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Evaluation of an Exercise-Based Phase Program as Part of a Standard Care Model for Cancer Survivors Jessica Marlene Brown, Daniel Yoon Kee Shackelford, Maria Lyn Hipp, and Reid Hayward

INTRODUCTION Advancements in cancer treatments such as chemotherapy

and radiation have increased survival rates but often result in many deleterious side effects during and after treatments.

Cancer survivors can suffer from physio- logical toxicities affecting the cardiovascu- lar, pulmonary, musculoskeletal, immune, gastrointestinal, hepatic, and neuroendocrine systems (1). In addition, many survivors will experience psychological decrements such as increased fatigue, increased depression, and decreased quality of life (QOL) (2,3), whereas exercise directly attenuates the toxicities and decrements of cancer and its concurrent treat- ments (4,5). The need to establish an exercise Standard of Care Model (SCM) has been recognized by many organizations. The American Cancer Society has established physical activity guidelines for cancer sur- vivors (6), and the American College of Sports Medicine (ACSM) established ex- ercise guidelines endorsed by the American Society of Clinical Oncology (7). In addi- tion, the National Comprehensive Cancer Network added guidelines to their inclu- sive treatment recommendations (8). Exer- cise programming should be included in the survivorship plan as early as possible and should be considered as a foundational component to improve lifelong QOL (9).

The addition of an SCM or, more specifically, a structured and empirically tested exercise intervention may increase patient benefit by reducing variations in practice and stan- dardizing program implementation.

To derive the greatest benefit, exercise-based interventions must be comprehensive and address the multidimensional needs of cancer survivors during and after treatment. For this reason, a “one size fits all” approach to exercise interventions will not suffice (10). Survivors require prescriptive exercise that is specialized for each individual based on treatment sta- tus, comorbidities, and placement on the cancer continuum. At the University of Northern Colorado Cancer Rehabilitation Institute (UNCCRI), we have developed an SCM that includes physician referral, medical and cancer screening, initial physi- ological and psychological assessments, and an individualized exercise prescription and intervention using a Phase Program

School of Sport and Exercise Science and the University of Northern Colorado Cancer Rehabilitation Institute, University of Northern Colorado, Greeley, CO

Address for correspondence: Reid Hayward, School of Sport and Exercise Science and the University of Northern Colorado Cancer Rehabilitation Institute, University of Northern Colorado, 913 19th Street, Greeley, CO 80639 (E-mail: [email protected]).

2379-2868/0407/0045–0054 Translational Journal of the ACSM Copyright © 2019 by the American College of Sports Medicine

ABSTRACT Exercise is a well-established method of alleviating cancer-related toxicities both during and after treatment. However, specific exercise prescription recommenda- tions for patients at varying points along the cancer continuum are not fully devel- oped. The Phase Program of cancer rehabilitation was created to address this issue. Purpose: This study aimed to evaluate the effectiveness of the Phase Pro- gram on cardiorespiratory fitness (V̇O2peak), muscular strength (MS), and fatigue in cancer survivors during and after treatment. Methods: A total of 183 cancer survi- vors were included in this study. The Phase Program consisted of four, 12-wk, se- quential phases representing differing time points from diagnosis, and prescribed intensity, progression, and goals unique to each phase. Changes in V̇O2peak, leg press MS, chest press MS, and fatigue were measured during transitions from phase 1 to phase 2, phase 2 to phase 3, and phase 3 to phase 4. Results: Eighty-one patients completed the entire program with entry into phase 4, with 71% retention. V̇O2peak, leg press MS, chest press MS, and fatigue significantly improved from phase 1 to phase 2 by 13%, 13%, 18%, and −25%, and from phase 2 to phase 3 by 14%, 19%, 26%, and −27%, respectively (P < 0.05). V̇O2peak and chest press MS significantly improved from phase 3 to phase 4 by 4% and 7%, respectively (P < 0.05). Conclusion: Current exercise guidelines do not fully address the mul- tifaceted needs of cancer survivors at different points along the cancer contin- uum, nor do most exercise programs properly adhere to the principles of exercise training necessary for a safe and effective intervention. The Phase Pro- gram expands on current exercise guidelines providing more precise exercise prescription. This study provides clear, reproducible, and empirical evidence of its effectiveness.

