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Getting Back To Living! The Role of Exercise in the Management of Post- Breast CA Treatment Side-Effects and Implementing an Exercise Program

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Title: Getting Back To Living! The Role of Exercise in the Management of Post- Breast CA Treatment Side-Effects and Implementing an Exercise Program


1
Getting Back To Living! The Role of Exercise in
the Management of Post- Breast CA Treatment
Side-Effects and Implementing an Exercise Program
  • Rebecca G. Smith, MD, MS
  • Director, Cancer Rehabilitation
  • Chief, Division of Cancer Rehabilitation
  • Assistant Professor
  • Department of Physical Medicine and
    Rehabilitation
  • University of Pennsylvania

2
  • When the only tool
  • you have is a hammer,
  • you tend to treat everything
  • as if it were a nail.

-Abraham Maslow Slide Compliments of Ann Webster,
PhD, Institute of Mind Body Medicine, Harvard
Medical School, Boston
3
The Three-Legged StoolSlide Compliments of Ann
Webster, PhD, Institute of Mind Body
Medicine,Harvard Medical School, Boston
Overall Health
Surgery Procedures
Pharmaceuticals
Self-care
4
EXERCISE
  • Planned, structured and repetitive bodily
    movement done to improve or maintain one or more
    components of physical fitness.

5
EXERCISE and
  • CHD, CVS, DM Well defined role in the prevention
    and treatment
  • Physiologic effects in persons with cancer
    Minimal research exists
  • Epidemiological studies of effects on risk factor
    modification and benefits of treatment Growing
  • Prognosis of Cancer and Survival - Unknown

6
What can exercise do for me?
  • Help maintain independence
  • Lift spirits and reduce feelings of depression
  • Reduce body fat and incr. lean body mass
  • Increase strength and endurance
  • Weight management
  • Improve feelings of self confidence and control
  • Make everyday tasks easier and more enjoyable
  • Reduce risk of illness

7
Physiological Benefits of Exercise
  • Stronger heart and lungs
  • Incr. muscle strength and endurance
  • Improve body composition
  • Reduce blood pressure
  • Increase metabolic rate
  • Increase good cholesterol (HDL)
  • Improve serum glucose regulation
  • Increase bone mineral density (wt-bearing
    exercises)

8
Psychological benefits of exercise
  • Decreased stress and tension
  • Increased self-esteem and self confidence
  • Increased ability to concentrate and cope with
    stressors
  • Improved feeling of general well-being
  • Reduced anxiety and depression

9
Role of EXERCISE in Cancer Rehabilitation
  • Improved
  • Fitness (VO2, VO2max, exercise performance, etc.)
  • strength
  • QOL
  • mood
  • sleep
  • locus of control
  • self image
  • Symptom management
  • Nausea
  • Fatigue
  • Weight control

10
Role of EXERCISE in Breast Cancer
RehabilitationAdapted from Irwin ML, et al.
Cancer Investigations Vol 22, No. 1, 2004, 36-37.
  • MacVicar, M.D. and Winningham, M. L.
  • Stage II breast CA survivors receiving
    chemotherapy
  • Results of 5 studies
  • RCT (3)
  • Nonrandomized-CT (2)
  • Exercisers
  • Able to improve fitness levels as much as healthy
    controls.
  • Reported increased locus of control
  • 80 of exercisers showed improvement in nausea
    vs. 14 of placebo and 39 controls
  • Showed a dec. in body fat (0.5) inc lean body
    mass (lbm) vs. 2.2 inc body fat and no change in
    lbm in controls
  • 40 inc in fitness vs. no change in controls

11
Role of EXERCISE in Cancer FatigueAdapted from
Irwin ML, et al. Cancer Investigations Vol 22,
No. 1, 2004, 36-37.
  • Schwartz, A.L., et al.
  • 72 Stage I-III breast CA survivors receiving
    chemotx
  • 1 sample-Pre/post- Aerobic training
  • 61 completed. 61 adopted the ex program and
    improved functional ability by 15. Non-ex dec
    by 16. Exercise reduced all four levels of
    fatigue
  • 2001, Med Sci Sports Exerc, 33, 718-723.
  • Segal, R.J., et al.
  • 155 men w/prostate CA receiving androgen
    deprivation
  • RCT - Resistance training
  • 135 completed.
  • Exercisers Fatigue decreased, QOL and musc
    fitness increased.
  • No change in skinfolds, testosterone/ PSA
  • 2003, Oncol Nurs Forum, 25, 107-112.

