The document outlines exercise oncology principles, highlighting the importance of physical activity and exercise for individuals with cancer at various stages of treatment. It discusses the five levels of cancer prevention, benefits of exercise, and offers guidelines for individualized exercise programs while addressing potential challenges faced by cancer patients. Emphasis is placed on assessing physical function and adapting exercise recommendations based on lab values and treatment status.

1. Exercise Oncology
Transforming Research to Practice
Andrew Chongaway PT, DPT
Board-Certified Oncologic Clinical Specialist
ACSM Certified Exercise Physiologist
ACSM/ACS Certified Cancer Exercise Trainer
Affiliations:
Beaumont Health, Royal Oak, MI
Deborah J Doherty, PT, PhD
Chair HMS Department
Associate Professor Oakland University
Owner, Center for Survivorship
Affiliations:
Human Movement Science (HMS) Department
School of Health Sciences, Oakland University, MI
Center for Survivorship, Brown City, MI

2. Intended Learning Outcomes
• Discuss the 5 levels of prevention & how they relate to exercise &
rehabilitation in the oncology setting
• Review the benefits of exercise in relation to optimizing physical function
& addressing adverse effects of cancer & related tx
• Introduce algorithms for assessing physical function in the inpatient, home
health, & outpatient physical therapy settings.
• Explore various ways to develop, prescribe, & progress an exercise
program in the oncology settings based on current research with respect
to tx status, lab values, & other risk factors
• Examine several case studies to foster confidence with exercise
prescription in the oncology population.

4. American Cancer Society. CancerTreatment & Survivorship Facts & Figures 2019-2021.Atlanta: American Cancer Society; 2019.
1

5. Statistics
• Only ~1/3 of persons living with & beyond cancer are meeting
exercise recommendations
• Number drops to about 10% of persons actively going through tx
• Up to 34% report NO leisure time physical activity or exercise
• Multitude of reasons why this number is so low
• Understanding of exercise & PA
• Fear
• Access
• Time
• Financial challenges

6. 5 Levels of Prevention
Primordial
Primary
Secondary
Tertiary
Quaternary

7. 5 Levels of Prevention
Primordial
Prevention
Risk reduction in populations and communities
Primary Prevention Risk Reduction in individuals - lifestyle behaviors to prevent cancer from occurring
Secondary
Prevention
Prehabilitation
Tertiary Prevention Treating the adverse effects caused from the treatments for cancer
Quaternary
Prevention
Risk reduction in the over-medicalization of care

8. A Good Time to Start 2,3
• Exercise programming can be initiated at any point – earlier is better
• Prehab
• In tx
• Post-tx
• Depending on the phase the focus & goals may be different
• Each phase may have its own focus & goals
• Within the S&C world: Macrocycle/Mesocycle/Microcycle
• Need to be aware of & account for changes in lab values, chemotherapy
cycles, radiation therapy, fatigue, nutrition, etc.

9. Effects of Aging on Physical Function 4
20 30 40 50 60 70 80 90
Debility/ Mortality
Physical
Function
Onset of Cancer
Age in years

10. Adverse Effects of Cancer &Treatment 5,6
• Fatigue
• Loss in muscle mass
• Reductions in muscle
strength/power
• Decrease joint mobility
• Cardiotoxicity
• Impaired cognition
• Myelosuppression
• Bone loss
• Impaired functional capacity/ VO2max
• Chemotherapy Induced polyneuropathy
• Pain
• Inflammation
• Altered nutrition
• Insulin resistance
• Depression/Anxiety

11. Adverse Effects of Cancer & Treatment 7
• Impairments lead to:
• Limited mobility
• Reduced independence
• Reduced physical function/ performance status
• Loss of work
• Loss of self-identity
• Frailty
• Physical
• Psychosocial
• Reduced Quality of Life

