Endurance and resistance training in patients with acute leukemia undergoing induction chemotherapy—a randomized pilot study



Acute leukemia (AL) and its initial treatment can impair physical functioning and capacity significantly. Exercise as a countermeasure has been investigated in few studies confirming its feasibility and safety during intensive induction chemotherapy, but the relative effects of diverse exercise programs have not been analyzed. Therefore, we aimed to investigate independent effects of endurance and resistance training on physical capacity and quality of life (QOL).


Twenty-nine adult AL patients were randomly allocated to an endurance (EG), resistance (RG), or control (CG) group. The intervention took place during induction chemotherapy with three exercise sessions per week for 30–45 min each. Endurance capacity at individual anaerobic threshold, maximum knee extension and flexion strength, standardized phase angle (SPA), and QOL were measured at baseline prior to induction chemotherapy and before discharge.


Endurance capacity changed in neither the EG, RG, or CG (P = 0.104); descriptively, the EG (− 0.05 W/kg) and RG (− 0.04 W/kg) exhibited a smaller decrease than CG (− 0.22 W/kg). We noted a significant difference in knee extension strength (P = 0.002); RG improved their maximum strength (+ 0.14 Nm/kg), while the EG’s (− 0.13 Nm/kg) and CG’s (− 0.19 Nm/kg) was significantly reduced. QOL and SPA revealed no change after the intervention.


We conclude that resistance training is a key component when exercising during induction chemotherapy: it improved maximum strength, but also influenced endurance capacity even during intensive treatment. Considering the prognostic value of physical function, we strongly propose integrating exercise, especially resistance-based training, already during induction chemotherapy to preserve AL patients’ physical capacity and functional status.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Subscribe to journal

Immediate online access to all issues from 2019. Subscription will auto renew annually.

US$ 199

This is the net price. Taxes to be calculated in checkout.

Fig. 1
Fig. 2


  1. 1.

    Deschler B, Ihorst G, Platzbecker U, Germing U, Marz E, de Figuerido M, Fritzsche K, Haas P, Salih HR, Giagounidis A, Selleslag D, Labar B, de Witte T, Wijermans P, Lubbert M (2013) Parameters detected by geriatric and quality of life assessment in 195 older patients with myelodysplastic syndromes and acute myeloid leukemia are highly predictive for outcome. Haematologica 98:208–216.

  2. 2.

    Redaelli A, Stephens JM, Brandt S, Botteman MF, Pashos CL (2004) Short- and long-term effects of acute myeloid leukemia on patient health-related quality of life. Cancer Treat Rev 30:103–117.

  3. 3.

    Miller KD, Siegel RL, Lin CC, Mariotto AB, Kramer JL, Rowland JH, Stein KD, Alteri R, Jemal A (2016) Cancer treatment and survivorship statistics, 2016. CA Cancer J Clin 66:271–289.

  4. 4.

    Klepin HD (2016) Definition of unfit for standard acute myeloid leukemia therapy. Curr Hematol Malig Rep 11:537–544.

  5. 5.

    Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvão DA, Pinto BM, Irwin ML, Wolin KY, Segal RJ, Lucia A, Schneider CM, von Gruenigen V, Schwartz AL, American College of Sports Medicine (2010) American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc 42:1409–1426.

  6. 6.

    Smith-Turchyn J, Richardson J (2015) A systematic review on the use of exercise interventions for individuals with myeloid leukemia. Support Care Cancer 23:2435–2446.

  7. 7.

    Bergenthal N, Will A, Streckmann F et al (2014) Aerobic physical exercise for adult patients with haematological malignancies. Cochrane Database Syst Rev (11):CD009075

  8. 8.

    Battaglini CL (2011) Physical activity and hematological cancer survivorship. Recent Results Cancer Res 186:275–304.

  9. 9.

    Bryant AL, Deal AM, Battaglini CL, Phillips B, Pergolotti M, Coffman E, Foster MC, Wood WA, Bailey C, Hackney AC, Mayer DK, Muss HB, Reeve BB (2017) The effects of exercise on patient-reported outcomes and performance-based physical function in adults with acute leukemia undergoing induction therapy: exercise and quality of life in acute leukemia (EQUAL). Integr Cancer Ther 17:263–270.

