Exercising With Cancer: Your Top Questions Answered by a Cancer Physiotherapist
Guidance to exercise safely and effectively with cancer
Anyone who has had cancer would probably share that the day they were diagnosed was a day they won’t forget. Immediately their lives changed, things felt uncertain. Discussions around treatment options quickly became top priority. As time is of the essence, most cancer journeys naturally become very treatment focused. Work, family, play and even self is often put a side due to the chaos of appointments. Everything just stops and surviving becomes top priority. I can only imagine; setting a side everything at the will to survive.
I have only awe for the oncology team that take patients under their care and inspiration from patients that embark on the treatment journey. Yet, there’s one unfortunate thing that often happens when someone with cancer stops everything and focuses only on treatment, often your physical health and self are put a side at a cost…
There is a term in cancer rehabilitation called ‘symptom burden’ and it encapsulates the side effects of treatment; in others ways it represents your lost self. Treatments often cause side effects that create your symptom burden, this can translate into to self-care, family and returning to work becoming difficult.
Symptom burden is often correlated with the duration and intensity of treatments such as chemotherapy, hormone therapy, surgery, radiation, and/or other pharmacological interventions. Often a symptom burden can involve diagnosable cancer related conditions; a cancer physio diagnose and can support through a personalized cancer rehab plan in any of the 5 rehab phases.
Your Symptom Burden may Include Diagnosable Cancer Related Condition(s)
Cancer related treatment side effects are common, often go undiagnosed and untreated (Cheville et Al. 2017). They can include many physical conditions such as chemotherapy induced peripheral neuropathies, cancer related fatigue, aromatase inhibitor musculoskeletal syndrome (AIMS), vestibular neuropathy, radiation fibrosis, symptoms from hormone therapy. Some may call this ‘long-haul cancer syndrome’. Long-haul can occur post treatment when patients don’t have any specific impairments but just feel taxed, sensitive to exertion and de-conditioned.
A symptom burden can also include a change in mental health such as a lostness of self, depressive symptoms, anxiety, neuro-cognitive dysfunction and decreased motivation (Carreira et Al. 2018). Together these challenges can make exercise as a habit difficult. A rehab plan involves many tools, at times it can include a cold Immersion protocol. This can be a tool to better mental well-being, motivation and hormone regulation as I spoke to in a previous blog on managing the side effects of hormone therapy in breast cancer.
Exercising with cancer can be very difficult, unfortunately leading to exercise requirements often not being met (Rock et Al. 2021). Exercise can feel like a burden. The emotions can run high bouncing between shame, self-sabotage, exhaustion and even anger; at times wanting nothing more than to push yourself.
A ‘how to exercise with cancer’ pamphlet is often not enough. We know that exercise is very powerful medicine; it reduces long term complications, reduces the chance of cardiac complication, optimizes chemotherapy treatment, improves well-being, and enhances recovery (Pedersen 2020). Hence, it is very important that in some form patients with cancer are exercising through all of the 5 rehab phases; pre-treatment, throughout treatment and into the long run.
Prehab can optimize surgical outcomes (Jones, Haykowsky et al 2007) and can reduce tumour regrowth by reducing vascularity of the tumour (Bedoya et al. Sept 2019). Hence, the cancer physio has 5 phases of rehab (pre-hab, treatment, recovery, return to work and active living) to account for the entire cancer journey.
Support is Available Through
all 5 Phases of Cancer Rehab
Imagine if at the time of diagnosis, the very first discussions around treatments included a personalized approach to treatment and rehab , helping you to understand how to manage any side-effects from treatment. Or imagine if immediately at the start you were provided with support from a cancer physiotherapist to try and maintain your physical conditioning throughout the cancer journey. Assuring that you optimize your outcomes and potential for a return to work.
Oncology care should include comprehensive rehab support. Some urban communities do have select rehabilitation and exercise supports BC Cancer has a list of resources. However many rural communities may benefit from Telehealth support.
Let’s take a deep dive together into exercising with cancer, a rehab tool available to all.