12. Frailty Phenotype 8
• Physical Frailty
• Weight loss
• Exhaustion
• Muscle weakness
• Sedentary behavior
• Slowness
• Psychosocial Frailty
• Impaired cognition
• Depressive symptoms
• Not leaving the house
• Eating alone
• Not talking to people/friends

13. Molecular Effects of Cancer & Treatment 9,10
• Muscle Weakness/Atrophy
• Proteolytic Pathways (Calpains, FoxO, UPP)
• Altered Vascular Dynamics
• Cardiotoxicity, Hypertension, Endothelial Alterations
• Insulin Resistance
• Systemic Inflammation
• IL-1; IL-6; TNF-α; IFN‐γ, CRP
• Hypothalamic Pituitary Adrenal Axis Dysfunction
• Cortisol; Myostatin

14. Benefits of Exercise

15. ADLs – Physical Activity - Exercise11-14
• Activities of Daily Living: getting out of bed, bathing, eating,
Transfers, dressing
• Physical Activity: any bodily movement produced by skeletal muscles
that requires energy expenditure (i.e. gardening, house cleaning,
playing with children or grandchildren, kayaking, pickleball…)
• Exercise: a subset of physical activity that is planned, structured, &
repetitive & has as a final or an intermediate objective - the
improvement or maintenance of physical fitness (i.e., aerobic
capacity, muscle strength power & endurance, balance, coordination,
& flexibility)

16. Potential Benefits of Exercise Oncology 15 .
• Strong Evidence
• Anxiety
• Fatigue
• Health Related QoL
• Lymphedema
• Physical Function
• Moderate Evidence
• Bone Health
• Sleep
• Insufficient Evidence
• Cardiotoxicity
• CIPN
• Cognitive Function
• Falls
• Pain
• Tx Tolerance
• Nausea

17. ExRX in Individuals with Cancer 15,16
• Minimum recommendations by ACSM:
• 30 minutes of aerobic exercise 3x per week
• Resistance training 2x per week focusing on large muscle groups
• 2 sets of 12-15 repetitions
• However, individuals with cancer should attempt to be active everyday 3x for at least 10
minutes
• Should aim to meet the ACSM/WHO minimum requirements of 150
minutes of moderate & or 75 minutes of vigorous exercise per week.
• Due to the importance of exercise in the oncology population it
should be considered a vital sign much like blood pressure, pain,
heart rate, etc.
• This is where we should regularly assess and advise about exercise

18. Assessing for Physical Activity/Exercise 17
• Regularly assess physical activity/ exercise participation across
multiple time points.
• Prospective surveillance model
• At time of diagnosis
• As the person is moving through treatment
• At the end of treatment
• Into survivorship
• Provide information on becoming physically active & refer if
necessary & willing
• How to become physically active
• Local resources (gyms, exercise groups, outdoor groups, etc.)

19. Foundations of an
Exercise Program

20. It Shouldn’t be a Siloed Approach 18
Exercise Program
Balance
Aerobic Resistance Mobility

21. Principles of
Exercise
Program
(ACSM)19
Frequency
Intensity
Type
Time
Progression
Volume
Overload

22. Aerobic Training 20
Frequency
 3-5x per week
Intensity
• 40-90% of VO2max or HRR
• METs: Moderate – 3 to 6 METs (walking 3.0 mph, stationary bicycling at 100 watts with light effort, light effort calisthenics)
• Vigorous - >6 METs (jogging, jumping rope, heavy effort calisthenics)
• RPE: Moderate 11-13/20 or 4-6/10
• Vigorous: 14-17/20 or 7-9/10
Type
• Can really be any type of movement that allows for appropriate intensity though at times a stationary bike or NuStep may
be the most appropriate if there are balance concerns.
Time
 Minimum of 150 minutes of moderate intensity, 75 minutes or vigorous, or a mix of both per week.
• Can be as little as 10 minutes or up to 60 minutes depending on the person’s physical function, fatigue, etc.

