It’s amazing to realize that only a few decades ago patients undergoing a knee replacement were bed bound for up to 30 days post operatively. This was based on a paradigm that the body heals best with little stress, hence rest was favoured. Conversely, today’s standard protocol is that patients are walking and loading their new knee joint as soon as day 1! This shift represents a very significant change in the understanding of ‘stress’ and ‘load’; maybe what we once thought was harmful actually promotes healing in the body. We’ve come to really understand that load can help regenerate and align cells optimally in tissues, specifically in the area of tendon research (Cook et Al. 2016). We’ve also come to understand that a month’s bed rest can reduce your overall life expectancy; as sedentary behaviours are receiving more attention due their negative health impacts. Although in the orthopaedic world the concept of ‘rest’ doesn’t apply to the same degree as it once did; those 2 words still hold clout in the every day conversations we have. Often after an injury, at the start of a head cold or with the onset of pain we still often hear ‘just rest’. Ironically, akin to knee replacements, we’ve come to learn in pain science that avoidance behaviour and absence of graded exposure, in other words ‘just resting’ can actually start to make pain worse. So perhaps the colloquial recommendation of ‘just rest’ isn’t necessary beneficial in all facets like it used to be. So it should be of no surprise that due to our recent discoveries, science has much more to tell us in many other realms of medicine about how ‘good stress’ and not ‘just resting’ could have great impact!
Low and behold this is where Cancer is really interesting. If you were to see someone undergoing chemotherapy or a stem cell transplant and they were looking very fatigued; I think our colloquial selves would still like to say ‘just rest’. After nearly a decade of vague exercise guidelines and a 250% increase in the amount of cancer and exercise randomized trials, the American College of Sports Medicine (ACSM) held an international round table discussion of many months. Consolidation of new research allowed for new guidelines to be released showing that exercise is very effective, in cancer prevention, symptom control and can “improv(e) longevity among cancer survivors” (Patel el al. 2019). Specific doses of exercise have shown to impact cancer-related health outcomes, including quality of life, fatigue, anxiety, physical function and depressive symptoms (Schmitz 2019). In terms of cancer prevention, there is strong evidence that physical activity actually lowers the risk of acquiring 6 specific cancer types: colon, breast, kidney, endometrium, bladder, stomach, and esophageal adenocarcinoma. There is a moderate amount of evidence to support the above specific to lung cancer (Patel et al. 2019). Rest may not be the answer; as science is starting to reveal “an association between increased sedentary time and risk of endometrial, colon and lung cancers” (Patel et al. 2019). It goes even further with some studies in mice showing that exercise combined with chemotherapy can impact tumour vascularity and is more effective than stand-alone chemotherapy; this suggests that exercise could act in a way to increase drug treatment efficacy(Patel et al 2019). The new general guidelines advise that cancer patients anywhere along the disease spectrum ‘avoid inactivity’. More so, it stated that generally 30 minutes of moderate aerobic exercise, 3 times/week and 2 resistance training sessions is a good goal to aim for, of course bearing in mind symptoms, health history, cancer type and baseline function.
So what’s the next step? Can any cancer patient just walk into the gym? How can we remove some of the barriers to safe exercise? Some barriers have been removed as patients without co-morbities despite any stage of cancer are actually safe to start aerobic and resistance training independently! This is assuming they
have the exercise knowledge base to lift weights appropriately and can safely judge their own capacity. With this population, one visit with a physiotherapist or exercise physiologist may suffice in establishing safe entry to strength training if necessary but if the patient has a strong exercise background they are good to get moving! As all cancer includes a myriad of potential complications with treatment, some patients are recommended to consult a medical professional for a pre-exercise medical evaluation, and some in addition may do best with supervised exercise for safety reasons. The prescribed decision making rubric states that patients with MSK pain/dysfunction, peripheral neuropathies, arthirtis, lymphedema and poor bone health should consult with a medical professional prior to commencing an exercise program (Campbell et Al 2019). A medical professional can be an oncologist, family physician or physiotherapist with advanced training in cancer rehabilitation.
What is the role of physiotherapy amongst all of this? As stated in the journal of medicine & Science in Sports & Science by Dr. Campbell physical therapy “might be a bridge to inform appropriate modifications to an individual’s exercise program and/or correct toxicities, impairments and limitations that prevent a survivor from working toward recommended levels of exercise”. An example of this would be coaching a patient to self gage in what ‘moderate aerobic’ exercise feels like through heart rate monitoring or modifying load due to tolerance. Please note that a Physician’s clearance alone is necessary for: patients who have undergone a lung or abdominal surgery, have cardiopulmonary disease, ataxia, extreme fatigue, severe nutritional deficiencies, worsening cardiac/renal or metabolic conditions, lymphedema exacerbation and bone metastases (Campbell et al 2019). All of the above is really important information to share with clinicians, patients, friends and family as the word on the street may still be ‘just rest’ and we really know now this isn’t good advice!
This latest release in guidelines and consolidation of research ties in nicely with the timing of Tall Tree Health’s Cancer Rehab program. ‘Improvements in anxiety, depressive symptoms, health related quality of life, physical functioning, appear to be greater in supervised training programs or those having a larger supervised component than those that are predominantly unsupervised or home-based (Campbell et al 2019). We hope that by offering various cancer rehab clinical services of working one on one, with telehealth or in a group based format we create individualized accessible care to those in need. In addition, as there is still many gaps in the research specific to cancer type, exercise type and lack of measurable tools to track exercise dosages/response we hope these programs can further research. Much thanks to the sponsors of the ACSM roundtable that allowed for the new release of guidelines, and a new call to action “to create the infrastructure and cultural adaptations needed so that people living with and beyond cancer can be as active as is possible for them”(J Clin 2019;0:1017 © American Cancer Society). We can start these cultural adaptations that often need to follow scientific discovery by sharing to those we know with cancer that they are safe to get moving on their own and/or point them towards supportive resources to do so!
Thank you to the roundtable funders who made this knowledge collaboration possible: