Performance-based activities of daily living using the Londrina ADL protocol in non-small cell lung cancer: A prospective cross-sectional controlled study: Performance-based ADL in NSCLC

Abstract

Objective assessment of activities of daily living (ADL) in non-small cell lung cancer (NSCLC) remains limited despite its clinical importance. The Londrina ADL protocol enables standardized evaluation of real-life functional performance. This study aimed to evaluate performance-based ADL in NSCLC and identify determinants of impaired ADL performance. In this prospective cross-sectional controlled study, 23 NSCLC patients who had completed adjuvant treatment and 27 healthy controls underwent pulmonary function testing, muscle strength assessment, a 6-minute walk test (6MWD), quality-of-life evaluation, and Londrina ADL testing. Group comparisons, correlations, and multivariable linear regression were performed. Performance-based ADL is markedly impaired in NSCLC, and reduced exercise capacity is the principal determinant of real-life functional limitation. Objective ADL assessment may support early, capacity-targeted rehabilitation to preserve independence. NSCLC patients showed significantly longer Londrina ADL completion times than controls (335.6 ± 63.7 s vs 270.7 ± 34.4 s; P < .001) with reduced pulmonary function, muscle strength, and exercise capacity. Within NSCLC, ADL time correlated inversely with 6MWD (r = −0.579, P = .004). Functional exercise capacity was the only independent predictor of ADL performance (β = −0.498, P = .022), and the model explained 36.1% of the variance in Londrina ADL completion time (R² = 0.361).

1. Introduction

Lung cancer remains the most commonly diagnosed malignancy and the leading cause of cancer-related mortality worldwide, accounting for approximately 2.5 million new cases and 1.8 million deaths annually according to the latest global estimates.^[1] Despite advances in diagnostic and therapeutic strategies, the disease is still frequently identified at an advanced stage, requiring intensive and often aggressive treatment approaches. Both late diagnosis and treatment-related toxicity impose a substantial symptom burden that contributes to impaired physical functioning, loss of independence, and reduced quality of life (QoL).^[2] In older adults with advanced-stage disease, treatment processes further accelerate declines in mobility autonomy and increase limitations in activities of daily living (ADL), which have emerged as key determinants of overall life restriction and clinical vulnerability in individuals with lung cancer.^[3]

Beyond metastatic burden and survival outcomes, deterioration in ADL performance has important clinical implications in surgical and elderly non-small cell lung cancer (NSCLC) populations, where a meaningful proportion of patients experience postoperative functional decline despite preserved baseline independence.^[4] Accurate assessment of ADL is therefore essential for risk stratification, treatment planning, and monitoring of functional outcomes. However, commonly used approaches such as self-reported questionnaires or isolated functional tests may not adequately reflect real-life activity performance, as they are influenced by subjective perception or evaluate only single components of function.^[5,6]

Performance-based protocols that objectively simulate daily activities have consequently gained increasing attention. The Londrina Activities of Daily Living protocol provides a standardized and reproducible assessment of ADL performance and demonstrates strong reliability together with clinically meaningful associations with functional exercise capacity and cardiopulmonary stress during real-life-like tasks across respiratory populations.^[5–7] Nevertheless, evidence specifically examining performance-based ADL outcomes in NSCLC remains limited, with most previous studies focusing primarily on survival, metastatic burden, or questionnaire-derived functional indices rather than objective real-life activity performance.

Therefore, the present study aimed to evaluate performance-based ADL using the Londrina ADL protocol in individuals with NSCLC and to investigate the clinical and functional determinants associated with impaired ADL performance in this population. By identifying clinical and functional determinants of impaired performance-based ADL, this study may facilitate early recognition of vulnerable patients and guide timely rehabilitation interventions aimed at preserving independence and improving real-life functional outcomes in NSCLC.

2. Methods

2.1. Participants

A prospective cross-sectional controlled study was conducted. Participants were recruited and data were collected between April 2019 and June 2020 at Hacettepe University. NSCLC patients who had completed adjuvant treatment 6 months prior were included, with exclusions for rehabilitation in the past year, neurological or orthopedic issues, systemic disease, acute infection, or inability to cooperate. Healthy individuals formed the control group. An a priori sample size calculation was conducted using G*Power software based on the total completion time of the Londrina ADL protocol reported in the original validation study.^[8] Assuming a two-tailed independent samples t-test, an alpha level of 0.05, and 80% statistical power, a minimum of 18 participants per group was required. The final sample size of 23 patients with NSCLC and 27 healthy controls therefore exceeded the minimum requirement, providing sufficient statistical power for the primary outcome analysis. This study was performed in accordance with the principles of the Declaration of Helsinki and was approved by the Hacettepe University Ethics Committee with the approval number GO 18/737. The study was registered at ClinicalTrials.gov on March 19, 2019, with the identifier NCT03881046. Written informed consent was obtained from all participants before study enrollment.

