Did you know that every 3 minutes another woman is diagnosed with breast cancer? Breast cancer is the most common caner diagnosed in women. Due to improved detection and treatment, these women and men (men can get breast cancer to) are living longer and healthier lives. The treatment that they must undergo is grueling; physically and psychologically.
How can you as a personal trainer maximize their function and bring enhanced wellness back into their lives? This article will explore in brief the treatments these brave women face, treatment implications, exercise goals ,and exercise program design However, it is advisable to do more research and obtain updated information as treatment continues to evolve.
When a woman is diagnosed with breast cancer, her cancer is staged from stage 1 to stage 4.Staging is a method of grouping patients to determine the type of treatment, predict prognosis ,and compare different treatment protocols. Stage 1 has a better prognosis because the tumor is smaller and no lymph nodes are involved while stage 4 is cancer that has spread to the bones, liver, lungs or brain from this staging and other tests, treatment can be prescribed. Menopausal status and lifestyle requirements are other factors that determine treatment.
There are 2 types of treatment; local and systemic .Local treatment includes surgery and radiation and refers to the actual site of the tumor. Surgery is indicated for all women but depends on other factors. The major types of surgery are as follows; lumpectomy (breast conservation surgery), mastectomy, and modified radical mastectomy. The least invasive procedure is the lumpectomy in which the tumor is removed with a partial axillary lymph node dissection (cancer spreads through the lymph nodes). Radiation usually follows this procedure. Mastectomies involve removal of the entire breast tissue without lymph node removal.
However, when a modified radical mastectomy is performed, the entire breast tissue is removed as well as some lymph nodes Cosmetic deformity, chest wall tightness, loss of a body part and body image changes are all side effects after a mastectomy. Tightness in the pectoral and axillary (armpit) regions are some complications of this surgery with loss of range of motion and strength in the affected shoulder a concern.
Radiation is a local treatment that damages cancer cells so that they cannot grow and multiply .One undergoes radiation for 5 days a week for 5-6 weeks. It usually follows chemotherapy administration or 3-4 weeks after surgery if chemotherapy is not indicated Scar fibrosis, skin irritation, burns, breast tenderness swelling and fatigue are side effects.
Systemic treatments affect the entire body and include chemotherapy and hormonal treatments. Chemotherapy is the use of cytotoxic (cell killing) drugs .Both cancerous and non-cancerous cells are effected. Hair loss, vomiting, and nausea are common as rapidly dividing cells in the hair and the intestine are most affected.
Other side effects include diarrhea, fatigue, risk of infection, premature menopause, weight gain, cardio-toxicity, anemia and peripheral neuropathy. Chemotherapy is administered once every 3-4 weeks for approximately 4-6 months .Hormonal treatment use cytostatic (cell blocking) drugs such as Tamoxifen This drug is usually well tolerated but approximately 25% of all women suffer menopausal like symptoms including hot flashes, weight gain, vaginal dryness, nausea and vomiting .Increased risk of uterine cancer and deep vein thrombosis is noted with this drug .Fortunately, it appears to maintain bone density in post menopausal women.
A woman’s quality of life and sense of self is affected by this disease. There are both physical and psychosocial implications which you must understand to formulate a viable program format.
These issues are as follows:
Impaired shoulder mobility: After major surgery, discomfort and pain is to be expected. Surgery to the axillary and pectoral regions can preclude full range of motion at all planes in the shoulder. As a result, there may not be a willingness to move which leads to a loss of strength and function in the affected arm Exercise must be done shortly after surgery to prevent any complications .In addition, a good range of motion in the shoulder is necessary to receive radiation Scar tissue continues to form for 1-2 years after surgery Thus, the area needs to be continually stretched to prevent adhesions.
Fatigue: Fatigue is the most common side effect associated with all treatments. Most clients report experiencing this debilitating condition. It sets up a vicious cycle of not doing activity thereby losing endurance and strength for daily tasks which leads to more fatigue. .Fatigue can be quite problematic.
