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Exercises for Cancer Supportive Care
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An Exercise Program
Kathleen Dzubur, MS and Francine Manuel, RTP
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The benefits of exercise in cancer prevention and treatment in the medical literature have documented causal relationships between exercise and prevention and exercise and quality of life issues. However, specific dosage for exercise programs have yet to be established. Some guidelines based on research in non-clinical populations offer clues for these exercise programs. For example, detrimental effects on the immune systems in athletes provide the common-sense suggestion that the cancer population exercise at levels that are moderate, not intense. The National Institute of Health (NIH) has recommended a program of moderate exercise, which includes such activities as walking, climbing stairs, and gardening, playing with children for non-clinical populations. These activities should be performed 6 - 7 days per week and can occur in 3 ten-minute sessions. The same moderate prescription is recommended for cancer patients.
The American College of Sports Medicine (ACSM) recommends for cancer patients undergoing treatment exercise programs that help patients meet the goal of maintaining cardiovascular endurance, muscular strength and level of functioning. Scientific research has documented that walking or bicycling 30 - 45 minutes per session, 3 - 5 days per week produces the following benefits: decreased nausea, decreased fatigue , increased physical endurance and increased quality of life. The benefits are believed to come from effects on hormone levels, adiposity, gut transport time, and endorphines produced by exercise that are believed to affect mood. Various types of aerobic and resistive exercises also improve the functioning of the heart/lung/circulation (cardiovascular system) and strength of the muscles. Aerobic exercise programs have added benefit of increasing the red blood cell count positively affecting the fatigue suffered by cancer patients undergoing treatment. While receiving the various cancer therapies, minimizing deconditioning of the body is the main goal of exercise program. The better condition you can maintain your body, the better you will tolerate the side affects of chemotherapy, radiation and other invasive treatments. It will also be easier to do the required activities of daily living
The Warm Up
Begin each exercise session with a warm up. The idea of the warms up is to start moving slowly and gradually increase the blood flow to the muscles to prepare them for further work. Begin with taking a resting heart rate. If your rate is above 100 beats per minute, do not exercise unless check with MD. The warm-up should be sustained for 2-3 minutes and elevate the heart rate 10 - 20 beats above resting. This should correspond with an RPE score of 8 - 9 (see RPE explanation and chart below). Three to five minutes of stretching should follow.
Suggested movements include:
Shoulder shrugs
Alternate shoulder rolls
Wrist rolls
Alternate opening and closing of the hands
Arm lifts to the side, front and back
Elbow bends which bring hands up to shoulder (biceps curls)
Alternate arms to ceiling
Double arm reaches to ceiling followed by pull downs
Add toe taps, heel touches, small knee lifts, marching, side stepping.
Instructions for RPE:
Pay attention to the cues your body gives you such as breathing rate, how fast your heart is beating, fatigue in your working muscles. Take all cues into consideration and assign a number as to how hard the work feels. For example, ``6'' would be how you might feel sitting comfortably in a chair and resting. Above ``18'' would be working so hard physically that you couldn't continue for more than several seconds.
Original RPE (2)
6
Very, very light
8
9 Very light
10
Fairly light
12
Somewhat hard
14
15 Hard
16
17 Very hard
18
Following the warm-up, begin your aerobic exercise of choice. The duration and intensity of the conditioning portion of the exercise session is based upon the patient's functional status. Please refer to the following Karnofsky Performance Scale to determine the appropriate status.
KARNOFSKY PERFORMANCE SCALE (We use this scale to determine level of exercise)
100% No evidence of disease
90% Normal activity with minor signs of disease
80% Normal activity with effort: signs of disease
70% Cannot do normal activity, but cares for self
60% Requires occasional assistance
50% Requires considerable assistance and frequent medical care
40% Disabled: requires special care
30% Severely disabled; hospitalization may be indicated
20% Very sick; hospitalization necessary for supportive treatment
10% Moribund
Aerobic Exercise
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Aerobic exercise is exercise that rhythmically uses the large muscles of the legs and arms to elevate the heart rate within a certain range. Examples are brisk walking, jogging, swimming, bicycling, gardening, dancing, playing actively with children, and sexual activity.
Recommendations for Aerobic Programs
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1) Those with Karnofsky scores of 70-100% can begin with 15 minutes of conditioning and increase the time by 1-2 minutes each session until a total of 40 minutes per session is achieved. Try to exercise 5 days per week. The conditioning portion of the exercise session should be intense enough to elevate the heart rate between 60 - 80% of the maximal heart rate as estimated by a treadmill test. For those who have not had a treadmill test, use the following formula to predict your maximal heart rate(MHR): 220 minus your age. Begin your program working at the low end of your MHR (60%) and as you become more fit increase the intensity of exercise by walking faster, gardening more vigorously, moving your arms more, etc, until you are working at 80% of your MHR. The time it takes to become conditioned enough to be comfortable exercising for 40 minutes at a higher heart rate varies with each individual, but a reasonable goal is eight weeks.
