Construction of an exercise management protocol for cancer patients with PICC-PORT totally implantable vascular access device

Abstract

Background:

Exercise management for cancer patients with arm peripherally inserted central catheter-PORT (PICC-PORT) requires standardization to prevent complications and optimize outcomes. However, evidence-based exercise protocols specifically designed for these patients are lacking.

Objective:

To develop a comprehensive exercise management protocol for cancer patients with PICC-PORT through systematic investigation and expert consensus.

Methods:

A three-phase approach was employed: (1) semi-structured interviews with 22 oncology nurses to identify practical challenges; (2) systematic evidence synthesis from clinical guidelines and databases; and (3) two-round Delphi consultation with 18 intravenous therapy experts.

Results:

The final protocol comprises five key dimensions with 25 evidence-based measures, including exercise assessment, exercise components, exercise timing, exercise dosage, and exercise precautions. Expert consensus was achieved with authority coefficients of 0.894 and 0.897 for two rounds, and variation coefficients ranging from 0 to 0.22 in the final round.

Conclusions:

This study established a standardized, evidence-based exercise protocol for cancer patients with PICC-PORT. The protocol integrates with established implantation guidelines and provides comprehensive guidance for clinical practice. Future research should evaluate its effectiveness through randomized controlled trials.

Keywords

Peripherally inserted central catheter port cancer exercise scheme construction

Introduction

The PICC-PORT is a totally implantable vascular access device with its reservoir completely embedded in the subcutaneous tissue of the upper arm, following the same catheter route as PICC.¹ With the increasing clinical application of PICC-PORT technology, its associated complications, particularly Central Venous Access Device-related Thrombosis (CRT), have garnered significant attention, with reported incidence rates ranging from 0.99% to 23.3%.^2
–4 The synergistic effect between malignant tumors and central venous catheters can increase the risk of CRT by 2.2–19.5 times.⁵

While proper implantation technique remains fundamental in preventing PICC-PORT-related complications, as emphasized by the SIP port protocol which focuses on appropriate vein selection, materials, and venipuncture technique,⁶ exercise management serves as a valuable complementary approach. The American Standards of Practice for Infusion Therapy recommends exercise therapy for CRT prevention, characterized by easy implementation and high patient compliance.⁷ However, existing research has primarily focused on PICC, with limited evidence regarding exercise protocols specifically designed for PICC-PORT patients.^8
–10

Based on this context, this study aims to develop a complementary exercise management protocol for cancer patients with PICC-PORT through semi-structured interviews, systematic literature evidence synthesis, and expert consultation, providing implementation guidance alongside standard implantation protocols.

Methods

Protocol development process

The exercise protocol was developed through a systematic approach combining semi-structured interviews with 22 oncology nurses, evidence synthesis from clinical guidelines and databases, and a two-round Delphi consultation with intravenous therapy experts. This methodological triangulation ensured the protocol’s practical applicability and evidence-based foundation. This study received ethical approval (Ethics Number: B2024-020-01).

Delphi expert consultation

Development of consultation questionnaire

The research team designed a custom expert consultation questionnaire comprising four sections: ①Preamble: Introduction to the study background, objectives, significance, questionnaire completion instructions, and principal investigator’s contact information; ②Expert Demographics Survey Form: including expert’s name, gender, age, educational background, professional position, years of work experience, institutional affiliation, etc. ③Main Questionnaire Content: Based on the dimensions and items from the protocol draft, the questionnaire employs a 5-point Likert scale to evaluate item importance. Each item includes a modification column for experts to suggest revisions, additions, deletions, and provide comments. Experts are asked to make recommendations based on seven aspects: comprehensive evidence quality, accuracy of description, impact level, benefit-risk balance, cost considerations, feasibility, and appropriateness; ④Authority Assessment Form: Experts self-evaluate their level of familiarity with the subject matter and provide the basis for their judgments based on their expertise and experience.

