The following blog post is a quick summary of a recent publication by our research team on the synergy between physical therapy and exercise physiology professionals. When we all work together – the patient wins!
Over the last several decades, there have been some major advances in the fight against cancer. Early detection and awareness are on the rise. Genetic sequencing and targeted therapies have yielded impressive results. Mortality rates from cancer are at an all time low.
Now, more than ever, cancer survivors have a reason to be optimistic about what the future holds.
Along with these advances comes one potential downside – cancer survivors are living with the long term and late effects of cancer longer than ever before. These include fatigue, muscle cachexia and weakness, pain, sleep disturbances, nausea, reduction in bone density, depression and anxiety, body image issues, weight gain, decreased range of motion, cognitive impairment, chemotherapy-induced neuropathy, and reduction in physical activity
Even survivors who are relatively fit and free of co-morbidities at the time of diagnosis are likely to experience negative effects of treatment, to some degree.
There is strong evidence to support the management of physical impairments through a comprehensive oncology rehabilitation program, involving a collaborative team of physical therapists and exercise physiologists.
Physical Therapists are trained to gage deficiencies in strength, endurance, mobility, balance, and motor control. Based on this assessment, they develop and implement a targeted treatment plan designed to restore optimal function while navigating co-morbidities, patient values and beliefs, schedule limitations, and other physical demands present in the patient’s life. In their sessions, physical therapists instill education to patients regarding their condition, empowering them for long term success and prevention of prolonged or future issues.
An Exercise Physiologist is trained to analyze an individual’s level of fitness in order to improve or maintain health, mitigate side effects, and improve quality of life. In an exercise program, the five components of fitness are addressed – body composition, cardiorespiratory fitness, muscular strength, muscular endurance, and flexibility. Based on the patient’s baseline assessment, the exercise physiologist develops an individualized exercise program to target patient strengths, weaknesses, and goals. Sessions are then carried out once each week for 45-60 minutes through a supervised, whole body workout.
Together, oncology-trained physical therapists and exercise physiologists can provide the best possible care for cancer survivors, meeting the comprehensive goals set by NCCN guidelines and using a whole person approach to cancer care.
Nationally, less than 5% of patients participate in an exercise program. Most studies report that barriers to participation include treatment-related side effects, emotional status, feelings of lack of control over health and cost. Further, insufficient patient education is believed to contribute to the belief that participation in a physical therapy or exercise program is not helpful. Therefore, we assert that identifying and addressing these barriers can lead to improved support and education from health professionals, thereby increasing patient involvement.
In light of this, we propose that at the time of diagnosis, each patient be referred to physical therapy for initial screening. The physical therapist will take baseline measurements and screen the patient for impairments. Based on this assessment, the patient will then be placed in one of two categories:
- Appropriate for physical therapy
- Not appropriate for physical therapy, but will benefit from individualized exercise therapy.
In this manner, the early and late effects of cancer will be monitored by the most appropriate oncology-trained exercise professional. This will maximize patient safety, reduce side effects, improve patient compliance to treatment, and improve patient quality of life.
Together, exercise physiology and physical therapy professionals can work together to create a unique patient experience, addressing their functional needs through a holistic approach to cancer care.
Table 1. Specific benefits of exercise on cancer-related toxicities.
|Adverse Effect of Cancer Treatment||Description||Physiological Effect of Exercise|
|Muscular Degeneration||Cancer treatments can damage the integrity of muscle tissue by decreasing protein synthesis. The release of hormones that cause muscle cell growth and development are blunted [29, 30].||Exercise increases the integrity of muscle tissue and protein synthesis, stimulates the release of numerous hormones that increase muscle cell growth and development, and improves metabolism [30, 31].|
|Cardiotoxicity||Cancer treatments can lead to left ventricular dysfunction, reduced ejection fraction, diminished contractility, reduced cardiac output, decreased nutrient and oxygen delivery to tissues [29, 30].||Exercise can improve cardiovascular efficiency by:
o Strengthening the myocardium
o Increasing cardiac output and stroke volume
o Decreasing resting heart rate and lowering exercise heart rate [30, 31].