Top Questions About Exercising with Cancer
Is exercising with cancer safe? Is exercising when undergoing chemotherapy safe?
New research over the last decade has confirmed that in most cases exercising when undergoing cancer treatment is highly recommended. In some studies, exercise together with treatment has been shown to act synergistically making the chemotherapy more effective (Patel et Al 2019 and Van Haren et Al. 2013). It is therefore beneficial to continue with your routine amount of exercise prior to diagnosis and throughout treatment. However, if you are new to exercise, it is best to start with a slow graded exercise program such as a walking program 15-30 minutes/day 5 days/week and 2 days/week of light resistance training; or seek support from a cancer physiotherapist.
Cancer related treatments may cause symptom burden such as fatigue, neuropathies, dizziness and nausea. Due to other systemic impacts of chemotherapy treatment, patients routinely undergo blood count testing to detect any concerns in the form of anemia, thrombocytopenia, or myelosuppression.
In addition, some patients may receive an ECG (electrocardiogram) to watch for declining cardiac output (i.e. left ejection fraction rate.) as some therapies have a cardio-toxic effect. The results of these tests may indicate the safety of exercise, stay informed of the results of your ECG/blood work and follow the ‘SAFE cancer+exercise guidelines’ below. Pool therapy may be a safe entry level exercise for those undergoing cardio-toxic treatment.
Do I need medical clearance to exercise? What if I’ve had surgery recently?
Tracking blood counts, blood pressure, heart rate and general well-being are all accessible tools to assure that you are safe to practice exercise as medicine. If you have bone metastasis, metastasizing cancer or a complex health history, consider obtaining medical clearance by a physician before starting an exercise program with the support of a cancer physiotherapist. (see guidelines above). Pool therapy is a great option for those with bone metastasis.
If you are post-operative, even if you’ve obtained medical clearance consider the support of a cancer physiotherapist for a safe return. Surgeries can often involve immense de-conditioning and stages of wound healing. If you have recently undergone a surgery week 0-8, follow the medical recommendations from your surgeon and doctor on when it is safe to return to exercise due to your wound healing. Considering that each surgery is unique, wound healing can take several weeks and can be sensitive to stretch or elevating blood pressure.
When should I avoid exercise? What indicates I should stop?
As noted above, if your body is carrying a viral load such as fighting an infection, likely your white blood cell count may be elevated, and you may be running a fever. Reference the guidelines above. There are circumstances such as viral loads, infections, fevers, elevated nausea, cardiac conditions, blood pressure dysregulation and exacerbated fatigue where someone with cancer may need to use caution when exercising. There are general exercise termination guidelines for all individuals, which your physician should know, but just in case exercise should be stopped in the following circumstances:
ACSM Exercise Termination Guidelines:
Recent acute cardiac event, or significant change in your resting ECG suggesting ischemia
Unstable Angina, or uncontrolled cardiac dysrhythmias causing hemodynamic compromise
Sever aortic stenosis, acute pulmonary infarction or embolism
suspected dissecting aneurysm
Acute systemic infection, accompanied by fever, body aches or swollen lymph glands
Typically, in these circumstances higher intensity exercise is contraindicated, and light intensity exercise is safest such as gentle walks.
Prior to Exercise, Measuring Vitals is a Good Habit.
What if I am cleared to exercise but keep experiencing worsening fatigue?
If fatigue is exacerbated by exercise even after 3 weeks of consistent light exercise and continues to result in a push crash cycling, consider consulting with a cancer physiotherapist to obtain a personalized rehab plan specific to cancer-related fatigue. Similar to long-covid, long-haul cancer symptoms may occur leading to sensitivities with exertion.
How much exercise is recommended and how intense?
If you are new to exercise or feeling very de-conditioned, a graded walking program or pool therapy program is a safe place to start. If you’ve been exercising routinely prior to diagnosis then maintaining 90 minutes/week of moderate intensity aerobic exercise is recommended, increasing to 150 minutes/week if well tolerated.