http://www.acsm-tj.org Translational Journal of the ACSM 45

Original Investigation

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

(Fig. 1). Numerous exercise studies have been conducted in cancer patients, most of which have focused primarily on breast cancer, with varying modes, intensities, and outcome measures making standardization and interpretation of results challeng- ing (11). Furthermore, to date, virtually all exercise programs reported in the literature have failed to properly apply and adhere to the standard principles of exercise training: individual- ity, specificity, progressive overload, reversibility, and diminishing returns (12). ACSM has established exercise intensity guidelines for cancer patients; however, they are broad and have been adapted from recommendations for the apparently healthy population (7). Because of a lack of information in previous studies, these guidelines do not provide strict training intensi- ties for exercise prescribed during and after treatment, and they recommend long-term goals that may be inappropriate for sedentary or debilitated patients. Likewise, a detailed med- ical history and direct patient referrals by an oncologist may be necessary to ensure safety and to individualize the exercise pre- scription for the patient’s specific needs. As a result, it is diffi- cult for exercise professionals and clinicians to formulate exercise prescriptions for cancer patients at different points along the cancer continuum and does not specify why or when to modify exercise dosage to elicit optimal adaptations. It has been reported that 80% of oncology care providers are un- aware of the availability of exercise guidelines and lack knowl- edge about when to implement them (13).

The Phase Program proposed here was created to address these concerns while providing a clear method of exercise pre- scription and intervention to alleviate treatment-related toxic- ities in cancer survivors. Therefore, the purpose of this study was to evaluate the effectiveness of the Phase Program on car- diovascular fitness (V̇O2peak), muscular strength (MS), and fatigue in a group of cancer survivors at each phase transition and in those who completed the entire program. We hy- pothesized that significant improvements would be made in V̇O2peak, MS, and fatigue after completion of the Phase

Program, and that these improvements would be evident dur- ing each phase transition.

METHODS Participants

Patients were male and female (n = 183) cancer survivors 18 yr and older who were undergoing or had completed surgical inter- vention, chemotherapy, radiation therapy, immunotherapy, hor- monal therapy, and/or other types of treatment. Inclusion criteria were as follows: 1) diagnosed with cancer, 2) at least 18 yr of age, and 3) medically cleared and referred to the program by the participant’s oncologist or physician. Clearance criteria were based on the discretion of the individual oncologist or physician. Exclusion criteria for all subjects included 1) history of congestive heart failure, 2) history of myocardial infarction, 3) chronic lung disease, 4) history of coughing up blood, 5) fainting, and 6) epilepsy. Upon entry into the program, every subject con- sented to dissemination and interpretation of their assessment values for research.

All participants were referred and cleared to participate in an ex- ercise program by the supervising oncologist or primary care physi- cian. A detailed medical and cancer history accompanied each referral and was screened before any testing was conducted (see Patient Summary, Supplemental Content 1, which documents all patient screening information compiled before data collection, http://links.lww.com/TJACSM/A31). Participants provided written informed consent, and all protocols were approved by the Univer- sity of Northern Colorado’s Institutional Review Board.

Data Collection The Phase Program of cancer rehabilitation uses a four-phase

system with assessments of physiological and psychological vari- ables conducted at the beginning of each phase. Each reassess- ment marked the completion of the phase and subsequent entry into the next. The point of entry into the Phase Program was de- termined by patient treatment status. Patients currently undergo- ing chemotherapy and radiation treatment entered at phase 1, and all posttreatment patients, or those without chemotherapy or radiation treatment, entered at phase 2, which altered the length of the intervention depending on which phase the partici- pant entered the Phase Program. Phases 1 through 3 are consid- ered “true cancer rehabilitation” and are each composed of 12 wk of exercise-based rehabilitation. The program was marked as completed once the patient had entered phase 4 (Fig. 1).

Data were obtained from initial assessments occurring at entry into the program and subsequent reassessments every 12 wk (see Data Collection Sheet, Supplemental Content 2, which comprises all physical tests and data acquired during each assessment, http:// links.lww.com/TJACSM/A32). At each assessment, fatigue was measured via the Piper Fatigue Inventory (14). Cardiovascular en- durance was evaluated using the cancer-specific UNCCRI Tread- mill Protocol, which yields V̇O2peak values (15). MS was assessed via an estimated one-repetition maximum protocol (EST 1-RM) using the Brzycki equation for chest press, lat pulldown, seated row, shoulder press, leg press, leg curl, and leg extension (16).

