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Why keep fit?

Cancer Rehab Physiotherapist Lim Junhong looks at the importance of tailored exercise programmes following a cancer diagnosis.

“What can I do to increase my chances of survival?” This is a question most people will ask when they are diagnosed with a cancer. It is a natural question, and most people will be thinking of what they can eat or do to improve their health and the effectiveness of the treatment that is prescribed.

One answer that you may not expect, however, is this: Exercise.

This may come as a surprising answer to those who might think that people with cancer should rest more.

This sounds logical, as many who have undergone surgery or are being treated with radiotherapy or chemotherapy tend to feel fatigued and experience a decline in their fitness, strength and flexibility. Many would be advised to rest and conserve their energy.

However, recent research has shown that exercise, when done in a safe manner, can actually alleviate the effects of cancer treatment. A roundtable on exercise guidelines for cancer survivors by the American College of Sports Medicine in 2010 recommended that cancer survivors “should be as active as their abilities and condition allow” and, overall, “avoid inactivity”.

Research suggests that exercise can help reduce the chance of relapse and even reduce the risk of getting cancer. A review by Canadian researchers of almost 70 medical journal papers concluded that among all the methods of modifying lifestyle to reduce the risk of breast cancer recurrence and death, exercise is the most effective way.

Several other studies have also showed that people who remain physically active after being diagnosed with various types of cancer have a lower risk of cancer recurrence and higher chance of survival.

Fighting fatigue

To be sure, the majority of cancer patients experience varying degrees of fatigue when undergoing treatment such as chemotherapy and radiation therapy. The fatigue, which may be physical, mental as well as emotional, is likely to make it hard for patients to continue their normal activities for long. Some will feel a prolonged tiredness after doing something, and some feel extremely weak, tired, or exhausted even after sleeping. This may encourage many to avoid activities that seem strenuous.

Inactivity, however, can lead to muscle wasting and loss of physical function – which, ironically, makes it even harder to carry out further activity.

Aerobic exercise can help break this vicious circle. Regular exercise has been shown to reduce fatigue and improve cancer patients’ ability to do their normal daily activities. An aerobic exercise programme can thus be prescribed as treatment for fatigue in cancer survivors both during and after treatment. Other forms of exercise, including resistance and flexibility training, have also shown to be useful (see below).

Some simple strategies to combat fatigue include:

• Getting enough rest, but not too much. This can be achieved by establishing a good sleeping pattern at night, and taking short naps rather than one long rest during the day.
• Staying active. Regular moderate exercise can ease fatigue, though this needs to be done at a safe, reasonable pace.
• Saving energy. Careful planning can help patients ensure that they do not try to squeeze in too many activities each day, and to get enough rest.

Types of exercise

Aerobic exercise

Aerobic exercise training, sometimes known as ‘cardio exercise’, includes activities such as walking, running, cycling, aerobics (or dancing), and swimming. It involves large movements of the arms, hips and legs to increase the heart rate and breathing rate, which allows the heart to continuously pump blood and oxygen (or oxygen-rich blood) to the working muscles.

Aerobic exercise has consistently been shown to improve physical fitness, especially for breast and prostate cancer patients. A physiotherapist with specialised training in cancer rehabilitation can customise an exercise programme to increase physical fitness and reduce cancer-related fatigue.

A general guide is to start the exercise programme slowly (10 to 15 minutes per session) and aim for consistency (three to five days per week) while monitoring the response to the exercise and modifying the programme accordingly. As fitness improves, the duration of the exercise can be increased; a general goal is to reach 30 minutes or more of moderate physical activity every day. This target, however, may not be appropriate for some patients because of their condition. In such cases, physiotherapists can help them remain active in different ways.

Resistance exercise

Resistance exercise, which involves muscle contractions/exertions against gradual increases in resistance/difficulty level, improves muscular strength and endurance.

Some examples of resistance exercises include the use of dumbbells, elastic exercise tubing, your own body weight, bottles of water, or any other object that offers some resistance when contracting the muscles

It also improves bone mineral density, especially in those with breast and prostate cancers. Moreover, by improving muscular strength and physical function, it can help people with osteopenia or osteoporosis to avoid falling.

Resistance exercise is safe for even women with breast cancer, as it does not increase the risk of developing upper limb lymphedema or making pre-existing lymphedema worse. It is also beneficial for prostate cancer patients who undergo androgen deprivation therapy (ADT), as they tend to suffer from lower testosterone levels and lose muscle mass and strength. Resistance exercise will thus not only increase their muscular strength and endurance, but also help them control their weight during treatment.

Range of motion and flexibility exercises

Range of motion and flexibility exercises involve moving the trunk and limbs as far as possible to maintain or improve joint movement.

Examples are static stretching, dynamic stretching and many Pilates or yoga poses. They can help cancer patients regain their full body motions after they undergo surgery.

As cancer surgeries cut through soft tissues, they can result in the scarring of soft tissues and reduce the range of motion. A rehabilitation programme that is customised to include stretching and range of motion exercises can help patients improve their flexibility.

Along with resistance training, flexibility exercises are especially important for those who have undergone neck dissection surgeries, which can damage or affect their spinal accessory nerves and surrounding muscles. This, in turn, often affects the normal functioning of their shoulders.

Stretching, range-of-motion and shoulder-strengthening exercises are useful in such cases, as well as for those who have undergone breast surgery or have radiation fibrosis syndrome due to radiation therapy.

How to start

• Start your exercise programme slowly, say with 10-15 minutes per session. Aim for consistency (3-5 days a week).
• Try to be moderately physically active for at least 30 minutes every day. As your fitness improves, increase this to 60 minutes or more of moderate activity, or 30 minutes or more of vigorous activity. Moderate-intensity exercise is any physical activity that requires a moderate amount of effort and noticeably increases the heart rate.
• Cut down on sedentary behaviour and habits, such as watching television.
• Check with your doctor before starting an exercise programme. Your doctor may refer you to supervised training sessions with a qualified physiotherapist.
• Get a physiotherapist with specific training in cancer rehabilitation who can customise an exercise programme that takes into account your needs, limitations and condition.
• Stay safe: Exercise with a partner, caregiver or exercise professional. Take note of risks associated with specific cancers and treatments.