23. Resistance Training 20-22
Frequency
 2-3x per week on non-consecutive days
Volume (Sets x Reps x Resistance)
• Often 60-70% or 1RM is often considered the baseline for improving strength
• Resistance as low as 30% of 1RM may promote improvement in physical function as long as volume is appropriate.
• 10-20 sets per week per muscle
• Overall volume may be the biggest factor to improving strength/muscle mass/physical function when the
resistance is at appropriate level
Type
• Can be free weights, machines, resistance bands, or bodyweight.*
• Focus on large muscle groups with supplementary exercises for smaller muscle groups.
Time
 Can be as little as 15 minutes per day

24. Mobility Training 23-24
Frequency
• 2-3x per week
Type
• May be body part/ joint specific but should be progress to full body
• Can be passive or active holds in end range positions of functional
movements.
Time
 At least 10 minutes per day; may be broken into segments throughout

25. Balance Training 23,24
Frequency
• 2-3x per week
Intensity
• No clear evidence on initial starting intensity
• Should be specific, progressive, & challenging
Time
• 20-30 second bouts of multiple repetitions
• 20-45 minutes has shown to be beneficial, but evidence is still limited

26. Rate of Perceived Exertion (RPE) scale25
Adapted from Haddad et al. 2017
Borg RPE Scale Modified Borg (CR-10) RPE Scale Perceived Effort
6
Very, Very Light Effort
7
8
9 0 Very Light Effort
10 1
Light Effort
11 2
12 3 Moderate Effort
13
4 Somewhat Hard Effort
14
15 5
Hard Effort
16 6
17 7
Vigorous Effort
18 8
19 9
Maximum Effort
20 10

27. Repetitions in Reserve 26
Rating Perceived Effort with Reps Remaining
10 Max Effort
9 1 rep remaining
8 2 reps remaining
7 3 reps remaining
6 4 reps remaining
5 6 reps remaining
3-4 Little Effort – 10+ reps remaining
1-2 No Effort
Adapted from Helms et al 2016

28. Rate of
Perceived
Stability
(RPS) scale27

29. Designing an Exercise Program

30. Designing an Exercise Program
• Assess
• Medical Background
• Primary Diagnosis
• Comorbidities
• Lab Values
• Cognition
• Nutrition
• Perceptions and Beliefs of Exercise
• Goals and Main Concerns
• Mobility and Physical Function
• Then we synthesize all of it to
build an individualized exercise
program
• Routinely reassess the to ensure
progress with mobility and
physical function

31. Reference for Lab Values 28
• White Blood Cells
• Reference Values
• 5.0-10.0 109/L
• Hemoglobin
• Reference Values
• Male: 14-17.4 g/dL
• Female: 12-16 g/dL
• Platelets
• Reference Values
• 140-400 k/uL
• Hematocrit
• Reference Values
• Male: 42-52%
• Female: 37-47%

32. Lab Values 28
• Symptom-based approach
• May see fatigue, weakness, shortness
of breath, joint pain
• Biggest concern is when the patient is
neutropenic
White Blood Cells
• May see reduced functional tolerance,
fatigue, tachycardia, shortness of
breath, dizziness, headache,
arrhythmia with lower levels
• Vitals
• Shorter bouts may be beneficial
Hemoglobin/Hematocrit

33. Platelets 29
• Concern when platelets drop below 50k/uL
• Monitor for signs of bleeding (nose & gums), bruising, bleeding with
bowel movements.
<150k/uL Symptom-based approach, monitor tolerance to exercise
> 50k/uL Progressive exercise as tolerated, aerobic, & resistive with monitoring for symptoms
associated with bleeding
49k – 30k/uL Active range of motion exercise, moderate exercise, can consider aquatic therapy
29-20k/uL Light exercise, walking, ADLs without strenuous effort; fall reduction plan
<20k/uL Walking, light ADLs, monitor symptoms

