1. Cancer: Exercise and Fatigue
Melora Rennie, OTR/L, CLT, LANA
Northside Hospital- Atlanta

2. How Cancer Can Impact the Body
Muscles & Bones
Presence of cancer in bones can lead to fractures
(ex: Multiple Myeloma)
Nervous System
Tumors can cause numbness, tingling, or weakness by putting pressure on the nerves or spinal cord
Heart & Lungs
Lung cancer can decrease the lung’s volume

3. How Treatment Can Impact the Body
Chemotherapy
Chemotherapy induced peripheral neuropathy (CIPN)
Cancer related fatigue1,2
Increase in fat mass and worsened bone health1
Radiation
Stiffening of tissues, including skin1
Surgery
Impacting organs and structures that are nearby
All of the above treatments can lead to pain, changes in lung function, mental changes, and digestive tract changes2

4. Lymphedema
Abnormal swelling that develops, usually in the arm(s) or leg(s)
May occur after certain types of chemotherapy, lymph node removal or radiation to an area with lymph nodes
Early signs and symptoms include a feeling of tightness, heaviness and fullness in the limb, increased size of a limb and a loss in flexibility
Notify your physician if you begin to experience this

5. Chemotherapy Induced Peripheral Neuropathy
Symptoms include: numbness, tingling, pain, burning, loss of function, weakness, & balance problems
Typically affects hands and feet
Recovery time can vary depending on the amount of damage

6. Cancer Related Fatigue (CRF)
Cancer Related Fatigue is an unusual, persistent sense of physical, emotional and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that interferes with ones’ normal activity.

7. Cancer Related Fatigue (CRF)
Symptoms include1:
Weak feeling all over the body
Difficulty concentrating
Waking up tired after sleeping
Lack of energy or decreased energy
Lack of motivation to be physically active
Increased irritability, nervousness, anxiety, impatience
No relief from fatigue, even with rest or sleep
Symptoms are present every day or nearly every day for a 2 week period within the last month1

8. What Causes CRF? Medical Factors Anemia Pain Infection
Impaired nutritional status or weight loss
Electrolyte and fluid imbalance
Chemotherapy/radiation
Medication side effects

9. What Causes CRF? 2. Psychosocial Factors Emotional distress
Anxiety/depression
Lack of social support
Poor coping skills
Sleep disturbances

10. What Causes CRF? 3. Physical Factors Lack of exercise or inactivity
Loss of muscle mass
Decreased cardiovascular or respiratory function
Other coexisting health issues
(due to high dose steroids or inactivity)
(i.e underactive thyroid, decreased cardiac/kidney/liver function)

11. 4. Lack of Energy Conservation
What Causes CRF?
4. Lack of Energy Conservation
Poor pacing
Attempting to do too much too soon
Lack of rest

12. What is your FATIGUE level?

13. Energy Conservation What is Energy Conservation?
The practice of decreasing the amount of energy used during a task of activity while achieving a similar result

14. Energy Conservation Techniques
Sitting to complete daily tasks
Use cart to push items opposed to carrying
Avoid bending, use a reacher or other adaptive equipment
Breaking up components of a task
Asking for assistance
Spread energy consuming tasks throughout the week
Do tasks that require the most energy at the times you have the most energy
Utilizing recovery breaks, “Do a little, Rest a little”
Implementation of relaxation techniques

15. Energy Conservation 3 Key Strategies Pacing Prioritizing
Changing Positions

16. Understand how to conserve your energy
Strategy: Pacing
Understand how to conserve your energy
Think of your personal energy as being held in an Energy Tank
The lower the energy in the tank, the longer it takes to build back up
Before starting a task rate your current energy level
If your energy level is 5-10 you can use 2 levels of energy before you need to rest
If your energy level is 1-4 you can use 1 level of energy before you need to rest
Ask yourself frequently “What is my energy level?”
Listen to your body and don’t do too much at one time
Therapeutic Recovery – taking a break can be just as important as doing exercise to get stronger. The break allows your body to recover to allow for more efficient return of overall activity and exercise tolerance.
Avoid letting the gas tank get completely empty
Think about activities you will have throughout the week so that you can conserve days before and after those with lots of activity/appts
Empty Tank
Least Energy
Full Tank
Most Energy

17. Strategy: Prioritizing
Make a prioritized to do list for the day
Spread out activities between the morning, afternoon, and evening
Think about the time of day that you have the most energy and complete tasks during this time that require the most energy
Spread energy consuming tasks throughout the week
Save energy for doing what you enjoy and want to do, by adjusting your schedule each day
Look at your overall week and divide activities up accordingly.

