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Exercising After a Cancer Diagnosis
1. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
Exercising After a Cancer
Diagnosis
Allison Barber, PT, DPT, CLT-LANA
April 16, 2016
2. Identify patient population appropriate for exercise and
resistance training
Describe benefits of resistance training in the oncology
setting
Describe the “Overload Principle” and how it relates to
lymphedema
2
Objectives
3. 35-58% of Breast Cancer survivors have
arm/shoulder issues
Lymphedema
Rotator cuff issues
Health disparity issue
Upper-body function is vital for manual
labor
Exercise is associated with reduced
recurrence
3
Why do we need to worry about
deconditioning and exercise?
4. General
Increase gradually, progress slowly, monitor at-risk limb
If you have lymphedema, wear a compression garment
while exercising
Let symptoms guide you and modify program accordingly
Stay well-hydrated
Avoid getting overheated
Lymphedema Exercises
Non-resistive active motion of the affected arm
Part of treatment and risk reduction
4
National Lymphedema Network (NLN) Exercise
Guidelines5
5. Flexibility/Stretching
May improve lymph flow by decreasing scarring and
tightness
Avoid over-stretching
Strength Training
Modifications are needed
Adequate rest between sessions is crucial
Modify your program according to your symptom response
5
NLN Exercise Guidelines continued...
6. Aerobic Conditioning
Deep respiration enhances lymph drainage
Avoid injury by increasing very gradually
Avoid getting overheated
Modify your program according to your symptom
response
6
NLN Exercise Guidelines continued...
7. Avoid Inactivity
Build to 150 minutes/week of aerobic activity
Daily flexibility activities are encouraged
Strength training activities are safe
Start with SUPERVISED program
Start low, progress slow
If you have changes in upper body symptoms that last a
week or longer, get an evaluation by a clinician
Careful with overall arm work (i.e if you garden on a
Monday, wait to do strength training until Tuesday)
Back off resistance after an exercise “holiday”
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NCCN/ACS/ACSM Guidelines for Breast
Cancer Survivors
8. Pre-Existing:
Rotator cuff
Upper body deconditioning
Surgery:
Rest of arm/shoulder = further deconditioning
Muscles/soft tissue/nerves severed, damaged, altered
Inflammation
Radiation:
Soft tissue and nerve damage
Inflammation
Lymphedema Risk?
8
Musculoskeletal Effects of Treatments on
Arm/Shoulder
9. Avoid overusing the upper body
Translation into practice:
Avoid using the upper body which leads to deconditioning
of the upper body
Example: Cardiac rehabilitation (Overload Principle)
Gradually progress program to rebuild damaged body
systems
Strengthen gradually to reduce overuse of the system
9
Long-Held Clinical Advice
10. Primary aim: To determine whether there are any
changes in lymphedema outcomes
Two separate trials (with lymphedema and at-risk for
lymphedema)
1 year, randomized, controlled intervention
Twice weekly, progressive strength training
Non-exercising control
All women with lymphedema (at entry or onset during
study) were provided with custom-fitted compression
garments (JOBST)
10
The Physical Activity and Lymphedema (PAL)
Trial8
11. Twice-weekly, slowly progressive strength training in
populations with or at-risk for lymphedema
Risk of lymphedema flare-ups decreased by half
Among at-risk women with 5+ nodes removed, risk of
increased arm swelling reduce by 70%
Substantive strength improvements
Body image improved
Prevention of decline in physical function as measured
by the SF-36
11
Summary of PAL Program8
12. Strength After Breast Cancer (SABC) Program
Choice of self-pay or insurance co-pay
Can by offered by PTs, OTs, ATCs, or nationally-certified
exercise professionals
Insurance is covering the SABC program as skilled PT
12
Revised Intervention8
13. Participants had these benefits:
50% reduced likelihood of lymphedema worsening
70% reduced likelihood of lymphedema onset among
women with 5 or more nodes removed
Improved strength and energy
Improved body image
Reduced body fat
Prevented decline in physical function
13
Strength ABC Program results8
15. Anemia
Appetite loss
Bleeding and bruising
Bone Loss
Constipation
Diarrhea
Edema
Fatigue
Hair loss
Infection
Lymphedema
Memory or
concentration
problems
Mouth or throat
problems
Nausea or vomiting
Nerve problems
Pain/arthralgias
Sexuality and fertility
problems
Skin and nail changes
Sleep disturbances
Urinary and bladder
problems
15
Possible Barriers to Exercise – Chemotherapy
