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

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

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?

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

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...

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...

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

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

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

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

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

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Summary of PAL Program8

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

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

Chemotherapy Radiation Therapy Surgical Interventions

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Possible Barriers to Exercise

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

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

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

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

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Contraindications for Exercise and Chemotherapy?

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

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

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

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

How do we know who is appropriate for exercise

interventions?

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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

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

LABAT evaluation

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Pre-Exercise Evaluation continued...

© Klose Training 2015

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...

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

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How do you know a person is ready for independent resistance training?

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Stretches

Chest Stretch Shoulder Stretch Triceps Stretch

Quadriceps Stretch Calf Stretch

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Upper Extremity Exercises

Chest Press Row- One or Two Arm

Bicep Curl Tricep Kick-Back

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Lower Extremity Exercises

Squat Calf Raises

Step-up

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Core Exercises

Partial Sit-ups Bridging

Superman/Woman

American College of Sports Medicine Cancer Exercise Trainer Certification

Chemocare.com Provides information regarding chemotherapeutic drugs

and side-effects

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Resources

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Questions

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

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