Selection of expert consultants

Experts in intravenous therapy were selected nationwide through purposive sampling. Selection criteria included: a minimum of 5 years of professional experience; bachelor’s degree or higher education; intermediate or higher professional rank; proficiency in central venous catheter management and maintenance; demonstrated academic influence in the field; willingness to participate; and commitment to complete a minimum of two rounds of consultation during the study period.

Expert consultation process

The expert consultation was implemented between April and July 2024 through email and WeChat platforms. Two rounds of consultation were conducted. Following the first round, the research team analyzed the collected data and synthesized expert opinions. Team meetings were held to discuss and modify items based on selection criteria, leading to the development of the second-round questionnaire, which was distributed 2 weeks later. Items were included based on a mean importance score greater than 4.00 and a coefficient of variation (CV) less than 0.25. After achieving expert consensus through two rounds of consultation, the research team conducted final refinements to develop the final protocol.

Statistical analysis

Data were analyzed using SPSS version 26.0. Quantitative data were expressed as mean ± standard deviation, while qualitative data were presented as frequencies and percentages. Expert participation was evaluated through the effective response rate, and expert authority was assessed using the authority coefficient. The degree of expert consensus was measured using the Coefficient of Variation (CV) and Kendall’s Coefficient of Concordance (W), while the concentration of expert opinions was represented by mean item scores. Statistical significance was defined as p < 0.05.

Results

Expert panel characteristics

Eighteen experts from ten provinces and municipalities (Beijing, Shanghai, Zhejiang, Jiangsu, Guangdong, Guangxi, Hubei, Jiangxi, Sichuan, and Chongqing) completed both rounds of consultation. These experts specialized in intravenous therapy and nursing management. The mean age of the expert panel was 46.61 ± 5.36 years, with an average of 25.78 ± 7.61 years of professional experience. Seven experts (38.90%) held master’s degrees or higher qualifications, and sixteen experts (88.90%) held associate senior professional titles or above.

Expert response rate and authority coefficient

The first round of consultation achieved an effective response rate of 85.71% (18 valid responses from 21 distributed questionnaires), with 15 experts providing specific feedback. The second round achieved a 100.00% response rate (18 out of 18), with 10 experts offering additional comments. The authority coefficients for the first and second rounds were 0.894 and 0.897 respectively, indicating a consistently high level of expert authority throughout the consultation process.

Degree of expert consensus

Analysis of expert opinion coordination showed that in the first round, the Coefficient of Variation (CV) ranged from 0 to 0.35, with Kendall’s Coefficient of Concordance of 0.167 (x² = 87.309, p < 0.05). In the second round, the CV range decreased to 0–0.22, with Kendall’s Coefficient of Concordance of 0.120 (x² = 51.909, p < 0.05). These results indicate satisfactory coordination of expert opinions throughout both consultation rounds.

Results of expert consultation

Following two rounds of Delphi consultation, the final exercise protocol was established with five key dimensions: exercise assessment, exercise components, exercise timing, exercise dosage, and exercise precautions. The protocol consists of 25 evidence-based measures designed to complement standard implantation procedures (Table 1).

Table 1.

Exercise management protocol for cancer patients with PICC-PORT.