34. Platelets30-32

35. Platelets 30-32
• Overall, there does not appear to be a significant increase in risk or
events of bleeding with physical activity/ exercise &
thrombocytopenia
• Aerobic exercise whether walking or stationary biking may have
better adherence compared to resistance training
• Neal et al. saw a trend for bleeding events related to prophylactic use
of anti-coagulant with platelets counts >50k/uL

36. Nutrition 33
• Often persons will report weight loss prior to being diagnosed with cancer
• Appetite & intake can be affected by:
• Taste changes
• Lack of appetite
• Early satiety
• Difficulty with eating
• Nausea
• Vomiting
• Mucositis
• Pain
• Xerostomia
• Depression/ Anxiety

37. Nutrition 33
• Besides lack of calories, protein malnutrition is common
• Should aim to get 1-1.5g of protein per kg of bodyweight per day
• May even need upwards of 2g of protein per kg of bodyweight
• Need to consider the person’s diet & goals of the exercise program
• Strength vs. muscle hypertrophy
• Endurance training: would it be beneficial or harmful
• Also educating on timing of protein supplementation
• Food log

38. Co-morbidities 34-36
• Co-morbidities need to be considered within exercise program
• Hypertension
• Cardiovascular Disease
• Diabetes
• Chronic Obstructive Pulmonary Disease
• Sarcopenia
• Osteoporosis/osteopenia
• Role of exercise in prehabilitation setting to optimize the performance
status
• Post tx - co-morbidities may affect as much or more than adverse
effects of tx

39. Cognition
• Need to consider the ability of the person to follow instructions &
complete exercises safely
• Not just at home but also in the facility
• Not just about safety but also understanding rest, fatigue, weakness
for safety
• Exercise/ physical activity log for home
• Can be adapted based on needs of the person

40. Bone Metastases 37,38
• Overall, exercise is safe for persons with Bone Metastases
• A supervised program is best but transition to an individual program is
feasible
• Important to have as much information as possible
• Number & Location of Lesions
• Type of lesion(s): Lytic/ Blastic
• Size of Lesion(s)
• Stable vs. Unstable
• Pain at rest vs pain with movement vs pain with weight-bearing
• May be best to avoid end range & explosive movements
• May have to pivot from the thought of:
• “If there’s pain then don’t do it” to
“How bad does the pain get with each movement?”

41. Mirels’ Classification 39

42. Taneichi Score40

43. Bone Metastases 41

44. Performance Potential 42
• Performance may vary day to day & between sessions based on
numerous intrinsic factors:
• Fatigue
• Sleep
• Soreness
• Pain
• Anxiety
• Lab Values
• Same weight/volume may not “feel” the same each session
• 185 lb leg press 4x4 may be an RPE of 7 on Monday but on Thursday may be
RPE of 10 which then could result in greater fatigue down the line.

45. 43 Kirkham AA, Bland KA, Zucker DS, et al. "Chemotherapy-periodized" Exercise to Accommodate for Cyclical
Variation in Fatigue. Med Sci Sports Exerc. 2020;52(2):278-286. doi:10.1249/MSS.0000000000002151

46. Pain vs. Soreness 44
Soreness
• Dull, tight, & achy feeling
• Burning like feeling when exercising
• May experience symptoms during
exercise or within 24 hrs after &
last 48-72 hrs
• Mobility, movement, rest, &
recovery may improve symptoms
Pain
• Sharp pain (stabbing, throbbing,
aching) at rest or with activity
• During exercise or within 24 hrs
after exercise/ activity
• May linger & get worse with each
bout of exercise or activity
• Targeted exercises, recovery,
mobility, & rest may improve pain

47. Pain vs. Soreness 44
• If the person reports increased soreness from previous session(s) or
pain with a specific movement may need to modify the session or
movement.
• Before removing an exercise completely should attempt to modify
• Modify the range of motion
• Reduce the load or volume
• Change the tempo
• Break the movement into parts
• Focus on either concentric or eccentric only
• Want to avoid promoting fear of movement and kinesiophobia

