Part 2 of this series will focus on exercise recommendations for breast cancer survivors. Although research is relatively new, studies have consistently demonstrated cardiovascular, psychological and body composition benefits for those survivors who participate in exercise programs. Exercise appears to be useful therapy for survivors. However, more research needs to be conducted to determine what exercise type, frequency, duration, intensity or rate of progression is best. Furthermore, additional research needs to be undertaken that examines resistance training for this population due to concerns regarding lymphedema. Each client will have his or her own unique needs. However, your exercise goals should incorporate the following:
- Foster optimal range of motion in the chest and shoulder - This is the first priority to prevent functional limitations. The shoulder is one of the most mobile joints in the body accomplishing flexion, extension, abduction, adduction and external/internal rotation. I recommend consulting with an occupational/physical therapist if your client complains of pain, is having difficulty moving, if the arm is swollen or if shoulder range of motion continues to be limited three to four weeks after the drains are removed. The axillary region and pectoralis major are the trouble sites where you should concentrate your efforts, with pain tolerance a consideration.
- Promote optimal weight – Strength training exercises should be incorporated to increase lean body mass in the unaffected arm, legs, hip, back and abdominals (provided that a TRAM flap reconstruction was not provided) along with a regular program of aerobic conditioning three to five times a week. Healthy diet choices should be emphasized such as increasing intake of fruits, vegetables and whole grains, decreasing fat intake to less than 30% of calories and minimizing intake of cured, pickled and smoked foods.
- Decrease Lymphedema risk – Maintaining a healthy body weight is important since excess weight has been linked to Lymphedema risk. There are precautions that one can take to minimize risk; these will be discussed in Part 3. Strength training to the affected arm is undertaken in a gradual manner, while monitoring any changes in the size of the arm. In addition, a sleeve should be worn if the client is at risk of Lymphedema while strength training. (Read more on Lymphedema here.)
- Improve functional capacity - Maximize the ability to participate in daily tasks by gradually increasing the duration and frequency of exercise rather than exercise intensity.
- Reduce osteoporosis risk - Risk of Osteoporosis can be decreased by participating in weight-bearing exercise and strengthening the hips, spine and wrist, which tend to be at most risk of fracture.
- Revitalize optimal psychological functioning - Psychosocial issues are normal after a diagnosis of cancer. Use your client's exercise program to promote new skills, incorporate social interaction, reduce stress and promote some control over her environment.
Your clients will include women of various ages and fitness levels who have undergone different treatments. Therefore, screening clients is essential before recommending exercise to meet each individual’s level of fitness, age, stage of the disease, current treatment type or any other medical conditions. A detailed medical history is necessary including current treatment (i.e., surgery, reconstruction and any other systemic therapies), other medical conditions and medications. Before beginning an exercise program, I advise careful evaluation by a physician for any woman over age 45, for those currently in treatment or those who have other diseases such as cardiovascular, respiratory, musculoskeletal or renal complications. A heart rate monitored test may be needed for those clients whose health profiles suggest possible risk (i.e., those with heart conditions).
Women with significant functional problems should be referred to a rehabilitation specialist. Unfortunately, exercise is not thought to be an integral part of treatment at this point, but its benefits are becoming more and more well known to the medical community. Before implementing your program, be sure to assess your client's fitness level, posture, flexibility and strength in the usual manner. However, standard strength testing may not be appropriate especially to the affected arm or abdominals (i.e., TRAM flap reconstruction.) In addition, it is important to establish a baseline circumferential measurement around the wrist and elbow creases of the affected arm for Lymphedema management.
Components of Your Exercise Program
Range of motion
Achieving maximal range of motion at the shoulder is the most important goal during treatment. Clients must be able to achieve adequate shoulder range of motion in abduction and external rotation before they can receive radiation. However, pain and swelling may limit their ability and willingness to do so. Physicians follow different time sequences in recommending motion to the shoulder, but usually, the sooner the better. Once medical clearance for exercise has been obtained, I would consult with an occupational or physical therapist who can recommend appropriate exercises and methods to reduce swelling. There are many appropriate exercises to stretch both the axillary and pectoral regions, which are the tightest secondary to scar tissue after surgery.