Items contents		$\bar{x} \pm s$	CV
1. Exercise assessment	1.1 Patient exhibits stable vital signs and can cooperate with exercise protocols	5.00	0
	1.2 Normal muscle strength in the port-implanted limb	4.89 ± 0.47	0.10
	1.3 Absence of port rotation, poor wound healing, or uncontrollable hemorrhage	4.89 ± 0.47	0.10
2. Exercise components	2.1 Digital flexion-extension: Sequential flexion and extension of all five digits	4.67 ± 0.77	0.16
	2.2 Grip exercise: With an extended arm, grasp a ball on the port-implanted side, and gradually apply force in a grip-and-release pattern (2-s hold, 2-s release) involving finger, wrist, and elbow joints. Intensity should be adjusted to individual maximum tolerable grip strength	4.89 ± 0.47	0.10
	2.3 Wrist rotation: Circumduction of the wrist joint as a pivot point	4.78 ± 0.65	0.14
	2.4 Elbow flexion-extension: 90-degree flexion-extension movement of the forearm relative to the upper arm on the port-implanted side	4.89 ± 0.47	0.10
	2.5 Arm elevation: From the natural pendant position, elevate the port-implanted upper limb to ⩽90° relative to the torso	4.78 ± 0.65	0.14
	2.6 Shoulder rotation: With shoulders depressed, perform clockwise anterior and counterclockwise posterior circumduction, progressively increasing to the maximum achievable amplitude	4.61 ± 0.92	0.20
	2.7 External rotation: With a flexed elbow, maintain forearm parallel to the ground, upper arm adducted, chest elevated, and maximize forearm abduction before returning to the initial position	4.67 ± 0.77	0.16
	2.8 Internal rotation: Support port-implanted elbow anteriorly, move toward contralateral shoulder attempting to reach the ear, limited by the maximum range of motion	4.50 ± 0.99	0.22
	2.9 Translational movement: Posteriorly grasp port-implanted wrist, facilitate parallel movement toward contralateral side, return to initial position within comfort limits	4.44 ± 0.92	0.21
	2.10 Lateral rotation: Initiate cervicoscapular rotation toward contralateral posterior aspect to maximum amplitude, return to initial position, then rotate toward port-implanted side	4.44 ± 0.92	0.21
3. Exercise timing	3.1 Digital flexion-extension may commence on implantation day; other exercises are recommended 24 h post-implantation	4.78 ± 0.65	0.14
4. Exercise dosage	4.1 10–15 repetitions/set, 3 sets/day, minimum duration ⩾2 weeks	4.78 ± 0.65	0.14
5. Exercise precautions	5.1 Avoid high-amplitude or vigorous activities (e.g. basketball, badminton, pull-ups, dumbbell exercises)	5.00	0
	5.2 Avoid prolonged compression of the port-implanted limb during infusion therapy and sleep	5.00	0
	5.3 Protect port from impact, friction, or compression during exercise	5.00	0
	5.4 Discontinue exercise if palpitations or chest discomfort occur	5.00	0
	5.5 Suspend exercise if active bleeding or exudation at the puncture site occurs	5.00	0
	5.6 Cease exercise if swelling or pain develops in the port-implanted arm	5.00	0
	5.7 Peripheral venous thrombosis: Routine immobilization not recommended; limb elevation permitted with normal exercise continuation	4.89 ± 0.47	0.10
	5.8 Deep venous thrombosis: For extensive thrombosis, primarily subclavian vein proximal thrombosis with significant edema in the acute phase (within 2 weeks of onset), elevate affected limb 30°	5.00	0
	5.9 Thrombophlebitis: Avoid extensive movement, massage, and heat application to the thrombotic limb; maintain 30° elevation	5.00	0
	5.10 For pocket hematoma within 24 h post-procedure, apply local cold compression and minimize port-implanted limb movement	4.89 ± 0.47	0.10

Discussion

Reliability of the exercise management protocol for cancer patients with PICC-PORT

This study developed an exercise management protocol through a three-phase approach incorporating semi-structured interviews, evidence synthesis, and Delphi expert consultation. The semi-structured interviews were instrumental in identifying current barriers in exercise management and provided a foundation for the dimensional framework of the protocol. The systematic literature review supplied comprehensive evidence-based support for the initial protocol draft, while the Delphi expert consultation served as a crucial step in protocol refinement, with expert selection being key to ensuring protocol quality.

The study engaged 18 intravenous therapy experts from various provinces and municipalities across China, all possessing extensive knowledge of PICC-PORT infusion technology. The authority coefficients for both consultation rounds were 0.894 and 0.897 respectively, indicating high expert credibility. Expert engagement was demonstrated by 15 and 10 experts providing constructive feedback in the first and second rounds respectively, reflecting strong commitment to the research. Following the second round of consultation, all items achieved a Coefficient of Variation (CV) less than 0.25, indicating strong expert consensus on the protocol content. These methodological strengths and statistical validations collectively demonstrate the reliability of the developed exercise management protocol.