48. Assessing Physical Function

49. Functional Mobility
• Bed Mobility/ Transfers/ Gait/ Stairs
• Range of Motion (ROM)
• Mobility
• Squatting
• Stairs
• Carrying
• Pushing/Pulling
• Sensation
• Coordination & Sequencing
• Problem Solving/ Cognition

50. Assessing Cardiorespiratory Fitness/
Functional Capacity 45,46
• University of Northern Colorado Cancer Rehabilitation
Institute (UNCCRI) Treadmill test
• 2- or 6-Minute Walk Test
• Recommended by APTA Oncology EDGE Taskforce
• 2- Minute Step Test

51. Stage Speed Grade Time BP HR RPE SpO2
0 1.0 mph 0% 1 min
1 1.5 mph 0% 1 min
2 2.0 mph 0% 1 min
3 2.5 mph 0% 1 min
4 2.5 mph 2% 1 min
5 3.0 mph 2% 1 min
6 3.3 mph 3% 1 min
7 3.4 mph 4% 1 min
8 3.5 mph 5% 1 min
9 3.6 mph 6% 1 min
10 3.7 mph 7% 1 min
11 3.8 mph 8% 1 min
12 3.9 mph 9% 1 min
13 4.0 mph 10% 1 min
14 4.1 mph 11% 1 min
15 4.2 mph 12% 1 min
16 4.3 mph 13% 1 min
17 4.4 mph 14% 1 min
18 4.5 mph 15% 1 min
19 4.6 mph 16% 1 min
20 4.7 mph 17% 1 min
Cool Down * 0% **
45

52. Assessing Muscular
Strength/Power/Endurance 47-49
• Repetition Max Training
• Can use free weights, machines, resistance bands, ankle weights
• 1 repetition max testing may not be the safest option
• Can opt for 5/8/10/15 repetition testing
• Benchmark to use for retesting versus using for exercise programming
• Can also test for muscular endurance
• Timed tests (30/45/60/120 seconds)
• Can utilize machines, bodyweight movements, or use weights to load for bodyweight
movements.
• Quick Tests
• 5x or 30 second sit to stand
• Short Performance Physical Battery (SPPB)

53. ACSM Guide to Repetition Max Testing
47,50
• 10-minute warm-up
• Initial load should be around 50-70% of individuals max
• If lift is successful a rest period of 3-5 minutes should be given.
• Resistance should be progressed in increments of 5-40lbs
• Should not exceed four sets to prevent neural & muscular
fatigue.

54. Assessing Balance 49,51
• Fullerton Advanced Balance Scale
• MiniBEST test
• Berg Balance Scale
• Quick Assessments
• Modified Clinical Test of Sensory Interaction in Balance (mCTSIB)
• Timed Up & Go
• Gait Speed
• All are considered acceptable to be used in clinical setting by APTA
Oncology EDGE Taskforce

55. Synthesize
• So again
• Putting all the pieces together based on:
• What adverse effects they are or may be dealing with
• How they move
• What they have the most difficulty with
• What they want to get back to
• And then designing an exercise program to work towards their goals
while addressing their main concerns.

56. Where Exercise
Programs Fall Short

57. The Pitfalls in an
Exercise Program
52,53
• Often the exercise program
is insufficient in:
• Specificity
• Volume
• Progressive Loading to
Adaptation

58. The Pitfalls 52,53
1. Specificity: Exercise program needs to be specific to the goals
• If the goals are to improve strength, then the program needs to reflect that
• A walking program won’t improve strength
2. Volume: Needs to be sufficient volume to the program to promote the
required gains
• Depending on the intensity (% of max, RPE, RIR) the volume may differ but
percentages as low as 30% have shown to promote gains
• Total Time Under Tension (TUT) per session or week
3. Progressive Loading: To get positive adaptations there needs to be
progressive loading & to get progressive loading there needs to be
positive adaptations
• Moving away from the progressive overload where the thought is to just keep
putting weight on the bar or machine