Related Side-Effects
**Bold indicates side effect that may directly effect therapy services
16. Tends to peak following chemotherapy (or at end of
radiation) treatments
Remain physically active
If muscle is not being used, can atrophy and become
weaker
Over 34 controlled exercise trials show reduction in
fatigue during and after cancer treatment
Exercise studies have shown a reduction in cancer
related fatigue on the average of 35%
Exercise interventions done during and after
treatment
Studies done in multiple diagnostic groups including:
breast, prostate, multiple myeloma, and colorectal and
patients undergoing BMT/PSCT
16
Fatigue
17. Light to moderate exercise is good to
avoid disuse atrophy
Research poor with regards to effective
interventions for peripheral neuropathy
Current OSU study:
Chemotherapy Induced Peripheral
Neuropathy study: OSU 14219
The effects of a sensorimotor
rehabilitation program on the upper and
lower limbs of persons with cancer
following taxane-based chemotherapy
for early stage breast cancer
17
Peripheral Neuropathy
18. Fever, infection, blood counts
Vinca Alkaloid Class:
Numbness/tingling
Weakness of distal muscles
Foot drop (with high doses)
Anemia
Fatigue
Nausea
Platinum Compounds
Numbness/tingling
Vestibular toxicity
anemia
Taxanes:
Muscle pain
Numbness/tingling
Weakness of distal muscles
Neutropenia
Anemia
Nausea
Patient may have decreased
tolerance to exercise on these
medications
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Contraindications for Exercise and
Chemotherapy?
19. Suppression of sex hormones (antiestrogens
and antiandrogens)
Loss of bone mineral density
Increased risk of fragility fractures
In a study of serial bone mineral density
measurements after oophoprectomy, women
had lost 18-19% of spine bone mineral
density at two years
Bilateral orchiectomy the rate of loss in bone
mineral density is estimated at approximately
8-10% over the first two years
Loss with androgen deprivation therapy is 3-
7% per year
Universal counseling on bone health includes
providing advice on calcium and vitamin D
intake, exercise, behavior (no tobacco, limit
alcohol), the risk of falling, and certain
medications such as steroids
19
Endocrine Therapy6
20. Higher bone turnover markers
Lower bone mineral density
Fracture rates range from 0.9% to 11%
Higher osteoporotic fracture rate than
with Tamoxifen
1.5 times greater fracture risk with AI
therapy than with Tamoxifen
Interventions such as bisphosphonates
reduce risk of vertebral fractures by 30-
70%
20
Aromatase Inhibitors (AI)1
21. Study by Layne3 et al:
1 year, randomized control trial of high-intensity resistance
training in postmenopausal women
Women in 2 day/week resistance training program
Gained average of 1% in bone mineral density of the femoral
neck and lumbar spine whereas the control group lost 2.5%
and 1.8% at the sites, respectively
Resistance trained women had a 35-76% increase in
strength, 14% improvement in dynamic balance, and 1.2-kg
increase in total body muscle and a 27% increase in physical
activity unrelated to the intervention
Control group showed declines in all of the aforementioned
parameters
21
Exercise and Bone Health
22. Platelets:
Platelets (PLT) < 20,000: No exercise
PLT: 20,000-50,000: Light exercise (No PROM, but
light AROM is permitted)
PLT > 50,000: Resistive AROM is permitted
Hemoglobin
Hgb < 8 gm/dL = Essential daily activities only
Hgb < 8 to 10 gm/ dL = Essential activities of daily
living, assistance as needed for safety, light aerobics
and light weights of 1 to 2 lbs.
Hgb > than 8 gm/dL = Ambulation and self-care as
tolerated and resistance exercise.
Hematocrit
Hct < 25% = Essential activities of daily living and assistance as
needed for safety only.
Hct < 25% - 35% = You can add light aerobics and light weights
of 1 to 2 lbs.
Hct > 35% = Ambulation and self-care as tolerated.
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Lab Values to Monitor2
23. How do we know who is
appropriate for exercise
interventions?
23
24. Clear the participant as being ready to do the exercises
in the program
Do they have ROM restrictions from surgical interventions
(i.e. port placements, reconstructive surgeries, lymph node
dissections, etc.)?
Review current or past chemotherapy drugs administered
and possible side-effects
Ensure that those with lymphedema get adequate
compression prior to starting the exercise program
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LABAT and Pre-Exercise Evaluation Goals
25. Lymphedema Education Session
What is lymphedema?