Exercise Intervention The Phase Program exercise intervention prescribed one-on-one

sessions with trained Clinical Cancer Exercise Specialists (CCES) certified by UNCCRI. These clinicians had over 500 h of training and patient contact and were certified by a written examination and practical evaluation. All sessions for all participants were con- ducted at UNCCRI by a trained CCES.

Training frequency was three sessions per week for 12 wk, per phase. The duration of each exercise session was 60 min with

Figure 1: Overview of the UNCCRI SCM.

46 Volume 4 • Number 7 • April 1 2019 Phase Program for Cancer Survivors

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

20 min designated for aerobic exercise, 30 min for resistance exer- cise, 10 min for flexibility training, and balance exercises incorpo- rated throughout the session. Each CCES prescribed the mode of aerobic exercise based on the participants’ assessment results and desired goals in adherence to both the principles of individuality and specificity. The following modes were used for the aerobic portion of the exercise session: treadmill, cycle ergometer, NuStep, Aquaciser (underwater treadmill), and outdoor walking or jog- ging. During the resistance portion of each exercise session, the following muscle groups were targeted: chest (pectoralis major and minor), back (rhomboids and latissimus dorsi), lower body (quadriceps and hamstrings), and core (trunk stabilizers and pelvic floor). All resistance exercises included three sets of 10 repetitions of each exercise. Other muscle groups may have been included (del- toids, biceps, triceps, adductors, etc.) within the 30 min of strength training if time permitted. Modes of resistance training included Cybex® resistance machines, resistance bands, dumbbells, medi- cine balls, body weight, and resistance tubing. The resistance training regimen was designed to target all major muscle groups needed for activities of daily living and to limit single-joint exer- cises until larger, multijoint exercises were complete for efficiency in the sessions. With this in mind, the repetition and set range was set so that those less familiar with standard weight training could progress using only intensity (weight). The entirety of the exercise intervention has been designed for enhanced reproducibility with an individualized, but formulaic layout.

The Phase Program The intensity and the general purpose of the individualized ex-

ercise interventions were prescribed based on the standards of the Phase Program, the participants’ assigned phase, and dictated by the results of each assessment and subsequent reassessments (Fig. 2). Each phase represents a unique time point on the cancer continuum, and exercise is prescribed to adhere to goals and in- tensity ranges matched with the expected toxicities, limitations, and ability level. In addition to these predetermined objectives, our SCM follows the goals and objectives of exercise prescription set by the ACSM Roundtable (7). For exercise prescription, the as- sessment results, and specifically the classifications achieved by the participant during each assessment, were used for the selection of appropriate starting intensities and progression prescribed dur- ing the intervention. Higher assessment values resulted in the se- lection of greater starting intensities (overload), whereas lower

functioning indicated the use of the lower ranges of intensity pre- scribed for each phase (see Patient Overview, Supplemental Con- tent 3, which dictates the exercise prescription of intensity and progression for each patient in the Phase Program, http://links. lww.com/TJACSM/A33).

PHASE 1

Phase 1 is designed for cancer survivors still receiving chemo- therapy and/or radiation treatments. Because of the fact that side effects are more prevalent during treatment, the goal of this phase is to maintain or slightly increase physiological and psychological parameters and prevent any decline in functional capacity. Phase 1 is specifically designed to adhere to the exercise training principles of individuality and specificity. Decrements below baseline values obtained at the onset of the program should not occur because this phase is designed to attenuate the toxicities of cancer treatment. In phase 1, the initial exercise intensity is categorized as low, ranging between 30% and 45% of heart rate reserve (HRR) and EST 1-RM (17). The rate of progression (i.e., how quickly overload is applied) is small representing only a 0%–5% and 10%–15% range of increase in aerobic and resistance exercise intensity, re- spectively, over the course of the intervention. Phase 1 is intended to last a total of 12 wk. However, participants remained in this phase for the duration of treatment regardless of its length, or for the full 12 wk if treatment was less than 12 wk.

