This section will include exercise contraindications and blood parameters. In addition, Lymphedema advisories will be discussed for trainer self education and education for your clients. Reducing the risk of Lymphedema is extremely important for your clients' physical and psychological well being.
The following are exercise contraindications which should be adhere to when working with clients diagnosed with breast cancer. Be sure to notify the physician if any of these signs/symptoms develop during exercise.
Contraindications to Exercise
- Irregular or resting pulse greater ^ than 100 bpm
- Any bony or back pain of recent onset
- Dizziness/blurred vision
- Dyspnea of sudden onset
- Intravenous chemotherapy within 24 hours
- Muscular weakness of recent onset
- Nausea, diarrhea or vomiting within previous 24 to 36 hours
- Unusual prolonged fatigue
- Chest pain
- Febrile illness
- Bleeding from any source
- Sudden onset of muscular weakness, shortness of breath
- Recurring leg cramps
Be aware of your client's blood parameters and familiarize yourself with their blood counts, especially while they are undergoing treatment (i.e., chemotherapy). Ask for and keep a record of your client's blood work to plan a safe program. You will know where their blood levels are by comparing them to the normal value ranges that are usually indicated to the side of the values. This will provide you with valuable information regarding their immune systems.
|White Blood Cells
||Check absolute granulocyte
|Absolute Granulocyte Count
||Take infection precautions
||Restrict activity due to risk of bleeding
||No vigorous activity
If the platelet count is low, avoid activities that increase the risk of bleeding such as contact sports, jogging or jump roping. Stretching and gentle exercise is acceptable. Abstain from high intensity activity if the hemoglobin is low as fatigue will set in quickly. Be sure to provide adequate rest periods. When the absolute granulocyte count is low, activities such as swimming should be avoided, along with pools, saunas and hot tubs secondary to the risk of infection. Exercise at home to decrease one's exposure to infectious agents such as other people!! If ataxia, dizziness or peripheral neuropathy is a concern, activities that require balance and coordination (i.e., treadmill) should be avoided. If bone metastases is an issue, activities such as high impact aerobics that increase fracture risk should be precluded. If your client is experiencing periods of nausea (not acute), exercise to tolerance as the nausea often dissipates after exercise.
During treatment, it is best to perform cardiovascular exercise at a low intensity (50 to 65 percent of maximum heart rate) if the client is a beginner. Once treatment has been terminated, one can exercise from 60 to 85 percent of the maximum heart rate. It is not recommended to go above 80 percent of the maximum heart rate for three to six months following treatment. However, this can depend on your client's cardiac condition before treatment. Recovery can vary from individual to individual. Extra recovery time is needed with more intense and longer treatments. Usually three weeks to four months of time should be expected for most radiation and chemotherapy regimens, but some side effects can linger for years.
Be aware that inadequate nutrition or insufficient fluid intake may compromise exercise capabilities. Awareness of a client's nutritional status is important due to the effects of chemotherapy or the mechanics of the tumor itself. In addition, knowing your client's drug treatment and side effects tendency is integral. For example, doxorubicin (Adriamycin), is a drug used for breast cancer that can cause cardio-toxic effects such as arrhymias or cardiomyopathy. Thus, routine cardiac assessment may be appropriate such as pulse rate and rhythm. Vincristine causes neuropathies and paresthesias, which are sensations of numbness, prickling/tingling or heightened sensitivity generally in the hands and feet. Neuropathies can interfere with your client's ability to perform certain activities. Thus, gripping weights or using the stair climber may be difficult.
Lymphedema is a condition that is not well understood. The incidence of Lymphedema varies from 10 to 50 percent of breast cancer survivors reporting symptoms. Lymphedema can be triggered by infection or injury or can develop more gradually. It is different from the temporary swelling experienced after surgery. Women should continue to participate in activities, but modifications may be necessary. This can be challenging, as one is at risk for this condition throughout life. Lymphedema is easier to treat when detected early. It is important to focus on the signs and symptoms to ensure early referral to a Lymphedema specialist. That is why recognition is so important. Symptoms of Lymphedema can include the following:
- A watch, jewelry or clothing that seems tight or uncomfortable
- A feeling of fullness, heaviness or pressure
- Numbness, tingling, dull aching or pain
- A change in the usual strength or function in the arm
It is important to obtain an objective assessment of your client's arm when you first start working with her and to monitor her condition on a regular basis. A baseline measurement of your client's status is performed by using a tape measure that is placed around the circumference of each landmark from the shoulder to the hand. Good landmarks include three inches above the elbow crease, the elbow crease itself and the wrist crease. Be sure to measure around each landmark in the same manner on a regular basis and to document the circumference in inches. Any significant change of a quarter inch to one inch along with any of the symptoms mentioned above should be reported to the client's medical provider. Lymphedema is usually treated with a combination of manual lymph drainage massage and compression garments such as bandages or compression sleeves. Manual lymph drainage is a gentle type of massage that is performed is a certain manner according to lymphatic anatomy and physiology. One removes the protein rich fluid and encourages it to move into another area where it can drain normally. Thus, more proximal regions of the body are cleared first, so lymph fluid can be redirected to these areas. The massage starts at the neck and moves on to the unaffected arm and then gradually to the involved side. Bandages are rolls of short stretch cloth that are wrapped around the extremity (they look similar to ACE wrap) after the massage. ACE wrap should not be substituted for bandages. The bandages create a rigid support for the muscles to work against. This results in lymph fluid movement and improvement in muscle pumping. Exercises are then performed with the bandages on to facilitate optimal lymph flow. In addition, proper skin care and preventative measures are very important to decrease infection risk. Signs of an infection include warmth, redness, blotchiness or inflammation. Clients should be referred to a physician immediately if any of these signs are noted.
