Lecture 3 - Cancer & Exercise

Question 1

Exercise as medicine for Advanced Cancer:

Define Advanced Cancer:

Answer 1

AC is a primary cancer that is unlikely to be cured

AC is a secondary metastatic Cancer that’s unlikely to be cured

Question 2

Why could exercise be important in advanced cancer?

Answer 2

Those with best cardiorespiratory fitness have longer survival
Those that are more physically active have better QOL, anxiety, and depression.

Question 3

What are the goals of Exercise for Advanced Cancer:

Answer 3

Improve or maintain QOL, well-being
Maintain/improve functional independence
Maintain/improve cardiorespiratory fitness and muscular strength
Manage symptoms such as fatigue and cachexia

Question 4

Exercise & Advanced Cancer: Evidence in advanced lung cancer

Answer 4

Evidence suggests:
It’s safe and feasible with acceptable completion rates
Results in improvements in: functional capacity & strength
Results for QOL are mixed

Question 5

Advanced Cancers: Stage IV

Answer 5

Exercise prescription is tricky [Tumour burden, side effects of treatments and tumor]

Beware:
Bone Mets
Pain
SOBOE
Cognitive changes [Brain mets]
Changes in organ function as a result of tumor [SVCO]
Medication to treat side effects 
Depression/anxiety 
Deconditioning

Depends on extent of disease spread
Cancer can progress or change quickly

Question 6

Advanced cancer - Bone Mets

Answer 6

Bone disease:

• use extreme caution, need to work with clinicians
• avoid contact sports or activities
• activities with high risk of falls/injury
• avoid high impact activities, heavy lifting, twisting & turning

Exercise in water:

• aqua size
• strengthening exercises
• swimming

Stationary bike/recumbent bike
-low resistance

Proceed with caution

Question 7

Advanced Cancer: Goals & Guidelines

Answer 7

Goals:

• needs to have a focus on QOL
• maintaining function
• spending time with family
• home-based
• avoiding activity

No Guidelines
Little research

Proceed with caution and multidisciplinary team

• need to communicate with care providers
• physical therapy, OT, dietician, physician, nurses

Question 8

Exercise:Children & young adult survivors of cancer

Answer 8

Limited research

Exercise resulted in positive intervention effects for:

• body comp
• flexibility
• cardiorespiratory fitness
• muscle strength
• health related QOL

Question 9

Cancer Specific Side Effects Fatigue:

Answer 9

Rest doesn’t relieve CRF
Deconditioning makes fatigue worse
-decreases in cardiorespiratory fitness can precipitate and exacerbate CRF

Exercise needs to be appropriately prescribed

• can prevent, alleviate, and manage CRF
• aerobic exercise had moderate effect for those completed treatment
• exercise had effect during treatment
• multimodal exercise also effective [aerobic + resistance + stretching]

Role for education

Question 10

Exercise Prescription based on fatigue severity: Mild Fatigue [<3/10]

Answer 10

Start with appropriate ACSM recommendations coupled with a RT program in line with standard guidelines

Question 11

Exercise Prescription based on fatigue severity: Moderate Fatigue [4-6/10]

Answer 11

Start with repeated short bouts of aerobic activity [5-10min as tolerated], progressing to 60-80% of HRmax

Progression should increase freq and duration prior to intensity

RT should include the major muscle groups, but could need to be prescribed to a low intensity [e.g. 30-50% of 1RM], with high reps [e.g. 10-15], for 1 to 2 sets. Progression to a standard prescription should occur over time.

Question 12

Exercise Prescription based on fatigue severity: Severe Fatigue [7+/10]

Answer 12

Prescription could begin with low intensity bouts of aerobic activity [e.g. 5-10 min] spaced throughout the day

Duration should be progressed gradually as tolerated

Referral to a Physio for active ROM, gravity only resistance, or light weight if tolerated.

Question 13

Tips for Avoiding Fatigue:

Answer 13

Program considerations:
-RT = increases recovery between sets [2-3min between sets, decreasing recovery time can be used as a variable for progression]
=use lighter loads and higher reps
=decrease intensity if fatigue gets worse
=progress slowly
=break training up into smaller bouts

RET alone might be necessary for the first 6-12 weeks in very fatigued survivors.

Question 14

Describe Lymphoedema:

Answer 14

Caused by abnormality of lymphatic system

• secondary to surgery radiation
• melanoma or breast
• head and neck, prostate

Upper or lower extremity
Leads to build up of protein rich fluid and cell debris
Causes swelling

Left untreated can cause :

• chronic inflammation
• infection
• hardening of skin
• could cause further lymph vessel damage

Can develop immediately - or weeks, months, years later.
Risk of lymphoedema increase with obesity
Early detection and treatment important

Question 15

Who’s at risk of developing lymphoedema?

