How To Begin An Exercise Routine (For Cancer Patients And Survivors): Part I

This is the first article in our series on “How To Begin An Exercise Routine (for cancer patients and survivors.)”  If you are currently living with cancer or had cancer in the past you may be facing a unique set of challenges or uncertainties due to side effects from your treatment or the cancer itself. By following our safe practice recommendations we hope that you will be able to include exercise into your daily life as soon as possible. 

Authored By: Sophie Mc Greevy (Certified cancer exercise trainer / Health coach), Janette Powell (Physical Therapist, Orthopedic Certified Specialist, Sports Certified Specialist, MHSc) and Brian D. Lawenda, MD

Why Is Exercise So Important During & After Cancer?

• Exercise can help alleviate side effects of cancer treatment (i.e. fatigue, pain, bone & muscle loss, etc.)
• Exercise improves quality of life (i.e. stress, anxiety, depression, etc.)
• Exercise can reduce the risk of cancer recurrence (decreased inflammation, decreased free radical production, decreased cancer growth factor production, etc.)
• Exercise can improve self-image and confidence

Learn more about the importance of exercise on cancer outcomes in “Exercise and Cancer 101”

You Can Do It…The Most Important Step Is Getting Started:

Remember these main points:

• Avoid long periods of inactivity during the day (this is linked to worse health outcomes even if you exercise every day).
• Any exercise is better than no exercise (the more exercise you do the better your health).
• Only be as physically active as your ability and condition allow.
• Allow yourself adequate time to recover after cancer treatment. It’s important to recognize that getting back to your pre-treatment fitness level takes time.
• Start slowly and aim for consistency. Jumping immediately into a strenuous exercise routine can lead to  frustration, excessive fatigue and rapid burn-out or injury. ‘Slow and steady’ is the name of the game. 

Get Your Doctor’s Permission Before Starting An Exercise Routine If You Answer “Yes” To Any Of These Questions:

• Are you currently undergoing cancer treatment?
• Do you have a heart condition?
• Should you only do exercises that your doctor recommends?
• Do you have chest pain or discomfort when you are physically active? Do you have this pain even when you are not exercising?
• Does your heart often beat too fast or too slow when you are at rest?
• Does your heart beat irregularly? 
• Do you become dizzy, lose your balance, or lose consciousness?
• During the past year, have you fallen more than two times?
• Do you have problems with your bones or joints? If so, does this problem become worse when you exercise?
• Do your legs or buttocks hurt when you walk?
• Do you take medicines to treat a heart condition or a blood pressure problem?
• Do you have any wounds on your feet? Do these wounds take a long time to heal?
• During the past six months, have you lost weight for no apparent reason?
• Do you feel unusually tired or weak?
• Do you have a fever or infection?
• Do you have severe diarrhea or vomiting?
• Do you suddenly feel nauseous during exercise?
• Do you have leg pain or cramps?
• Have you ever had lymphedema (swelling of you arms or legs)?
• Have you noted any changes in the look or feel at or near the site or your cancer?
• Have you had any changes in your vision or hearing?
• Can you think of any reason why you should not get involved in an exercise program?

Many of the questions above are derived from the Canadian Society for Exercise Physiology’s PAR-Q form. A slightly more detailed form is also available called the PAR-Q+. If you answer yes to any of the PAR-Q questions, your physician would then administer a more detailed questionnaire called the PARmed-X form to determine whether exercise is safe for you, what type of exercise is permissible and what further studies might be indicated to assess your medical condition.

We created the following form that you can download and give to your physician to use if your gym or trainer requires medical clearance before you exercise: IOE Medical Clearance and Exercise Consent Form

Who Does Your Doctor Turn To For Help In Customizing A Safe Exercise Routine Specifically For You?

Most physicians receive very little if any training or education in assessing for physical limitations and designing exercise routines, so they will often refer you to either a physiatrist (physical medicine & rehabilitation physician), a physical therapist or a personal trainer with enhanced experience and education in working with cancer patients and survivors (i.e. American College of Sports Medicine/American Cancer Society Certified Cancer Exercise Trainer, American College on Exercise Advanced Health and Fitness Specialist Certification.)