Lymphedema Education for Clients
There are lists of forbidden and acceptable activities, but they are not always based on research. For example, women are told not to lift more than five pounds, yet functional tasks including lifting groceries may require the ability to lift greater than five pounds. Hopefully, future research will clarify some of these issues. Your clients should adhere to the following advisories as much as possible:
- Protect the affected arm from sunburn
- Avoid insect bites by wearing insect repellent
- Wear gloves when gardening
- Wear gloves when doing housework
- Wear a thimble when sewing
- Wear oven mitts when moving hot plates from the oven
- Daily Living
- Keep the arm as cool as possible
- Elevate the arm when sleeping
- Keep the arm clean, supple and well moisturized
- Immediately clean and place antibiotics and bandages to any cut
- Use warm water when bathing (not hot) and keep the affected arm out and elevated if in a hot tub
- Wear loose clothing, jewelry and watches
- Keep the arm safe by avoiding trauma (i.e. pet bites, cuts or nicks)
- Use a well maintained electric razor to shave under the arm
- Nail polish is fine, but cutting cuticles is not advised
- Wear a compression sleeve when traveling by air
- Pack soaps, moisturizers, antibiotic creams and bandages for emergencies
- Medical: It is very important to request that blood pressure, blood drawing, vaccines or shots only be performed on the unaffected arm. Trainers should take blood pressure only on the unaffected arm.
- Stay in good physical condition as women with a high body mass are at an increased risk of Lymphedema.
- Repetitive large, long motions (i.e., painting a wall) may not be well tolerated if the arm is not used regularly in a functional manner.
- Use some form of compression garment on the arm when exercising.
- Start exercise very slowly with few repetitions and monitor the response of the limb through symptoms and objective measurement.
- Use proper posture as it facilitates good breathing and body mechanics.
- lear the trunk of the body first by using deep abdominal breathing. In addition, this stimulates lymph circulation.
The goal of exercise for women with Lymphedema is to pump the muscles to move lymph from a congested area to an area where it can drain. Thus, the trunk is cleared first through deep abdominal breathing. In addition, one should increase the mobility of the shoulder girdle and spine. Encourage smooth breathing patterns, along with good posture while moving the shoulder. Both the deltoids and triceps are paths of alternative lymphatic drainage and should be focused on during your sessions.
In summary, here are 10 important points for you to remember when working with breast cancer clients:
- Emphasize flexibility of the affected shoulder and chest before initiating strengthening to the affected arm.
- Observe Lymphedema advisories as indicated above and never take blood pressure in the affected arm.
- Strength training to the affected arm should be done in a gentle progressive manner emphasizing the triceps, deltoids, rhomboids, biceps, rotator cuff and trapezius musculature. Compression garments or bandages should be worn if client is at risk of Lymphedema.
- Aerobic conditioning should be progressed in duration and frequency rather than intensity at first.
- Be aware of the side effects of the different medications and treatments your client is taking.
- Proper deep breathing is extremely important for ensuring lymphatic return.
- Your clients may have good days and bad days or days when they just want to talk. You should be responsive to their needs and modify activities accordingly. Be joyful, encouraging and enthusiastic in your sessions, but also be real in your interactions with them.
- Be aware of the support groups in your area that you can refer clients to if necessary.
- Alternative practices such as yoga and meditation can be quite helpful, especially in terms of stress management.
- Do additional research to establish a solid knowledge base. Respect your professional limitations, and refer clients to medical providers who may be able to offer more suitable options.
Working with breast cancer survivors has been very rewarding for me both personally and professionally. Bringing clients from a state of decreased physical function to one that allows greater ease of motion, improved strength and increased endurance to perform their daily tasks can be powerful therapy. Furthermore, many of these techniques and modalities can be applied to other cancer survivors in your community. Providing exercise to cancer survivors can promote optimal functional abilities and facilitate overall well being!
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