Comprehensiveness of the exercise management protocol for cancer patients with PICC-PORT

The exercise management protocol was constructed across five comprehensive dimensions: exercise assessment, timing, dosage, content, and precautions. Exercise assessment serves as a prerequisite for implementation, addressing a current gap in PICC-PORT patient evaluation. The assessment criteria were specifically designed to focus on factors closely related to PICC-PORT, establishing a foundation for safe exercise implementation.

Following the assessment, exercise content was developed by considering the similarities and differences between PICC-PORT and PICC technologies, incorporating factors such as effectiveness, feasibility, and safety. The exercise content, representing the protocol’s core component, follows a progressive approach based on post-operative risk and exercise complexity. The progression sequence moves from fingers to fist-making, wrist, elbow, shoulder, and neck movements, with detailed specifications for each component. This systematic organization facilitates both clinical instruction by nurses and patient self-management at home.

The protocol quantifies exercise timing and dosage to enhance patient compliance and improve scientific rigor and operational feasibility. Exercise precautions serve as safety measures, clearly outlining situations to avoid and symptoms that warrant exercise cessation. Additionally, specific exercise interventions are provided for potential complications. This comprehensive approach ensures that the protocol addresses all key aspects of exercise management for cancer patients with upper arm ports.

Clinical application value of the exercise management protocol for cancer patients with PICC-PORT

Currently, there is a notable lack of research regarding exercise management for patients with PICC-PORT. Existing studies on central venous catheter exercise protocols are limited, primarily focusing on fist-clenching exercises for PICC patients. Only one study addressing shoulder mobility exercises for PICC-PORT has been identified, though its feasibility and safety were not adequately demonstrated.¹¹ Furthermore, nurses often lack comprehensive knowledge about catheter-related exercises, resulting in insufficient quantification and standardized guidance regarding exercise dosage and content in clinical practice.

Current guidelines and standards merely suggest early exercise implementation without detailing practical specifications. Studies^12
–18 have shown that quantified functional exercises are more effective in preventing thrombosis. Dai et al.¹⁹ investigated the effects of different fist-clenching durations on axillary vein blood flow velocity in PICC patients, finding that a 2-s clench followed by a 2-s release achieved maximum peak blood flow velocity and vascular pressure without causing patient discomfort. Meta-analysis by Liu et al.¹³ indicated that PICC patients exercising for ⩾4 weeks showed better prevention of deep vein thrombosis. Research has shown²⁰ that 92.9% of CRT occurs within 2 weeks post-catheterization. Considering expert feedback regarding the low feasibility of 4-week exercise duration, this protocol recommends an exercise duration of ⩾2 weeks.

Integration with standard implantation protocols

The exercise management protocol developed in this study serves as a complementary approach to established implantation guidelines, particularly the SIP port protocol,⁶ which provides comprehensive guidance for PICC-PORT placement. While proper implantation technique remains fundamental for preventing complications, our exercise protocol aims to enhance post-implantation outcomes through structured physical activity. Future research should evaluate the combined outcomes of the SIP port protocol and exercise management, investigate potential synergistic effects in thrombosis prevention, and develop integrated care pathways incorporating both technical and behavioral interventions. This integrated approach may provide a more comprehensive framework for preventing PICC-PORT-related complications, potentially improving patient outcomes through the combination of optimal implantation techniques and structured exercise management.

Conclusion

This study established an exercise management protocol for cancer patients with PICC-PORT as a complementary approach to standard implantation techniques. While proper device placement following established protocols (such as the SIP port protocol) remains fundamental, structured exercise management may provide additional benefits in preventing complications. Future research should focus on evaluating the integrated effectiveness of proper implantation techniques combined with standardized exercise protocols.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Chinese Nursing Journal Society 2023 Venous Treatment Nursing Special Research Project, ZHHLZZS-202309.

