment, aged 21 years or older, experiencing fatigue in the past 7 days on average of ≥ 3/10, able to participate in a moderate-intensity exercise training program, self-report ability to complete the 6 min walk test with a perceived exertion of 3 or below, and can communicate in English. Methods: Participants who meet the inclusion criteria will be randomly assigned to the TEHE only, APA only or TEHEplus or TEHE-MBI or control group. All exercise groups (TEHE) will be offered a 12-week exercise program through an online communication. In additional to the TEHE, the TEHEplus group will receive an instruction on how to apply the pressure on the ear points through online meeting/communication. The TEHE-MBI group will perform 5 min mindfulness body scan daily. The control (usual care) group will report participant's fatigue level daily. At the end of week 12, participants will answer open-ended questions about participant's opinions on the programs. Fatigue will be assessed and blood will be drawn before and after the program.
Detailed description
Home-based exercise interventions have a significant effect on fatigue; however, motivation and intervention compliance are the main challenges. The use of personalized exercise and immediate feedback though smartphome communication has been found to increase motivation. We developed a 12 weeks technology enhanced home exercise (TEHE) program using mobile technologies that provide immediate feedback and sends reminder messages to improve exercise motivation. Moreover, to enhance the effectiveness of exercise, we combine this TEHE program with techniques--auricular point pressure and brief mindfulness body scan--, which have been found to affect fatigue and physical activities. The Auricular Point Acupressure (APA) and Mindfulness Based Intervention (MBI) may enhance the effect of exercise on fatigue; however, the feasibility and effectiveness of this combination have not been tested. This study will examine the feasibility of the TEHEplus program and ascertain the effect of TEHE program alone, APA alone, the TEHEplus program and the TEHE-MBI program on fatigue among cancer survivors and cancer patients receiving immunotherapy. In addition we will explore peripheral and central markers (e.g., Phosphorous levels) of cancer-related fatigue using magnetic resonance spectroscopy (MRS). This study will also investigate whether specific types of fatigue (e.g., physical fatigue, cognitive fatigue) will have different levels of these peripheral and central energy markers). Conceptual Framework: The biopsychosocial model will be used. Main Research Variable(s): The independent variables are the 12-week program of TEHE alone, APA alone, combined APA and TEHE (TEHEplus) and combined MBI and TEHE (TEHE-MBI). Outcome variables are fatigue, physical activity, contributing factors of fatigue (depressive symptom, anxiety, sleep, relationship with others), and biomarkers. Design: Repeated measures randomized controlled trial design. Setting: Participants will be recruited through the Comprehensive Cancer Center, Johns Hopkins University. Sample: Participants diagnosed with non-metastatic solid tumor cancer; who had completed all primary cancer treatment (surgery, chemotherapy, and radiation therapy )within at least 3 months OR non-metastatic prostate cancer completed all primary cancer treatment and have hormone therapy for at least 6 month, OR participants diagnosed with solid tumor cancer; who are receiving immunotherapy for at least 3 months before enrollment, aged 21 years or older, experiencing fatigue in the past 7 days on average of ≥ 3/10, able to participate in a moderate-intensity exercise training program, self-report ability to complete the 6 min walk test with a perceived exertion of 3 or below, and can communicate in English. Methods: Participants who meet the inclusion criteria will be randomly assigned to the TEHE only, APA only, TEHEplus or TEHE-MBI or control (usual care) group. All exercise groups will be offered a 12-week exercise program. The program will based on personal exercise preference and physical activity goals to reach moderate intensity based on readings from a heart rate monitor and exertion level. Activity/steps will be monitored daily using the FitBit Charge. Reminders to exercise will be sent to the patient through a mobile phone application based on the participants' personal schedule and frequency. In additional to the TEHE, the APA only, and the TEHEplus group will receive an instruction on how to apply the pressure on the ear points through the online meeting and mobile application. The TEHE-MBI group will perform 5 min of mindfulness body daily. The control (usual care) group will report their fatigue level daily and attend weekly meetings with the researcher to discuss fatigue. At the end of week 12, in addition to the questionnaires, participants will answer open-ended questions about their opinions on the program. Fatigue will be assessed and blood will be drawn before and after the program. Participants who enrolled in the sub-study will be scheduled for a visit for an MRS before the exercise intervention. 2\. Objectives (include all primary and secondary objectives) Purpose/Specific Aims: The study primary aims are to (1) test the feasibility of a 12-week technology-enhanced home exercise (TEHE) program and combined technology-enhanced home exercise and Auricular Point Acupressure (TEHE plus) program among cancer survivors; (2) to determine the effect of the TEHE plus program on fatigue, physical activity and serum biomarkers (Heat Shock Protein 90 and Brain-Derived Neurotrophic Factor) compared to the control (usual care) group. The secondary aims are to (3) compare the effect of the TEHE only, TEHE plus, APA only, combined MBI and TEHE on fatigue and physical activity; and (4) determine the change in serum biomarkers at week 12 compared to baseline in the TEHE only, TEHE plus, APA only, MBI+TEHE, and control (usual care) groups (5) explore the associations of muscle and brain energetic markers using magnetic resonance spectroscopy (MRS) with fatigue symptoms of cancer survivors.