Answer 15

Those with:

• sustained damage to lymphatic system due to surgery or radiation therapy
• surgical incision in vicinity of lymph transport vessel

These risks could change over time depending on factors such as:

• weight gain
• age
• changes in delicacy conditions

Question 16

Symptoms of lymphoedema:

Answer 16

Feeling of heaviness or tightness
Notice swelling or puffiness in affected area
Arm/chest becomes hot or red
Full sensation
Tightness of skin
Decreased flexibility in hand and wrist
Difficulty fitting into clothing in one specific area

Question 17

How to avoid exacerbating lymphoedema:

Answer 17

Incorrect or unsafe exercise may increase risk of lymphoedema
Beware cuts, bruises, as risk of infection high
Skin care very important
Avoid trauma - avoid falls, and injuries

Follow advice of treating physician or physio - compression, or other treatments

Avoid taking BP on affected or at risk arm - if necessary use tactics to reduce high pressure of measurements
Be cautious with use of hot/cold therapies

Question 18

Exercise Prescription

Answer 18

Recommended for those at risk for and with a diagnosis of lymphoedema

Program should start low and progress slow

• 40% of 1RM to start, no weight, or very low weight
• very gradual progression [smallest increments possible after 2 sessions of reaching the desired repetition range]

Exercise should be:

• started gradually
• increased cautiously
• stopped for pain, increased swelling or discomfort

Beware of participants with breaks in training
-reduce intensity and gradually increase

Monitor for symptoms

Avoid high stress or inappropriate tests
-push up test

Use caution with 1RM testing

• e.g. bench press
• complete a warm up of 5-10 min of low intensity aerobic exercise
• warm up with 5 lbs of weight on chest press
• resistance is added until can no longer perform the complete movement without change in biomechanics, or failure.

Question 19

NLN position stand: Recommendations

Answer 19

Participants should be cleared by physician before beginning a program
Should perform aerobic and resistance exercise in ‘safe manner
Allow adequate rest between sets
Avoid weights that wrap tightly around extremity or clothiers that cause constriction
Wearing a compression garment when recommended
Maintaining hydration
Avoid extreme heat or overheating
Incorporate variety
Form is very important
Avoid repetitive use
Sudden increases in usual exercise duration or intensity could trigger or worsen lymphoedema
Slowly progressive exercise could decrease risk of overuse.

Question 20

Cancer-specific Side effects: Other

Answer 20

Effect of exercise on cancer related cognitive impairment - insufficient evidence

Peripheral neuropathy

Limited evidence in cancer

• balance training appears to be the most effective
• strength, or a combination of endurance and strength, appear to have a lower impact.

Question 21

Immunology

Answer 21

Neutropenia or low white blood cell count due to the effect of treatment can result in a increase risk of infection

Sign and symptoms- fever, sore throat, SOB

Exercise recommendation during time of infection include: avoid high intensity exercise, exercise to ability to tolerate activity, avoid public places with increase risk of infection.

Question 22

Neurological:

Answer 22

Neurological issues such as:

• impaired sensation [numbness, tingling] in the extremities
• brain foggiest, chemo brain
• seizures
• impaired balance and coordination

Exercise recommendations with these conditions:
-wear good shoes
-avoid exercise that requires high levels of coordination
-walk on even surfaces
=increased risk of thermal and ischemic injury of the extremities if your ability to feel hot or cold temp is impaired
-use caution with balance exercises
-use caution with activities such as treadmills, free-weights

Question 23

Peripheral Neuropahty

Answer 23

Impaired sensation in the extremities as a result of cancer treatments may pose specific risks when exercising

Wear good shoes

Walk on even surfaces- increased risk of falls and injury if you cant sense change in terrain while walking

Protect extremities of hot and cold when exercising
Use caution with balance exercises
Use caution with activities such as treadmills
Blood pressure alterations

Question 24

Haematological

Answer 24

Anaemia or low RBC count can be cause by cancer treatment

Sign and symptoms:

• SOB
• dizziness, chest pains extreme fatigue
• cold hands and feet
• irregular HR

Exercise recommendations for these patients include:

• avoid high intensity exercise
• reduce volume till condition is resolved
• delay exercise if severe anaemia

Question 25

Catheter or an ostomy:

Answer 25

Certain treatment commonly used catheters for treatment purposes and usually are inserted just under the skin in the forearm, upper arm, or chest.

These sites are susceptible to bleeding or infection and there is a possibility it may move position or pull during exercise movement

Consideration for exercise include:

• measure BP with other arm
• avoid vigorous exercise
• avoid repetitive upper limb exercises
• avoid swimming

Some cancer survivors have a stoma and wear an ostomy bag for waste removal

Consideration for exercise include:

• avoid vigorous abdominal exercises - low level is suitable
• care need to be taken as this new stoma is a route for infection

Question 26

Shortness of breath

Answer 26

Common and distressing symptom
Research indicates that 85% of patients report suffering from intermittent SOB that largely tends to be brought on by exertion
Deconditioning, muscle weakness, and loss of cardiovascular fitness can make sob worse
Being inactive can lead to a downward spiral of sob

Seek medical advice
Encourage to remain physical active
Take frequent breaks
Use interval training if appropriate 
Start slowly and build up slowly
Take breaks when required
Avoid supine exercises
Try relaxation techniques to manage anxiety
Use RT, induces less SOBOE
Being active can help with ‘sensitisation’ to sob