|Pulmonary toxicity||Cancer treatments can cause a disruption in the structural integrity of the airways [31, 32].||Exercise can improve ventilation and transport of oxygen from the environment to the cellular level [32, 33].|
|Fatigue||Cancer treatments cause persistent, whole-body exhaustion that interferes with daily functioning .||Exercise has been shown to decrease fatigue and anxiety, and improve quality of life .|
|Pain||Pain can be caused by damage to tissue and nerves from the original tumor by the cancer itself or its related treatment.||Pain thresholds and pain tolerance levels have been reported to increase both during and following exercise. In addition, intensity ratings of pain appear to decrease following exercise [36-41].|
|Neuropathy||Damage to the peripheral nervous system caused by chemotherapy is referred to as chemotherapy-induced peripheral neuropathy, and produce pain symptoms that are often described as burning, paroxysmal, stabbing, or electric shock-like sensations  and are often accompanied by pins-and-needles sensations and itching .||Several studies report improvements in muscular strength following moderate resistance exercise programs in patients with hereditary motor and sensory neuropathies [44-47].|
|Immune Dysfunction||White blood cells have the ability to destroy foreign cells, including cancer cells in the body. Certain cancer treatments may cause a decrease in the body’s white blood cell count, making it harder to fight off infection .||Chronic exercise training at a moderate intensity is associated with improved immune function through increases the amount of white blood cells and therefore strengthens the immune system.|
|Endocrine changes||The majority of endocrine changes are tumor-specific and treatment-specific. Reproductive function, thyroid health, and bone health are often adversely affected.||During exercise, extracellular substrates are mobilized that augment the effects of the endocrine system.|
|Gastrointestinal dysfunction||Cancer treatments can often result in disruption to the gastrointestinal system, causing constipation, malabsorption, diarrhea .||Exercise can improve gastric emptying and lower the relative risk of colon cancer. Overtime, regular physical activity can strengthen the digestive tract, making muscles more efficient.|
|Weight loss||Some patients may experience weight loss both before diagnosis and as an effect of chemotherapy and radiation treatments. Factors that contribute to weight loss during treatment include loss of appetite, early satiety (feeling full), altered sense of taste and smell, difficulty chewing and swallowing, nausea, vomiting, diarrhea, and compromised nutrient intake||Exercise training has been suggested as a promising measure to prevent cachexia and restore muscular strength and endurance.|
Table 2. General exercise program guidelines.
|Aerobic Training||Strength Training||Flexibility Training|
|Frequency||3-5 days/wk||2-3 days/wk||2-7 days/wk|
|Intensity||40-60% HRR*||40-60% HRR*||Stretch to the point of mild discomfort|
|Duration||20-60 min/session||1-3 sets, 8-12 reps per exercise||10-30 seconds per stretch|
|Mode||Walking, cycling, cross trainers, swimming||Free weights, machines, resistance bands, resistance balls||Static stretching|
Figure 1. Screening Chart.
|1. Do you have trouble completing your daily home and self care tasks due to weakness or physical limitations?|
|2. Can you walk more than one block without difficulty?|
|3. Can you climb more than one flight of stairs without difficulty?|
|4. Are you able to complete your job responsibilities?|
|5. Do you have pain that limits function or makes it difficult to sleep?|
|* If Physical Therapist answers yes to any of the above questions, patient is referred to physical therapy first. If answers to all questions are no, patient is referred to exercise oncology.|
Figure 2. Synergy Between Physical Therapy and Exercise Physiology.
- American Cancer Society. Cancer Facts & Figures 2017. https://www.cancer.org/research/cancer-facts-statistics/all-cancer-facts-figures/cancer-facts-figures-2017.html
Date of Access: May 9, 2017.
- Schmitz KH, Courneya KS, Matthews C, Denmark-Wahnerfried, Galvao, DA, Pinto, BM, Irwin, ML, Wolin, KY, Segal RJ, Lucia A, Schneider CM, von Gruenigen VE, Schwartz AL. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–26.
- Mustian KM, Alfano CM, Heckler C, Kleckner AS, Leach CR, Mohr D, Palesh OG, Peppone LJ, Piper BF, Scarpato J, Smith T, Sprod LK, Miller SM. Comparison of Pharmaceutical, Psychological, and Exercise Treatments for Cancer-Related Fatigue. A Meta-analysis. JAMA Oncol. 2017 Jul 1;3(7):961-8.