Interventions
BEHAVIORALTechnology Enhanced Home Exercise (TEHE)
A 12 week program including one 60-minute goal setting and exercise training program and follow up phone calls.
BEHAVIORALAuricular Point Acupressure (APA)
A non invasive complementary method to provide pressure on the ear points.
BEHAVIORALMindfulness body scan (MBI)
The open, nonjudgmental attention to move one's attention calmly to the different part of the body
Sponsors
Johns Hopkins University
Oncology Nursing Society
Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
TRIPLE (Subject, Caregiver, Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
21 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* diagnosed with non-metastatic solid tumor cancer; who had completed all primary cancer treatment (surgery, chemotherapy, and radiation therapy )within at least 3 months OR non-metastatic prostate cancer completed all primary cancer treatment and have hormone therapy for at least 6 month, OR participants diagnosed with solid tumor cancer; who are receiving immunotherapy for at least 3 months before enrollment * aged 21 years or older, experiencing fatigue in the past 7 days on average of ≥ 3/10 * able to participate in a moderate-intensity exercise training program (self-report ability to complete the 6 min walk test with a perceived exertion of 3 or below) * able to communicate in English.
Exclusion criteria
* diagnosed with comorbidities, such as cardiovascular, lung, kidney, liver, or thyroid diseases * have an active infection (e.g., fever, localized redness, swelling, sinus congestion) * diagnosed with a psychological disorder (e.g., suicidal or homicidal tendencies, extreme anxiety or depression)
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | Baseline and week 12 (post-intervention) | Fatigue will be measured by the self-report questionnaire including 1) the PROMIS-F, self self-report measure that assesses fatigue over the past 7 days. Score range 8-40 with higher score indicating worse fatigue. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | Baseline and week 12 (post-intervention) | Skeletal muscle strength was assessed by averaging the maximum force exerted across three trials for each hand using a hand-held dynamometer, with results recorded in pounds (lb). |
| Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | Baseline and week 12 (Post-intervention) | Skeletal muscle strength was assessed by averaging the maximum force exerted across three trials for each hand using a hand-held dynamometer, with results recorded in pounds (lb). |
| Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | Between baseline and week 12 (post-intervention) | Peripheral venous blood was collected in serum tubes for plasma BDNF analysis both before and after the intervention. Plasma level of Brain Derived Neurotrophic Factors measured in ug/ml |
| Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | Baseline and week 12 (post-intervention) | Plasma level of Heat Shock Protein 90 (HSP90) measured in ug/ml from baseline to Week 12 (post-intervention) |
Countries
United States
Participant flow
Recruitment details
Participants were recruited from Johns Hopkins-affiliated hospitals (Sibley Memorial, Bayview, and JHH) and via social media, co-investigator referrals, and JHU-ICTR MyChart messages. Flyers and bookmarks directed potential participants to a REDCap screening survey. Recruitment included clinical settings and online platforms. Participants were contacted by the PI or research staff.
Participants by arm
| Arm | Count |
|---|---|
| Technology Enhanced Home Exercise Only Participants in TEHE group will receive a combined technology and home exercise program. Participants will schedule an online meeting with the research team for exercise goal setting and preference. Participants will receive a daily symptoms survey. They will receive, reminder, motivation message and physical performance feedback though the mobile phone application.
Technology Enhanced Home Exercise (TEHE): A 12 week program including one 60-minute goal setting and exercise training program and follow up phone calls. | 22 |
| Technology Enhanced Home Exercise Plus In additional to the TEHE program, participants will receive auricular point acupressure (APA) training on how to locate the ear points, place the seeds and apply the pressure on the seed.
Participants will be instructed to press the tape and seeds covering each ear point for 3 minutes per time with a 2-second pause in between pressing, three times daily (morning, afternoon and evening: 9 minutes total).
The tape and seeds will remain on ear points for 5 days. Participants will be instructed to remove both at the end of the 5th day.
Technology Enhanced Home Exercise (TEHE): A 12 week program including one 60-minute goal setting and exercise training program and follow up phone calls.
