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Athletic development specialists dedicated to the art and science of excellence in movement

Training Considerations for Cancer Patients

For the past several years, Katherine has been heavily involved with coaching the Better than Ever running group, which is operated out of the Arizona Cancer Center…one of the world’s finest.  During this time we’ve had the opportunity to observe the good and the bad in the physical rehabilitation of cancer patients.  The running group has been instrumental not only in raising money for cancer research, but also to provide an outlet for survivors, their families, and friends to return to physical activity with the support of a group and defined race goals. 

It’s important for anyone working in this field to understand the unique situation of each individual, each type of cancer, and the treatment specifics past, present, and future.  Effects of cancer treatment impact multiple systems, from nervous, immune, musculoskeletal, vision, auditory, digestion…pretty much everything!  Training must respect this interrelationship to provide the safest and most effective programming.     

Many survivors face enormous mental and emotional climbs just to resume normal life.  They also face conflicting messages from some medical professionals who discourage physical activity and see their job as being complete once the patient leaves the hospital alive (which is fine, so long as appropriate communication happens with providers downstream…).  Cheerleading certainly has its role to get people off the couch, but should never cause additional harm.  “I’m just getting old” is a commonly use, yet bald rationalization for ineffective training….   

The general concept of exercise and cancer has been studied at length in recent years.  A wealth of studies provided evidence that resistance training and aerobic training, when delivered appropriately, are not only safe but can improve muscle strength, aerobic conditioning, body composition, mental state, fatigue levels, quality of life and other measures of health.  The idea of wrapping cancer survivors in a sheet of bubble wrap lest something bad happen (as if that didn’t already occur…) largely exists on the fringes of medical thought, although a few holdouts remain pathologically against exercise despite the volumes of research.   Risks of each type of cancer treatment are highlighted in the chart below from the American College of Sports Medicine:

Despite the proven safety of exercise for cancer patients, significant risks definitely abound for those returning to physical activity.  Lymphedema in breast cancer patients is the foremost concern, although can be managed effectively with proper attention (Kwan 2011).  Another concern is that of fractures, particularly in those of advanced age already predisposed to a weakened skeleton (Winters-Stone 2011).  Compound that with the weight gain associated with certain cancers and skeletal stress adds up.  Doctors may also be concerned about fatigue levels, but again, the research validates the safety of exercise both for those currently undergoing treatment and those who have finished treatment (Fong 2012).  However, exercise interventions should be optimally tailored with the timing of those treatments and the recovery process.  All these listed setbacks have appeared in the literature and in anecdotal observation and thus deserve care…but not bubble wrap.   

Fitness and rehab professionals have a weighty responsibility in moving forward with survivors.  Sets, reps, sweat, and effort are only a very small part of the training equation.  Consider the following from the American College of Sports Medicine...

[F]itness professionals should understand the most common toxicities associated with cancer treatments, including increased risk for fractures and cardiovascular events with hormonal therapies, neuropathies related to certain types of chemotherapy, musculoskeletal morbidities secondary to treatment, and treatment-related cardiotoxicity. Survivors with metastatic disease to the bone will require modification of their exercise program (e.g., reduced impact, intensity, volume) given the increased risk of bone fragility and fractures (Schmitz 2010)

Physical setbacks are not limited to the extremes of broken bones and lymphatic emergencies.  In fact, the most troublesome setbacks in the physical training realm relate to missed opportunities to restore survivors to a reasonable standard of movement proficiency.  For example with invasive procedures for breast cancer, it is important to understand bodily changes unique to each procedure, whether lumpectomy, mastectomy, or auxiliary procedures after the cancerous source has been removed.   Each procedure can result in profound changes to muscle, skin, nerves, and many other sensitive structures in the area.  Some procedures may be superficial with little if any lasting damage done to the area.  Others make profound changes not only to the breast area itself but also to large muscle groups such as the latissimus dorsi (back muscles) and the pectorals (chest muscles).    

Training and rehabilitation should accommodate any changes specific to that individual.  With significant changes happening unilaterally, the possibility asymmetries between the left and right side of the bodies is high.  Such changes are highly predictive of subsequent physical injury and must be addressed.  In some cases the appropriate intervention may be to weaken the unaffected side to create symmetry with the affected side, to prevent one side from overpowering the other. This will vary on a case-by-case basis, which underscores even further the importance of individualized care in the physical rehabilitation process.  Group exercise is a powerful force in restoring one to physical and mental health (Rajotte 2012), but the actual exercise intervention must be fully tailored to the individual. 

Shoulder morbidity is a major concern among breast cancer patients (Edbaugh 2011) but not only because of the structural damages.  Each patient will present differently: some may present with hypertonicity in the affected side (excess tension).  Others may exhibit loss of tone.  Important to recognize that dysfunction can take different forms, and the appropriate exercise intervention will vary by procedure, related therapies (content, dose, and timing), and specific structural changes.  Someone with significant changes to the larger muscles of the chest and back may require a far different program than someone who underwent a less invasive procedure.  Likewise, the timing of exercise interventions must coordinate with therapy.  This is a common sense observation, but not enough planning occurs to optimize training with therapy.  Failing to coordinate can put the patient at further risk of injury and can miss valuable opportunities to create synergies between fields.