12
Dimeo, F. et al. Summary of pertinent
findingsAdapted from Irwin ML, et al. Cancer
Investigations Vol 22, No. 1, 2004, 36-37.
  • Pre-post tests showed inc. in all physical
    performance parameters
  • 1996 Bone Marrow Transplant, 18, 1157-1160
  • Exercisers inc fitness, inc Hb and dec fatigue
  • 1997 Cancer, 79, 1717-1722
  • 14 dec perform ex vs 19 control. Ex showed inc
    fitness, dec neutropenia, thrombocytopenia,
    ptl trans, pain, diarrhea and LOS
  • 1997 Blood, 90, 3390-3394
  • Inc. in training speed, distance, maximal
    performance, and clear improvements in fatigue
  • 1998 Med Sci Sports Ex 30, 475-478
  • Exercisers adhered to 82 of sessions ex. dec in
    anger, interpersonal sensitivity,
    obsessive-compulsive traits, anxiety, phobic
    anxiety, and global psychological distress.
    Controls showed inc fatigue, somatization, and
    dec vigor
  • 1999 Cancer 85,2273-2277

13
Role of EXERCISE on Immune Function in Cancer
RehabilitationAdapted from Irwin ML, et al.
Cancer Investigations Vol 22, No. 1, 2004, 36-37.
  • Exercise resulted in inc. NKCell activity and
    psychological wellbeing PETERS,
    1992-Dissertation, Unpublished
  • Inc. lymphocytes and leukocytes _at_ 29 weeks as
    compared to baseline and 6 week. PETERS, 1994,
    Anticancer Res., 14(3a), 1033-1036
  • Inc. NKCell activity (lysis) in exercisers
    compared to controls
  • NA, 2000, Arch Phys Med Rehabil, 81 (6),
    777-779.
  • 3 /6 pediatric exercisers adhered to study.
    Leukocytes dec w/chemotx at baseline No
    difference at 12 weeks Inc aerobic power in ex
    group SHORE 1999, J Sports Med Phys Fitness, 39
    (3), 24-243
  • Exercise did not facilitate faster immune cell
    recovery, but it did not delay recovery HAYES,
    2000, Med Sci Sports Exerc, 35 (1), 2-9.

14
Exercise and Cancer Proposed Physiological
Mechanisms
  • EXERCISE
  • Decreases transit time of GI tract
  • Helps maintain energy balance
  • Helps regulate glycemic load
  • Promotes an immune response
  • Promotes PGF2 and inhibit PGE2
  • May exert genetic influences

15
Exercise and Cancer Proposed Physiological
Mechanisms
  • Changes in sex hormones
  • Decreased concentrations of estrone, estradiol
    and free estradiol in postmenopausal women who
    lost at least 0.5 body fat while participating
    in an exercise program
  • Increased SHBG
  • McTiernan A, et al. Cancer Research 64,
    2923-2928, April 15, 2004

16
ACS Guidelines on Nutrition and Physical Activity
for Cancer Prevention
  • Eat a variety of healthful foods, w/ an emphasis
    on plant sources
  • Eat 5 or gt servings of a variety of vegetables
    and fruits each day
  • Choose whole grains instead of processed grains
    and sugars
  • Limit consumption of red meats, especially those
    that are high in fat and processed
  • Choose foods that help maintain a healthful
    weight
  • Limit consumption of alcoholic beverages
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1804

17
ACS Guidelines on Nutrition and Physical Activity
for Cancer Prevention
  • Adopt a physically active lifestyle
  • Adults Mod. activity for at least 30 min. on 5
    or more days/wk 45 min or more of mod.-vigorous
    activity on 5 or more days/wk may further enhance
    reductions in the risk for breast and colon
    cancer
  • Children and adolescents At least 60 minutes/day
    of mod-vigorous physical activity at least 5
    days/wk
  • Maintain a healthy weight throughout life
  • Balance caloric intake w/physical activity
  • Lose weight if currently overweight or obese
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1804

18
ACS Guidelines on Physical Activity During
Treatment and Recovery
  • Pts. receiving RXT and chemotx Alter program or
    begin exercise at a lower intensity and progress
    at a slower rate
  • Pts. exercising regularly before diagnosis Try
    to maintain levels of activity as much as
    possible
  • Sedentary pts. before diagnosis Adopt
    low-intensity activities such as short, slow
    walks and stretching
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1803-1805

19
ACS Guidelines on Physical Activity During
Treatment and Recovery
  • Consider physical therapy interventions to
  • Maintain ROM of joints and prevent contractures
    if prolonged bedrest
  • Improve balance
  • Reduce risk of falls in elderly and those w/
    significant impairments
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1803-1805