PHASE 2

Phase 2 is designed for cancer survivors who have completed phase 1, or for survivors who have completed or are undergoing cancer treatment that is not categorized as chemotherapy or radi- ation therapy (e.g., hormonal therapy, immunotherapy, and stem cell transplant). Side effects of chemotherapy and radiation are fundamentally different from the side effects experienced during other forms of cancer treatment, which are generally less severe. As a result, the starting intensity of phase 2 is prescribed as low to moderate and ranges between 40% and 60% of HRR and EST 1-RM (17). The rate of progression is moderate to vigorous, representing a 10%–20% and a 30%–50% range for increases in aerobic and resistance exercise intensity, respectively, over 12 wk. This intensity serves as a natural progression for those completing phase 1, which prescribes lower intensity and aligns with the ACSM guidelines. Phase 2 is designed to continue adherence to

Figure 2: Overview of the Phase Program.

http://www.acsm-tj.org Translational Journal of the ACSM 47

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

the principles of individuality and specificity and to begin incorpo- rating progressive overload based on physiological assessment re- sults and treatment-related functional deficits. Therefore, the goal of phase 2 is to reduce the physical and functional limitations cre- ated by cancer treatment and to improve cardiovascular and mus- cular function. An additional focus of phase 2 is to build a foundational base using corrective and functional training with an emphasis on developing and stabilizing the core, pelvic floor, shoulder girdle, or any other joints or muscles affected by surgery, hormonal treatments, as well as the long-term effects of chemo- therapy or radiotherapy. Stabilizer muscles such as the core, pelvic floor, and shoulder girdle may be prominently affected by cancer and its treatments (18). Strengthening these components will im- prove functional capacity, assist with activities of daily living, and enhance general movement patterns that are key to optimiz- ing outcomes in subsequent phases.

PHASE 3

Phase 3 is designed for cancer survivors who have completed phase 2. This is the final phase of what is considered “true cancer rehabilitation” and allows the participant to transition to an exer- cise intervention prescribed for the apparently healthy population. As phase 3 represents the last phase of cancer rehabilitation, a major goal is to teach participants the specific skills necessary to implement and maintain an exercise program on their own. Participants should transition from phase 3 with the ability to per- form exercises with self-efficacy, they should have an understanding of proper technique to avoid injury, and they should have a founda- tional grasp of exercise training principles to create progression. This goal exists to support the principles of diminishing returns and reversibility. Phase 3 also aims to improve physiological and psychological parameters beyond phase 2 and to incorporate the principle of progressive overload to the highest extent during cancer rehabilitation. At the completion of this phase, cancer survivors should achieve a categorical classification at or near apparently healthy status for all physiological assessment variables. Phase 3 training is classified as moderate to high, and intensities range be- tween 60% and 85% of HRR and EST 1-RM. The rate of progres- sion is modest, representing a 5%–15% and a 30%–50% range of increase in aerobic and resistance exercise intensity, respectively, over 12 wk. This range has been deemed appropriate for vigorous exercise in the cancer population (17) and can elicit overload.

PHASE 4

Phase 4 is designed for those who have completed phase 3. This phase has no time limits on its duration and is meant to assist can- cer survivors in the maintenance of physical activity and a healthy lifestyle. The exercise intensity can vary between 65% and 95% of HRR and EST 1-RM during this phase and is dependent on the patient’s goals. Phase 4 can be conducted independently by the cancer survivor, one on one with a certified CCES, or in a group setting.

Statistical Analysis Individual paired-sample t-tests were used to determine whether

significant differences occurred in cardiovascular endurance, MS, and fatigue during each phase transition. The statistical package G*Power (3.1.9.2) was used to calculate statistical power. Individ- ual paired-sample t-tests were used to obtain a power of 0.95 with a medium effect size. According to the statistical program, to achieve a power of 0.95, each statistical test suggested an N of at least 47, which was met by all phase transitions. A Bonferroni adjustment was used to reduce the chance of committing type I error. The fol- lowing dependent variables were measured: V̇O2peak, EST 1-RM of the leg press, EST 1-RM of the chest press, and fatigue. The

following phase transitions (assessment vs reassessment) were eval- uated: phase 1 to phase 2, phase 2 to phase 3, and phase 3 to phase 4. The statistical package G*Power (3.1.9.2) was used to calculate the power of the statistics. All data are presented as mean ± SD, and statistical analyses were performed using the Statistical Package for

TABLE 1. Participant Demographics and Treatment Characteristics.