These are professionals who can customize and adapt exercises based on surgeries, type of cancer, underlying and associated medical conditions and your interests.  Each participant is evaluated prior to participation so that modifications and appropriate recommendations can be made. Program design for patients in treatment or with underlying health challenges requires additional attention.

These professionals help you get started with a game plan to:

• Minimize your risk of injury during exercise
• Maximize your benefits of exercise
• Help you become more confident in your ability to be active
• Increase your exercise program adherence
• Adapt exercise routines to your individual needs and interest

Your Immune System (Precautions):

Any patient who is actively receiving (or recently completed) cancer treatment needs to take precautions to prevent infections, as their immune system may be weakened. This is particularly true during or after chemotherapy or when recovering after surgery.  Infections are potentially life-threatening if they develop in someone with a weak immune system. If your physician has told you that you need to be careful to avoid infections or your immune system is weak:

• Avoid training in crowded places (i.e. gym, yoga studio)…use your best judgement as some gyms and studios are kept cleaner than a hospital room
• Wash your hands frequently
• Do not exercise if you have fever or chills, and let your doctor know immediately.

Your Nervous System (Precautions):

Cancer treatment may cause numerous neurologic side effects that can affect your ability to exercise.

Neuropathy is one of the most common side effects. This can cause pain, burning, tingling, weakness or numbness. It can be caused by surgery, radiation therapy, chemotherapy and numerous medications. If neuropathy affects your hands or feet (peripheral neuropathy), you are more susceptible to injury due to numbness, decreased temperature sensitivity, walking (gait) difficulties and/or diminished perception of the location of your limbs (proprioception.)

• If peripheral neuropathy affects your balance, you may need exercise modifications to reduce your risk of falling. Balance training may also be recommended.
• If peripheral neuropathy affects your hands, you may not be able to safely hold weights so the use of stationary equipment or resistance bands may be recommended instead.

Read more about an integrative oncology approach to managing neuropathy in a previous IOE post. 

Your Musculoskeletal System (Precautions):

Surgery can cause temporary or permanent injury to muscles, tendons, lymphatic channels and nerves, all of which can affect your ability to exercise through decreased strength or range of motion. 

Decreased bone strength and density can develop as a result cancer spread to the bones (metastatic disease) or from decreased physical activity during and after treatment. Additionally, many drugs (i.e. corticosteroids) and certain radiation techniques can also lead to thinning or weakening of the bones. Patients with known bone metastasis or osteoporosis should be monitored closely. Weightlifting should be limited to weights that can be managed using correct form throughout the full range of motion. Balance, core and lower extremity strengthening exercises should be used to help survivors with balance problems to decrease risk of fall. High-impact activities (i.e. jumping, running) should be avoided in anyone at risk of bone fractures.

Read more about an integrative oncology approach to managing bone loss after cancer treatment in a previous IOE post.

Muscle weakness from disuse (‘use it or lose it’) is very common among cancer patients and survivors. Exercise routines may need to be modified to accommodate for loss of limb function, limited range of motion, peripheral neuropathy, and impaired balance.

Lymphedema (swelling of the limb) is one of the more common side effects of breast cancer and melanoma treatments (although it can also occur after the treatment of many other cancers.) If this is not detected early and managed, it can lead to permanent changes in the affected tissues. One of the most concerning complications of lymphedema is the increased risk of developing potentially serious infections in the affected limb. Additionally, chronic lymphedema can decrease the range of motion of the limb. Even if you have lymphedema, you can exercise (both aerobic and resistance) safely. Recent studies have indicated that exercise and weight loss are highly encouraged in the management of this condition. Many patients with lymphedema wear compression garments to control the swelling. If you have lymphedema or are at-risk of lymphedema, always work with an expert who has training and experience assessing and treating patients with this condition before you begin an exercise routine.

Read more about lymphedema in a previous IOE post. 

Helpful Tips For Overcoming A Common Barrier To Exercise: “I’m Tired” (Fatigue)

Simply going to the gym is not going to be motivating for most people unless that’s your thing. It helps to choose an activity or type of exercise that you enjoy, as you will be much more likely to continue with it.

If you are not in top shape yet, don’t try to complete an extensive exercise routine in one session. Consider breaking up your exercise into shorter sessions at different times during the day.

If you know that you have more stamina at a particular time of day (i.e. morning or evening), schedule your exercise during the time of day when you are less tired.

