In the United States, more than 1.9 million people are diagnosed with cancer annually.1 Largely due to improved medical management and targeted treatment techniques, there are an estimated 16.9 million survivors of cancer living across the United States.2 With improved survival, the long-term effects of cancer treatment have become evident; chronic health complaints in survivorship may include cardiac impairments, increased body mass index, peripheral neuropathies, and low bone mineral density (BMD).3 As a result of treatment side effects, health-related quality of life is negatively impacted for survivors.4,5 Physical activity improves functional capacity and health-related quality of life for patients during and after cancer treatment6; however, adverse effects associated with antineoplastic agents, including nausea, fatigue, and depression, act as barriers to participation.7 The lack of participation in physical activity results in sarcopenia, furthering the decline of functional capacity and quality of life.8

Whole-body vibration (WBV) is a noninvasive, nonpharmacological modality that can be used to treat impairments caused by cancer treatment without worsening side effects of antineoplastic treatment.9 WBV units consist of flat vibrating platforms that oscillate in various directions at user-defined frequencies and intensities. Closed-chain exercises can be performed in various positions including standing, sitting, and quadruped. Exercise intensity can be adjusted by the therapist to suit the needs of individual patients. Existing studies have demonstrated improved aerobic capacity, pain, muscular strength, BMD, urinary incontinence, balance, and peripheral nerve stimulation.9-18 Mechanical oscillation during WBV results in reactive forces within the body impacting various systems.19 Muscular hypertrophy is thought to be achieved through repetitive contraction and relaxation of fibers and cyclical concentric-eccentric muscle lengthening.19 Acting as an osteogenic stimulus, WBV safely provides benefits for those with lower BMD.20 Animal studies have demonstrated the use of mechanical vibration to be beneficial in the preservation of BMD for mice with ovarian cancer without negatively affecting longevity or promoting tumor progression.21 With the application of low-magnitude, high-frequency stimuli, WBV may safely reduce negative effects of antineoplastic treatment for patients with cancer diagnoses.9-12,14-18,22

Despite promising results in the literature, current utilization and clinician awareness of WBV as a treatment technique for patients with cancer diagnoses are unknown. The aims of this study were to (1) determine the current practices in the use of WBV for cancer rehabilitation across the United States, (2) highlight perceived benefits, indications, and barriers of the use of WBV for patients with cancer, and (3) assess clinician willingness to consider utilization of WBV, particularly for those treating the pediatric population. It is hypothesized that current utilization across the United States will be low, but clinicians will be willing to implement WBV as a treatment method.

METHODS

A Web-based survey was created to assess current knowledge, usage, and perceived benefits and barriers of clinicians regarding the use of WBV as a treatment technique. Participants were included if they held a health care license, provide care for patients with cancer diagnoses, and were able to complete the survey in its entirety. Consent was gained prior to completion of the survey. This study was granted exemption following review by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center.

Survey Development

A 28-item survey was developed to observe current practices and clinician perceptions regarding WBV. Visual analog scales (VAS; scaled 0-10) were included to measure current knowledge of, perceived benefits of, and willingness to implement WBV. Knowledge was rated from no knowledge to excellent knowledge, benefits were rated from worsen to improve, and willingness to implement ranged from unwilling to very willing. Appropriateness of various diagnoses and perceived barriers were also assessed (see Survey, Supplemental Digital Content, available at: https://links.lww.com/REHABONC/A57). The survey was assessed for face validity, which was completed by clinicians (occupational therapists and physical therapists [PTs]), administrators, and researchers through a survey feedback form that assessed clarity, response completeness, and navigation. Following assessment of face validity, surveys were distributed to potential respondents in November 2021 and remained accessible for 3 months.

Data Collection

Data were collected through the survey built on the Research Electronic Data Capture (REDCap) platform. Recruitment was achieved by sending e-flyers to professional organization’s mailing lists, in addition to social media posts on various professional pages. e-Flyers and social media posts contained a link to the survey.

Data Analysis

Analysis was performed using R (version 4.1), Microsoft Excel, and SPSS for MacOS (version 28.0; IBM Corp, Armonk, New York). Analysis was completed using frequencies, percentages, mean, and standard deviations (SD) of the data.

RESULTS

A total of 98 responses were collected over 3 months, with 72 fully completed survey responses meeting inclusion criteria for analysis.

Demographics

Respondent demographics are included in Table 1. Professions included PTs (69.4%), occupational therapists (16.7%), physicians (9.7%), and nurse practitioners (2.8%). Most respondents reported working in inpatient (43.1%) and outpatient (47.2%) practice settings. The majority of clinicians provided care for pediatric populations (41.7%) and had served clinically for 0 to 5 years (27.8%) or 6 to 10 years (25.0%).