20
ACS Guidelines on Physical Activity After
Recovery from Treatment
  • Most cancer survivors are free of disease or
    stable after the initial diagnosis and treatment
  • Set and achieve lifelong goals for appropriate
    weight, healthy diet and physically active
    lifestyle.
  • Address residual impairments and sequalae of
    treatment that may be limiting function and
    physical activity
  • Following the ACS Guidelines on diet, nutrition,
    physical activity and cancer prevention may help
    reduce risk of recurrence.
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1803-1805

21
ACS Guidelines on Physical Activity Living with
Advanced Cancer
  • Nutrition and physical activity are vital to
    establishing and maintaining well-being and
    quality of life.
  • Physical activity may help increase appetite,
    reduce fatigue and relieve constipation
  • Adapted from Brown JK, et al. CA Cancer J Clin
    200353273 Neff M, American Family Physician
    April 1, 2004, Vol 69 (7) 1803-1805

22
Breast Cancer Treatment
  • Surgery
  • Breast Reconstruction
  • Chemotherapy
  • Hormonal Therapy
  • Radiation

23
Breast Cancer Treatment Surgery
  • Axillary Lymph Node Dissection
  • Sentinel Lymph Node Biopsy
  • Breast-conserving Surgery
  • Total Mastectomy
  • Modified Radical Mastectomy
  • Radical Mastectomy
  • Halverstadt, Amy, et. Al. Exercise, Breast
    Cancer and You Essential Exercises for Breast
    Cancer Survivors,

24
Axillary Lymph Node Dissection Potential Side
Effects
  • Axillary lymph node dissection
  • Tightness of skin? movement difficult and painful
  • Weakness of shoulder girdle and chest wall
  • Pain
  • Lymphedema

25
Breast Cancer Surgery
  • Mastectomy
  • Modified Radical Mastectomy/Radical Mastectomy

26
Breast Cancer TreatmentPotential Side Effects
of Surgery
  • Muscular Weakness
  • Pectoralis, serratus anterior, postural weakness
  • Chest wall adhesions
  • Scar tissue
  • Lymphedema
  • Axial and peripheral
  • Pain
  • Myofascial pain, frozen shoulder

27
Breast Cancer Treatment Potential SideEffects
of Radiation
  • Fatigue
  • Temporary burns
  • Shoulder dysfunction
  • Breast swelling
  • Tightening of the skin
  • Red, dry or irritated skin
  • Hardening of the surgical scar (fibrosis)
  • Reduced white blood cell count
  • Scarring of the heart or lungs (rare)
  • Lymphedema

28
Breast Cancer Treatment Potential Side-Effects
of Chemotherapy
  • Hair loss, dry skin, rash
  • Weight gain
  • Nausea, vomiting, diarrhea
  • Decreased appetite
  • Peripheral neuropathy
  • Numbness, tingling, pain in distal limbs
  • Muscle weakness
  • Cardiomyopathy or accelerated atherosclerosis
  • Decreased blood cell counts
  • anemia, infections, blood clotting problems

29
Breast Cancer Treatment Potential Side-Effects
of Hormone Therapy
  • Weight gain
  • Hot flashes
  • Sweats
  • Irregular menses
  • Vaginal dryness or irritation

30
Breast Cancer Treatment Potential Side-Effects
of Reconstruction
  • Saline Implants and Tissue Expanders
  • Latissimus Dorsi Flap
  • TRAM Flap
  • Free Flap
  • Nipple-Areolar Construction and Tattooing

31
Breast Cancer Treatment Potential Side-Effects
of Reconstruction
  • Saline Implants and Tissue Expanders
  • Main complication Capsular contracture
  • Reactive spasms of pectoralis major muscle
  • Treatment focuses on relaxation, stretching and
    isometric exercises of the pectoralis major muscle

32
Breast Cancer Treatment Potential Side-Effects
of Reconstruction
  • Latissimus Dorsi Flap
  • Weakness around shoulder blade
  • TRAM Flap (Transverse Rectus Abdominis
    Myocutaneous)
  • Abdominal weakness
  • Back pain, hernia, decreased trunk stability
  • Standing may be difficult
  • Create muscle stress, tension and biomechanical
    imbalances
  • TRAM Flap Stretch abdomen, strengthen back, work
    on improving posture

33
Reconstructive Surgeries of the Breast
  • Latissimus Dorsi Flap
  • TRAM Flap

34
Breast Cancer Treatment Potential Side-Effects
of Reconstruction
  • Free Flap
  • Muscular weakness
  • Stiffness and soreness where tissue was
    reattached
  • Recovery time is longer
  • Nipple-Areolar Construction and Tatooing
  • Flap is taken from breast mound or other area of
    body
  • Modified skate flap
  • Performed as second surgery after treatment is
    finished.