Make sure to drink lots of water throughout the day. How much water should you drink? The best gauge is to look at your urine color. If it is clear or clear-yellow, you are probably drinking enough. If it is yellow or dark yellow, you need to drink more water.

Get enough sleep. Most people need a minimum of 6-8 hours each night. If you aren’t getting enough sleep, you’ll likely be chronically tired and have much less energy to exercise. 

• How to Sleep Better: Tips for Getting a Good Night’s Sleep (one of the better articles I’ve read on tips for improving your sleep)
• Twelve Simple Tips to Improve Your Sleep (Division of Sleep Medicine, Harvard Medical School)

Read about the potential links between not getting enough sleep and cancer on a previous IOE post.

Use an exercise diary. This is one of the most motivational ways to help you stick with your routine. Track your activity (time exercised, distance covered, number of reps, number of sets, weights, etc.), your weight and waist circumference. Here’s the one Dr. Lawenda uses:

Consider using a ‘fatigue dairy or log’ to track your level of fatigue during the week and during exercise sessions. You and your trainer can use the log to make adjustments to your exercise routine. Here’s a good one from the MS Society of Canada:

Listen to music when you exercise. If you enjoy music, listening to your favorite tunes can make exercise more fun. It helps to distract you and reduce your perception of effort. 

Work out or exercise with a partner. Studies have shown that by partnering up with a workout buddy, you’re more likely to work our harder and consistently. They also hold you accountable for showing up to your exercise activity.

Variety is the spice of life. A repetitive exercise routine can cause boredom and fatigue. If you are a member of a fitness club, switch up your routine by using a different cardio machine on alternating days, and change your weightlifting program every couple of months to work different muscle groups.  

A Winning 5-Step Strategy:

1. Get motivated: Ask yourself “What triggered your decision to set this goal?” and “Do you want to improve your health, have more energy, and improve quality of life?”
2. Your first goal should be easy to achieve: To avoid getting discouraged, have realistic expectations. After achieving your first goal, your sense of accomplishment will motivate you to aim higher.
3. Make physical activity a part of your lifestyle: Look for ways to be active every day. Choose activities that are easy to fit into your schedule and opt for the types of activities you enjoy.
4. Enjoy being active: Develop a taste for exercising. A training partner is a great way to do this. Support from a friend or family member increases your chances of success; someone going through the paces with you and offering encouragement will help you stay motivated.
5. Progress at your own speed: This will permit your body to adapt to your new regimen while avoiding fatigue and injuries. Respect your limits. Keeping a training journal is a good way to gradually intensify your workouts. Take it one step at a time and you’ll be able to go further than you ever thought possible.

Ready? Set Goal!

It is important to have positive and realistic expectations about the outcomes of exercise. Appropriate goal setting can motivate you to exercise, while setting and reaching those goals can help you stay on track with the exercise plan.

The goals of your exercise routine may differ depending on when and what type of cancer treatments you had, the type of cancer you had/have, side effects, other medical conditions, physical limitations, etc. Here are some example goals:

• To regain and improve physical function, aerobic capacity, strength and flexibility
• To improve body image and quality of life
• To improve body composition (increased muscle, decreased fat)
• To improve cardiorespiratory, hormonal, neurological, muscular, psychological or cognitive function.
• Potentially to reduce or delay recurrence or a second cancer

To be effective goals should be specific, measurable, realistic, and attainable in a fairly short time period. Keeping your goal(s) in mind can help motivate you. Answer the following questions and write down your answers:

1. What is your long-term goal?
2. What is a realistic short-term goal for you for the next week?
3. How are you going to monitor your progress?
4. How will you reward yourself when you reach your goal?

In Summary:

We hope that this post was helpful in introducing you to various precautionary signs & symptoms that you should discuss with your doctors, discussing with you the referral experts that can help assess and design your exercise routines, and providing you a few motivational & goal setting tips to help you get started exercising.

Exercise is not just another ‘chore’ to fit in your schedule if you have time. It is our sincere hope that you will view exercise as an essential anti-cancer lifestyle component that you will incorporate into your daily life for many years to come.

Stay tuned…

Our next article will tell you how total beginners can start incorporating exercise into their life by walking, running, cycling and/or swimming.