- Griffith K, Wenzel J, Shang J, Thompson C, Stewart K, Mock V. Impact of a walking program intervention on cardiorespiratory fitness, self-reported physical function, and pain in patient undergoing treatment for solid tumors. Cancer.2009;115:4874-84.
- Winningham ML. “Effects of a bicycle ergometry program on functional capacity and feelings of control in women with breast cancer.” PhD diss., The Ohio State University, 1983.
- Winningham ML, MacVicar MG. The effect of aerobic exercise on patient reports of nausea. Oncology nursing forum.1987;15(4):447-50.
- Mohamad NV, Soelaiman IN, Chin KY. Effect of Androgen Deprivation Therapy (ADT) on Bone Health Status in Men with Prostate Cancer. Endocr Metab Immune Disord Drug Targets. 2017; 17(4):276-84.
- Schmitz KH, Ahmed RL, Troxel AB, Cheville A, Lewis-Grant L, Smith R, Bryan CL, Williams-Smith CT, Chittams J. Weight lifting for women at risk for breast cancer-related lymphedema: a randomized trial. JAMA. 2010;304(24):2699-705.
- Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, Bryan CJ, Williams CT, Greene QP. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009;361(7):664-73.
- Galatino ML, Stout NL. Exercise interventions for upper limb dysfunction due to breast cancer treatment. Phys Ther. 2013;93(10):1291-7.
- Wonders KY & Drury DG. Current exercise behaviors of breast cancer patients diagnosed with chemotherapy-induced peripheral neuropathy. J Integr Oncol 2012;1(1): 103–7.
- Wonders KY. The effect of supervised exercise training on chemotherapy-induced peripheral neuropathy. Int J Phys Med Rehabil. 2014; 2(4): 210–5.
- Smith SR, Zheng JY. The Intersection of Oncology Prognosis and Cancer Rehabilitation. Curr Phys Med Rehabil Rep. 2017;5:46-54.
- The Physical Therapist Scope of Practice. APTA. http//www.apta.org. 4/23/2018. Accessed 8/19/2018.
- MacVicar MG, Winningham ML, Nickel JL. Effects of aerobic interval training on cancer patients’ functional capacity. Nursing Research.1989;38(6):348-53.
- Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. Support Oncol. 2012;10(5):171-7.
- Quist M, Rorth M, Zacho M, Andersen C, Moeller T, Midtgarrd J, Adamsen L. High-intensity resistance and cardiovascular training improve physical capacity in cancer patients undergoing chemotherapy. J. Med. Sci. Sports. 2006;16: 349-357.
- Wiggins MS, Simonavice EM. Quality of life benefits in cancer survivorship with supervised exercise. Rep. 2009; 104: 421-4.
- Baumann FT, Reike A, Reimer V, Schumann M, Hallek M, Taaffe DR, Newton RU, Galvao DA. Effects of physical exercise on breast cancer-related secondary lymphedema: a systematic review. Breast Cancer Research and Treatment2018;170:1, 1-13.
- Dimeo F, Bertz H, Finde J, Fetscher S, Mertelsmann R, Kuel J. An aerobic exercise program for patients with hematological malignancies after bone marrow transplantation. Bone Marrow Transplant. 1996;18: 1157-60.
- Mock V, Dow KH, Meares CJ, Grimm PM, Dienemann JA, Haisfield-Wolfe ME, Quitasol W, Mitchell S, Chakravorthy A, Gage I. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Nurs. Forum. 2007; 24: 991-1000.
- Mori AI, Gao M, Nail LM, King ME. Exercise reduced daily fatigue in women with breast cancer receiving chemotherapy. Sci. Sports Exerc. 2001;33: 718-23.
- Segal R, Evans W, Johnson D, Smith J, Colletta S, Gayton J, Woodard S, Walls G, Reid R. Structured exercise improves physical functioning in women with stages I and II breast cancer: Results of a randomized controlled trial. Clin. Oncol. 2001; 19: 657-65.
- Wiggins MS, Simonavice EM. Quality of life benefits: A 12-month exercise cancer recovery case study. KAHPERD J. 2008; 44:16-9.