TABLE 1 - Survey Respondent Demographics (N = 72) n (%) Profession  Physical therapist 50 (69.4)  Occupational therapist 12 (16.7)  Physician 7 (9.7)  Nurse practitioner 2 (2.8)  Other 1 (1.4) Practice setting  Outpatient 34 (47.2)  Inpatient 31 (43.1)  Other 7 (9.7) Patient population served  Pediatrics 48 (41.7)  Adolescents/Young adults 35 (30.5)  Adults 32 (27.8) Highest level of education  Doctoral degree 39 (54.2)  Master’s degree 20 (27.8)  MD/DO 7 (9.7)  Undergraduate 4 (5.6)  PhD 2 (2.8) Years of clinical practice  0-5 y 20 (27.8)  6-10 y 18 (25.0)  20+ y 14 (19.4)  11-15 y 12 (16.7)  16-20 y 8 (11.1)
Current Utilization and Knowledge of WBV

Only 2 (2.78%) respondents were currently using WBV for patients with cancer diagnoses in their clinical practice. The clinicians reported using WBV twice per week. Awareness of WBV as an intervention in patients with cancer diagnoses was low among respondents, with 31% (n = 22) of respondents stating awareness of WBV for patients with cancer diagnoses. Clinicians ranked their level of knowledge of WBV at an average VAS score of 1.89 (SD = 2.36).

Perceived Benefits

Respondents indicated that WBV could be used safely during both active treatment (outpatient: 76.4%; bone marrow transplantation: 58.4%; inpatient: 48.6%) and survivorship (76.4%). Respondents felt that WBV would be most useful during active outpatient treatment (70.8%).

Perceived system benefits ranked on a 10-point VAS are included in Figure 1. The highest-ranking perceived benefits for WBV included blood flow, BMD, proprioception, pain, and sensory peripheral neuropathy. Respondents rated WBV to be less impactful on aerobic capacity, flexibility, and lymphedema.

Fig. 1.:

Perceived benefits of whole-body vibration on body systems. BMD indicates bone mineral density; PN, peripheral neuropathy.

Perceived Barriers

When asked to highlight barriers for using WBV for patients with cancer, most respondents reported lack of trained clinicians (81.7%), access to equipment (74.6%), cost of equipment (73.2%), risk of fracture (47.9%), and lack of supportive research (43.7%). Details of all barriers are included in Table 2.

TABLE 2 - Perceived Barriers to WBV Implementation Barrier n (% of Respondents Reporting) Lack of trained clinicians 58 (81.7) Access to equipment 53 (74.6) Cost of equipment 52 (73.2) Risk of fracture 34 (47.9) Lack of supportive research 31 (43.7) Time taken to perform WBV 20 (28.2) Patient perception/Apprehension 20 (28.2) Risk of falls 19 (26.8) Setup time of unit 18 (25.4) Family perception/Apprehension 16 (22.5) Other 5 (7.0) Risk of infection 2 (2.8)

Abbreviation: WBV, whole-body vibration.

Perceived Appropriate and Inappropriate Diagnoses

Responses are included in Figure 2. Respondents selected the most appropriate diagnoses for WBV to be leukemia/lymphoma (63.6%), lymphedema (50.6%), central nervous system cancers (49.4%), and neuroblastoma (46.8%). The 2 diagnoses selected as most inappropriate for WBV were bone tumors (49.4%) and head and neck cancers (24.7%).

Fig. 2.:

Appropriate and inappropriate diagnoses to receive whole-body vibration. CNS indicates central nervous system.

Willingness to Implement WBV

Clinician willingness to implement WBV on average was ranked at 7.32 (SD = 1.90) on a 10-point VAS.

DISCUSSION

This is the first study examining clinician knowledge, usage, and perceptions of WBV for patients with cancer diagnoses. Responses suggested low current utilization and awareness of WBV as a treatment technique for patients with cancer diagnoses across disciplines and practice environments. Only 30.6% of clinicians stated that they were aware of WBV, and less than 3% of respondents used WBV for this patient population. Despite low awareness, respondents expressed willingness to use WBV and believed that it was safe to implement across the continuum of cancer care. The results of this study align with literature suggesting that WBV is feasible and safe for patients undergoing active chemotherapy treatment and into survivorship.9-12,14-18,22-24

Perceived appropriateness of WBV varied depending upon diagnosis. Patients with hematological cancers were perceived as the most appropriate candidates to receive WBV. This aligns with existing literature suggesting WBV for patients with hematological cancer diagnoses is feasible, safe, and potentially improves functional ability.9,15 The most commonly studied diagnosis in existing literature, breast cancer,18,22,23 was ranked the sixth most appropriate diagnosis in this survey’s results, falling behind other diagnoses, such as central nervous system cancers and neuroblastoma, which have not been previously studied. Less than 40% of respondents felt that WBV was appropriate for prostate and lung cancers diagnoses, contradicting literature that suggests WBV is in fact safe and feasible for both diagnoses.12,14,17 Bone cancers were the most reported inappropriate diagnosis for treatment with WBV, likely as a result of the increased risk of fracture caused by disruption to bone integrity.25 Patients with bone cancer were also commonly excluded from previous studies,9,16,23 suggesting good agreement between survey and existing literature.