2.2. Measurements

Physical characteristics (age, gender, height, body weight, and smoking history) were recorded. Body mass index was calculated as weight/height² (kg/m²). Smoking history was recorded as pack-years.

Pulmonary function tests were performed with a spirometer (Spirodoc, Medical International Research, Rome, Italy) according to ATS/ERS criteria.^[9,10]

The Londrina ADL protocol was used to evaluate ADL performance. This performance-based objective method is based on the repetition of activities commonly used in daily life. It comprises five activities organized in “stations” inside a room. The activities include moving objects from one half of a table to the other (station 1), walking with weights (station 2), moving objects between shelves (station 3), hanging laundry on a clothesline (station 4), and walking without weight (station 5). Before starting the protocol, all stations and tasks were explained to the participants. They were asked to perform the tasks at their usual pace and to move to the next station after completing each task. They were also told that they could stop whenever they wanted to if they had difficulty due to symptoms. The time spent at each station and the total completion time of the protocol were recorded.^[6] Before and after the test, heart rate and oxygen saturation were measured with a pulse oximeter (Shenzhen Jumper Medical Equipment Co., Ltd., Shenzhen, China), and perceived dyspnea and arm/leg fatigue were assessed using the Modified Borg Scale. Outcome assessors were not blinded to participants’ clinical characteristics or group membership. However, the Londrina ADL protocol was administered using standardized instructions and predefined procedures, and completion time was recorded objectively to minimize potential measurement bias.

Strength of the knee extensors, shoulder abductors, and shoulder flexors was measured using a digital dynamometer (Lafayette, Lafayette Instrument, Lafayette, IN). A Jamar hand dynamometer (Fabrication Enterprises, New York) was used to measure handgrip strength. Tests were repeated 3 times on the dominant side, and the highest values in kilograms were used for analysis.^[11]

The six-minute walk test was performed twice with a 30-minute rest interval, in accordance with ATS/ERS criteria. The total distance that the individuals walked was recorded in meters (m). The highest value obtained was used for statistical analysis.^[12,13]

The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) was used to evaluate QoL in patients with NSCLC. Higher scores reflect better function, while lower scores suggest impairment. In the symptom scale, higher scores also indicate increased symptoms.^[14,15]

2.3. Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics (version 22.0). Data distribution was assessed using the Shapiro–Wilk test and visual inspection methods. Continuous variables were compared using the independent-samples t-test or Mann–Whitney U test, as appropriate, and categorical variables using the χ² or Fisher exact test. Correlations between Londrina ADL completion time and clinical or functional parameters were examined using Pearson or Spearman correlation coefficients. Univariable subgroup comparisons according to chemotherapy exposure status were performed using the independent-samples t-test, with effect size quantified by Cohen d. Independent predictors of ADL performance were assessed using multivariable linear regression with a parsimonious model including chemotherapy status and 6-minute walk distance; model assumptions, multicollinearity, and residual distributions were verified. The number of predictors was restricted according to sample size considerations to minimize overfitting. All tests were two-tailed, and P < .05 was considered statistically significant. There were no missing data for the variables included in the analyses.

3. Results

Of the 83 patients with NSCLC referred for eligibility, 60 were excluded, resulting in a final sample of 23 patients with NSCLC and 27 healthy controls included in the analyses (Fig. 1). Demographic characteristics were comparable between groups (P > .05), whereas pulmonary function parameters were significantly reduced in the NSCLC group (Table 1, P < .05). In addition, peripheral muscle strength, six-minute walk distance (6MWD), and minimum oxygen saturation during exercise were all significantly lower in patients compared with controls (Table 2, P < .05), indicating impaired functional capacity. Performance-based assessment using the Londrina ADL protocol demonstrated significantly prolonged completion times in the NSCLC group across all stations and for total duration (Table 3, P < .05).

Figure 1.