18. Strategy: Changing Position
Using less energy for an activity allows you to do more
Adaptive equipment can help maintain independence and use less energy
Examples:
Sitting on the bed or in a chair for getting dressed
Sit at the table to meal prep
Sit in a chair for bathing
Use a rollator for seated break when walking long distances

19. Why Exercise
Published research has determined that exercise is safe for cancer survivors and aids in management of CRF2,3,4
Exercise has been shown to have several different benefits for survivors including2,3,4:
Better physical functioning
Improved balance
Increased strength & flexibility
Decreased fatigue
Decreased pain
Improved heart function
Increased energy levels
Improved quality of life
Increasing our body’s endurance helps us build up energy
Certain exercises can also help with osteoporosis improving bone strength
Exercise can also help in reducing depression by releasing chemicals (internally) that help us to feel good (endorphins)

20. “All You’ve Got to do is Challenge Yourself.”
avoid inactivity
Try it multiple times each day
What is easy for you may be moderate for someone else. Keep in mind that you are just trying to challenge yourself a little each time.
A simple reference for how hard you are working is monitoring how hard it is to talk or sing. If you can sing and talk then you are likely exercising at an easy level for you. If you cannot sing but can talk you are likely working at a moderate level. If you cannot talk or sing, you are working at a hard/vigorous level.
You may exercising at a vigorous level even if you are walking. If you can’t easily talk, then you are exercising at least at a moderate intensity…
You always need to consult your physician prior to initiating an exercise program

21. Exercise Recommendations
American College of Sports Medicine (ACSM) Guidelines for Cancer Survivors2,3
Aerobic:
150 min/week of moderate intensity, 75 min/week of vigorous intensity or a combination of the two
Resistance:
Muscle strengthening activities of at least moderate intensity at least 2 days a week for major muscle groups
Flexibility:
Stretch major muscle groups and tendons on days other activities are performed
All of these are the same as the recommendations for a healthy adult

22. Aerobic Activities Walking Jogging Biking Hiking Swimming Dancing
Aerobics
Gardening
Tennis
Sports that require running
Marching in place
Jumping Jacks
Activity Circuits
Climbing stairs

23. Resistance Activities - Lower Body

24. Resistance Activities - Upper Body

25. Flexibility

26. Balance

27. What to Watch Out for While Exercising
Unusual Fatigue – more than expected based on the activity level
Shortness of breath
Dizziness or light headedness
Unusual heart palpitations
Leg cramping
Headaches
Visual changes
If you have any of these symptoms during exercise, stop immediately.
Contact your physician if they continue.
Cancer Specific Precautions:
Recent surgery
Infection
Fever > 100 degrees Fahrenheit
Uncontrolled pain or nausea
Low blood counts
Cancer affecting bones (follow osteoporotic recommendations for exercise)

28. Survivorship
At any time throughout your journey of treatment and survivorship there are various rehabilitation resources available to you if you experience a change in your function.
Physical, Occupational, Speech, and Lymphedema therapy is available:
Home Health
Outpatient
Inpatient

29. Role of Rehabilitation Services
Our job is to guide and assist you in improving your quality of life, maintaining or restoring function, and minimizing symptoms when your cancer diagnosis presents a roadblock.
Physical Therapy – can help improve mobility, balance, lower extremity strength/range of motion, pain and endurance
Occupational Therapy – can help improve activities of daily living, upper extremity strength/range of motion, fatigue management, and energy conservation
Speech Therapy – can help improve speech and language, cognition, swallowing, and communication skills
Lymphedema Therapy- can help improve skin quality, range of motion, pain and reduce limb volume

30. References
Osborne J. Advanced Oncology Rehabilitation for Successful Outcomes. North American Seminars. Inc; 2012.
Schmitz K, Courneya K, Matthews C, Demark-Wahnefried W, Galvão D, Pinto BM, et al. American College of Sports Medicine Roundtable on Exercise Guidelines for Cancer Survivors. Med Sci Sports Exerc. 2010;42:1409–265
Wolin KY, Schwartz AL, Matthews CE, Courneya KS, Schmitz KH. Implementing the exercise guidelines for cancer survivors. J Support Oncol. 2012;10(5):171–177.
Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, Bandera EV, Hamilton KK, Grant B, McCullough M, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):242–274.
BMT Unit: Rehabilitation Exercise Program