59. Specificity 15,54,55
• Making the case for Reps over Steps
• Often strength/power is significantly lacking in this population
• Muscle Weakness is routinely seen before Muscle Atrophy
• Type IIa/IIx atrophy is escalated due to sedentary nature
• A walking program is beneficial to promote activity but isn’t specific
• Further looking at mortality and overall survival there is a correlation with muscle strength/mass
and improved outcomes
• There is the thought of repetition range for producing strength, hypertrophy, or
endurance
• If strength increases hypertrophy will most likely occur and vice versa
• Neuromuscular adaptations
• Motor Unit recruitment (quantity and quality)
• Sequencing
• Rate Firing

60. Volume
• Volume (load x sets x reps) is often the critical factor in eliciting
positive adaptations
• Often what is lacking in the oncology population for exercise programs
• Don’t want to just pick a resistance but want to progressively load
within the exercise program
• Piling on the weights; going to failure; increasing volume too quickly can all
result in deterioration in performance (physical function) & lead to increased
fatigue & extended recovery
• When volume is sub-threshold there will either be null or blunted
positive adaptations & improvement in physical function

61. Progressive Loading
• So how do we progressively load through an exercise program?
• Consider Performance Potential
• Shouldn’t just arbitrarily select a weight & using % of max may not be the best
in this population
• Use of Rating of Perceived Exertion (RPE) & Reps in Reserve (RIR) - best option
• Allows for autoregulation from a session to session/ week to week basis
• Can use RPE with endurance exercises as well
• Can even use Rate of Perceived Stability (RPS) with balance exercises

62. Progressive Loading 56
• Rehab & Wellness is training for life not necessarily a competition or trying
to hit a new personal best on the back squat, bench press, & deadlift so
using other variables may be more appropriate & functionally related
• Don’t have to only manipulate exercise volume, intensity, & duration to
progressively load
• Lying/sitting → Standing
• Uni-planar or one-dimensional → Multi-planar or three-dimensional
• Stable → Unstable
• Without visual deprivation → With visual deprivation
• Bilateral → Unilateral
• Single task → Double task

63. Exercise Periodization 43
• Macrocycle: Traditionally thought of a full season or year
• Meso- & Microcycles can be broken into weeks or sessions to allow for optimal
programming
• Allows for considerations of chemotherapy, radiation therapy, surgery, functional performance
status
• Linear
• Incremental increase in volume & load
• In traditional setting of S&C for an athlete: Hypertrophy  Strength  Power
• May not necessarily conform to the rehab/wellness settings
• Undulating
• Varying volume & load from week to week
• Strength  Deload  Hypertrophy  Deload  Strength
• Fitting for the rehab/wellness setting
• Stabilize  Restore  Strengthen
• Balance  Strengthen  Mutlimodal  Maintanence

64. From Diagnosis to End of Life2
Prehab
 Education on physical
activity guidelines/
potential adverse
effects of tx
 Baseline data
 Functional
Mobility
 Performance
Status
 Optimize
performance status.
 Address
comorbid
conditions
In tx
 Maintain physical
function.
 Address
impairments (ROM
restrictions, pain,
fatigue)
 Week-to-Week
alterations in
program
Post tx
 Continue to
address
impairments.
 Optimize physical
function.
 Address residual
impairments.
Wellness
 Promote long life
adoption of
healthy lifestyle.
 Assist in transition
to individualized
exercise program.