Who is at risk?
When is it likely to occur?
Why does it happen?
How do I reduce my risk?
How is it treated?
What are the exercise guidelines?
Skin care
Activity and lifestyle
Garments
Components of Complete Decongestive Therapy (CDT)
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Pre-Exercise Evaluation
27. RPE before exercise
6-minute walk test as evaluation
Pulse and blood pressure before and after 6-minute walk
test
27
Pre-Exercise Evaluation continued...
28. Can they:
Use resistance appropriately?
Properly perform all stretching, core, and weightlifting
exercises appropriately?
Progress resistance appropriately?
Monitor changes in lymphedema and musculoskeletal
symptoms appropriately?
If not, recommend further supervised PT sessions
28
How do you know a person is ready for
independent resistance training?
33. American College of Sports Medicine
Cancer Exercise Trainer Certification
Chemocare.com
Provides information regarding chemotherapeutic drugs
and side-effects
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Resources
35. 1. Becker, Taryn, Lorraine Lipscombe, Steven Narod, Christine Simmons, Geoffrey M. Anderson, and Paula A.
Rochon. "Systematic Review of Bone Health in Older Women Treated with Aromatase Inhibitors for Early-Stage
Breast Cancer." Journal of the American Geriatrics Society J Am Geriatr Soc 60.9 (2012): 1761-767. Pubmed.org.
Web.
2. Ghazinouri, Roya, Samidha Deshmukh, Sharon Gorman, Angela Hauber, Mary Kroohs, Elizabeth Moritz, Babette
Sanders, and Darrin Trees, comps. "LAB VALUES INTERPRETATION." The Critical Edge in Physical Therapy
(n.d.): n. pag. American Physical Therapy Association. Web. 15 Mar. 2016.
3. Layne, Jennifer E., and Miriam E. Nelson. "The Effects of Progressive Resistance Training on Bone Density: A
Review." Medicine & Science in Sports & Exercise 31.1 (1999): 25-30. Pubmed.org. Web. 23 Mar. 2016.
4. Miller, Linda, Nancy Roberge, and Cathy Bryan. "Breastcancer.org - Breast Cancer Information and Awareness."
Exercise Safety. N.p., n.d. Web. 28 Jan. 2016.
5. "NLN Position Paper: Exercise." National Lymphedema Network. The National Lymphedema Network, 2013. Web.
28 Jan. 2016.
6. Poznak, Catherine H. Van. "Bone Health in Adults Treated with Endocrine Therapy for Early Breast or Prostate
Cancer." American Society of Clinical Oncology Educational Book 35 (2015): E567-574. Pubmed.org. Web. 22
Mar. 2016.
7. Schmitz, Kathryn. "Exercise, Breast Cancer and You: The Benefits of Physical Activity and How to Get Started."
Living Beyond Breast Cancer. N.p., n.d. Web. 28 Jan. 2016.
8. Schmitz, Kathryn H., Kerry S. Courneya, Charles Matthews, Wendy Demark-Wahnefried, Daniel A. Galvão,
Bernardine M. Pinto, Melinda L. Irwin, Kathleen Y. Wolin, Roanne J. Segal, Alejandro Lucia, Carole M. Schneider,
Vivian E. Von Gruenigen, and Anna L. Schwartz. "American College of Sports Medicine Roundtable on Exercise
Guidelines for Cancer Survivors." Medicine & Science in Sports & Exercise 42.7 (2010): 1409-426. Print.
9. Schmitz, Kathryn H., Rehana L. Ahmed, Andrea B. Troxel, Andrea Cheville, Lorita Lewis-Grant, Rebecca Smith,
Cathy J. Bryan, Catherine T. Williams-Smith, and Jesse Chittams. "Weight Lifting for Women at Risk for Breast
Cancer–Related Lymphedema." Jama 304.24 (2010): 2699. Print.
10. Schmitz, Kathryn H., Rehana L. Ahmed, Andrea Troxel, Andrea Cheville, Rebecca Smith, Lorita Lewis-Grant,
Cathy J. Bryan, Catherine T. Williams-Smith, and Quincy P. Greene. "Weight Lifting in Women with Breast-
Cancer–Related Lymphedema." New England Journal of Medicine N Engl J Med 361.7 (2009): 664-73. Print.
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References
36. Thank You
To learn more about Ohio State’s cancer
program, please visit cancer.osu.edu or
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