Lymphedema: Any woman that has received lymph node dissection and/or radiation is at risk for lymphedema. This is a protein rich fluid which collects in the arm, chest or axillary region when the lymphatic system is unable to pump it normally it back to the heart. This is due to scar tissue or lymph node removal .It can develop right after surgery or many years later, and is an omnipresent issue. It is difficult to prevent, as many factors may cause it to develop. However, precautions must be undertaken to decrease the risk.. Clients may complain that their arm feels heavy, is aching feels numb or tires easily when experiencing this condition and should be referred to a medical professional immediately.
Osteoporosis: Since chemotherapy can cause premature menopause, these women are at risk for osteoporosis Age seems to be the best predictor of who will go through menopause. The older one is during chemotherapy, the more likely that one will go through menopause. Rapid bone loss occurs during the first 5 years and the risk of fractures to the spine, hip or wrist is a serious concern.
Weight gain: Many women seem to gain 5-15 pound after undergoing treatment. This weight gain is influenced by the type of treatment, node status, menopausal status, and length of treatment. .It is unknown whether it is due to a decreased level of activity, reduced metabolic rates after treatment or the chemotherapy drugs themselves .It is an additional stressor and influences ones self esteem.
Psychosocial issues: After a diagnosis of cancer, psychosocial concerns are paramount. Fear of death, disfigurement and dependency are common. High stress levels are experienced along with feelings of anger , depression, fear or anxiety .Everyone reacts differently to this diagnosis therefore, humor, communication and empathy are extremely important when working with this population.
Breast cancer is a serious illness that requires an understanding of the disease and the issues that you will most likely encounter. A decrease in the quality of life is a tremendous concern. You can have a great role in promoting wellness through education and the provision of a goal oriented fitness program. However, it is very important to educate yourself regarding exercise precautions and contraindications which are beyond the scope of this article Modifications may be necessary due to fitness level, common conditions and exercise tolerance.
These are the primary goals of your exercise program, but individual needs and concerns should be addressed. It is recommended to refer any woman with significant functional limitations or lymphedema to a rehabilitation specialist. In addition, it is essential to screen clients before recommending an exercise program to meet the individual’s level of fitness, age, treatment concerns or any other health issues.
A detailed medical history is necessary to adhere to any precautions or contraindications especially while undergoing treatment. Older women, women still undergoing treatment, or those with any concurrent diseases especially cardiovascular, respiratory musculoskeletal, or renal should be evaluated by a physician for medical clearance.
Breast Cancer Exercise Goals
- Promote optimal range of motion at the shoulder — This is the most important goal for your client to achieve. It is essential for clients to have a good range of motion at the shoulder to undergo radiation. However, pain and swelling may limit ones ability and willingness to perform exercises on a regular basis. Physicians follow different time frames when recommending range of motion, but the sooner the better.
These shoulder exercises must perform daily for at least a year or two after surgery.
Scar tissue continues to form and must be stretched on a regular basis to prevent adhesions.
The axillary region and pectoralis major are the main areas to be stretched.
Some good exercises include the triceps stretch for the axillary region, the child’s pose in yoga (if client is able to go down on their knees and rock forward and back) the traditional wall pectoralis stretch, or holding a towel in both arms and using the unaffected arm to pull the other behind the ear and behind the back into external /internal rotation respectively.
Pain is to be respected and the stretch should be held to the point of discomfort not pain .The stretches should be held from 5-10 seconds at first, gradually increasing the length of time. It is better to perform the exercises several times during the day, rather than all at once. The type of exercises should be varied to obtain good range of motion in all planes at the shoulder.