Walking is accessible and enjoyable but yet the medicine behind exercise lies in intensity. Once you have been cleared for exercise according to the guidelines and have been consistent with light exercise adherence for ~3 weeks, you have therefor built some functional capacity, which is a great first step! Consider increasing your exercise intensity to moderate. Measuring intensity can be done by the following:
Once moderate exercise has been consistent and well tolerated, the recommended guidelines involve 3x 30 minutes/week of moderate to vigorous exercise followed by 2 strength training sessions/week. Moderate to vigorous exercise doesn’t mean pushing at maximum for 30 minutes, but more so should involve interval style or circuit training where you are working hard for 30 second increments, followed by moderate periods of exertion and even rest. It should involve catching your breath at times, and talking should not feel easy. Circuit or Interval training can be a nice bridge into vigorous states of work, helping patients to adapt to this style of exercise and the experience within the body.
What type of exercise is recommended?
As mentioned above, aerobic activity that elevates your heart rate such as walking, cycling, hiking, swimming or cardio equipment use are all suitable. The most important type of exercise is the one that gets done! Pick a form of cardiovascular exercise that interests you, use the talk test noted above and aim for consistency. Consistency is the most important variable, and leads to improvements in functional capacity which is your body’s ability to handle exertion over time.
The second type of exercise that is highly recommended is strength training. Strength training promotes bone density, joint health, improves posture, minimizes muscle wasting and reduces falls risk. Strength training involves progressively overloading muscles to fatigue and can involve the use of a variety of exercise equipment such as machines, kettle-bells, dumb bells, barbells and even your own body weight to some extent.
A strength training program is very important within breast cancer journey. Routine strength training can help to maintain bone density and counteract the changes in estrogen with hormone therapy treatment.
Typically strength training programs start with higher repetitions of 10-12 and 3 sets to build muscle endurance and motor patterning. Strength programs require consistent progress, optimization and personalization to your diagnosis, health history, body type and goals. Consider connecting with a cancer physiotherapist to receive a rehab plan for a strength routine specific to your needs. Strength training can also take the form of circuit or interval training to incorporate aerobic work, combining both types of exercise recommended in the guidelines.
When is a cancer physiotherapist or cancer exercise specialist necessary?
Firstly, all cancer physiotherapists are cancer exercise specialists. The term ‘cancer exercise specialist’ evolved to be inclusive to other professions that may have the clinical education to help support cancer and exercise such as an exercise physiologist or occupational therapist. Check the credentials of whoever you chose to receive exercise support from, assuring that they are a clinician and have a credited cancer specialization from a credited institution or university.
If you have an avid exercise background and were very active pre-diagnosis, it’s safe to continue with your routine independently bearing in mind the safe exercise guidelines. If you have an avid exercise history but a heavy symptom burden, you may be encountering limitations with exercise. As an example, you may have an avid running history, but have found the side effects of hormone therapy for breast cancer in the form of fatigue and joint pain to be exacerbated by your typical running routine. When the symptom burden is limiting, the support of a cancer physiotherapist and a rehab plan specific to your diagnosis may be needed to help you exercise confidently once again.
Progressing an exercise routine skillfully or reaching a goal is difficult for any individual with or without cancer. Post-treatment, the recovery phase can often involve wanting to simply feel like yourself again, return to a sport or set new goals. A comprehensive cancer rehabilitation initial performed by a cancer physiotherapist, can help you adhere to an evidence based strength program progressing you through a plateau to regain your baseline fitness of the past and obtain results.
Lastly, if your work demands are very different than your current functional capacity and you are concerned about your return to work, consider a functional evaluation specific to your work demands performed by a cancer physiotherapist. A gradual modified return to work plan can help patients adjust to the physical and cognitive load of returning to work. A registered cancer physiotherapist can provide the needed documentation required by insurance providers and advocate for a return-to-work date and gradual return to work plan that can optimize patient success.
Return to work simulation and a rehab plan can help you return to work with confidence.
What limitations might I expect when I first start to exercise with cancer?