Patient flow diagram.

Table 1.

Characteristics of the non-small cell lung cancer patients and the control group.

	Lung cancer (n = 23)			Control group (n = 27)
Characteristics	M		SD	M	SD	P
Age (yr)	59.08		9.02	55.18	6.22	.078
Gender (F/M)	7/16			7/20		.726
Height (m)	1.66		0.09	1.69	0.09	.383
Body weight (kg)	78.73		9.70	77.40	8.20	.601
BMI (kg/m2)	28.38		4.01	27.17	3.42	.293
Smoking history (pack-years)	25.47		26.18	15.44	25.26	.292
Cancer stage	n	%
I	8	34.78
II	7	30.44
III	7	30.44
IV	1	4.34
Pulmonary function test
FEV1 (%)	67.54		19.62	94.92	20.29	<.001*
FVC (%)	78.21		20.38	100.03	20.23	<.001*
FEV1/FVC (%)	71.13		11.45	77.08	9.38	.009*
PEF (%)	54.13		17.81	82.55	24.46	<.001*
FEF25–75 (%)	47.26		21.83	75.25	20.44	<.001*

BMI = body mass index, F = female, FEV₁ = forced expiratory volume in 1 s, FVC = forced vital capacity, PEF = peak expiratory flow rate, FEF_25–75 = flow rate value between 25% and 75% of the forced expiratory volume, M = male, SD = standard deviation.

^*P < .05. Data are expressed as mean and standard deviation.

Table 2.

Peripheral muscle strength and functional exercise capacity of patients with non-small cell lung cancer.

	Lung cancer (n = 23)		Control group (n = 27)
	M	SD	M	SD	P
6-Minute walk test
Distance (m)	509.17	115.62	599.33	75.80	.002*
%Max HR (%)	73.69	8.13	73.31	16.55	.830
Min SpO2 (%)	90.56	5.63	93.44	3.36	<.001*
Knee extension (kg)	16.73	3.74	18.95	3.15	.028*
Shoulder abduction (kg)	13.28	3.45	16.61	2.74	<.001*
Shoulder flexion (kg)	12.98	3.12	15.89	2.93	.002*
Handgrip strength (kg)	32.69	10.79	41.55	8.66	.002*

HR = heart rate, M = male, Max = maximum, Min = minimum, SD = standard deviation, SpO₂ = oxygen saturation.

^*P < .05, Data are expressed as mean and standard deviation.

Table 3.

Comparison of Londrina ADL protocol parameters.

	Lung cancer (n = 23)		Control group (n = 27)
	M	SD	M	SD	P	Cohen d
Station 1: moving objects from one half of a table to the other (s)	46.07	7.84	39.14	8.16	.004*	0.86
Station 2: walking with weights (s)	33.87	8.91	25.03	5.70	<.001*	1.15
Station 3: moving objects between shelves (s)	71.58	14.63	58.51	10.55	.001*	1.03
Station 4: hanging laundry on a clothesline (s)	160.31	44.36	127.51	28.51	.010*	0.88
Station 5: walking without weight (s)	25.28	4.92	20.14	3.05	<.001*	1.20
Total duration (s)	335.60	63.68	270.70	34.44	<.001*	1.32
%Max HR	55.39	10.12	50.44	9.20	.077	0.51
Post-Londrina ADL protocol test (SpO2) (%)	94.82	2.77	95.59	2.59	.204	−0.29
∆Dyspnea	0.67	1.54	0.07	0.38	.011*	0.53
∆Body Fatigue	0.47	1.05	0.05	0.21	.088	0.48

 ∆ = post-test – pretest measurement, ADL = activities of daily living, HR = heart rate, M = male, SD = standard deviation, s = second, SpO₂ = oxygen saturation.

^*P < .05, Data are expressed as mean ± standard deviation.

QoL assessed using the EORTC QLQ-C30 showed a heterogeneous pattern compared with normative values (Fig. 2). Patients with NSCLC demonstrated lower physical and cognitive functioning scores, whereas social and emotional functioning scores were only slightly lower than normative values. Role functioning and global health status were broadly preserved. Symptom scores were higher in patients, particularly for fatigue, pain, and dyspnea, with dyspnea showing the most pronounced difference. These findings indicate that the main patient-reported impairments were concentrated in physical and cognitive functioning and symptom burden rather than in all quality-of-life domains.

Figure 2.