  10. 10.

    Alibhai SMH, Durbano S, Breunis H, Brandwein JM, Timilshina N, Tomlinson GA, Oh PI, Culos-Reed SN (2015) A phase II exercise randomized controlled trial for patients with acute myeloid leukemia undergoing induction chemotherapy. Leuk Res 39:1178–1186.

  11. 11.

    Alibhai SMH, O’Neill S, Fisher-Schlombs K, Breunis H, Brandwein JM, Timilshina N, Tomlinson GA, Klepin HD, Culos-Reed SN (2012) A clinical trial of supervised exercise for adult inpatients with acute myeloid leukemia (AML) undergoing induction chemotherapy. Leuk Res 36:1255–1261.

  12. 12.

    Klepin HD, Danhauer SC, Tooze JA, Stott K, Daley K, Vishnevsky T, Powell BL, Mihalko SL (2011) Exercise for older adult inpatients with acute myelogenous leukemia: a pilot study. J Geriatr Oncol 2:11–17.

  13. 13.

    Battaglini CL, Hackney AC, Garcia R, Groff D, Evans E, Shea T (2009) The effects of an exercise program in leukemia patients. Integr Cancer Ther 8:130–138.

  14. 14.

    Chang P-H, Lai Y-H, Shun S-C, Lin LY, Chen ML, Yang Y, Tsai JC, Huang GS, Cheng SY (2008) Effects of a walking intervention on fatigue-related experiences of hospitalized acute myelogenous leukemia patients undergoing chemotherapy: a randomized controlled trial. J Pain Symptom Manag 35:524–534.

  15. 15.

    Padilha CS, Marinello PC, Galvão DA, Newton RU, Borges FH, Frajacomo F, Deminice R (2017) Evaluation of resistance training to improve muscular strength and body composition in cancer patients undergoing neoadjuvant and adjuvant therapy: a meta-analysis. J Cancer Surviv 11:339–349.

  16. 16.

    Coyle EF, Martin WH, Ehsani AA, Hagberg JM, Bloomfield SA, Sinacore DR, Holloszy JO (1983) Blood lactate threshold in some well-trained ischemic heart disease patients. J Appl Physiol 54:18–23

  17. 17.

    Gupta D, Lammersfeld CA, Burrows JL, Dahlk SL, Vashi PG, Grutsch JF, Hoffman S, Lis CG (2004) Bioelectrical impedance phase angle in clinical practice: implications for prognosis in advanced colorectal cancer. Am J Clin Nutr 80:1634–1638

  18. 18.

    Paiva SI, Borges LR, Halpern-Silveira D, Assunção MCF, Barros AJD, Gonzalez MC (2011) Standardized phase angle from bioelectrical impedance analysis as prognostic factor for survival in patients with cancer. Support Care Cancer 19:187–192

  19. 19.

    Schwenk A, Beisenherz A, Romer K et al (2000) Phase angle from bioelectrical impedance analysis remains an independent predictive marker in HIV-infected patients in the era of highly active antiretroviral treatment. Am J Clin Nutr 72:496–501

  20. 20.

    Urbain P, Birlinger J, Ihorst G, Biesalski HK, Finke J, Bertz H (2013) Body mass index and bioelectrical impedance phase angle as potentially modifiable nutritional markers are independent risk factors for outcome in allogeneic hematopoietic cell transplantation. Ann Hematol 92:111–119.

  21. 21.

    Bosy-Westphal A, Danielzik S, Dörhöfer R-P, Later W, Wiese S, Müller MJ (2006) Phase angle from bioelectrical impedance analysis: population reference values by age, sex, and body mass index. JPEN J Parenter Enteral Nutr 30:309–316.

  22. 22.

    Fayers P, Bottomly A (2002) Quality of life research within the EORTC— the EORTC QLQ-C30. Eur J Cancer 38:125–133

  23. 23.

    Frey I, Berg A, Grathwohl D, Keul J (1999) Freiburger Fragebogen zur körperlichen Aktivität-Entwicklung, Prüfung und Anwendung. Soz- Präventivmedizin SPM 44:55–64.