- Reduce the risk of lymphedema; All clients at risk should be instructed in lymphedema precautions and reminders provided to adhere to them regularly. Clients should be instructed in recognizing the symptoms, i.e., warmth, swelling redness, or numbness in the arm .Avoiding heat, bug bites, and scratches to the affected arm decreases ones risk of infection. Infection can lead to lymphedema. If lymphedema is a concern, your client should be fitted with a sleeve which is worn while they exercise especially when lifting weights. Progress your client slowly and start with a light weight i.e.1 pound.Shoulder raises, shoulder abductions, triceps extensions and bicep curls are all appropriate exercises. Gauge the response of the arm to the activity .If the arm swells either the weight or the number of repetitions was too much for the limb to handle and should be modified. Repetitions and weights should not be progressed at the same time. I generally start with 1 set of each exercise described above to the effected arm 2-3 times a week. .Do not take blood pressure in the affected arm!!!
- Improve endurance and lean body mass.-Help clients to adhere to a well balanced diet .Providing weight training to increase LBM and aerobic exercise to increase metabolism, can assist in achieving weight loss. Unless there are musculoskeletal limitations, you can use the traditional weight training exercises to the unaffected arm, legs, hips, abdominals and back. Cardiovascular exercise can be performed at 50-75% of heart rate reserve 3-5 days a week for 20-60 minutes.A RPE of 11-14 on a 1-20 scale is the best guideline. Walking and cycling are quite beneficial, but most exercises involving the large muscles are appropriate including swimming, cross training ,or aerobics .It is best to begin with a 5-10 minute walk to judge your clients tolerance. Some clients who are severely deconditioned or experiencing treatment side effects may require multiple shorter aerobic sessions. Your goal will be to gradually increase the time period engaged in aerobic exercise and to slowly increase their exercise tolerance. You may find that they have treatment side effects and may not be able to participate on a regular basis while undergoing treatment.
- It is important to be sensitive to ongoing needs and flexible with your exercise program design .Frequency and duration should be progressed rather than intensity in the beginning whenever possible. Women who have undergone TRAM flap reconstruction should not perform sit-ups. However, gentle abdominal strengthening to the obliques and transverse rectus abdominis can begin 8-10 weeks after surgery. In addition, high intensity exercise should be avoided during treatment.
- Reduce risk for osteoporosis related factors- Encourage your clients to obtain a baseline bone density screening such as a DEXA Calcium should be taken on a regular basis .There are some drugs that breast cancer survivors can take to maintain bone density, but hormone replacement therapy is contraindicated.
When clients are able, they should participate in weight bearing exercise to the hips and spine.
Although swimming and cycling are excellent vehicles for cardiovascular conditioning, they are non weight bearing activities. Weight training to the back, hips, wrist and forearms should be performed as a preventative measure along with balance training to prevent falls .If your client already has osteoporosis, sit-ups are contraindicated for fracture risk to the spine.
- Improve psychological functioning- Participation in a regular well balanced exercise program that is gentle, slow and progressive can enhance self esteem. As one is physically challenged, sense of self improves as mastery is achieved a body which has once betrayed them. In addition, group exercise can provide companionship, fellowship and support to adhere to an exercise program. Exercise such as yoga can
provide flexibility benefits as well as instruction in stress reduction techniques that can prove beneficial.
Working with this population provides numerous benefits. It can be very rewarding, as you see your clients progress .However, adaptability and tolerance are necessary personal assets, as clients my not be able to adhere to a regular program while undergoing treatment. Educate yourself regarding exercise contraindications and consult with rehabilitation professionals who can offer suggestions on range of motion exercises and lymphedema risk reduction.
Research has indicated numerous psychological and physical results after participation in exercise by breast cancer survivors. Bear in mind that more research needs to be conducted to determine what particular type, frequency, duration, intensity ,or rate of progression is most useful .In addition, the effect of exercise on the development of lymphedema should be addressed in future studies.
Naomi Aaronson MA OTR/L CHT is an occupational therapist and fitness instructor who created the Recovercises program for breast cancer survivors at SHARE and Ellen Bodner’s Next Step Fitness. Visit Naomi’s web site at http://www.recovercisesforwellness.com/.