Getting fit after treatment                        

Helpline 0808 808 5555

Val Young, Grad.Dip.Phys.MCSP. Superintendent Physiotherapist, Southampton Cancer Centre.

Val graduated from Bath School of Physiotherapy in 1982.She initially specialised in rehabilitation for spinal cord injury patients, working on units in Salisbury and Cape Town, South Africa.

This also included a six-month secondment to the British Red Cross, which was involved in setting up a spinal cord injury unit in Armenia following the 1988 earthquake. This interest continued into the field of oncology and spinal cord compression. Val has been in her current post for seven years and is now Superintendent Physiotherapist at Southampton Cancer Centre. In 1999 she gained a Certificate in Oncology for Allied Health Professionals from Clatterbridge Centre for Oncology and is currently studying for an MSc in Advanced Clinical Practice.

She has been the newsletter editor for the Association of Chartered Physiotherapists in Oncology (ACPOPC) for the past two years and is the physiotherapy representative on the Clinical Advisory Board for CancerBACUP.

Southampton Cancer Centre provides radiotherapy, chemotherapy and bone marrow/stem cell transplants for the South Coast Cancer Network, which means that Val is involved with lymphoma patients throughout their treatment in hospital.

Why Exercise? 

Cancer treatments such as surgery, chemotherapy and radiotherapy often last for months or even years and may result in a significant impact in the quality of people’s lives ¹. People with cancer may also experience fatigue, or feelings of excessive tiredness and this can continue for some time after treatment finishes. (If you would like to receive a copy of the Fatigue fact file please contact the Helpline). Morrow et al ² describe fatigue as ‘an unusual, excessive, whole body experience that is disproportionate or unrelated to activity or exertion and not relieved by rest or sleep’. People who have cancer have identified fatigue as an important problem. It affects more people for more of the time than any other symptom and is regarded as being more important than either pain or nausea/vomiting³. For some people it may be severe enough to further delay or prevent a return to normal activities, or even to work, and can affect people physically, psychologically and emotionally. Fatigue may be associated with:

• a lack of concentration and memory
• an inability to begin tasks or a tendency to avoid social contacts and activities
• tiredness and easy exhaustion from activities requiring physical effort.

The actual cause of fatigue is not fully understood. However, it’s probably due to a number of different factors such as cancer treatment, cancer itself, pain, inactivity, altered cell metabolism, poor appetite, anxiety, stress and depression, and anaemia. Anaemia is caused by low levels of red blood cells. Red blood cells carry oxygen around the body to the tissues and muscles. The muscle cells need a good supply of oxygen to obtain their energy for work and several changes due to cancer and its treatment can affect this:

• chemotherapy and occasionally radiotherapy can damage bone marrow where the red blood cells are produced. This will reduce the number of red blood cells circulating in the body and cause anaemia.  As the red blood cells carry oxygen, this results in a reduction of the amount of oxygen reaching the cells
• some drugs can be damaging to the function of the heart (cardio toxic), which can cause less blood to be circulated
• lung fibrosis or scarring of lung tissue following radiotherapy may reduce the working ability of the lungs, which means less oxygen will reach the red blood cells. Disease in the lungs will have the same effect. 

During treatment for cancer people are often less active than usual. This, combined with a poor appetite, can cause further muscle wasting and make fatigue more of a problem. The effects of toxic treatment and a decreased level of activity cause reduced physical capacity making it harder to do your usual activities. This means that more effort is needed to do simple tasks such as climbing the stairs, making meals, walking or housekeeping. This could explain why feelings of fatigue can last so long after treatment has finished^{4, 5}.

Exercise improves muscle strength, but it also improves the functioning of the heart, lungs, and circulation thereby increasing the levels of red blood cells, which supply the muscles with oxygen allowing them to work more efficiently. It also:

·                reduces blood pressure and the risk of having a stroke or heart attack

·                improves cholesterol levels

·                reduces excess weight

·                improves overall well-being and quality of life.

Studies have also shown that exercise may have a beneficial effect on anxiety, stress and depression by increasing feelings of control, independence and self-esteem ^{4, 6, 7}. Current research shows too that aerobic exercise, or endurance training is particularly beneficial for combating fatigue and helping to regain fitness ^{8, 9, 10}. Most of the studies have been performed using bicycles or walking on treadmills, but other examples of aerobic exercise can be seen in table 1.

Table1

There is no data about the effects of resistance training on the well-being and physical performance of people with cancer and more studies need to be done on the effects of physical activity on the immune system ⁴.

What Exercise?

Corneya et al¹ after reviewing the literature, prescribe moderate intensity aerobic exercise 3-5 days per week for 20-30 minutes. They recommend that initial progression should be in frequency and duration rather than in intensity ie exercise more often for longer before making it more difficult. This of course depends on how fit you are and people who are deconditioned or who are experiencing severe side-effects from treatment may need to combine short exercise bouts (2-3 minutes) with rest intervals to reach the total 20-30 minutes.