2) Those with a Karnofsky score of 50 - 70% can begin with five minutes of exercise at 55% of MHR three times per day, adding one minute to each interval each time until ten minute intervals are achieved. Follow this program 6-7 days per week. Then reduce the number of intervals to two, adding one minute each time until fifteen minutes are achieved. At that time, exercise once a day, adding on a minute each day and following the program prescribed for Karnofsky 70-100% as explained in the beginning of this paragraph. In addition to determining your exercise intensity by taking your heart rate, use the RPE scale. Your RPE for the conditioning phase should be 11-14. Note: Those who are taking certain blood pressure medicines may not be able to elevate their heart rate and may have to use the RPE scale exclusively for determining appropriate work levels. Check with your physician to find out if your medications blunt your heart rate.
Dynamic
Resistive and Isometric Exercises
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Dynamic resistive exercise is performed with weights or resistive tubing of some type. The joints are moved through excursion of the various range of motions. The force applied is sufficient to result in increased fiber thickness of the muscle belly. Isometric exercises are performed with the same types of resistance, but do not involve joint movement or can just consist of contraction (squeezing) of the muscles without any movement of the limb. Examples are holding in your stomach, tightening buttocks, holding the leg straight. These squeezes are held for six seconds and released.
There are many professionally prepared exercise tapes which can be purchased for home usage. In general it is more motivating to exercise in groups, but if you can push yourself, this is a good way to get well balanced programs. There are many exercise machines, which provide the necessary activity. You can go to health clubs and work with personal trainers. Be sure to explain the specifics of your illness to a trainer.
We have prepared a three-stage program of progressive exercises and found it to be helpful in maintaining physical function through all stages of cancer treatment.
We also have an exercise and fitness group at the hospital run by Kathleen Dzubur.
Francine Manuel, Physical Therapist, and Kathleen Dzubur, Kinesiologist meet with patients to design exercise programs that meet the various needs of each patient including conventional physical therapy, yoga and Tai CHI.
Special instructors for Yoga and Tai Chi are available as needed.
Three Stage Cancer Exercise Program
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Stage I: In Bed-Beginning to move-exercise program for when patients are too ill to get out of bed. It is just range of motion for all four limbs and does not have any resistance other than gravity.
Stage II: Bed/Chair with Resistance-exercise program designed for patients who are out of bed part of the day and walking around home and in a limited capacity into the community. It incorporates the use of weights and other resistance devices like surgical tubing.
Stage III: Up and around-These are general fitness programs for patients that have recovered enough to go out into the community. They can be used to regain full prior function or just for a healthier way of life after recovery.
Weight should be advanced beginning with one set of 10 repetitions. Work up to 3 sets of 10 reps. Advance weights so that no discomfort or strain is experienced up to desired intensity of work out.
Rules and Precautions
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- Do not exercise if blood counts are any of the following
A. Abnormal levels of sodium and potassium (electrolytes)
B. Abnormal protein
- Numbness
in legs, hands (Oncvin, Velban, Vincristine, Vinblastine, Platinol,
Taxol, Taxotere, Euflex)
Alternately contract, relax limbs
Avoid excessive weight-bearing-alternate walking with cycling- avoid uneven surfaces
- Infection, anemia, low blood pressure, bleeding (possibly due to abnormal blood count and plasma volume - all chemo drugs)
A. Identify nadir period (7-12 days post chemo) avoid public swimming during this time
B.Check lab values
C. Drink lots of fluids
- Cardiac
Problems ( Doxorubicin, Cerubidine, Idamycin, Vovantron, Pharmarubicin)
Best if EKG, blood pressure monitored
Watch for swollen ankles, shortness of breath and consult physician
- Bone Weakening (long term Prednisone)
Do strength training with resistive bands - no heavy weights! Be careful when walking
- Other
A. Pulmonary tumors - watch for shortness of breath
B. Neck, back pain should be evaluated for spinal cord compression or bowel obstruction
Francine Manuel, RPT
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Yoga can help a person react to potentially stressful situations in beneficial ways by counteracting many of the body's natural responses to stress.
Many of the yoga practices activate the parasympathetic nervous system to bring relaxation and restoration to the body by stabilizing blood pressure, lowering heart rate and the body's demand for oxygen, slowing breath rate, increasing lung capacity, improving digestion, increasing feelings of calm and tranquility and bringing about a measurable improvements in the immune system. In a yoga class designed especially for cancer patients, students are encouraged to gently extend their awareness of their physical, emotional, sensory and thinking levels. They practice a slow, deliberate yoga adapted to their own needs and physical limitations. Attention to breathing and a focused awareness of the movements and the stillness of each yoga pose characterize this particular style of yoga.
As the body gains flexibility and the breath deepens, the mind and emotions settle into greater ease and balance. In quiet times of deep relaxation and meditation, habituated patterns of thinking and behaving may become more obvious and lend themselves to change. Yoga practices include yoga postures and stretches, breathing practices, imagery, meditation and progressive relaxation. While each technique has its own specific purposes, all have the common aim of helping to develop a focused awareness of what is happening in the body and mind--emotionally, physically and spiritually.
- Supportive Cancer Care
- by Ernest H. Rosenbaum, MD & Isadora R. Rosenbaum, MA
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