  24. 24.

    Dimeo F, Schwartz S, Wesel N, Voigt A, Thiel E (2008) Effects of an endurance and resistance exercise program on persistent cancer-related fatigue after treatment. Ann Oncol 19:1495–1499.

  25. 25.

    Knols R, Aaronson NK, Uebelhart D, Fransen J, Aufdemkampe G (2005) Physical exercise in cancer patients during and after medical treatment: a systematic review of randomized and controlled clinical trials. JClinOncol 23:3830–3842

  26. 26.

    Borg G (1982) Psychophysical bases of perceived exertion. Med Sci Sports Exerc 14:377–381

  27. 27.

    Julious SA (2005) Sample size of 12 per group rule of thumb for a pilot study. Pharm Stat 4:287–291.

  28. 28.

    Barbosa-Silva MCG, Barros AJD (2005) Bioelectrical impedance analysis in clinical practice: a new perspective on its use beyond body composition equations. Curr Opin Clin Nutr Metab Care 8:311–317

  29. 29.

    Norman K, Stobäus N, Zocher D, Bosy-Westphal A, Szramek A, Scheufele R, Smoliner C, Pirlich M (2010) Cutoff percentiles of bioelectrical phase angle predict functionality, quality of life, and mortality in patients with cancer. Am J Clin Nutr 92:612–619.

  30. 30.

    Rao AV (2016) Fitness in the elderly: how to make decisions regarding acute myeloid leukemia induction. Hematol Am Soc Hematol Educ Program 2016:339–347.

  31. 31.

    Wedding U, Röhrig B, Klippstein A, Fricke HJ, Sayer HG, Höffken K (2006) Impairment in functional status and survival in patients with acute myeloid leukaemia. J Cancer Res Clin Oncol 132:665–671.

  32. 32.

    Hickson RC, Marone JR (1993) Exercise and inhibition of glucocorticoid-induced muscle atrophy. Exerc Sport Sci Rev 21:135–167

  33. 33.

    LaPier TK (1997) Glucocorticoid-induced muscle atrophy. The role of exercise in treatment and prevention. J Cardiopulm Rehabil 17:76–84

  34. 34.

    Adamsen L, Quist M, Midtgaard J, Andersen C, Møller T, Knutsen L, Tveterås A, Rorth M (2006) The effect of a multidimensional exercise intervention on physical capacity, well-being and quality of life in cancer patients undergoing chemotherapy. Support Care Cancer 14:116–127

  35. 35.

    Kuehl R, Scharhag-Rosenberger F, Schommer K et al (2015) Exercise intensity classification in cancer patients undergoing allogeneic HCT. Med Sci Sports Exerc 47:889–895.

  36. 36.

    Faude O, Kindermann W, Meyer T (2009) Lactate threshold concepts: how valid are they? Sports Med Auckl NZ 39:469–490

  37. 37.

    Roecker K (2013) Die sportmedizinische Laktatdiagnostik: Technische Rahmenbedingungen und Einsatzbereiche. Dtsch Z Für Sportmed 64:367–371

  38. 38.

    Scharhag-Rosenberger F, Becker T, Streckmann F et al (2014) Studien zu körperlichem Training bei onkologischen Patienten: Empfehlungen zu den Erhebungsmethoden. Dtsch Z Für Sportmed 65:304–313

Download references


We thank all patients who participated in this study. We are grateful to Carole Cürten (English Copy Editor) for proofreading our manuscript and we thank Manfred Baumstark for statistical assistance.


This trial was supported by Baden-Württemberg foundation.

Author information

Correspondence to Anja Wehrle.

Ethics declarations

All patients gave written informed consent for the study protocol and data collection; this pilot study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Commission of the University of Freiburg, Germany.

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wehrle, A., Kneis, S., Dickhuth, H. et al. Endurance and resistance training in patients with acute leukemia undergoing induction chemotherapy—a randomized pilot study. Support Care Cancer 27, 1071–1079 (2019) doi:10.1007/s00520-018-4396-6

Download citation


  • Hematologic neoplasms
  • Hospitalization
  • Exercise therapy
  • Muscle strength
  • Physical endurance
  • Quality of life