65. Example Routines to Build Exercise Programs
• Full Body & Split Routines
• Aerobic/ Balance/ Resistance
• Upper/ Lower Body
• Push or Pull or Combined
• Metcons
• Couplet
• Triplet
• Circuit Training
• Interval Training
• Traditional Sets
• Cluster Sets
• High Speed Resistance Training
• SuperSets
• Drop Sets
• Isometrics
• Eccentrics

66. Exercise Programming:
Full/Split Routines 57
• Full or Split Routines
• Probably what comes to mind
when thinking of an exercise
program
• Can incorporate all aspects of
the exercise program by varying
focus day-to-day
• Aerobic training or balance
training for HEP while
resistance training within the
supervised session.
• Monday & Wednesday:
• Lower Body
• Tuesday:
• Balance at home
• Thursday:
• Aerobic exercise
• Friday:
• Full Body HEP exercise
• Monday, Wednesday, Friday:
• Full Body exercise routine
• Tuesday &Thursday
• Physical Activity outside of PT/Gym

67. Exercise Programming: Metcon
• Couplet (2 movements)
• Triplet (3 movements)
• Can be for time or have a time limit
• Predetermined volume prior to
starting the movements
• Useful for including aerobic
movements & resistance movements
• As much rest as needed & whenever
just has to complete all the
repetitions
• Couplet:
• 40-30-20-10
• Step Up and Overs
• Wall Push Ups
• Triplet
• 3 Rounds
• 25 squats
• 10 Modified Burpees
• 12 TRX Rows

68. Exercise Programming:
Circuit Training 19,58
• Circuit Training
• Beneficial as it can include all four
groups of the program within a
session
• Use of balance exercises as
planned rest periods
• Exercises can be completed for
time or repetitions to include
aerobic & resistance training
• Also allows for continuous volume
accumulation
• 4 Rounds
• 20 reps - TRX Lunges
• 12 reps - Machine Rows
• 40 reps - Modified Mountain
Climbers
• 12 reps - Lat Pulldowns
• 8 reps - Leg Press
• 12 reps - Modified Push Ups

69. Exercise Programming: Intervals 58
• Interval Training
• More based on Work to Rest
Intervals
• Will often be a higher effort
whether perceived (RPE) or
physiologically (heart rate)
• Work to Rest ratio can vary based
on the person
• Work can be as little as 10 sec. up
to 180 sec.
• Tabata
• 8 Rounds of 20 sec/ 10 sec (W/R)
• 6 Rounds
• 30 sec/30 sec (W/R)
• Mini Squats
• Wall Push Ups
• Step Ups
• Modified Mountain Climbers

70. Resistance
Training:
Cluster Sets 59

71. Resistance Training:
High Speed Resistance Training (HSRT)/ Power
Training (PT) 60,61
• Load is usually heavier but lower load (40-60% 1RM)
• Moves away from the “don’t go too fast/ fast is not better”
philosophy
• Concentric phase is completed as fast as possible with a controlled
eccentric phase
• Promotion of power; maximal motor unit recruitment; favoring of
Type IIa & Type IIx fibers (fast twitch) which are more prone to disuse
& atrophy
• Focus on multi-joint movements utilizing larger musculature

72. Resistance Training:
SuperSets & Drop Sets 19, 62
• SuperSets
• Numerous variations with
supersets
• Paired Set (Push/Pull)
• Compound (single joint into multi
joint of the same muscle group)
• Staggered (Upper Body then Lower
Body flexion exercises)
• Only transitional rest is given
between exercise 1 & exercise 2 then
a standard of 120-180 second rest is
given
• Drop Sets
• With the completion of each set
resistance is reduced with little to
no rest between sets.
• Sets are often completed to
fatigue.
• Example:
• 55# - 45# - 35# ( each completed to
fatigue)

73. Resistance Training:
Eccentrics & Isometrics 63-65
• Eccentrics (Lastayo et al.)
• Lower metabolic cost compared to
concentric exercise
• May have a lower perceived effort
for the load being controlled
• Higher potential for greater motor
unit recruitment
• Potential to activate anabolic
pathways that promote muscle
hypertrophy independent of
growth hormone & testosterone
• Isometrics (Lum et al.)
• Also has a lower metabolic cost
compared to concentric exercise
• Again, lower perceived effort
compared to other forms of
exercise.
• May be tolerated well in setting of
bone metastases compared to
other forms of exercise
• Holds of 5-30 seconds with a
cumulative contraction time of 30-
150 seconds