Demographic Characteristics N = 183

Male, n 70 (38%)

Female, n 113 (62%)

Age, yr 61 ± 13

Height (cm) 167 ± 10

Weight (kg) 79 ± 20

Cancer types N (%)

Breast 67 (37%)

Liquid 21 (12%)

Prostate 18 (10%)

Lung 18 (10%)

Head and neck 15 (8%)

Colorectal 11 (7%)

Gynecological 10 (6%)

Other 23 (13%)

Cancer stage N (%)

I 43 (24%)

II 45 (25%)

III 44 (24%)

IV 30 (16%)

Unknown/not staged 21 (12%)

Treatment demographics N (%)

Surgery only 25 (14%)

Chemotherapy only 19 (10%)

Radiation only 6 (3%)

Surgery and chemotherapy only 49 (27%)

Surgery and radiation only 31 (17%)

Chemotherapy and radiation only 6 (3%)

Surgery, chemotherapy, and radiation 45 (25%)

No treatment 2 (1%)

Average months since treatment 7.4 ± 15

Data are presented as the mean and frequency (percent) or mean ± SD.

48 Volume 4 • Number 7 • April 1 2019 Phase Program for Cancer Survivors

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

the Social Sciences software package (SPSS, Chicago, IL). All anal- yses were two-tailed, and an alpha level of 0.05 was used to define statistical significance.

RESULTS Table 1 displays the demographic characteristics of all

participants. A total of 183 cancer survivors were included in the study (70 males and 113 females) with a mean age of 61 ± 13 yr. Breast cancer survivors represented 37% of partic- ipants, with similar numbers representing liquid (12%), pros- tate (10%), and lung cancers (10%). Cancer stages I, II, and III were represented near equally (24%, 25%, and 24%, re- spectively), and 16% were diagnosed as stage IV. Of the partic- ipants, 65% underwent chemotherapy and 25% received all three major treatment modalities (surgery, chemotherapy, and radiation). On average, patients entered this study 7.4 months after treatment was completed, whereas 38% entered this study during chemotherapy and/or radiation treatment.

Of the 183 program participants, 81 (44%) completed the entire Phase Program and entered phase 4. The mean atten- dance for all subjects was 80% ± 3.8%, and the average reten- tion was 71% between each phase transition. Retention rate for phase 1 was 69% (i.e., 69% of the patients completing phase 1 entered phase 2). Of the 70 patients who entered the program at phase 1, 18 remained in treatment and completed a postassessment as phase 1 (i.e., phase 1 to 1 transition). Including those who remained in phase 1 for treatment contin- uation, total retention was 94%. The average retention rate for those who transitioned from phase 2 was 88%. Specifically, retention for those patients who entered the program at phase 2 was 83%, whereas retention was 100% in those who entered phase 2 after graduation from phase 1. Finally, retention rate for those completing phase 3 was 57% (Table 2).

Changes in Peak Volume of Oxygen Consumption, MS, and Fatigue

Table 3 summarizes absolute values (pre- to posttreatment) for all phase transitions for V̇O2peak (mL·kg

−1·min−1), leg press MS (kg), chest press MS (kg), and fatigue. Fig. 3 depicts mean percent change in V̇O2peak, leg press MS, chest press MS, and fatigue. Ad- ditional assessment data and results can be viewed online (Supple- mental Content 4, http://links.lww.com/TJACSM/A34).

PHASE 1 TO 2 TRANSITION

Statistically significant improvements were observed in V̇O2peak (P < 0.001), leg press MS (P < 0.05), chest press MS (P < 0.001), and fatigue (P < 0.001) when comparing data obtained at entry into phase 1 versus data obtained after completion of phase 1 (i.e., entry into phase 2). Mean percent changes in V̇O2peak, leg press MS, and chest MS were 13%, 13%, and 18%, respectively. Mean values of fatigue decreased as a result of completing phase 1, lowering the fa- tigue classification from “moderate” to “mild” according to the Piper Fatigue Inventory.

PHASE 2 TO 3 TRANSITION

When comparing data obtained at entry into phase 2 versus data obtained after completion of phase 2 (i.e., entry into phase 3), sig- nificant improvements were observed in V̇O2peak (P < 0.001), leg press MS (P < 0.001), chest press MS (P < 0.001), and fatigue (P < 0.001). Mean percent changes in V̇O2peak, leg press MS, and chest MS were 14%, 19%, and 26%, respectively. Mean values of fatigue decreased, as a result of completing phase 2, lowering the fatigue classification from “moderate” to “mild.”

