1

Strength after Cancer: How to

safely progress with an exercise

program from treatment to

survivorship

Julie Everett DPT, CLT

Laurie Fitz PT, CLT

Objectives

• Provide an overview of common

physical side effects experienced by

cancer survivors

• Define lymphedema and appropriate

exercise guidelines

• Discuss cancer related fatigue and

management

• Educate on general exercise guidelines2

Cancer Survivor

“Any person who has been diagnosed

with cancer, from the time of diagnosis

through the balance of life”

3ACS Facts and Figures 2014-15

14.5

million

As Physical Therapists

Our goal is to improve

quality of life of cancer

survivors by

managing/reducing

physical side effects of

treatment

4

Side Effects of Treatment

• Pain

• Fatigue

• Weakness

• Stiffness

• Balance

• Decreased

endurance

• Lymphedema

5

Good News: Positive health

outcomes of an exercise program

• Endurance

• Cardio respiratory

fitness

• Insulin level

• Body composition

and weight

• Bone mass

• Muscle strength

• Balance

• Reduced Fatigue

• Reduced Nausea

• Sleep

• Social well being

• Decreased risk of

reoccurrence

6

Lymphedema

Disruption to system

7

Arteries

Veins

Capillaries

Lymph

vessels

Causes

• Surgery

• Node removal

from axilla,

groin, neck

• Radiation

• Scar tissue

http://en.wikipedia.org/wiki/File:Blausen

_0623_LymphaticSystem_Female.png

8

Lymphedema Need to Know

Symptoms

• Visible swelling

• Feeling of

fullness/firmness/heaviness

• Feeling of tightness from

clothes or jewelry

Reducing Your Risk

• Avoid:

– Blood Pressure

– Needle Sticks

– Tight/restrictive clothing

• DO:

– Take care of your skin

– Exercise

9

If you develop lymphedema:

• Notify your doctor

• Evaluation by a Certified Lymphedema

Therapist (CLT)

• Treatment is called Complete Decongestive

Therapy (CDT)

– Massage, skin care, compression,

education, exercise**

10

Exercise and Lymphedema

• Scientific literature

demonstrates safety

• Should be done in a

systematic manner

• May have a

protective benefit

11

Exercise Key Points:

• Lymphedema must be stable

• Initial exercise should be

supervised

• Start with lowest possible

weight

• Monitor for symptoms

• Increase weight slowly after

2-4 sessions of no negative

changes

• Wear compression garment

12

Compression Garments

• Should be worn with

exercise if diagnosed

with lymphedema

• Enhances lymphatic

return

• Evidence less clear for

women at risk for

lymphedema

13

Discussion for Cancer Related

Fatigue

• Cancer pain- what is it?

• Cancer related fatigue- how is this

different?

• Exercise- how can it help?

• Moving forward- what can I do?

Cancer Related Pain

– “An unpleasant sensory and emotional experience associated with actual or potential tissue damage”

– Survivors can have pain from surgery, chemotherapy, or radiation

– 33% of people with cancer will continue to have pain after curative care (National Cancer Institute)

– Medication, therapy, exercise and relaxation techniques are useful treatment options

Pain

• Healing Through Movement

– Using safe and appropriate exercises to help

increase the healthy movement

– Move the sensation of pain further away from painful

activities

Healthy Movement

Pain

Injury

Cancer Related Fatigue

– Most common side-effect complaint

– “Physical, emotional, or cognitive tiredness

or exhaustion that is not proportional to

recent activities and interferes with

functioning. This fatigue does not get

better with rest.”

– 14-96% of people during treatment and 19-

82% of people after treatment (National

Cancer Institute)

Cancer Related Fatigue

• Other reasons for fatigue

– Anemia

– Medications

– Poor nutrition

– Emotions

18

Treatments for Fatigue and Pain

• #1 Treatment?

EXERCISE!

Fatigue and Exercise

• “I’m way too tired to workout today.”

• “I’m scared I’m going to hurt myself.”

• “I need to save what little energy I have to go

home and take care of my family.”

• “I’ll start an exercise program tomorrow.”

• “Everything hurts and you want me to do

WHAT?!?”

Treatments

• Exercise!– Improved energy level

– Appetite stimulation

– Increased blood flow to tissues

– Decreased pain

– Improved quality of life

– Increased strength and flexibility

– Mood stimulation

– Improved outlook on cancer challenges

• 2007 Study: Moderate physical activity after treatment (not household activities) had decreased fatigue and pain

Exercise Principles

• Speak to your health care provider before

starting an exercise program!

