This document discusses guidelines for exercise after a cancer diagnosis. It provides: 1) National guidelines for exercise that reduce lymphedema risk and include strength training, aerobic exercise, and flexibility. 2) Evidence from clinical trials showing strength training reduces lymphedema risk by 50% and flare-ups by 70% while improving strength and function. 3) Recommendations for pre-exercise evaluations to identify limitations and ensure safe exercise for those with cancer treatment effects like lymphedema.

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
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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
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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
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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
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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
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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?
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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
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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)
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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
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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
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Strength ABC Program results8

14.  Chemotherapy
 Radiation Therapy
 Surgical Interventions
14
Possible Barriers to Exercise

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
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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
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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
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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
18
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
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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%
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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
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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

26.  LABAT evaluation
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Pre-Exercise Evaluation continued...
© Klose Training 2015

27.  RPE before exercise
 6-minute walk test as evaluation
 Pulse and blood pressure before and after 6-minute walk
test
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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?

29. 29
Stretches
Chest Stretch Shoulder StretchTriceps Stretch
Quadriceps Stretch Calf Stretch

30. 30
Upper Extremity Exercises
Chest Press Row- One or Two Arm
Bicep Curl Tricep Kick-Back

31. 31
Lower Extremity Exercises
Squat Calf Raises
Step-up

32. 32
Core Exercises
Partial Sit-ups Bridging
Superman/Woman

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

34. 34
Questions

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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