Initial assessment values for those entering the program at phase 2 who had undergone chemotherapy and/or radiation before starting the Phase Program were evaluated against those who grad- uated from phase 1 to determine whether the effectiveness of the phase 1 intervention was due to the exercise prescription or the spontaneous healing effect of time. For those patients entering the program at phase 2, mean values for V̇O2peak, leg press, chest press, and fatigue were 19.7 ± 7.0 mL·kg−1·min−1, 79.2 ± 34 kg, 30.1 ± 18 kg, and 4.8 ± 2.2, respectively. These values are signif- icantly lower (P < 0.05) when compared with values observed in those who completed phase 1 and transitioned to phase 2. In ad- dition, fatigue was significantly (P < 0.001) elevated in those entering as phase 2 after treatment.

PHASE 3 TO 4 TRANSITION

Significant improvements were observed in V̇O2peak (P < 0.05) and chest press MS (P < 0.05) when comparing data obtained at entry into phase 3 versus data obtained after completion of phase 3 (i.e., entry into phase 4). Mean percent change of V̇O2peak, leg press MS, and chest MS were 4%, 5%, and 7%, respectively. Mean values of fatigue decreased during this transition but re- mained at a “mild” Piper Fatigue Inventory classification.

Changes in Patients Who Completed the Entire Phase Program (Entry to Phase 4)

In the 81 patients who completed the Phase Program and en- tered phase 4, significant improvements were observed in V̇O2peak (21.0 ± 6.8 to 26.1 ± 7.3 mL·kg−1·min−1; P < 0.001), leg press MS (78.6 ± 31 to 105.8 ± 41 kg; P < 0.001), chest press MS (26.3 ± 17 to 39.2 ± 19 kg; P < 0.001), and fatigue (4.9 ± 2.2 to 3.2 ± 2.2; P < 0.001). Total mean percent change for V̇O2peak, leg press MS, chest press MS, and fatigue were 24%, 35%, 49%, and −35%, respectively (Fig. 3). For those patients completing the Phase Program, mean values of fatigue decreased yielding a mild classification.

TABLE 2. Retention between Phase Transitions.

Phase Transition

Entry (n)

Completion (n)

Retention (%)

Phase 1 to phase 2 70 48 69

Phase 1 to 1 18 26

Phase 2 to phase 3 161 142 88

Phase 2 at entry 113 94 83

Phase 1 Graduates 48 48 100

Phase 3 to phase 4 142 81 57

Entry as phase 1 or 2 183 81 44

Phase 1 to 1: patients in phase 1 who completed a reassessment but re- mained in phase 1 due to treatment continuation.

Phase 2 at entry: patients who did not participate in phase 1 and started the program in phase 2 after treatment.

Phase 1 graduates: patients who started and completed the program in phase 1 and then entered phase 2.

Entry as phase 1 or 2: patients who completed the entire Phase Program by starting in phase 1 or 2.

http://www.acsm-tj.org Translational Journal of the ACSM 49

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

DISCUSSION Exercise-based interventions are widely considered a via-

ble method of cancer rehabilitation because of the clear evi- dence that exercise improves functional capacity, reduces cardiovascular disease risk factors (19), decreases mortality (20), may limit the risk of cancer recurrence (21,22), and im- proves QOL (23). The Phase Program of our SCM for cancer rehabilitation elicited improvements in cardiovascular endur- ance, MS, and fatigue during all phase transitions, and only leg MS and fatigue resulted in nonsignificant improvement in those transitioning from phase 3 to phase 4. Substantial im- provements occurred across each phase in those who completed the entire program, suggesting the effective use of progressive overload and individuality throughout the program.

The standardization and consistency of medical screening and assessments between each phase transition is critical for the successful use of the Phase Program. Although each phase prescribes an appropriate range for starting intensities and rates of progression, essentially governing the use of the princi- ple of progressive overload, the clinician truly individualizes the exercise intervention. This is accomplished through the use and interpretation of the patients’ comprehensive assess- ment results and corresponding classifications. Higher levels of functioning will result in the creation of an

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