Auricular Point Acupressure (APA): A non invasive complementary method to provide pressure on the ear points. | 23 |
| Technology Enhanced Home Exercise-Mindfulness Intervention In addition to the TEHE program, the TEHE+MBI group will receive a audio-recording of a mindfulness-based body scan.
During the weekly study visit: Participants will be instructed to listen to the recorded mindfulness-based body scan in the morning and before bedtime.
At home: Participants will be asked to listen to this audiotape daily in the morning and before bedtime.
Technology Enhanced Home Exercise (TEHE): A 12 week program including one 60-minute goal setting and exercise training program and follow up phone calls.
Mindfulness body scan (MBI): The open, nonjudgmental attention to move one's attention calmly to the different part of the body | 21 |
| Control (Usual Care) The control group will receive instructions on how to use the physical activity tracker and mEMA application. Participants will be asked to meet with a research team member weekly to discuss their fatigue experience and receive general information about fatigue management. | 22 |
| Auricular Point Acupressure Only Participants will receive auricular point acupressure (APA) training on how to locate the ear points, place the seeds and apply the pressure on the seed.
Participants will be instructed to press the tape and seeds covering each ear point for 3 minutes per time with a 2-second pause in between pressing, three times daily (morning, afternoon and evening: 9 minutes total).
The tape and seeds will remain on ear points for 5 days. Participants will be instructed to remove both at the end of the 5th day.
Auricular Point Acupressure (APA): A non invasive complementary method to provide pressure on the ear points. | 22 |
| Total | 110 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 | FG002 | FG003 | FG004 |
|---|---|---|---|---|---|---|
| Overall Study | Lost to Follow-up | 3 | 2 | 3 | 1 | 3 |
| Overall Study | Withdrawal by Subject | 5 | 3 | 2 | 8 | 6 |
Baseline characteristics
| Characteristic | Technology Enhanced Home Exercise Plus | Total | Auricular Point Acupressure Only | Control (Usual Care) | Technology Enhanced Home Exercise Only | Technology Enhanced Home Exercise-Mindfulness Intervention |
|---|---|---|---|---|---|---|
| Age, Continuous | 61 years STANDARD_DEVIATION 12 | 60 years STANDARD_DEVIATION 12 | 58 years STANDARD_DEVIATION 13 | 60 years STANDARD_DEVIATION 13 | 59 years STANDARD_DEVIATION 12 | 61 years STANDARD_DEVIATION 12 |
| Education Bachelor's degree or higher | 18 Participants | 81 Participants | 15 Participants | 11 Participants | 19 Participants | 18 Participants |
| Education High school and below | 1 Participants | 3 Participants | 0 Participants | 0 Participants | 1 Participants | 1 Participants |
| Education Not reported | 0 Participants | 6 Participants | 2 Participants | 3 Participants | 1 Participants | 0 Participants |
| Education Some college/associate degree | 4 Participants | 20 Participants | 5 Participants | 8 Participants | 1 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants | 8 Participants | 2 Participants | 1 Participants | 2 Participants | 2 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 17 Participants | 86 Participants | 18 Participants | 19 Participants | 16 Participants | 16 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 5 Participants | 16 Participants | 2 Participants | 2 Participants | 4 Participants | 3 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 3 Participants | 1 Participants | 1 Participants | 1 Participants | 0 Participants |
| Race (NIH/OMB) Black or African American | 2 Participants | 6 Participants | 1 Participants | 2 Participants | 0 Participants | 1 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 1 Participants | 0 Participants | 0 Participants | 1 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants | 5 Participants | 1 Participants | 1 Participants | 2 Participants | 0 Participants |
| Race (NIH/OMB) White | 20 Participants | 95 Participants | 19 Participants | 18 Participants | 18 Participants | 20 Participants |
| Sex/Gender, Customized Sex Female | 9 Participants | 45 Participants | 8 Participants | 9 Participants | 9 Participants | 10 Participants |
| Sex/Gender, Customized Sex Male | 14 Participants | 64 Participants | 14 Participants | 13 Participants | 12 Participants | 11 Participants |
| Sex/Gender, Customized Sex Not reported | 0 Participants | 1 Participants | 0 Participants | 0 Participants | 1 Participants | 0 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk | EG004 affected / at risk |
|---|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 22 | 0 / 23 | 0 / 21 | 0 / 22 | 0 / 22 |
| other Total, other adverse events | 0 / 22 | 1 / 23 | 0 / 21 | 0 / 22 | 0 / 22 |
| serious Total, serious adverse events | 0 / 22 | 0 / 23 | 0 / 21 | 0 / 22 | 0 / 22 |
Outcome results
Primary
Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention)
Fatigue will be measured by the self-report questionnaire including 1) the PROMIS-F, self self-report measure that assesses fatigue over the past 7 days. Score range 8-40 with higher score indicating worse fatigue.