In pediatric populations, such as cerebral palsy, WBV has been demonstrated to be a noninvasive method of providing improved bone health, muscular strength, balance, gait, and motor skills while decreasing spasticity.26-31 Similar benefits have been demonstrated for those with cancer diagnoses; however, results are contradictory between studies. This adds to the confusion as to the true effect of WBV on body systems. Alignment with previous literature is demonstrated, with respondents suggesting BMD, proprioception, and pain are among the systems most likely to benefit from WBV. Surprisingly, respondents identified improved blood flow as the greatest benefit of WBV. To the authors’ knowledge, this has not been empirically studied in patients with cancer diagnoses; however, WBV has been shown to increase blood flow in patients with diabetes and spinal cord injuries.32,33 The effect of increased blood flow in patients receiving intravenous chemotherapy is not known, though animal studies conclude that neither disease progression nor worsening of prognosis occurred using WBV.21 Interestingly, respondents indicated they were less certain about positive effects on aerobic capacity. The average survey response for aerobic capacity was neutral (5/10 on the VAS). In contrast, WBV has been stated to be a practical intervention to improve aerobic capacity post–cancer treatment.13

WBV is used as an adjunct to standard intervention in existing literature and does not appear to substitute for conventional resistive equipment.14 WBV may complement existing therapy interventions, though resistance activities may need to be adapted to allow performance using the vibrating platform. Nearly all studies examining WBV in patients with cancer have examined the effect of WBV with participants performing body weight resisted exercise while standing on the WBV platform, with results varying between studies.9,14,16-18,22 Only one study examined the effects of WBV on participants who stood without actively exercising while on the WBV platform; no significant improvements between the control and intervention groups were demonstrated.23 Further study is needed to examine the parameters and exercise format using WBV that may provide optimal improvements for patients with cancer diagnoses.

The greatest potential that WBV offers for patients with cancer diagnoses is in the prevention of osteopenia, sarcopenia, and other side effects of antineoplastic treatment. Careful investigation for the most appropriate time to implement WBV for optimal effect is key to understanding and harnessing potential positive effects. More than 70% of survey respondents selected active treatment on an outpatient basis and into survivorship as the most useful and safe time to implement WBV. Respondents were less certain that patients receiving active treatment while inpatient would be a useful and safe time for WBV. This is possibly due to the increased acuity of patients admitted for treatment and fear of interference of WBV on the effect of chemotherapy. Although both exercise and WBV have been demonstrated to be plausible interventions during inpatient intensive chemotherapy without side effects or adverse events,9,34 other studies continue to exclude patients concurrently receiving chemotherapy.18

Barriers to using WBV identified by respondents must be overcome to improve clinical application. Risk of fracture was reported as a barrier to using WBV despite no such events being reported in existing literature. Risk of fracture when using WBV, as with exercise, should remain a consideration for clinicians when choosing appropriate patients. Previously reported adverse events include syncope and increased upper extremity edema.23 To overcome barriers of cost and access to equipment, future research must include high-quality, adequately powered randomized controlled trials to provide clear justification of cost and value added to patient outcomes using WBV.

Limitations of this study include the recruitment methods, small sample size, and a survey with only face validity that limits larger generalization of results. The high proportion of PTs responding to the survey may limit generalizations to other clinicians; however, it is likely that PTs will be most likely to use this modality. It is possible that clinicians with an interest or underlying knowledge of this survey topic were more motivated to provide responses, thus overinflating the current level of knowledge of WBV. A further limitation of this study was our convenience sampling of clinicians in pediatric institutions. Future knowledge and research are needed to understand clinical use of WBV with children and adolescents compared with the adult population.

CONCLUSIONS

Awareness of WBV as a treatment intervention for cancer diagnoses is low among health care professionals. Most clinicians would be willing to use WBV and feel it is safe to use as part of a cancer rehabilitation program throughout the oncology continuum of care. More research is needed to determine the appropriate timing and dosage of this intervention. The greatest perceived benefits reported by respondents target frequently affected systems following antineoplastic treatment, offering hope for symptom relief for patients. Mitigation of barriers to enable clinical application of WBV, continued collaboration on the management of side effects related to antineoplastic treatment, and future studies in the use of WBV for cancer diagnoses are warranted.

STUDY DETAILS Author Contributions Role Author Conceptualization BR, JBer, KM, MS, KG Data curation BR Formal analysis JBen Funding acquisition Investigation BR Methodology BR, JBer, KM, KG Project administration BR Resources Software JBen Supervision MS KG Validation Visualization JBen Writing – original draft BR, JBer, JBen, KG Writing – review & editing BR, JBer, KM, MS, JBen, KG
Funding

Intradepartmental funds from the Division of Clinical Therapies at Nationwide Children’s Hospital funded biostatistician support.

Ethics Approval

Consent was gained prior to completion of the survey. This study was granted exemption following review by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center.

Data Sharing Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

ACKNOWLEDGMENTS

The authors are grateful to Ms Sula Bernstein for her valuable input and suggestions. The authors are also grateful to Mss McKenzie Stevens, Alisha Pratt, Jessica Lloyd, and Kelli Hobart for their role in the development of the survey.

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