35
Myofascial Pain MPS
36
Lymphatic Circulation
37
Secondary Lymphedema
  • Protein rich fluid accumulation in the upper
    limb, axilla, chest wall, and/or neck
  • Due to loss of lymph nodes and/or damage to lymph
    vessels

38
Lymphedema Risk Reduction
  • Keep skin clean and moist
  • Avoid venupuncture and blood pressure measurement
    in affected limb
  • Avoid jewelry
  • Protect against sunburn and bug bites
  • Seek medical attention if signs of infection
    occur, I.e. redness, warmth, fever

39
Lymphedema Risk Reduction
  • Speak to your physician before returning to
    vigorous exercise
  • Slow progressive increase in limb activity
  • Monitor for sign of swelling with activity
  • Seek further evaluation if swelling develops

40
Lymphedema Treatment
  • Complex Decongestive Therapy
  • Phase I
  • Daily Manual Lymphatic Drainage
  • Daily bandaging
  • Remedial exercises
  • Meticulous skin care
  • Education
  • Complex Decongestive Therapy
  • Phase II
  • Daily compression garment
  • Nightly bandaging
  • Remedial exercises
  • Meticulous skin care
  • Monitor for signs of infection

41
Lymphedema CDT-Bandaging
42
Lymphedema CDT Phase II- Upper Extremity
Compression Garments
43
Stress Management
44
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45
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46
Exercise
47
Implementing an Exercise Program
  • A good program includes
  • 10 Minute warm-up
  • 20-40 minutes of Aerobic exercises with level of
    moderate intensity
  • 15 minutes of strengthening
  • 10 minutes of stretching and cool down 

48
Implementing a Home Exercise Program
  • The aerobic component may include
  • Walking
  • Jogging
  • Swimming, water walking
  • Stationary Bicycling
  • Stair Climbing
  • Elliptical Machine

49
Implementing a Home Exercise Program
  • To improve the cardiac component you need to
    perform aerobic type exercises for at least 20
    minutes at a level of moderate intensity (can
    talk but feels like you are working). Ideally
    you would increase to a greater level to tolerate
    30-40 minutes 3-5 times per week.

50
Implementing a Home Exercise Program
  • The strengthening and stretching components
    should focus on
  • Deficient areas that are causing pain and
    dysfunction
  • Generalized strengthening and stretching to
    include the major muscle groups of your arms,
    forearms, shoulders, neck, back, abdomen,
    buttocks/pelvis, hip, thighs and legs.

51
Warning Signs to Stop ExercisingHalverstadt,
Amy, et. Al. Exercise, Breast Cancer and You
Essential Exercises for Breast Cancer Survivors,
  • Chest pain or pressure
  • Irregular pulse
  • Resting heart rate gt 100
  • Excessive rise in blood pressure
  • Recurring leg pain or cramps
  • Disorientation or confusion
  • Pallor (paleness), cyanosis (bluish skin)
  • Sudden shortness of breath, muscular weakness,
    excessive fatigue
  • Sudden onset of nausea
  • Blurred vision, dizziness, faintness
  • Vomiting or diarrhea past 24-36 hours
  • Tenderness/pain in a joint that worsens with
    activity

52
Exercise Shortcomings
  • The main shortcoming is that it requires
    motivation and persistence. It doesnt take long
    to lose the benefits if stopped. It is not as
    easy as taking medication, but it should be
    regarded as just as important.
  • Rebecca G.Smith, MD, MS 

53
Affirmations to say regularly to keep yourself
motivated
  • Exercise may possibly reduce my chances of
    getting cancer again.
  • Exercise can help me regain the feeling of
    controlling my life, my body, and my destiny can
    increase strength and mobility to my arms and
    shoulders and can improve my ability to perform
    daily activities without becoming fatigued.
  • Halverstadt, Amy, et. Al. Exercise, Breast
    Cancer and You Essential Exercises for Breast
    Cancer Survivors, Page 8, The Harvard Common
    Press, 2000

54
Affirmations to say regularly to keep yourself
motivated
  • I can make my life better by choosing to do
    something that may be a little difficult and
    challenging for me.
  • I have already faced one of the hardest things
    in life, and I survived. I can handle a little
    exercise.
  • I am beautiful, strong and a survivor. I want
    to be strong, healthy and enjoy life. Exercise
    can help me reach this goal.
  • Halverstadt, Amy, et. Al. Exercise, Breast
    Cancer and You Essential Exercises for Breast
    Cancer Survivors, Page 8, The Harvard Common
    Press, 2000

55
It is time to start LIVING!!!!
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