Evaluation of quality of life in non-small cell lung cancer patients using the EORTC QLQ-C30. EORTC QLQ-C30 = European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30.

Correlation analyses performed within the NSCLC group (n = 23) revealed a moderate-to-strong negative correlation between Londrina ADL total completion time and 6MWD (r = −0.579, P = .004), as well as a moderate negative correlation with percentage-predicted 6MWD (r = −0.452, P = .031). No significant correlations were observed between ADL completion time and knee extensor strength or forced vital capacity percentage (P > .05).

When stratified by chemotherapy exposure, patients who had received chemotherapy demonstrated longer Londrina ADL completion times compared with those without chemotherapy (t = 2.26, P = .038), with an approximate mean difference of 51 seconds and a large effect size (Cohen d = 0.86).

To identify independent predictors of Londrina ADL completion time within the NSCLC group, a parsimonious multivariable linear regression model was constructed. Candidate predictors were selected based on preliminary univariable analyses and clinical relevance. 6MWD was included because it showed a moderate-to-strong negative correlation with Londrina ADL total completion time within the NSCLC group, whereas chemotherapy exposure status was included because patients who had received chemotherapy demonstrated significantly longer Londrina ADL completion times in subgroup analysis. To reduce the risk of overfitting due to the limited sample size, the final model was restricted to these 2 predictors, and both predictors were entered simultaneously into the model. The overall model was statistically significant (F = 5.649, P = .011) and explained approximately 36% of the variance in Londrina ADL completion time (R² = 0.361). Within this model, 6-minute walk distance was the only independent predictor of Londrina ADL completion time (B = −0.274, 95% CI: −0.505 to −0.044, β = −0.498, P = .022). Chemotherapy exposure status was not independently associated with Londrina ADL completion time after adjustment for 6-minute walk distance (B = 22.415, 95% CI: −30.232–75.063, β = 0.178, P = .385). Collinearity diagnostics indicated no multicollinearity between predictors (variance inflation factor = 1.263).

Overall, these findings demonstrate that objectively measured ADL performance is markedly impaired in NSCLC and that reduced functional exercise capacity, rather than chemotherapy exposure, represents the principal determinant of prolonged performance-based daily activity duration in this population.

4. Discussion

The present study demonstrates that individuals with NSCLC exhibit marked impairment in performance-based ADL, characterized by substantially prolonged completion time in the Londrina ADL protocol (335.6 ± 63.7 s vs 270.7 ± 34.4 s in controls; P < .001), together with reduced pulmonary function, diminished peripheral muscle strength, and lower functional exercise capacity. Most importantly, functional exercise capacity emerged as the sole independent determinant of ADL performance within the NSCLC group. The multivariable model including 6MWD and chemotherapy exposure status explained approximately 36% of the variance in Londrina ADL protocol completion time (R² = 0.361), with 6MWD remaining independently associated with ADL completion time (β = −0.498, P = .022). These findings extend current knowledge beyond symptom- or survival-focused outcomes and highlight exercise capacity as the principal driver of real-life functional limitation in NSCLC.

Performance-based ADL assessment provides a more ecologically valid representation of daily activity demands than questionnaire-based or single-task tests. The Londrina ADL protocol has demonstrated strong reliability, validity, and meaningful associations with functional capacity in chronic disease populations, supporting its use for objective evaluation of real-life activity performance.^[8,16] Our results expand this evidence to lung cancer, showing that all individual Londrina stations required significantly longer completion times in patients, indicating multidimensional impairment across upper- and lower-extremity–dependent tasks rather than isolated functional limitation.

The magnitude of functional impairment observed is clinically meaningful. Although patients in our cohort demonstrated a relatively preserved mean 6MWD of 509 ± 116 m (≈96% predicted),^[12] ADL performance remained significantly slower and strongly correlated with walking capacity (r = −0.579, P = .004). This suggests that even subclinical reductions in exercise capacity may translate into measurable deterioration in real-life activity performance, supporting the concept that ADL limitation represents an early and sensitive marker of functional decline in NSCLC. Previous studies in lung cancer populations similarly indicate that deterioration in ADL is common following treatment and is associated with vulnerability and poorer clinical outcomes, reinforcing the clinical relevance of objective ADL assessment.^[4]

Although patients exposed to chemotherapy demonstrated longer Londrina ADL completion times in univariable analysis, chemotherapy exposure did not remain an independent determinant after adjustment. This finding suggests that the relationship between treatment exposure and ADL limitation may be partly mediated or confounded by reduced exercise capacity, muscle dysfunction, pulmonary impairment, dyspnea, fatigue, or other treatment-related symptoms. Because disease stage, comorbidities, treatment toxicity, and habitual physical activity may also influence functional performance, these factors should be considered when interpreting the determinants of ADL impairment in NSCLC.