Time frame: Baseline and week 12 (post-intervention)
Population: Participants with data collected at both baseline and post-intervention are reported.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Technology Enhanced Home Exercise Only | Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | -3.8 score on a scale | Standard Deviation 11 |
| Technology Enhanced Home Exercise Plus | Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | -7.9 score on a scale | Standard Deviation 19.8 |
| Technology Enhanced Home Exercise-Mindfulness Intervention | Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | -5.8 score on a scale | Standard Deviation 13.3 |
| Control (Usual Care) | Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | -3.2 score on a scale | Standard Deviation 9.2 |
| Auricular Point Acupressure Only | Change in Fatigue on the Patient-reported Outcomes Measure Information System (PROMIS-F) From Baseline to Week 12 (Post-intervention) | -3.3 score on a scale | Standard Deviation 9.3 |
Secondary
Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention)
Peripheral venous blood was collected in serum tubes for plasma BDNF analysis both before and after the intervention. Plasma level of Brain Derived Neurotrophic Factors measured in ug/ml
Time frame: Between baseline and week 12 (post-intervention)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Technology Enhanced Home Exercise Only | Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | -4945.7 ug/ml | Standard Deviation 8777.9 |
| Technology Enhanced Home Exercise Plus | Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | -3971.3 ug/ml | Standard Deviation 9551.5 |
| Technology Enhanced Home Exercise-Mindfulness Intervention | Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | -106.5 ug/ml | Standard Deviation 1078.8 |
| Control (Usual Care) | Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | -2013.3 ug/ml | Standard Deviation 5807 |
| Auricular Point Acupressure Only | Change in Brain Derived Neurotrophic Factors Between Baseline to Week 12 (Post-intervention) | -2912.8 ug/ml | Standard Deviation 13780 |
Secondary
Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention)
Plasma level of Heat Shock Protein 90 (HSP90) measured in ug/ml from baseline to Week 12 (post-intervention)
Time frame: Baseline and week 12 (post-intervention)
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Technology Enhanced Home Exercise Only | Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | -325.6 ug/ml | Standard Deviation 860.9 |
| Technology Enhanced Home Exercise Plus | Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | -106.5 ug/ml | Standard Deviation 1078.8 |
| Technology Enhanced Home Exercise-Mindfulness Intervention | Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | 3.39 ug/ml | Standard Deviation 859.1 |
| Control (Usual Care) | Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | -297.0 ug/ml | Standard Deviation 753.1 |
| Auricular Point Acupressure Only | Change in Heat Shock Protein Level Measured in pg/ml From Baseline to Week 12 (Post-intervention) | -396.7 ug/ml | Standard Deviation 1465.3 |
Secondary
Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention)
Skeletal muscle strength was assessed by averaging the maximum force exerted across three trials for each hand using a hand-held dynamometer, with results recorded in pounds (lb).
Time frame: Baseline and week 12 (Post-intervention)
Population: Participants with data collected at both baseline and post-intervention are reported.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Technology Enhanced Home Exercise Only | Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | 4.4 pounds (lb) | Standard Deviation 17.6 |
| Technology Enhanced Home Exercise Plus | Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | -0.7 pounds (lb) | Standard Deviation 12 |
| Technology Enhanced Home Exercise-Mindfulness Intervention | Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | 3.0 pounds (lb) | Standard Deviation 1.3 |
| Control (Usual Care) | Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | -2.4 pounds (lb) | Standard Deviation 11.6 |
| Auricular Point Acupressure Only | Change in Left-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | 19.8 pounds (lb) | Standard Deviation 45.7 |
Secondary
Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention)
Skeletal muscle strength was assessed by averaging the maximum force exerted across three trials for each hand using a hand-held dynamometer, with results recorded in pounds (lb).
Time frame: Baseline and week 12 (post-intervention)
Population: Participants with data collected at both baseline and post-intervention are reported.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| Technology Enhanced Home Exercise Only | Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | 9.9 pounds (lb) | Standard Error 33.2 |
| Technology Enhanced Home Exercise Plus | Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | -2.5 pounds (lb) | Standard Error 10.2 |
| Technology Enhanced Home Exercise-Mindfulness Intervention | Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | 2.8 pounds (lb) | Standard Error 2.1 |
| Control (Usual Care) | Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | -3.1 pounds (lb) | Standard Error 6.6 |
| Auricular Point Acupressure Only | Change in Right-hand Skeletal Muscle Strength, Measured Using a Hand-held Dynamometer, From Baseline to Week 12 (Post-intervention) | -0.4 pounds (lb) | Standard Error 3.6 |