We must also respect the role of training to restore emotional health.  Movement has an expressive role for the body and has a profound impact on the rehabilitative process.  Cancer can almost work as a “reverse development” on the body’s posture.  From infancy through adulthood, humans work from a flexion bias (ie, the fetal position) to upright posture with extensor muscles in balance with the flexor muscles (Berényi 2011).  Ultimately, this optimal balance occurs via input from the nervous system, though can be disturbed with interference from other systems or disturbance to any aspect of the brain.  Cancer and treatment can reverse this process of postural development (known as ontogenesis), leading to kyphotic and lordotic postures (Malika 2010), both of which have unique training needs.  Know that posture is a vast field unto itself but offers many avenues through which to guide the recovery process via exercise.    

The nature of postural changes is unclear, but emotion and physical weakness are both possible culprits.  Kyphosis (rounding of the spine) may be a sign of weakness, poor motor control, or impaired self-confidence.   Weakness in the lateral structures may also remove some of the more expressive profile poses.  Flexion becomes a means to express insecurity about oneself, which becomes even more disarming when the suggestive or seductive presentation of one’s profile (especially for females) is altered.  I know this may be an esoteric consideration, but what goes through the subconscious mind will surprise many people.  Anthropometric measurements only tell part of the story and it is critical to examine each pathway into the physical and emotional that can be unlocked via appropriate movement training.  We must not only satisfy these needs but also honor sound training principles needed to get there. 

The effect of procedures on innervation and circulation must also be considered.  Considering the prevalence of shoulder problems among breast cancer patients, we must pay careful attention to the nearby areas of the head, neck, shoulders, arms, and thorax.  The head and neck are the body’s gearbox.  Try running an electric substation for an entire town through your in-house circuit breaker and see how that turns out.  Overload of the neck region is necessary for growth, but misinformed programming can cause the body to create “defense mechanisms” that manifest via tightness, weakness, and poor coordination.     

Finally, there’s the issue of pain.  With a confusing mix of pain coming from the cancer itself, understanding the involvement of pain as it relates to musculoskeletal issues can be a challenge.  Pain is often classified as nocioceptive (the brain’s response to a noxious threat) or neuropathic (related to nerves), but others may classify cancerous pain into a separate category.  These may be simplified classifications, but know that exercise pain can be hard to decode when so many other sources of pain are involved.  As we have written in the context of athletics, teamwork is the key to sort out the complexities of pain.  I’m not so naïve to expect that superstar surgeons will begin interfacing with us in the athletic trenches to design exercise programs for optimal gains of survivors, but with cancer patients perhaps more than anyone, respecting the differences in types of pain can guide the appropriate exercise interventions during rehab. 

Summary

This post was a very broad overview on considerations unique to the cancer population based on the literature and our own anecdotal observation.  Survivors should demand a level of informed physical training on a level similar the care they demand to confront the disease itself.  Entertainment in training does not equate to efficacy, although people are free to trade efficacy for entertainment as a personal choice.  Ultimately, a choice of best-practices in selecting cancer treatment should extend into the physical rehabilitation process.    

References

Fong DY, Ho JW, Hui BP, Lee AM, Macfarlane DJ, Leung SS, Cerin E, Chan WY, Leung IP, Lam SH, Taylor AJ, Cheng KK. Physical activity for cancer survivors: meta-analysis of randomised controlled trials. BMJ. 2012 Jan 30;344:e70. doi: 10.1136/bmj.e70.

Rajotte EJ, Yi JC, Baker KS, Gregerson L, Leiserowitz A, Syrjala KL.  Community-based exercise program effectiveness and safety for cancer survivors.  J Cancer Surviv. 2012 Jan 13. [Epub ahead of print]

Berényi M, Katona F, Sanchez C, Mandujano M.  [Phylo- and ontogenetic aspects of erect posture and walking in developmental neurology].  Ideggyogy Sz. 2011 Jul 30;64(7-8):239-47.

Malicka I, Barczyk K, Hanuszkiewicz J, Skolimowska B, Woźniewski M.  Body posture of women after breast cancer treatment.  Ortop Traumatol Rehabil. 2010 Jul-Aug;12(4):353-61.

Ebaugh D, Spinelli B, Schmitz KH.  Shoulder impairments and their association with symptomatic rotator cuff disease in breast cancer survivors.  Med Hypotheses. 2011 Oct;77(4):481-7. Epub 2011 Jul 18.

Kwan ML, Cohn JC, Armer JM, Stewart BR, Cormier JN. Exercise in patients with lymphedema: a systematic review of the contemporary literature.  J Cancer Surviv. 2011 Dec;5(4):320-36. Epub 2011 Oct 16.

Winters-Stone KM, Dobek J, Nail L, Bennett JA, Leo MC, Naik A, Schwartz A.  Strength training stops bone loss and builds muscle in postmenopausal breast cancer survivors: a randomized, controlled trial.  Breast Cancer Res Treat. 2011 Jun;127(2):447-56. Epub 2011 Mar 19.

Schmitz, Kathryn H. PhD, MPH, FACSM; Courneya, Kerry S. PhD; Matthews, Charles PhD, FACSM; Demark-Wahnefried, Wendy PhD; GALVÃO, DANIEL A. PhD; Pinto, Bernardine M.; IRWIN, Melinda L.; WOLIN, KATHLEEN Y.; SEGAL, ROANNE J.; LUCIA, ALEJANDRO; SCHNEIDER, CAROLE M.; VON GRUENIGEN, VIVIAN E.; SCHWARTZ, ANNA  American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Medicine & Science in Sports & Exercise:  July 2010 - Volume 42 - Issue 7 - pp 1409-1426

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