ORCID iDs

Mengna Luo

Zhenming Wu

Zeyin Hu

Jia Li

References

Bertoglio

Cafiero

Meszaros

, et al. PICC-PORT totally implantable vascular access device in breast cancer patients undergoing chemotherapy. J Vasc Access 2020; 21(4): 460–466.

Qiu

Jin

Guo

, et al. Incidence and risk factors of upper limb venous thrombosis in cancer patients with implanted upper arm infusion ports. J Intervent Radiol 2019; 28(3): 242–246.

Ren

Analysis of risk factors for catheter-related thrombosis in breast cancer patients with implanted upper arm infusion ports. (Master’s thesis). Gansu Univ Chin Med 2022.

Goltz

Petritsch

Thurner

, et al. Complications after percutaneous placement of totally implantable venous access ports in the forearm. Clin Radiol 2012; 67(11): 1101–1107.

Zhang

Construction and validation of a risk prediction model for PICC-related thrombosis in cancer patients. Doctoral Dissertation, Sichuan University, China, 2021.

Brescia

Annetta

Pinelli

, et al. A GAVeCeLT bundle for PICC-port insertion: the SIP-Port protocol. J Vasc Access 2024; 25(6): 1713–1720.

Gorski

Hadaway

Hagle

, et al. Infusion therapy standards of practice, 8th edition. J Infus Nurs 2021; 44(1S): S1–S224.

Mei

Yang

Effects of different frequencies of handgrip exercise on venous hemodynamics in patients with PICC. Chin J Clin Med Imaging 2013; 24(11): 798–800.

Yin

Wang

Cai

Application of quantified PICC exercise in patients with PICC catheters. Nurs Res 2017; 31(29): 3712–3714.

10.

Liu

Zhou

Xie

, et al. Handgrip exercise reduces peripherally-inserted central catheter-related venous thrombosis in patients with solid cancers: a randomized controlled trial. Int J Nurs Stud 2018; 86: 99–106.

11.

Zhang

Liu

Wang

, et al. Application of shoulder exercise in patients with implanted upper arm infusion ports. Chin Nurs J 2021; 56(5): 710–715.

12.

Luo

Jin

, et al. Quantified versus willful handgrip exercises for the prevention of PICC-related thrombosis: a meta-analysis and systematic review. Medicine (Baltimore) 2023; 102(10): e32706.

13.

Liu

, et al. Effect of exercise therapy on PICC-associated venous thromboembolism: a meta-analysis. Phlebology 2023; 38(2): 103–114.

14.

Shu

Ying

Zhao

, et al. A meta-analysis on quantified hand exercise for the prevention of PICC-related thrombosis. Chin Med Herald 2021; 18(16): 168–172+196.

15.

Wang

Yang

Shao

, et al. Meta-analysis of the effectiveness of modified activity patterns in preventing PICC-related thrombosis in cancer patients. Chin J Mod Nurs 2021; 27(2): 199–203.

16.

Lao

Chen

Wang

, et al. Meta-analysis of handgrip exercise in preventing PICC-related venous thrombosis. Chin J Pract Nurs 2019; 35(36): 2869–2874.

17.

Zhang

Wang

Mou

, et al. Meta-analysis of upper limb exercise to prevent venous thrombosis in PICC patients. Chin J Integr Nurs 2018; 4(12): 57–61.

18.

Hui

Evidence-based study on nursing strategies for the prevention of PICC-related thrombosis in patients with malignant tumors. Master’s Thesis, PLA Medical College, China, 2018.

19.

Dai

Qiao

, et al. Effect of different handgrip durations on axillary vein blood flow in PICC patients. Chin Nurs J 2019; 54(5): 721–724.

20.

Lin

Zhu

YihanZhang , et al. Development and validation of a prediction model of catheter-related thrombosis in patients with cancer undergoing chemotherapy based on ultrasonography results and clinical information. J Thromb Thrombolysis 2022; 54(3): 480–491.