Patients with neurological complications such as peripheral neuropathy (tingling, numbness or pins and needles in the hands and feet) affecting co-ordination or balance should avoid less stable exercises such as treadmills.

Older or weaker patients should be closely supervised whilst exercising, but age and frailty are not contraindications to exercise. Whilst the physiological benefits of aerobic exercise for this group of people remains unclear, progressive resistance training and balance training such as one legged stand and heel stands are known to be of benefit. However, before you can walk, it is necessary to be able to get out of a chair (requiring muscle power) and maintain the erect posture while moving through space (requiring balance). Therefore aerobic conditioning should follow strength and balance training¹¹. It is important to start, or to continue with some form of exercise as soon as possible, even whilst undergoing treatment. This can help to minimise the loss of muscle bulk and keep you as active as possible. If you are still undergoing treatment it is important to be guided by your physiotherapist and medical staff. A simple regime of exercises can be provided and you should be made aware of any limitations (such as those in table 2).

 Table 2

After treatment has finished it is important to continue with your exercises and to progress your activities if you can. Walking is one of the best forms of aerobic exercise because it is a major component of daily life and doesn’t require specialised or expensive equipment. It stimulates major muscle groups, and is safe and convenient for many patients regardless of age and disease status. Keeping a walking diary may help motivation¹⁰.

You may have an 'Exercise on Prescription' scheme operating in your area, which your doctor can refer you to. These schemes operate from local leisure centres and involve supervised sessions by qualified Health and Fitness consultants who design appropriate and safe exercise programmes for you. All sessions are closed to the general public, so you will only be exercising with others referred for this scheme. A report is sent to your doctor after you’ve completed a number of sessions and the aim is to motivate continuous exercising and improve your fitness levels. 

Conclusion

Current research has shown promising results for using endurance or aerobic exercise to reduce cancer fatigue. Physical exercise is also associated with numerous other benefits including improvement in cardiovascular fitness, lung function, anxiety and improved self-esteem⁷.

It is important to try to return to as normal a life as possible after treatment for cancer. This includes maintaining fitness levels and keeping as active as possible.  Any new activity should be entered into slowly and gradually, so building up your exercise tolerance. Listen to your body - it will tell you what is comfortable.

As long as you don’t have a central line (a flexible tube which opens into a large vein in the chest) and are not neutropenic (low white cell count), which would affect your resistance to infection, you can go swimming and use your local gym. Ask your GP for information on 'Exercise on Prescription' schemes in your area. Choose an activity that you enjoy and start exercising.... today.

If you have any concerns about exercising or require specific advice you should have access to a physiotherapist either via your GP, or at the hospital where you had your treatment.

References

¹Courneya K, (2000) Exercise after cancer diagnosis. Sportex Medicine: The Multidisciplinary Journal for Professionals Vol 5 June pp17-22

²Morrow G, Andrews P, Hickok J, Matteson S. (2002) Fatigue associated with cancer and its treatment. Supportive Care in Cancer. 10(5): 389-98.

³Stone P, Richardson A, Ream E, Smith A, Keer D, Kearnery N (2000) Cancer-related fatigue: inevitable, unimportant and untreatable? Results of a multi-centre survey. Annals of Oncology. 11 pp971-975.

⁴Dimeo F. (2001) Effects of exercise on cancer-related fatigue. Cancer. 92 (6 Suppl) pp1689-93.

⁵Winningham M (2001) Strategies for managing cancer-related fatigue syndrome. A rehabilitation approach. Cancer 92 (4 Suppl) Aug. pp 988-97.

⁶Friedenreich C, Courneya K. (1996) Exercise as rehabilitation for cancer patients. Clinical Journal of Sports Medicine (6) pp 237-244

⁷Dimeo F, Stieglitz RD, Novelli-Fischer U, Fetscher S, Keul J. (1999) Effects of physical activity on the fatigue and psychological status of cancer patients during chemotherapy. Cancer. 85 (10) pp2273-7

⁸Dimeo F,Tilmann M, Bertz H, Kanz L,Mertelsmann R, Keul J. (1997) Aerobic exercise in the rehabilitation of cancer patients after high dose chemotherapy and autologous peripheral stem cell transplantation. Cancer Vol 79 pp 1717-22

⁹Dimeo F, Bertz H, Finke J, Fetscher S, Mertelsmann R, Keul J (1996) An aerobic exercise program for patients with haematological malignancies after bone marrow transplantation.

Bone Marrow Transplantation Vol18 pp1157-1160

¹⁰Winningham M. (1991) Walking program for people with cancer. Getting started. Cancer Nursing 14 (5) pp 270-276

¹¹American College of Sports Medicine (1998). Position stand on: Exercise and physical activity for older adults. Medicine and Science in Sports and Exercise  (30) pp 992-1008