Be sure to provide warm ups that focus on the shoulders, neck and back such as neck lateral flexion, shoulder raises and rolls and shoulder protraction/retraction with deep breathing in preparation for the more strenuous exercises. This will also open up the lymph nodes and ducts. Wall climbing in both flexion and abduction is a traditional exercise. The child’s pose found in yoga is excellent along with lying prone over a ball and walking the arms on the floor forward and back. The traditional triceps stretch opens up the axillary region, and the pectoralis corner stretch stretches the pectoralis muscle. In addition, you can hold a towel with both arms behind the ears into external rotation or behind the back into internal rotation respectively. Shoulder abduction, extension and external rotation are usually the problem motions.
Pain is to be respected, and stretches should be held to the point of discomfort not pain. Hold the stretches for five to 10 seconds at first and gradually increase the length of time as the client’s tolerance increases. Deep breathing should be encouraged throughout to promote optimal lymphatic flow along with exhalation upon the effort (i.e., when holding the stretch). It is better to exercise several times during the day rather than all at once. Exercise type should be varied to achieve good range of motion. These exercises should be performed daily for at least a year after surgery. Scar tissue continues to form one to two years after surgery and must be stretched regularly to prevent adhesions. Remind your clients to keep their arms elevated above the heart to decrease swelling, especially at night when there is minimal arm movement during sleep.
Moderate intensity activity (50 to 75 percent of heart rate reserve) three to five days a week for 20 to 60 minutes is generally recommended. A RPE of 11-14 on a 1-20 scale (if heart rate maximum is estimated) is the best guideline. If undergoing treatment, it is best to stay at the lower end (50 to 60 percent of heart rate reserve). All clients should be instructed in heart rate monitoring and should be made aware of their target heart range. Walking and cycling are quite beneficial, but most exercises involving the large muscle groups are appropriate including swimming or cross training machines. However, the exercise mode should be modified based on acute or chronic treatment side effects. For example, those individuals who are on chemotherapy may be at risk for infection. Therefore, participation in swimming, large group activities or those with children is inadvisable.
It is best to begin with a brief five to 10 minute walk and monitor your client closely. Your long-term goal should be 20 to 30 minutes of continual activity. However, multiple intermittent shorter sessions of five to 10 minutes is feasible for those clients who are experiencing treatment side effects such as nausea or who are severely de-conditioned. The duration of your sessions and the frequency should be progressed gradually, rather than imposing intensity in the beginning. Thus, only two to three sessions a week of 10 minute aerobic activity on a cycle may be feasible at first. However, 20 minutes of aerobic activity three times a week would be a long-term goal for this client. Your clients may demonstrate inconsistent participation due to treatment and personal demands. Therefore, adaptability is a necessary personal skill when working with this population. Once frequency and duration goals have been achieved, intensity can be increased.
Strengthening to the arm can be initiated once good range of motion in the affected shoulder has been achieved. Physicians have often discouraged survivors from engaging in upper body exercise due to fear of precipitating Lymphedema. However, in a recent study of women who participated in dragon boat racing, there was no development of Lymphedema. The training program involved repetitive upper body exercise, strength training and aerobic exercise. Lymphatic flow is enhanced with muscle contractions, as a change of tissue pressure develops. However, it is highly recommended that women wear compression garments (sleeves or bandages) if at Lymphedema risk while they perform strengthening exercises to the affected arm as a precaution.
The bandages facilitate muscle pumping. In addition, they help to reduce the increased arterial flow that occurs with exercise. Resistance exercises to the affected arm should progress gradually and begin with a light weight (i.e., one pound). Emphasis should be placed on the muscles of the shoulder girdle, back and arm. The weight and number of repetitions can be slowly increased depending on the limb's tolerance. In the beginning, increases should be small and less than 10 percent of the weight per week. I generally start with two sets of 10 repetitions two to three times a week and gauge the response of the arm to activity. Triceps extensions, biceps curls, frontal raises, rotator cuff exercises and seated rows are all appropriate. Be sure to monitor the response of the limb to exercise as increased swelling indicates that the weight was too much or that too many exercises were performed.