- Courneya KS, Friedenreich CM, Quinney HA, Fields ALA, Jones LW, Fairey AS. A randomized trial of exercise and quality of life in colorectal cancer survivors. Eur J Pharmacol. 2003;12: 347-57.
- Courneya KS, Keats MR, Turner AR. Physical exercise and quality of life in cancer patients following a high dose chemotherapy and autologous bone marrow transplantation. 2000;9: 127-36.
- Galvo DA, Newton RU. Review of exercise intervention studies in cancer patients. Clin. Oncol. 2005; 23: 899-09.
- Doyle C, Kushi L, Byers T, Courneya KS, Denmark-Wahnerfried W, Grant B, McTiernan A, Rock CL, Thompson C, Gansler T, Andrews KS. Nutrition and physical activity during and after cancer treatment: an American Cancer Society for informed choices. Cancer J. Clin. 2006;56: 323-53.
- DeVita VT, Hellman S, Rosenberg SA. Cancer: Principles and practice of oncology (6th). Vols. 1 and 2. 2001. Philadelphia: Lippincott-Williams & Wilkins.
- Fischer DS, Knobf MT, Durivage HJ. The cancer chemotherapy handbook (4th). 1993. St. Louis: Mosby.
- Chabner, B.A., & Longo D.L. Cancer and alveolar sacs, and fatigue of the intercostal muscles. Chemotherapy and biotherapy (3rd). 2001. Philadelphia: Lippincott Williams & Wilkins.
- Wilson JKV. Pulmonary toxicity of antineoplastic drugs. Cancer Treat Rep 1978; 62: 2003.
- Koltyn KF, Wertz AL, Gardiner RL, Nelson TF. Perception of pain following aerobic exercise. Med Sci Sports Exerc 1996;28: 1418-21.
- Gurevich M, Kohn PM, Davis C. Exercise-induced analgesia and the role of reactivity in pain sensitivity. J Sports Sci 1994;12: 549-59.
- Sternberg WF, Bokat C, Kass L, Alboyadjian A, Gracely RH. Sex-dependent components of the analgesia produced by athletic competition. Pain 2001; 94: 65-74.
- Sternberg WF, Bailin D, Grant M. Competition alters the perception of noxious stimuli in male and female athletes. Pain 1998; 76 (1-2): 231-8.
- RJ, Quaid K, Mills JSC. Naloxone alters pain perception after jogging. Psychiatry Res 1981;5: 231-2.
- Koltyn KF, Arbogast RW. Perception of pain after resistance exercise. Br J Sports Med 1998; 32: 20-4.
- National Health & Medical Research Council. Acute pain management: scientific evidence. Australia, Commonwealth of Australia.
- Verstappen CP, Heimans JJ, Hoekman K, Postma TJ. Neurotoxic complications of chemotherapy in patients with cancer: Clinical signs and optimal management. Drugs 2003; 63(15): 1549-63.
- Lindeman E, Leffers P, Spaans F, Drukker J, Reulen J, Kerckhoffs M, Koke A. Strength training in patients with myotonic dystrophy and hereditary motor and sensory neuropathy: a randomized clinical trial. Arch Phys Med Rehabil 1995:76(7): 612-20.
- Kilmer DD, McCroy MA, Wright NC, Aitkens SG, Bernauer EM. The effect of a high resistance exercise program in slowly progressive neuromuscular disease. Arch Phys Med Rehabil, 1994;75(5): 560-3.
- Aitkens SG, McCrory MA, Kilmer DD, Bernauer EM. Moderate resistance exercise program: its effect in slowly progressive neuromuscular disease. Arch Phys Med Rehabil 1993;74(7): 711-5.
- Lindeman E, Leffers P, Reulen J, Spaans F, Drukker J. Quadriceps strength and timed motor performances in myotonic dystrophy, Charcot-Marie-Tooth disease, and healthy subjects. Clin Rehabil 1998;12(2): 127-35.
- Coping with Cancer. http://www.cancer.net/coping-with-cancer
Date of Access: May 9, 2017.
- Grumann MM, Noack EM, Hoffmann IA, Schlag PM. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg, 2001; 233(2): 149-52.
- American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription, 7th Lippincott Williams and Wilkins: Philadelphia; 2006.