Given today’s pandemic climate, you might feel some hesitation with public gyms especially if you are undergoing treatment and are immunocompromised. This is a very personal decision as exercising with a mask can increase the work of breathing and produce some breathlessness. Exercising at home or cleaning equipment before and after use, along with avid hand sanitizing are perhaps more secure options.
You might also encounter some joint pain when starting a program for the first time. A simple rule with pain is to try and find your ‘sore but safe’. As pain is protection and not detection, this means you can feel some push back from your body as you try something new and this can be very normal. Treatment can make the nervous system more protective, hence we need to calm it down with some de-sensitization strategies such as exercise! Mild discomfort is expected, rated as a 3/10 on a pain scale. Think of traffic lights, a yellow light is where most of rehab happens, a dance between stopping and going. If pain does occur try this:
Pain Tool
Rate the pain /10
Observe the pain and your function for the next 24 hrs
Change your exercise program (intensity and duration) as needed
If the pain settles shortly after the exercise that is an indicator of a sore but safe intensity and duration, meaning your body is adapting. The same exercise routine will get easier and feel more comfortable. If pain persists for the next 24hrs, then consider reducing the intensity or duration. If you are finding difficulty adjusting your exercise routine to find the yellow traffic light experience, then consider connecting with a cancer physiotherapist for exercise support.
Fatigue is also a very common when those with cancer start exercising for the first time or particularly when in the treatment phase. When first starting to exercise, some fatigue is expected within the first 2 to 3 weeks, however this should settle and be substituted with a general feeling of well-being. If the fatigue persists beyond 3 weeks and produces unmanageable crashes, consider reducing your exercise duration and intensity and reaching out to a cancer physiotherapist to learn more on how to rehabilitate through cancer related fatigue syndrome.
If you are in the middle of treatment, such as chemotherapy, the goal is simply to find a manageable about of exercise on the days that you have energy. Chemotherapy can cause immense changes in blood cell quantity and overall energy, making exercising during this time very difficult. There will be a cycle to your energy that matches your body’s reaction to the chemotherapy, get to know this pattern and try to work within it. Follow the guidelines and be kind to yourself, aim to simply avoid inactivity.
What are the benefits of exercising with cancer?
As most behavioural change starts with a why, it’s so important to ask what the value is behind something! When habits are made easy, when they are supported and when we understand ‘why’, magic happens as stuff gets done! For brevity sake, I am going to list all of the reasons we understand how exercise is medicine for those with cancer:
Exercise makes treatment more effective, acting synergistically
Exercise improves well-being, reduces depressive symptoms
Exercise provides a sense of power in a powerless time
Exercise helps memory and attention
When consistent, exercise can help boost immunity
Exercise reduces treatment side effects such as fibrosis, fatigue, pain and stiffness
Exercise lessens complications of musculoskeletal pathologies (stiff, painful joints etc.)
Exercise decreases the chance of cancer related fatigue and long haul cancer syndrome
Exercise minimizes the chance of falls
Exercise improves cardiac health and reduces the risk of cardiac complication
Exercise promotes angiogenesis (blood vessel growth) and the reduction of both insulin and inflammation
Exercise supports a successful return to work
Exercise supports returning to sport more efficiently
Exercise improves longevity and can reduce tumour growth
Exercise promotes survivorship
I think we’ll end on that note.
As always, thank you for your interest in rehab and science.
Kindly, The Cancer Physio
References
Carreira, Helena, et al. “Associations between Breast Cancer Survivorship and Adverse Mental Health Outcomes: A Systematic Review.” JNCI: Journal of the National Cancer Institute, vol. 110, no. 12, 2018, pp. 1311–1327., https://doi.org/10.1093/jnci/djy177.
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Pedersen, Bente Klarlund. “Regular Exercise Helps Patients Combat Cancer.” The Scientist Magazine®, https://www.the-scientist.com/features/regular-exercise-helps-patients-combat-cancer 67317?utm_campaign=TS_DAILY+NEWSLETTER_ 2020&utm_source =hs_email&utm_medium=email&utm_content=86608256&_hsmi=86608256.
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