Impact of exercise rehabilitation and behavioral interaction nursing on postoperative quality of life and psychological outcomes in lung cancer patients

Figure 1. Study flow diagram according to STROBE guidelines for retrospective cohort studies. Patients classified based on documented participation in structured intervention program. Propensity score matching performed to address potential selection bias.

Figure 2. Primary outcomes over time in lung cancer patients receiving combined exercise rehabilitation and behavioral interaction nursing. Quality of life (QLICP-LU), anxiety (SAS), and depression (SDS) scores were measured at baseline, 2-, 4-, and 8-weeks post-intervention initiation. Data are presented as mean values. (A) shows the QLICP-LU scores, where higher values indicate a better quality of life. (B, C) show the SAS and SDS scores, respectively, with the Y-axis inverted so that improvement (lower scores) appears as an upward movement on the graph. The intervention group (blue, n=103) received exercise rehabilitation plus behavioral interaction nursing, the and control group (red, n=102) received standard postoperative care only. Between-group differences were analyzed using linear mixed-effects models with adjustments for baseline values. All P<0.001 at eight weeks. QLICP-LU, Quality of Life Instrument for Chronic Diseases-Lung Cancer; SAS, Self-Rating Anxiety Scale; SDS, Self-Rating Depression Scale.

Figure 3. Hope level improvements measured by Herth Hope Index. Hope scores were measured at baseline, 2, 4, and 8 weeks using the validated Herth Hope Index (HHI). Data are presented as mean ± SE with 95% confidence intervals (shaded areas). Higher scores indicate greater hope levels (possible range 12-48). Between-group difference at 8 weeks: 10.5 points (95% CI: 7.8-13.2, P<0.001), representing a 34.5% improvement in the intervention group. The intervention group demonstrated progressive improvement throughout the study period, while the control group scores remained stable.

Figure 4. Secondary physiological outcomes demonstrating intervention efficacy. Arterial oxygenation (PaO2), systemic inflammation (hs-CRP), and upper limb muscle tone recovery were measured at baseline, 2, 4, and 8 weeks. Data are presented as mean values. (A) shows the PaO2, where higher values indicate better oxygenation. (B, C) show hs-CRP and muscle tone scores, respectively, with the Y-axis inverted so that improvement (lower values) appears as an upward movement on the graph. Lower muscle tone scores indicate improved function, and lower hs-CRP levels indicate reduced inflammation. All between-group differences were significant at P<0.001 at 8 weeks using linear mixed-effects models. PaO2, partial pressure of arterial oxygen; hs-CRP, high-sensitivity C-reactive protein.

Figure 5. Psychological morbidity prevalence at 8 weeks post-intervention. Percentage of patients meeting the clinical criteria for anxiety (SAS≥50), depression (SDS≥53), and combined depression and anxiety at the study endpoint. Bars represent prevalence rates, with the control (red) and intervention (blue) groups shown side by side for each condition. Error bars represent the 95% confidence intervals. Statistical significance was determined using chi-square tests comparing the intervention and control groups. ***P<0.001. The intervention group demonstrated a significantly lower prevalence of psychological morbidity across all categories, with relative risk reductions of 53.3%, 62.0%, and 60.2% for anxiety, depression, and combined conditions, respectively.

Figure 6. Long-term sustainability of intervention benefits. Quality of life (QLICP-LU scores) and depression prevalence trajectories from baseline to the 5-month extended follow-up period. (A) shows the mean QLICP-LU scores demonstrating sustained quality of life improvements in the intervention group, with a modest decline from peak values at 8 weeks but maintenance of clinically significant benefits above control levels. (B) shows depression prevalence (percentage meeting SDS≥53 criteria) with the Y-axis inverted so that improvement (lower prevalence) appears as an upward movement; the intervention group demonstrated a continued reduction in depression prevalence, while the control group prevalence remained elevated. Shaded areas represent 95% confidence intervals. Between-group differences remained statistically significant at all follow-up time points (P<0.001 at 5 months for both outcomes), indicating durable intervention effects that extended beyond the active treatment period. Sample sizes at 5 months: intervention, n=99; control, n=100.

Figure 7. Effect sizes for primary and secondary outcomes. Forest plot displaying Cohen’s d effect sizes with 95% confidence intervals for all measured outcomes at 8 weeks post-intervention. Blue circles indicate primary outcomes (QLICP-LU, SAS, SDS, HHI); red circles indicate secondary outcomes (PaO2, hs-CRP, upper and lower limb muscle tone). All values were oriented such that positive values favored the intervention group. Vertical dashed reference lines indicate the conventional thresholds for small (0.2), medium (0.5), and large (0.8) effect sizes. Most outcomes demonstrated large effect sizes exceeding 0.8, with hs-CRP showing a medium-to-large effect size (d=0.75). Primary psychological outcomes (SAS and SDS) showed the largest effects. The results remained consistent in the propensity score-matched sensitivity analyses.