74. Home Exercise Program
• May be focused specifically on main concern of the person
(limited ROM or tissue restriction after mastectomy) or be focus
on complimentary aspect of the exercise program (mobility &
aerobic exercise)
• Should have elements of progression & overload though
consistency with sets & repetitions may be easier to follow &
remember for HEP.
• An exercise/ physical activity log is beneficial & can be adapted
to meet the needs of the person

75. Case Studies

76. Case Study 1: Background Info
• 55-year-old female
• Oncologic History:
• Stage IA grade 3 mucinous retroperitoneal adenocarcinoma;
• XPL, TAH, BSO, omentectomy, peritoneal biopsies, pelvic node dissection, appendectomy &
resection of right sided retroperitoneal mass.
• Completed 3 cycles of adjuvant carboplatin & Taxol
• Metastatic disease in left lung (upper & lower lobe) a year later
• Completed another 6 cycles of carboplatin & Taxol, last four with Avastin; & completed SBRT
• Currently receiving maintenance Avastin every 3 weeks
• Past Medical History
• Lumbar laminectomy ~20 years prior with residual lower back pain & lateral right foot
numbness.

77. Case 1: Main Concerns & Goal(s)
• Her main concerns at the time of initial evaluation are:
• Shortness of breath with exertion
• Fatigue (weekly rating of 5-6/10)
• Numbness in bilateral feet
• Generalized weakness
• Unable to work full-time (works an extremely active job in healthcare setting)
• Goals of PT
• Be able to return to full-time work duties
• Be able to walk her dog for at least 35 minutes
• Reduce fatigue
• Be able to play a full round of golf

78. Case Study 1: Pre-Post Assessment
• Initial Assessment
• 5x Sit to Stand: 13 sec  7 seconds
• FAB- 28/40  34/40
• 6MWT: 414 meters  503 meters
• Fatigue 5-6/10  1-2/10
• Exercise Program
• Multimodal (Aerobic, Resistance, Balance, & Mobility)
• Use of Traditional Routines, Interval Training, & Circuit Training
• Home Program mainly included mobility& aerobic exercise.

79. Case Study 1: HEP Interval Program
• 4 Rounds (30 second work/ 90 second rest)
• Squats
• Wall Push Ups
• Lunges
• Banded Rows (Heavy Resistance)
• Mountain Climbers
• DB Shoulder Press
• Work period remains the same, but the rest period gradually reduces
as able.

80. Case 1: Sample Session
• Circuit Training - 3 Rounds
• 2 minutes on NuStep – RPE of 6-8/10 @ Level 4
• 15 Lat Pulldowns @55#
• 15 Leg Press @135#
• 1 minute of balancing on dyna discs
• 30 sec planks
• 10 TRX rows
• 10 DB Deadlifts (15# DBs)
• 30 sec tandem stance on foam each side
• Rest within session was only transitional rest ranging from 10-20
seconds max

81. Wrap Up

82. Key Points
• If you really want Exercise to be Medicine, then it needs to be specific
& at the correct dose just like chemotherapy, radiation therapy, etc.
• However, some exercise is better than none
• Reps over Steps
• HIIT Bodyweight/Resistance Training >>>> Walking/ Aerobic Program
• Supervision is most beneficial with promoting significant changes in
body composition, performance status, & QoL
• Though after a period of supervision, unsupervised programs have been
shown to further optimize or maintain physical function
• Even better with routine follow-up or check-ins

83. Key Points
Moving exercise forward in oncology population
We know exercise is beneficial
but we need to figure out
how to get persons living with & beyond cancer
• moving
• improving their understanding of the benefits
• providing access to
• Oncology Rehab
• Oncology Exercise personnel & facilities

84. Questions?

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