In addition to objective functional impairment, quality-of-life assessment revealed a heterogeneous pattern of patient-reported limitations in patients with NSCLC, with more pronounced impairment in physical functioning and symptom-related domains. Lower physical and cognitive functioning, together with increased fatigue, pain, and particularly dyspnea, was consistent with the observed prolongation in performance-based ADL and reduced exercise capacity, whereas emotional and social functioning were relatively preserved. These findings support the concept that diminished functional exercise capacity represents not only a physiological limitation but also a key determinant of patient-perceived health status in NSCLC. The parallel impairment across objective performance measures and subjective quality-of-life domains further emphasizes the clinical importance of early functional assessment and targeted rehabilitation strategies in this population.

Skeletal muscle dysfunction and systemic disease burden are recognized contributors to functional limitation in lung cancer.^[3] In the present study, both upper- and lower-extremity muscle strength and functional capacity were significantly reduced compared with controls. This finding indicates that global exercise capacity integrates the cumulative effects of pulmonary impairment, muscle dysfunction, and symptom burden, making it the most proximate determinant of real-life functional performance. Comparable relationships between prolonged ADL duration and reduced functional capacity have also been reported in other chronic disease populations, suggesting a shared pathophysiological pathway of deconditioning-driven activity limitation.

From a clinical standpoint, identifying exercise capacity as the only independent predictor of ADL performance has important implications. Interventions targeting aerobic capacity and overall physical conditioning – rather than isolated strength or symptom-focused approaches – may provide the greatest benefit for preserving independence in NSCLC. Moreover, the Londrina ADL protocol elicited meaningful physiological and symptom responses, supporting its value as a comprehensive functional assessment tool that captures multidimensional activity demands beyond walking distance alone.

The main strength of this study is the use of an objective, performance-based ADL assessment together with multivariable modeling to identify functional determinants in patients with NSCLC. However, several limitations should be acknowledged. First, the relatively small sample size may limit the statistical robustness of the multivariable regression analysis; therefore, the findings should be interpreted cautiously. Second, because this was a single-center study, the generalizability of the results to broader NSCLC populations with different clinical characteristics, treatment histories, or rehabilitation access may be limited. Third, the cross-sectional design prevents causal inference; therefore, although reduced exercise capacity was independently associated with prolonged ADL completion time, it cannot be concluded that reduced exercise capacity directly causes impaired ADL performance. In addition, potential confounding factors such as cancer stage, treatment-related toxicity, comorbidities, physical activity level, and symptom burden may have influenced ADL performance. Although emotional functioning was assessed using the EORTC QLQ-C30, specific psychological factors such as anxiety, depression, and cancer-related distress were not evaluated using dedicated instruments. These factors may also have influenced functional performance and should be examined in future studies. Finally, the absence of subjective ADL measures prevented comparison between perceived and observed functional limitations.

Clinically, the finding that reduced exercise capacity independently determines ADL performance highlights the potential importance of early, capacity-targeted pulmonary rehabilitation to preserve independence and QoL in NSCLC. Future longitudinal and interventional studies should determine whether improving exercise capacity leads to measurable gains in real-life ADL performance and clinical outcomes.

5. Conclusion

Patients with non-small cell lung cancer show significant impairment in performance-based ADL, characterized by prolonged Londrina ADL completion time and reduced functional capacity. Functional exercise capacity emerged as the only independent determinant of ADL performance, highlighting its central role in real-life functional limitation. These findings support the use of objective ADL assessment and emphasize the importance of early, capacity-targeted rehabilitation to preserve independence in NSCLC.

Acknowledgments

The authors thank all participants who volunteered for this study.

Author contributions

Supervision: Melda Saglam, Naciye Vardar-Yagli, Ebru Calik, Deniz Inal-Ince, Saadettin Kilickap.

Writing – original draft: Hamide Sahin Yildiz, Kubra Kilic.

Writing – review & editing: Hamide Sahin Yildiz.