Patients’ Exercise Needs May Differ After Cancer Therapy

NEW YORK—"Use it or lose it," exercise buffs like to say, and the dictum is just as true for cancer patients, according to physical therapist Eileen Donovan, PT, MEd, manager of rehabilitation services at the University of Texas M.D. Anderson Cancer Center. Ms. Donovan discussed the topic during a Cancer Care teleconference.

"While cancer and its treatment may not cause a patient to stay in bed for weeks at a time, most people do not feel up to their normal routine and may significantly reduce their activity levels," Ms. Donovan said, "and we all know that decreased physical activity results in a decreased capacity to work and ability to perform."

Ms. Donovan cited the work of M.L. Winningham, an oncology nurse and exercise physiologist who did the first exercise studies in people with cancer. Ms. Winningham’s work showed that women who were receiving chemotherapy for breast cancer and who participated in a carefully managed exercise program reported decreased fatigue, improved mood, and decreased nausea, compared with those who were not in an exercise program.

But an appropriate exercise level for people who are still going to work every day, even if they feel very tired, is different from an appropriate level for someone who gets tired just walking to the bathroom, Ms. Donovan said. The specific disease or its treatment will also play a role in determining the type of exercise needed by individual patients.

For example, patients should not exercise on the day they are receiving IV chemotherapy, unless they have checked with their physician first, nor if they are experiencing severe nausea, vomiting, or diarrhea, she said.

Another issue for many patients is loss of sensation in their feet, including a loss of sensation to light touch. "They actually don’t know where their feet are in space because of the drugs they are taking," she said, "and if this is the case, they should see a rehabilitation professional to make sure they can exercise without hurting themselves. This may mean exercising differently or using a brace or special footwear."

In general, Ms. Donovan advised patients to ask themselves whether they are able to perform the activities of daily life, to get dressed by themselves, feed themselves, or bathe. Are they able to walk around the house, in the yard, on uneven surfaces, or up and down steps?

Trouble with any of these things, she said, indicates that they need to see a rehabilitation professional—a physical therapist, occupational therapist, or physiatrist—who can make recommendations regarding exercise, special equipment, or other strategies that will allow the patient to take care of the basic activities of daily living.

Solutions Vary

The solutions will vary according to the nature of the problem. For example, for someone who cannot carry groceries or cook a full meal, the clinician should ask, "Is it because the muscles are too weak or because of shortness of breath or just being too tired?"

"Often, when I test a patient’s muscles, I find that their muscle power is normal, but they don’t have any staying power or stamina. Others do have specific muscle weakness that interferes with their ability to do daily activities," Ms. Donovan said.

Therefore, each exercise program can have different goals, she said. It might be maintaining overall strength and stamina, increasing overall strength or flexibility, or fixing a specific problem by strengthening or stretching a specific muscle group. People who have had a mastectomy, for example, frequently feel tight or stiff in the shoulder or trunk. Surgery in other areas may cause joint restrictions or painful tightness, Ms. Donovan pointed out.

"Some people find they do not realize they are getting weak until they notice they are having trouble getting up from a really low chair or from the toilet, so for these people strengthening would focus on the leg muscles, and that could be done in a number of ways," Ms. Donovan said.

One way, she said, is to ask the patient to find a chair that he or she can get up from without too much difficulty. It could be a dining room chair or a chair with cushions that raises the seat height. The patient is asked to get up and down from that chair several times a day for several days.

Then the patient is asked to get up from a chair that is an inch or so lower and harder to get up from, and practice that several times a week. Gradually, the height of the chairs is reduced until the patient is able to get up and down from a low toilet.

‘Exercise Is Just Activity’

It is important to remember that exercise is just activity, Ms. Donovan said. "In addition to or instead of specific exercise programs, some patients may just start at the baseline of what they are able to do now and increase that activity a little each week, either by increasing how much they do or how strenuously they do it," she said.

For example, the distance a person is able to walk comfortably in 10 minutes, would be the starting point. The person might walk this distance for 10 minutes three times a week for a week, and the next time might walk faster and go farther in the 10 minutes, Ms. Donovan said.

Instead of walking faster, the person may decide to walk the same speed but to walk for 12 minutes. This increases the duration of the exercise. Either way it increases the total amount of work.

It is important to increase exercise slowly and not to increase intensity and duration at the same time, Ms. Donovan said.

Walking is good exercise because it is rhythmic and uses large muscle groups. "It doesn’t take any equipment, and most people can do it, even if they have to start by walking from the bed to the bathroom and back," she said.

It is important to walk in a safe location. "I wouldn’t recommend walking on uneven sidewalks or in the middle of the night," she said.

Starting Slow

If someone is very deconditioned or weak with little endurance, sitting on the edge of the bed for a few minutes may be enough exercise to start, Ms. Donovan said.

Other simple ways to increase exercise include getting up to change the TV channel instead of using the remote control, walking to the mailbox instead of driving, or parking one row away from the front door of a store. "It’s not very much exercise, but over the day, it winds up being a significant increase over baseline," she said.

Patients should stop exercising if they experience any new or increased bone or joint pain or if they become nauseated during exercise, she said. These symptoms might indicate that the person is becoming dehydrated.

"Of course, you would stop if you had sudden chest pains or shortness of breath," Ms. Donovan said. She recommends that patients learn how to take their pulse rate and not exercise past their target heart rate, as determined by their physician.

Keeping an Activity Journal

Ms. Donovan also advises patients to keep an activity journal. "Jot down what you do each day and how you felt afterward," she said. "Did you experience any exercise-related symptoms? Did you feel short of breath? Did you have any cramping?"

This allows patients to track their progress, as well as note any patterns that might be present. "For instance," she said, "you may find you always have to stop when you exercise at a certain time of the day or at a certain point in your treatment cycle."

In summary, Ms. Donovan said, "exercise can be a formal prescription for a specific problem or something as simple as parking your car a little farther from the front door."