If the swelling does not resolve within a day, the weights and repetitions must be decreased. If the arm size remains the same, the exercise has been well tolerated. Repetitions and weight should not be increased at the same time. Strengthening to the unaffected arm and lower body strength training can be conducted in the usual manner to the abdominals, hamstrings, quadriceps, hips and back. However, those women who received a TRAM flap reconstruction should only perform sit ups six to eight weeks after their surgery has been performed. In addition, it is highly recommended to perform strength and balance training to the spine, hips, forearms and wrist secondary to their high risk of fracture. Poor posture due to pain can lead to protective posturing of the arm with over development of the anterior musculature. Therefore, muscle strengthening to the rhomboids, trapezius, etc. is advised.
Sample Resistance Training Program
- Frequency - Two to three times per week
- Equipment - Light weights or bands
||Week 1 (1 lb.)
||Week 2 (1 lb.)
||Week 3 (1 lb.)
||Week 4 (2 lb.)
|1 x 10
||2 x 10
||3 x 10
||2 x 10
|Overhead Triceps Extensions
|1 x 10
||2 x 10
||3 x 10
||2 x 10
|1 x 10
||2 x 10
||3 x 10
||2 x 10
|Prone Trunk Extensions on Ball
(with weight behind head)
|1 x 10
||2 x 10
||3 x 10
||2 x 10
The exercise program should be self paced secondary to periods of decreased performance due to treatment or disease side effects. It is best to set small goals to encourage success, rather than large unobtainable ones. Your program should be easily modified to meet changing needs. A client's medical status determines the exercise protocol on any given day. Usually range of motion can be accomplished and should be encouraged to prevent disuse and loss of strength and function in the affected arm.
Cancer can be a wake up call regarding both exercise and nutrition as it motivates one to reevaluate both dietary and health practices. Diet, exercise and stress management all have a role in increasing overall health and well being. The National Cancer Institute provides guidelines for cancer prevention, which can be used to decrease the chance of a recurrence. These guidelines include the following:
- Increase intake of fruits, vegetables and whole grains as they contain phyto-chemicals with anti-oxidant, anti-estrogenic and chemo-preventative properties. Five or more servings of fruits and vegetables is recommended daily. Broccoli, cabbage and kale are especially high in phyto-chemicals. Whole grains are high in complex carbohydrates, fiber, vitamins and minerals, which may have a positive benefit by altering the stimulation of cancer by hormones. Fiber intake should be 25 to 35 grams of both insoluble and soluble fiber.
- Decrease fat intake to less than 30 percent of calories. Some animal and epidemiological studies have found that the type of fat ingested may initiate breast cancer development. Thus, the consumption of highly saturated foods such as beef, lamb, cheeses and ice cream should be limited. In addition, foods made with transfatty acids such as commercially prepared baked goods and crackers should be eaten in moderation. Intake of fish three times per week is recommended, especially fish with omega 3s, which may inhibit breast cancer tumors.
- Maintain a healthy body weight through healthy eating choices along with exercise. Many studies have demonstrated a link between high body mass and breast cancer in post-menopausal women.
- Minimize eating cured, pickled and smoked foods.
- Consume alcohol in moderation as studies have shown association between alcohol and breast cancer.
What is the role of soy? Women with estrogen receptor positive breast cancer (breast cancer fueled by estrogen) and women on hormonal treatment are advised to limit soy intake. The estrogenic effect of soy is unknown. However, studies are being conducted to ascertain the role of the phytoestrogens contained in soy in cancer cell development. Other women can ingest soy in moderation.
Thus, breast cancer survivors should be encouraged to adopt healthy eating patterns by identifying and recording what has been eaten, increasing intake of vegetables and fruits, limiting the consumption of high fat foods and those with transfat, developing new food traditions that emphasize different choices and balancing energy intake with energy output through exercise participation.
Part 3 will include exercise contraindications and blood parameters. In addition, Lymphedema advisories will be discussed for trainer self education and education for your clients.
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