• Become knowledgeable about the resources

out there:

– Physical Therapists

– Occupational Therapists

– Personal Trainers

• “Start LOW and go SLOW”

Exercise Principles

• Heart rate targets– Stay between 50-80% of maximal heart rate

– Maximal Heart rate: 220 minus age (ex: 220- 32= 188)

– 188 X .5 = 94 188 x .8= 154

• Breathing– You should be able to have a conversation while

working out.

• You can start exercising during treatment!

• Know your exercise level BEFORE diagnosis/treatment

Fatigue and Exercise

• Beginners– Sedentary lifestyle and/or low level of exercise

– Able to complete household chores and family obligations

• Intermediates– 2-4 x a week to the gym

– Exercises classes and/or “weekend warrior”

• Experts– 4-5 x week at the gym

– Competitive athlete and/or active lifestyle

Exercise for Beginners

• Start with 3-4 days a week building up

• Start with smaller bouts (10 minutes) and

building up the time (45 minutes)

• Choose an activity that interests you:

– Walking, swimming, biking, hiking

• Have buddy that will encourage you

• Balanced program:

– cardio, stretching, and weight training

6 Exercises Daily

1. Shoulder and Pec Stretch– Lie on your back

– Hold a broom or umbrella in both hands

– Reach overhead until you feel the stretch

– Hold for 15 seconds

6 Exercises Daily

2. External Rotation– Standing with arms bent and at side

– Rotate arms outward with elbows still at side

– Slowly return to standing position

6 Exercises Daily

3. Shoulder Flexion

– Start with arms at your

side

– Keep elbows straight and

raise arms to shoulder

height

– Can do with palm down

(as shown) or thumbs up

– Slowly lower arms to

starting position

6 Exercises Daily

4. Abdominals– Lay on your back with knees bent

– Slight press your low back into the floor

– Keeping back flat, slowly raise one knee to chest

– Maintaining control in the back, slowly return

6 Exercises Daily

5. Bridging– Lay on your back with knees bent

– Squeeze buttock

– Lift buttock off the floor

– Slowly return back to floor

6 Exercises Daily

6. Clamshells– Lay on side with knees bent, keeping feet together

– Lift top knee up, not allowing body to roll

backwards

– Slowly lower to starting position

– Repeat on other side

Intermediates and Experts

• Don’t be concerned if you need to scale back your

previous activities during treatment- YOU WILL GET

BACK!

• Consider joining group fitness challenges to stay

motivated

• Certified Personal Trainers to help you reach your

goals

– Cancer Exercise Specialist

Additional Exercise Tips:

• Aerobic exercise

– Walking

– Stationary bike

• Circuit Training

– Work large muscle

groups

• Flexibility

– Stretching

34

Exercise Alternatives

• Yoga

• Tai Chi

• Qigong

References:

• http://www.lymphnet.org/

• http://www.hopkinsmedicine.org/kimmel_cancer_cent

er/centers/cancer_rehab

• http://www.hopkinsmedicine.org/physical_medicine_r

ehabilitation/index.html

• www.thecancerspecialist.com/ceti-new/default.aspx

• National Cancer Institute (www.cancer.gov)

• AlfanoCm, Smith AW, Irwin ML, et al. Physical activity, long-term

symptoms, and physical health related quality of life among breast

cancer survivors: a prospective analysis. J Cancer Surviv 1 (2):116-28,

2007

36

References

• www.thecancerspecialist.com/ceti-new/default.aspx

• National Cancer Institute (www.cancer.gov)

• Alfano CM, Smith AW, Irwin ML, et al. Physical

activity, long-term symptoms, and physical health

related quality of life among breast cancer survivors:

a prospective analysis. J Cancer Surviv 1 (2):116-28,

2007

• Garcia, DO, Thomson, CA. Physical Activity and

Cancer Survivorship. Nutrition in Clin Practice 29 (6):

768-779, 2014

37

Thank you!

• To learn more about our program, visit our website-

http://bit.ly/JHBreastCaSurvivorship

• To view this webinar and previous webinars, check

out our media library-

http://bit.ly/JHBreastCaSurvivorshipWebinars

• Questions or concerns, please contact Elissa Bantug-

ebantug1@jhmi.edu

38